Angioarchitectural Analysis of Arteriovenous Shunts in Dural Arteriovenous Fistulas and Its Clinical Implications.

BACKGROUND: Detailed understanding of the angioarchitecture of arteriovenous shunts in dural arteriovenous fistulas (DAVFs) is essential when planning endovascular treatment. OBJECTIVE: To analyze shunt patterns and their clinical implications in transverse-sigmoid sinus and superior sagittal sinus DAVFs. METHODS: A total of 48 DAVFs treated with endovascular embolization between January 2010 and June 2021 were investigated. The preprocedural and intraprocedural digital subtraction angiograms were examined to characterize the shunt patterns of DAVFs in terms of anatomic relations to the sinuses and cortical veins. Treatment characteristics and outcomes were evaluated. RESULTS: The shunt patterns were categorized into 4 types: the direct sinus fistula (n = 8/48, 16.7%), compartmental sinus channel (n = 14/48, 29.1%), mural channel (n = 13/48, 27.1%), and bridging vein shunt (n = 13/48, 27.1%). Mural channel lesions revealed direct (n = 4/13, 30.8%) and indirect (n = 6/13, 46.2%) cortical venous connections. Multiple shunt types were seen in 7 patients. Overall, complete or near-complete occlusion was achieved in 43 patients (89.6%) after the final embolization. Patients with mural channels received the most embolization sessions (1.4 sessions per patient). Procedural venous drainage-related complications occurred in patients with multiple shunt types including mural channel shunts (n = 3). All bridging vein shunts were completely occluded during a single transarterial embolization session. CONCLUSION: The 4 shunt patterns of DAVFs demonstrate distinct characteristics for the fistula, sinus and cortical vein connection. Meticulous analysis of the angioarchitectural characteristics and clinical implications is warranted for safe and effective treatment.

Endovascular treatment for large (> 10 mm) basilar tip aneurysms: a retrospective case series.

PURPOSE: To report the long-term clinical and angiographic outcomes of the endovascular treatment of large/giant basilar tip aneurysms (BTAs) in our institutions. METHODS: We retrospectively reviewed cases of BTA larger than 10 mm that received endovascular treatment between January 2009 and December 2019. Data on the demographic and clinical characteristics and radiologic severity were obtained from the patients' medical records. The collected clinical follow-up data included neurological evaluation. Magnetic resonance angiography (MRA) was performed 6 to 12 months after the procedure, followed by once every 1 to 2 years as needed. RESULTS: A total of 12 patients with BTA were included in this study. The median age was 60.08 years (27-80 years), and the mean clinical follow-up was 66.78 months (19.00-142.87 months). Almost half of the patients presented with unruptured BTAs (58.33%, n = 7). The median maximum aneurysm diameter was 13.00 mm (10.46-20.90 mm) and the mean neck size was 8.34 mm (4.82-13.04 mm). A Modified Raymond Roy Classification (MRRC1) of 1 or 2 was observed in 66.67% of the patients (n = 8) immediately after the first procedure. Procedural morbidity and mortality were 33.33% and 8.33%, respectively. Major recanalization occurred in two patients, one of whom underwent additional coiling with the other being merely observed due to older age. CONCLUSION: It is very difficult to cure a large BTA completely at once and recanalization occurred often after endovascular treatment. Conducting long-term follow-up studies at short intervals is warranted, as well as improving existing treatment methods and developing new approaches.

Intraventricular hemorrhage clot clearance rate as an outcome predictor in patients with aneurysmal subarachnoid hemorrhage: A retrospective study.

