Predictors of Ventriculostomy-Associated Infections: A Retrospective Study of 243 Patients.

OBJECTIVE: Risk factors of ventriculostomy-associated infection (VAI) reported in the literature are variable owing to heterogeneity of external ventricular drainage (EVD) procedures and management. This study aimed to assess the rate of VAI and its risk factors. METHODS: The medical records of patients >18 years old who received EVD catheterizations between January 2015 and December 2020 were retrospectively reviewed. RESULTS: Among 243 patients with 355 catheters, 23 VAIs were identified, yielding VIA rates of 9.5% per patient and 6.5% per catheter. VAI was associated with a longer total EVD duration (29.2 days vs. 15.8 days, P < 0.001), a longer procedural time (72 minutes vs. 41 minutes, P < 0.001), intraoperative ventriculostomy (39.1% vs. 9.1%, P < 0.001), craniotomy (87.0% vs. 60.9%, P = 0.014), and other systemic infections (30.4% vs. 8.2%, P = 0.004). On multivariate analysis, a longer total EVD duration (odds ratio 1.086, P < 0.001), intraoperative ventriculostomy (odds ratio 6.119, P = 0.001), and other systemic infections (odds ratio 4.620, P = 0.015) were associated with VAI. There was no statistical difference between the VAI rates of patients with and without prophylactic EVD exchanges at a mean 12.6 days (7.1% vs. 2.2%, P = 0.401). CONCLUSIONS: Intraoperative ventriculostomy was independently associated with VAI. Prophylactic EVD exchange at 12.6 days did not lower VAI rate.

Recurrence and risk factors of posterior communicating artery aneurysms after endovascular treatment.

BACKGROUND: Endovascular treatment (EVT) of posterior communicating artery aneurysms (PcomA) is challenging because of posterior communicating artery (Pcom) architecture. Additionally, these aneurysms have a high risk of recanalization compared with those located elsewhere. METHODS: The radiographic findings of 171 patients treated with EVT at two institutions were retrospectively reviewed. Univariate and multivariate analyses were performed, and subgroup analyses were performed based on Pcom characteristics. RESULTS: Recanalization of PcomAs occurred in 53 patients (30.9%). Seven patients (4.0%) were retreated (six endovascularly and one with microsurgical clipping). The mean follow-up duration was 27.7 months (range: 3.5-78.6). The maximum diameter (odds ratio [OR] 1.23, P = .006, 95% CI 1.07-1.44), a Raymond-Roy classification of grade II or III (OR 2.26, P = .03, 95% CI 1.08-4.82), and the presence of reinforcement (balloon or/and stent, OR 0.44, P = .03, 95% CI 0.20-0.91) were associated with recanalization using multivariate logistic regression. Significant differences were found in maximum aneurysm diameter (P = .03) between normal- and fetal-type Pcoms on analysis of variance. CONCLUSIONS: The recanalization rate of PcomAs after EVT was 30.9%; the retreatment rate was 4.0%. Maximum diameter, Raymond-Roy classification, and presence of reinforcement were significantly associated with recanalization but not associated with fetal-type Pcom. Aneurysm size was larger in patients with a fetal-type Pcom than in those with a normal Pcom. Pcom size was not related to recanalization rate.

Evaluation of the angiographic outcomes after clipping of intracranial aneurysms: determination of predisposing factors for occurrence of aneurysm remnants.

