How Cerebral Vessel Tortuosity Affects Development and Recurrence of Aneurysm: Outer Curvature versus Bifurcation Type / 대한뇌졸중학회지

Background@#and Purpose Previous studies have assessed the relationship between cerebral vessel tortuosity and intracranial aneurysm (IA) based on two-dimensional brain image analysis. We evaluated the relationship between cerebral vessel tortuosity and IA according to the hemodynamic location using three-dimensional (3D) analysis and studied the effect of tortuosity on the recurrence of treated IA. @*Methods@#We collected clinical and imaging data from patients with IA and disease-free controls. IAs were categorized into outer curvature and bifurcation types. Computerized analysis of the images provided information on the length of the arterial segment and tortuosity of the cerebral arteries in 3D space. @*Results@#Data from 95 patients with IA and 95 controls were analyzed. Regarding parent vessel tortuosity index (TI; P<0.01), average TI (P<0.01), basilar artery (BA; P=0.02), left posterior cerebral artery (P=0.03), both vertebral arteries (VAs; P<0.01), and right internal carotid artery (P<0.01), there was a significant difference only in the outer curvature type compared with the control group. The outer curvature type was analyzed, and the occurrence of an IA was associated with increased TI of the parent vessel, average, BA, right middle cerebral artery, and both VAs in the logistic regression analysis. However, in all aneurysm cases, recanalization of the treated aneurysm was inversely associated with increased TI of the parent vessels. @*Conclusions@#TIs of intracranial arteries are associated with the occurrence of IA, especially in the outer curvature type. IAs with a high TI in the parent vessel showed good outcomes with endovascular treatment.

How Cerebral Vessel Tortuosity Affects Development and Recurrence of Aneurysm: Outer Curvature versus Bifurcation Type / 대한뇌졸중학회지

Background@#and Purpose Previous studies have assessed the relationship between cerebral vessel tortuosity and intracranial aneurysm (IA) based on two-dimensional brain image analysis. We evaluated the relationship between cerebral vessel tortuosity and IA according to the hemodynamic location using three-dimensional (3D) analysis and studied the effect of tortuosity on the recurrence of treated IA. @*Methods@#We collected clinical and imaging data from patients with IA and disease-free controls. IAs were categorized into outer curvature and bifurcation types. Computerized analysis of the images provided information on the length of the arterial segment and tortuosity of the cerebral arteries in 3D space. @*Results@#Data from 95 patients with IA and 95 controls were analyzed. Regarding parent vessel tortuosity index (TI; P<0.01), average TI (P<0.01), basilar artery (BA; P=0.02), left posterior cerebral artery (P=0.03), both vertebral arteries (VAs; P<0.01), and right internal carotid artery (P<0.01), there was a significant difference only in the outer curvature type compared with the control group. The outer curvature type was analyzed, and the occurrence of an IA was associated with increased TI of the parent vessel, average, BA, right middle cerebral artery, and both VAs in the logistic regression analysis. However, in all aneurysm cases, recanalization of the treated aneurysm was inversely associated with increased TI of the parent vessels. @*Conclusions@#TIs of intracranial arteries are associated with the occurrence of IA, especially in the outer curvature type. IAs with a high TI in the parent vessel showed good outcomes with endovascular treatment.

Treatment Outcomes with Selective Coil Embolization for Large or Giant Aneurysms : Prognostic Implications of Incomplete Occlusion

