Sclerotherapy with intralesional bleomycin injection under guidance of multi-slice CT for retrobulbar orbital low-flow vascular lesions-single-center experience.

OBJECTIVE: This study investigated the safety and efficacy of sclerotherapy with intralesional bleomycin injection (IBI) for retrobulbar orbital low-flow vascular lesions under multi-slice computed tomography (CT) guidance. METHODS: Between January 2010 and September 2021, consecutive patients with retrobulbar orbital low-flow vascular lesions who underwent CT-guided IBI at a tertiary centre in Taiwan were enrolled. Their medical records and imaging data were retrospectively collected. RESULTS: This study enrolled 13 patients (7 male and 6 female patients; age range: 1-57 years; mean age: 25.9 years) with lymphatic malformation (LM, n = 4), venolymphatic malformation (n = 1), and venous malformation (VM, n = 8). The overall radiological response rate was 76.9% (10 of 13); the radiological response rate was 75.0% in the VM group (6 of 8) and 75.0% in the LM group (3 of 4). Moreover, 3 patients (23.1%) had minor complications and 1 (7.7%) had a major complication. The mean clinical and radiological follow-up was 8.3 months and no recurrence or progression was reported. CONCLUSION: CT-guided IBI is an effective and relatively safe minimally invasive treatment for retrobulbar orbital low-flow vascular lesions, with an overall radiological response rate of 76.9% in a mean of 1.5 sessions and a low complication rate. ADVANCES IN KNOWLEDGE: CT-guided sclerotherapy with IBI is a relatively safe, effective, and feasible alternative treatment option for retrobulbar orbital low-flow vascular lesions.

Demands for medical imaging and workforce Size: A nationwide population-based Study, 2000-2020.

PURPOSE: The aim of this study was to investigate associations between workforce and workload among radiologists in Taiwan. MATERIALS AND METHODS: Data for the period 2000-2020 describing the demand for imaging services and radiologists have been obtained from databases and statistical reports of the Ministry of Health and Welfare. The future demand for radiologists was based on Taiwanese people aged 40 and over. RESULTS: The workforce of Taiwan's radiologists has increased by 6 % annually over the past 20 years (from 450 to 993), performing 2125, 3202 and 3620 monthly examinations (mainly conventional radiography and CT) in medical centers, regional hospitals and district hospitals. Between 2000 and 2020, the use of CT and MRI increased by more than 3.5 times. Demand for interventional radiology also increased by 1.77 times, 2.25 times, and 5 times, respectively. To maintain this volume of services in 2040, at least 1168 radiologists are needed, about 1.18 times more in 2020. CONCLUSION: Taiwan has 2.4 to 2.9 times fewer radiologists than the United States and 3 times fewer than Europe, while the annual workload is approximately 2 to 3.4 times greater than that of the United States and 1.4 to 2.5 times greater than that of the United Kingdom. This report may serve as a reference for policy makers who address the challenges of the growing workload among radiologists in countries of similar situations.

Comparing transvenous coiling and transarterial embolization with Onyx/NBCA for cavernous sinus dural arteriovenous fistulas: a retrospective study in a single center.

BACKGROUND: Endovascular management is the gold standard for cavernous sinus dural arteriovenous fistulas (CS-dAVFs) in patients with signs of ophthalmoplegia, visual defects, or intolerable clinical symptoms. Although the efficacy of embolization has been confirmed, complications during post-endovascular management have not been compared in a more extensive CS-dAVFs case series. Therefore, we compared the effectiveness and peri-procedural complications of transvenous coiling with those of transarterial embolization (TAE) using liquid embolic agents. MATERIAL AND METHODS: We reviewed 71 patients with CS-dAVFs in one medical center from 2005/7 to 2016/7. We performed seventy-seven procedures on 71 patients, including six recurrent cases. We compared the efficacy and peri-procedural complications of transvenous coiling and TAE. RESULTS: The complete occlusion rate for transvenous coiling was 79.2%, and that for TAE was 75.0%. Findings revealed (1) similar ophthalmoplegia complication rates (p = 0.744); (2) more frequent and permanent CN5 or CN7 neuropathy with liquid embolic agent use (p = 0.031 and 0.028, respectively); and (3) a higher risk of infarction or ICH (p =0.002 and 0.028, respectively) in response to aggressive TAE. CONCLUSION: Transvenous cavernous sinus coiling resulted in a similar occlusion rate and lower complication risk than transarterial Onyx/n-butyl cyanoacrylate (NBCA). We can access via an occluded inferior petrosal sinus (even contralateral), and direct transorbital puncture was a safe alternative. TAE with Onyx/NBCA was helpful in cases of oligo-feeders, but multidisciplinary treatment and multi-session TAE were usually needed for patients with multiple feeders and complex fistulas.