BACKGROUND: The development of intraventricular hemorrhage (IVH) in aneurysmal subarachnoid hemorrhage (aSAH) is linked with higher mortality and poor neurological recovery. Previous studies have investigated the effect of the amount and distribution of the initial IVH on the prognosis of aSAH. However, no studies have assessed the relationship between the changes in IVH over time and the prognosis of aSAH. The aim of this study was to analyze the effect of the clearance rate of IVH, which can be represented by the IVH clot clearance rate (CCR), on the outcomes of aSAH. METHODS: The IVH CCR was calculated based on the difference between the initial and follow-up modified Graeb scores (mGS), which were assessed by initial and 7-day follow-up brain computed tomography, respectively. Poor functional outcome was defined as a modified Rankin Scale score of 3-6. Univariate and multivariable analyses were performed to assess the relationships between IVH CCR and other risk factors and the prognosis of patients. Receiver operating characteristic curve analysis was performed to identify cut-off values of IVH CCR for predicting poor functional outcome. RESULTS: In total, 196 consecutive patients were diagnosed with aSAH between January 2014 and March 2018. According to the inclusion and exclusion criteria, 67 patients were finally included in the study. The univariate analysis revealed that a lower IVH CCR (p<0.001), higher initial mGS (p<0.001), older age (p<0.001), higher initial Hunt and Hess grade (p<0.001), presence of delayed infarction (p=0.03), and presence of shunt-dependent hydrocephalus (p=0.004) were significantly related to poor functional outcome. The multivariable analysis revealed that IVH CCR (odds ratio [OR] 0.941; p=0.029), initial mGS (OR 1.632; p=0.043), age (OR 1.561; p=0.007), initial Hunt and Hess grade (OR 227.296; p=0.030), and delayed infarction (OR 5310.632; p=0.023) were independent predictors of poor functional outcome. Optimal cut-off values of IVH CCR and mGS for poor outcome were 36.27%, and 13.5, respectively (all p< 0.001). CONCLUSIONS: The IVH CCR might have an important predictive value on poor functional outcome in patients with aSAH and IVH, along with initial mGS, age, initial Hunt and Hess grade, and delayed infarction.

Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. MATERIALS AND METHODS: From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017-2019). RESULTS: Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0-106.0), pre-COVID-19; 40.0 min (27.0-98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0-560.0), pre-COVID-19; 184.0 min (134.0-271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID19, 46.7% in pre-COVID-19, p=0.039). CONCLUSION: During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.

Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms.

OBJECTIVE: Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques. METHODS: The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively. RESULTS: There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0-2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance. CONCLUSION: In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.

Recurrence and risk factors of posterior communicating artery aneurysms after endovascular treatment.

BACKGROUND: Endovascular treatment (EVT) of posterior communicating artery aneurysms (PcomA) is challenging because of posterior communicating artery (Pcom) architecture. Additionally, these aneurysms have a high risk of recanalization compared with those located elsewhere. METHODS: The radiographic findings of 171 patients treated with EVT at two institutions were retrospectively reviewed. Univariate and multivariate analyses were performed, and subgroup analyses were performed based on Pcom characteristics. RESULTS: Recanalization of PcomAs occurred in 53 patients (30.9%). Seven patients (4.0%) were retreated (six endovascularly and one with microsurgical clipping). The mean follow-up duration was 27.7 months (range: 3.5-78.6). The maximum diameter (odds ratio [OR] 1.23, P = .006, 95% CI 1.07-1.44), a Raymond-Roy classification of grade II or III (OR 2.26, P = .03, 95% CI 1.08-4.82), and the presence of reinforcement (balloon or/and stent, OR 0.44, P = .03, 95% CI 0.20-0.91) were associated with recanalization using multivariate logistic regression. Significant differences were found in maximum aneurysm diameter (P = .03) between normal- and fetal-type Pcoms on analysis of variance. CONCLUSIONS: The recanalization rate of PcomAs after EVT was 30.9%; the retreatment rate was 4.0%. Maximum diameter, Raymond-Roy classification, and presence of reinforcement were significantly associated with recanalization but not associated with fetal-type Pcom. Aneurysm size was larger in patients with a fetal-type Pcom than in those with a normal Pcom. Pcom size was not related to recanalization rate.

Scepter dual-lumen balloon catheter for Onyx embolization for dural arteriovenous fistula.

