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Basilar artery (BA) perforator aneurysms are exceedingly rare causes of subarachnoid hemorrhage. Therefore, the natural history and optimal treatment have not been established, and surgical, endovascular, and conservative management have been used. However, there is no consensus on the optimal treatment strategy. Herein, we report the case of a 52-year-old man presenting with a ruptured BA perforator aneurysm. First, we deployed an Enterprise stent from the left P1 segment to the BA because the microcatheter could not enter the aneurysm. Then, we deployed a helical coil on the orifice of the BA perforator. Finally, we deployed another Enterprise stent, sandwiching the helical coil between the two Enterprise stents. The aneurysm was completely obliterated without recurrence on the follow-up angiography. Our technique of sandwiching the small helical coil between two Enterprise stents might help other surgeons by offering another feasible treatment option for ruptured BA perforator aneurysms.
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Purpose@#Breast cancer brain metastases (BCBM) may involve subtypes that differ from the primary breast cancer lesion. This study aimed to develop a radiomics-based model that utilizes preoperative brain MRI for multiclass classification of BCBM subtypes and to investigate whether the model offers better prediction accuracy than the assumption that primary lesions and their BCBMs would be of the same subtype (non-conversion model) in an external validation set. @*Materials and Methods@#The training and external validation sets each comprised 51 cases (102 cases total). Four machine learning classifiers combined with three feature selection methods were trained on radiomic features and primary lesion subtypes for prediction of the following four subtypes: 1) hormone receptor (HR)+/human epidermal growth factor receptor 2 (HER2)-, 2) HR+/HER2+, 3) HR-/HER2+, and 4) triple-negative. After training, the performance of the radiomics-based model was compared to that of the non-conversion model in an external validation set using accuracy and F1-macro scores. @*Results@#The rate of discrepant subtypes between primary lesions and their respective BCBMs were 25.5% (n=13 of 51) in the training set and 23.5% (n=12 of 51) in the external validation set. In the external validation set, the accuracy and F1-macro score of the radiomics-based model were significantly higher than those of the non-conversion model (0.902 vs. 0.765, p=0.004; 0.861 vs. 0.699, p=0.002). @*Conclusion@#Our radiomics-based model represents an incremental advance in the classification of BCBM subtypes, thereby facilitating a more appropriate personalized therapy.
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We present a case of delayed migration of an open-cell design carotid stent, which is a rare complication following carotid artery stenting (CAS). A 65-year-old patient with carotid artery stenosis underwent CAS with an open-cell stent, initially achieving successful deployment. However, 4 months later, the stent migrated and resulted in restenosis. The patient underwent balloon angioplasty and received an additional stent, leading to improved blood flow. The rarity of stent migration, particularly in the absence of risk factors, highlights the need for clinicians to be vigilant and consider early imaging follow-up for patients at risk of this complication after CAS.
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Purpose@#While symptomatic basilar artery (BA) stenosis is associated with a higher risk of recurrent stroke or death, there is no consensus on the management of these patients who are refractory to antiplatelet therapy. This study retrospectively assesses the outcomes of endovascular treatment (EVT) for symptomatic BA stenosis. @*Materials and Methods@#We conducted a retrospective review of patients with symptomatic BA stenosis who underwent EVT, including angioplasty or stenting, from 2006 to 2018. A total of 15 patients, who experienced transient ischemic attacks or strokes despite dual antiplatelet therapy, were included. EVT was performed under local anesthesia after pretreatment with antiplatelet medications. Angiographic follow-up was performed at 12 and 24 months post-EVT. Clinical outcomes were evaluated using the modified Rankin Scale (mRS). @*Results@#EVT was successfully completed in all patients. Peri/post-procedural complications occurred in 33% of cases, including in-stent thrombosis, intracranial hemorrhage, and pontine infarction. At long-term follow-up (mean 98.5±80.5 months), 73.3% of patients achieved a favorable functional outcome (mRS≤2) without disability or mortality. Patients with unfavorable outcomes had previous infarcts, with 2 experiencing new pontine infarctions after stenting. @*Conclusion@#This study suggests that EVT, including angioplasty and stenting, may offer promise as a treatment option for symptomatic BA stenosis refractory to medical therapy. However, the procedure carries a notable risk of complications, especially in patients with severe stenosis and previous infarcts. Careful patient selection, based on clinical and radiological criteria, is crucial.
