Correlation between contrast leakage period of procedural rupture and clinical outcomes in endovascular coiling for cerebral aneurysms.

OBJECTIVE: Intraprocedural rupture (IPR) is a fatal complication of endovascular coiling for cerebral aneurysms. We hypothesized that contrast leakage period may be related to poor clinical outcomes. This study aimed to retrospectively evaluate the relationship between clinical outcomes and contrast leakage period. METHODS: Data from patients with cerebral aneurysms treated via endovascular coiling between January 2010 and October 2018 were retrospectively assessed. The enrolled patient's demographic data, the aneurysm related findings, endovascular treatment and IPR related findings, rescue treatment, and clinical outcome were analyzed. RESULTS: In total, 2,859 cerebral aneurysms were treated using endovascular coiling during the study period, with IPR occurring in 18 (0.63 %). IPR occurred during initial frame coiling (n=4), coil packing (n=5), stent deployment (n=7), ballooning (n=1), and microcatheter removal after coiling (n=1). Tear sites included the dome (n=14) and neck (n=4). All IPRs were controlled and treated with coil packing, with or without stenting. Flow arrest of the proximal balloon was not observed. Temporary focal neurological deficits developed in two patients (11.1%). At clinical follow-up, 14 patients were classified as modified Rankin Scale (mRS) 0, three as mRS 2, and one as mRS 4. The mean contrast leakage period of IPR was 11.2 min (range: 1-31 min). Cerebral aneurysms with IPR were divided into late (n=9, mean time: 17.11 min) and early (n=9, mean time: 5.22 min) control groups based on the criteria of 10 min of contrast leakage period. No significant between-group differences regarding clinical outcomes were observed after IPR (p=1). CONCLUSIONS: In our series, all patients with IPR were controlled with further coil packing or stenting without proximal balloon occlusion within 31 min of contrast leakage. There was no difference in clinical outcomes when the long contrast leakage period group and short contrast leakage period group were compared.

Telemedicine Protocols for the Management of Patients with Acute Spontaneous Intracerebral Hemorrhage in Rural and Medically Underserved Areas in Gangwon State: Recommendations for Doctors with Less Expertise at Local Emergency Rooms.

Previously, we reported the concept of a cloud-based telemedicine platform for patients with intracerebral hemorrhage (ICH) at local emergency rooms in rural and medically underserved areas in Gangwon state by combining artificial intelligence and remote consultation with a neurosurgeon. Developing a telemedicine ICH treatment protocol exclusively for doctors with less ICH expertise working in emergency rooms should be part of establishing this system. Difficulties arise in providing appropriate early treatment for ICH in rural and underserved areas before the patient is transferred to a nearby hub hospital with stroke specialists. This has been an unmet medical need for decade. The available reporting ICH guidelines are realistically possible in university hospitals with a well-equipped infrastructure. However, it is very difficult for doctors inexperienced with ICH treatment to appropriately select and deliver ICH treatment based on the guidelines. To address these issues, we developed an ICH telemedicine protocol. Neurosurgeons from four university hospitals in Gangwon state first wrote the guidelines, and professors with extensive ICH expertise across the country revised them. Guidelines and recommendations for ICH management were described as simply as possible to allow more doctors to use them easily. We hope that our effort in developing the telemedicine protocols will ultimately improve the quality of ICH treatment in local emergency rooms in rural and underserved areas in Gangwon state.

Assessment of thrombus using susceptibility-weighted filtered-phase images in patients with acute ischemic stroke.

