Three-dimensional fusion imaging to assess apposition of low-profile visualized intraluminal support stent for intracranial aneurysm coiling.

Objective: To investigate on three-dimensional (3D) fusion images the apposition of low-profile visualized intraluminal support (LVIS) stents in intracranial aneurysms after treatment and assess inter-rater reliability. Materials and methods: Records of all patients with unruptured intracranial aneurysms who were treated with the LVIS stent were retrospectively accessed and included in this study. Two neurosurgeons evaluated the presence of malapposition between the vessel walls and the stent trunk (crescent sign) and the vessel wall and the stent edges (edge malappostion) on 3D fusion images. These images were high-resolution cone-beam computed tomography images of the LVIS stent fused with 3D-digital subtraction angiography images of the vessels. Associations between malapposition and aneurysm location were assessed by Fisher's exact test, and inter-rater agreement was estimated using Cohen's kappa statistic. Results: Forty consecutive patients were included. In all patients, 3D fusion imaging successfully visualized the tantalum helical strands and the closed-cell structure of the nitinol material of the low-profile visualized intraluminal support. A crescent sign was observed in 27.5 % and edge malapposition in 47.5 % of the patients. Malapposition was not significantly associated with location (p = 0.23 crescent sign, p = 0.07 edge malapposition). Almost perfect (κ = 0.88) and substantial (κ = 0.76) agreements between the two raters were found for the detection of crescent signs and edge appositions, respectively. Conclusions: 3D fusion imaging provided clear visualization of the LVIS stent and parent arteries, and could detect malapposition with excellent inter-rater reliability. This technique may provide valuable guidance for surgeons in determining postoperative management.

[Simulation for Endovascular Treatment].

With the advent of high-resolution imaging and advancements in computational fluid dynamics(CFD)and computational structural mechanics(CSM)analyses, clinical simulation of endovascular intervention has gradually become feasible. Virtual stents have become indispensable for coil embolization. For braided stents, such as those with low-profile visualized intraluminal support and flow diverters, predicting postplacement elongation and contraction is challenging; however, software development has enabled more precise treatment planning. Additionally, simulations utilizing three-dimensional(3D)printer models can enable realistic simulations of procedures such as intracranial stents and Woven EndoBridge placement. This approach is beneficial for shunt disorders such as arteriovenous malformations and dural arteriovenous fistulas, offering 3D visualization of shunt access routes and intuitive treatment strategy planning, even for beginners. Furthermore, it can be applied to procedures such as open surgical clipping and nidus resection, aiding in the selection of suitable clips and considerations for ideal resection based on nidus curvature. Simulations using CFD, CSM, and 3D printers are crucial for training surgeons and handling new devices. Harnessing medicine-engineering synergy is essential, and regulatory approval(insurance coverage)and appropriate commercialization of simulations are paramount for the future.

Risk factors and management of intraprocedural rupture during coil embolization of unruptured intracranial aneurysms: role of balloon guiding catheter.

Introduction: Intraprocedural rupture (IPR) is a serious complication of endovascular coil embolization of unruptured intracranial aneurysms (UIAs). Although outcomes after IPR are poor, methods to prevent subsequent neurological deterioration have not yet been investigated. We evaluated the risk factors and management strategies for IPR, particularly the role of balloon guiding catheters (BGCs) in rapid hemostasis. Methods: We retrospectively reviewed all UIA cases treated with coil embolization at three institutions between 2003 and 2021, focusing on preoperative radiological data, operative details, and outcomes. Results: In total, 2,172 aneurysms were treated in 2026 patients. Of these, 19 aneurysms in 19 patients (0.8%) ruptured during the procedure. Multivariate analysis revealed that aneurysms with a bleb (OR: 3.03, 95% CI: 1.21 to 7.57, p = 0.017), small neck size (OR: 0.56, 95% CI: 0.37 to 0.85, p = 0.007), and aneurysms in the posterior communicating artery (PcomA) (OR: 4.92, 95% CI: 1.19 to 20.18, p = 0.027) and anterior communicating artery (AcomA) (OR: 12.08, 95% CI: 2.99 to 48.79, p < 0.001) compared with the internal carotid artery without PcomA were significantly associated with IPR. The incidence of IPR was similar between the non-BGC and BGC groups (0.9% vs. 0.8%, p = 0.822); however, leveraging BGC was significantly associated with lower morbidity and mortality rates after IPR (0% vs. 44%, p = 0.033). Discussion: The incidence of IPR was relatively low. A bleb, small aneurysm neck, and location on PcomA and AcomA are independent risk factors for IPR. The use of BGC may prevent fatal clinical deterioration and achieve better clinical outcomes in patients with IPR.