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Cerebral amyloid angiopathy-related inflammation (CAA-RI) is a rare encephalopathy characterized by the coexistence of a perivascular inflammatory reaction in patients with cerebral amyloid angiopathy. CAA-RI diagnosis is challenging as its final diagnosis requires invasive procedures such as autopsy or brain biopsy. Therefore, multimodal imaging approaches with clinical considerations are essential for the probable diagnosis of CAA-RI. In particular, in the case of CAA-RI presented with uncommon clinical symptoms, the need for imaging in diagnosis is further highlighted by difficulties of clinical approaches. Herein, we report a case of CAA-RI with unusual clinical manifestation diagnosed using multimodal imaging including magnetic resonance imaging (MRI) and amyloid positron emission tomography-computed tomography (PET-CT). Multimodal imaging approaches using adequate MRI sequences and PET-CT scans could facilitate the diagnosis of CAA-RI without requiring invasive pathological confirmation.
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Objective@#We aimed to evaluate the efficacy of EmboTrap II in terms of first-pass recanalization and to determine whether it could yield favorable outcomes. @*Materials and Methods@#In this multicenter, prospective study, we consecutively enrolled patients who underwent mechanical thrombectomy using EmboTrap II as a front-line device. The primary outcome was the first pass effect (FPE) rate defined by modified Thrombolysis In Cerebral Infarction (mTICI) grade 2c or 3 by the first pass of EmboTrap II. In addition, modified FPE (mFPE; mTICI grade 2b–3 by the first pass of EmboTrap II), successful recanalization (final mTICI grade 2b–3), and clinical outcomes were assessed. We also analyzed the effect of FPE on a modified Rankin Scale (mRS) score of 0–2 at 3 months. @*Results@#Two hundred-ten patients (mean age ± standard deviation, 73.3 ± 11.4 years; male, 55.7%) were included. Ninetynine patients (47.1%) had FPE, and mFPE was achieved in 150 (71.4%) patients. Successful recanalization was achieved in 191 (91.0%) patients. Among them, 164 (85.9%) patients underwent successful recanalization by exclusively using EmboTrap II. The time from groin puncture to FPE was 25.0 minutes (interquartile range, 17.0–35.0 minutes). Procedure-related complications were observed in seven (3.3%) patients. Symptomatic intracranial hemorrhage developed in 14 (6.7%) patients. One hundred twenty-three (58.9% of 209 completely followed) patients had an mRS score of 0–2. Sixteen (7.7% of 209) patients died during the follow-up period. Patients who had successful recanalization with FPE were four times more likely to have an mRS score of 0–2 than those who had successful recanalization without FPE (adjusted odds ratio, 4.13;95% confidence interval, 1.59–10.8; p = 0.004). @*Conclusion@#Mechanical thrombectomy using the front-line EmboTrap II is effective and safe. In particular, FPE rates were high. Achieving FPE was important for an mRS score of 0–2, even in patients with successful recanalization.
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Dynamic contrast-enhanced MRI (DCE-MRI) is a noninvasive imaging technique used to evaluate tissue vascularity/permeability features through consecutive imaging acquisitions after gadolinium-based contrast agent administration. Over the past several decades, techniques and protocols for DCE-MRI have evolved, leading to growing applications of DCE-MRI for different neurological disorders. Although most established applications of DCE-MRI are for studying tumors, an increasing number of studies have been evaluating the use of this technique for neurodegenerative and other miscellaneous diseases. The purpose of this article was to provide an overview of DCE-MRI and its clinical applications in various neurological diseases.
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Purpose@#To analyze trends in mortality rates from hemorrhagic stroke (HS) according to HS subtypes, using nationwide data from January 2012 to December 2020. @*Materials and Methods@#We used data from the National Health Claims Database provided by the National Health Insurance Service for 2012–2020 using the International Classification of Disease. The age-adjusted mortality rates of HS, which included subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), were calculated, and additional analyses were conducted according to age and sex. @*Results@#The age-adjusted mortality rates for HS, SAH, and ICH decreased substantially in both sexes between 2012 and 2020. During the study period, mortality rates for HS decreased from 8.87 deaths per 100,000 inhabitants to 6.27 deaths per 100,000 inhabitants. Regarding SAH, mortality rates decreased from 3.72 deaths per 100,000 inhabitants to 2.57 deaths per 100,000 inhabitants. Concerning ICH, mortality rates decreased from 6.91 deaths per 100,000 inhabitants to 4.75 deaths per 100,000 inhabitants. The average annual percentage change for HS, SAH, and ICH was –0.04, –0.04, and –0.05, respectively. Mortality rates from HS, SAH, and ICH in both sexes decreased from 2012 to 2020 in all age groups. @*Conclusion@#In Korea, the age-adjusted mortality rate of HS, SAH, and ICH demonstrated a declining trend in both sexes and across all age groups. These results may aid in the design and improvement of preventive strategies.
