Utility of Low-Profile Visualized Intraluminal Support Junior Stent as a Rescue Therapy for Treating Ruptured Intracranial Aneurysms During Complicated Coil Embolization.

BACKGROUND: Coil protrusion occasionally occurs during embolization and can lead to thromboembolic complications. We aimed to evaluate the efficacy of rescue stenting procedures with a low-profile stent system (LVIS Jr.) for treating ruptured intracranial aneurysms during complicated coil embolization. METHODS: We performed a retrospective review to identify patients who had subarachnoid hemorrhage and were treated with LVIS Jr. stent rescue therapy. We enrolled 15 patients with intracranial aneurysms and evaluated the technical success and immediate postprocedural clinical and angiographic outcomes. RESULTS: All 15 patients underwent successful rescue-stent treatment, and no thrombotic or hemorrhagic complications occurred. Immediate postprocedural angiography revealed complete aneurysm occlusion in 40% (6/15) of the patients, whereas 60% (9) of the patients had a residual neck. Among the 12 patients who underwent follow-up angiography, 10 (83.3%) patients had complete aneurysm occlusion, 1 (8.3%) had a residual neck, and 1 (8.3%) showed an increase in the filling status of the aneurysm. There were no thrombotic complications during the follow-up period. CONCLUSIONS: Our findings indicate that LVIS Jr. stent rescue therapy is clinically useful for handling coil protrusion during the embolization of ruptured intracranial aneurysms.

Solitary intraventricular hemorrhage without subarachnoid hemorrhage due to aneurysmal rupture: a case report.

The presence of primary intraventricular hemorrhage (IVH) without vascular lesion is very rare. We experienced solitary IVH without subarachnoid hemorrhage due to aneurysmal rupture in a 58-year-old man treated with coil embolization, which contributed to his good prognosis. After 33 days of hospitalization, he had mild right hemiplegic symptoms remaining, and he was transferred to a rehabilitation institute for further treatment. In cases of primary IVH, computed tomography angiography seems worthwhile for making a differential diagnosis, although the possibility of IVH due to cerebral aneurysmal rupture is very low. Endovascular intervention is a good option for diagnosis and treatment.

Preliminary Study of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms.

BACKGROUND: There have been some reports on the use of intra-arterial tirofiban in ruptured intracranial aneurysms, but few studies have reported on the use of 24 h of intravenous tirofiban infusion in patients with subarachnoid hemorrhage. OBJECTIVE: To present our experience with intravenous tirofiban infusion, in the form of a monotherapy as well as in addition to intra-arterial tirofiban, as a prophylactic, and as a rescue management for thrombus in patients who have undergone embolization with coils for ruptured intracranial aneurysms. METHODS: Between December 2008 and January 2015, we retrospectively reviewed 249 ruptured intracranial aneurysms that were treated with coiling at our institutions. A total of 28 patients harboring 28 ruptured and 3 unruptured intracranial aneurysms underwent intravenous tirofiban infusion during or after coil embolization of an aneurysm. Intra-arterial infusion of tirofiban via a microcatheter was also performed in 26 patients. RESULTS: Thromboembolic formation during the procedure was detected in 25 cases. Intra-arterial tirofiban dissolved the thromboembolus under angiographic control after 10 or more minutes in 19 (76%) of 25 patients. Two intracranial hemorrhagic complications (increase in the extent of hematoma) occurred during the follow-up period. Two cases of other complications occurred: hematuria and perioral bleeding. CONCLUSION: Intravenous tirofiban, as a monotherapy or in addition to intra-arterial tirofiban for thrombotic complications, seems to be useful as a treatment for acute aneurysm. However, alternatives to tirofiban should be considered if an associated hematoma is discovered before a patient receives a tirofiban infusion.

Association of Left Atrial Enlargement with Cortical Infarction in Subjects with Patent Foramen Ovale.

