Reproducibility for carotid wall segmentation using T1-weighted DANTE-SPACE sequence on high-resolution 3-T carotid MRI.

BACKGROUND: T1-weighted (T1W) magnetic resonance imaging (MRI) using the delay alternating with nutation for excitation-sampling perfection with application-optimized contrasts using different flip angle evolution (DANTE-SPACE) is the preferred imaging technique for evaluation of the vessel wall. PURPOSE: To evaluate the intra- and inter-rater reproducibility of carotid wall segmentation on T1W DANTE-SPACE in patients with symptomatic (acute stroke or transient ischemic attack) internal carotid artery (ICA) stenosis. MATERIAL AND METHODS: This prospective study included 25 patients with acute (≤3 months) stroke or transient ischemic attack and 50%-99% stenosis of the ICA. All patients underwent 3.0-T high-resolution carotid MRI. Two radiologists independently performed the manual segmentation of the vessel wall and inner lumen of the bilateral carotid artery on DANTE-SPACE. The intraclass correlation coefficient (ICC), Dice similarity coefficient (DSC), and Hausdorff distance (HD) were calculated. RESULTS: The ICCs for intra-rater reproducibility of carotid wall volume, inner lumen volume, and normalized wall index were 0.965, 0.990, and 0.962, respectively. The ICCs for inter-rater reproducibility of carotid wall volume, inner lumen, and normalized wall index were 0.856, 0.981, and 0.904. DSC and HD for intra- and inter-rater reproducibility of carotid wall segmentation were as follows: 0.873 and 0.809 (DSC); and 0.079 and 0.118 (HD), respectively. For evaluation of reproducibility only in the carotid artery with symptomatic stenosis, the ICCs for intra- and inter-rater reproducibility indicated all perfect agreement. CONCLUSION: T1W DANTE-SPACE is a reproducible sequence for evaluation of the carotid wall using carotid MRI in patients with symptomatic ICA stenosis.

Transvenous embolization along with intraprocedural image fusion technique for complex intracranial dural arteriovenous fistula.

PURPOSE: This study aimed to investigate the efficacy and safety of an intraprocedural image fusion technique using flat-panel detector computed tomography-based rotational angiography (FDCT-RA) and image fusion (IF) for the transvenous approach in treating intracranial dural arteriovenous fistulas (dAVFs). METHODS: A retrospective review was conducted on patients who underwent transvenous embolization for dural AVFs. The patients were classified into two groups according to the treatment technique used: the FDCT-RA and IF technique group and the conventional technique group. The primary outcomes assessed were the angiographic and clinical outcomes, complications, fluoroscopy time, and radiation exposure. Univariate analyses were performed to compare the two treatment modalities. RESULTS: Eighty-six patients with intracranial dAVFs were treated with transvenous embolization (TVE), of which 37 patients underwent transvenous approach with flat-panel detector computed tomography-based rotational angiography (FDCT-RA) and image fusion (IF) technique used. The FDCT-RA and IF group showed difference in the location of dAVFs, occlusion state of the sinus, and access routes in comparison to the conventional treatment group. The FDCT-RA and IF technique was predominantly used for dAVFs involving the anterior condylar confluence and cavernous sinus with ipsilateral inferior petrosal sinus (IPS) occlusion. Patients treated with this technique demonstrated a higher rate of complete occlusion (91.9%, n = 34) compared to those treated with the conventional technique (79.6%, n = 39), but this difference was not statistically significant (p = 0.136). Although the implementation of this technique during the treatment procedure showed a tendency to decrease both fluoroscopy duration and radiation dose, the observed results did not reach statistical significance (p = 0.315, p = 0.130). CONCLUSION: The intraprocedural image fusion technique using FDCT-RA for transvenous treatment of intracranial dAVFs could provide help in treatment of dAVFs of certain locations or access routes. It might provide aid in microcatheter navigation, without increasing the radiation exposure and fluoroscopy time.

Symptomatic ischemic complications following endovascular treatment of vertebral artery dissecting aneurysms.