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Purpose@#The purpose of this study was to evaluate the prevalence and risk factors of unruptured intracranial aneurysms (UIAs), which can help establish guidelines of treatment for asymptomatic Korean adults using 3T magnetic resonance angiography (MRA). @*Materials and Methods@#Our Institutional Review Board approved this retrospective study, and informed consent was waived. All patients consisted of healthy individuals who underwent brain MRA using 3T magnetic resonance imaging between January 2011 and December 2012 as part of a routine health examination. Patient data and follow-up results were obtained from medical records. @*Results@#A total of 2,118 individuals (mean age=53.9±9.6 years, male:female=1,188:930) who had undergone brain MRA were enrolled in the study. UIAs were found in 80 patients with 105 UIAs (3.77%). Female predominance (55% in UIA vs. 43.47% in non-UIA, P=0.0416) and hypertension were more common in the UIA group (43.75% vs. 28.8%, P=0.004, respectively). The mean size of the aneurysms was 3.10±1.62 mm, and they were all saccular in shape and asymptomatic. The UIAs were most common in the internal carotid artery (59.1%), internal carotid-posterior communicating artery (15.2%), middle cerebral artery (9.5%), anterior communicating artery (8.6%), anterior cerebral artery (4.8%), and vertebral artery (2.9%). Twenty-eight of 80 patients (35%) had multiple aneurysms. The incidence of UIAs increased significantly with age (P=0.014). @*Conclusion@#In single center experience, we demonstrated the characteristics and prevalence of UIAs in asymptomatic adults, which may help establish guidelines or therapeutic standards for UIAs.
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Purpose@#The purpose of this study was to evaluate the prevalence and risk factors of unruptured intracranial aneurysms (UIAs), which can help establish guidelines of treatment for asymptomatic Korean adults using 3T magnetic resonance angiography (MRA). @*Materials and Methods@#Our Institutional Review Board approved this retrospective study, and informed consent was waived. All patients consisted of healthy individuals who underwent brain MRA using 3T magnetic resonance imaging between January 2011 and December 2012 as part of a routine health examination. Patient data and follow-up results were obtained from medical records. @*Results@#A total of 2,118 individuals (mean age=53.9±9.6 years, male:female=1,188:930) who had undergone brain MRA were enrolled in the study. UIAs were found in 80 patients with 105 UIAs (3.77%). Female predominance (55% in UIA vs. 43.47% in non-UIA, P=0.0416) and hypertension were more common in the UIA group (43.75% vs. 28.8%, P=0.004, respectively). The mean size of the aneurysms was 3.10±1.62 mm, and they were all saccular in shape and asymptomatic. The UIAs were most common in the internal carotid artery (59.1%), internal carotid-posterior communicating artery (15.2%), middle cerebral artery (9.5%), anterior communicating artery (8.6%), anterior cerebral artery (4.8%), and vertebral artery (2.9%). Twenty-eight of 80 patients (35%) had multiple aneurysms. The incidence of UIAs increased significantly with age (P=0.014). @*Conclusion@#In single center experience, we demonstrated the characteristics and prevalence of UIAs in asymptomatic adults, which may help establish guidelines or therapeutic standards for UIAs.
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Purpose@#To assess patient radiation doses during diagnostic and therapeutic neurointerventional procedures from multiple centers and propose dose reference level (RL). @*Materials and Methods@#Consecutive neurointerventional procedures, performed in 22 hospitals from December 2020 to June 2021, were retrospectively studied. We collected data from a sample of 429 diagnostic and 731 therapeutic procedures. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time (FT), and total number of image frames (NI) were obtained. RL were calculated as the 3rd quartiles of the distribution. @*Results@#Analysis of 1160 procedures from 22 hospitals confirmed the large variability in patient dose for similar procedures. RLs in terms of DAP, CAK, FT, and NI were 101.6 Gy·cm2, 711.3 mGy, 13.3 minutes, and 637 frames for cerebral angiography, 199.9 Gy·cm2, 3,458.7 mGy, 57.3 minutes, and 1,000 frames for aneurysm coiling, 225.1 Gy·cm2, 1,590 mGy, 44.7 minutes, and 800 frames for stroke thrombolysis, 412.3 Gy·cm2, 4,447.8 mGy, 99.3 minutes, and 1,621.3 frames for arteriovenous malformation (AVM) embolization, respectively. For all procedures, the results were comparable to most of those already published. Statistical analysis showed male and presence of procedural complications were significant factors in aneurysmal coiling. Male, number of passages, and procedural combined technique were significant factors in stroke thrombolysis. In AVM embolization, a significantly higher radiation dose was found in the definitive endovascular cure group. @*Conclusion@#Various RLs introduced in this study promote the optimization of patient doses in diagnostic and therapeutic interventional neuroradiology procedures. Proposed 3rd quartile DAP (Gy·cm2) values were 101.6 for diagnostic cerebral angiography, 199.9 for aneurysm coiling, 225.1 for stroke thrombolysis, and 412.3 for AVM embolization. Continual evolution of practices and technologies requires regular updates of RLs.