Long-term outcomes of coils embolization for superior hypophyseal artery aneurysms.

Objective: Superior hypophyseal artery (SHA) aneurysms are intradural, and their rupture can result in subarachnoid hemorrhage. Considering the related surgical difficulty and anatomical restrictions, endovascular treatment (EVT) is considered the most favorable modality for SHA aneurysms; however, the long-term outcomes of EVT have rarely been reported. The study assessed the incidence of and risk factors for recurrence of SHA aneurysms after EVT as well as the correlation factors for SHA aneurysm rupture. Methods: We included 112 patients with SHA aneurysms treated with EVT at our facility between 2009 and 2020. Here, EVT included non-stent-assisted (simple or balloon-assisted) or stent-assisted coiling. Flow diverter was not included because it was barely used due to its high cost under our national insurance's limitation, and a high proportion of ruptured aneurysms in our series. Univariate and multivariate logistic regression was performed to evaluate the correlation factors for SHA aneurysm rupture, along with the incidence of and risk factors for post-EVT SHA aneurysm recurrence and re-treatment. Results: In our patients, the mean angiographic follow-up period was 3.12 years. The presence of type IA or IB cavernous internal carotid artery (cICA) was strongly correlated with SHA aneurysm rupture. Recurrence occurred in 17 (13.4%) patients, of which only 1 (1.4%) patient had received stent-assisted coiling. All cases of recurrence were observed within 2 years after EVT. The multivariate logistic regression results showed that ruptured aneurysm and non-stent-assisted coiling were independent risk factors for aneurysm recurrence. Of the 17 cases of aneurysm recurrence, 9 (52.9%) received re-treatment. Moreover, aneurysm rupture was the only factor significantly correlated with re-treatment in multivariate logistic regression. No re-recurrence was observed when a recurrent aneurysm was treated with stent-assisted coiling. Conclusion: Type I cICA was common factor for aneurysm rupture. Although flow-diverter treatment serves as another suitable technique that was not compared with, coils embolization was effective treatment modality for SHA aneurysms, leading to low recurrence and complication rates, especially with stent use. All cases of recurrence occurred within 2 years after EVT; they were strongly associated with prior aneurysm rupture. Further stent-assisted coiling was noticed to prevent re-recurrence.

Comparison of neostigmine and sugammadex for hemodynamic parameters in neurointerventional anesthesia.

