The "distal-to-proximal" strategy for the treatment of posterior circulation tandem occlusions: a single-centre experience.

PURPOSE: Data on posterior circulation tandem occlusions in acute ischemic stroke are scarce: recognition may be challenging and little is known about optimal treatment strategy. We report our endovascular treatment strategy for posterior circulation tandem occlusion. METHODS: Consecutive patients with posterior circulation tandem occlusions in our centre were enrolled retrospectively. The preferred strategy was "distal-to-proximal" strategy, which means opening the distal occlusion first followed by treatment of the proximal pathology. The imaging characteristics, treatment strategy, clinical outcomes, and complications of patients with posterior circulation tandem occlusions were analyzed. RESULTS: In total, 21 patients with posterior circulation tandem occlusions were enrolled in the study, which accounted for 23.6% of patients with posterior circulation stroke in our centre. The mean age was 60 years (range 32 to 80), and median pre-procedure NIHSS score was 28 (interquartile range: 13-31). Eighteen patients (85.7%) had vertebrobasilar artery tandem occlusions and 3 (14.3%) had basilar artery to basilar artery tandem occlusions. All distal occlusions were successfully recanalized (modified TICI 2b/3). Two (9.5%) of the proximal lesions were not treated. A total of 57.1% of the patients had stents implanted on the proximal occlusions. The rate of mRS 0-3 at 3 months was 57.1% and the mortality rate was 19.0%. CONCLUSION: In patients with acute ischaemic stroke caused by posterior circulation tandem occlusions, we favor "distal-to-proximal" strategy based on the positive results in this small series. Nevertheless, a more extensive study is required to explore the optimal treatment strategy further.

Outcome and Prognostic Factors of Ruptured Middle Cerebral Artery Aneurysms Treated via Endovascular Approach: A Single-Center 11-Year Experience.

OBJECTIVE: To investigate outcomes and prognostic factors of ruptured middle cerebral artery (MCA) aneurysms, treated via endovascular approach, with improving treatment materials and techniques. PATIENTS AND METHODS: A total of 185 consecutive patients, admitted with acutely ruptured MCA aneurysms and treated by endovascular methods between 2006 and 2016, were retrospectively reviewed. Their baseline characteristics, procedure-related complications, and angiographic and clinical outcomes were collected. Univariate analysis and logistic regression analysis were completed to identify any association between procedure-related complications or clinical outcomes and potential risk factors. RESULTS: Procedure-related complications occurred in 28 patients (15.1%), including aneurysm rebleeding in 7 (3.8%), hematoma expansion in 10 (5.4%), and ischemia in 13 (7.0%) (concurrent hemorrhage and ischemia in 2 patients), which resulted in morbidity/mortality of 7% and 1.4%. Final evaluations indicated that 153 patients (82.7%, 153/185) had a good outcome (modified Rankin Scale score 0-2). Among 120 (69.4%) who underwent angiographic follow-up, 89 (74.2%) were completely occluded and 20/120 (16.7%) were recanalized. Multivariate analysis of clinical outcome indicated that a high preoperative Hunt and Hess grade (IV-V), intrasylvian/intracerebral hematoma, and early period treatment (2006-2013) were associated with unfavorable outcomes. CONCLUSIONS: Endovascular treatment for patients with ruptured middle cerebral artery aneurysms may offer favorable clinical and angiographic outcomes. With the evolution of treatment materials and updated techniques, treatment complications have become less common than previously reported in literature, and clinical outcomes have been improved in recent years.

Factors Predicting De Novo Formation of Fistulas After Dural Fistula Embolization Using Venous Sinus Balloon Protection.