BACKGROUND: This study aimed to evaluate the efficacy and safety of Scepter dual-lumen balloon catheter for transarterial Onyx embolization of dural arteriovenous fistula (DAVF). METHODS: Transarterial Onyx embolization using a Scepter dual-lumen balloon catheter (Scepter-assisted Onyx embolization) for DAVF was attempted in a total of 35 patients (mean age, 52.5 years; M:F = 24:11) between October 2012 and December 2018. The results of Scepter-assisted Onyx embolization were evaluated with respect to total procedural and Onyx injection times, the types and number of feeders requiring embolization, angiographic and clinical outcomes, and treatment-related complications. RESULTS: Initial presentations were non-hemorrhagic neurological deficits in 10, intracranial hemorrhage in 8, seizure in 7, headache in 7, and intractable tinnitus in 3. All DAVF were aggressive type (Borden type 2, 14.3 %; type 3, 85.7 %). Scepter-assisted Onyx embolization resulted in immediately complete occlusion in 33 patients (94.3 %) and near complete occlusion in 2 patients. Middle meningeal artery (51.4 %) was the most commonly used for Scepter-assisted technique, followed by occipital artery (42.9 %), ascending pharyngeal artery (2.9 %) and superficial temporal artery (2.9 %). There was no difference in complete occlusion rate between middle meningeal artery and the other arteries (94.4 % versus 94.1 %). The median number of total feeders embolized was 1 (range, 1-3). The median total procedural time was 45 minutes (range, 21 minutes - 127 minutes) and the median Onyx injection time was 11 minutes (range, 3 minutes - 25 minutes). All patients recovered completely (n = 31) or partially (n = 4) from presenting symptoms. Treatment-related complications occurred in 2 patients, of whom one had a permanent morbidity (2.8 %, ipsilateral facial nerve palsy). No patient showed a recurrence on follow-up imaging (median, 15 months; range, 3-56 months). CONCLUSIONS: Scepter-assisted transarterial Onyx embolization showed a very high complete occlusion rate with a low morbidity and no recurrence in aggressive type DAVF. Scepter dual-lumen balloon catheter seems to be a useful tool for transarterial Onyx embolization of DAVF.

Clinical Features and Outcomes of Intracranial Aneurysm Associated with Moyamoya Disease.

BACKGROUND AND PURPOSE: Moyamoya disease (MMD) is a rare form of intracranial stenoocclusive disease that can be associated with intracranial aneurysms. We evaluated the clinical features and outcomes of MMD-associated aneurysms while focusing on their locations. METHODS: Between January 1998 and December 2018 there were 1,302 adult and pediatric patients diagnosed as MMD at a single institution. These patients included 38 with 44 MMD-associated aneurysms. The MMD-associated aneurysms were classified into two groups based on their locations: major-artery aneurysms and non-major-artery aneurysms. The clinical and radiological data for patients with MMD-associated aneurysms were reviewed retrospectively. RESULTS: The 44 MMD-associated aneurysms comprised 28 in major arteries and 16 in nonmajor arteries. All of the major-artery aneurysms were initially unruptured lesions, and follow-up angiography showed that 23 (82.1%) had an improved or stable status and 5 (17.9%) had a worse status. The non-major-artery aneurysms comprised 10 ruptured and 6 unruptured lesions, and follow-up angiography showed that 11 (68.8%) had improved or were stable and 5 (31.2%) had worsened. At the latest follow-up, there were four cases of unfavorable outcome: two initial hemorrhagic insults, one treatment-related morbidity, and one repeated-hemorrhage case. CONCLUSIONS: MMD-associated aneurysms occurred in 3.3% of the MMD cohort in this study, of which 63.6% were major-artery aneurysms and 36.4% were non-major-artery aneurysms. The major-artery group included 17.9% that became angiographically worse, while 31.2% were growing or hemorrhaging in the non-major-artery group.

Recurrence and retreatment of anterior communicating artery aneurysms after endovascular treatment: a retrospective study.