OBJECTIVE: The objectives of this study were to evaluate the immediate and long-term efficacy and safety of coil embolization for large or giant aneurysms. METHODS: One hundred and fifty large or giant aneurysm cases treated with endovascular coil embolization between January 2005 and February 2014 at a single institute were included in this study. Medical records and imaging findings were reviewed. Statistical analysis was performed to evaluate prognostic factors associated with major recurrence (major recanalization or rupture) and delayed thromboembolism after selective coil embolization. RESULTS: Procedure-related symptomatic complications occurred in five (3.3%) patients. The mean clinical and radiological follow-up periods were 38 months (range, 2–110) and 26 months (range, 6–108), respectively. During the follow-up period, the estimated recurrence rate was 4.6% per year. Multivariate analysis using Cox regression showed the degree of occlusion to be the only factor associated with recurrence (p=0.008, hazard ratio 3.15, 95% confidence interval 1.34–7.41). The patient’s history of rupture in addition to the size and location of the aneurysm were not associated with recurrence in this study. Delayed infarction occurred in eight cases, and all were incompletely occluded. CONCLUSION: Although immediate postprocedural safety profiles were reasonable, longterm results showed recanalization and thromboembolic events to occur continuously, especially in patients with incomplete occlusion. In addition, incomplete occlusion was associated with delayed thromboembolic complications. Patients with incomplete occlusions should be followed carefully for delayed recurrence or delayed thromboembolic events.

Contrast-Induced Acute Kidney Injury after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage

PURPOSE: Contrast-induced acute kidney injury (CI-AKI) is associated with poor outcomes after percutaneous coronary intervention. However, CI-AKI has rarely been evaluated within the neurovascular field. The aim of this study was to investigate the incidence and clinical implication of CI-AKI after coil embolization in patients with an aneurysmal subarachnoid hemorrhage (aSAH). MATERIALS AND METHODS: Between January 2005 and March 2016, 192 patients who underwent coil embolization were enrolled in this study. CI-AKI was defined as an increase from baseline serum creatinine concentration of >25% or >0.5 mg/dL within 72 hours after coil embolization. A poor clinical outcome was defined as a score of ≥3 on the modified Rankin Scale at one-year post-treatment. RESULTS: A total of 16 patients (8.3%) died as a result of medical problems within one year. CI-AKI was identified in 14 patients (7.3%). Prominent risk factors for one-year mortality included CI-AKI [odds ratio (OR): 16.856; 95% confidence interval (CI): 3.437–82.664] and an initial Glasgow Coma Scale (GCS) score ≤8 (OR: 5.565; 95% CI: 1.703–18.184). A poor clinical outcome was associated with old age (≥65 years) (OR: 7.921; 95% CI: 2.977–21.076), CI-AKI (OR: 11.281; 95% CI: 2.138–59.525), an initial GCS score ≤8 (OR 31.02; 95% CI, 10.669–90.187), and a ruptured aneurysm (p=0.016, OR: 4.278) in posterior circulation. CONCLUSION: CI-AKI seems to be an independent predictor of the overall outcomes of aSAH after endovascular treatment.

Treatment Outcomes with Selective Coil Embolization for Large or Giant Aneurysms : Prognostic Implications of Incomplete Occlusion

OBJECTIVE: The objectives of this study were to evaluate the immediate and long-term efficacy and safety of coil embolization for large or giant aneurysms.METHODS: One hundred and fifty large or giant aneurysm cases treated with endovascular coil embolization between January 2005 and February 2014 at a single institute were included in this study. Medical records and imaging findings were reviewed. Statistical analysis was performed to evaluate prognostic factors associated with major recurrence (major recanalization or rupture) and delayed thromboembolism after selective coil embolization.RESULTS: Procedure-related symptomatic complications occurred in five (3.3%) patients. The mean clinical and radiological follow-up periods were 38 months (range, 2–110) and 26 months (range, 6–108), respectively. During the follow-up period, the estimated recurrence rate was 4.6% per year. Multivariate analysis using Cox regression showed the degree of occlusion to be the only factor associated with recurrence (p=0.008, hazard ratio 3.15, 95% confidence interval 1.34–7.41). The patient’s history of rupture in addition to the size and location of the aneurysm were not associated with recurrence in this study. Delayed infarction occurred in eight cases, and all were incompletely occluded.CONCLUSION: Although immediate postprocedural safety profiles were reasonable, longterm results showed recanalization and thromboembolic events to occur continuously, especially in patients with incomplete occlusion. In addition, incomplete occlusion was associated with delayed thromboembolic complications. Patients with incomplete occlusions should be followed carefully for delayed recurrence or delayed thromboembolic events.

