Tailored antiplatelet agent medication in clopidogrel hyporesponsive patients before stent-assisted coiling: single-center experience.

PURPOSE: In patients requiring stent procedures, resistance or hyperresponsiveness to antiplatelet medications is often observed. This study aims to evaluate the efficacy and safety of tailoring medications in these patients. METHODS: This retrospective study included 223 patients who underwent endovascular treatment for intracranial aneurysm between October 2018 and October 2019. Patients were categorized as hyporesponsive, hyperresponsive, and normoresponsive groups according to the initial PRU response. For the hypo- or hyperresponders, we tailored medication by modifying the dose or changing the drug. PRUs before and after tailoring were compared in each group. PRU reponses in patients who underwent Cytochrome P450 2C19 (CYP2C19) genotyping were also determined. RESULTS: Of the 73 clopidogrel-resistant patients, the mean PRU values after tailoring showed a greater decrease in the group that switched to prasugrel (n = 56), from 223 to 131, than in the clopidogrel reloading group (n = 17), from 238 to 209. In 31 hyperresponders, PRU increased from 49 to 94 after the dose adjustment. CYP2C19 genotyping showed that PRU tended to increase as the number of mutated alleles increased. There were five (2.3%) ischemic events (three transient ischemic attacks and two minor strokes) in a mean follow-up of 8 months, but no hemorrhage. CONCLUSIONS: The stent-assisted coiling was successfully performed with acceptable range of ischemic events and without hemorrhage in all patients, including those who applied tailored medication. Low-dose prasugrel was effective for obtaining appropriate PRU values for initial medication as well as for clopidogrel-resistant patients. The genetic test did not provide reliable results in determining clopidogrel resistance.

New grading system for the clinical evaluation of patients with spinal vascular lesions.

PURPOSE: Neurointerventional approaches have improved myelopathy in patients with spinal vascular lesions by providing effective management, particularly when surgical approaches are difficult. However, there have been challenges in describing and comparing recovery status during the post-treatment period. METHODS: We evaluated 43 patients with venous congestive myelopathy (VCM) using Aminoff-Logue Disability Scale for gait (AL-G) and micturition (AL-M) scores. These results were compared with our new PSMS grading system that evaluates four categories (grades 0-3): pain, sensory symptoms, motor deficit, and sphincter change. Simple linear regression was used to identify the association or trend among the scales. We also calculated an overall area under the receiver operating characteristic curve to compare the predictive ability of the PSMS system with that of the previous grading system (AL-G and AL-M). RESULTS: Compared with other grading system, the PSMS system was more sensitively correlated with patient status and the results were easy to compare with previous clinical statuses during follow-up. The PSMS system also measured pain, which is commonly associated with spinal dural arteriovenous fistula and not precisely evaluated by other grading system. CONCLUSIONS: The new PSMS grading system for patients with VCM correlated well with the previously used systems and included pain evaluation. This new grading system is an easy tool for the evaluation and comparison of outcomes before and after endovascular treatment.

Loop microcatheter technique for coil embolization of paraclinoid aneurysms.

BACKGROUND: Although paraclinoid aneurysms do not exhibit a high risk of rupture, coil embolization is not always easy because of unstable microcatheter position. We present a technique that allows a stable microcatheter position for coil embolization of paraclinoid aneurysms. METHODS: We enrolled 34 consecutive patients who underwent coil embolization for paraclinoid aneurysms. A loop of distal microcatheter was shaped based on three-dimensional rotational angiography. The basic concept is to keep the proximal loop abutting the opposite wall of the aneurysm while using the distal loop for coiling. Then, a proximal curve was made to accommodate the shape of the carotid siphon, which may decide the direction of the loop. Stent-assisted coil embolization was performed in 19 wide-necked aneurysms. Immediate radiological outcomes were analyzed with Raymond classification and clinical outcomes were evaluated with modified Rankin Scale (mRS) scores. RESULTS: Satisfactory occlusion of aneurysm was achieved in 94.1% (32/34) of patients with a Raymond score of 1 or 2. Packing density of ≥ 31% was achieved in 71% (24/34) of patients. No significant differences were observed between stent-assisted coiling and coiling-only groups. Follow-up magnetic resonance angiography and/or angiogram showed stable coil position, except in one patient with tiny recurrence (from Raymond scores 1 to 2) that did not require retreatment at the 6-month follow-up. mRS scores of 0-1 were obtained in all patients at 6 months. CONCLUSIONS: Loop microcatheter technique allowed safe and stable coil packing for paraclinoid aneurysms. The same procedural concept is also being used for aneurysms in other vascular territories.