BACKGROUND AND PURPOSE: Recognizing the location and length of the thrombus responsible for large vessel occlusion in patients with acute ischemic stroke can facilitate effective endovascular recanalization therapy (ERT). We hypothesized that the aliasing or dipole effect produced by filtered-phase susceptibility-weighted imaging (SWI) would facilitate thrombus delineation. METHODS: Of the patients with middle cerebral artery occlusion who underwent ERT, we screened those who underwent noncontrast CT (NCCT), multiphase CT angiography (mCTA), and SWI before the endovascular procedure. We used an arbitrary index termed measurement of equivalence in thrombus assessed by digital subtraction angiography (METAD) defined as having the same location as the thrombus observed in the digital subtraction angiography (DSA) and length differing by less than 5 mm. For NCCT, mCTA, SWI_m (magnitude), and SWI_p (phase), the length of the thrombus and METAD were assessed. RESULTS: The mean lengths of the thrombi determined using NCCT, mCTA, SWI_m, SWI_p, and DSA were 14.03, 13.47, 13.89, 9.93, and 8.96 mm, respectively. The absolute agreement for thrombus length was excellent for SWI_p and DSA (intraclass correlation coefficient [ICC] = .96), moderate for SWI_m and DSA (ICC = .53), and poor for mCTA and DSA (ICC = .14). The METADs were 26.7%, 40.0%, 33.3%, and 73.3% for NCCT, mCTA, SWI_m, and SWI_p, respectively. The METADs for NCCT and SWI_p were significantly different (p = .045) and those for mCTA and SWI_m were not (p = .537 and .093, respectively). CONCLUSIONS: The SWI_p was best matched with the DSA for the measurement of the lengths and locations of thrombi. The use of pre-thrombectomy SWI_p imaging for acute ischemic stroke may facilitate a successful ERT strategy.

Clinical and radiological outcomes of mechanical thrombectomy in simultaneous anterior cerebral artery and middle cerebral artery occlusion.

OBJECTIVE: Simultaneous anterior cerebral artery (ACA) and middle cerebral artery (MCA) occlusion is rare. We investigated the clinical and radiological outcomes of patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy. METHODS: We analyzed the clinical and radiological outcomes of 12 patients with simultaneous ACA and MCA occlusion treated with mechanical thrombectomy from January 2018 to December 2020. The clinical outcome was assessed using the modified Rankin Score (mRS) after 3 months of thrombectomy. The radiological outcome was assessed using the thrombolysis in cerebral infarction (TICI) score. RESULTS: The median National Institutes of Health Stroke Scale score at hospital arrival was 18 (interquartile range, 16-20). M1 was the most common occlusion lesion (n=8), and A3 was the most common lesion in the ACA (n=6). Six patients were first treated for MCA occlusion and later for ACA occlusion (MCA group). Other patients were first treated for ACA occlusion and later for MCA occlusion (ACA group). There was no difference in clinical outcomes between the MCA and ACA groups (p=0.180). Successful recanalization (TICI ≥2b) of MCA was achieved in 10 patients (83.3%). Successful recanalization of ACA was achieved in 10 patients (83.3%). Successful recanalization of both ACA and MCA occlusion was observed in eight patients (66.7%). Three patients (25%) had good clinical outcomes (mRS ≤2). CONCLUSIONS: In our series, simultaneous ACA and MCA occlusion showed relatively poor successful recanalization rates and poor clinical outcomes despite treatment with mechanical thrombectomy.

Salvage treatment with stenting and temporary balloon occlusion for subarachnoid hemorrhage after stent retrieval following acute proximal M3 occlusion treatment.

Procedure-related subarachnoid hemorrhage (SAH) after mechanical thrombectomy is known to be a clinically benign presentation. However, the treatment in the presence of definite contrast leakage without vessel rupture is controversial. Here, we report a case in which a salvage technique was performed for procedure-related SAH after mechanical thrombectomy for a proximal M3 occlusion. A 56-year-old female patient presented with global aphasia and right hemiparesis within 2 hours after symptom onset. The initial National Institute of Health Stroke Scale score of the patient was 18 points, and Computed tomography (CT) angiography showed that the superior division of the left middle cerebral artery (MCA) was occluded. We decided to treat the patient with mechanical thrombectomy. Control angiography showed a left proximal M3 occlusion. We performed mechanical thrombectomy with a partially deployed technique using a Trevo 3 mm stent (Stryker). Control angiography showed recanalization of the occluded vessel but contrast leakage after stent retrieval. We decided to treat the lesion presenting with contrast leakage with stenting using a Neuroform Atlas 3 mm stent (Stryker). Serial control angiography continued to show contrast leakage of the recanalized artery. We decided to treat the lesion with temporary balloon occlusion using a Scepter C balloon catheter (MicroVention). The patient recovered and had a modified Rankin scale score at discharge of 0. Given the results of our case, stenting and subsequent repeat temporary balloon occlusion should be considered for SAH with contrast leakage after mechanical thrombectomy, as spontaneous cessation of the arterial bleeding is unlikely.