Predictor and Prognosis of Procedural Rupture during Coil Embolization for Unruptured Intracranial Aneurysm

OBJECTIVE: The objectives of this study was to determine the incidence and outcomes of procedural rupture (PR) during coil embolization of unruptured intracranial aneurysm (UIA) and to explore potential risk factors. METHODS: This retrospective study evaluated 1038 patients treated with coil embolization between January 2001 and May 2013 in a single tertiary medical institute. PR was defined as evidence of rupture during coil embolization or post procedural imaging. The patient's medical records were reviewed including procedure description, image findings and clinical outcomes. RESULTS: Twelve of 1038 (1.1%) patients showed PR. Points and time of rupture were parent artery rupture during stent delivery (n=2), aneurysm rupture during filling stage (n=9) and unknown (n=1). Two parent artery rupture and one aneurysm neck rupture showed poor clinical outcomes [modified Rankin Scale (mRs) >2] Nine aneurysm dome rupture cases showed favorable outcomes (mRS < or =2). Location (anterior cerebral artery) of aneurysm was associated with high procedural rupture rate (p<0.05). CONCLUSION: The clinical course of a patientwith procedural aneurysm rupture during filling stage seemed benign. Parent artery and aneurysm neck rupture seemed relatively urgent, serious and life threatening. Although the permanent morbidity rate was low, clinicians should pay attention to prevent PR, especially when confronting the anterior cerebral artery aneurysm.

Prevalence of Unruptured Intracranial Aneurysm on MR Angiography

OBJECTIVE: To evaluate the prevalence of incidentally found unruptured intracranial aneurysms (UIAs) on the brain MR angiography (MRA) from a community-based general hospital. MATERIALS AND METHODS: This was a prospectively collected retrospective study, carried out from January 2004 to December 2004. The subjects included 3049 persons from a community-based hospital in whom MRA was performed according to a standardized protocol in an outpatient setting. Age- and sex-specific prevalence of UIAs was calculated. The results by MRA were compared with intra-arterial digital subtraction angiography (DSA) findings. RESULTS: Unruptured intracranial aneurysms were found in 137 (5%) of the 3049 patients (M:F = 43:94; mean age, 60.2 years). The prevalence of UIAs was 5% (n = 94) in women and 4% (n = 43) in men, respectively (p = 0.2046) and showed no age-related increase. The most common site of aneurysm was at the distal internal carotid artery (n = 64, 39%), followed by the middle cerebral artery (n = 40, 24%). In total, 99% of aneurysms measured less than 12 mm, and 93% of aneurysms measured less than 7 mm. Direct comparisons between MRA and DSA were available in 70 patients with 83 UIAs; the results revealed two false positive and two false negative results. CONCLUSION: This community-hospital based study suggested a higher prevalence of UIAs observed by MRA than previously reported. These findings should be anticipated in the design and use of neuroimaging in clinical practice.

Endovascular Coil Embolization of Very Small Intracranial Aneurysms

OBJECTIVE: We aimed to evaluate the results of endovascular coil embolization for very small aneurysms ( or = 4), with no bleeding of the treated aneurysms during a mean follow-up period of 13.3 months. On 27 follow-up MRA, there was no recurrence, and the five incompletely occluded aneurysms showed a spontaneous amelioration resulting in an adequate occlusion. CONCLUSION: Coil embolization of very small aneurysms is technically feasible with good results. The long-term efficacy and the potential as a standard treatment strategy remain to be determined by randomized large trials.

Endovascular Treatment for Isolated Dissecting Aneurysm of The Pericallosal Artery Presenting with Spontaneous Subarachnoid Hemorrhage: A Case Report / 신경중재치료의학

Dissecting aneurysms of intracranial artery often arise in the posterior circulation, but those in the anterior circulation are rare, presenting with hemorrhagic event. So, we report an unusual case of isolated dissecting aneurysm of the pericallosal artery presenting with spontaneous subarachnoid hemorrhage. A 46-year-old hypertensive woman presented with severe headache and intense nuchal rigidity after onset of two days. Computed tomography (CT) brain scan revealed a subarachnoid hemorrhage and an interhemispheric hematoma. This was due to dissecting aneurysm of left pericallosal artery on conventional cerebral angiography. Total occlusion of the dissecting aneurysm was performed with five Guglielmi detachable coils, with no apparent procedure-related complications. Endovascular treatment by aneurysm and parent artery occlusion is a relatively reliable alternative to surgery for isolated dissecting aneurysm of pericallosal artery.