Low-angled microcatheter approach for coil embolization of the anterior choroidal artery aneurysm.

PURPOSE: Thromboembolic complication is a serious concern following coil embolization for aneurysms involving the anterior choroidal artery (AChA). To minimize this complication and to improve packing density, we present a technical concept of coil embolization. METHODS: We attempted packing of the aneurysmal sac by lowering the microcatheter approach angle into an aneurysm to secure AChA origin as well as to improve coil packing density of the aneurysm. This technical concept involves approaching the aneurysm sac with an adjusted shaping of the microcatheter tip to achieve the effect which was not obtained when the microcatheter approach angle into the aneurysm sac was high (≥90°). We evaluated immediate angiographic outcome by the Raymond classification, coil packing density, and follow-up results (modified Rankin Scale (mRS) and recurrence) in seven aneurysms involving AChA in six patients. RESULTS: We achieved immediate angiographic outcome of the Raymond classes I or II with 31% mean packing density. The AChA origin was preserved without any procedure-related complication. There was neither clinical event (mRS = 0) nor aneurysm recurrence confirmed on the source image of magnetic resonance angiography during 6-9 months follow-up. CONCLUSIONS: The technical concept of low-angled microcatheter approach can be useful to improve coil packing density and to secure AChA origin when AChA arises near the aneurysm.

Preoperative embolization in patients with metastatic spinal cord compression: mandatory or optional?

BACKGROUND: The contribution of preoperative embolization in reducing intraoperative blood loss and its clinical importance are unclear. So, we aimed to compare the perioperative clinical outcomes based on whether preoperative embolization was performed and assess the role and safety of preoperative embolization in metastatic spinal cord compression (MSCC) patients. METHODS: We enrolled 52 patients (men, 37; women, 15) who underwent palliative decompression for MSCC. Demographic data, neurologic status, surgery-related data (operation time, estimated blood loss, and transfusion), complications, and survival time were recorded. Patients were categorized based on whether they received preoperative embolization: groups E (embolization) (n = 18) and NE (non-embolization) (n = 34) and the clinical parameters were compared. Subgroup analysis was performed specifically for cases of hypervascular tumors (23/52, 44%). RESULTS: The transfusion degree was greater in the NE group (4.6 pints) than in the E group (2.5 pints, P = 0.025); the other parameters did not differ between the groups. However, massive bleeding (>2000 mL) was more frequent in the NE group (10/34) than in the E group (0/18, P = 0.010). Subgroup analysis indicated that intraoperative blood loss was greater in the NE group (1988 mL) than in the E group (1095 mL, P = 0.042) in hypervascular tumor patients. Although massive bleeding was more frequent among hypervascular tumor patients, 3 patients with non-hypervascularized tumors also exhibited massive bleeding (P = 0.087). CONCLUSIONS: Intraoperative blood loss and perioperative transfusion can be reduced by preoperative embolization in MSCC patients. Neurologic recovery, operation time, and complications did not differ according to the application of embolization. As preoperative embolization is relatively safe and effective for controlling intraoperative bleeding without any neurologic deterioration, it is highly recommended for hypervascular tumors. Moreover, it may also be effective for non-hypervascular tumors as massive bleeding may be noted in some cases.

Multi-Contrast High-Resolution Magnetic Resonance Findings of Spontaneous and Unruptured Intracranial Vertebral Artery Dissection: Qualitative and Quantitative Analysis According to Stages.

