Successful stent-assisted coil embolization for a recurrent distal posterior inferior cerebellar artery aneurysm: A case presentation.

Background: Distal posterior inferior cerebellar artery (PICA) aneurysms are exceedingly rare intracranial aneurysms. In the acute phase of rupture, interventions commonly involve parent artery occlusion through endovascular treatment or direct trapping surgery. There is no consensus on the best treatment of chronic ruptured or unruptured aneurysms, and stent-assisted coil embolization has not yet been reported in the chronic phase of rupture. Case Description: We present a case of a 46-year-old female with a recurrent distal PICA aneurysm at 18 months following the initial treatment for subarachnoid hemorrhage and was treated by stent-assisted coil embolization with Neuroform Atlas (Stryker, USA), with a favorable outcome. Conclusion: Distal PICA aneurysms occur at the apical curvature, where primitive arterial anastomoses existed during development, pointing to the potential vulnerability of the vessel wall at these sites. Stent-assisted coil embolization has shown effectiveness in preserving the parent artery for chronic ruptured and unruptured distal PICA aneurysms. Nonetheless, the narrowness and tortuosity of the PICA present obstacles to treatment. In our case, the procedure was feasible utilizing the Neuroform Atlas (Stryker, USA) with the Transcell approach. A thorough grasp of the characteristics of stents and their application is pivotal for achieving effective treatment outcomes.

Considerations and Literature Review for Treating Subarachnoid Hemorrhage due to Blood Blister-Like Aneurysms.

Objective: Subarachnoid hemorrhage (SAH) due to blood blister-like aneurysm (BBA) is rare but very risky during treatment. Moreover, there is no established treatment method. In this study, we performed endovascular treatment (EVT) as the first-line treatment on patients with SAH during the subacute phase, and cases were analyzed in this series. Methods: Patients with SAH due to BBA who visited our hospital between April 2021 and March 2023 were enrolled in this study. We waited as long as possible during the acute phase and performed EVT during the subacute phase. We performed stent-assisted coiling (SAC) as the first-line treatment and performed DSA approximately 6 months after treatment. Results: Ninety-six patients with SAH visited our hospital during the study period and six had SAH due to BBAs. There were two males and four females aged 56.2 ± 14.6 years. We performed SAC in five patients, and one died owing to rebleeding before treatment. Two patients received treatments because of rebleeding. One patient died on the day after rebleeding, whereas the other experienced rebleeding and treatments twice and achieved a good outcome. Four patients had good outcomes (modified Rankin scale [mRS]: 0). The surviving patients achieved complete occlusion at follow-up DSA. However, two patients had poor outcomes (mRS: 6). Conclusion: Patients with SAH due to BBA treated in the subacute phase may achieve good outcomes; however, there is a risk of rebleeding during the waiting period, which often causes poor outcomes.

A Case of a Perianeurysmal Cyst Following Stent-Assisted Coil Embolization of an Unruptured Vertebral Artery Aneurysm.

Objective: To report the rare case of a patient with a perianeurysmal cyst following stent-assisted coil embolization of an unruptured vertebral artery aneurysm. Case Presentation: A 63-year-old woman underwent stent-assisted coil embolization for an unruptured vertebral artery aneurysm embedded in the brainstem (pons). Complete occlusion of the aneurysm was successfully achieved. However, subsequent magnetic resonance imaging (MRI) conducted 8 months after the procedure showed perilesional edematous changes surrounding the aneurysm, and at 20 months, cyst formation was observed in the vicinity of the aneurysm. Progressive enlargement of the cyst eventually led to the development of paralysis and dysphagia, necessitating cyst fenestration surgery. Although postoperative reduction in the cyst size was achieved, the patient experienced complications in the form of aspiration pneumonia and bacterial meningitis, which resulted in a life-threatening condition. Conclusion: Aneurysms embedded in the brain parenchyma should be carefully followed up, recognizing the risk of perianeurysmal cyst formation after coil embolization.

Factors predicting recanalization following stent-assisted coil embolization of unruptured intracranial aneurysms with long-term follow-up.