A case of petrous carotid artery pseudoaneurysm presenting with epistaxis after radiotherapy in a patient with nasopharyngeal cancer / 대한내과학회지

Rupture of an internal carotid artery pseudoaneurysm is a rare but lethal complication in patients with nasopharyngeal cancer. Here, we report a case of severe nasal bleeding from a left petrous internal carotid artery aneurysm after chemoradiotherapy in a patient with nasopharyngeal cancer. A 76-year-old man who was being treated with concurrent chemoradiotherapy and who had achieved a complete response for 14 months developed massive epistaxis . A postnasal space computed tomography scan showed an enhanced nodular lesion at the left petrous internal carotid artery, and angiography revealed a pseudoaneurysm measuring 11.5x9.1 mm in the left internal carotid artery. Bleeding was well controlled with endovascular occlusion using a coil. The patient showed no recurrence of bleeding during follow-up.

Comparison of Outcomes between Primary Closure vs. Patch Angioplasty in Carotid Endarterectomy

PURPOSE: The aim of this study was to compare the short and long-term outcomes following carotid endarterectomy (CEA) with either primary closure (PC) or patch angioplasty (PAT) performed by single center vascular surgeons. METHODS: Between November 1994 and March 2008, a total of 366 patients underwent 401 consecutive primary CEA procedures at our institution. We retrospectively reviewed patients' medical records. Two vascular surgeons prefer routine PC and one vascular surgeon prefer routine patch closure using bovine pericardial patch. Postoperative neurologic complications were determined by clinical neurologists. Restenosis was defined as >50% stenosis on follow-up duplex scan. Data was analyzed to compare the early (< or =30 days) and late results of CEA between PC group and PAT group. RESULTS: The mean follow-up duration was significantly longer in the PC group than that in the PAT group (61.7 months vs. 41.2 months, P<0.001). Coronary artery disease and combined CEA with coronary artery bypass were more common in the PAT group (39% vs. 55%, P<0.002; 4% vs. 12%, P<0.004). Perioperative ipsilateral TIA/stroke rates in the PC and PAT groups were 1.5% and 0.7% (PC=4/270 vs. PAT=1/131, P=0.564). Regarding late outcomes, Kaplan-Meier analysis failed to show any difference between 2 groups on freedom from ipsilateral transient ischemic attack (TIA)/stroke, freedom from restenosis and TIA/stroke-free survival (P=0.851, P=0.232, P=0.103, log-rank test). CONCLUSION: Our results suggest that PC following CEA is not necessarily inferior to PAT for experienced surgeons.

Ethanol Sclerotherapy for the Management of Craniofacial Venous Malformations: the Interim Results

OBJECTIVE: We wanted to evaluate the safety and feasibility of ethanol sclerotherapy for treating craniofacial venous malformations (CVMs). MATERIALS AND METHODS: From May 1998 to April 2007, 87 patients (40 men and 47 women; age range, 2-68 years) with CVMs underwent staged ethanol sclerotherapy (range, 1-21 sessions; median number of sessions, 2) by the direct puncture technique. Clinical follow up (range, 0-120 months; mean follow up, 35 months; median follow up, 28 months) was performed for all the patients. Therapeutic outcomes were established by evaluating the clinical outcome of the signs and symptoms in all patients, as well as the degree of devascularization, which was determined on the follow-up imaging, in 71 patients. RESULTS: A total of 305 procedures with the use of ethanol were performed in 87 patients. Follow-up imaging studies were performed for 71 of 87 patients. Twenty-three (32%) of the 71 patients showed excellent outcomes, 37 patients (52%) showed good outcomes and 11 patients (16%) showed poor outcomes. Ethanol sclerotherapy was considered effective for 60 patients. All the minor complications such as bulla (n = 5) healed with only wound dressing and observation. Any major complication such as skin necrosis did not develop. CONCLUSION: Percutaneous ethanol sclerotherapy is an effective, safe treatment for CVMs.