BACKGROUND AND PURPOSE: Left atrial dysfunction has been reported in patients with patent foramen ovale (PFO). Here we investigated the role of left atrial dysfunction in the development of embolic stroke in patients with PFO. METHODS: We identified consecutive patients with embolic stroke of undetermined sources except for PFO (PFO+ESUS). Healthy subjects with PFO served as controls (PFO+control). A stratified analysis by 10-year age group and an age- and sex- matching analysis were performed to compare echocardiographic markers between groups. In the PFO+ESUS group, infarct patterns of PFO-related stroke were determined (cortical vs. cortico-subcortical) and analyzed in correlation with left atrial function parameters. RESULTS: A total of 118 patients and 231 controls were included. The left atrial volume indices (LAVIs) of the PFO+ESUS patients were higher than those of the PFO+controls in age groups of 40-49, 50-59, and 60-69 years (P<0.001, P=0.003, and P=0.027, respectively), and in the age- and sex-matched analysis (P=0.001). In the PFO+ESUS patients, a higher (>28 mL/m2) LAVI was more associated with the cortical infarct pattern (P=0.043 for an acute infarction and P=0.024 for a chronic infarction, both adjusted for age and shunt amount). The degree of right-to-left shunting was not associated with infarct patterns, but with the posterior location of acute infarcts (P=0.028). CONCLUSIONS: Left atrial enlargement was associated with embolic stroke in subjects with PFO. Left atrial physiology might contribute to the development of PFO-related stroke and need to be taken into consideration for optimal prevention of PFO-related stroke.

Pipeline Embolization Device for Large/Giant or Fusiform Aneurysms: An Initial Multi-Center Experience in Korea.

PURPOSE: The purpose of this study was to assess the safety and early outcomes of the Pipeline device for large/giant or fusiform aneurysms. MATERIALS AND METHODS: The Pipeline was implanted in a total of 45 patients (mean age, 58 years; M:F=10:35) with 47 large/giant or fusiform aneurysms. We retrospectively evaluated the characteristics of the treated aneurysms, the periprocedural events, morbidity and mortality, and the early outcomes after Pipeline implantation. RESULTS: The aneurysms were located in the internal carotid artery (ICA) cavernous segment (n=25), ICA intradural segment (n=11), vertebrobasilar trunk (n=8), and middle cerebral artery (n=3). Procedure-related events occurred in 18 cases, consisting of incomplete expansion (n=8), shortening-migration (n=5), transient occlusion of a jailed branch (n=3), and in-stent thrombosis (n=2). Treatment-related morbidity occurred in two patients, but without mortality. Both patients had modified Rankin scale (mRS) scores of 2, but had an improved mRS score of 0 at 1-month follow-up. Of the 19 patients presenting with mass effect, 16 improved but three showed no changes in their presenting symptoms. All patients had excellent outcomes (mRS, 0 or 1) during the follow-up period (median, 6 months; range, 2-30 months). Vascular imaging follow-up (n=31, 65.9%; median, 3 months, range, 1-25 months) showed complete or near occlusion of the aneurysm in 24 patients (77.4%) and decreased sac size in seven patients (22.6%). CONCLUSION: In this initial multicenter study in Korea, the Pipeline seemed to be safe and effective for large/giant or fusiform aneurysms. However, a learning period may be required to alleviate device-related events.

Angiographic findings of in-stent intimal hyperplasia after stent-assisted coil embolization: are they permanent findings?

OBJECTIVE: Stent-assisted coil embolization for the treatment of intracranial aneurysms has been used widely. This study aimed to investigate the effect of stent implantation in the nonatherosclerotic parent artery with cerebral aneurysms. The authors evaluated luminal changes and the related factors following stent-assisted coil embolization. METHODS: This study included 97 patients harboring a total of 99 unruptured aneurysms of the distal internal carotid artery (ICA) who underwent single-stent implantation and more than 1 session of conventional angiography during follow-up (midterm follow-up only, n = 70; midterm and long-term follow-up, n = 29) between January 2009 and April 2014. The luminal narrowing point was measured using a local thickness map (ImageJ plug-in). RESULTS: Stent-assisted coil embolization caused dynamic luminal narrowing of approximately 82% of the parent artery diameter on average after 8 months, which was reversed to 91% after 25 months. In addition, luminal narrowing greater than 40% was noticed in 2 (7%) of the 29 patients who experienced spontaneous reversion without additional management during follow-up. Most luminal narrowing changes seen were diffuse. CONCLUSIONS: Luminal narrowing after aneurysm stent-assisted coil embolization is a dynamic process and appears to be a spontaneously reversible event. Routine management of luminal narrowing may not cause adverse events that require additional treatment.

Adult Moyamoya Disease: A Burden of Intracranial Stenosis in East Asians?