Objective: Stents have been widely used for coil embolization for intracranial aneurysms. Few studies have analyzed the risk factors of recanalization through long-term follow-up observation of only stent-assisted coiling. We analyzed the risk factors for recanalization through long-term observations. Methods: A total number of 399 unruptured aneurysms treated by stent-assisted coil embolization between 2003 and 2016 in a single institution were analyzed for determining the factors associated with recanalization including the patient characteristics, aneurysms, and procedural variables. All patients underwent angiographic follow-up with digital subtraction angiography or magnetic resonance angiography at 24 months or more following the procedure. Results: Recanalization occurred in 8%. The mean time for the recanalization was 21.1 ± 14.0 months (range, 5-51 months). The receiver operating characteristic curve analysis indicated areas under the curve for a maximum aneurysm size of 0.773 (cut-off, 6.415 mm). Multivariate analysis revealed that the maximum aneurysm size and parent artery curvature at which the aneurysm developed were significantly associated with recanalization. In parent artery curvature, the bifurcation group (OR, 9.02; 95% CI, 2.53-32.13; p = 0.001) and the convex group (OR, 3.68; 95% CI, 1.17-11.50; p = 0.025) were independent predictors of recanalization compared with the straight group. Conclusion: The maximum aneurysm size and parent artery curvature are risk factors associated with recanalization in stent-assisted coil embolization.

Balloon-Assisted Stent Visualization: A Simple Technique for Precise Measurement of Previously Placed Stent Diameter.

Stent-assisted coil embolization is effective for treating intracranial aneurysms, improving outcomes and reducing recurrence rates. However, accurately measuring the diameter of a previously placed stent during imaging can be challenging due to coil artifacts. This poses difficulties in determining the coil packing and size of additional stents needed during retreatment. In a reported case, the use of a balloon enabled precise assessment of stent deployment. A 50-year-old male with a history of basilar artery-left superior cerebellar artery aneurysm underwent coil embolization, direct clipping, and stent-assisted coil embolization (SAC) over a span of 14 years. However, the aneurysm showed reenlargement over time. To address the recurrence, a balloon was used to assess the previously placed Neuroform Atlas stent. Additional coils were inserted outside the stent, and a Low-profile Visualized Intraluminal Support Blue stent was added. Postoperatively, there were no new neurological issues, and a follow-up magnetic resonance imaging showed no ischemic lesions . Balloon-assisted stent visualization (BASV) may be a useful method in the retreatment of SAC. It has the potential to provide valuable information for treatment planning.

The white-collar sign after Neuroform Atlas stent-assisted coil embolization of unruptured intracranial aneurysms.

PURPOSE: Although stent-assisted technique is expected to help provide a scaffold for neointima formation at the orifice of the aneurysm, not all aneurysms treated with stent-assisted technique develop complete neointima formation. The white-collar sign (WCS) indicates neointimal tissue formation at the aneurysm neck that prevents aneurysm recanalization. The aim of this study was to explore factors related to WCS appearance after stent-assisted coil embolization of unruptured intracranial aneurysms (UIAs). METHODS: A total of 59 UIAs treated with a Neuroform Atlas stent were retrospectively analyzed. The WCS was identified on digital subtraction angiography (DSA) 1 year after coil embolization. The cohort was divided into WCS-positive and WCS-negative groups, and possible predictors of the WCS were explored using logistic regression analysis. RESULTS: The WCS appeared in 20 aneurysms (33.9%). In the WCS-positive group, neck size was significantly smaller (4.2 (interquartile range (IQR): 3.8-4.6) versus 5.4 (IQR: 4.2-6.8) mm, p = .006), the VER was significantly higher (31.8% (IQR: 28.6%-38.4%) versus 27.6% (IQR: 23.6%-33.8%), p = .02), and the rate of RROC class 1 immediately after treatment was significantly higher (70% vs 20.5%, p < .001) than in the WCS-negative group. On multivariate analysis, neck size (odds ratio (OR): 0.542, 95% confidence interval (CI): 0.308-0.954; p = .03) and RROC class 1 immediately after treatment (OR: 6.99, 95% CI: 1.769-27.55; p = .006) were independent predictors of WCS appearance. CONCLUSIONS: Smaller neck size and complete occlusion immediately after treatment were significant factors related to WCS appearance in stent-assisted coil embolization for UIAs using the Neuroform Atlas stent.