BACKGROUND: Endovascular embolization with transvenous sinus preservation using balloon is at present the preferred modality for dural arteriovenous fistulas involving venous sinuses (sagittal, transverse, and sigmoid) with potential drainage function. The aim of the study was to evaluate the necessity and medium-term efficacy of this technique. METHODS: Patients with dural arteriovenous fistulas involving large sinuses who underwent vascular embolization with transvenous balloon protection technique at our center from December 2012 to July 2017 were retrospectively reviewed. The clinical symptoms, postoperative and mid-term follow-up imaging results, perioperative complications, and follow-up clinical outcomes were analyzed. RESULTS: Eighteen patients (8 women and 10 men) with mean age 49 years were included in this study. Complete (16 of 18) or near-complete (1 of 18) occlusion of original fistula was achieved in 17 patients (94.4%). Recurrence of original fistula (1 of 18) or de novo fistula (3 of 18) occurred in 4 patients (22.2%). The patency rate of balloon-protected sinus was 72.2% (13 of 18) during the follow-up, and the involved sinuses were eventually occluded in 5 patients (27.8%). The frequency of de novo fistulas was higher in patients with sinus occlusion (P < 0.05). Stenosis of the involved sinus was more likely related to balloon-protected sinus occlusion (P < 0.05). After a mean follow-up of 17.6 months, 17 patients (94.4%) achieved remission of the original symptoms. CONCLUSIONS: Transvenous balloon protection technique maintains sinus patency in most cases, and preoperative stenosis increases the probability of sinus occlusion. De novo fistula is related to sinus occlusion during the follow-up.

Stent Angioplasty for Acute Intracranial Atherosclerotic Occlusion After Failed Thrombectomy: A Single-Institution Series of 55 Patients.

INTRODUCTION: Analysis of safety and effectiveness of stent angioplasty for failure of thrombectomy in patients with acute intracranial atherosclerotic occlusion. METHODS: Retrospective continuous analysis of the clinical data of 458 patients with acute stroke undergoing endovascular artery thrombectomy in Changhai Hospital of Second Military Medical University from May 2013 to February 2018. Patients with acute intracranial atherosclerotic occlusion treating with stent implantation were included and the safety and effectiveness of stent angioplasty was evaluated. RESULTS: There was successful stent release in 55 patients. There were 36 cases (65.5%) with occlusion located in the anterior circulation and 19 cases (34.5%) in the posterior circulation. Twenty patients underwent intravenous thrombolysis before surgery, and the time of admission to intravenous thrombolysis was (39.9 ± 13.2) minutes. Fifty-four patients (98.2%) achieved modified thrombolysis in cerebral infarction 2b-3 recanalization. The National Institutes of Health Stroke Scale score 2.0 (0.0,6.0) 7 days after surgery was significantly improved compared with the preoperative National Institutes of Health Stroke Scale score 12.5 (6.0-20.0) (Z = -4.073, P < 0.05). Intracranial hemorrhage occurred in 7 patients (12.7%) after surgery, among them, symptomatic intracranial hemorrhage occurred in 2 cases (3.6%). CTP examination of the skull 3-5 days after operation showed: Among 39 cases (70.9%): 33 cases (84.6%) were patency, 4 cases (10.3%) were occlusion, 2 cases (5.1%) were moderate stenosis, and 16 cases (29.1%) were not examined by computed tomography perfusion. Ninety-day follow-up showed that a total of 43 cases were followed up, and 12 cases were lost to follow-up. Thirty-four patients (79.1%) had a good prognosis 90 days after surgery (modified Rankin scale score 0-2) and 9 patients died (20.9%). CONCLUSION: When thrombectomy in patients with acute intracranial atherosclerotic occlusion fails, stent angioplasty is safe and effective; however, short-term stent reocclusion after surgery cannot be ignored. Because of the small sample size, larger multicenter clinical studies are needed to confirm this result.

[Basic soil productivity in the double rice cropping system under long-term fertilization regimes in the Poyang Lake region, China]. / 鄱阳湖流域长期施肥下双季稻田的土壤基础地力.