PURPOSE: The aim of this study is to investigate the clinical and radiological features related to the symptomatic ischemic complications of vertebral artery dissecting aneurysm (VADA) following endovascular treatment (EVT). METHODS: The clinical and radiological features of 127 VADAs, which were treated in a single tertiary institute between September 2008 and December 2020, were retrospectively reviewed. We defined a thrombosed aneurysm as being one which the thrombus was in the aneurysm in magnetic resonance imaging (MRI). Symptomatic ischemic complication was defined as a case in which acute infarction was confirmed on diffusion weighted image after EVT with associated clinical symptoms. Univariate and multivariate analyses were executed to demonstrate the associations between symptomatic ischemic complication and characteristics of VADA. RESULTS: The rate of symptomatic ischemic complication was 13.4% (17 of 127). The thrombosed aneurysms were observed in 24.4% (31 of 127) and posterior inferior cerebellar artery (PICA) involvement was shown in 38.6% (49 of 127). Multivariate logistic regression analysis demonstrated that thrombosed aneurysms (odds ratio [OR] = 8.54, 95% confidence interval [CI] 1.98-36.87, p = 0.004) and PICA involvement (OR = 4.26, 95% CI 1.03-17.68, p = 0.046) were significantly associated with symptomatic ischemic complications following EVT. CONCLUSION: This study showed that the VADAs with intra-aneurysmal thrombose and PICA involvement may be independent risk factors for symptomatic ischemic complications following EVT. Therefore, when the thrombosed VADAs with PICA involvement are observed, practitioners may consider close postoperative monitoring for early detection of ischemic complications.

Long-term clinical and angiographic outcome from angioplasty and stenting for intracranial stenosis.

BACKGROUND: Severe intracranial atherosclerotic stenosis (ICAS) is a major cause of stroke. Although percutaneous transluminal angioplasty and stenting (PTAS) treatment methods have increased over the last decade as alternative therapies, there is debate regarding the best method of treatment, with medical and surgical therapies often suggested. METHODS: We analyzed the long-term follow-up results from 5 years of intracranial stenting for intracranial stenosis from three stroke centers. The primary endpoints were early stroke complications or death within 30 days after stent insertion, and the secondary endpoint was a recurrent stroke between 30 days and 60 months. Correlating factors and Kaplan-Meier survival curves for recurrent stroke and in-stent restenosis (ISR) were also obtained. RESULTS: Seventy-three PTAS in 71 patients were examined in this study. The primary and secondary endpoints were all 8.2% (n = 6), and restenosis was 13.7% (n = 10) during the 5-year follow-up. The primary endpoints were significantly frequent in the high National Institutes of Health Stroke Scale (NIHSS) and early stent (≤ 7 days after dual antiplatelet medication) groups. Secondary endpoint and ISR were identically frequent in the younger age group and in the presence of tandem stenosis in other major intracranial arteries. The cumulative probability of recurrent stroke and ISR at 60 months was 16.4% and 14.1%, respectively. CONCLUSIONS: This study shows that PTAS is safe and effective for major ICAS. Reducing the early complication rate is still an important factor, despite the fact that long-term stroke recurrence was low.

Multiple anterior choroidal arteries and perioperative ischemic complications in unruptured anterior choroidal artery aneurysms treated with microsurgical clipping.