BACKGROUND: Both Moyamoya disease (MMD) and intracranial atherosclerotic stenosis (ICAS) are more prevalent in Asians than in Westerners. We hypothesized that a substantial proportion of patients with adult-onset MMD were misclassified as having ICAS, which may in part explain the high prevalence of intracranial atherosclerotic stroke in Asians. METHOD: We analyzed 352 consecutive patients with ischemic events within the MCA distribution and relevant intracranial arterial stenosis, but no demonstrable carotid or cardiac embolism sources. Conventional angiography was performed in 249 (70.7%) patients, and the remains underwent MRA. The occurrence of the c.14429G>A (p.Arg4810Lys) variant in ring finger protein 213 (RNF213) was analyzed. This gene was recently identified as a susceptibility gene for MMD in East Asians. RESULTS: The p.Arg4810Lys variant was observed in half of patients with intracranial stenosis (176 of 352, 50.0%), in no healthy control subjects (n = 51), and in 3.2% of stroke control subjects (4 of 124 patients with other etiologies). The presence of basal collaterals, bilateral involvement on angiography, and absence of diabetes were independently associated with the presence of the RNF213 variant. Among 131 patients who met all three diagnostic criteria and were diagnosed with MMD, three-fourths (75.6%) had this variant. However, a significant proportion of patients who met two criteria (57.7%), one criterion (28.6%), or no criteria (20.0%) also had this variant. Some of them developed typical angiographic findings of MMD on follow-up angiography. CONCLUSIONS: Careful consideration of MMD is needed when diagnosing ICAS because differential therapeutic strategies are required for these diseases and due to the limitations of the current diagnostic criteria for MMD.

Comparison of Enoxaparin and Warfarin for Secondary Prevention of Cancer-Associated Stroke.

Background. The aim of this study was to determine which anticoagulant is superior for secondary prevention of cancer-associated stroke, using changes in D-dimer levels as a biomarker for recurrent thromboembolic events. Methods. We conducted a retrospective, single center observational study including patients with cancer-associated stroke who were treated with either enoxaparin or warfarin. Blood samples for measuring the initial and follow-up D-dimer levels were collected at admission and a median of 8 days after admission, respectively. Multiple logistic regression analysis was conducted to evaluate the factors that influenced D-dimer levels after treatment. Results. Although the initial D-dimer levels did not differ between the two groups, the follow-up levels were dramatically decreased in patients treated with enoxaparin, while they did not change with use of warfarin (3.88 µg/mL versus 17.42 µg/mL, p = 0.026). On multiple logistic regression analysis, use of warfarin (OR 12.95; p = 0.001) and the presence of systemic metastasis (OR 18.73; p = 0.017) were independently associated with elevated D-dimer levels (≥10 µg/mL) after treatment. Conclusion. In cancer-associated stroke patients, treatment with enoxaparin may be more effective than treatment with warfarin for lowering the D-dimer levels. Future prospective studies are warranted to show that enoxaparin is better than warfarin for secondary prevention in cancer-associated stroke.

Susceptibility Vessel Sign for Intra-arterial Thrombus in Acute Posterior Cerebral Artery Infarction.

BACKGROUND: Susceptibility vessel sign (SVS) on susceptibility-weighted imaging (SWI) has a high sensitivity and specificity to detect the intra-arterial thrombus in anterior circulation stroke. However, SVS has not been evaluated in posterior circulation stroke. METHODS: We reviewed the data from patients with acute posterior cerebral artery (PCA) infarction within 24 hours from stroke onset. To elucidate the usefulness of SVS for the detection of intraluminal thrombus in acute PCA infarction, the frequency and location of SVS were compared with those of occlusion on magnetic resonance angiography (MRA) and hyperdense PCA sign on computed tomography (CT). RESULTS: Twenty-five patients with acute PCA infarction were enrolled in the study. The SVS was found in 92% (23 of 25). MRA showed occlusions in 64% (16 of 25). The SVS was identified in 100% (16 of 16) of patients with occlusion on MRA. Patients without occlusion on MRA also showed the SVS in 78% (7 of 9; P = .0233). The positive SVS without occlusion on MRA was mainly identified in patients with occlusion of distal branches of PCA; P3 segment in 4 and P4 segment in 3. However, the hyperdense PCA sign on CT showed in only 8% (2 of 25) of all patients; its sensitivity was significantly lower than those of the SVS on SWI (P < .001). CONCLUSIONS: SWI is more sensitive than MRA for the detection of intraluminal thrombus, especially peripheral one, in patients with acute ischemic stroke of the PCA territory. In addition, irrespective of thrombus location, SWI is significantly superior to CT in detecting thrombus in acute PCA infarction.