We aimed to explore changes in basic soil productivity (BSP) under different fertilization regimes in the Poyang Lake region, Jiangxi Province, China. Soil samples were collected from a long-term fertilization experiment (since 1981) that included treatments of no fertilization (CK), chemical fertilization (NPK), and combined chemical and organic fertilization (NPKM). Then, a three-year pot experiment (from 2012 to 2014) with double rice cropping was conducted with two different fertilization regimes (no fertilization, F0; fertilization, F1) using CK, NPK and NPKM soils. Grain yield and BSP were analyzed among soils with different fertilization regimes to identify the key factors driving changes in BSP. Results showed that grain yields in NPKM soil were higher than in NPK and CK soils regardless of fertilization in the pot experiment. Under the F0 condition, annual grain yields of NPKM soil were 37.7%-143.9% and 20.8%-66.7% higher than CK and NPK soils, respectively. The BSP values of CK, NPK and NPKM soils in three years were 41.8%-53.1%, 45.2%-62.6% and 59.1%-88.1%, respectively. NPKM soil had significantly higher BSP than NPK and CK soils. Furthermore, there were significant positive correlations between soil organic matter and BSP as well as between organic carbon balance and BSP. These results suggested that long-term application of chemical and organic fertilizers could improve BSP in the double rice cropping system of the Poyang Lake region. In addition, soil organic matter and organic carbon balance are important factors for improving BSP in this region.

Stromal cell-derived factor 1α facilitates aneurysm remodeling in elastase-induced rabbit saccular aneurysm.

AIMS: Inflammation plays a crucial role in aneurysm wall remodeling, which could lead to the rupture of intracranial aneurysms. Stromal cell-derived factor 1α (SDF-1α), a vital inflammation cytokine, is also related to aneurysm pathogenesis. However, the characteristics of SDF-1α expression and its role in aneurysm remodeling remain largely unknown. In this study, we aimed to investigate the expression dynamics of SDF-1α and its correlation with aneurysm remodeling. METHODS: Saccular aneurysms were induced by porcine pancreatic elastase in New Zealand White rabbits. Aneurysm size was measured by digital subtraction angiography. Endothelial-like cells on the aneurysm wall were assessed on postoperative days 1, 3, 7, 14, 21, and 30. SDF-1α levels in the aneurysmal wall and serum were examined at several follow-up time points. Adherent molecule expression was examined, and migration assays were performed in vitro. After SDF-1α stimulation, the mobilization of endothelial-lineage cells and its role in the reendothelialization of the aneurysm wall were investigated in a saccular aneurysm rabbit model. RESULTS: After the creation of saccular aneurysms in rabbits, the aneurysm sacs were filled with acute thrombosis within 3days, followed by a significant enlargement on day 14 and maturation on day 21. Serum SDF-1α levels increased in a bimodal fashion on day 1 and day 14, whereas SDF-1α expression in the aneurysm wall reached its maximum on day 14. VE-cadherin was up-regulated after SDF-1α stimulation and down-regulated by the SDF-1α ligand blocker AMD3100. Endothelial progenitor cell migration was enhanced by SDF-1α and blocked by AMD3100. The in vivo administration of SDF-α to rabbits with saccular aneurysms promoted endothelial-lineage cell mobilization into the peripheral blood and reendothelialization of the aneurysm wall. CONCLUSIONS: The SDF-1α expression level in the peripheral blood and local aneurysm wall correlated with the aneurysm remodeling process in rabbits with elastase-induced saccular aneurysms. We conclude that SDF-1α may facilitate aneurysm wall remodeling by up-regulating VE-cadherin expression and mobilizing endothelial-lineage cells.

A Novel Flow Diverter (Tubridge) for the Treatment of Recurrent Aneurysms: A Single-Center Experience.

OBJECTIVE: The Tubridge flow diverter (FD) is a novel device aimed at reconstructing the parent artery and occluding complex aneurysms. Retreatment of recurrent aneurysms using the FD is challenging. We report our initial experience in the repair of aneurysm recurrence with the FD. MATERIALS AND METHODS: A database was reviewed prospectively, and 8 patients with 8 recurrent aneurysms (mean size, 16.7 mm) were identified. Four aneurysms had previously ruptured. The previous aneurysm treatment consisted of coiling in 1 aneurysm and single-stent-assisted coiling in 7 aneurysms. The procedural complications and clinical and angiographic outcomes were analyzed. RESULTS: Six aneurysms were treated by using a single Tubridge FD alone, while the remaining 2 were treated with FD + coiling. The immediate results of the 8 aneurysms were that they all showed incomplete occlusion. Neither major ischemic nor hemorrhagic complications occurred; however, 1 patient experienced a vasospasm. Follow-up angiographies were available for 7 aneurysms; the mean follow-up was 16.9 months (7-36 months). Five aneurysms were completely occluded, whereas 2 had a residual neck. Severe asymptomatic stenosis of 1 parent artery of a vertebral artery dissecting aneurysm was found. All visible branches covered by the FD were patent. All patients were clinically assessed as having attained a favorable outcome (modified Rankin Scale score ≤ 2) at discharge and follow-up. CONCLUSION: In selected patients, the Tubridge FD can provide a safe and efficient option for the retreatment of recurrent aneurysms. Nevertheless, attention should be paid to several technical points.

