Neurogenic pulmonary edema and Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage.

PURPOSE: Neurogenic pulmonary edema (NPE) combined with Takotsubo cardiomyopathy (TCM) is a rare condition associated with aneurysmal subarachnoid hemorrhage (aSAH). Although several mechanisms have been proposed, the pathophysiology and management strategies are not yet fully established. We aimed to determine the radiological and clinical outcomes of patients with NPE and with TCM after aSAH to propose management strategies. METHODS: We analyzed the data of 564 patients with aSAH recorded at a single medical center from February 2015 to July 2022. This study retrospectively investigated the incidence and demographics of SAH combined with both NPE and TCM and the clinical outcomes of the patients. Correlating factors, independently associated with NPE-TCM, were also investigated. RESULTS: During the 7 years, 11 (2.0%) of 564 patients had NPE complicated with TCM after aSAH. Seven of 11 (63.6%) patients had poor-grade SAH (Hunt-Hess Grade 4 to 5). Three of 11 patients had a posterior circulation in the NPE-TCM group. The most prevalent treatment option was endovascular coil embolization, except for one case of clip. Long-term outcomes were favorable in 6 of 11 patients, and there was one case of mortality. Age, troponin I level, and alveolar-arterial oxygen gradient were correlating factors of NPE-TCM. CONCLUSION: Although NPE-TCM represents a rare complication associated with aSAH, achieving active resolution of underlying neurological causes through early and appropriate treatment may contribute to a favorable prognosis. Considering the limited incidence of SAH complicated with NPE-TCM, a multi-center study may be needed.

Depression or Anxiety According to Management Modalities in Patients With Unruptured Intracranial Aneurysms.

BACKGROUND: In the treatment of unruptured intracranial aneurysms, the risk was usually estimated by objective neurological sequelae. However, their effects on depression and anxiety are rare and remain controversial. We aimed to evaluate the risk of depression and anxiety in patients with unruptured intracranial aneurysm stratified by management strategies in a population-based, longitudinal cohort study. METHODS: Using the Korean National Health Insurance Research Database, 71 750 patients with unruptured intracranial aneurysms between 2008 and 2011 were identified and followed up until the end of 2020. The risk of depression and anxiety was compared among management strategies with respect to age, sex, and medical comorbidities. RESULTS: The Kaplan-Meier survival curves indicated that the treatment (clipping and endovascular treatment) group developed depression more frequently than the observation group (P<0.001). The adjusted hazard ratio was 1.11 (95% CI, 1.07-1.15) in the treatment group. According to the management modality, the Kaplan-Meier survival curves indicated that clipping and endovascular treatment groups developed depression more frequently than the observation group (P<0.0001). The adjusted hazard ratio was 1.15 (95% CI, 1.10-1.21) for clipping and 1.07 (95% CI, 1.02-1.12) for endovascular treatment. The depression risk was higher with advanced age (hazard ratio for 45-64 years, 1.37 [95% CI, 1.29-1.45] and hazard ratio for ≥65 years, 2.04 [95% CI, 1.92-2.17]). The risk for anxiety did not differ among the management modalities. CONCLUSIONS: In this study, the risk of depression was slightly greater after clipping surgery than endovascular treatment. Data on treatment-related, long-term psychological outcomes, such as depression, may aid decision-making for preventive treatment of asymptomatic unruptured intracranial aneurysm patients.

Transdural Revascularization by Multiple Burrhole After Erythropoietin in Stroke Patients With Cerebral Hypoperfusion: A Randomized Controlled Trial.