Carotid Endarterectomy: Analysis of Early Complications (<30 days) and Risk Factors for Postoperative New Brain Infarction

PURPOSE: We aimed to evaluate the early (70%) carotid stenosis. We also found that plaque with ulceration was a significant risk factor for the development of postoperative NBI.

MR Imaging of the Internal Auditory Canal and Inner Ear at 3T: Comparison between 3D Driven Equilibrium and 3D Balanced Fast Field Echo Sequences

OBJECTIVE: To compare the use of 3D driven equilibrium (DRIVE) imaging with 3D balanced fast field echo (bFFE) imaging in the assessment of the anatomic structures of the internal auditory canal (IAC) and inner ear at 3 Tesla (T). MATERIALS AND METHODS: Thirty ears of 15 subjects (7 men and 8 women; age range, 22-71 years; average age, 50 years) without evidence of ear problems were examined on a whole-body 3T MR scanner with both 3D DRIVE and 3D bFFE sequences by using an 8-channel sensitivity encoding (SENSE) head coil. Two neuroradiologists reviewed both MR images with particular attention to the visibility of the anatomic structures, including four branches of the cranial nerves within the IAC, anatomic structures of the cochlea, vestibule, and three semicircular canals. RESULTS: Although both techniques provided images of relatively good quality, the 3D DRIVE sequence was somewhat superior to the 3D bFFE sequence. The discrepancies were more prominent for the basal turn of the cochlea, vestibule, and all semicircular canals, and were thought to be attributed to the presence of greater magnetic susceptibility artifacts inherent to gradient-echo techniques such as bFFE. CONCLUSION: Because of higher image quality and less susceptibility artifacts, we highly recommend the employment of 3D DRIVE imaging as the MR imaging choice for the IAC and inner ear.

Endovascular Treatment for a Persistent Trigeminal Artery Aneurysm Presenting as Isolated Sixth Nerve Palsy / 신경중재치료의학

The trigeminal artery is the most common persistent carotid-basilar anastomotic channel observed in adult life, and its occurrence probably represents a defect in cerebrovascular development. It can be associated with other congenital abnormalities such as cerebral aneurysms, but only rarely do aneurysms of the persistent trigeminal artery itself arise. Endovascular treatment of these aneurysms has not been attempted so much. We report a case of endovascular treatment for a persistent trigeminal artery aneurysm causing isolated sixth nerve palsy.

Guideline for Management of Unruptured Intracranial Aneurysms: Preliminary Report / 신경중재치료의학

Over the past decade, development of noninvasive diagnostic modalities for the diagnosis of intracranial aneurysms have led to a dramatic change in the management in which patients with unruptured intracranial aneurysms are diagnosed and treated. A patient with an unruptured intracranial aneurysm has three treatment options: endovascular coiling, surgical clipping, and observation. The decision making about management of intracranial aneurysms should be based on the risk of rupture and risks associated with surgical or endovascular treatment. In this report, we review the recent published articles pertaining to diagnositic modalities, natural history, management, and follow-up of unruptured intracranial aneurysms.

Cerebral Ischemia Detected with Diffusion-Weighted MR Imaging after Protected Carotid Artery Stenting: Comparison of Distal Balloon and Filter Device