Introduction: Hemodynamic stability is important during neurointerventional procedures. However, ICP or blood pressure may increase due to endotracheal extubation. The aim of this study was to compare the hemodynamic effects of sugammadex and neostigmine with atropine in neurointerventional procedures during emergence from anesthesia. Methods: Patients undergoing neurointerventional procedures were allocated to the sugammadex group (Group S) and the neostigmine group (Group N). Group S was administered IV 2 mg/kg sugammadex when a train-of-four (TOF) count of 2 was present, and Group N was administered neostigmine 50 mcg/kg with atropine 0.2 mg/kg at a TOF count of 2. We recorded heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure (MAP), and peripheral arterial oxygen saturation during administration of the reverse agent and at 2, 5, 10, 15, 30, 120 min, and 24 h thereafter. The primary outcome was blood pressure and heart rate change after the reversal agent was given. The secondary outcomes were systolic blood pressure variability standard deviation (a measure of the amount of variation or dispersion of a set of values), systolic blood pressure variability-successive variation (square root of the average squared difference between successive blood pressure measurements), nicardipine use, time-to-TOF ratio ≥0.9 after the administration of reversal agent, and time from the administration of the reversal agent to tracheal extubation. Results: A total of 31 patients were randomized to sugammadex, and 30 patients were randomized to neostigmine. Except for anesthesia time, there were no significant differences in any of the clinical characteristics between the two groups. The results demonstrated that the increase in MAP from period A to B was significantly greater in Group N than in Group S (regression coefficient = -10, 95% confidence interval = -17.3 to -2.7, P = 0.007). The MAP level was significantly increased from period A to B in the neostigmine group (95.1 vs. 102.4 mm Hg, P = 0.015), but it was not altered in Group S. In contrast, the change in HR from periods A to B was not significantly different between groups. Conclusion: We suggest that sugammadex is a better option than neostigmine in interventional neuroradiological procedures due to the shorter extubation time and more stable hemodynamic change during emergence.

Transperineal Targeted Microwave Ablation (TMA) of localized prostate cancer guided by MRI-Ultrasound fusion and organ-based tracking: a pilot study.

BACKGROUND: To investigate the efficacy of transperineal targeted microwave ablation (TMA) in treating localized prostate cancer (PCa). METHODS: This is a single-centre prospective phase 2 trial recruiting men with low to intermediate-risk localized PCa to undergo transperineal TMA. TMA was performed with MRI-Ultrasound fusion guidance and organ-based tracking. A per-protocol 6-month MRI and biopsy were performed for all patients. The primary outcome was any cancer detected on biopsy of each ablated area. Secondary outcomes included per-patient analysis of positive biopsy, complications, urinary symptom score, erectile function and quality of life (QOL) scores. RESULTS: In the first 15 men, 23 areas were being treated. The median age was 70 years, number of TMA ablations were 5 (range 2-8), and the total ablation time and operating time was 22 (IQR 14-28) and 75 (IQR 65-85) minutes, respectively. PSA level dropped from a median of 7.7 to 2.4 ng/mL. For the primary outcome, 91.3% (21/23) ablated area had no cancer in 6-month biopsy. In per-patient analysis, 33.3% (5/15) had in or out-of-field positive biopsy at 6 months. Among these five cases, four of them were amenable to active surveillance and 1 (6.7%) case with out-of-field ISUP grade group 2 cancer received radiotherapy. The urinary symptoms, uroflowmetry, erectile function, and QOL scores had no significant difference at 6 months. One patient (out of five patients with normal erection) in the cohort complained of significant worsening of erectile function after TMA. Grade 1 complications including hematuria (33.3%), dysuria (6.7%), and perineal discomfort (13.4%) were observed. CONCLUSIONS: In this first pilot study, transperineal TMA guided by MRI-Ultrasound fusion guidance and organ-based tracking was shown to be effective, safe, and easily applicable in men with localized PCa.

Deep Learning-Based Brain Computed Tomography Image Classification with Hyperparameter Optimization through Transfer Learning for Stroke.

Brain computed tomography (CT) is commonly used for evaluating the cerebral condition, but immediately and accurately interpreting emergent brain CT images is tedious, even for skilled neuroradiologists. Deep learning networks are commonly employed for medical image analysis because they enable efficient computer-aided diagnosis. This study proposed the use of convolutional neural network (CNN)-based deep learning models for efficient classification of strokes based on unenhanced brain CT image findings into normal, hemorrhage, infarction, and other categories. The included CNN models were CNN-2, VGG-16, and ResNet-50, all of which were pretrained through transfer learning with various data sizes, mini-batch sizes, and optimizers. Their performance in classifying unenhanced brain CT images was tested thereafter. This performance was then compared with the outcomes in other studies on deep learning-based hemorrhagic or ischemic stroke diagnoses. The results revealed that among our CNN-2, VGG-16, and ResNet-50 analyzed by considering several hyperparameters and environments, the CNN-2 and ResNet-50 outperformed the VGG-16, with an accuracy of 0.9872; however, ResNet-50 required a longer time to present the outcome than did the other networks. Moreover, our models performed much better than those reported previously. In conclusion, after appropriate hyperparameter optimization, our deep learning-based models can be applied to clinical scenarios where neurologist or radiologist may need to verify whether their patients have a hemorrhage stroke, an infarction, and any other symptom.