BACKGROUND: In patients with acute symptomatic stroke, reinforcement of transdural angiogenesis using multiple burr hole (MBH) procedures after EPO (erythropoietin) treatment has rarely been addressed. We aimed to investigate the efficacy and safety of cranial MBH procedures under local anesthesia for augmenting transdural revascularization after EPO treatment in patients with stroke with perfusion impairments. METHODS: This prospective, randomized, blinded-end point trial recruited patients with acute ischemic stroke with a perfusion impairment of grade ≥2 within 14 days of symptom onset, steno-occlusive mechanisms on imaging examinations, and absence of transdural collaterals on transfemoral cerebral angiography. Patients were randomly assigned to receive MBH + EPO or MBH alone. The primary and secondary outcomes were revascularization success (trans-hemispheric and trans-burr hole) at 6 months and adverse events, respectively. RESULTS: We evaluated 42 of the 44 targeted patients, with 2 patients lost to follow-up. The combined and MBH-only (n=21 each) groups showed no differences in demographic characteristics and baseline perfusion parameters. Significantly, more cases of trans-hemispheric (19/21 [90.5%] versus 12/21 [57.1%]) and trans-burr hole (42/58 [72.4%] versus 30/58 [51.7%]) revascularization and significant improvements in perfusion parameters were observed in the combined group relative to the MBH-only group. No differences in treatment-related complications were observed between groups. Even after adjustment for potential covariates, EPO usage was an independent factor of successful hemispheric revascularization in this study (odds ratio, 6.41 [95% CI, 1.08-38.02]). CONCLUSIONS: The combination of MBH and EPO is safe and feasible for reinforcing transdural revascularization in acute steno-occlusive patients with perfusion impairments. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02603406.

New Simple 3-Dimensional Computed Tomogram Classification Leading to Successful Conservative Treatment in 51 Atlanto-Axial Rotatory Fixation Children.

OBJECTIVE: to present a new and easy classification of atlanto-axial rotatory fixation (AARF) and to investigate the efficiency of conservative treatment of AARF. BACKGROUND: Although there is a precise definition and diagnostic classification of AARF, there is still significant difficulty in measuring the atlas and axis angles because all of the atlas or axis cannot be seen in a certain 2-dimensional computed tomogram image. In addition, some recent case reports showed that long-term conservative treatment can reduce pediatric AARFs, even that are severe or chronic. METHODS: Fifty-one children with AARF were analyzed retrospectively with new 3-dimensional computed tomogram (3DCT)-based AARF classification; the mean age was 72.7 ± 35.2 months (19-139 months). In the new AARF classification, type 1 was defined as that when the C1C2 angle is not 0° on midline and type 2 as that when the C1C2 angle is 0° on the midline. RESULTS: All 7 children with AARF type 1 were treated successfully only with Halter tractions. Twenty among 44 children with type 2 did not show any difference in improvement compared with not-treated 24 children with type 2. CONCLUSION: The first new AARF classification based on 3DCT appears to be easy to use and even the most severe children with AARF may be managed only with conservative treatment such as long-term Halter traction.

Prevalence of Intracranial Aneurysms in Patients With Systemic Vessel Aneurysms: A Nationwide Cohort Study.

Background and Purpose- Most aneurysms are a focal manifestation of a systemic condition. Some reports have suggested genetic and environmental factors may play a role in pathogenesis. The aim of the present study was to evaluate the prevalence of intracranial aneurysms (IA) in a large cohort of patients with other systemic vessel aneurysms and dissections (OVAD) and identify potential risk factors for IA in this population. Methods- We defined OVAD as systemic vessel aneurysms, excluding aortic dissections and aneurysms. A cohort of 1.1 million patients was extracted from the population-based cohort from the Korea National Health Insurance Service, which holds almost all medical data including diagnostic codes, procedures, and personal information. Using χ2 or Fisher exact test, the prevalence of the IA concerning OVAD status was analyzed. Results- In OVAD individuals, 25.7% (261/1017) of patients had been concurrently diagnosed with IA. The odds ratios for having concurrent IA in patients with OVAD were 56.31 (95% CI, 48.821-64.949; P=0.000). OVAD patients with dyslipidemia were >7× likely to be affected by IA (adjusted odds ratio, 7.7 [95% CI, 6.59-9.01]; P=0.000). Hypertension, diabetes mellitus, old age (>60 years), and male sex had increased odds for having concurrent IA by 5.89, 3.48, 1.83, and 1.35, respectively. Subgroup analysis with socioeconomic or disability revealed that the prevalence of IA was significantly higher in all groups. Uncertainty regarding the temporal sequence of onset and lack of detail on disease severity and subtype prevented more conclusive results. Conclusions- Patients with OVAD have a higher prevalence of IA than control groups. Therefore, we may approach aneurysms as systemic disease, and further investigations about their pathophysiology must follow.