Objectives: Aneurysm remnants after microsurgical clipping have a risk of regrowth and rupture and have not been validated in the era of three-dimensional angiography. Therefore, this study aimed to evaluate the angiographic outcome using three-dimensional rotational images and determine the predictors for remnants after microsurgical clipping.Methods: Between January 2014 and May 2017, 139 aneurysms in 106 patients who were treated with microsurgical clipping, were eligible for this study. For the determination of aneurysm remnants after microsurgical clipping, the angiographic outcomes were evaluated using follow-up digital subtraction angiography within 7 days for unruptured aneurysms or within 2 weeks for ruptured aneurysms. According to the Sindou classification, the aneurysm remnants were dichotomized, and subgroup analysis was performed to identify the predictors of aneurysm remnants after clipping with various imaging parameters and clinical information.Results: The overall rate of aneurysm remnants was 29.5% (41/139), in which retreatments were needed in 6.5% (9/139). The neck size and maximum diameter of aneurysms were independent predisposing factors for the aneurysm remnants that need retreatment (OR: 2.30; p < 0.001; OR: 1.38; p < 0.001, respectively).Conclusions: This study demonstrated a low incidence of aneurysm remnants after microsurgical clipping which need to retreatment. However, selective postoperative angiography could provide us clear information of surgical result and evidence for long-term follow-up for some aneurysms with larger neck size (>5.7 mm) and maximum diameter (>7.1 mm).

Rete middle cerebral artery anomalies: a unifying name, case series, and literature review.

OBJECTIVE: Rete middle cerebral artery (MCA) is extremely rare and has not been frequently discussed. Rete MCA is a weblike anomaly of the MCA that does not coalesce and forms a prominent, large single branch from the plexiform vessels in the fetal stage. The purpose of this study was to further elucidate the clinical and radiological characteristics of patients with rete MCA. METHODS: A total of 2262 cerebral digital subtraction angiography procedures were performed on 1937 patients at the authors' institution from February 2013 to May 2017. Data analysis included age, sex, clinical symptoms, underlying diseases, coexisting cerebral arterial anomalies, and operative methods and findings. RESULTS: Rete MCAs were found in 13 patients, and the incidence of this anomaly was 0.67% (13 of 1937) in this study. Of the 13 patients, 3 had hemorrhagic strokes, 6 had ischemic strokes, and 4 had no symptoms. Eight patients underwent conservative treatment, and 5 patients underwent surgical treatment. Rete MCA is considered a congenital disease of the cerebral vasculature with the possibility of an acquired abnormality, such as an aneurysm, caused by hemodynamic stress. Although an epidemiological survey of rete MCA was not conducted, it is assumed that rete MCA has a high prevalence in Asia. Ischemic and hemorrhagic stroke events are fairly common in rete MCA. CONCLUSIONS: Clinicians should understand the radiological and clinical features of patients with rete MCA to avoid misdiagnosis and unnecessary treatment. This anomaly should be differentiated from other vascular diseases and patients presenting incidentally should be carefully monitored because of their vulnerability to both hemorrhagic and ischemic strokes.

Radiographic and microsurgical characteristics of proximal (A1) segment aneurysms of the anterior cerebral artery.

BACKGROUND: Proximal A1 segment aneurysms of the anterior cerebral artery (ACA) radiologically resemble internal carotid artery bifurcation (ICBIF) aneurysms because of their anatomical proximity. However, proximal A1 aneurysms exhibit distinguishing features, relative to ICBIF aneurysms. We report our experience of managing proximal A1 aneurysms, then compare them to ICBIF aneurysms. METHODS: Among 2191 aneurysms treated between 2000 and 2016 in a single institution, we retrospectively reviewed 100 cases categorized as ICBIF or A1 aneurysms. We included aneurysms originating from the ICBIF and ACA, proximal to the anterior communicating artery (A1 segment) and divided them into two groups: proximal A1 (n = 32) and ICBIF (n = 50). If any portion of the aneurysm involved the ICBIF, it was classified as ICBIF. Aneurysms wholly located in the A1 segment were classified as proximal A1. Patient factors and angiographic factors were evaluated and compared. RESULTS: The proximal A1 group exhibited differences in aneurysm size (p = 0.013), posterior aneurysm direction (p = 0.001), and A1 perforators as incorporating vessels (p = 0.001). The proximal A1 group tended to rupture more frequently when the aneurysm was smaller (p = 0.046). One case of morbidity occurred in the proximal A1 group. CONCLUSION: Compared to ICBIF aneurysms, proximal A1 aneurysms were smaller and directed posteriorly, with incorporating perforators. Because of these characteristics, it may be difficult to perform clipping with 360° view in microsurgical field. Therefore, when planning to treat proximal A1 aneurysms, different treatment strategies may be necessary, relative to those used for ICBIF aneurysms.