BACKGROUND: Surgical treatment of anterior communicating artery (Acom) aneurysm is challenging due to anatomic complexity. We aimed to describe our experiences with endovascular treatment (EVT) of Acom aneurysms, and to evaluate the incidence and risk factors of recurrence and retreatment. METHODS: The study comprised 260 patients who were treated at a single center between January 2010 and December 2018. Patients who had EVT, including stent-assisted coiling of Acom aneurysms, were included. All medical records were retrospectively reviewed. The incidence and risk factors of recurrence and retreatment were evaluated. Univariate and multivariate analysis were conducted. RESULTS: Recurrence of Acom aneurysms occurred in 38 (14.6%) patients. Mean follow-up duration was 27 months (range 1-110). Multivariate logistic regression indicated that ruptured aneurysm (odds ratio [OR] 3.55, P = 0.001), dome direction (anterior) (OR 3.86, P = 0.002), maximal diameter (OR 1.19, P = 0.02), and mean age (OR 0.96, P = 0.02) were independent risk factors for aneurysm recurrence. Of 38 cases of recurrence, 10 (3.8%) patients underwent retreatment. Ruptured aneurysm (OR 14.7, P = 0.004), maximal diameter (OR 1.56, P = 0.02), inflow angle (OR 1.04, P = 0.03), and Raymond-Roy classes II and III (OR 6.19, P = 0.03) showed significant relation to retreatment in multivariate logistic regression analysis. CONCLUSIONS: In our study, recurrence rate of Acom aneurysms after EVT was 14.6%. Rupture, anterior dome direction, maximal diameter, and mean age were significantly associated with recurrence. Retreatment rate of recurrent Acom aneurysms after EVT was 3.8%. Patients with Acom aneurysms with large inflow, rupture, large size, or incomplete occlusion may be at a high risk of retreatment of recurring aneurysm.

Microsurgical clipping of ruptured anterior choroidal artery aneurysms: Incidence of and risk factors for ischemic complications.

OBJECTIVE: Temporary clipping of the internal carotid artery can be required during microsurgery of a ruptured anterior choroidal artery (AchoA) aneurysm. Although it is suspected that such temporary clipping might be related to ischemic complications following surgery, no detailed analysis has been reported yet. PATIENTS AND METHODS: Eighty-nine patients with ruptured AchoA aneurysms treated by microsurgical clipping were recruited between January 1996 and December 2017. Patient medical records, radiographic data, and intraoperative video findings were retrospectively reviewed. Multivariate logistic regression analysis was conducted to investigate the risk factors for treatment-related ischemic complications. RESULTS: Treatment-related ischemic complications occurred in eight (9.0 %) patients, all of whom underwent temporary clipping during microsurgery. Patients who did not undergo temporary clipping (n = 20) did not experience treatment-related ischemic complications. Among patients who underwent temporary clipping (n = 69), multivariate logistic regression analyses indicated that the total duration, number of attempts, and longest time per attempt were not risk factors for poor clinical outcome at discharge. However, the longest time per attempt was identified as the only independent risk factor for treatment-related ischemic complications (odds ratio, 2.883; 95 % confidence interval, 1.725-6.525; P = 0.042). CONCLUSION: The longest time per attempt might be associated with a higher risk of treatment-related ischemic complications during microsurgery for ruptured AchoA aneurysms. Treatment-related ischemic complications may be minimized by intermittent application of temporary clipping during surgery.

Gamma Knife Radiosurgery Followed by Flow-Reductive Embolization for Ruptured Arteriovenous Malformation.