Spinal Arteriovenous Malformation Associated with Parkes Weber Syndrome: Report of Two Cases and Literature Review.

OBJECTIVE: To present 2 cases of Parkes Weber syndrome (PWS) with spinal arteriovenous malformation (AVM) and discuss the radiologic features and clinical treatment with literature review. METHODS: Clinical data on 2 patients with PWS with spinal AVM was acquired in a prospective follow-up investigation. Clinical manifestations, radiographic features, procedural results, and follow-up outcome were collected and reviewed together with a literature review. RESULTS: The first patient presented with limb weakness and urinary dysfunction and the second with repetitive subarachnoid hemorrhage followed by paraplegia. Limb hypertrophy, skin ulceration, and extensive microfistulas in the affected limb were observed in both patients. Spinal AVM was confirmed by digital subtraction angiography and endovascular embolization was performed. The first patient experienced limb amputation at 6-year follow-up as a result of chronic ulceration and the second did not have neurologic improvement. After literature review, 15 cases (male/female ratio, 5:10; mean age, 22±10.4 years) were included. The presentations comprised subarachnoid hemorrhage in 6, radicular pain in 5, myelopathy in 4, and asymptomatic in 1. Embolization was performed in 9 cases, solitary surgery in 2, and combined therapy in 4. Among 10 cases with known follow-up results, 6 achieved neurologic recovery after surgery and 1 died after solitary surgery. CONCLUSIONS: Awareness of the association between spinal AVM and PWS is essential for radiographic screening of spinal lesions with myelopathy or intracranial subarachnoid hemorrhage. Clinical therapeutic strategy should be multidisciplinary and individualized on the basis of vasculature and lesion behavior.

Reconstructive endovascular treatment of vertebral artery dissecting aneurysms with the Low-profile Visualized Intraluminal Support (LVIS) device.

INTRODUCTION: The Low-profile Visualized Intraluminal Support (LVIS) device is a new generation of self-expanding braided stent recently introduced in China for stent assisted coiling of intracranial aneurysms. The aim of our study is to evaluate the feasibility, safety, and efficacy of the LVIS device in reconstructive treatment of vertebral artery dissecting aneurysms (VADAs). METHODS: We retrospectively reviewed the neurointerventional database of our institution from June 2014 to May 2016. Patients who underwent endovascular treatment of VADAs with LVIS stents were included in this study. Clinical presentation, aneurysmal characteristics, technical feasibility, procedural complications, and angiographic and clinical follow-up results were evaluated. RESULTS: 38 patients with VADAs who underwent treatment with LVIS stent were identified, including 3 ruptured VADAs. All VADAs were successfully treated with reconstructive techniques including the stent-assisted coiling (n = 34) and stenting only (n = 4). Post-procedural complications developed in 3 patients (7.9%) including two small brainstem infarctions and one delayed thromboembolic event. Complications resulted in one case of minor permanent morbidity (2.6%). There was no procedure-related mortality. The follow-up angiogram was available in 30 patients at an average of 8.3 months (range, 2 to 30 months), which revealed complete occlusion in 23 patients (76.7%), residual neck in five patients (16.7%), and residual sac in two patients (6.7%). The follow-up of 25 aneurysms with incomplete immediate occlusion revealed 22 aneurysms (88%) with improvement in the Raymond class. One aneurysm (3.3%) showed recanalization and required retreatment. Clinical followed-up at 5-28 months (mean 14.1 months) was achieved in 36 patients because two patients died of pancreatic cancer and basal ganglia hemorrhage, respectively. No new neurologic deterioration or aneurysm (re)bleeding was observed. CONCLUSIONS: Our preliminary experience with reconstruction of VADAs with the LVIS device demonstrates that this treatment approach is feasible with good short-term angiographic and clinical outcomes. Long-term and larger cohort studies are necessary to determine long-term outcomes of this therapy.