Classification and hemodynamic characteristics of delayed intracerebral hemorrhage following stent-assisted coil embolism in unruptured intracranial aneurysms.

Background and objective: Stent-assisted coil (SAC) embolization is a commonly used endovascular treatment for unruptured intracranial aneurysms (UIAs) but can be associated with symptomatic delayed intracerebral hemorrhage (DICH). Our study aimed to investigate the hemodynamic risk factors contributing to DICH following SAC embolization and to establish a classification for DICH predicated on hemodynamic profiles. Methods: This retrospective study included patients with UIAs located in the internal carotid artery (ICA) treated with SAC embolization at our institution from January 2021 to January 2022. We focused on eight patients who developed postoperative DICH and matched them with sixteen control patients without DICH. Using computational fluid dynamics, we evaluated the hemodynamic changes in distal arteries [terminal ICA, the anterior cerebral artery (ACA), and middle cerebral artery (MCA)] pre-and post-embolization. We distinguished DICH-related arteries from unrelated ones (ACA or MCA) and compared their hemodynamic alterations. An imbalance index, quantifying the differential in flow velocity changes between ACA and MCA post-embolization, was employed to gauge the flow distribution in distal arteries was used to assess distal arterial flow distribution. Results: We identified two types of DICH based on postoperative flow alterations. In type 1, there was a significant lower in the mean velocity increase rate of the DICH-related artery compared to the unrelated artery (-47.25 ± 3.88% vs. 42.85 ± 3.03%; p < 0.001), whereas, in type 2, there was a notable higher (110.58 ± 9.42% vs. 17.60 ± 4.69%; p < 0.001). Both DICH types demonstrated a higher imbalance index than the control group, suggesting an association between altered distal arterial blood flow distribution and DICH occurrence. Conclusion: DICH in SAC-treated UIAs can manifest as either a lower (type 1) or higher (type 2) in the rate of velocity in DICH-related arteries. An imbalance in distal arterial blood flow distribution appears to be a significant factor in DICH development.

Duration of dual-antiplatelet therapy after stent-assisted coil for unruptured intracranial aneurysm: A nationwide cohort study.

BACKGROUND: Stent-assisted coil (SAC) is increasingly used to treat unruptured intracranial aneurysm (UIA). However, the optimal duration of dual-antiplatelet therapy (DAPT) after SAC insertion remains unknown. AIM: To assess the time-dependent effect of DAPT on the risk of ischemic and hemorrhagic complications after SAC. METHODS: This is a retrospective cohort study among patients with UIA treated with SAC using the nationwide health claims database in South Korea between 2009 and 2020. Multivariate Cox regression analysis was used, which included the use of DAPT as a time-dependent variable. The effect of DAPT was investigated for each period of "within 90 days," "91 to 180 days," "181 to 365 days," and "366 to 730 days" after SAC. The primary outcome was a composite of ischemic stroke and major bleeding in each period within two years after SAC. RESULTS: Of the 15,918 patients, mean age at SAC was 57.6 ± 10.8 years, and 3815 (24.0%) were men. The proportion of patients on DAPT was 79.4% at 90 days, 58.3% at 180 days, and 28.9% at 1 year after SAC. During the 2 years after SAC, the primary composite outcome occurred in 356 patients (2.2%). DAPT significantly reduced the primary composite outcome within 90 days after SAC (adjusted hazard ratio (aHR), 0.44; 95% confidence interval (CI), 0.28-0.69; p < 0.001); however, this was not the case after 90 days (all p > 0.05). DAPT reduced ischemic stroke risk within 90 days (aHR, 0.31; 95% CI 0.18-0.54; p < 0.001), and 91 to 180 days after SAC (aHR 0.40; 95% CI 0.18-0.88; p = 0.022); however, after 180 days, DAPT was no longer beneficial. CONCLUSIONS: In patients with UIA treated with SAC, 3 months of DAPT was associated with a decreased risk of the composite of ischemic and hemorrhagic complications.