BACKGROUND: Although high-resolution magnetic resonance imaging (HR-MRI) has been used as a strong imaging method for diagnosing intracranial vertebral artery dissection (IVAD), the diagnosis is sometimes challenging because a dissection has geometric changes in the natural course. The radiologic features may change or disappear over time, which makes the diagnosis confusing. Our study was to present radiological findings according to the stages in spontaneous and unruptured, IVAD on 3T HR-MRI and to guide the age estimation of IVAD with the distinguishing findings according to the stages. METHODS: From January 2011 to July 2014, the 41 vertebral arteries (M:F = 18:12; age range 32-67 years) were retrospectively enrolled. Spontaneous, unruptured IVAD was diagnosed if it had a clear onset based on clinical and radiological findings. The stages were classified as acute (0-3 days), early subacute (3-10 days), late subacute (10-60 days) and chronic stage (>60 days; recovery and non-recovery groups) according to the time intervals from symptom onset, based on the prior published studies. HR-MR findings were assessed and compared in the intimal flap, double lumen, aneurysmal dilatation (maximal outer diameter, maximal wall thickness, wall thickness index and remodeling index), intramural hematoma (relative signal intensity) and vessel wall enhancement according to the stages with qualitative and quantitative methods. Two radiologists analyzed the HR-MR findings with consensus reading. RESULTS: IVAD was classified into acute (n = 6), early subacute (n = 8), late subacute (n = 16) and chronic (n = 11) stages. HR-MR dissection findings such as intimal flap, double lumen, aneurysmal dilatation and intramural hematoma significantly decreased from the earlier stages to the chronic stage (p < 0.05). The quantitative indices in aneurysmal dilatation and the relative signal intensity of intramural hematoma showed significant higher values in the earlier stages followed by a significant decrease in the chronic stage recovery group (p < 0.05). The degree of vessel wall enhancement was higher in the earlier stage and decreased in the chronic stage (p < 0.05), but mild vessel wall enhancement was identified 900 days after symptom onset. CONCLUSION: The 3T HR-MRI reveals the vessel wall characteristics and provides distinguishing findings between earlier stages and the chronic stage in spontaneous and unruptured IVAD. Characterization of these radiological findings according to stages may assist with the age estimation of the dissection and may help to understand IVAD as a whole.

Virtual stenting of intracranial aneurysms: application of hemodynamic modification analysis.

BACKGROUND: Practical application of hemodynamic modification analysis based on computational fluid dynamics (CFD) in intracranial aneurysms is still under study. PURPOSE: To determine the clinical applicability of virtual stenting of aneurysms by comparing the simulated results with clinical outcome of real stenting. MATERIAL AND METHODS: Three-dimensional (3D) digital subtraction angiography (DSA) images were imported to a dedicated integrated prototypic CFD platform (Siemens Healthcare GmbH) which allows all necessary steps of 3D models for CFD analysis. The results of CFD simulation with virtual implantation of a stent can be visualized in the same platform for qualitative comparisons on a color-coded volume visualization window. Five small intracranial aneurysms with and without virtual stenting were analyzed and assessed on a qualitative level. Expert rating were performed for evaluating the simulated results, and comparing those to the long-term follow-up outcomes of real stenting. RESULTS: CFD simulation after virtual stenting was feasible in five differently located aneurysms and corresponded to the long-term changes of stented aneurysms by showing alteration in flow pattern. There was no significant difference (P = 0.5) between the simulated hemodynamic changes after virtual stenting and the angiographic changes after stenting in four aneurysms except one. There was good agreement regarding the assessment of the changes by two raters (kappa = 0.657). CONCLUSION: CFD analysis using patient-specific virtual stenting of the CFD platform may be used as a simple and less time-consuming test tool predicting the involution of aneurysms after stent placement by analyzing the vector visualization of the flow changes.

Hemangioblastomas with leptomeningeal dissemination: case series and review of the literature.