Relationships between Head Circumference Percentile, Lumbar Puncture Pressure, and Cerebrospinal Fluid Space in Young Children: Increased Cerebrospinal Space and Pressure May Result in Compensatory Enlargement of Head Circumference Only in the Infant Period.

BACKGROUND: The aim of this study was to retrospectively evaluate and analyze the relationships between head circumference percentile (HCP), lumbar puncture pressure (LPP), and cerebrospinal fluid (CSF) space. METHODS: The 88 patients were divided into 3 age groups (group 1, up to 12 months; group 2, 12-36 months; group 3, 36-72 months). RESULTS: In group 1 (n = 40), there was a significant positive correlation of the HCP with the LPP (r =0.414, p =0.008), Evans ratio (r =0.365, p =0.021), and thickness of subdural hygroma (SDHG; r =0.403, p =0.010). Group 2 (n = 29) revealed a significant positive correlation between the LPP and the thickness of SDHG (r =0.459, p =0.012). Group 3 (n = 19) showed no significant correlation among these factors. Overall, age was related with SDHG thickness both in infants and toddlers, while HCP was related with LPP, Evans ratio, and SDHG thickness only in infants, and LPP was related with SDHG thickness only in toddlers. CONCLUSION: We suggest that increased cerebrospinal space and pressure may result in compensatory enlargement of head circumference only in the infant period, and the SDHG thickness decreases with age during the infant and toddler phases.

Feasibility of Multiple Burr Hole With Erythropoietin in Acute Moyamoya Patients.

BACKGROUND AND PURPOSE: In patients with acute symptomatic moyamoya (<2 weeks), the feasibility of a combination therapy of multiple burr hole procedure under local anesthesia and intravenous erythropoietin pretreatment was assessed. We also identified the factors associated with transdural revascularization. METHODS: In this prospective single-arm study, perfusion-impaired patients presenting with transient ischemic attack or acute cerebral infarction were assessed. Combination therapy was performed to patients lacking transdural collaterals. Primary outcomes were evaluated clinically with modified Rankin Scale scores and radiologically with revascularization success (transhemispheric, trans-burr hole, and sufficient revascularizations [filling ≥33% of ipsilateral supratentorium]) at 6 months. Treatment-related adverse events were analyzed in 3 phases: pre burr hole, post burr hole, and after-discharge as secondary outcome. Factors associated with sufficient revascularization were investigated. RESULTS: Fifty hemispheres from 37 patients were included. Compared with discharge, modified Rankin Scale score at 6 months significantly improved (2.0 [0.0-5.0] versus 1.0 [0.0-4.0]; P<0.001). Majority had successful revascularization: trans-burr hole arteriogenesis (89.5%), transhemispheric arteriogenesis (98.0%), and sufficient revascularization (52.0%). There was no significant pre burr hole or post burr hole complication. Two (5.4%) transient ischemic attack and 1 (2.7%) cerebral infarction occurred after discharge. Presentation with acute infarction (odds ratio, 4.8; 95% confidence interval, 1.1-21.4), ipsilateral basal moyamoya vessels (odds ratio, 13.9; 95% confidence interval, 1.3-144.2), and delayed mean transit time (odds ratio, 3.9; 95% confidence interval, 1.3-12.2) predicted sufficient revascularization. CONCLUSIONS: Combination therapy allows safe and effective revascularization in moyamoya patients with acute ischemic presentation. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03162588.

Initial misdiagnosis of aneurysmal subarachnoid hemorrhage: associating factors and its prognosis.