Stent assisted coil embolization for a dissecting cerebral aneurysm of middle cerebral artery: A case report and the literature review.

Background: Dissecting aneurysms of the middle cerebral artery (MCA) are very rare. We herein report a case of an unruptured dissecting aneurysm of the MCA treated by stent-assisted coil embolization. Case Description: A 65-year-old man with no history of trauma presented with a headache. Time-of-flight imaging revealed a dissecting cerebral aneurysm in the right M1 segment of the MCA, and the aneurysm had increased in size within a short time. We treated the aneurysm by endovascular stenting with coils, and the patient developed no neurological deficits. Conclusion: Because of the potential involvement of the lenticulostriate artery (LSA) in the area of dissection, choosing the best treatment (such as direct surgery or endovascular treatment) may be challenging. Treatment efficacy depends on whether the LSA is affected and on the length of the dissection. In our case, the dissection did not involve the LSA and could therefore be treated by stent-assisted coil embolization.

Stent-Assisted Coil Embolization of Ruptured Aneurysms in the Acute Stage: Advantages and Disadvantages.

Objective: In the acute stage of ruptured cerebral aneurysms, limited devices are available, making the treatment difficult. We aimed to evaluate the outcomes of the coil embolization with stenting for the ruptured cerebral aneurysms in the acute stage. Methods: We assessed 22 cases treated with stenting among 134 of 169 consecutive patients with subarachnoid hemorrhages undergoing an endovascular treatment between April 2014 and December 2021, of which 134 underwent an embolization during the acute stage. A stent was used in the patients wherein the treatment with the balloon-assisted or double catheter technique was difficult. Stenting was performed under the loading of two or more antiplatelet agents. Results: The mean age of the patients was 68.9 years, of which five were male and 14 (63.6%) had severe grade (World Federation of Neurosurgeons grade IV, V). The aneurysm site was the anterior communicating artery in four cases, internal carotid artery in nine, middle cerebral artery in two, vertebrobasilar artery in six, and posterior cerebral artery in one. The aneurysm shape was saccular in 13 cases, dissection in seven, and fusiform in two. Stents were used for wide-neck aneurysms in 12 cases, vascular preservation in seven, and rescue in three. The mean maximum diameter was 9.6 mm. The mean neck size was 6.4 mm. Complete occlusion and neck remnant were found in eight and seven cases, respectively. The perioperative complication rate was 45.5% (thromboembolism in five cases, stent occlusion in two, re-bleeding in two, and cerebral hemorrhage in one). The outcomes included modified Rankin Scale 0-2 in seven cases, 4-5 in five, and 6 in nine. Stent-related death occurred in one case. The rate of morbidity and mortality was 18.2%. Although stents were used in the acute stage of rupture, they were used for the right reasons. However, a high rate of complications occurred: two cases of re-bleeding, in which an incomplete occlusion was a factor. Conclusion: Stent placement in patients with the acute ruptured cerebral aneurysms should be carefully determined and efforts should be made to reduce the embolic and hemorrhagic complications. However, it may be an effective treatment option when other options could be extremely difficult.

How does the recurrence-related morphology characteristics of the Pcom aneurysms correlated with hemodynamics?