Improving Door-To-Puncture Time in Mechanical Thrombectomy with Direct Care from a Neurointerventionalist in the Emergency Department.

OBJECTIVE: A shorter door-to-puncture time is an independent predictor of good clinical outcomes in patients with acute ischemic stroke (AIS) who undergo mechanical thrombectomy (MT). We recently initiated a protocol for direct care from neurointerventionalists (NIs) in the emergency department (ED) rather than from non-NI neurologists for patients with AIS. Our aim was to investigate whether NIs, as the first point-of-care physicians for stroke in the ED, could shorten door-to-puncture time compared to non-NI neurologists. METHODS: From January 2020 to December 2020, 50 patients with AIS underwent MT at our hospital. Patients were divided into 2 groups based on the type of physician who provided initial care for stroke in the ED: (a) NI group (n = 20) and (b) non-NI group (n = 30). The door-to-puncture time was retrospectively analyzed. RESULTS: The NI group had a significantly shorter door-to-puncture time than the non-NI group (135.2 ± 50.0 minutes vs. 167.2 ± 54.3 minutes, P = 0.040). A door-to-puncture time of ≤120 minutes was more frequently achieved in the NI group than in the non-NI group (55.0% vs. 23.3%, P = 0.022). Multivariable logistic regression analysis revealed that a door-to-puncture time of ≤120 minutes was independently associated with the NI group (adjusted odds ratio 4.098, 95% confidence interval 1.085-15.479, P = 0.037). CONCLUSIONS: Our study showed that NIs, as the first point-of-care stroke physicians in the ED, were associated with shorter door-to-puncture times. We suggest that NIs should be at the forefront of care for patients with AIS in the acute setting by performing triage and deciding on and performing MT.

Vertebral Artery Dissecting Aneurysm Causing Central Tapia's Syndrome: A Case Report.

The central type of Tapia's syndrome is an extremely rare presentation, characterized by unilateral paralysis of the vagal and hypoglossal nerves, contralateral hemiparesis, or hemihypesthesia. This report describes a case of a middle-aged patient who developed central Tapia's syndrome due to a right vertebral artery dissecting aneurysm (VADA). The patient complained about swallowing difficulty and odynophagia. Right vocal cord paralysis, mild tongue deviation to the right side, left hypesthesia, and decreased temperature sensation with left hemiparesis were observed in neurologic exams. A right VADA and compression of the medulla oblongata due to the VADA were diagnosed on magnetic resonance imaging. Endovascular flow diversion of the right VADA was performed. After 1 year, all neurological symptoms and vocal cord paralysis were nearly resolved, but left hypesthesia remained with decreased nociception. We present and discuss how a VADA caused those symptoms and propose endovascular flow diversion as a treatment option.

Differences between proximal and distal M1 occlusions after mechanical thrombectomy.