Post-traumatic headache in patients with minimal traumatic intracranial hemorrhage after traumatic brain injury: a retrospective matched case-control study.

BACKGROUND: No evidence is available on the risks of neurologically asymptomatic minimal traumatic intracranial hemorrhage (mTIH) in patients with traumatic brain injury (TBI) for post-traumatic headache (PTH). The purpose of this study was to investigate whether mTIH in patients with TBI was associated with PTH and to evaluate its risk factors. METHODS: Between September 2009 and December 2014, 1484 patients with TBI were treated at our institution, 57 of whom had mTIH after TBI and were include in this study. We performed propensity score matching to establish a control group among the 823 patients with TBI treated during the same period. Patients with TBI rated their headaches prospectively using a numeric rating scale (NRS). We compared NRS scores between mTIH group (n = 57) and non-mTIH group (n = 57) and evaluated risk factors of moderate-to-severe PTH (NRS ≥ 4) at the 12-month follow-up. RESULTS: Moderate-to-severe PTH was reported by 21.9% of patients (29.8% in mTIH group and 14.0% in non-mTIH group B, p = 0.012) at the 12-month follow-up. The mean NRS was higher in mTIH group than in non-mTIH group throughout the follow-up period (95% confidence interval [CI], 0.11 to 1.14; p < 0.05, ANCOVA). Logistic regression analysis showed that post-traumatic seizure (odds ratio, 1.520; 95% CI, 1.128-6.785; p = 0.047) and mTIH (odds ratio, 2.194; 95% CI, 1.285-8.475; p = 0.039) were independently associated with moderate-to-severe PTH at the 12-month follow-up. CONCLUSIONS: Moderate-to-severe PTH can be expected after TBI in patients with mTIH and post-traumatic seizure. PTH occurs more frequently in patients with mTIH than in those without mTIH.

Preventive Effect of Clazosentan against Cerebral Vasospasm after Clipping Surgery for Aneurysmal Subarachnoid Hemorrhage in Japanese and Korean Patients.

BACKGROUND: Clazosentan has been explored worldwide for the prophylaxis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (aSAH). In a dose-finding trial (CONSCIOUS-1) conducted in Israel, Europe, and North America, clazosentan (1, 5, and 15 mg/h) significantly reduced the incidence of cerebral vasospasm, but its efficacy in Japanese and Korean patients was unknown. We conducted a double-blind comparative study to evaluate the occurrence of cerebral vasospasm in Japanese and Korean patients with aSAH. METHODS: The aim of this multicenter, double-blind, randomized, placebo-controlled, dose-finding phase 2 clinical trial, was to evaluate the efficacy, pharmacokinetics, and safety of clazosentan (5 and 10 mg/h) against cerebral vasospasm after clipping surgery in Japanese and Korean patients with aSAH. Patients aged between 20 and 75 years were administered the study drug within 56 h after the aneurysm rupture and up to day 14 post-aSAH. The incidence of vasospasm, defined as an inner artery diameter reduction of major intracranial arteries ≥34% based on catheter angiography, was compared between each treatment group. Cerebral infarction due to vasospasm at 6 weeks and patients' outcome at 3 months was also compared. RESULTS: Among 181 enrolled patients, 158 completed the study and were analyzed. The incidence of vasospasm up to day 14 after aSAH onset was 80.0% in the placebo group (95% CI 67.0-89.6), 38.5% in the 5 mg/h clazosentan group (95% CI 25.3-53.0), and 35.3% in the 10 mg/h clazosentan group (95% CI 22.4-49.9), indicating that the incidence of vasospasm was significantly reduced by clazosentan treatment (placebo vs. 5 mg/h clazosentan, p < 0.0001; placebo vs. 10 mg/h clazosentan, p < 0.0001). The occurrence of cerebral infarction due to vasospasm was 20.8% in the placebo group (95% CI 10.8-34.1), 3.8% in the 5 mg/h clazosentan group (95% CI 0.5-13.2), and 4.2% in the 10 mg/h clazosentan group (95% CI 0.5-14.3), indicating that clazosentan significantly reduced the occurrence of cerebral infarctions caused by vasospasm (placebo vs. 5 mg/h clazosentan, p = 0.0151; placebo vs. 10 mg/h clazosentan, p = 0.0165). The overall incidence of all-cause death and/or vasospasm-related morbidity/mortality was significantly reduced in the 10 mg/h clazosentan group compared with the placebo group (p = 0.0003). CONCLUSION: These results suggest that clazosentan prevents cerebral vasospasm and subsequent cerebral infarction, and could thereby improve outcomes after performing a clipping surgery for aSAH in Japanese and Korean patients.