Alternative Detachment Technique for Electrically Detachable Coils: Rescue From an Unintended Complication.

BACKGROUND: Embolization of intracranial aneurysms with the use of detachable coils has become the most widely used therapy for this condition. However, unexpected device failure can lead to critical complications. OBJECTIVE: To describe an alternative detachment technique for various electrically detachable coils (eg, Target of Stryker Neurovascular, Presidio and Microphere of Codman Neurovascular, and MicroPlex and Hydrocoil of MicroVention Terumo) that can be used when standard troubleshooting techniques are not effective and the physician is not able to remove a coil. METHODS: The alternative detachment method involved the restoration of the current pathway with the use of an alligator clip wire and the distal end of a new coil delivery wire of the same type. The detachment mechanism used in this method is the same as that normally used for each system. RESULTS: We found that this alternative maneuver was both feasible and reproducible. Moreover, an electrically detachable coil was successfully detached with the use of this method, especially when detachment failure was the result of distal delivery wire and connector damage. No additional complications were noted. CONCLUSION: An alternative detachment technique involving the reconstruction of the electric circuit could be a safe method of rescue in the potentially risky situation caused by detachment failure during embolization of cerebral aneurysms with electrically detachable coils.

Eligibility and preference of new oral anticoagulants in patients with atrial fibrillation: comparison between patients with versus without stroke.

BACKGROUND AND PURPOSE: Recent randomized clinical trials (RCTs) have evaluated the benefit of new oral anticoagulants in reducing the risk of vascular events and bleeding complications in patients with atrial fibrillation (AF). However, abundant and strict enrollment criteria may limit the validity and applicability of results of RCTs to clinical practice. We estimated the eligibility for participation in RCTs of an unselected group of patients with AF. In addition, we compared features favoring new oral anticoagulant use between patients with versus without stroke. Randomized Evaluation of Long-Term Anticoagulation Therapy METHODS: We applied enrollment criteria of 4 RCTs (RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48) to 695 patients with AF taking warfarin, prospectively and consecutively collected at a university medical center; 500 patients with and 195 patients without stroke. Time in therapeutic range and bleeding risk scheme (anticoagulation and risk factors in atrial fibrillation) were also measured. RESULTS: The proportions of patients fulfilling the trial enrollment criteria varied, ranging from 39% to 72.8%, depending on the differences in indications/contraindications among studies and presence/absence of stroke. The main reasons for ineligibility for RCTs were hemorrhagic risk (anticoagulation and risk factors in atrial fibrillation [ATRIA] score) (10.8%-40.5%) and planned cardioversion (5.1%-7.7%) for nonstroke patients, and a low creatinine clearance (5.6%-9.2%) and higher risk of bleeding (15.2%-20.8%) for patients with stroke. When compared with nonstroke patients, patients with stroke showed a lower time in therapeutic range (54.4±42.8% versus 65.4±34.9%, especially with severe disability) and a high hemorrhagic risk (ATRIA score) (3.06±2.30 versus 2.18±2.16) (P<0.05 in both cases). CONCLUSIONS: Patients enrolled in RCTs are partly representative of patients with AF in clinical practice. When time in therapeutic range and bleeding tendency with warfarin use were considered, the use of new oral anticoagulants was preferred in patients with stroke than in nonstroke patients, but they were more likely to be excluded in RCTs.

Bilateral basal ganglia and unilateral cortical involvement in a diabetic uremic patient.

We report a 57-year-old woman with uremic encephalopathy who presented with dysarthria, dysphagia, hypophonia, and drowsiness. The patient's radiologic findings were rather unusual in that magnetic resonance imaging (MRI) showed abnormal findings involving the basal ganglia bilaterally and frontal cortex unilaterally. After intensified hemodialysis, her symptoms and follow-up brain MRI showed marked improvement. We postulated that the underlying mechanism of uremic encephalopathy based on diffusion-weighted imaging and apparent diffusion coefficient maps.