PURPOSE: Whether M1 occlusions proximal (pM1) and distal (dM1) to the lenticulostriate perforators result in different clinical outcomes after mechanical thrombectomy (MT) is unknown. We retrospectively compared the clinical outcomes and baseline characteristics of patients with these two types of occlusions. METHODS: From March 2010 to May 2019, we performed MT for 141 M1 occlusions, including pM1 occlusions (n = 58) and dM1 occlusions (n = 83). RESULTS: Good clinical outcomes (modified Rankin Scale score 0 to 2) were achieved in 28 out of 58 (48.3%) patients with pM1 occlusions and 46 out of 83 (55.4%) patients with dM1 occlusions without significance (p = 0.493). Cardioembolic occlusions represented 19 out of 58 (32.6%) pM1 occlusions and 53 out of 83 (63.9%) dM1 occlusions, and atherosclerotic occlusions represented 37 out of 58 (63.8%) pM1 occlusions and 27 out of 83 (32.5%) dM1 occlusions, with significance (p = 0.001). Rescue treatments, such as balloon angioplasty or stenting, were needed more for pM1 occlusions than dM1 occlusions (21 out of 58 (36.2%) vs. 8 out of 83 (9.8%), p < 0.001). The multivariable logistic regression analysis demonstrated that the need for rescue treatment was associated with pM1 occlusions (adjusted odds ratio; 3.804, 95% confidence interval; 1.306-11.082, p = 0.014). CONCLUSIONS: In our series, pM1 and dM1 occlusions did not significantly differ in good clinical outcomes. Our study also showed that pM1 occlusions were more strongly associated with atherosclerotic occlusions, while dM1 occlusions were more strongly associated with cardioembolic occlusions, and rescue treatments were needed more often for pM1 occlusions than dM1 occlusions.

Compressed sensing time-of-flight magnetic resonance angiography with high spatial resolution for evaluating intracranial aneurysms: comparison with digital subtraction angiography.

BACKGROUND AND PURPOSE: Compressed sensing is used for accelerated acquisitions with incoherently under-sampled k-space data, and intracranial time-of-flight magnetic resonance angiography is suitable for compressed sensing. Compressed sensing time-of-flight is beneficial in decreasing acquisition time and increasing spatial resolution while maintaining acquisition time. In this retrospective study, we aimed to evaluate the image quality and diagnostic performance of compressed sensing time-of-flight with high spatial resolution and compare with parallel imaging time-of-flight using digital subtraction angiography as a reference. MATERIAL AND METHODS: In total, 39 patients with 46 intracranial aneurysms underwent parallel imaging and compressed sensing time-of-flight in the same imaging session and digital subtraction angiography before or after magnetic resonance angiography. The overall image quality, artefacts and diagnostic confidence were assessed by two observers. The contrast ratio, maximal aneurysm diameters and diagnostic performance were evaluated. RESULTS: Compressed sensing time-of-flight showed significantly better overall image quality, degree of artefacts and diagnostic confidence in both observers, with better inter-observer agreement. The contrast ratio was significantly higher for compressed sensing time-of-flight than for parallel imaging time-of-flight in both observers (source images, P < 0.001; maximum intensity projection images, P < 0.05 for both observers); however, the measured maximal diameters of aneurysms were not significantly different. Compressed sensing time-of-flight showed higher sensitivity, specificity, accuracy and positive and negative predictive values for detecting aneurysms than parallel imaging time-of-flight in both observers, with better inter-observer agreement. Compressed sensing time-of-flight was preferred over parallel imaging time-of-flight by both observers; however, parallel imaging time-of-flight was preferred in cases of giant and large aneurysms. CONCLUSIONS: Compressed sensing-time-of-flight provides better image quality and diagnostic performance than parallel imaging time-of-flight. However, neuroradiologists should be aware of under-sampling artefacts caused by compressed sensing.

Usefulness of pointwise encoding time reduction with radial acquisition sequence in subtraction-based magnetic resonance angiography for follow-up of the Neuroform Atlas stent-assisted coil embolization for cerebral aneurysms.