The course of headache in patients with moderate-to-severe headache due to mild traumatic brain injury: a retrospective cross-sectional study.

BACKGROUND: Little is known about the long-term course of headache in patients with moderate-to-severe headache due to traumatic brain injury (TBI). We evaluated the course of headache in patients with moderate-to-severe headache due to mild TBI. METHODS: Since September 2009, patients with TBI prospectively rated their headache using a numeric rating scale (NRS). From the database containing 935 patients with TBI between September 2009 and December 2013, 259 patients were included according to following criteria: (1) newly onset moderate-to-severe headache (NRS ≥ 4) due to head trauma; (2) age ≥ 15 years; (3) Glasgow Coma Scale ≥ 13; (4) transient loss of consciousness ≤ 30 min; and (5) radiographic evaluation, such as computed tomography or magnetic resonance image. We evaluated initial and follow-up NRS scores to determine the significance of NRS changes and identified risk factors for moderate-to-severe headache at 36-month follow-up. RESULTS: At 36-month follow-up, 225 patients (86.9%) reported improved headache (NRS ≤ 3) while 34 (13.1%) reported no improvement. The NRS scores were significantly decreased within a month (P < 0.001). The follow-up NRS scores at 12-, 24-, and 36-months were lower than those at one month (P < 0.001). Multiple logistic regression analysis showed that post-traumatic seizure (odds ratio, 2.162; 95% CI, 1.095-6.542; P = 0.041) and traumatic intracranial hemorrhage (odds ratio, 2.854; 95% CI, 1.241-10.372; P = 0.024) were independent risk factors for moderate-to-severe headache at 36-month follow-up. CONCLUSIONS: The course of headache in patients with mild TBI continuously improved until 36-month follow-up. However, 13.1% of patients still suffered from moderate-to-severe headache at 36-month follow-up, for whom post-traumatic seizure and traumatic intracranial hemorrhage might be risk factors.

Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage After Clipping of an Unruptured Aneurysm.

BACKGROUND: Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage with an excellent clinical outcome. The cause of PNSAH remains unknown. We report a case of PNSAH in a patient with a history of clipping of an unruptured aneurysm. PNSAH after clipping of an unruptured aneurysm is extremely rare. CASE DESCRIPTION: A 56-year-old man with a history of clipping surgery for an unruptured aneurysm 10 months previously presented with severe headache. No precipitating causes were shown; however, the patient had been engaged in an exertional activity before the event. After conservative treatment, he was discharged home without any complication from the hemorrhage. CONCLUSIONS: On the basis of this case report, clinicians should consider the possibility of PNSAH in a patient who had an unruptured aneurysm previously treated with clipping. Nevertheless, diagnostic workup can be more important than keeping in mind that a subarachnoid hemorrhage might be a PNSAH.

Multidisciplinary management for the treatment of proximal posterior inferior cerebellar artery aneurysms.