BACKGROUND: Leptomeningeal dissemination of hemangioblastomas (HB) of the central nervous system (CNS) is extremely rare. Few studies have reported leptomeningeal involvement in sporadic HB or in HB associated with von Hippel-Lindau syndrome. The clinical and radiological features of leptomeningeal involvement in HB after surgery have not been described in detail. MATERIALS AND METHODS: This retrospective case review involved patients from three different tertiary referral centers with leptomeningeal dissemination of HB after surgery for the primary mass. A literature review was also performed to describe the clinical and radiological characteristics and long-term outcomes of patients who developed leptomeningeal dissemination after initial surgical resection. RESULTS: This study included seven patients, five males and two females, ranging in age from 36 to 54 years. Incidence of leptomeningeal dissemination in patients with HB was about 4.3 % (3/69). It appeared at a mean 94.9 months (range, 39-204 months) after gross total resection of CNS HBs. Three of the seven patients died 5, 38, and 79 months, respectively, after diagnosis of leptomeningeal dissemination. Review of the literature identified 21 patients with characteristics of leptomeningeal dissemination similar to those in our series. CONCLUSIONS: Leptomeningeal dissemination of HB is a rare pattern of long-term recurrence. Long-term outcomes may be fatal. The long developmental period suggests that early detection and aggressive management may improve prognosis in patients with CNS leptomeningeal dissemination of HB.

Intraoperative direct puncture and embolization (IOPE) using a glue material for spinal cord arteriovenous fistula: a case report.

INTRODUCTION: Spinal arteriovenous fistula (AVF) is treated by embolization or surgery. However, transarterial embolization or surgery is difficult in rare cases when the fistula site is very complicated to access especially as in fistular nidus supplied by posterior and anterior spinal artery. We present the case which was treated with intraoperative direct puncture and embolization (IOPE) using glue material, since the usual transarterial or transvenous neurointerventional approach was difficult to embolize the AVF. METHODS: A 36-year-old woman presented with progressive leg weakness and pain after a 20-year history of lower back pain. She had pelvic and spinal AVF combined with arteriovenous malformation (AVM). Despite prior treatment of the pelvic lesion with radiotherapy and coil embolization, the spinal lesion persisted and caused repeated subarachnoid hemorrhages. A spinal angiogram revealed a tortuous and long feeder of the AVF which had growing venous sac, as well as AVM. Two embolization trials failed because of the long tortuosity and associated anterior spinal artery. Four months later, drastic leg weakness and pain occurred, and IOPE was performed using a glue material. RESULTS: The subsequent recovery of the patient was rapid. One month later, the use of a strong opioid could be discontinued, and the patient could walk with aid. A follow-up spinal angiogram revealed that the venous sac of the AVF had disappeared. CONCLUSION: In spinal AVF which is not feasible to access by usual intervention approach and to dissect surgically, IOPE with glue material can be considered for the treatment.

Reperfusion injury on magnetic resonance imaging after carotid revascularization.

BACKGROUND AND PURPOSE: Reperfusion injury can be revealed as delayed gadolinium enhancement in the subarachnoid space on a fluid-attenuated inversion recovery image, which is designated as a hyperintense acute reperfusion marker (HARM). We sought to investigate the occurrence and predictors of HARM and its association with new ischemic infarcts after carotid revascularization. METHODS: Forty-five patients who underwent carotid endarterectomy or stenting were prospectively enrolled. Diffusion-weighted imaging and fluid-attenuated inversion recovery were performed before and 24 hours after the procedures. Postprocedural fluid-attenuated inversion recovery was done after intravenous gadolinium injection. RESULTS: HARM was observed in 8 (17.8%) patients. Of these, 4 patients showed neurological deterioration associated with HARM. These symptomatic HARMs disappeared on follow-up magnetic resonance imaging. Patients with symptomatic HARM were older (P=0.010) and had more frequent leukoaraiosis (P=0.012) and higher postprocedural systolic blood pressure (P=0.025) than those without. New brain infarcts on postprocedural diffusion-weighted imaging were identified in 13 (28.9%) patients. HARM was not associated with new infarcts. CONCLUSIONS: HARM after carotid revascularization is not uncommon. Symptomatic HARM was associated with old age, underlying leukoaraiosis, and postprocedural high blood pressure.