BACKGROUND: This study aimed to identify the association between the number of anterior choroidal arteries (AchoAs) and procedure-related ischemic complications in microsurgical clipping of unruptured AchoA aneurysms. METHODS: We retrospectively reviewed the clinical, radiological, and intraoperative findings of 153 patients with unruptured AchoA aneurysms treated with microsurgical clipping between January 2012 and November 2020 in a single tertiary institution. Intraoperative video clips were reviewed, and the AchoA type was categorized into two according to the number of AchoAs: (1) single-type group with single origin and single branch and (2) multiple-type group with duplicated origin or divided multiple branches. Uni- and multivariate analyses were performed to assess the relationship between clinical and radiological factors and perioperative ischemic complications. RESULTS: Of the 153 patients, 52 (34%) were categorized as multiple-type group. The frequency of perioperative ischemic complications, including decreased intraoperative motor evoked potential (MEP), silent infarction, and postoperative ischemic symptoms, was significantly higher in the multiple-type group than in the single-type group (13 [25%] vs 6 [5.9%], p = 0.001). Multivariate logistic regression analysis showed that multiple-type group (odds ratio [OR], 3.725; 95% confidence interval [CI], 1.171-11.845, p = 0.026) and multilobulated shape (OR, 9.512; 95% CI, 2.093-43.224; p = 0.004) were significantly associated with perioperative ischemic complications. Among 9 patients with decreased MEP, postoperative ischemic symptoms developed in 2 patients after clip adjustment. CONCLUSIONS: Multiple-type AchoA aneurysms and multilobulated shape are significantly correlated with perioperative ischemic complications. Postoperative ischemic complications can be minimized by recognizing these variations and using multimodal approach with MEP monitoring.

Risk Factors for the Recurrence of Posterior Communicating Artery Aneurysm: The Significance of Fetal-Type Posterior Cerebral artery.

OBJECTIVES: The purpose of this study was to investigate the risk factors associated with recurrence of posterior communicating artery aneurysms after treatment and to evaluate the significance of fetal-type posterior cerebral artery as an independent risk factor for recurrence of posterior communicating artery aneurysms. MATERIALS AND METHODS: The clinical and radiological findings of 220 posterior communicating artery aneurysms treated between January 2009 and December 2016 in a single tertiary institute were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the association between clinical and radiological variables and recurrence. RESULTS: Of 220 posterior communicating artery aneurysms, 148 aneurysms were unruptured and 82 aneurysms were treated with surgery. Forty-six out of 220 aneurysms (20.9%) were associated with fetal-type posterior cerebral artery. Overall recurrence rate was 19% (42 out of 220 aneurysms) during mean 54.6 ± 29.8 months follow-up. Multivariate logistic regression analysis showed that size (OR=1.238; 95% CI, 1.087-1.409, p = 0.001), ruptured status (OR=2.699; 95% CI, 1.179-6.117, p = 0.019), endovascular treatment (OR=3.803; 95% CI, 1.330-10.875, p = 0.013), incomplete occlusion (OR=4.699; 95% CI, 1.999-11.048, p = <0.001) and fetal-type posterior cerebral artery (OR=3.533; 95% CI, 1.373-9.089, p = 0.009) were significantly associated with recurrence after treatment. CONCLUSIONS: The results demonstrated that fetal-type posterior cerebral artery may be an independent risk factor for the recurrence of posterior communicating artery aneurysms. Therefore, fetal-type posterior cerebral artery can be considered as an important risk factor for the recurrence of posterior communicating artery aneurysms, along with other known risk factors such as size, ruptured status, endovascular treatment, and incomplete occlusion.

Treatment outcomes of large and giant intracranial aneurysms according to various treatment modalities.

PURPOSE: This study aimed to compare the treatment outcomes of large (15-25 mm) and giant (> 25 mm) intracranial aneurysms (IAs), according to different treatment modalities. METHODS: In total, 112 patients with large and giant IAs treated with various treatment modalities between January 2009 and December 2018 were retrospectively reviewed. Clinical and radiological parameters were analyzed and correlated with the treatment modality. RESULTS: A total of 141 procedures were performed on 112 patients. We initially treated 47 cases with coil embolization, 39 with flow diverter (FD), 13 with direct clipping, and 13 with parent artery occlusion (PAO). Recurrence (46.8%) and retreatment (31.9%) rates were significantly higher in the coiling group (p < 0.001). Complete occlusion rate (36.3%) was significantly lower in the coiling group (p = 0.027). PAO could achieve a high complete occlusion rate (90.9%) with low complication rate (12.5%). The total complication rate was 17%. In the multivariate logistic regression analysis, FD (OR 3.406, p = 0.036) and direct clipping (OR 5.732, p = 0.017) showed a significantly higher complication rate than coiling. The overall mortality rate was 8% (8/139 procedures). At the last follow-up (mean 30.6 ± 26.4 months), 70 of 96 patients (72.9%) showed complete or near-complete occlusion. Good functional outcome (mRS ≤ 2) was observed in 90 of 112 (80.3%) patients at the last follow-up (mean 33.2 ± 30.5 months). CONCLUSIONS: Good clinical and radiologic outcomes with acceptable complication and mortality rates can be achieved by various treatment modalities. The selection of appropriate modality should be individualized based on the angiographic findings and clinical symptoms.