Introduction: Posterior communicating artery (Pcom) aneurysm has unique morphological characteristics and a high recurrence risk after coil embolization. This study aimed to evaluate the relationship between the recurrence-related morphology characteristics and hemodynamics. Method: A total of 20 patients with 22 Pcom aneurysms from 2019 to 2022 were retrospectively enrolled. The recurrence-related morphology parameters were measured. The hemodynamic parameters were simulated based on finite element analysis and computational fluid dynamics. The hemodynamic differences before and after treatment caused by different morphological features and the correlation between these parameters were analyzed. Result: Significant greater postoperative inflow rate at the neck (Qinflow), relative Qinflow, inflow concentration index (ICI), and residual flow volume (RFV) were reported in the aneurysms with wide neck (>4 mm). Significant greater postoperative RFV were reported in the aneurysms with large size (>7 mm). Significant greater postoperative Qinflow, relative Qinflow, and ICI were reported in the aneurysms located on the larteral side of the curve. The bending angle of the internal carotid artery at the initiation of Pcom (αICA@PCOM) and neck diameter had moderate positive correlations with Qinflow, relative Qinflow, ICI, and RFV. Conclusion: The morphological factors, including aneurysm size, neck diameter, and αICA@PCOM, are correlated with the recurrence-inducing hemodynamic characteristics even after fully packing. This provides a theoretical basis for evaluating the risk of aneurysm recurrence and a reference for selecting a surgical plan.

Usefulness of PETRA-MRA for Postoperative Follow-Up of Stent-Assisted Coil Embolization of Cerebral Aneurysms.

Objective: Image evaluation after stent-assisted coil embolization (SAC) for a cerebral aneurysm is difficult with conventional MRA or CTA because of metal artifacts. Pointwise encoding time reduction with radial acquisition (PETRA)-MRA is a noninvasive imaging examination that can reduce metal artifacts. This study aimed to examine whether PETRA-MRA can be used as a follow-up imaging after SAC. Methods: Twelve patients (eight women and four men; mean age, 66.9 ± 13.2 years) underwent SAC for unruptured aneurysms and were retrospectively evaluated using time-of-flight (TOF)- and PETRA-MRA data from the same follow-up session. Two neurosurgeons independently compared the aneurysm occlusion status and flow visualization score in the stented parent artery (4-point scale, where 4 points represented excellent visualization) between TOF- and PETRA-MRA images. If DSA was performed within 3 months before or after PETRA-MRA, the aneurysm assessment was compared between MRA and DSA. The interobserver agreement for each MRA was evaluated. Results: Nine of the 12 patients underwent DSA within 3 months before and after TOF- and PETRA-MRA. The aneurysm occlusion status on DSA was more consistent with PETRA-MRA (eight of nine cases) than with TOF-MRA (one of nine cases; P = 0.023). The median visualization score of the stented parent artery was significantly higher for PETRA-MRA (4 [interquartile range {IQR} 3-4]) than for TOF-MRA (1 [IQR 1-1], P = 0.003). The interobserver agreement for evaluation of the aneurysm occlusion status and visualization score of the parent artery for PETRA-MRA were excellent (κ = 0.98 and 0.93, respectively). In one case, PETRA-MRA was able to detect aneurysm recurrence, leading to subsequent retreatment. Conclusion: PETRA-MRA is a noninvasive examination that can be used to evaluate the occlusion status of aneurysms after SAC and visualize the stented parent artery. PETRA-MRA is useful for repeated follow-up examinations after SAC.

Six-month Outcomes after PulseRider- and Conventional Single Stent-assisted Embolization for Bifurcation Aneurysms: A Propensity-adjusted Comparison.

Endovascular treatment of wide-necked bifurcation aneurysms (WNBAs) remains challenging despite using a stent. PulseRider is a novel device specifically designed to treat WNBAs, protecting both daughter branches, but the outcomes have not been compared with conventional single stent-assisted embolization. This study aimed to compare the six-month outcomes of PulseRider and single stent-assisted embolization for intracranial unruptured WNBAs using propensity score adjustment. Between February 2012 and October 2021, 46 unruptured WNBAs (34 basilar and 12 middle cerebral arteries) smaller than 10 mm in diameter were treated with PulseRider-assisted embolization (n = 17) or single stent-assisted embolization (n = 29). The immediate and six-month outcomes were compared using inverse probability of treatment weighting analysis. The immediate adequate occlusion rates for the PulseRider- and single stent-assisted embolization were similar (47.1% vs. 62.1%). At six months, adequate occlusion rates for the two groups were also similar (94.1% vs. 86.2%). However, the complete obliteration rate was significantly high after PulseRider-assisted embolization (88.2% vs. 41.4%, adjusted OR 10.54, 95% CI 1.93-57.63). The angiographical improvement rate was also significantly high after PulseRider-assisted embolization (70.6% vs. 37.9%, adjusted OR 6.06, 95% CI 1.54-23.76). The neurologic thromboembolic complication rate was 0% after PulseRider-assisted embolization and 3.4% after single stent-assisted embolization. PulseRider-assisted embolization of WNBAs smaller than 10 mm in diameter was associated with complete obliteration and angiographical improvement at six months. The unique shape of the PulseRider might contribute to the improved midterm aneurysm occlusion.