BACKGROUND: Although time-of-flight magnetic resonance angiography (TOF-MRA) is widely used, it has limited usefulness for follow-up after stent-assisted coil embolization. Contrast-enhanced MRA (CE-MRA) and ultrashort echo time MRA have been suggested as alternative methods for visualization after this procedure. PURPOSE: To compare efficacy and usefulness of pointwise encoding time reduction with radial acquisition (PETRA) sequence in subtraction-based MRA (qMRA), TOF-MRA, and CE-MRA during the follow-up after Neuroform Atlas stent-assisted coil embolization for intracranial aneurysms. MATERIAL AND METHODS: This retrospective study included 23 patients with 24 aneurysms who underwent Neuroform Atlas stent-assisted coil embolization for intracranial aneurysms. All patients were evaluated with PETRA qMRA, TOF-MRA, and CE-MRA at the same follow-up session. The flow within stents, occlusion status, and presence of pseudo-stenosis were evaluated; inter-observer and intermodality agreements for the three methods were also graded. RESULTS: The mean score for flow visualization within the stents was significantly higher for PETRA qMRA and CE-MRA than for TOF-MRA (although no significant difference was found between PETRA qMRA and CE-MRA). Good inter-observer agreement was observed for each modality. PETRA qMRA and CE-MRA were more consistent with digital subtraction angiography (DSA) than TOF-MRA for aneurysm occlusion status. The intermodality agreement was better between PETRA qMRA and DSA, and between CE-MRA and DSA, than between DSA and TOF-MRA. Pseudo-stenosis was most frequently observed in TOF-MRA, followed by CE-MRA and PETRA qMRA. CONCLUSION: PETRA qMRA is useful for evaluating the parent artery patency and occlusion status of aneurysms after Neuroform Atlas stent-assisted coil embolization.

Differences in thromboembolism after stent-assisted coiling for unruptured aneurysms between aspirin plus clopidogrel and ticagrelor.

PURPOSE: To reduce procedural thromboembolisms, tailored antiplatelet drug preparation has been used according to antiplatelet resistance for endovascular coiling of unruptured aneurysms. We compared an aspirin plus clopidogrel group with a ticagrelor group using diffusion-weighted imaging (DWI) after stent-assisted coiling for unruptured aneurysms. METHODS: From October 2018 to April 2019, 72 patients with 78 aneurysms underwent stent-assisted coiling, with aspirin plus clopidogrel (n = 20 patients with 22 aneurysms) or ticagrelor (n = 52 patients with 56 aneurysms) as an antiplatelet preparation, and were enrolled in our study. All patients were evaluated using DWI 2 h after coiling to detect procedural thromboembolisms. RESULTS: Postprocedure infarction was observed on DWI in 37 procedures (47.4%), and symptomatic infarction occurred in 1 procedure (1.28%). Postprocedure infarction was significantly lower in the aspirin plus clopidogrel than in ticagrelor group (27.3% vs. 55.4%, p = 0.043). Postprocedure infarction was associated with aneurysm type (sidewall aneurysm (30.8%) vs. aneurysm with incorporated branches (64.1%), p = 0.006) and guiding catheter type (single (23.8%) vs. double (56.1%), p = 0.020). Multivariable logistic regression analysis demonstrated that postprocedure infarction was related to aneurysm type (adjusted odds ratio (OR); 3.317, confidence interval (CI); 1.223-8.991, p = 0.018), guiding catheter type (adjusted OR; 2.783, CI; 0.828-9.353, p = 0.098), and antiplatelet medication (adjusted OR; 1.295, CI; 0.969-1.730, p = 0.080). CONCLUSIONS: Postprocedure infarction was observed on DWI after stent-assisted coiling for unruptured aneurysms more frequently in the ticagrelor group than in the aspirin plus clopidogrel group. However, our study suggests that postprocedure infarction is more associated with aneurysm type than antiplatelet medication.

Disappearance of a Distal Shunt Catheter: A Case Report of an Unusual Cause of Shunt Malfunction.

Shunt malfunction is a common complication in patients who undergo ventriculoperitoneal shunt (VPS) placement for the treatment of hydrocephalus. A plethora of reports regarding shunt malfunctions due to distal catheter migration have been demonstrated in the literature. However, to our knowledge, there have been no reports thus far of shunt malfunctions caused by the complete disappearance of a distal catheter. A 70-year-old man was admitted to our hospital for progressive gait disturbance beginning approximately 5 months ago. He received a VPS for posthemorrhagic hydrocephalus and was doing well over the course of 18 months of follow-up. Since no increase in the size of the ventricle was observed on brain computed tomography taken at the outpatient clinic, we tried to readjust the pressure setting of his programmable shunt valve to relieve his symptoms. Without any progression, we discovered later by chance that the distal shunt catheter was missing. Shunt revision surgery was performed. At the 2-year follow-up, a slight improvement in gait was observed. Although it is very rare, the distal catheter can disappear without any noticeable symptoms. If shunt malfunction is suspected, it is important to check whether the entire shunt system is structurally intact.