OBJECTIVES: Aneurysms of the proximal posterior inferior cerebellar artery (PICA) are rare. The management of proximal PICA aneurysms is challenging with either surgical or endovascular treatment. We report our successful experience of treating PICA aneurysms with a multimodal approach. METHODS: Of 2382 treated aneurysms, 22 aneurysms in 21 patients (male:female 8:13, mean age 48.9 years) were enrolled from March 1998 to December 2015. We treated the aneurysms with a multimodal approach and performed angiography to examine aneurysm regrowth at the 12 months follow-up. Clinical outcomes were evaluated based on the modified Rankin Score (mRS) at the time of discharge and 12 months postoperatively. The treatment modality was mainly dependent on the character of the aneurysms and the clinical presentation of the patients. RESULTS: Microsurgery was performed in seven patients, which entailed proximal occlusion with distal revascularization in two and microsurgical clipping in five. Endovascular treatment was performed in 10 patients because of a serious medical condition, or vertebral artery (VA)/ or PICA tortuosity. Four were treated with coil embolization and six with stent or balloon-assisted coil embolization. Combined surgical and endovascular treatment was applied in four patients. They were treated with distal revascularization followed by occlusion with coils of the aneurysm-incorporated PICA. All patients achieved complete cure of the PICA aneurysms without complications except for one case of cerebrospinal fluid (CSF) leakage. DISCUSSION: Endovascular and microvascular neurosurgeons should work closely in managing these challenging problems. Neurosurgeons should consider multimodal treatment in these cases including trapping after occipital artery (OA)-PICA bypass.

Borderline basal ganglia hemorrhage volume: patient selection for good clinical outcome after stereotactic catheter drainage.

OBJECTIVE The purpose of this study was to determine predisposing factors for good clinical outcome in patients with spontaneous basal ganglia hemorrhage with borderline volumes (defined as a hematoma volume between 20 and 50 cm3) who had undergone treatment by stereotactic catheter drainage. METHODS From the 298 patients whose information had been prospectively collected in the institutional database between January 2010 and December 2013, 93 patients were included in this retrospective study and divided into 2 groups: best medical treatment alone (Group A, n = 44) and best medical treatment plus catheterization (Group B, n = 49). All patients met the following criteria: 1) a diagnosis of spontaneous basal ganglia hemorrhage, and 2) a borderline hematoma volume (20 to 50 cm3). Postoperative modified Rankin Scale (mRS) scores and recovery of motor weakness were compared between the 2 groups, and predisposing factors for good clinical outcome were evaluated. RESULTS Patients in Group B showed earlier recovery of motor weakness and improved mRS scores than patients in Group A. The final mRS score at 12 months was better in Group B than in Group A (p = 0.006). Predisposing factors for a good clinical outcome were a hematoma volume < 30 cm3 (OR 6.158, 95% CI 1.221-31.053, p = 0.028), an initial Glasgow Coma Scale (GCS) score ≥ 13 (OR 6.331, 95% CI 1.129-35.507, p = 0.036), the absence of internal capsule involvement (OR 4.680, 95% CI 1.152-19.010, p = 0.031), and catheterization (OR 13.376, 95% CI 2.423-73.842, p = 0.003) based on logistic regression analysis. CONCLUSIONS Good clinical outcome can be expected after stereotactic catheter drainage in patients with a hematoma volume between 20 and 30 cm3, an initial GCS score ≥ 13, and the absence of internal capsule involvement. Among these patients, stereotactic catheter drainage may have a beneficial effect on early recovery of motor weakness and functional outcome, indicating that lateral-type basal ganglia hematoma compression not involving the internal capsule may be better treated using stereotactic catheter drainage than treated medically.

Effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory: a prospective cohort study.