Three-dimensional reconstruction imaging by C-arm computed tomography accurately visualizes in-stent neointimal formation in patients with stent-assisted coil embolization.

Background: Stent apposition to the vessel wall and in-stent neointimal formation after stent-assisted coil embolization for intracranial aneurysm are important factors associated with postoperative thromboembolic complications. No assessment methods have been established to depict 3-dimensional (3D) all-round in-stent neointimal formation. Objective: To demonstrate the superiority of Dyna-3D imaging assessment as a modality for all-round ISNF in comparison with conventional two-dimensional digital subtraction angiography (2D-DSA). Methods: Consecutive patients who underwent braided stent-assisted coil embolization for unruptured aneurysm between November 2016 and September 2021 were enrolled. Radiological assessments for stent apposition to the parent vessel after stent deployment and in-stent neointimal formation after 3 months were obtained. Dyna-3D was reconstructed by overlapping a plain image showing stent struts with a rotational DSA image showing the vessel lumen. Reconstructed Dyna-3D images can be rotated to any angle on the screen to evaluate to stent apposition around the vessel and in-stent neointimal formation in 3D, for comparison with 2D-DSA evaluations. Results: Among the 73 patients enrolled, 70 patients (96%) showed complete stent wall apposition on Dyna-3D. Higher intra-rater agreement was confirmed on assessment of in-stent neointimal formation with Dyna-3D (Cohen's κ = 0.811) than with conventional 2D-DSA (Cohen's κ = 0.517). in-stent neointimal formation could not be confirmed on conventional imaging in 9 cases (16%) and on Dyna-3D in 2 cases (3%). The number of in-stent neointimal formations rated as stent wire completely outside the endothelial line was significantly higher with Dyna-3D than with 2D-DSA (p = 0.0001). Conclusion: All-round 3D evaluation by Dyna-3D imaging appears useful for confirming in-stent neointimal formation after braided stent deployment in patients after stent-assisted coil embolization.

Perioperative Antiplatelet Therapy for the Stent-Assisted Coil Embolization: Results of the Questionnaire Survey.

Objective: This study aimed to determine the status of perioperative antiplatelet therapy in stent-assisted coil embolization (SAC) in Japan. Methods: The questionnaire consisted of 13 questions and used Google forms, and was sent to institutions where endovascular specialists were employed. The results were analyzed. Results: The responses from 307 centers indicated that the timing of initiation of antiplatelet therapy was 14 days-1 month before treatment in half of centers, and 7-14 days before treatment in the other half. Platelet function tests were performed at 165 centers (56.2%), of which 136 centers (46.3%) performed these tests for all patients, with the VerifyNow system being the most widely used tool. The duration of postoperative dual antiplatelet therapy was 6, 3, and 12 months in 169 (57.7%), 70 (23.5%), and 42 (14.3%) centers, respectively. The antiplatelet agents used for monotherapy were P2Y12 receptor antagonists or aspirin, with a postoperative period of up to 12 months in 139 centers (47.3%), 24 months in 68 centers (23.1%), and longer than 24 months in 50 centers (17%). Conclusion: Current antiplatelet therapy for SAC in Japan varies widely among institutions. Moreover, each center has its own empirical rules for SAC. Therefore, the findings of this survey suggest the need to establish guidelines for optimal periprocedural antiplatelet therapy for SAC.