Relationship between diabetes mellitus with dural arteriovenous fistula.

INTRODUCTION: The aetiology of dural arteriovenous fistula (DAVF) is not well known, but it has been suggested that abnormality in angiogenesis plays a pathological role. Abnormality in angiogenesis is also involved in diabetes mellitus (DM). The purpose of this study was to quantify the relation between DAVF and DM in a Korean population. METHODS: Medical records of 192 patients with DAVF between 2002 and 2011 were reviewed. Age, sex and the presence of DM, hypertension, hyperlipidaemia, stroke, coronary artery disease and cancers were compared between DAVF and control subjects. Data for control were obtained from the Korean National Health and Nutrition Examination Survey. The relationship of DM and DAVF location, presenting symptoms (benign vs. aggressive) and classification (Borden and Geibprasert) were assessed using the Pearson's chi-square test. RESULTS: Prevalence of DM was higher in DAVF patients (19.8 %) than in controls (9.5 %; p = 0.004). Univariate analysis showed that DM (odds ratio (OR), 2.356; 95 % confidence interval (CI), 1.634-3.399; p < 0.001) and age (OR, 1.022; 95 % CI, 1.012-1.032; p < 0.001) increased the odds of DAVF. This was supported by multivariate analysis (DM: OR, 2.092; 95 % CI, 1.391-3.145; p = 0.0004 and Age: OR, 1.021; 95 % CI, 1.009-1.033; p = 0.001). When these analyses were repeated after stratification by sex, there was no relation between age and DAVF in men. Borden II and III (p = 0.038) and aggressive symptoms (p = 0.023) were related to DM. CONCLUSION: There was a positive relation between DM and DAVF in a Korean population. DAVFs with aggressive symptoms and behaviour were more commonly related to DM.

Pseudoprogression in patients with glioblastoma: added value of arterial spin labeling to dynamic susceptibility contrast perfusion MR imaging.

BACKGROUND: Pseudoprogression is a treatment-related reaction with an increase in contrast-enhancing lesion size, followed by subsequent improvement. Differentiating tumor recurrence from pseudoprogression remains a problem in neuro-oncology. PURPOSE: To validate the added value of arterial spin labeling (ASL), compared with dynamic susceptibility contrast (DSC) perfusion magnetic resonance imaging (MRI) alone, in distinguishing early tumor progression from pseudoprogression in patients with newly diagnosed glioblastoma multiforme (GBM). MATERIAL AND METHODS: We retrospectively evaluated 117 consecutive patients with newly diagnosed GBM who underwent surgical resection and concurrent chemoradiotherapy (CCRT) as standard treatment modality. Sixty-two patients who developed contrast-enhancing lesions were assessed by both ASL and DSC perfusion MRI and classified into groups of early tumor recurrence (n = 34) or pseudoprogression (n = 28) based on pathologic analysis or clinical-radiologic follow-up. We used a qualitative analysis and semi-quantitative grade system on the basis of the tumor perfusion signal intensity into those equal to white matter (grade I), gray matter (grade II), and blood vessels (grade III) on ASL imaging. ASL grade was correlated with histogram parameters derived from DSC perfusion MRI. RESULTS: Pseudoprogression was observed in 15 (53.6%) patients with ASL grade I, 13 (46.4%) with grade II, and 0 (0%) with grade III, with early tumor progression observed in seven (20.6%) patients with ASL grade I, 11 (32.3%) with grade II, and 16 (47.1%) with grade III (P = 0.0022). DSC perfusion histogram parameters differed significantly among ASL grades. ASL grade was an independent predictor differentiating pseudoprogression from early tumor progression (odds ratio, 4.73; P = 0.0017). On qualitative review, adjunctive ASL produced eight (12.9%) more accurate results than DSC perfusion MRI alone. CONCLUSION: ASL improves the diagnostic accuracy of DSC perfusion MRI in differentiating pseudoprogression from early tumor progression.