OBJECTIVE: The aim of this study was to examine the incidence of ischemia during protected carotid artery stenting (CAS) as well as to compare the protective efficacy of the balloon and filter devices on diffusion-weighted MR imaging (DWI). MATERIALS AND METHODS: Seventy-one consecutive protected CAS procedures in 70 patients with a severe (> 70%) or symptomatic moderate (> 50%) carotid artery stenosis were examined. A balloon device (PercuSurge GuardWire) and a filter device (FilterWire EX/EZ, Emboshield) was used in 33 cases (CAS-B group) and 38 cases (CAS-F group) to prevent distal embolization, respectively. All the patients underwent DWI within seven days before and after the procedures. The number of new cerebral ischemic lesions on the post-procedural DWI were counted and divided into ipsilateral and contralateral lesions according to the relationship with the stenting side. RESULTS: New cerebral ischemic lesions were detected in 13 (39.4%) out of the 33 CAS-Bs and in 15 (39.5%) out of the 38 CAS-Fs. The mean number of total, ipsilateral and contralateral new cerebral ischemic lesion was 2.39, 1.67 and 0.73 in the CAS-B group and 2.11, 1.32 and 0.79 in the CAS-F group, respectively. No statistical differences were found between the two groups (p = 0.96, 0.74 and 0.65, respectively). The embolic complications encountered included two retinal infarctions and one hemiparesis in the CAS-B group (9.09%), and one retinal infarction, one hemiparesis and one ataxia in the CAS-F group (7.89%). There was a similar incidence of embolic complications in the two groups (p = 1.00). CONCLUSION: The type of distal protection device used such as a balloon and filter does not affect the incidence of cerebral embolization after protected CAS.

Intra-arterial Nimodipine for the Treatment of Symptomatic Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage : Preliminary Report Clinical Research / 대한뇌혈관외과학회지

OBJECTIVE: We evaluated the efficacy of intra-arterial nimodipine, a calcium-channel blocker acting mainly on cerebral vessels, in patients with symptomatic cerebral vasospasm following subarachnoid hemorrhage. METHODS: Clinical records of 8 consecutively treated patients were reviewed. Patients were considered to determine the indication for cerebral angiography and subsequent endovascular treatment if they presented symptomatic cerebral vasospasm. Nimodipine was infused intra-arterially via microcatheter in the internal carotid artery or basilar artery at a rate of 0.1 mg/min. Immediate angiographic vasodilatation and clinical improvement were assessed. RESULTS: Thirteen procedures were performed in 8 patients. Clinical improvement was observed in 7 (88%) patients. 5 of 8 patients were clinically improved within 24 hours after the first endovascular treatment, and two after the third. The notable arterial dilatation at postprocedural angiography was observed in 9 (70%) of 13 procedures. After follow-up of 3-6 months, 7 (88%) patients had a favorable outcome (Glasgow Outcome Scale score of 5-4). No procedure related complications were observed. CONCLUSION: Intra-arterial nimodipine infusion is effective and safe for the treatment of symptomatic vasospasm after subarachnoid hemorrhage. Further prospective randomized studies are needed to support these results.

Intracardiac Foreign Body Formation from Bone Cement Material Following Total Hip Replacement: A Case Report

A linear intracardiac foreign body was identified following a total hip replacement (THR) on chest CT and transesophageal echocardiography in a 60-year-old woman with rheumatoid arthritis. Leakage and migration of bone cement during arthroplasty is a possible explanation for this rare complication. Therefore, adequate preparation and handling of cement using biplane fluoroscopy are recommended during arthroplasty.

Buccal Space Lesions: A New Classification Based on CT and MR Imaging Findings

PURPOSE: To present a new classification based on the CT and MR imaging findings of buccal space lesions, and to propose guidelines for their radiologic differentiation. MATERIALS AND METHODS: Sixty-two histopathologically confirmed or clinically diagnosed buccal space lesions were classified on the basis of their morphologic appearance and extension to adjacent space as either (1) a mass with a distinct margin, confined to the buccal space; (2) a mass with surrounding infiltration, confined to the buccal space; or (3) a multi-space occupying mass. RESULTS: Type 1 included pleomorphic adenoma, ex-pleomorphic adenoma, carcinoma, B-cell lymphoma, acinic cell carcinoma, rhabdomyosarcoma, glomus tumor and ameloblastoma, and differentiation between malignant and benign neoplasms was not possible. Type 2 included adenoid cystic carcinoma, abscess, complicated dermoid cyst, and Kimura disease. T-cell lymphoma, neurofibroma, vascular malformation, inflammation, and foreign body granuloma pertained to type 3, and each type-3 entity showed different imaging characteristics. CONCLUSION: This new classification based on CT and MR imaging characteristics may provide useful guidelines for predicting the differential diagnosis of buccal space lesions.