Concomitant spinal dural arteriovenous fistula and nodular fasciitis in an adolescent: case report.

BACKGROUND: Spinal dural arteriovenous fistula (SDAVF) usually occurs during the 4th to 6th decades of life, and adolescent SDAVF is rarely reported. SDAVF arising around a tumor is also rare, and reported tumors are mostly schwannoma and lipoma. CASE PRESENTATION: We reported a 16-year-old male presented with progressive weakness and numbness of lower limbs for 3 months. A SDAVF was found, which was fed by right radicular arteries from segmental artery at L2 level and drained retrogradely into perimedullary veins. A concomitant spinal extradural nodular fasciitis at right L1/L2 intervertebral foramen was also noted. The SDAVF was completely obliterated by endovascular treatment and the tumor was debulked. The patient recovered well after the procedures. CONCLUSIONS: Our case report suggests SDAVF can occur in adolescent. The concomitant presence with a nodular fasciitis indicates that although it usually arises in subcutaneous tissue but can rarely form on the dura of spine.

Endovascular Treatment of Medial Tentorial Dural Arteriovenous Fistula Through the Dural Branch of the Pial Artery.

Background: Tentorial dural arteriovenous fistula is a rare subtype of intracranial dural arteriovenous fistula (DAVF) with a deteriorating natural course, which may be attributed to its pial angioarchitecture. TDAVF often harbors feeders arising from pial arteries (FPAs). Reports have revealed that, if these feeders are not obliterated early, the restricted venous outflow during the embolization process may cause upstream congestion in the fragile pial network, which increases the risk of hemorrhagic complications. Because most reported cases of TDAVF were embolized through feeders from non-pial arteries (FNPAs), little is known of the feasibility of direct embolization through FPAs. Methods: We present three patients with medial TDAVFs that were embolized through the dural branches of the posterior cerebral and superior cerebellar arteries. Findings from brain magnetic resonance imaging, computed tomography, angiography, and clinical outcomes are described. Furthermore, we performed a review of the literature on TDAVFs with FPAs. Results: The fistulas were completely obliterated in two patients; both recovered well with no procedure-related complications. The fistula was nearly obliterated in one patient, who developed left superior cerebellum and midbrain infarct due to the reflux of the embolizer into the left superior cerebellar artery. Including our cases, eight cases of TDAVFs with direct embolization through the FPAs have been reported, and ischemic complications occurred in three (37.5%). Conclusions: Advancing microcatheter tips as close to the fistula point as possible and remaining highly aware of potential embolizer flow back into the pial artery are key factors in achieving successful embolization. Balloon-assisted embolization may be an option for treating TDAVFs with FPAs in the future.

Predictors of Invasive Adenocarcinomas among Pure Ground-Glass Nodules Less Than 2 cm in Diameter.