Flow Diverter Treatment Using a Flow Re-Direction Endoluminal Device for Unruptured Intracranial Vertebral Artery Dissecting Aneurysm: Single-Center Case Series and Technical Considerations.

PURPOSE: This study aimed to evaluate the effectiveness, safety, and technical considerations of flow diverter (FD) treatment using a Flow Re-direction Endoluminal Device (FRED) for unruptured intracranial vertebral artery dissecting aneurysms (VADAs). MATERIALS AND METHODS: We conducted a retrospective study of 23 patients with unruptured intracranial VADAs who underwent FD treatment using a FRED between June 2017 and August 2021. Symptoms, imaging findings, treatment strategies, and angiographic and clinical outcomes were evaluated. Dissections were categorized according to the dominance of the VA in which they occurred: dominant VA, co-dominant VA, and non-dominant VA. RESULTS: All patients successfully underwent FD treatment with either a FRED (n=11) or FRED Jr. (n=12). Complete occlusion rates were 78.3% at 6-month follow-up magnetic resonance angiography and 91.3% at 12-month. There were no instances of complications, recurrence, or retreatment during a median follow-up of 20 months. Dissections occurred in the dominant VA in 3 cases (13.0%), the co-dominant VA in 13 cases (56.5%), and the non-dominant VA in 7 cases (30.4%). Intimal flap and true lumen stenosis were observed in 39.1% and 30.4% of cases, respectively. Four cases required a bilateral VA approach due to technical difficulties, all in the non-dominant VA. CONCLUSION: Flow diversion treatment using a FRED for unruptured intracranial VADAs proved feasible and safe, yielding satisfactory occlusion rates. Technical challenges were more likely in lesions involving non-dominant VAs in the acute or subacute stage, mainly due to associated intraluminal lesions compromising the arterial lumen.

Addendum: Outpatient Day-Care Management of Unruptured Intracranial Aneurysm: A Retrospective Cohort Study.

This corrects the article on p. 828 in vol. 23, PMID: 35762182.

Neuroprotection by urokinase plasminogen activator in the hippocampus.

Tissue plasminogen activator (tPA) and urokinase plasminogen activator (uPA), which are both used for thrombolytic treatment of acute ischemic stroke, are serine proteases that convert plasminogen to active plasmin. Although recent experimental evidences have raised controversy about the neurotoxic versus neuroprotective roles of tPA in acute brain injury, uPA remains unexplored in this context. In this study, we evaluated the effect of uPA on neuronal death in the hippocampus of mice after kainate-induced seizures. In the normal brain, uPA was localized to both nuclei and cytosol of neurons. Following severe kainate-induced seizures, uPA completely disappeared in degenerating neurons, whereas uPA-expressing astrocytes substantially increased, suggesting reactive astrogliosis. uPA-knockout mice were more vulnerable to kainate-induced neuronal death than wild-type mice. Consistent with this, inhibition of uPA by intracerebral injection of the uPA inhibitor UK122 increased the level of neuronal death. In contrast, prior administration of recombinant uPA significantly attenuated neuronal death. Collectively, these results indicate that uPA renders neurons resistant to kainate-induced excitotoxicity. Moreover, recombinant uPA suppressed cell death in primary cultures of hippocampal neurons exposed to H2O2, zinc, or various excitotoxins, suggesting that uPA protects against neuronal injuries mediated by the glutamate receptor, or by oxidation- or zinc-induced death signaling pathways. Considering that tPA may facilitate neurodegeneration in acute brain injury, we suggest that uPA, as a neuroprotectant, might be beneficial for the treatment of acute brain injuries such as ischemic stroke.

Factors and outcomes associated with recanalization timing after thrombolysis.