BACKGROUND: We prospectively evaluated the effects of preventive surgery for unruptured intracranial aneurysms on attention, executive function, learning and memory. METHODS: Between March 2012 and June 2013, 56 patients were recruited for this study. Fifty-one patients met the inclusion criteria and were enrolled. Inclusion criteria were as follows: (1) age ≤65 years and (2) planned microsurgery or endovascular surgery for unruptured intracranial aneurysm. Exclusion criteria were as follows: (1) preoperative intelligence quotient <80 (n = 3); (2) initial modified Rankin scale ≥1 (n = 1); (3) loss to follow-up (n = 1). An auditory controlled continuous performance test (ACCPT), word-color test (WCT) and verbal learning test (VLT) were performed before and after (6 months) preventive surgery. RESULTS: ACCPT (attention), WCT (executive function) and VLT (learning and memory) scores did not change significantly between the pre- and postoperative evaluations. The ACCPT, WCT, total VLT scores (verbal learning) and delayed VLT scores (memory) did not differ significantly between patients undergoing microsurgery and those undergoing endovascular surgery. However, ACCPT, WCT and delayed VLT scores decreased postoperatively in patients with leukoaraiosis on preoperative FLAIR images (OR 9.899, p = 0.041; OR 11.421, p = 0.006; OR 2.952, p = 0.024, respectively). CONCLUSIONS: Preventive surgery for unruptured intracranial aneurysms did not affect attention, executive function, learning or memory. However, patients with leukoaraiosis on FLAIR images might be prone to deficits in attention, executive function and memory postoperatively, whereas learning might not be affected.

Headache After Cerebral Angiography: Frequency, Predisposing Factors, and Predictors of Recovery.

BACKGROUND AND PURPOSE: Headache after cerebral angiography is frequent but has received little attention. The purpose of this study was to evaluate the incidence and risk factors of headache after cerebral angiography. This study also addressed the predisposing factors that facilitate headache recovery. METHODS: A total of 327 patients were included. The patients were ≥20 years old, had alert consciousness, and had received digital subtraction cerebral angiography (DSA) for cerebrovascular diseases or intracranial tumors. All the patients stayed in the hospital for ≥24 hours after DSA. Among them, 277 patients who did not complain of headache on admission were analyzed for headache risk factors and incidence after DSA. RESULTS: Headache developed after DSA in 154 (55.6%) patients. Headache occurrence was independently associated with history of headache (odds ratio [OR] 4.625; P = .014), the indication for DSA (OR 4.141; P < .001), and the education level (OR 1.366; P = .036). Of the 154 patients who experienced headache after DSA, 120 (77.9%) patients recovered within 24 hours. Both diabetes (OR 2.469; P = .043) and the indication for DSA (OR 2.276; P = .028) were independent predisposing factors for headache recovery. CONCLUSIONS: The incidence of headache after DSA was 55.6%. Patients with a previous history of headaches, cerebrovascular disease, or a college education may have a higher risk of developing post-DSA headaches than do those without such history. Headache recovery may be associated with a patient history of diabetes or cerebrovascular disease.

Deep Intracerebral Hemorrhage Caused by Rupture of Distal Lenticulostriate Artery Aneurysm : A Report of Two Cases and a Literature Review.

Intracerebral hemorrhage (ICH) is common among various types of storkes; however, it is rare in young patients and patients who do not have any risk factors. In such cases, ICH is generally caused by vascular malformations, tumors, vasculitis, or drug abuse. Basal ganglia ICH is rarely related with distal lenticulostriate artery (LSA) aneurysm. Since the 1960s, a total of 29 distal LSA aneurysm cases causing ICH have been reported in the English literature. Despite of the small number of cases, various treatment methods have been attempted : surgical clipping, endovascular treatment, conservative treatment, superficial temporal artery-middle cerebral artery anastomosis, and gamma-knife radiosurgery. Here, we report two additional cases and review the literature. Thereupon, we discerned that young patients with deep ICH are in need of conventional cerebral angiography. Moreover, initial conservative treatment with follow-up cerebral angiography might be a good treatment option except for cases with a large amount of hematoma that necessitates emergency evacuation. If the LSA aneurysm still persists or enlarges on follow-up angiography, it should be treated surgically or endovascularly.