Intermediate catheter use is associated with complete occlusion and dense packing in coil embolization of unruptured cerebral aneurysms: a propensity score matched study.

BACKGROUND: An intermediate catheter (IMC) can improve the maneuverability and stability of the microcatheter. OBJECTIVE: To investigate the efficacy and safety of using an IMC in triaxial systems for coil embolization of unruptured cerebral aneurysms (UCAs). METHODS: A total of 2430 consecutive saccular UCAs (2259 patients) that underwent initial coil embolization at three institutions between November 2003 and May 2023 were retrospectively reviewed. Patients were classified into two groups: with IMC (IMC(+)) and without IMC (IMC(-)). To investigate whether IMC use increased the rate of complete occlusion and the packing density, a propensity score-matched analysis was used to control for clinical, anatomical, and procedural features. RESULTS: Ultimately, 595 (24.5%) coil embolization used an IMC. Propensity score matching was successful for 424 paired IMC(+) and IMC(-) aneurysms. Compared with the IMC(-) group, the IMC(+) group had significantly higher rate of Raymond-Roy Occlusion Classification class 1 immediately after treatment (30.0% vs 20.8%, P=0.003) and at 6 months (28.8% vs 20.0%, P=0.004) and a higher volume embolization ratio (27.2% (SD 6.5%) vs 25.9% (SD 6.2%), P=0.003). Re-treatment rates were not significantly different between the two groups (0.7% vs 0.2%, P=0.624). No significant differences in the incidences of ischemic and hemorrhagic complications and IMC-related parent artery dissection were found between the two groups. CONCLUSION: Use of IMCs in triaxial systems can provide effective and safe support in coil embolization of UCAs because complete occlusion and dense coil packing can be achieved without increased complications.

Diagnostic Yield of Bone Window Computed Tomography and Cerebral Angiography Testing Congenital Bilateral Hypoplasia of the Internal Carotid Artery.

We herein report a case of congenital bilateral hypoplasia of the internal carotid artery (ICA) that was diagnosed by bone window computed tomography (CT) and cerebral angiography. A 23-year-old woman presented with left dominant quadriplegia. Brain magnetic resonance imaging showed not only massive infarcts in the anterior circulation but also poor depiction of the bilateral ICAs. Bilateral carotid canals on bone window CT suggested hypoplasia. Cerebral angiography revealed narrowing of each ICA above its bifurcation, and the blood supply to the intercranial carotid systems developed from the vertebrobasilar system through the posterior communicating arteries and posterior cerebral arteries. We diagnosed the patient with congenital bilateral hypoplasia of the ICA based on bone CT and cerebral angiography findings. Performing both bone window CT and cerebral angiography can facilitate the diagnosis of congenital hypoplasia of the ICA.

Diagnostic performance of intraoperative cone beam computed tomography compared with postoperative magnetic resonance imaging for detecting hemorrhagic transformation after endovascular treatment following large vessel occlusion.

OBJECTIVES: Early detection of hemorrhagic transformation (HT) in patients with large vessel occlusion (LVO) after endovascular treatment is important for postoperative patient management. We investigated the diagnostic performance of intraoperative cone beam computed tomography (CBCT) with reference standard magnetic resonance imaging (MRI) for detecting HT. MATERIALS AND METHODS: Consecutive patients with LVO treated by endovascular treatment who underwent intraoperative CBCT and postoperative MRI were included. Two observers evaluated all images for the presence of HT. Sensitivity and specificity for detecting HT were calculated with MRI as reference standard. The observers classified HT according to the European Cooperative Acute Stroke Study (ECASS). Inter-method and inter-rater agreement for the detection of HT and for the ECASS classification were assessed using kappa or weighted Brennan-Prediger (wBP) statistics. RESULTS: Images of 106 procedures (94 for anterior circulation) were analyzed. The sensitivity and specificity for detecting HT on CBCT were 0.77 and 0.83, respectively, for all procedures and 0.83 and 0.8, respectively, for anterior circulation. The inter-method agreement for HT detection (κ = 0.63 overall, κ = 0.69 anterior circulation) and ECASS classification (wBP = 0.67 overall, wBP = 0.77 anterior circulation) were substantial. The inter-rater agreement for HT detection (κ = 0.87 overall, κ = 0.85 anterior circulation) and for ECASS classification (wBP = 0.95 overall, wBP = 0.92 anterior circulation) were almost perfect. CONCLUSIONS: The diagnostic performance of CBCT for the detection of HT in stroke patients treated for LVO was acceptable with excellent inter-rater agreement. Intraoperative CBCT may be useful to trigger early interventions if HT is detected, although detailed classifications of HT may be difficult.