Clinical and morphological risk factors for the recurrence of anterior communicating artery aneurysms after clipping or coiling.

BACKGROUND: The aim of this study was to evaluate clinical and morphological factors associated with recurrence in anterior communicating artery (AcomA) aneurysms after clipping or coiling. METHODS: We retrospectively reviewed the clinical and radiologic features of consecutive 214 patients with AcomA aneurysms treated between January 2012 and December 2016 in a single tertiary institute. Univariate and multivariate analyses were performed to identify the relationship between clinical and morphological variables and recurrence. RESULTS: Of 214 patients, 166 were unruptured aneurysms and 109 were treated with coiling. Overall recurrence rate was 13% (28 out of 214 aneurysms) during mean 36.9 ± 18.4-month follow-up. Multivariate logistic regression analysis showed that size greater than 10 mm (OR = 5.651; 95% CI, 1.317-24.242; p = 0.020), smoking (OR = 3.474; 95% CI, 1.342-8.996; p = 0.010), coiling (OR = 2.98; 95% CI, 1.005-8.832; p = 0.049), and anterior direction of aneurysm (OR = 3.77; 95% CI, 1.12-12.66; p = 0.032) were significantly associated with recurrence of AcomA aneurysms after treatment. CONCLUSIONS: The results of this study demonstrated that coiling, large aneurysm, anterior direction, and smoking history may be independent risk factors for the recurrence of AcomA aneurysms. Therefore, careful follow-up should be needed especially in large AcomA aneurysms with anterior direction after coiling.

Morphological and clinical risk factors for the rupture of posterior communicating artery aneurysms: significance of fetal-type posterior cerebral artery.

BACKGROUND: Posterior communicating artery (PcomA) aneurysm can be classified into sidewall or bifurcation types based on the anatomical variation of fetal-type posterior cerebral artery (fPCA). The aims of this study were to investigate the significance of fPCA as an independent risk factor for the rupture of PcomA aneurysm and to evaluate other associated morphological and clinical risk factors. METHODS: We retrospectively reviewed clinical and radiological findings of 255 patients with PcomA aneurysms, which were treated in a single tertiary institute between January 2009 and December 2016. Univariate and multivariate analyses were performed to evaluate the associations between morphological and clinical variables and rupture status. Subgroup analysis was also performed based on the aneurysms with and without fPCA. RESULTS: Fifty-five out of 255 PcomA aneurysms (21.6%) were associated with fPCA. Multivariate logistic regression analysis showed that the superior direction of aneurysm dome (OR 9.106, p = 0.007), the presence of a bleb (OR 4.780, p < 0.001), a high aspect ratio (OR 1.878, p = 0.045), and fPCA (2.101, p = 0.040) were significantly associated with PcomA aneurysm rupture. In the fPCA group, only the presence of a bleb varied significantly between ruptured and unruptured PcomA aneurysms. However, in the non-fPCA group, larger aneurysms, the superior direction of dome, the presence of a bleb, and a high aspect and dome-to-neck ratio were significantly higher in the ruptured aneurysm group than in the unruptured aneurysm group. CONCLUSIONS: The results demonstrate that fPCA may be an independent risk factor for rupture, especially together with the presence of a bleb.

Risk factors for recurrence and retreatment after endovascular treatment of intracranial saccular aneurysm larger than 8 mm.

