Targeted and Staged Treatment for Ruptured Wide-neck Intracranial Aneurysms: Bleb Coiling Strategy as a New Approach.

RATIONALE AND OBJECTIVE: This study aimed to investigate the feasibility, safety, and efficiency rates of the bleb coiling technique for the treatment of acute ruptured wide-neck bifurcation aneurysm (WBNAs) by comparing it with device-assisted coiling. MATERIALS AND METHODS: Patients with ruptured WNBAs who underwent endovascular treatment (EVT) were reviewed. The study sample was divided into five groups according to treatment type: bleb coiling, single catheter coiling, balloon-assisted coiling (BAC), neck remodeling mesh-assisted coiling, and stent-assisted coiling (SAC). The feasibility, safety, efficiency and complication rates of the bleb coiling technique were compared with each group. RESULTS: This study included 109 patients with ruptured WNBAs. Bleb coiling was performed in 24 blebs of 20 WNBAs. The mean time interval between initial and complementary treatment in the bleb coiling group was 12.53± 5 .27 weeks (min-max: 4-23 weeks). No rebleeding occurred during this interval time, and no mortality or new permanent neurologic deficit caused by the bleb coiling technique was noted. The bleb coiling technique had a lower complication rate than other techniques (p <0.05). CONCLUSION: The bleb coiling strategy led to favourable clinical outcomes with low complication rates and it can be considered as an alternative treatment option at acute phase of SAH in the endovascular treatment of ruptured WBNAs with coilable-bleb.

Modified balloon-assisted coiling instead of acute stenting in the treatment of ruptured wide necked intracranial aneurysms.

BACKGROUND: The aim of this study was to investigate the safety and efficiency of the modified balloon assisted coiling (mBAC) technique in endovascular treatment (EVT) of ruptured wide-necked aneurysms (WNAs) to avoid stent placement in the acute phase of subarachnoid hemorrhage (SAH). METHODS: The local neurointerventional radiology database was retrospectively reviewed to identify patients who underwent EVT due to ruptured WNAs by the authors. According to the EVT technique performed, the study sample was divided into 3 groups: conventional BAC, stent assisted coiling (SAC), and mBAC. The patient demographics, aneurysm features, technical and clinical complications, aneurysm occlusion grades, morbidity, and mortality rates were comparatively analyzed. RESULTS: This study involved a total of 113 patients who had ruptured WNAs. The mBAC technique was performed on 26 aneurysms (23 saccular and 3 fusiform) in 26 patients to avoid acute phase stenting. The mean continuous balloon inflation time was 7.1 ± 2.12 min. The initial and follow-up angiographic and clinical outcomes were better in the mBAC group than in the SAC group (p < 0.05). CONCLUSIONS: The mBAC technique offers a prolonged, continuous balloon inflation time during the whole coiling process in the treatment of ruptured WNAs. The mBAC technique has the potential to obviate the need for SAC in patients who are candidates for stenting during the acute phase of SAH, and it might be considered a safe and effective endovascular approach with low complication rates and good angiographic and clinical outcomes.

Early choroidal structure and choroidal vascularity index change after carotid stenting.

PURPOSES: We aimed to evaluate changes in subfoveal choroidal thickness (SFCT) and choroidal vascularity index (CVI) in the first postoperative day and month in patients with severe internal carotid artery (ICA) stenosis after ICA stenting. METHOD: The patients who diagnosed with severe ICA stenosis and was performed ICA stenting were included in the study. Patients with any ocular disease and refractive error more than 3 diopters were not included in the study. The imaging of the choroid was performed using enhanced depth imaging (EDI) techniques by spectral domain optical coherence tomography (SD-OCT) (OptovueRTVue XR, Optovue Inc., Fremont, CA).The choroidal vascularity index (CVI), total choroidal area (TA), luminal area (LA), and stromal area (SA) were measured in the subfoveal 2 mm area. These measurements before ICA stenting was compared with the first day and first month after ICA stenting. RESULTS: The study included 41 eyes from 41 patients (11 women [26.83%]; 30 men [73.17%]). The mean age of patients was 62.25 ± 4.85 (57-71) years. The differences in subfoveal CT, TA, LA, SA between before ICA stenting and 1 day after ICA stenting, before ICA stenting and 1 month after ICA stenting was statically significant(p<0.05 for each). CONCLUSION: We have observed increases in SFCT, CVI, LA, SA, and TA on the 1st day and 1st month after ICA stenting in patients with severe carotid stenosis.  Improvement in choroidal thickness and choroidal vascular flow is seen even in the early period of ICA stenting.