Successful hybrid repair of a giant coronary artery aneurysm after previous coronary artery bypass grafting.

A 64-year-old woman had undergone coronary artery bypass grafting (CABG) for right coronary occlusion and the Dor procedure for a left ventricular apex aneurysm 10 years previously. A follow-up computed tomography scan showed the evolution of a giant coronary artery aneurysm (CAA) located on the proximal left circumflex artery (CX). It also revealed a previous saphenous vein graft (SVG) that was patent and located on the midline. Surgical exclusion was regarded as invasive, and isolated percutaneous intervention was unsuitable for a wide-necked CAA. Thus, a hybrid approach was planned. First, CABG (SVG-CX) via left thoracotomy was performed. Following the surgery, stent-assisted coil embolization was performed. A coronary angiogram revealed complete CAA exclusion. Learning objective: Many authors have reported successful repair for coronary artery aneurysm (CAA) with a percutaneous approach or surgery. Although there is no consensus for giant CAA repair, surgical repair including resection, ligation, and coronary artery bypass grafting have been recommended in previous reports. However, every decision should be tailored to suit each condition. In this case with the history of previous cardiovascular surgery, our hybrid approach was thought to be less invasive and feasible than isolated surgical or percutaneous repair.

Case report: Late in-stent thrombosis in a patient with vertebrobasilar dolichoectasia after stent-assisted coil embolization due to the discontinuation of antiplatelet therapy.

Vertebrobasilar dolichoectasia (VBD) is a rare type of cerebrovascular disorder with high rates of morbidity and mortality. Due to the distinct pathological characteristics that fragmented internal elastic lamina and multiple dissections, VBD is difficult to treat and cured. Stent-assisted coil embolization is one of the main treatment modalities for such lesions. However, the duration of healing remained questionable, and there were no effective measures for evaluating endothelial coverage. Before complete endothelial coverage, the discontinuation of antiplatelet therapy may lead to fatal in-stent thrombosis; however, continued antiplatelet therapy could also result in bleeding complications. Thus, we present an autopsy case of late in-stent thrombosis due to the discontinuation of antiplatelet therapy and systematically review the literature to provide a reference for endovascular treatment and antiplatelet regimen of VBD.

Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms.

PURPOSES: Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. METHODS: Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. RESULTS: The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. CONCLUSIONS: Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.

A Case of Horizontal Stent-assisted Coiling for an Aneurysm Arising from Fenestration of the Vertebral Artery: A Technical Case Report.

Horizontal stenting protects the aneurysm neck with stent deployment across the aneurysm neck via the circle of Willis. A saccular aneurysm associated with intracranial arterial fenestration is very rare. Herein, we describe the first case of an unruptured aneurysm related to intracranial arterial fenestration treated with horizontal stenting. A 23-year-old woman presented with a 7-mm broad-necked aneurysm at the fenestration of the right intracranial vertebral artery (VA), which was incidentally found on magnetic resonance imaging. The patient underwent endovascular treatment with horizontal stenting via the vertebrobasilar junction from the contralateral left VA, followed by coil embolization using a jailed microcatheter from the ipsilateral right VA. The procedure was finished with sufficient embolization, and no complications occurred. Horizontal stent delivery via the vertebrobasilar junction for coil embolization of a broad-necked aneurysm arising from the fenestration of the VA is a safe and effective therapeutic strategy.

Case report: isolated trochlear nerve palsy associated with posterior cerebral artery aneurysm.

We describe a case of isolated trochlear nerve palsy caused by an unruptured posterior cerebral artery (PCA) aneurysm in an 82-year-old male who consulted an ophthalmologist after developing diplopia. Magnetic resonance angiography showed a left PCA aneurysm in the ambient cistern, and T2WI showed an aneurysm compressing the left trochlear nerve to the cerebellar tentorium. Digital subtraction angiography revealed that the lesion was located between the left P2a segment. We attributed this isolated trochlear palsy to left PCA unruptured aneurysm pressure. Thus, we performed stent-assisted coil embolization. The aneurysm was obliterated, and trochlear nerve palsy improved completely.