BACKGROUND: Predicting the fate of patients who are given a misdiagnosis of aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. The purpose was to examine factors associated with initial misdiagnosis of aSAH and to investigate the impact of initial misdiagnosis of aSAH on clinical outcomes. METHODS: Between January 2007 and December 2015, medical records and radiographic data for 3118 consecutive patients with aSAH were reviewed. There were 33 patients who had been documented with an initial misdiagnosis of aSAH, and all met the following criteria: (1) failure to correctly identify aSAH upon initial presentation to health care professionals; and 2) subsequently documented aSAH after the initial misdiagnosis. After applying exclusion criteria, remaining 2898 patients were included in the control group. RESULTS: The most common cause of the misdiagnosis is failure to detect aSAH on the initial radiographic imaging. Misdiagnosis group showed lower initial Glasgow Coma Scale, better Hunt-Hess grade, and lower Fisher's grade. Logistic regression analysis showed that initial HH grade (OR, 0.216; p = 0.014), initial Fisher's grade (OR, 0.732; p = 0.036), and hospital type during initial contact (OR, 2.266; p = 0.042) were independently associated with misdiagnosis of aSAH. CONCLUSIONS: Patients with initially good HH grade, lower Fisher's grade, and visiting non-teaching hospital for initial contact were at risk of being misdiagnosed. Misdiagnosis of aSAH in patients with initial good HH grade did affect clinical outcomes negatively. The rebleeding rate was not significantly different between two groups. However, the mortality rate due to rebleeding was higher in MisDx group than in non-MisDx group.

Preventive Suboccipital Decompressive Craniectomy for Cerebellar Infarction: A Retrospective-Matched Case-Control Study.

BACKGROUND AND PURPOSE: No evidence is available on the benefits of preventive suboccipital decompressive craniectomy (SDC) for patients with cerebellar infarction. The purpose of this matched case-control study was to investigate whether preventive SDC was associated with good clinical outcomes in patients with cerebellar infarction and to evaluate its predisposing factors. METHODS: Between March 2007 and September 2015, 28 patients underwent preventive SDC. We performed propensity score matching to establish a proper control group among 721 patients with cerebellar infarction during the same period. Group A (n=28) consists of those who underwent preventive SDC, and group B (n=56) consists of those who did not undergo preventive SDC. We analyzed and compared clinical outcomes between groups. RESULTS: Clinical outcomes were better in group A than in group B at discharge (P=0.048) and 12-month follow-up (P=0.030). Group B had more deaths within 12 months than group A (log-rank, P<0.05). Logistic regression analysis showed that preventive SDC (odds ratio, 4.815; P=0.009) and the absence of brain stem infarction (odds ratio, 2.862; P=0.033) were independently associated with favorable outcomes (modified Rankin Scale score of 0-2) at 12-month follow-up. CONCLUSIONS: Favorable clinical outcomes including overall survival can be expected after preventive SDC in patients with a volume ratio between 0.25 and 0.33 and the absence of brain stem infarction. Among these patients, preventive SDC might be better than the best medical treatment alone.

Endovascular treatment of ruptured blood blister-like aneurysms with multiple (≥3) overlapping Enterprise stents and coiling.

BACKGROUND: Blood blister-like aneurysms (BBAs) are difficult to treat both surgically and endovascularly, and the optimal treatment remains controversial. The aim of this study was to evaluate the clinical and angiographic feasibility of multiple overlapping stents (≥3) with coiling for treating BBA. METHODS: A retrospective review from four institutions identified ten patients with ruptured BBAs who were treated with multiple overlapping stents (≥3). We included both the patients who were initially treated with more than three stents and those who eventually had more than three stents as a consequence of retreatment. Angiographic results (Raymond scale), clinical outcomes (mRS) and treatment courses were evaluated. RESULTS: Initially, seven patients were treated with triple stents and three with double stents. Immediate angiographic results revealed that six aneurysms were Raymond grade 1, three were grade 2, and one was grade 3. Complementary treatment was required in four patients. All three patients who were initially treated with double stents required complementary treatment (100 %). One patient required complementary treatment among the seven patients who were initially treated with three stents (14.3 %). The last follow-up angiography (mean, 12.2 ± 14.7 months; range, 1-44 months) revealed grade 1 in all ten patients. Clinical data (mean follow-up period, 18.2 ± 20.1 months; range, 1-62 months) revealed eight patients with a mRS score of 0-2 and two with mRS 3-5. CONCLUSIONS: Even in the era of flow diverter stents, multiple overlapping stents (≥3) with coiling could be a feasible alternative for treating ruptured BBAs. Additional experience and follow-up are needed in a larger series to state the long-term efficacy of this treatment.