: Background: Aggressive treatment to achieve complete obliteration of brain arteriovenous malformation (AVM) is necessary in patients with a recent history of hemorrhage. The major drawback of Gamma knife radiosurgery (GKRS) alone for AVM is risk of bleeding during the latent period until the AVM occludes. At our center, patients who present with ruptured AVMs are frequently offered GKRS followed by embolization. The goal of this study was to compare outcomes of embolization for patients who have previously undergone GKRS for ruptured AVMs. METHODS: A database including 150 GKRS for ruptured AVMs between November 2008 and October 2017 was reviewed. The embolized group was selected by including AVMs with post-GKRS embolization. The non-embolized group was defined as AVMs treated by GKRS alone. Outcomes including obliteration rate, incidence of repeat hemorrhage, and delayed cyst formation were compared between two groups. The predictive factors related to AVM obliteration and complications were analyzed. RESULTS: The study consisted of 81 patients in the non-embolized group and 17 patients in the embolized group. Statistically significant differences were detected between the two groups with respect to age, Pollock-Flickinger score, Spetzler-Martin (SM) grade, eloquence of adjacent brain, and presence of aneurysms. The embolized group included more AVMs with larger median nidus volume. The predictive factors for the obliteration of ruptured AVMs were nidus volume, SM grade, Virginia Radiosurgery AVM Scale (VRAS), and Pollock-Flickinger score and for the subsequent hemorrhage were marginal dose, nidus volume, SM grade, VRAS, and Pollock-Flickinger score. The obliteration rates and complication rates after GKRS between groups were not significantly different. However, this study demonstrated statistically significant difference in the cumulative incidence of obliteration in AVMs with SM grade III and IV (p = 0.037). CONCLUSION: Although the current study demonstrated similar results in patients who underwent GKRS with and without embolization, the embolized group included more AVMs with larger nidus volume, higher SM grade, Pollock-Flickinger score, and aneurysm, which have a lower chance of obliteration and a higher probability of repeat hemorrhage. GKRS followed by embolization appears to be a beneficial approach for the treatment of ruptured AVMs that are at risk for obliteration failure and repeat hemorrhage during the latency period after single-session GKRS alone. Further studies involving a larger number of cases and continuous follow-up are necessary to confirm our conclusions.

Usefulness of high-resolution three-dimensional proton density-weighted turbo spin-echo MRI in distinguishing a junctional dilatation from an intracranial aneurysm of the posterior communicating artery: a pilot study.

BACKGROUND: Discriminating a junctional dilatation from a true saccular aneurysm is clinically important. PURPOSE: To evaluate the usefulness of high-resolution three-dimensional proton density-weighted turbo spin-echo magnetic resonance imaging (PD MRI) in distinguishing a junctional dilatation from an aneurysm of the posterior communicating artery (PcomA). METHODS: Eighty-two consecutive patients with 83 PcomA lesions, which were evaluated by time-of-flight (TOF) MR angiography (MRA), PD MRI, and digital subtraction angiography (DSA), were enrolled. These radiologic data were retrospectively and independently reviewed by two neurosurgeons, and each diagnosis based on TOF MRA, PD MRI, and DSA was compared. The diagnostic efficacy (interobserver agreement, intermodality agreement, and diagnostic performance) of PD MRI was compared with that of TOF MRA. RESULTS: PD MRI showed higher AC1 (Gwet's agreement coefficient, PD MRI: 0.8942, 95% CI 0.8204 to 0.968; TOF MRA: 0.7185, 95% CI 0.5753 to 0.8617) and prevalence-adjusted bias-adjusted kappa coefficient (PABAK) (PD MRI: 0.8554, TOF MRA: 0.5904) than TOF MRA for interobserver agreement. For intermodality agreement, PD MRI also showed higher AC1 (PD MRI: 0.9069, 95% CI 0.8374 to 0.9764; TOF MRA: 0.7983, 95% CI 0.6969 to 0.8996) and PABAK (PD MRI: 0.8735, TOF MRA: 0.7289) than TOF MRA. The diagnostic performance of PD MRI was statistically superior to that of TOF MRA in sensitivity, specificity, positive predictive value, and negative predictive value. CONCLUSIONS: PD MRI could provide excellent diagnostic accuracy and better information in distinguishing a junctional dilatation from a true saccular aneurysm of the PcomA compared with TOF MRA.

Symptomatic Sinus Pericranii with Adult Onset Headache: A Case Report with Pathologic Perspective.

Sinus pericranii (SP) is a rare vascular anomaly of the scalp that consists of an abnormal pericranial venous channel connected to adjacent dural venous sinuses. Most SP are asymptomatic and are found in the pediatric age group. We aim to report a case of symptomatic SP in adult and describe the clinical, radiological, and pathohistological findings to help understand and differentiate this lesion from other scalp lesions. A 40-year-old man with a scalp mass was admitted to our hospital complaining of headache. The lesion enlarged when the patient was in a recumbent position or during Valsalva maneuver. The radiologic imaging suggested its diagnosis as an accessory type of SP with bone erosion. Surgical resection and cranioplasty were successfully performed, and the related headache also gradually subsided. At the 3-year follow-up, there was no recurrence on magnetic resonance imaging.