Effects of Prophylactic Antiepileptic Drugs on Clinical Outcomes in Patients with a Good Clinical Grade Suffering from Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Routine use of prophylactic antiepileptic drugs (AED) has been debated. We retrospectively evaluated the effects of prophylactic AED on clinical outcomes in patients with a good clinical grade suffering from aneurysmal subarachnoid hemorrhage (aSAH). MATERIALS AND METHODS: Between September 2012 and December 2014, 84 patients who met the following criteria were included: (1) presence of a ruptured aneurysm; (2) Hunt-Hess grade 1, 2, or 3; and (3) without seizure presentation. Patients were divided into two groups; the AED group (n = 44) and the no AED group (n = 40). Clinical data and outcomes were compared between the two groups. RESULTS: Prophylactic AEDs were used more frequently in patients who underwent microsurgery (84.1%) compared to those who underwent endovascular surgery (15.9%, p < 0.001). Regardless of prophylactic AED use, seizure episodes were not observed during the six-month follow-up period. No statistical difference in clinical outcomes at discharge (p = 0.607) and after six months of follow-up (p = 0.178) were between the two groups. After six months, however, favorable outcomes in the no AED group tended to increase and poor outcomes tended to decrease. CONCLUSION: No difference in the clinical outcomes and systemic complications at discharge and after six months of follow-up was observed between the two groups. However, favorable outcomes in the no AED group showed a slight increase after six months. These findings suggest that discontinuation of the current practice of using prophylactic AED might be recommended in patients with a good clinical grade.

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.

Clinical Risk Factors Affecting Procedure-Related Major Neurological Complications in Unruptured Intracranial Aneurysms.

PURPOSE: The operative risk and natural history rupture risk for the treatment of unruptured intracranial aneurysms (UIAs) should be evaluated. The purpose of this study was to report our experience with treating UIAs and to outline clinical risk factors associated with procedure-related major neurological complications. MATERIALS AND METHODS: We treated 1158 UIAs in 998 patients over the last 14 years. All patients underwent operation performed by a single microvascular surgeon and two interventionists at a single institution. Patient factors, aneurysm factors, and clinical outcomes were analyzed in relation to procedure-related complications. RESULTS: The total complication rate was 22 (2.2%) out of 998 patients. Among them, complications developed in 14 (2.3%) out of 612 patients who underwent microsurgery and in 8 (2.1%) out of 386 patients who underwent endovascular procedures. One patient died due to intraoperative rupture during an endovascular procedure. The procedure-related complication was highly correlated with age (p=0.004), hypertension (p=0.002), and history of ischemic stroke (p<0.001) in univariate analysis. The multivariate analysis revealed previous history of ischemic stroke (p=0.001) to be strongly correlated with procedure-related complications. CONCLUSION: A history of ischemic stroke was strongly correlated with procedure-related major neurological complications when treating UIAs. Accordingly, patients with UIAs who have a previous history of ischemic stroke might be at risk of procedure-related major neurological complications.

Microsurgical clipping of unruptured middle cerebral artery bifurcation aneurysms: incidence of and risk factors for procedure-related complications.