Three-year follow-up of blood pressure after treating hypertensive patients with symptomatic carotid artery stenosis.

BACKGROUND: Blood pressure (BP) was reported to decrease significantly after carotid endarterectomy (CEA) or carotid stenting (CAS) up to the 1-year follow-up. We evaluated changes in BP for 3 years after treating hypertensive patients with symptomatic carotid artery stenosis by either CEA or CAS and determined predisposing factors for normotensive BP at the 3-year follow-up. METHODS: A total of 123 hypertensive patients with at least 3 years of clinical and radiographic follow-up after treatment were included in this study and placed in the CEA (n = 65) or CAS group (n = 58). BP changes for 3 years, the number of patients with a normotensive BP (≤120/80 mmHg), and the percentage decrease in BP were evaluated and compared between groups. RESULTS: Compared to pretreatment BP, the CEA group had significantly decreased BP at the 1- and 2-year follow-up (p < 0.05), but not the 3-year follow-up. The CAS group had significantly decreased BP at the 1-, 2-, and 3-year follow-up (p < 0.05). Stenosis location (body lesions over apical lesions; OR = 1.526, 95 % CI, 1.341 to 6.224; p = 0.034) was an independent predisposing factor for normotensive BP at the 3-year follow-up. CONCLUSIONS: For hypertensive patients with symptomatic carotid artery stenosis, BP was lowered at 3 years after both CEA and CAS compared to pretreatment BP. CAS might lower BP better over the long term than did CEA, and hypertensive patients with stenosis at body lesions might be normotensive at 3 years after CEA or CAS.

The Course of Headache in Patients With Moderate-to-Severe Headache Due to Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cross-Sectional Study.

OBJECTIVES: The purpose of this study was to evaluate the course of headache in patients with moderate-to-severe headache due to aneurysmal subarachnoid hemorrhage (aSAH) and to identify its predisposing factors. BACKGROUND: Little is known about the long-term course of headache in patients with aSAH. METHODS: Since September 2009, patients with aSAH have had their headaches prospectively rated using a numeric rating scale (NRS). From this database containing 838 patients, 217 were included and all included patients met the following criteria: (1) presence of ruptured intracranial aneurysms on computed tomography angiography or magnetic resonance angiography; (2) alert consciousness (Glasgow Coma Scale 15); (3) newly onset moderate-to-severe headache (NRS ≥ 4) due to ruptured intracranial aneurysms; and (4) good clinical outcome at discharge (modified Rankin Scale 0, 1, or 2). We observed the changes in NRS scores from initial to 12-month follow-up and identified the predisposing factors of NRS changes. RESULTS: Of the 217 patients, 182 (83.9%) experienced improvement in NRS score ≤ 3 upon discharge. The NRS scores at discharge were significantly lower than those on admission (P < .001). The independent predisposing factors for headache improvement included previous stroke (odds ratio [OR] = 0.141; 95% CI 0.051-0.381; P < .001), previous headache treated with medication (OR = 0.079; 95% CI 0.010-0.518; P = .008), and endovascular treatment (EVT; OR = 2.531; 95% CI 1.141-5.912; P = .026). The NRS scores tended to decrease continuously until the 12-month follow-up. EVT and symptomatic vasospasm were independently associated with a decrease of NRS in the follow-up periods. CONCLUSIONS: The course of headache in patients with aSAH continuously improved during the 12 months of follow-up. Headache improvement might be expected in patients who were treated with EVT and in those who did not have previous stroke or headache.

Blood pressure-lowering effect of carotid artery stenting in patients with symptomatic carotid artery stenosis.