Benign lesions, atypical adenomatous hyperplasia (AAH), and malignancies such as adenocarcinoma in situ (AIS), minimally invasive adenocarcinoma (MIA), and invasive adenocarcinoma (IA) may feature a pure ground-glass nodule (pGGN) on a thin-slide computed tomography (CT) image. According to the World Health Organization (WHO) classification for lung cancer, the prognosis of patients with IA is worse than those with AIS and MIA. It is relatively risky to perform a core needle biopsy of a pGGN less than 2 cm to obtain a reliable pathological diagnosis. The early and adequate management of patients with IA may provide a favorable prognosis. This study aimed to disclose suggestive signs of CT to accurately predict IA among the pGGNs. A total of 181 pGGNs of less than 2 cm, in 171 patients who had preoperative CT-guided localization for surgical excision of a lung nodule between December 2013 and August 2019, were enrolled. All had CT images of 0.625 mm slice thickness during CT-guided intervention to confirm that the nodules were purely ground glass. The clinical data, CT images, and pathological reports of those 171 patients were reviewed. The CT findings of pGGNs including the location, the maximal diameter in the long axis (size-L), the maximal short axis diameter perpendicular to the size-L (size-S), and the mean value of long and short axis diameters (size-M), internal content, shape, interface, margin, lobulation, spiculation, air cavity, vessel relationship, and pleural retraction were recorded and analyzed. The final pathological diagnoses of the 181 pGGNs comprised 29 benign nodules, 14 AAHs, 25 AISs, 55 MIAs, and 58 IAs. Statistical analysis showed that there were significant differences among the aforementioned five groups with respect to size-L, size-S, and size-M (p = 0.029, 0.043, 0.025, respectively). In the univariate analysis, there were significant differences between the invasive adenocarcinomas and the non-invasive adenocarcinomas with respect to the size-L, size-S, size-M, lobulation, and air cavity (p = 0.009, 0.016, 0.008, 0.031, 0.004, respectively) between the invasive adenocarcinomas and the non-invasive adenocarcinomas. The receiver operating characteristic (ROC) curve of size for discriminating invasive adenocarcinoma also revealed similar area under curve (AUC) values among size-L (0.620), size-S (0.614), and size-M (0.623). The cut-off value of 7 mm in size-M had a sensitivity of 50.0% and a specificity of 76.4% for detecting IAs. In the multivariate analysis, the presence of air cavity was a significant predictor of IA (p = 0.042). In conclusion, the possibility of IA is higher in a pGGN when it is associated with a larger size, lobulation, and air cavity. The air cavity is the significant predictor of IA.

Management of intracranial vertebral artery stenosis with ipsilateral vertebral artery hypoplasia and contralateral vertebral artery occlusion via type 2 proatlantal intersegmental artery.

BACKGROUND: Proatlantal intersegmental artery (PIA) is a rare primitive carotid-basilar anastomosis. PIA may accompany with ipsilateral or bilateral vertebral arteries (VAs) agenesis. Here, we presented the case with intracranial VA stenosis supplying via PIA and demonstrated how we evaluated and managed. METHODS: Dual antiplatelet therapy and adequate hydration were given for three weeks for intracranial atherosclerotic disease (ICAD). We arranged magnetic resonance (MR) vessel wall imaging to survey both intracranial VAs. Intracranial right VA stenosis supplying via PIA with ipsilateral VA hypoplasia and contralateral intracranial VA occlusion caused multiple posterior circulation infarcts. We performed angioplasty and intracranial stenting for ICAD at the right VA V4 segment via PIA. RESULTS: National Institute of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS) got improved at discharge and ten months. CONCLUSIONS: This case is the first report for ICAD management via PIA. A persistent type 2 PIA is essential for supplying posterior circulation.

Left ventricular systolic dysfunction is associated with poor functional outcomes after endovascular thrombectomy.