Effect of Baseline Characteristics on the Outcome of Stent Retriever-Based Thrombectomy in Acute Basilar Artery Occlusions: A Single-Center Experience and Pooled Data Analysis.

OBJECTIVES: To explore the association of baseline characteristics and the outcome of patients with acute basilar artery occlusion (BAO) after stent retriever-based thrombectomy (SRT). METHODS: Clinical and imaging information of consecutive SRT-treated patients with BAO from a comprehensive stroke center and up-to-date literature were reviewed respectively. The impact of baseline variables toward favorable outcome was evaluated using subgroup analysis and odds ratio (OR) extracted from published data together with single-center records using pooled analysis. RESULTS: Nineteen cases from our center and 15 published studies involving 487 cases were included. Estimated pooled favorable outcome rate was 0.3746 (95% confidence interval [CI], 0.3165-0.4327), mortality was 0.2950 (95% CI, 0.2390-0.3510). Pooled estimates showed that successful reperfusion (modified thrombolysis in cerebral ischemia scale 2b or 3) gained by SRT alone was 0.7317 (95% CI, 0.6532-0.8102) and final successful reperfusion rate with or without additional reperfusion procedures was 0.8834 (95% CI, 0.8279-0.9390). Univariate analysis indicated that patients with successful reperfusion (OR, 2.05; P = 0.05), distal segment occlusion (OR, 2.03; P = 0.03), and cardioembolus origin (OR, 2.13; P = 0.01) were more likely to have favorable outcome (modified Rankin Scale score ≤2 at 3 months). Study series that applied intra-arterial thrombolysis, angioplasty, or stenting as rescuing therapy had higher successful reperfusion rate but they did not show a higher rate of favorable outcome. CONCLUSIONS: SRT with or without additional treatment appeared to be effective for the treatment of BAO. Successful reperfusion, distal segment occlusion, and cardiac embolism were associated with favorable outcome. The overall benefit of lesions requiring additional reperfusion therapy was unclear.

Regulation of Kruppel-like factor 2 (KLF2) in the pathogenesis of intracranial aneurysm induced by hemodynamics.

Kruppel-like factor 2 (KLF2) has been found to regulate the reconstruction of vascular wall tissue and participate in the pathogenic mechanism of intracranial aneurysms. However, there is a paucity of research in this area. The present study aimed to investigate the regulatory effect of KLF2 on intracranial aneurysm (IA) and explore novel therapeutic strategies for treating IA. Experimental animal models were established with SPF New Zealand rabbits by bilateral carotid artery ligation (BCAL). Morphology of basilar artery bifurcation was detected using HE, EVG, Masson and immunohistochemical (IHC) staining. Vascular smooth muscle cells were harvested from basilar artery and cultured to establish KLF2 up-regulated and down-regulated cell models. The mRNA expression of KLF2, eNOS, ICAM-1 and MMP-9 were detected using real-time quantitate PCR (RT-qPCR). Protein expression of KLF2 and MAPKs pathway were measured using western blot. IA models were successfully established by bilateral carotid artery ligation. KLF2 expression was inconsistent with the variation of hemodynamics. In the KLF2 overexpression group, the mRNA expression of eNOS was increased, while that of ICAM-1 and MMP-9 was decreased. When KLF2 was up-regulated, the phosphorylation activity of p38 pathway was increased. In conclusion, results reveal that KLF2 is up-regulated in the vascular wall of basilar artery, and its overexpression regulates the pathogenesis of IA, which may be a self-protection mechanism of the arterial wall, providing a novel insight for therapy of IA.

Angiographic Characteristics and Endovascular Treatment of Anterior Cerebral Artery A1 Segment Aneurysms.