Preliminary experience of stent-assisted coiling of wide-necked intracranial aneurysms with a single microcatheter.

BACKGROUND: The purpose of this study was to report our preliminary experience of stent-assisted coiling (SAC) of wide-necked intracranial aneurysms with a single microcatheter in patients with parent arteries that were small-caliber, with stenosis, or a very tortuous course. METHODS: Between March 2018 and December 2018, we treated 394 aneurysms in 359 patients with endovascular treatment. Among 197 aneurysms treated by SAC, there were 16 cases (all wide-necked unruptured aneurysms) treated by SAC with a single microcatheter and a Neuroform Atlas stent. Follow-up angiography was performed at 6 to 12 months after SAC, and clinical follow-up was performed from 6 to 12 months in all patients. RESULTS: The reasons for SAC with a single 0.0165-in. microcatheter were small-caliber (n = 4), stenosis (n = 2), and very tortuous course (n = 10) of the parent arteries. There was no complication related to delivering or deploying the Neuroform Atlas stent as well as no failure of selecting aneurysm by cell-through technique. All patients had a modified Rankin score of 0 at discharge and at follow-up. Initial angiographic results showed six cases (37.5%) of complete occlusion. In follow-up angiographies, 12 cases (75.0%) achieved compete occlusion. CONCLUSION: When performing SAC of wide-necked intracranial aneurysms in parent arteries with small-caliber, stenosis, or a very tortuous course, cell-through SAC using a single microcatheter and a Neuroform Atlas stent within a 5 Fr- (or smaller) guiding or intermediate catheter might be a useful option.

A Newly-Developed Flow Diverter (FloWise) for Internal Carotid Artery Aneurysm: Results of a Pilot Clinical Study.

OBJECTIVE: We report the results of a pilot clinical study that evaluated the safety and efficacy of a newly-developed, retrievable flow diverter (FloWise; Taewoong Medical) for the treatment of internal carotid artery (ICA) aneurysm. MATERIALS AND METHODS: A total of 10 patients were enrolled. Inclusion criteria were 1) unruptured aneurysm with a dome size of ≥ 8 mm and a neck size of ≥ 4 mm at the ICA, or 2) two or more unruptured aneurysms of any size able to be spanned by a single FloWise at the ICA. Co-primary effectiveness end points were technical success of FloWise placement, and a 50% or greater decrease in aneurysm volume at the 6-month follow-up angiogram. The primary safety end point was the new development of neurological deficits persisting for more than 1-month post-treatment. RESULTS: Ten patients harboring 14 ICA aneurysms (median diameter, 9.4 mm; range, 2.3-31.0 mm) were enrolled between January 2016 and July 2017. FloWise placement was successful in all patients. There were no newly-developed neurological deficits during the 6-month clinical follow-up period. One patient did not receive follow-up imaging due to pregnancy. Nine patients with 12 aneurysms received a 6-month angiographic follow-up. Ten aneurysms (83.3%) showed decreases in volume greater than 50% (mean volume decrease, 82.8 ± 32.9%), of which 8 (66.7%, 95% confidence interval, 35.4-98.0%) showed complete occlusion. One patient was retreated due to mass symptom aggravation. CONCLUSIONS: In this pilot study, FloWise appeared to be safe and effective for ICA aneurysm treatment. A prospective multicenter study to validate the effectiveness and safety of FloWise would be worthwhile.

Y-configuration stenting for coiling of wide-neck bifurcation aneurysms using Low-profile Visualized Intraluminal Support Junior.