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Purpose@#In Korea, endovascular treatment (EVT) for intracranial aneurysms (IAs) has increased steadily. We conducted a nationwide survey to evaluate the current status of EVT for IAs and to identify treatment preference in the real world. @*Materials and Methods@#A Google online survey was distributed to representative clinicians at hospitals treating IAs, where members of Korean Society of Interventional Neuroradiology (KSIN). The data was collected from October 2017 to December 2017. The responding hospitals were divided into 2 groups (tertiary and non-tertiary hospitals). And variable factors involved in decision making for treatment were evaluated. @*Results@#In total, 73 hospitals (tertiary: 37, non-tertiary: 36) responded to the survey. Most hospitals that responded had over 100 cases of diagnostic angiography (93%) and over 50 cases of EVT for IAs (74%) performed in 2016. The proportion of EVT for ruptured aneurysms in non-tertiary hospitals was significantly higher than tertiary hospitals (49% vs. 9%). The proportion of EVT for unruptured aneurysms at non-tertiary hospitals was significantly higher than tertiary hospitals (66% vs. 44%). Most physicians tended to make decision for treatment on location, shape, and size of unruptured IAs and patients’ age, more than the results from previous clinical trials for unruptured IAs. Although EVT was preferred for older patients (age >70) with unruptured IAs (99%), surgical clipping was still considered as the first treatment of choice for younger patients (age 30 to 50 years) at considerable rates (56%). Over two-thirds of respondents preferred surgical clipping for middle cerebral artery aneurysms, while EVT was preferred initially at other locations. @*Conclusion@#This nationwide survey showed that EVT is considered as the first treatment modality for IAs and there is a discrepancy between current guidelines and real-world practice for decision making of treatment options.
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Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset since the five landmark ERT trials up to 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thorough reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make their well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.
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Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset, since five landmark ERT trials conducted by 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window of up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch, defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thoroughly reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.
Subject(s)
Humans , Arteries , Caregivers , Cerebral Infarction , Consensus , Health Personnel , Korea , Mechanical Thrombolysis , Reperfusion , Standard of Care , Stroke , WritingABSTRACT
PURPOSE: Although carotid endarterectomy (CEA) is recommended as a treatment for carotid stenosis rather than carotid artery stenting (CAS), CAS has been preferred in Korea. The aim of this study was to analyze long-term outcomes after CAS compared with CEA using Korean nationwide insurance data. MATERIALS AND METHODS: We obtained all data from the nationwide database of the Health Insurance Review & Assessment Service (HIRA) during the study period using several codes regarding the procedure or operation. We included the HIRA data, which included at least one-year follow-up after the procedures. The outcomes associated with both procedures were death, recurrence of ischemic stroke, and admission for cerebral hemorrhage. RESULTS: A total of 16,065 eligible patients who were treated with CAS or CEA between 1 January 2007 and 31 December 2016 were analyzed. The number of patients with CAS and CEA was 12,173 (75.8%) and 3,892 (24.2%), respectively. 8,976 patients (55.9%) were classified as symptomatic patients. CAS was associated with a higher risk of all-cause mortality (adjusted hazard ratio [HR], 1.282; 95% confidence interval [CI], 1.173–1.400). The adjusted rates for recurrent ischemic stroke and cerebral hemorrhage between CAS versus CEA were 24.9% versus 15.9% (HR, 1.474; 95% CI, 1.325–1.639) and 1.5% versus 0.9% (HR, 2.026; 95% CI, 1.322–3.106), respectively. In young symptomatic patients, there was no statistically significant difference in all-cause mortality and cardiovascular death between CAS and CEA. CONCLUSION: Our study using Korean nationwide insurance data demonstrated similar results to previous studies. Until further evidence of CAS is established through prospective studies, CAS should be performed in selected patients according to current guidelines.