OBJECTIVE: This report aimed to review the angiographic characteristics and evaluate the safety and feasibility of endovascular treatment of A1 aneurysms. METHODS: Nineteen ruptured and 13 unruptured A1 aneurysms treated endovascularly were evaluated in this study. The angiographic and clinical records were retrospectively reviewed. RESULTS: Endovascular treatments were successfully applied in all 32 aneurysms. Conventional coiling was performed in 24 aneurysms, stent-assisted coiling in 7, and solo stenting in 1. The immediate angiographic result was 1 aneurysm in 15, two aneurysms in 10, and 3 in 7 aneurysms according to the Raymond grade. Intraoperative rupture was detected in 1 case without clinical consequence, and no other procedure-related complication occurred. Angiographic follow-up (mean, 12 months; range, 2-42 months) of 25 aneurysms showed total occlusion in 20, improvement in 1, stability in 3, and recurrence in 1. The only recurrence was detected in a case treated using conventional coiling, and it was retreated with stent-assisted coiling. Clinical follow-up (mean, 25 months; range, 6-93 months) was available in 24 of 30 patients, and the modified Rankin Scale score was 0-1 in 22 patients. CONCLUSIONS: Endovascular treatment is technically feasible and safe for A1 aneurysms.

Endovascular Treatment of 48 Early Branch Aneurysms of the Middle Cerebral Artery.

OBJECTIVE: To evaluate the feasibility of endovascular treatment (EVT) for early branch aneurysms (EBAs) of the middle cerebral artery (MCA). METHODS: We reviewed 211 MCA aneurysms that received EVT between January 2012 and December 2014. The EBAs were identified according to their special patterns on cerebral angiography. The angiographic features, clinical outcomes, and angiographic results were investigated. RESULTS: Forty-eight EBAs (22.7%) in 47 patients were identified among the MCA aneurysms. The treatments were successful in all EBAs, including coiling in 23 aneurysms, balloon-assisted coiling in 4, and stent-assisted coiling in 21. Immediate angiograms showed complete occlusion in 15 aneurysms, residual neck in 18, and residual aneurysm in 15. A procedure-related complication occurred in 1 patient (2.1%) who experienced rebleeding during treatment, and no neurologic function was insulted. Thirty-nine patients underwent angiographic follow-up (mean, 8.2 months), which showed 36 aneurysms were not aggravated, 3 had minor recanalization, and none showed major recanalization. The clinical follow-up (mean, 22.8 months) of all patients demonstrated no neurologic deterioration or rebleeding; however, 1 patient died of unexplained cerebral hemorrhage. CONCLUSIONS: Preliminary experience demonstrates that EVT for EBAs is feasible and safe. Direct comparison of clipping and coiling is warranted.

Endovascular Embolization of Intracranial Aneurysms: To Use Stent(s) or Not? Systematic Review and Meta-analysis.

OBJECTIVES: We sought to review the literature concerning stent-assisted coiling (SAC) in comparison with coiling without stents for treating intracranial aneurysms and to evaluate the safety and effectiveness of SAC by conducting a meta-analysis of published studies. METHODS: According to the methods and guidelines for meta-analysis, PubMed, Embase, and Cochrane Database were searched. All articles that compared SAC and coiling without stent were reviewed. The data extracted were the rates of immediate occlusion, progressive thrombosis, angiographic occlusion, angiographic recurrence, overall complications, ischemic stroke, and hemorrhagic stroke. RESULTS: Sixteen studies with 4294 aneurysms were analyzed. SAC was performed for 1466 aneurysms; and coiling without stent was performed for 2828 aneurysms. No significant difference in immediate occlusion rate was found between the 2 groups (odds ratio [OR] = 1.01; 95% confidence interval [CI], 0.73-1.39, P = 0.96). However, SAC had an advantage in terms of angiographic occlusion rate during follow-up (OR = 1.62, 95% CI: 1.16-2.26, P < 0.01), progressive thrombosis rate (OR = 2.54, 95% CI: 2.00-3.24, P < 0.01), and reduction in recurrence rate (OR = 0.46; 95% CI, 0.35-0.59, P < 0.01). No significant differences were shown in overall complication rate (OR = 1.30, 95% CI: 086-1.96, P = 0.21) and hemorrhagic stroke rate (OR = 0.72, 95% CI: 0.43-1.20, P = 0.21). Ischemic strokes were more common in the SAC patients than in the non-stent-assisted patients (OR = 1.66; 95% CI: 1.05-2.63, P = 0.03). CONCLUSION: Compared with coiling without stent, stent-assisted coiling of intracranial aneurysms achieved satisfactory results, with higher long-term angiographic occlusion rate and lower recurrence rate. However, ischemic stroke remains a problem that cannot be ignored.