Strut remodeling with hypercompliant balloon: A new approach to Y stent-assisted coil embolization in the treatment of complex wide-neck bifurcation aneurysms.

BACKGROUND: The objective of this study was to present the long-term safety and effectiveness of strand remodelling with a hypercompliant balloon. METHODS: Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent strand remodelling with a hypercompliant balloon via Y-stent-assisted coil embolization (Y-SACE) between September 2016 and January 2020 were included in the study. The feasibility, safety, effectiveness, and complication rates of the strand remodelling technique were investigated. RESULTS: A total of 12 patients (6 females, 6 males) were included in this study. Significant expansion was obtained in the intersection zone after remodelling. No regression was observed in the expansion rates during follow-up. There was no additional morbidity or mortality. No delayed thromboembolic complications occurred in our patients during long-term follow-up. CONCLUSIONS: Performing strand remodelling to reduce thromboembolic complications triggered by structural faults caused by the Y-stent configuration is feasible, safe, and effective. This new approach can aid in the prevention of thromboembolic complications in Y-SACE.

Analysis of branch artery orifice angulation: Feasibility of the shelf technique for the treatment of wide-neck bifurcation aneurysms.

BACKGROUND AND PURPOSE: The aim of this study was to investigate the feasibility of the shelf technique by analyzing the angle between the two branch orifices and to present its safety and effectiveness compared with that of the double-stent technique. MATERIALS AND METHODS: Patients with complex wide-neck bifurcation aneurysms (WNBAs) who underwent stent-assisted coiling (SAC) were reviewed. The study sample was divided into two groups: single SAC (shelf technique) and double SAC. The angle between the lines connecting the superior and inferior points of each branch orifice (α angle) was measured by two neurointerventional radiologists in both groups. The inter- and intraobserver repeatability and consistency of the α angle were assessed. The effect of the α angle on the feasibility of using the shelf technique to treat WNBA was analyzed. Technical and clinical success rates were investigated by comparing both groups. RESULTS: Forty-eight patients (32 shelf technique and 16 double-stent technique) were included. There was excellent agreement between the intra- and interobserver repeatability and consistency of α angle measurements. The α angle was smaller in the shelf technique group than in the double-SAC group (p < 0.001). The technical and clinical success rates of both groups were similar based on long-term follow-up (p > 0.05). CONCLUSION: WNBA treatment with the shelf technique is safe and effective. The α angle is a useful parameter to evaluate the performance of the shelf technique. The shelf technique is more suitable for WNBAs with a narrow α angle.

Spontaneous migration of a bullet in the cerebrum.

Herein, we report the case of a 32-year-old man who experienced spontaneous migration of a bullet within the brain following a gunshot injury. Emergent computed tomography revealed the bullet located in the posterosuperior side of mesencephalon. During follow-up after 10 days, the neurological status of the patient had worsened. Computed tomography revealed that the bullet had migrated posteriorly and lodged in the occipital lobe. Although a few studies have reported on the spontaneous migration of a bullet within the brain, the present case is unique as the patient examination changed with migration. We recommend serial imaging and surgery in cases of bullet migration in the brain.

Assessment of Imaging Features of Crohn's Disease with MR Enterography.