BACKGROUND: Endovascular thrombectomy (ET) has transformed acute ischemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD, as measured by LV ejection fraction (LVEF), and clinical outcomes in patients with anterior cerebral circulation LVO who underwent ET. METHODS: This multicenter retrospective cohort study examined anterior circulation LVO AIS patients from six international stroke centers. LVSD was measured by assessment of the echocardiographic LVEF using Simpson's biplane method of discs according to international guidelines. LVSD was defined as LVEF <50%. The primary outcome was defined as a good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3 months. RESULTS: We included 440 AIS patients with LVO who underwent ET. On multivariate analyses, pre-existing diabetes mellitus (OR 2.05, 95% CI 1.24 to 3.39;p=0.005), unsuccessful reperfusion (Treatment in Cerebral Infarction (TICI) grade 0-2a) status (OR 4.21, 95% CI 2.04 to 8.66; p<0.001) and LVSD (OR 2.08, 95% CI 1.18 to 3.68; p=0.011) were independent predictors of poor functional outcomes at 3 months. On ordinal (shift) analyses, LVSD was associated with an unfavorable shift in the mRS outcomes (OR 2.32, 95% CI 1.52 to 3.53; p<0.001) after adjusting for age and ischemic heart disease. CONCLUSION: Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to consider cardiac factors for ET, the degree of monitoring and prognostication post-procedure.

Sectoral cancer detection and tolerability of freehand transperineal prostate biopsy under local anaesthesia.

BACKGROUND: To investigate the feasibility of a freehand transperineal (TP) systematic prostate biopsy protocol under local anaesthesia (LA) and the value of different sectors in diagnosing prostate cancer (PCa). METHODS: A total of 611 consecutive freehand TP biopsies under LA in 2 hospitals were prospectively evaluated. Cancer detection rate in each of the four different sectors (anterior, mid, posterior, basal) was recorded to evaluate the value of each sector. Procedure tolerability was assessed by pain score and complications were documented. RESULTS: Systematic biopsies were performed in 556 out of 611 men with a median of 20 (IQR 12-24) biopsy cores taken. The median PSA was 9.9 (Inter-quartile range[IQR] 6.4-16.2) ng/mL, and 89.0% were first biopsies. All PCa and ISUP grade group (GG) ≥ 2 PCa (HGPCa) were diagnosed in 41.4% (230/556) and 28.2% (157/556) biopsies respectively. 77.0% HGPCa was diagnosed in ≥2 sectors. Single-sector HGPCa was predominantly found in anterior or posterior sector. Omitting base sector would have missed 1.5% (1/65) HGPCa out of the 219 cases with ≥24-core biopsies performed. Further omission of mid sector would have missed 3.1% (2/65) HGPCa and 7.4% (7/94) ISUP GG1 PCa (in which 3/7 involved 2 sectors). LA TP biopsy was well tolerated and the mean pain scores of the different steps of the procedure were between 1.9-3.1 (out of 10). Post-biopsy fever occurred in 0.3% of patients (2/611) and no sepsis was reported. The risk of urinary retention in men with ≥20 cores in ≥60 ml prostate was 7.8% (14/179), compared with 1.7% (7/423) in other groups (p < 0.001). CONCLUSIONS: TP sectoral prostate biopsy under LA was well tolerated with minimal sepsis risk. Basal sector biopsies had minimal additional value to HGPCa detection and its omission can be considered.

Long-term Outcome of Neurological Complications after Infective Endocarditis.

Severe neurological complications following infective endocarditis remain a major problem with high mortality rate. The long-term neurological consequences following infective endocarditis remain uncertain. Otherwise, neurosurgeries could be performed after these complications; however, few clinical series have reported the results. Therefore, we utilized a large, nationwide database to unveil the long-term mortality and neurosurgical outcome following infective endocarditis. We included patients with a first-time discharge diagnosis of infective endocarditis between January 2001 and December 2013 during hospitalization. Patients were further divided into subgroups consisting of neurological complications under neurosurgical treatment and complications under non-neurosurgical treatment. Long-term result of symptomatic neurological complications after infective endocarditis and all-cause mortality after different kinds of neurosurgeries were analyzed. There were 16,495 patients with infective endocarditis included in this study. Symptomatic neurological complications occurred in 1,035 (6.27%) patients, of which 279 (26.96%) accepted neurosurgical procedures. Annual incidence of neurological complications gradually increased from 3.6% to 7.4% (P < 0.001). The mortality rate among these patients was higher than that among patients without complications (48.5% vs. 46.1%, P = 0.012, increased from 20% initially to nearly 50% over the 5-year follow-up). However, neurosurgery had no effect on the long-term mortality rate (50.9% vs. 47.6%, P = 0.451). Incidence of neurological complications post-infective endocarditis is increasing, and patients with these complications have higher mortality rates than patients without. Neurosurgery in these populations was not associated with higher long-term mortality. Therefore, it should not be ruled out as an option for those with neurological complications.