BACKGROUND: A substantial number of acute stroke patients do not respond immediately to aggressive intra-arterial (IA) recanalization therapy. The factors and outcomes associated with timing of recanalization after IA thrombolysis, however, have not yet been determined. METHODS: Factors and outcomes in 75 acute ischemic stroke patients treated with IA urokinase (± intravenous tissue plasminogen activator) within 6 h of onset were retrospectively assessed. Immediate recanalization (IR) was assessed by the angiogram at the end of the IA procedure, and delayed (DR) and no (NR) recanalization were assessed by 5-day MR angiography. Modified Rankin Scale (mRS) scores were determined at 7 days and 3 months. RESULTS: Of the 75 patients, 32 (42.7%) achieved IR, 21 (28%) achieved DR, and 22 (29.3%) showed NR. Good functional outcomes (mRS score ≤2) at 7 days and 3 months were observed in 59.4 and 62.5%, respectively, of the IR group, 14.3 and 38.1% of the DR group, and 22.7 and 27.3% of the NR group (p = 0.001 for 7 days, p = 0.028 for 3 months). Multivariate analysis showed that cardioembolism [odds ratio (OR), 3.74; 95% confidence interval (CI), 1.15-12.19] and middle cerebral artery occlusion (OR, 3.23; 95% CI, 1.04-10.04) were independent predictors of IR or DR compared with NR. Age (OR, 0.86; 95% CI, 0.77-0.95) and initial NIHSS score (OR, 1.20; 95% CI, 1.04-1.37) were independent predictors of DR compared with IR. CONCLUSIONS: Patients receiving IA thrombolysis show different clinical and radiological characteristics according to the timing of recanalization. Earlier identification of DR patients and their more efficient recanalization may improve overall clinical outcomes after IA thrombolysis.

Treatment of acute ischemic stroke: feasibility of primary or secondary use of a self-expanding stent (Neuroform) during local intra-arterial thrombolysis.

INTRODUCTION: We evaluated the feasibility of employing a self-expanding stent (Neuroform) in treatment of acute cerebral ischemia and compared the results of primary and secondary stenting. METHODS: We analyzed the treatment results of 14 acute ischemic stroke patients (11 men and three women; median age, 65 years) who were treated with Neuroform stents. Seven patients received stent placement for primary recanalization and a further seven for secondary recanalization. We performed between-group comparisons of all of overall procedure duration, recanalization rate immediately after stenting, need for additional measures after stenting, final recanalization rate, occurrence of hemorrhagic transformation, early re-occlusion rate after 24 h, and 3-month functional recovery rate (mRS ≤2). RESULTS: The median interval from femoral puncture to stent placement was 61.5 min and was significantly shorter in the primary than in the secondary group (55 vs. 95 min, p = 0.004). The recanalization rate immediately after stenting was 42.9% and was greater in the primary than in the secondary group (71.4% vs. 14.3%, p = 0.1). Thirteen patients required various additional therapeutic measures. The final recanalization rate was 78.6%, attributable to improvements in the recanalization rate of the secondary group (71.4% vs. 85.7%). Early hemorrhagic transformation was noted in four patients, but only one patient became symptomatic (symptomatic hemorrhage, 7.1%). Good functional recovery was noted in eight patients (57.1%). CONCLUSION: Placement of a self-expanding stent during endovascular recanalization of acute ischemic stroke was both feasible and safe. Primary use of this method may enhance early recanalization.

Physiologic Flow Diversion Coiling Technique for Wide-Necked Aneurysms with an Asymmetric Bidirectional Flow at the Aneurysm Neck.