Hybrid mechanical thrombectomy for acute ischemic stroke using an intermediate aspiration catheter and Trevo stent simultaneously.

PURPOSE: To overcome the limitations of traditional mechanical thrombectomy (MT), including catheter aspiration and stent retrievers, such as thrombus fragmentation or migration, we designed hybrid MT using an intermediate aspiration catheter and a Trevo stent simultaneously. We retrospectively compared hybrid MT with the traditional MT. METHODS: From January 2017 to January 2019, we performed MT on 91 occlusions, including internal carotid artery bifurcation (n = 17), M1 segment (n = 53) and M2 segment (n = 21), using hybrid MT (n = 42) and traditional MT (n = 49). RESULTS: Hybrid MT had a shorter procedure time (52.4 ± 22.0 vs. 73.0 ± 36.2 min, p = 0.002) and fewer attempts (1.50 ± 0.86 vs. 1.92 ± 1.10 times, p = 0.049) than traditional MT did. Hybrid MT achieved more good clinical outcome (3-month modified Rankin Scale score, 2 or less) and better successful recanalization (Thrombolysis In Cerebral Infarction grade, 2b or 3) than traditional MT did, but the difference was not significant (61.9% vs. 55.1%, p = 0.531, 92.9% vs. 87.8%, p = 0.498). Hybrid MT showed a higher first pass successful recanalization rate than traditional MT did (69.0% vs. 40.8%, p = 0.011). Multivariable logistic regression analysis demonstrated that first pass successful recanalization is related to the M1 segment rather than other segments (adjusted odds ratio (OR); 3.277, confidence interval (CI); 1.227-8.749, p = 0.018) and hybrid MT rather than traditional MT (adjusted OR; 4.995, CI; 1.725-14.460, p = 0.003). CONCLUSIONS: Hybrid MT can be used as a first-line MT modality, particularly in M1 occlusion, based on our high first pass successful recanalization results.

Unexpected abnormal intraoperative neurophysiologic monitoring change by multiple spontaneous intracerebral haemorrhage during endovascular coiling.

We report a patient with multiple angiographically negative intracerebral haemorrhages, which were recognized by significant changes in intraoperative neurophysiologic monitoring during the coil embolization of a left middle cerebral artery aneurysm.

Thrombectomy in acute vertebrobasilar occlusion: a single-centre experience.

PURPOSE: Acute vertebrobasilar occlusion (VBO) has a grave clinical course; however, thrombectomy in VBO patients has rarely been reported. We retrospectively evaluated the clinical and radiological outcomes of thrombectomy in VBO patients. METHODS: From March 2010 to December 2017, 38 patients with 40 acute VBOs underwent thrombectomy at our hospital. Thrombectomy was performed using catheter aspiration (n = 11, 26.8%) or a stent retriever (n = 29, 70.7%). RESULTS: Good clinical outcomes (3-month modified Rankin scale (mRS) of 2 or lower) were achieved in 9 cases (22.5%), and successful recanalization (thrombolysis in cerebral infarction (TICI) grade of 2b or 3) was achieved in 35 cases (87.5%). Good clinical outcomes were significantly related to aetiologies other than atherosclerosis (p = 0.020) and lower National Institutes of Health Stroke Scale (NIHSS) scores on admission (p = 0.025). The clinical and radiological outcomes did not differ significantly between catheter aspiration and stent retriever thrombectomy (p = 1.000 and p = 0.603, respectively); however, stent retriever thrombectomy had a shorter procedure time than catheter aspiration (59.7 ± 31.2 vs. 84.5 ± 35.1 min, p = 0.037). CONCLUSION: In our series, good clinical outcomes were associated with a lower NIHSS score on admission and stroke aetiologies other than atherosclerosis. The two thrombectomy modalities showed similar clinical and radiological outcomes. However, stent retrievers seemed to allow more rapid recanalization than catheter aspiration in VBO.