Clinical outcomes of procedures combining endovascular embolization with a direct surgical approach in a hybrid operating room for the treatment of refractory dural arteriovenous fistulas.

BACKGROUND: We reviewed the clinical outcomes of a procedure that combines endovascular embolization and a direct surgical approach in a hybrid operating room (OR) for the treatment of refractory dural arteriovenous fistulas (dAVFs). METHODS: All patients with intracranial dAVFs who underwent a procedure combining endovascular embolization and direct surgical approach with biplane angiography or a robotic C-arm system in a hybrid OR between February 2004 and June 2020 were considered. Borden grading, occlusion rate, pre-and post-operative modified Rankin Scale (mRS) scores, and complications were retrospectively investigated. The pre-and postoperative mRS scores were compared using the Wilcoxon signed-ranks test. RESULTS: We evaluated 14 arteriovenous fistulas (AVFs) in consecutive 13 patients. Of these, ten AVFs were previously treated with endovascular embolization, ten were located in the transverse-sigmoid sinus, and four in the cortical vein. The Borden grade was II in two AVFs and III in 12 AVFs. Immediate occlusion of the AVF was achieved in 13 AVFs, and gradual occlusion was observed in one case. The median preoperative mRS was 1 (0-3), whereas the median postoperative mRS was 0 (0-1) which indicated marked improvement (P = 0.006). Complications including postoperative transient visual disturbance and intraprocedural extravasation were observed in only two cases. CONCLUSION: The combination of endovascular embolization and direct surgical approach in a hybrid OR could achieve sufficient occlusion of refractory AVFs with acceptable complication rates and improved symptoms.

Visualization of extracranial-intracranial bypass in moyamoya patients using intraoperative three-dimensional digital subtraction angiography with intravenous contrast injection and robotic C-arm: patient series.

BACKGROUND: The authors describe a noninvasive intraoperative imaging strategy of three-dimensional (3D) digital subtraction angiography (DSA) with intravenous (IV) contrast injection, using indocyanine green (ICG) as a test bolus, during extracranial-intracranial (EC-IC) bypass surgery for moyamoya disease. OBSERVATIONS: Four patients underwent EC-IC bypass surgery in a hybrid operating room. During the surgery, bypass patency was verified using ICG videoangiography and Doppler ultrasonography. After skin closure, the patients under anesthesia underwent IV 3D-DSA with a robotic C-arm in which the scan delay time for the 3D-DSA scan was estimated from the arrival time of ICG during the ICG videoangiography. One day after the surgery, the patients underwent magnetic resonance angiography (MRA). The IV 3D-DSA images were retrospectively compared with those obtained with other modalities. Good bypass patency was confirmed on IV 3D-DSA, ICG videoangiography, Doppler ultrasonography, and postoperative MRA in all cases. The delay time determined using ICG videoangiography as a test bolus resulted in IV 3D-DSA with adequate image quality, allowing assessment of the spatial relationships between the vessels and anastomoses from all directions. LESSONS: To evaluate bypass patency and anatomical relationships immediately after EC-IC bypass surgery, IV 3D-DSA may be a useful modality. ICG videoangiography can be used to determine the scan delay time.

Flow Diverter Apposition in Patients with Large or Giant Intracranial Aneurysms Evaluated on Three-Dimensional Fusion Images Acquired by High-Resolution Cone-Beam Computed Tomography and Digital Subtraction Angiography.

OBJECTIVE: To investigate flow diverter (FD) apposition on fused images acquired by high-resolution cone-beam computed tomography (CBCT) and 3-dimensional (3D) digital subtraction angiography. METHODS: Patients with large or giant internal carotid artery aneurysms treated with Pipeline FDs who underwent CBCT imaging at our institution between October 2016 and May 2019 were included. Two neurosurgeons measured the maximum malapposition between FDs and vessel walls on 3D fusion images of high-resolution CBCT images displaying the FD and 3D digital subtraction angiography images displaying the vessels. Associations between the relative malapposition, FD diameter, vessel diameter, proximal and distal vessel diameter discrepancy, and siphon angle were evaluated by linear regression analysis. Inter-rater and intermethod (3D and 2D image) agreements of the malapposition measurements were assessed by Bland-Altman analysis and by interclass correlation coefficients. RESULTS: Images of 2 patients were excluded because of image artifacts or fusion errors, and 3D fusion images were acquired in the remaining 26 patients. Our results did not suggest that relative malapposition was associated with vessel diameter (P = 0.12), vessel diameter discrepancy (P = 0.60), or syphon angle (P = 0.34), but relative malapposition increased by an estimated 13% (95% confidence interval: 4%-23%, P = 0.006) for each 1 mm increase in FD diameter. Inter-rater and intermethod agreements for apposition measurements were excellent and good, respectively. CONCLUSIONS: Three-dimensional fusion images provided clear visualization of structures of both the stent and parent artery with excellent diagnostic reliability. Careful deployment may be needed for FDs with larger diameters, as they tended to have larger relative malapposition.