BACKGROUND: In patients with symptomatic carotid artery stenosis, long-term effects of carotid artery stenting (CAS) on blood pressure (BP) changes have not been documented well. We evaluated the effects of CAS on BP and found out its predisposing factors in patients with symptomatic carotid artery stenosis. METHODS: Between January 2003 and June 2012, a total of 107 patients were recruited, and all subjects met the following inclusion criteria: (1) patients underwent CAS with symptomatic carotid artery stenosis > 50%; (2) patients had clinical and radiographic data for at least 1 year of follow-up after CAS; and (3) patients had BP measurements at four different time points: pretreatment, post-treatment, 1-month follow-up, and 1-year follow-up. We evaluated the significance of the BP changes between the pretreatment BP and follow-up BPs, and determined its predisposing factors. RESULTS: Compared to the mean systolic/diastolic BP value (141.0/87.4 mmHg) at the pretreatment BP, the follow-up BPs were significantly decreased after CAS (120.5/74.5, 126.2/76.9, and 129.2/79.0 mmHg at the post-treatment, the 1-month follow-up, and the 1-year follow-up, respectively [p < 0.01]). The location of the stenosis (odds ratio = 1.856, 95% confidence interval, 1.388 to 5.589; p = 0.003) and hypertension (odds ratio = 1.627, 95% confidence interval, 1.101 to 3.757; p = 0.014) were independent predisposing factors for BP-lowering effects of CAS on multivariate analysis. CONCLUSIONS: For patients with symptomatic carotid artery stenosis, CAS might have a BP-lowering effect at the 1-year follow-up, especially in patients with hypertension or the stenosis at body lesions.

Monocyte Count and Systemic Immune-Inflammation Index Score as Predictors of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage.

OBJECTIVE: Delayed cerebral ischemia (DCI) is a major cause of disability in patients who survive aneurysmal subarachnoid hemorrhage (aSAH). Systemic inflammatory markers, such as peripheral leukocyte count and systemic immune-inflammatory index (SII) score, have been considered predictors of DCI in previous studies. This study aims to investigate which systemic biomarkers are significant predictors of DCI. METHODS: We conducted a retrospective, observational, single-center study of 170 patients with SAH admitted between May 2018 and March 2022. We analyzed the patients' clinical and laboratory parameters within 1 hour and 3-4 and 5-7 days after admission. The DCI and non-DCI groups were compared. Variables showing statistical significance in the univariate logistic analysis (p<0.05) were entered into a multivariate regression model. RESULTS: Hunt-Hess grade "4-5" at admission, modified Fisher scale grade "3-4" at admission, hydrocephalus, intraventricular hemorrhage, and infection showed statistical significance (p<0.05) on a univariate logistic regression. Lymphocyte and monocyte count at admission, SII scores and C-reactive protein levels on days 3-4, and leukocyte and neutrophil counts on days 5-7 exhibited statistical significance on the univariate logistic regression. Multivariate logistic regression analysis revealed that monocyte count at admission (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.04-2.65; p=0.036) and SII score at days 3-4 (OR, 1.55; 95% CI, 1.02-2.47; p=0.049) were independent predictors of DCI. CONCLUSION: Monocyte count at admission and SII score 3-4 days after rupture are independent predictors of clinical deterioration caused by DCI after aSAH. Peripheral monocytosis may be the primer for the innate immune reaction, and the SII score at days 3-4 can promptly represent the propagated systemic immune reaction toward DCI.

Outcomes of Bypass Surgery in Adult Moyamoya Disease by Onset Type.