BACKGROUND: Large intracranial aneurysm is challenging for both surgical and endovascular treatment. High recurrence and retreatment rates are still limitations for endovascular treatment. Analysing risk factors of recurrence after endovascular treatment can be useful for planning future treatment strategies. METHOD: We retrospectively reviewed patients with intracranial saccular aneurysm (≥ 8 mm) who underwent endovascular treatment from 2008 to 2017 at our institution. The demographic features, clinical information and angiographic results were analysed to reveal the risk factors for recurrence and retreatment. Subgroup analysis was performed according to packing density (PD) and stent insertion status. RESULTS: The total recurrence and retreatment rates were 25.7% (44/171) and 10.5% (18/171), respectively. Independent risk factors for recurrence after endovascular treatment were larger aneurysm size (OR 1.32; 95% CI 1.17-1.51; p < 0.001), ruptured status (OR 3.91; 95%CI 1.44-10.90; p = 0.008), initial incomplete occlusion (OR 2.72; 95%CI 1.18-6.41; p = 0.020), and low dome-to-neck ratio (OR 0.61; 95%CI 0.36-0.97; p = 0.047). The recurrence rate for the no-stent with low PD (< 17.5%) group was 50% (14/28); 37.5% (6/16) for stent-assisted coil (SAC) with low PD group, 22.0% (20/91) for no-stent with high PD group and 11.1% (4/36) for SAC with high PD group. CONCLUSION: The independent risk factors for recurrence after endovascular treatment in large (≥ 8 mm) intracranial saccular aneurysm were larger aneurysm size, ruptured status, low dome-to-neck ratio and initial incomplete occlusion state. SAC is a useful method for lowering recurrence after endovascular treatment for relatively large (≥ 8 mm) cerebral aneurysm.

Initial misdiagnosis of aneurysmal subarachnoid hemorrhage: associating factors and its prognosis.

BACKGROUND: Predicting the fate of patients who are given a misdiagnosis of aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. The purpose was to examine factors associated with initial misdiagnosis of aSAH and to investigate the impact of initial misdiagnosis of aSAH on clinical outcomes. METHODS: Between January 2007 and December 2015, medical records and radiographic data for 3118 consecutive patients with aSAH were reviewed. There were 33 patients who had been documented with an initial misdiagnosis of aSAH, and all met the following criteria: (1) failure to correctly identify aSAH upon initial presentation to health care professionals; and 2) subsequently documented aSAH after the initial misdiagnosis. After applying exclusion criteria, remaining 2898 patients were included in the control group. RESULTS: The most common cause of the misdiagnosis is failure to detect aSAH on the initial radiographic imaging. Misdiagnosis group showed lower initial Glasgow Coma Scale, better Hunt-Hess grade, and lower Fisher's grade. Logistic regression analysis showed that initial HH grade (OR, 0.216; p = 0.014), initial Fisher's grade (OR, 0.732; p = 0.036), and hospital type during initial contact (OR, 2.266; p = 0.042) were independently associated with misdiagnosis of aSAH. CONCLUSIONS: Patients with initially good HH grade, lower Fisher's grade, and visiting non-teaching hospital for initial contact were at risk of being misdiagnosed. Misdiagnosis of aSAH in patients with initial good HH grade did affect clinical outcomes negatively. The rebleeding rate was not significantly different between two groups. However, the mortality rate due to rebleeding was higher in MisDx group than in non-MisDx group.

Antiplatelet drug resistance did not increase the thromboembolic events after stent-assisted coiling of unruptured intracranial aneurysm: a single center experience of 99 cases.

We aimed to evaluate the correlation between aspirin or clopidogrel resistance and the risk of thromboembolic events (TEs). Between June 2011 and April 2015, we reviewed clinical and angiographic characteristics, and TEs in the patients undergoing stent-assisted coil embolization (SAC) of unruptured intracranial aneurysms (UIA) at our institution. We did not modify antiplatelet medication in patients with resistance. The relationships between antiplatelet resistance and the occurrence of acute symptomatic TEs, any diffusion-positive lesions, multiple diffusion-positive lesions, or delayed TEs were investigated. Ninety-nine endovascular treatments with stent-assisted technique were performed on 99 patients. The prevalence of aspirin resistance was 12% and clopidogrel resistance was 62.6%. Acute symptomatic TEs were demonstrated in 4 patients (4%). Diffusion-positive lesions were found in 82 patients [82.1%; 36 patients were group I (≤5) and 46 patients were group II (>5)]. Delayed TEs were demonstrated in 10 patients (10.1%). Neither aspirin resistance nor clopidogrel resistance was relevant to the development of acute symptomatic TEs, any diffusion-positive lesions, multiple diffusion-positive lesions, and delayed TEs (P logistic = not available, 0.448, 0.362, and 0.829 for aspirin resistance and P logistic = 0.607, 0.367, 0.278, and 0.245 for clopidogrel resistance). Without modification of antiplatelet medication, we demonstrated 4% of acute symptomatic TEs and 10% of delayed TEs. Aspirin or clopidogrel resistance did not show significant relationships with acute and delayed TEs in the SAC of UIA.