Cerebral Air Embolism and Vasospasm after Carotid Revascularization: A Case Report.

Cerebral air embolism can be of venous and arterial origin and cause severe medical complication. Vasospasm is a severe complication of carotid artery stenting. We report a 63-year-old male with severe carotid artery stenosis who suddenly died due to acute myocardial infarction during carotid artery stenting. His brain computed tomogram showed a remarkable amount of air in the gyriform spaces, and the cerebral angiogram showed vasospasm in the internal carotid artery resulting from stent manipulation. Presence of gyriform air could be caused by air entering the catheter due to sudden collapse after acute myocardial infarction and severe carotid vasospasm.

Endovascular management of spontaneous delayed migration of the flow-diverter stent.

BACKGROUND AND PURPOSE: Spontaneous delayed migration of the flow-diverter stent (FD) is an unusual complication that can be fatal. The purpose of this study is to report our experience and review the literature for the management of delayed FD migration. MATERIALS AND METHODS: Between November 2013 and June 2017, 122 patients treated by FD at our institution were enrolled. We also performed a comprehensive review of the literature. RESULTS: Six patients (4.9%) were found to have spontaneous delayed migration of their FD. The device migrated proximally in 4 patients and distally in 2 patients. One patient had temporal lobe infarction due to stent migration, and another had subarachnoid haemorrhage (SAH). Three patients were treated with a 2nd or 3rd FD, while 2 were treated with stent-assisted coiling, and one was treated with sacrifice of the parent internal carotid artery. According to our results and the literature, the prevalence rate of delayed FD migration ranges from 2.2% to 4.9%, and the mortality and morbidity rate of delayed FD migration is 40%. CONCLUSIONS: Neuro-interventionalists should be aware of this complication and be familiar with risk factors, preventive methods and treatment options. If there is any concern regarding the size or position of the FD, early imaging follow-up and endovascular treatment should be indicated.

Endovascular Treatment of Ruptured Proximal Segment of the Anterior Cerebral Artery Aneurysms: Single-Center Experience and Literature Review.

BACKGROUND: Proximal anterior cerebral artery (A1) aneurysms are rare among all intracranial aneurysms and are regarded as difficult to treat endovascularly. Treatment is even more challenging in patients with ruptured aneurysms and acute subarachnoid hemorrhage owing to the small size and proximity to perforators. Though challenging, endovascular treatment can provide favorable outcomes in such patients. We report our case series of endovascular treatment in ruptured proximal A1 aneurysms. METHODS: Between January 2010 and December 2017, 1200 aneurysms were treated endovascularly at our center. There were 15 patients with 15 ruptured proximal A1 aneurysms who presented with subarachnoid hemorrhage. Five patients underwent simple coiling, 9 underwent balloon-assisted coiling, and 1 underwent catheter protective coiling. Medical records and angiographic results were obtained retrospectively. RESULTS: All aneurysms were successfully treated with endovascular techniques. Multiplicity rate was 53.3% (n = 8). Initial complete obliteration rate was 93.3% (n = 14), with a 13.3% recurrence rate (n = 2). One patient experienced intraoperative bleeding; this was the only procedure-related complication. Eleven patients (73.3%) had a good clinical outcome. When excluding Hunt and Hess grade 4 patients, the good outcome rate was 81.8%. CONCLUSIONS: Ruptured proximal A1 aneurysm is a rare condition and is highly associated with multiple aneurysms. Despite being a more difficult and complicated technique, endovascular coiling performed in high-volume, experienced medical centers is an effective modality with excellent clinical outcomes.