Importance: Moyamoya disease (MMD) is a rare chronic cerebrovascular disease, and the outcomes of bypass management in adult patients remain controversial. Objective: To categorize adult MMD based on asymptomatic, ischemic, and hemorrhagic onset and compare the outcomes (death, hemorrhagic stroke [HS], and ischemic stroke [IS]) of bypass surgery (direct or indirect) with those of conservative management. Design, Setting, and Participants: This retrospective, nationwide, population-based longitudinal cohort study used Korean National Health Insurance Research data to identify adults (aged ≥15 years) with MMD who were diagnosed between January 1, 2008, and December 31, 2020, and followed up until December 31, 2021 (median follow-up, 5.74 [IQR, 2.95-9.42] years). A total of 19 700 participants (3194 with hemorrhagic, 517 with ischemic, and 15 989 with asymptomatic MMD) were included. Data were analyzed from January 2 to April 1, 2023. Exposures: Bypass surgery and conservative management. Main Outcomes and Measures: Death constituted the primary outcome; secondary outcomes consisted of HS or IS. Kaplan-Meier survival curve and Cox proportional hazards regression analysis were applied. The propensity score-matching and stratified analyses were performed to control covariate effects. Results: A total of 19 700 patients (mean [SD] age, 45.43 [14.98] years; 12 766 [64.8%] female) were included. Compared with conservative management, bypass was associated with a reduced risk of death (adjusted hazard ratio [AHR], 0.50 [95% CI, 0.41-0.61]; P < .001) and HS (AHR, 0.36 [0.30-0.40]; P < .001) in hemorrhagic MMD; reduced risk of IS (AHR, 0.55 [95% CI, 0.37-0.81]; P = .002) in ischemic MMD; and reduced risk of death (AHR, 0.74 [95% CI, 0.66-0.84]; P < .001) in asymptomatic MMD. However, bypass was associated with an increased risk of HS (AHR, 1.76 [95% CI, 1.56-2.00]; P < .001) in asymptomatic MMD. Both direct and indirect bypass demonstrated similar effects in hemorrhagic and asymptomatic MMD, except only direct bypass was associated with a reduced risk of IS (AHR, 0.52 [95% CI, 0.33- 0.83]; P = .01) in ischemic MMD. After stratification, bypass was associated with a reduced risk of death in patients younger than 55 years with ischemic (AHR, 0.34 [95% CI, 0.13- 0.88]; P = .03) and asymptomatic (AHR, 0.69 [95% CI, 0.60-0.79]; P < .001) MMD, but an increased risk of HS in patients 55 years or older with ischemic MMD (AHR, 2.13 [95% CI, 1.1-4.16]; P = .03). Conclusions and Relevance: The findings of this cohort study of bypass outcomes for patients with MMD emphasize the importance of tailoring management strategies in adult patients based on onset types.

Revascularisation patterns and characteristics after erythropoietin pretreatment and multiple burr holes in patients who had acute stroke with perfusion impairment.

BACKGROUND: Transdural collaterals, originating mainly from the extracalvarial superficial temporal artery and intracalvarial middle meningeal artery via the external carotid artery (ECA), have been observed after revascularisation surgery. However, the origin of these collaterals in patients with stroke with perfusion insufficiency is not yet known. Therefore, we studied the revascularisation patterns and characteristics based on the origin of these collaterals. METHODS: We employed erythropoietin pretreatment and performed multiple burr holes under local anaesthesia to achieve transdural revascularisation in patients with acute stroke with perfusion insufficiency. After 6 months, we reassessed the transfemoral cerebral angiography to evaluate the revascularisation patterns. The collaterals were categorised into intracalvarial ECA-dominant (originating from the middle meningeal artery), extracalvarial ECA-dominant (originating from the superficial temporal or occipital artery) and balanced groups. We compared various imaging parameters among these groups. RESULTS: Overall, 87 patients with 103 treated hemispheres were involved. Among them, 57.3% were classified as intracalvarial ECA-dominant, 20.4% as extracalvarial ECA-dominant and 22.3% as balanced. Most of the hemispheres with intracalvarial or extracalvarial collaterals (vs balanced collaterals) showed successful revascularisation (78/80 (97.5%) vs 12/23 (52.1%)), p<0.001). In ultrasonographic haemodynamic changes according to revascularisation pattern, only the intracalvarial ECA-dominant revascularisation was significantly associated with specific changes in ECA blood flow, leading to the conversion to a low-resistance ECA Doppler sonography waveform. CONCLUSIONS: Our findings suggest that intracalvarial ECA-dominant revascularisation plays a crucial role in the formation of transdural collaterals following combined therapy. These distinct changes in ECA haemodynamics can be non-invasively identified through bedside ultrasound studies.

The combined use of mechanical thrombectomy devices is feasible for treating acute carotid terminus occlusion.