Preventive Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Retrospective-Matched Case-Control Study.

BACKGROUND AND PURPOSE: No evidence is available on the benefits of preventive suboccipital decompressive craniectomy (SDC) for patients with cerebellar infarction. The purpose of this matched case-control study was to investigate whether preventive SDC was associated with good clinical outcomes in patients with cerebellar infarction and to evaluate its predisposing factors. METHODS: Between March 2007 and September 2015, 28 patients underwent preventive SDC. We performed propensity score matching to establish a proper control group among 721 patients with cerebellar infarction during the same period. Group A (n=28) consists of those who underwent preventive SDC, and group B (n=56) consists of those who did not undergo preventive SDC. We analyzed and compared clinical outcomes between groups. RESULTS: Clinical outcomes were better in group A than in group B at discharge (P=0.048) and 12-month follow-up (P=0.030). Group B had more deaths within 12 months than group A (log-rank, P<0.05). Logistic regression analysis showed that preventive SDC (odds ratio, 4.815; P=0.009) and the absence of brain stem infarction (odds ratio, 2.862; P=0.033) were independently associated with favorable outcomes (modified Rankin Scale score of 0-2) at 12-month follow-up. CONCLUSIONS: Favorable clinical outcomes including overall survival can be expected after preventive SDC in patients with a volume ratio between 0.25 and 0.33 and the absence of brain stem infarction. Among these patients, preventive SDC might be better than the best medical treatment alone.

Endovascular treatment of ruptured blood blister-like aneurysms with multiple (≥3) overlapping Enterprise stents and coiling.

BACKGROUND: Blood blister-like aneurysms (BBAs) are difficult to treat both surgically and endovascularly, and the optimal treatment remains controversial. The aim of this study was to evaluate the clinical and angiographic feasibility of multiple overlapping stents (≥3) with coiling for treating BBA. METHODS: A retrospective review from four institutions identified ten patients with ruptured BBAs who were treated with multiple overlapping stents (≥3). We included both the patients who were initially treated with more than three stents and those who eventually had more than three stents as a consequence of retreatment. Angiographic results (Raymond scale), clinical outcomes (mRS) and treatment courses were evaluated. RESULTS: Initially, seven patients were treated with triple stents and three with double stents. Immediate angiographic results revealed that six aneurysms were Raymond grade 1, three were grade 2, and one was grade 3. Complementary treatment was required in four patients. All three patients who were initially treated with double stents required complementary treatment (100 %). One patient required complementary treatment among the seven patients who were initially treated with three stents (14.3 %). The last follow-up angiography (mean, 12.2 ± 14.7 months; range, 1-44 months) revealed grade 1 in all ten patients. Clinical data (mean follow-up period, 18.2 ± 20.1 months; range, 1-62 months) revealed eight patients with a mRS score of 0-2 and two with mRS 3-5. CONCLUSIONS: Even in the era of flow diverter stents, multiple overlapping stents (≥3) with coiling could be a feasible alternative for treating ruptured BBAs. Additional experience and follow-up are needed in a larger series to state the long-term efficacy of this treatment.

Three-year follow-up of blood pressure after treating hypertensive patients with symptomatic carotid artery stenosis.