BACKGROUND: Little has been reported about the feasibility and durability of a Low-profile Visualized Intraluminal Support Junior (LVIS Jr) Y-stenting device for wide-neck bifurcation aneurysms. PURPOSE: To evaluate the feasibility and durability of LVIS Jr Y-stenting for coiling of unruptured wide-neck bifurcation aneurysms. METHODS: We identified patients in whom LVIS Jr Y-stenting was attempted for unruptured wide-neck bifurcation aneurysms from a prospectively maintained registry of a referral hospital. Procedural success rate, treatment-related morbidity, and clinical and angiographic outcomes were retrospectively assessed. RESULTS: LVIS Jr Y-stenting was attempted for a total of 21 aneurysms in 21 patients (mean age 60±8.9 years; M:F=6:15): nine basilar artery, six anterior communicating artery, four middle cerebral artery, one internal carotid artery, and one vertebrobasilar fenestration aneurysms. The mean dome and neck size were 7.9±2.7 mm and 5.7±1.8 mm, respectively. All attempts were successful. Treatment-related morbidity occurred in one individual with a modified Rankin Scale (mRS) score of 2. Immediate postprocedural angiograms showed complete occlusion in 15 (71.4%) and neck remnant in 6 (28.6%) patients. All 21 patients had good outcomes (mRS score 0-2) for a mean of 12 months' follow-up (range 6-27 months); mRS score 0 in 20 patients and mRS score 2 in one patient, respectively. Follow-up imaging over a mean of 11 months (range 6-18 months) was available in 18 patients (85.7%). All aneurysms showed complete occlusion at follow-up. CONCLUSIONS: LVIS Jr Y-stenting and coiling for wide-neck bifurcation aneurysms seems to be feasible with acceptable safety and to provide durable aneurysm occlusion for wide-neck bifurcation aneurysms.

Microsurgical Treatment of Unruptured Anterior Choroidal Artery Aneurysms: Incidence of and Risk Factors for Procedure-Related Complications.

OBJECTIVE: To describe our experiences with microsurgical treatment of unruptured anterior choroidal artery (AchA) aneurysms, and to evaluate the incidence of and risk factors for procedure-related complications. METHODS: The study included 110 patients treated between January 2012 and December 2016. All patients met the following criteria: 1) microsurgical treatment of an unruptured AchA aneurysm was performed; and 2) clinical and radiographic follow-up data were available, including findings from preoperative digital subtraction angiography. The incidence of and risk factors for procedure-related complications were retrospectively evaluated. The χ2 test and Mann-Whitney U test were used in statistical analysis, and univariate analysis and multivariate logistic regression analysis were conducted. RESULTS: Procedure-related complications occurred in 5 patients (4.5%), including symptomatic complications in 4 patients (3.6%) and asymptomatic complications in 1 patient (0.9%). Multivariate logistic regression analysis indicated that the angle between the vertical line to the cranial base and the axis of the communicating segment of the internal carotid artery (MiC angle) (odds ratio [OR], 1.66; 95% confidence interval [CI], 1.13-5.26; P = 0.038) and the angle between the projection line of the aneurysmal dome and the axis of the communicating segment of the internal carotid artery (DC angle) (OR, 3.82; 95% CI, 1.49-11.7; P = 0.014) were independent risk factors for procedure-related complications. CONCLUSIONS: When microsurgical treatment of unruptured AchA aneurysms was performed, the procedure-related complication rate was 4.5%. Patients with AchA aneurysms with a smaller MiC angle and smaller DC angle may be at a higher risk of procedure-related complications when undergoing microsurgical treatment.

Therapeutic strategies for residual or recurrent intracranial aneurysms after microsurgical clipping.