BACKGROUND: To evaluate the frequency of pathological findings determined on magnetic resonance (MR) enterography (MRE) in patients with Crohn's Disease. METHODS: A retrospective analysis of the MRE images was made in 34 female and 41 male patients (mean age 41 years) with Crohn's disease. The prevalence of bowel wall (mural thickening, mural edema, mural fat deposits, mucosal enhancement, ulceration, cobblestone appearance, pseudopolyps) and mesenteric fatty tissue alterations (fatty tissue proliferation, mesenteric hypervascularity, enlarged lymph nodes, peri-enteric inflammation, reactive fluid), complications due to penetrating (fistula, sinus tract, abscess) and stenosing processes (fibrotic and inflammatory stenosis, obstruction, dilatation), and involvement of the colon were determined. RESULTS: The most frequently observed changes in the bowel wall and mesenteric fatty tissue were mural thickening (98.7%) and enlargement of mesenteric lymph nodes (76%), respectively. Stenosis was the most common complication (76%). The most frequently seen pathology of the colon was ileocecal valve thickening and enhancement (74.7%). CONCLUSION: MR enterography is a useful imaging modality for the evaluation of changes in both the mesenteric fatty tissue and the bowel wall. As there is no use of ionizing radiation, MR enterography should be the preferred imaging modality during follow-up of patients with Crohn's disease.

First multicenter experience using the Silk Vista flow diverter in 60 consecutive intracranial aneurysms: technical aspects.

BACKGROUND: The aim of this study was to assess the technical success and procedural safety of the new Silk Vista device (SV) by evaluating the intraprocedural and periprocedural complication rate after its use in several institutions worldwide. METHODS: The study involved a retrospective review of multicenter data regarding a consecutive series of patients with intracranial aneurysms, treated with the SV between September 2020 and January 2021. Clinical, intra/periprocedural and angiographic data, including approach, materials used, aneurysm size and location, device/s, technical details and initial angiographic aneurysm occlusion, were analyzed. RESULTS: 60 aneurysms were treated with SV in 57 procedures. 66 devices were used, 3 removed and 63 implanted. The devices opened instantaneously in 60 out of 66 (91%) cases and complete wall apposition was achieved in 58 out of 63 (92%) devices implanted. In 4 out of 66 (6%) devices a partial opening of the distal end occurred, and in 5 (8%) devices incomplete apposition was reported. There were 3 (5%) intraprocedural thromboembolic events managed successfully with no permanent neurological morbidity, and 4 (7%) postprocedural events. There was no mortality in this study. The initial occlusion rates in the 60 aneurysms were as follows: O'Kelly-Marotta (OKM) A in 34 (57%) cases, OKM B in 15 (25%) cases, OKM C in 6 (10%) cases, and OKM D in 5 (8%) cases. CONCLUSIONS: Our study demonstrated that the use of the new flow diverter Silk Vista for the treatment of intracranial aneurysms is feasible and technically safe.

Microwire navigation and microcatheter positioning by balloon manipulation for the treatment of intracranial aneurysms: A pilot study.

BACKGROUND AND OBJECTIVE: An intracranial aneurysm (IA) is a life-threatening condition and endovascular treatment (EVT) is a demanding procedure, especially in IAs with an unfavorable anatomy. The aim of this study was to investigate the safety and efficacy of balloon-assisted microwire navigation and microcatheter positioning in the EVT of IAs with challenging anatomies. MATERIALS AND METHODS: This retrospective study included patients that underwent balloon-assisted microwire navigation and microcatheter positioning in the EVT of IAs between September 2016 and January 2019. All EVT procedures and data collection were performed by the same two neurointerventional radiologists. Technical success and complication rates, safety, and efficiency of the balloon manipulation method were evaluated. Statistical software was used to analyze the basic descriptive data of the patients and aneurysms. RESULTS: This study included 14 patients. The microwire navigation of the target artery with balloon manipulation was used in 4 aneurysms of 4 patients. Microcatheter positioning with balloon manipulation was used in 10 aneurysms of 10 patients. There was no complication caused by the balloon manipulation technique. The technical success rate was 100%. CONCLUSION: In the EVT of IAs with challenging anatomies, the presented technique is a safe and effective option without additional complications, especially in the target artery with an acute angle and in small aneurysms.