BACKGROUND: Blood pressure (BP) was reported to decrease significantly after carotid endarterectomy (CEA) or carotid stenting (CAS) up to the 1-year follow-up. We evaluated changes in BP for 3 years after treating hypertensive patients with symptomatic carotid artery stenosis by either CEA or CAS and determined predisposing factors for normotensive BP at the 3-year follow-up. METHODS: A total of 123 hypertensive patients with at least 3 years of clinical and radiographic follow-up after treatment were included in this study and placed in the CEA (n = 65) or CAS group (n = 58). BP changes for 3 years, the number of patients with a normotensive BP (≤120/80 mmHg), and the percentage decrease in BP were evaluated and compared between groups. RESULTS: Compared to pretreatment BP, the CEA group had significantly decreased BP at the 1- and 2-year follow-up (p < 0.05), but not the 3-year follow-up. The CAS group had significantly decreased BP at the 1-, 2-, and 3-year follow-up (p < 0.05). Stenosis location (body lesions over apical lesions; OR = 1.526, 95 % CI, 1.341 to 6.224; p = 0.034) was an independent predisposing factor for normotensive BP at the 3-year follow-up. CONCLUSIONS: For hypertensive patients with symptomatic carotid artery stenosis, BP was lowered at 3 years after both CEA and CAS compared to pretreatment BP. CAS might lower BP better over the long term than did CEA, and hypertensive patients with stenosis at body lesions might be normotensive at 3 years after CEA or CAS.

The Course of Headache in Patients With Moderate-to-Severe Headache Due to Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cross-Sectional Study.

OBJECTIVES: The purpose of this study was to evaluate the course of headache in patients with moderate-to-severe headache due to aneurysmal subarachnoid hemorrhage (aSAH) and to identify its predisposing factors. BACKGROUND: Little is known about the long-term course of headache in patients with aSAH. METHODS: Since September 2009, patients with aSAH have had their headaches prospectively rated using a numeric rating scale (NRS). From this database containing 838 patients, 217 were included and all included patients met the following criteria: (1) presence of ruptured intracranial aneurysms on computed tomography angiography or magnetic resonance angiography; (2) alert consciousness (Glasgow Coma Scale 15); (3) newly onset moderate-to-severe headache (NRS ≥ 4) due to ruptured intracranial aneurysms; and (4) good clinical outcome at discharge (modified Rankin Scale 0, 1, or 2). We observed the changes in NRS scores from initial to 12-month follow-up and identified the predisposing factors of NRS changes. RESULTS: Of the 217 patients, 182 (83.9%) experienced improvement in NRS score ≤ 3 upon discharge. The NRS scores at discharge were significantly lower than those on admission (P < .001). The independent predisposing factors for headache improvement included previous stroke (odds ratio [OR] = 0.141; 95% CI 0.051-0.381; P < .001), previous headache treated with medication (OR = 0.079; 95% CI 0.010-0.518; P = .008), and endovascular treatment (EVT; OR = 2.531; 95% CI 1.141-5.912; P = .026). The NRS scores tended to decrease continuously until the 12-month follow-up. EVT and symptomatic vasospasm were independently associated with a decrease of NRS in the follow-up periods. CONCLUSIONS: The course of headache in patients with aSAH continuously improved during the 12 months of follow-up. Headache improvement might be expected in patients who were treated with EVT and in those who did not have previous stroke or headache.

Non-stenotic intracranial arteries have atherosclerotic changes in acute ischemic stroke patients: a 3T MRI study.