OBJECTIVE: To report our experiences in microsurgical clipping of unruptured middle cerebral artery (MCA) bifurcation aneurysms and to evaluate the incidence of and risk factors for procedure-related complications. METHODS: The study comprised 416 patients treated between March 2003 and February 2014. All patients met the following criteria: 1) microsurgical clipping of an unruptured MCA bifurcation aneurysm was performed, and 2) clinical and radiographic follow-up data were available including preoperative digital subtraction angiography. The incidence of and risk factors for procedure-related complications were retrospectively evaluated. RESULTS: Procedure-related complications occurred in 15 (3.6%) patients, including asymptomatic complications in 10 (2.4%) patients and symptomatic complications in 5 (1.2%) patients. Multivariate logistic regression analysis showed that posteroinferior projection of the aneurysm (odds ratio = 2.814, 95% confidence interval = 0.995-6.471, P = 0.042), distance between the internal carotid artery bifurcation and the MCA bifurcation (Dt) in a linear line (odds ratio = 1.813, 95% confidence interval = 0.808-6.173, P = 0.043), and horizontal angle between the vertical line to the base of the skull and Dt (odds ratio = 2.046, 95% confidence interval = 1.048-10.822, P = 0.048) were independent risk factors for procedure-related complications. CONCLUSIONS: When performing clipping of unruptured MCA bifurcation aneurysms, the procedure-related complication rate was 3.6%. Patients with MCA bifurcation aneurysms with posteroinferior projection, shorter Dt, and larger horizontal angle may be at a higher risk of procedure-related complications when performing microsurgical clipping.

Incidence and risk factors for rebleeding during cerebral angiography for ruptured intracranial aneurysms.

PURPOSE: The purpose was to evaluate the incidence and risk factors for rebleeding during cerebral angiography in ruptured intracranial aneurysms. MATERIALS AND METHODS: Among 1896 patients with ruptured intracranial aneurysms between September 2006 and December 2013, a total of 11 patients who experienced rebleeding of the ruptured aneurysms during digital subtraction angiography (DSA) were recruited in this study. RESULTS: There were 184 patients (9.7%) who had suffered rebleeding prior to the securing procedure. Among them, 11 patients experienced rebleeding during DSA and other 173 patients at a time other than DSA. Eight (72.7%) of the 11 patients experienced rebleeding during three-dimensional rotational angiography (3DRA). The incidence of rebleeding during DSA was 0.6% in patients with ruptured intracranial aneurysms. Multivariate logistic regression analysis showed that aneurysm location in anterior circulation [odds ratio=14.286; 95% confidence interval (CI), 1.877 to 250.0; p=0.048] and higher aspect ratio (odds ratio=3.040; 95% CI, 1.896 to 10.309; p=0.041) remained independent risk factors for rebleeding during DSA. CONCLUSION: Ruptured aneurysms located in anterior circulation with a high aspect ratio might have the risk of rebleeding during DSA, especially during 3DRA.

Preliminary experience with self-expanding closed-cell stent placement in small arteries less than 2 mm in diameter for the treatment of intracranial aneurysms.

OBJECT: The purpose of this study was to report the authors' preliminary experience using self-expanding closed-cell stents deployed in small arteries (< 2 mm in diameter) to treat intracranial aneurysms. METHODS: A total of 31 patients were studied. All subjects met the following criteria: 1) they received an Enterprise stent for treatment of a wide-necked aneurysm or a dissecting aneurysm or as part of a stent-salvage procedure; and 2) they had an Enterprise stent deployed in a small parent artery (< 2 mm in diameter) that had no atherosclerotic stenosis. Procedure-related complications and follow-up sizes of the parent arteries were evaluated for safety and patency. RESULTS: There were 16 ruptured aneurysms and 15 unruptured aneurysms. Three (9.7%) of the 31 patients experienced procedure-related complications, and they all were asymptomatic. Follow-up angiography was performed in 27 patients (87.1%) (at a mean 15.5 months after surgery). Parent arteries with 2 acute angles (n = 4) were occluded in 3 cases (75.0%), and those with no acute angles (n = 13) or 1 acute angle (n = 6) showed 100% patency on follow-up angiography. There was a significant difference between the follow-up sizes (mean 1.72 ± 0.30 mm) of parent arteries and their sizes (mean 1.59 ± 0.26 mm) before treatment (95% CI - 0.254 to - 0.009 mm; p = 0.037, paired-samples t-test). CONCLUSIONS: In the current series the deployment of self-expanding closed-cell stents in small arteries was safe and resulted in good patency, especially when the stents were deployed in segments of the parent artery with no acute angles or only 1 acute angle.