Development of a predictive scale for cardioembolic stroke using extracted thrombi and angiographic findings.

We analyzed the histopathological findings of the clots obtained from patients with acute ischemic stroke by mechanical thrombectomy. We then developed a clinical scoring system for predicting pathogenic causes in patients with undetermined ischemic stroke using these histopathological and the angiographic findings during endovascular treatment. Only cases with the occlusion of the intracranial internal carotid artery or the proximal part of the middle cerebral artery were included in this study. Histopathologic findings of clots were compared and analyzed using the Trial of Org 10,172 in Acute Stroke Treatment (TOAST; large artery atherosclerosis, cardioembolic, and undetermined groups) and angiographic occlusion type (AOT; branching-site occlusion and truncal-type occlusion groups) classification systems. Fifty-two patients had enough clots extracted by mechanical thrombectomy for full histopathologic examination. There was no significant within-group difference in the fraction of components in the thrombi for either the TOAST or AOT system; however, the platelet distribution patterns were different. The large artery atherosclerotic group and truncal-type occlusion group had mostly peripheral patterns, whereas the cardioembolic group, undetermined group and branching-site occlusion group had mostly clustering patterns (p = 0.02 in TOAST classification; p = 0.007 in AOT classification). Patients with scores of 3 or 4 on our new scale had a sensitivity of 93.5% and a specificity of 100% for cardioembolic stroke. The BOCS2 scale, developed using a combination of the TOAST and AOT classification systems, may be helpful as an adjunctive diagnostic tool for identifying cases caused by cardiogenic embolism in patients with undetermined ischemic stroke.

Transient neurological deterioration due to watershed shift after STA-MCA bypass surgery in acute atherosclerotic occlusion.

Superficial temporal artery (STA)-middle cerebral artery (MCA) bypass surgery is considered not the primary but the last treatment option for acute atherosclerotic occlusions refractory to medical treatment. We retrospectively evaluated patients who underwent STA-MCA bypass surgery for acute atherosclerotic occlusion intractable to other treatments. From June 2010 to May 2014, 10 patients underwent STA-MCA bypass surgery for acute atherosclerotic occlusion at our hospital. The sites of occlusion were the internal carotid artery (n = 5) and the proximal MCA (n = 5). All 10 patients showed good patency in the anastomosis after bypass surgery, and postoperative cerebral angiography showed a newly formed border zone between the existing collateral blood flow and bypass graft blood flow. Transient neurological deterioration (TND) developed in 4 patients after STA-MCA bypass surgery (40%). All 4 patients showed worsened hemiparesis or aphasia 2-3 days after bypass surgery and improvement in neurological deficits within 1 week after bypass surgery. Diffusion MRI in patients with TND showed new cerebral infarctions near the newly formed border zone. In our series of bypass surgeries for acute atherosclerotic occlusion, postoperative changes in hemodynamic status, also called watershed zone shift, may be one of the causes of new cerebral infarctions near the newly formed border zone.

Radiological and clinical outcomes of endovascular coiling of proximal A1 aneurysms.

Aneurysms of the proximal anterior cerebral artery (A1) are rare. Of these A1 aneurysms, proximal A1 aneurysms are among the most challenging for endovascular coiling. This study aimed to evaluate the angiographic features and radiological and clinical outcomes of endovascular coiling of proximal A1 aneurysms. We recruited 38 patients with 38 proximal A1 aneurysms treated with endovascular coiling between September 2005 and April 2016. Baseline patient characteristics, aneurysm morphology, endovascular treatment techniques, immediate post-procedural radiological outcome, and follow-up clinical and radiological outcomes were evaluated, as were risk factors for recurrence. Sixteen proximal A1 aneurysms ruptured (42.1%). Six procedural complications (15.8%), including 5 thromboembolisms and 1 coil migration, were noted. There was no procedural morbidity or mortality. Immediate post-procedural radiological outcomes showed complete occlusion in 23, residual necks in 12, and residual sacs in 3 lesions. Follow-up angiographic outcomes were possible for 28 lesions (73.7%). Follow-up angiography showed sac recurrence in 3 (10.7%) and neck recurrence in 3 (10.7%) lesions. Retreatment was performed in 4 lesions (14.3%); all were treated by endovascular coiling. The presence of aneurysmal ruptures was only significant regarding recurrence in univariate logistic regression analysis. In our study, endovascular coiling of proximal A1 aneurysms was associated with a relatively high rate of procedural complications but not with procedural morbidity and mortality. The recurrence and retreatment rates of endovascular coiling of proximal A1 aneurysms were relatively high, and presence of rupture was significant for recurrence.