Comparison of Clinical Outcomes After Stent-Assisted Coiling with 3 Types of Self-Expanding Laser-Cut Stents in Patients with Wide-Necked Intracranial Aneurysms.

OBJECTIVE: We report the clinical outcomes of stent-assisted coiling for wide-necked intracranial aneurysms using 3 low-profile laser-cut stents and compare the results according to stent type. METHODS: All patients treated with stent-assisted coiling for their intracranial aneurysms at our hospital between July 2010 and September 2019 were reviewed. We selected patients with Enterprise, Neuroform EZ, or Neuroform Atlas stents who underwent imaging follow-up and investigated aneurysm and stent features, stent-related complications, recanalization, and retreatment rates. We compared the retreatment risk among the patients treated with the 3 stent types using Kaplan-Meier survival analysis and Cox regression analysis. RESULTS: We evaluated 364 consecutive cases (103 Enterprise, 105 Neuroform EZ, and 156 Neuroform Atlas stents). Neuroform Atlas was more frequently used in distal vessels: 8 (7.8%) Enterprise, 2 (1.9%) Neuroform EZ, and 41 (26.3%) Neuroform Atlas cases, respectively. The median follow-up durations were 6.49, 4.91, and 1.24 years for the Enterprise, Neuroform EZ, and Neuroform Atlas cases, respectively, and retreatment was performed in 11 (10.1%), 9 (8.6%), and 6 (3.8%) cases. In the first 2 years of follow-up, the estimated retreatment risk ratios for Neuroform EZ and Neuroform Atlas with Enterprise as reference were 0.63 (95% confidence interval, 0.24-1.65; P = 0.35) and 0.54 (95% confidence interval, 0.18-1.59; P = 0.26), respectively. CONCLUSIONS: Neuroform Atlas stents were more frequently deployed in small-caliber vessels compared with the other 2 types of stents. The complication rate and retreatment risk until at least 1 year after the aneurysm treatment appeared to be similar for the 3 stent types.

4D Digital Subtraction Angiography for the Temporal Flow Visualization of Intracranial Aneurysms and Vascular Malformations.

PURPOSE: To assess the benefit and radiation dose of four-dimensional (4D) digital subtraction angiography (DSA) - a time resolved three-dimensional (3D) DSA application - to evaluate the flow and architecture of aneurysms and vascular malformations. METHODS: All patients with cerebrovascular disease were considered who underwent 4D-DSA at our institution between January 2015 and February 2016. For the aneurysm patients, we evaluated the image quality in terms of the visualization of contrast flow in the aneurysm on a 3-point scale (excellent, fair and poor). Interrater agreement between two raters was estimated using Cohen's Kappa statistics. For the shunt disease patients, the additional information obtained from the 4D-DSA was described for each disease. The median radiation dose and volume of contrast medium required for the acquisitions were estimated. RESULTS: A total of 173 patients underwent 4D-DSA; 126 intracranial aneurysms, 10 arteriovenous malformations (AVM), 15 dural arteriovenous fistula (dAVF) and 22 other diseases. For aneurysm patients, excellent and fair visualization of the intra-aneurysmal flow was observed in 27.7%, 72.3%, and excellent (κ = 0.9) agreement between the raters was found. For AVM and dAVF patients, 4D-DSA clarified the complex vasculature by viewing the discrete time phase of contrast filling. Median radiation dose for intracranial lesions was 79.6 mGy for 6s 4D-DSA, and 175 mGy for 12s 4D-DSA. The median amount of contrast medium used was 18.0 ml for 6s 4D-DSA and 21.0 ml for 12s 4D-DSA. CONCLUSIONS: 4D-DSA provided additional information regarding intra-aneurysmal flow and contributed to detect different component of nidus or shunt points.

Hybrid procedure combining clip on wrapping and stent placement for ruptured supraclinoid blood blister-like aneurysm of the internal carotid artery.

Blood blister-like aneurysms of the supraclinoid portion of the internal carotid artery are rare, fragile, and thin-walled lesions with a higher rate of rebleeding. Our case underwent a hybrid procedure combining direct surgical and endovascular approach.