INTRODUCTION: The aim of this study is to evaluate the degree of atherosclerotic changes in intracranial arteries by assessing arterial wall thickness using T1-weighted 3D-turbo spin echo (3D-TSE) and time-of-flight MR angiography (TOF-MRA) in patients with acute ischemic stroke as compared with unaffected controls. METHODS: Thirty-three patients with acute ischemic stroke and 36 control patients were analyzed. Acute ischemic stroke patients were divided according to TOAST classification. At both distal internal carotid arteries and basilar artery without stenosis, TOF-MRA was used to select non-stenotic portion of assessed arteries. 3D-TSE was used to measure the area including the lumen and wall (AreaOuter) and luminal area (AreaInner). The area of the vessel wall (AreaVW) of assessed intracranial arteries and the ratio index (RI) of each patient were determined. RESULTS: AreaInner, AreaOuter, AreaVW, and RI showed good inter-observer reliability and excellent intra-observer reliability. AreaInner did not significantly differ between stroke patients and controls (P = 0.619). However, AreaOuter, AreaVW, and RI were significantly larger in stroke patients (P < 0.001). The correlation coefficient between AreaInner and AreaOuter was higher in the controls (r = 0.918) than in large vessel disease patients (r = 0.778). RI of large vessel disease patients was significantly higher than that of normal control, small vessel disease, and cardioembolic groups. CONCLUSION: In patients with acute ischemic stroke, wall thickening and positive remodeling are evident in non-stenotic intracranial arteries. This change is more definite in stroke subtype that is related to atherosclerosis than that in other subtypes which are not.

Observation of cerebral aneurysm wall thickness using intraoperative microscopy: clinical and morphological analysis of translucent aneurysm.

Intracranial aneurysms suffer various interactions between hemodynamics and pathobiology, and rupture when this balance disrupted. Aneurysm wall morphology is a result of these interactions and reflects the quality of the maturation. However, it is a poorly documented in previous studies. The purpose of this study is to observe aneurysm wall thickness and describe the characteristics of translucent aneurysm by analyzing clinical and morphological parameters. 253 consecutive patients who underwent clipping surgery in a single institute were retrospectively analyzed. Only middle cerebral artery aneurysms (MCA) which exposed most part of the dome during surgery were included. Aneurysms were categorized based on intraoperative video findings. Aneurysms more than 90 % of super-thin dome and any aneurysms with entirely super-thin-walled daughter sac were defined as translucent aneurysm. A total of 110 consecutive patients with 116 unruptured MCA aneurysms were included. Ninety-two aneurysms (79.3 %) were assigned to the not-translucent group and 24 (20.7 %) to the translucent group. The relative proportion of translucent aneurysm in each age group was highest at ages 50-59 years and absent at ages 30-39 and 70-79 years. There was a trend that translucent aneurysms were smaller in size (p = 0.019). Multivariate logistic analysis showed that translucent aneurysm was strongly correlated with height <3 mm (p = 0.003). We demonstrated that the translucent aneurysms were smaller in size and the aneurysm height <3 mm was related. These results may provide information in determining treatment strategies in patients with small size aneurysm.

Treatment outcomes of unruptured intracranial aneurysm; experience of 1,231 consecutive aneurysms.

BACKGROUND: The aim of this study was to review our experience with surgical clipping and endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs), with a special focus on complications. METHODS: We retrospectively analyzed clinical and radiological data from patients who underwent surgery or EVT. Surgery was performed by one neurosurgeon, and EVT was performed by two neurointerventionists according to one hybrid neurosurgeon's decision. Adverse events included the following: (1) decline of the modified Rankin Scale (mRS) score from 1 to 2 and (2) any unexpected neurological deficit or imaging finding affecting the prognosis and/or requiring additional procedures, medication, or prolonged hospital stay. RESULTS: Of the 1231 UIAs in 1124 patients, 625 (50.7 %) aneurysms were treated with surgery, and 606 (49.3 %) aneurysms were treated with EVT. The overall complication rate of UIA treatment was 3.2 %. The rate of adverse events was 2.4 %, and the rates of morbidity and mortality were 0.6 and 0.2 %, respectively. The rates of adverse events, morbidity, and mortality were not significantly different between surgery and EVT. The rate of hospital use for EVT was stationary over the years of the study. Posterior circulation in surgery, large aneurysms (>15 mm) in EVT, and stent- or balloon-assisted procedures in EVT were associated with the occurrence of complications. Poor clinical outcome (mRS of 3-6) was 0.8 % at hospital discharge. CONCLUSIONS: Both UIA treatment modalities decided by one hybrid neurosurgeon showed low complication rates and good clinical outcomes in this study. These results may serve as a point of reference for clinical decision-making for patients with UIA.