Treatment of fenestrated vertebrobasilar junction-related aneurysms with endovascular techniques.

Fenestrated vertebrobasilar junction-related aneurysms (fVBJ-AN) are uncommon and endovascular management strategies have become the first options for the treatment of these lesions. This clinical study aimed to report our experience in the endovascular management of these lesions and to review the literature. We retrospectively reviewed 10 consecutive patients harboring 12 fVBJ-AN between January 2007 and December 2014. The demographic, angiographic and clinical data were reviewed. Additionally, a literature review was performed. Endovascular management strategies were successfully applied in all 10 patients. Post-procedural angiograms indicated total occlusion in eight (66.7%) aneurysms, a residual neck in one (8.3%) aneurysm, and three residual aneurysms (25%). No procedure-related complications were observed. Follow-up angiograms were obtained in eight patients and revealed nine occluded aneurysms and one improved aneurysm; two patients were lost to angiographic follow-up. Clinical follow-ups were obtained in all patients (until July 2015), and the modified Rankin Scale scores at 69.5months (range 17-101months) of follow-up were 0 in eight patients and 1 in two patients. Endovascular management strategies provided a high occlusion rate and an acceptable complication rate and are thus efficacious in the treatment of fVBJ-AN. Further studies are necessary to validate the utility of these treatments due to the low incidence of fVBJ-AN.

Parametric Digital Subtraction Angiography Imaging for the Objective Grading of Collateral Flow in Acute Middle Cerebral Artery Occlusion.

PURPOSE: To report the feasibility of parametric color-coded digital subtraction angiography (DSA) in complementing the traditional, subjective way of leptomeningeal collateral assessment in acute middle cerebral artery (MCA) occlusions. METHODS: Thirty-three consecutive patients with acute MCA occlusion who received endovascular treatment were recruited for investigation. Eighteen of 33 consecutive patients were included. The target downstream territory (TDT) of MCA and reference point at terminal internal carotid artery of each patient was contoured by 5 raters independently on the basis of anteroposterior 2-dimensional DSA. Two parameters of relative maximum density of TDT (rDensitymax) and peak time interval (ΔPT) between reference and TDT were extracted by the use of parametric DSA analysis software. Interrater reliability was tested with intraclass correlation coefficients. Parameters with sufficient interrater reliability entered validity evaluation. Then, the correlation test with the American Society of Interventional and Therapeutic Neuroradiology collateral grading system and efficacy in predicting favorable clinical outcome was evaluated. RESULTS: The intraclass correlation coefficient of rDensitymax and ΔPT were 0.983, 95% confidence interval 0.968-0.993 and 0.831, 95% confidence interval 0.705-0.923, respectively. The parameter rDensitymax showed a strong correlation with the American Society of Interventional and Therapeutic Neuroradiology collateral grading system score (r of Spearman correlation test = 0.869, P < 0.001) and mRS at 3 months (partial correlation coefficient = 0.616, P = 0.009), whereas ΔPT_average did not. A cut-off point of 0.224 in rDensitymax predicted a favorable clinical outcome with high sensitivity and specificity. CONCLUSIONS: The relative maximum contrast density of MCA territory on 2-dimensional DSA measured by parametric imaging technique appears to be a simple and reliable metric for the assessment of leptomeningeal collaterals in cases of acute MCA occlusion.

Single-stage endovascular treatment of subarachnoid hemorrhage related to bilateral vertebral artery dissecting aneurysms.