Subject(s)
Humans , Carotid Arteries , Carotid Stenosis , Cerebral Hemorrhage , Endarterectomy , Endarterectomy, Carotid , Follow-Up Studies , Insurance , Insurance, Health , Korea , Mortality , Prognosis , Prospective Studies , Recurrence , Stents , StrokeABSTRACT
Endovascular recanalization therapy (ERT) has been a standard of care for patients with acute ischemic stroke due to large artery occlusion (LAO) within 6 hours after onset, since five landmark ERT trials conducted by 2015 demonstrated its clinical benefit. Recently, two randomized clinical trials demonstrated that ERT, even in the late time window of up to 16 hours or 24 hours after last known normal time, improved the outcome of patients who had a target mismatch, defined as either clinical-core mismatch or perfusion-core mismatch, which prompted the update of national guidelines in several countries. Accordingly, to provide evidence-based and up-to-date recommendations for ERT in patients with acute LAO in Korea, the Clinical Practice Guidelines Committee of the Korean Stroke Society decided to revise the previous Korean Clinical Practice Guidelines of Stroke for ERT. For this update, the members of the writing group were appointed by the Korean Stroke Society and the Korean Society of Interventional Neuroradiology. After thoroughly reviewing the updated evidence from two recent trials and relevant literature, the writing members revised recommendations, for which formal consensus was achieved by convening an expert panel composed of 45 experts from the participating academic societies. The current guidelines are intended to help healthcare providers, patients, and their caregivers make well-informed decisions and to improve the quality of care regarding ERT. The ultimate decision for ERT in a particular patient must be made in light of circumstances specific to that patient.
Subject(s)
Humans , Arteries , Caregivers , Cerebral Infarction , Consensus , Health Personnel , Korea , Mechanical Thrombolysis , Reperfusion , Standard of Care , Stroke , WritingABSTRACT
PURPOSE: As endovascular therapy (EVT) has been approved as a treatment guideline for acute ischemic stroke (AIS), it has been increasing in Korea. We conducted a nationwide survey to evaluate the current status of EVT for patients with AIS in Korea. MATERIALS AND METHODS: An electronic survey was sent to a representative clinician at each hospital where EVT was available in Korea. A Google survey was used to distribute the questionnaires and receive responses from October 2017 to December 2017. RESULTS: Among 120 hospitals in our society, 76 participated in this survey. In 26% of the hospitals, more than 50 annual cases of EVT were performed, and 25–50 annual cases in 37%. Fifty-six hospitals (73.7%) achieved successful recanalization (thrombolysis in cerebral infarction ≥2b) in more than 80% of patients. Computed tomography (CT) angiography was the most common imaging modality for AIS treatment, and magnetic resonance (MR) diffusion, MR-perfusion/diffusion, and perfusion CT were frequently used in order. Non-eligibility criteria for EVT included a National Institutes of Health Stroke Scale < 4 (64.5%), the absence of MR perfusion/diffusion mismatch (52.6%), and a low Alberta Stroke Program Early CT Score (42.1%). For anterior circulation stroke, 60% of Korean hospitals adopted a wider time range of “8 hours” from symptom onset, while 70% of hospitals had a time limitation of 12–24 hours for posterior circulation stroke. The most preferred EVT device was a stentriever (89.4%). In the failed cases due to underlying stenosis, 79% of Korean hospitals performed angioplasty or stenting for revascularization. CONCLUSION: This first nationwide survey showed that most Korean hospitals conducted EVT for AIS patients according to the present guideline in the era of mechanical thrombectomy by integrating the clinical experiences of many medical institutions and specialists.
Subject(s)
Humans , Alberta , Angiography , Angioplasty , Cerebral Infarction , Constriction, Pathologic , Diffusion , Ischemia , Korea , Perfusion , Specialization , Stents , Stroke , ThrombectomyABSTRACT
No abstract available.
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A 43-year-old male presented with daytime sleepiness at work and indifferent behavior like never before. Two weeks prior to hospital admission, he had episodic memory loss with well preserved remote memory. Brain MRI showed a dural arteriovenous fistula (DAVF) in the right lateral transverse sinus with a bilateral thalamic venous infarction. Cerebral angiography confirmed a right transverse sigmoid dural arteriovenous fistula with a feeding artery of the right occipital artery and left posterior meningeal artery. The DAVF was completely eliminated through multiple endovascular interventions. Recently, endovascular treatment has become one of the main therapeutic options to obliterate a fistulous site, which has led to a rapid diagnostic approach and management of DAVFs with high curative rates. We report a rare case of posterior fossa located at a dural arteriovenous fistula that caused rapid progressive dementia and was successfully eliminated through only endovascular treatment.