BACKGROUND: Mechanical thrombectomy devices have recently been developed and approved for recanalization of intracranial arterial occlusion. Here, we investigated the feasibility of combined stent-assisted and clot aspiration mechanical thrombectomy for effective recanalization of acute carotid terminus occlusion (CTO). METHODS: Ten consecutive patients with acute ischemic stroke secondary to CTO who underwent intra-arterial (IA) treatment with both stent retrieval and negative-pressured clot aspiration systems were enrolled. Periprocedural and radiologic findings and clinical outcomes were evaluated. RESULTS: The median age was 69 years (range, 47-86 years), and the median initial NIHSS score was 17.5 (range, 12-33). Mechanical thrombectomy was performed using a combination of the Solitaire stents and Penumbra system. Thrombolysis in cerebral ischemia [TICI] grade II-III was achieved in eight patients (80.0 %); complete recanalization of the CTO (TICI III) was achieved in three of those patients. Any type of intracranial hemorrhages occurred in four patients (40.0 %), but parenchymal hematoma type 2 was not observed. Four patients died within 3 months (40.0 %). CONCLUSIONS: Combined mechanical thrombectomy treatment was effective for recanalization of acute CTO. The combination of Solitaire and Penumbra devices can be considered as a treatment option for CTO.

Stent salvage using the Enterprise stent for procedure-related complication during coil embolization of ruptured intracranial aneurysms.

BACKGROUND: Despite accumulated experience and improved understanding of the tools, endovascular treatment of intracranial aneurysms continues to have risks linked to the technique itself, and induces procedure-related complications. The purpose of this study was to report our series of stent salvage using the Enterprise stent for procedure-related complication during coil embolization in patients with ruptured intracranial aneurysms. METHODS: Parent artery thrombosis, parent artery dissection, and coil protrusion were considered to be the procedure-related complications. There were 18 consecutive cases (3 unruptured and 15 ruptured aneurysms) with procedure-related complications rescued by the Enterprise stent from December 2008 to December 2011. Follow-up angiography was performed in 14 of the 15 patients with ruptured aneurysms between 6 and 30 months (mean 14.6 months) after the procedure. RESULTS: The procedure-related complications were parent artery dissection (n = 1), parent artery thrombosis (n = 4), and coil protrusion (n = 10). There was no complication related to delivering or deploying of the Enterprise stent. Initial radiographic results showed 8 cases of complete occlusion and 7 cases of neck remnant. There was no change in the angiographic results during the follow-up periods. CONCLUSIONS: Facing with procedure-related complications during coil embolization of ruptured intracranial aneurysms, the closed-cell designed Enterprise stent might be a useful option for the salvage technique by restoring blood flow and minimizing thromboembolic events.

Long-Term Outcomes of Ruptured Blood Blister-Like Aneurysms with Multiple (≥2) Overlapping Stents and Coiling: A Single-Center Experience.

OBJECTIVE: To evaluate the long-term feasibility of multiple overlapping stents (≥2) with or without coiling for treating blood blister-like aneurysms (BBAs). METHODS: BBAs treated with stent-assisted coiling or stent-only therapy wasincluded. BBAs with atypical anatomical locations, other endovascular or surgical techniques performed, and delayed treatment (>48 hours) were excluded. Medical records of patients and procedures were retrospectively reviewed. RESULTS: Seventeen patients with BBAs were identified, and 15 were treated with stent-assisted coiling and 2 with stent-only therapy. Triple overlapping stents were performed in seven patients, double stents in nine, and a single stent with coiling in 1. One patient experienced in-stent fibrin formation and received intra-arterial tirofiban. Complementary treatment was required in four patients. Three patients were initially treated with double (3/9) and 1 with triple stents (1/7). Three recurred in the acute period (≤6 weeks) and 1 recurred 14 months after treatment. Three of 17 patients with Hunt Hess grade 5 died early. Thirteen patients were available for long-term angiographic follow-up (13.8 ± 8.9 months). Final angiography showed complete aneurysm occlusion in all patients without in-stent stenosis or perforating vessel occlusion. Clinical follow-up data were available for all 14 surviving patients (66.8 ± 40.9 months). Eight patients had favorable outcomes, five had unfavorable outcomes, and 1 died of a subarachnoid hemorrhage-unrelated cause. Delayed infarct or hemorrhage was not documented. CONCLUSIONS: Even in the era of flow diverter stents, the use of multiple overlapping stents with or without coiling can be a feasible alternative for treating ruptured BBAs.