PURPOSE: Wide-necked aneurysms in the circle of Willis (CoW) are prone to recur due to reciprocal bidirectional flow. We present a novel concept of coil embolization to prevent recurrence that uses physiologic flow diversion at the CoW. MATERIALS AND METHODS: We enrolled 14 patients (15 aneurysms) who underwent aneurysm coiling for wide-necked aneurysms with asymmetric bidirectional inflow into the aneurysm. Four patients had recurrent aneurysms after coiling. The concept of physiologic flow diversion included obliterating antegrade flow into the aneurysm sac as well as opposite CoW flow by performing compact coil packing with intentional protrusion out of the aneurysm neck to the communicating part. RESULTS: Fifteen aneurysms, including 4 recurrent aneurysms, in an anterior communicating artery (n=7), posterior communicating artery (n=5), and tip of the basilar artery (n=3) were treated with coil embolization (n=10) and stent-assisted coiling (n=5). All aneurysms had a wide neck, and the mean largest diameter was 9.0 mm. The mean packing density was 45.1%. Twelve aneurysms were completely occluded, and 3 aneurysms had tiny residual neck remnants. There was neither a neurological event nor recurrence during the mean 12.5 months of follow-up. CONCLUSION: Wide-necked aneurysms at the CoW tend to recur. As a strategy to prevent a recurrence, physiologic flow diversion can be an option in treating wide-necked aneurysms in the CoW.

Clinical Manifestation and Radiologic Patterns of Spontaneous Cervicocephalic Dissection According to the Anatomic Location: A Single-Center Analysis in Korean Patients.

PURPOSE: Spontaneous cervicocephalic dissection (SCAD) is an important cause of stroke and shows various lesion locations and clinical features. The purpose of this study was to analyze the location of SCAD and its clinical and radiologic patterns in Korean patients. MATERIALS AND METHODS: Patients with SCAD who were evaluated between 2013 and 2018 at a tertiary center in Korea were reviewed. We classified and compared the morphological (aneurysm or steno-occlusion) and presenting (hemorrhage or infarction) patterns according to the lesion locations (anterior circulation [AC] vs. posterior circulation [PC]; intradural [ID] vs. extradural [ED]). RESULTS: A total of 166 patients were included in this study. The SCAD most commonly occurred in the PC-ID location (65.1%), followed by AC-ID (13.3%), AC-ED (13.3%), and PC-ED (8.4%). Aneurysm and steno-occlusion patterns were observed in 66.9% and 57.8% of the cases, respectively. The aneurysm pattern was significantly more common in the PC-ID location (78.7%) than in other locations. As for the presenting pattern, cerebral infarction was the most common pattern (39.8%), and intracranial hemorrhage was observed only in the ID location (7.2%). CONCLUSION: In Korean patients, PC-ID, especially ID vertebral artery, was the most common location of SCAD, and most cases were accompanied by an aneurysm. It also suggested that these location trends differ by population or ethnicity.

Whole Exome Sequencing in Patients with Phenotypically Associated Familial Intracranial Aneurysm.

OBJECTIVE: Familial intracranial aneurysms (FIAs) are found in approximately 6%-20% of patients with intracranial aneurysms (IAs), suggesting that genetic predisposition likely plays a role in its pathogenesis. The aim of this study was to identify possible IA-associated variants using whole exome sequencing (WES) in selected Korean families with FIA. MATERIALS AND METHODS: Among the 26 families in our institutional database with two or more IA-affected first-degree relatives, three families that were genetically enriched (multiple, early onset, or common site involvement within the families) for IA were selected for WES. Filtering strategies, including a family-based approach and knowledge-based prioritization, were applied to derive possible IA-associated variants from the families. A chromosomal microarray was performed to detect relatively large chromosomal abnormalities. RESULTS: Thirteen individuals from the three families were sequenced, of whom seven had IAs. We noted three rare, potentially deleterious variants (PLOD3 c.1315G>A, NTM c.968C>T, and CHST14 c.58C>T), which are the most promising candidates among the 11 potential IA-associated variants considering gene-phenotype relationships, gene function, co-segregation, and variant pathogenicity. Microarray analysis did not reveal any significant copy number variants in the families. CONCLUSION: Using WES, we found that rare, potentially deleterious variants in PLOD3, NTM, and CHST14 genes are likely responsible for the subsets of FIAs in a cohort of Korean families.