OBJECTIVES: Therapeutic strategies for residual or recurrent aneurysm (RRA) after microsurgical clipping have not been well established. The purpose of this study was to report our retreatment experiences with previously clipped aneurysms and to demonstrate retreatment strategies for these RRAs. PATIENTS AND METHODS: From 1996-2016, we treated 68 RRAs after previous clipping. Among them, 34 patients underwent microsurgical retreatment, and the other 34 underwent endovascular retreatment. Radiographic images and clinical data were reviewed retrospectively to determine the treatment efficacy, clinical outcomes, and important factors for selecting the proper treatment modality. RESULTS: The most common aneurysm location was the middle cerebral artery (50%) in the microsurgery group and the internal carotid artery (47.1%) in the endovascular surgery group (p = 0.001). In the microsurgery group, 16 (47.1%) patients had additional clipping without removal of previous clips, 17 (50.0%) had clipping with removal of previous clips, and 1 (2.9%) had bypass surgery with trapping. In the endovascular surgery group, 28 (82.4%) patients had simple coiling, 5 (14.7%) had stent-assisted coiling, and 1 (2.9%) had a flow diverter. Procedure-related complications during retreatment occurred in 4 (5.9%) patients. Complete obliteration was achieved in 51 (75.0%) patients (microsurgery group, 82.4% and endovascular surgery group, 67.6%; p = 0.002). CONCLUSIONS: In properly selected cases, treatment of RRAs could be safely performed either by microsurgery or endovascular surgery and result in a good clinical outcome with acceptable morbidity. The decision to choose the treatment modality for RRAs after clipping is not easy but should be considered to lower the risk of retreatment.

Vision Outcomes of Endovascular Treatment for Unruptured Ophthalmic Artery Aneurysms.

OBJECTIVE: The purpose of this study was to report the authors' experience with endovascular treatment (EVT) of ophthalmic artery (OA) aneurysms and to investigate risk factors for visual complications of EVT for unruptured OA aneurysms. METHODS: Fifty-four patients with unruptured OA aneurysms subjected to EVT were recruited for this study from March 2010 to December 2017. The clinical and angiographic outcomes of all 54 patients were investigated and analyzed retrospectively. RESULTS: Of the 54 patients included in this study, 5 patients (9.3%) had visual complications, including asymptomatic unintended OA occlusion in 2 patients (3.7%) and symptomatic complications in 3 patients (5.6%); 2 patients (3.7%) had transient visual complications, and 1 (1.9%) had a permanent complication. No subacute or delayed visual complications occurred during the 20.8-month follow-up period. OA incorporation by the aneurysm (odds ratio [OR], 3.471; 95% confidence interval [CI], 1.115-9.184; P = 0.038) and intentional OA occlusion (OR, 1.820; 95% CI, 1.248-6.221; P = 0.044) were independent risk factors for visual complications in a multivariate logistic regression analysis. CONCLUSIONS: The visual complication rate was 9.3% when performing EVT for unruptured OA aneurysms. OA aneurysms with OA incorporation by the aneurysm might be at higher risk of visual complications when performing EVT. Intentional OA occlusion should be performed with caution, even though a patient may have favorable collaterals during balloon test occlusion.

Hand-Holding during Cystoscopy Decreases Patient Anxiety, Pain, and Dissatisfaction: A Pilot Randomized Controlled Trial.

OBJECTIVE: Often a sick or an anxious person can experience pain or anxiety relief if another person holds his or her hand. In this study, we conducted investigations to determine whether hand-holding during cystoscopy decreases patient anxiety, pain, and dissatisfaction while at the same time increasing patient comfort and tolerance during the procedure. PATIENTS AND METHODS: Eighty-six male patients who underwent flexible cystoscopy between November 2015 and March 2017 were randomized as follows: hand-holding (group I, n = 43) or non-hand-holding (group II, n = 43) during the procedure. Before flexible cystoscopy, lidocaine gel was instilled in the urethra. Patients' anxiety levels were quantified using the State-Trait Anxiety Inventory. A visual analog scale (0-10) was used for self-assessment of satisfaction, discomfort, and willingness to undergo repeat cystoscopy. RESULTS: Demographic characteristics, mean age, procedure duration, procedure indications, and preprocedural analyses did not differ significantly between the 2 groups. In group I, the postprocedural mean anxiety level, pain score, heart rate, and systolic blood pressure were significantly lower compared with those in group II (p = 0.009, p = 0.003, p = 0.022, and p = 0.014, respectively). In group I, postprocedural mean satisfaction score were higher, and patients were more likely to undergo a repeat cystoscopy, compared with those in group II (p = 0.001 and p = 0.004, respectively). CONCLUSIONS: Hand-holding during cystoscopy significantly reduced patients' feelings of anxiety, pain, discomfort, and dissatisfaction. Hand-holding served as a simple, inexpensive, and effective adjunct to sedation during cystoscopy.