Initial multicentre experience using the neuroform atlas stent for the treatment of un-ruptured saccular cerebral aneurysms.

Purpose: The Neuroform Atlas is a self-expandable and low-profiled stent that is used for aneurysm neck scaffolding and has been recently approved for clinical practice in Korea. We present our initial experiences of endovascular coiling using the Neuroform Atlas stent.Materials and methods: All cerebral aneurysms treated by stent-assisted coiling with a Neuroform atlas stent in two institutions between February and May 2018 were retrospectively evaluated. Fifty-one patients with 55 un-ruptured saccular cerebral aneurysms (mean size: 4.72 ± 1.81 mm, mean neck diameter: 3.82 ± 1.23 mm, mean dome-to-neck ratio: 1.21) were included in our study (40 females, mean age: 59.29 ± 11.96 years). Patient demographics, aneurysm characteristics, initial angiographic post procedural outcomes, and clinical and angiographic follow-up data were analysed.Results: There was one case of procedural failure due to a downward slip during stent deployment. The technical success rate was 98.2% (54/55). A post-procedure control angiogram showed complete occlusion in 27 (50%), residual neck in 16 (29.6%) and residual sac in 11 (20.4%) aneurysms. There were no procedure-related complications. In one case, a symptomatic thromboembolism with left hand grip weakness (grade IV) was observed two days after the procedure and resolved at discharge. The modified Rankin scale score at discharge was 0 in all patients. Angiographic follow-up data at a mean of 4.8 months were available for 51/54 (94.4%) aneurysms. Among them, 27 aneurysms (52.9%) were stable, 20 aneurysms (39.2%) showed progressive occlusion and 4 aneurysms showed an increased modified Raymond Roy occlusion classification score (only one of these patients was included in the recanalization criteria).Conclusion: Our findings suggest the Neuroform Atlas stent can be useful for the coiling of cerebral aneurysms without significant complications regardless of aneurysm location.

Advantages and disadvantages of the ENVOY 6F distal access guiding catheter in endovascular coiling for anterior circulation aneurysms.

OBJECTIVE: Selecting an appropriate guiding catheter to provide both sufficient supportability for working devices and sufficient distal navigability is essential for ensuring the success of a procedure. This study aimed to evaluate the advantages and disadvantages of using the ENVOY 6F distal access (DA) guiding catheter in coil embolization of anterior circulation cerebral aneurysms. METHODS: We included 98 patients (72 [73.5%] women, median age: 63 [range: 25-84] years) who underwent endovascular coiling with the ENVOY 6F DA guiding catheter from May to November 2016. We analyzed data on patient demographics and the number of co-axial techniques to position the guiding catheter, initial and final location of the catheter, and complications related to the catheter. RESULTS: The co-axial technique was used to position the ENVOY 6F DA guiding catheter in the internal carotid artery (ICA) in 20 cases (20.41%). The initial position of the ENVOY 6F DA guiding catheter involved the cervical ICA (79.6%), horizontal petrous ICA (17.3%), and vertical petrous ICA (3.1%). Final control angiograms after endovascular coiling showed proximal change in the final, compared to the initial, position of the ENVOY 6F DA guiding catheter in 25 cases (25.51%). Procedure-related complications were observed in nine patients (9.18%), involving vasospasm in all cases; however, there was no symptomatic case. CONCLUSION: The ENVOY 6F DA guiding catheter had relatively sufficient distal navigability without symptomatic procedural complications. However, the change in the catheter position after endovascular coiling denoted insufficient supportability.