OBJECTIVE: Treatment of bilateral vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage remains challenging as bilateral deconstructive procedures may not be feasible. In this case series, we describe our approach to their management and review the pertinent literature. METHOD: A retrospective review of our prospectively collected database on aneurysms was performed to identify all patients with acute subarachnoid hemorrhage in the setting of bilateral intradural vertebral artery dissections (VAD) encompassing a period from January 2000 and March 2012. RESULT: Four patients (M/F = 2/2; mean age, 51.5 years) were identified. In two cases the site of rupture could be identified by angiographic and cross-sectional features; in these patients deconstructive treatment (proximal obliteration or trapping) of the ruptured site and reconstructive treatment of the unruptured site (using stents and coils) were performed. In the patients in whom the site of hemorrhage could not be determined, bilateral reconstructive treatment was performed. No treatment-related complications were encountered. Modified Rankin scale scores were 0-1 at discharge, and on follow-up (mean 63 months), no recurrence, in-stent thrombosis or new neurological deficits were encountered. CONCLUSION: We believe that single-stage treatment in patients with bilateral VAD is indicated: If the site of hemorrhage can be determined, we prefer deconstructive treatment on the affected site and reconstructive treatment on the non-affected site to prevent increased hemodynamic stress on the unruptured but diseased wall. If the site of dissection cannot be determined, we prefer bilateral reconstructive treatment to avoid increasing hemodynamic stress on the potentially untreated acute hemorrhagic dissection.

Stepwise stent deployment technique for tandem intracranial aneurysms: a review of 21 cases.

OBJECTIVES: We performed this study to report our experience using a stepwise stent deployment technique for the treatment of tandem intracranial aneurysms. METHODS: Patients with intracranial tandem aneurysms that were treated with a stepwise stent deployment technique between May 2009 and June 2013 were retrospectively reviewed. RESULTS: Twenty-one patients with 42 tandem aneurysms were identified (11 men, 10 women), with a mean age of 53.7 years (range, 17-82 years). Subarachnoid haemorrhage was confirmed in 12 patients using computed tomography at onset. Complete occlusion was achieved in 20 of the aneurysms (47.6%) after the procedure, neck remnant in 9 (21.4%), and aneurysm remnant in 13 (31.0%). The perioperative complications included in-stent thrombosis in one case and vasospasm in two cases, none of which left a permanent neurological deficit. The modified Rankin Scale (mRS) score at discharge was 0-2 in 20 cases and 3 in one case. The follow-up angiograms available for 17 patients showed complete occlusion in 26 aneurysms, improved in 4, and stable in 4. All of the patients had mRS scores of 0-1 during the clinical follow-up period. CONCLUSIONS: The stepwise stent deployment technique is feasible and helpful in the treatment of intracranial tandem aneurysms. KEY POINTS: • Treating wide-necked intracranial aneurysms with stent-assisted coiling is preferable. • Tandem wide-necked intracranial aneurysms can be treated with a single stent. • Stepwise stent deployment is technically feasible for embolizing tandem intracranial aneurysms.

Comparison of the flow diverter and stent-assisted coiling in large and giant aneurysms: safety and efficacy based on a propensity score-matched analysis.

OBJECTIVES: The flow diverter (FD) is a device aimed at reconstructing the parent artery and occluding an aneurysm. We performed a propensity score-matched analysis to compare safety and efficacy between the FD and stent-assisted coiling. METHODS: A database review was conducted to identify patients with large and giant unruptured aneurysms (aneurysms located in the ACA, MCA, or PCA were excluded) treated with the FD or stent-assisted coiling. A propensity score, representing the probability of using the FD, was generated for each aneurysm using the relevant patient and aneurysmal variables. Angiographic results, complications, and clinical outcomes were compared. RESULTS: Forty-five aneurysms treated with the FD (FD alone: 32; FD+Coils: 13) and 45 treated with stent-assisted coiling were matched. The rate of complete occlusion was significantly (P = 0.0002) higher in the FD cohort than the conventional stent cohort at the 6-month follow-up. The FD cohort achieved greater improvement (P < 0.0001) and a lower rate of recurrence (P = 0.0001). The rate of periprocedural complications was similar, as was the proportion of patients who attained mRS ≤ 2 at discharge and at the 6-month follow-up. CONCLUSIONS: Our findings provide reliable evidence demonstrating that the FD may be a preferred treatment option for large and giant unruptured aneurysms. KEY POINTS: • Flow Diverter provided a higher complete occlusion rate at 6-month follow-up. • Flow Diverter achieved more progress occlusion and less recurrence. • Compared with the conventional stents, procedure-related morbidity of Flow Diverter was similar. • Flow Diverter is a preferred treatment for large and giant unruptured aneurysms.