Obscured Segments of Ruptured Brain Arteriovenous Malformations: Insights from Their Visualization during Emergency Transarterial Embolization / 신경중재치료의학

A ruptured brain arteriovenous malformation (bAVM) presenting with a hematoma may have unseen parts of the shunts in diagnostic angiography in the acute phase, which may lead to innate incomplete evaluation for the whole angioarchitecture of the bAVM. Even though it is generally accepted that the nidus of a ruptured bAVM may be underestimated in angiography during the acute phase due to hematoma compression, documentation of the underestimated parts has not been described in the literature. The authors report 2 cases of ruptured bAVMs in which the obscured segments were cast with liquid embolic material, which suggests a potential presence of obscured segments in bAVMs.

Single Center Experience of the Balloon-Stent Technique for the Treatment of Unruptured Distal Internal Carotid Artery Aneurysms: Sharing a Simple and Reliable Tip to Use Scepter-Atlas Combination

Purpose@#The balloon-stent technique (BST) has certain strengths as an assisted technique for the treatment of complex aneurysms. After Atlas release, the BST can be executed without an exchange maneuver of the balloon to the stent-delivery catheter. The purpose of this article is to share our experience with the BST using the Scepter-Atlas combination. @*Materials and Methods@#Device inspection led us to a simple method to avoid failure in loading Atlas to the Scepter. From March 2018 to December 2019, 57 unruptured distal internal carotid artery (dICA) aneurysms were treated with coil embolization; among which, 25 aneurysms in 23 patients were treated with BST. Clinical and angiographic data were retrospectively collected and reviewed. @*Results@#The technical success rate of the Scepter-Atlas combination increased from 50% to 100% after careful inspection. BST angiographic results were comparable to the stent-assisted coil (SAC) group treated during the immediately post-embolization same period (modified Raymond-Roy classification [MRRC] 1 & 2 84% in BST, 96.3% in SAC) and during short-term follow-up (MRRC 1 & 2 95.8% in BST, 88.4% in SAC). A small number of patients showed periprocedural complications, but none had clinical consequences. @*Conclusion@#BST using the Scepter-Atlas combination can provide an effective and safe method for the treatment of dICA aneurysms. Scepters can be used as delivery catheters for Atlas.

Single Center Experience of the Balloon-Stent Technique for the Treatment of Unruptured Distal Internal Carotid Artery Aneurysms: Sharing a Simple and Reliable Tip to Use Scepter-Atlas Combination

Purpose@#The balloon-stent technique (BST) has certain strengths as an assisted technique for the treatment of complex aneurysms. After Atlas release, the BST can be executed without an exchange maneuver of the balloon to the stent-delivery catheter. The purpose of this article is to share our experience with the BST using the Scepter-Atlas combination. @*Materials and Methods@#Device inspection led us to a simple method to avoid failure in loading Atlas to the Scepter. From March 2018 to December 2019, 57 unruptured distal internal carotid artery (dICA) aneurysms were treated with coil embolization; among which, 25 aneurysms in 23 patients were treated with BST. Clinical and angiographic data were retrospectively collected and reviewed. @*Results@#The technical success rate of the Scepter-Atlas combination increased from 50% to 100% after careful inspection. BST angiographic results were comparable to the stent-assisted coil (SAC) group treated during the immediately post-embolization same period (modified Raymond-Roy classification [MRRC] 1 & 2 84% in BST, 96.3% in SAC) and during short-term follow-up (MRRC 1 & 2 95.8% in BST, 88.4% in SAC). A small number of patients showed periprocedural complications, but none had clinical consequences. @*Conclusion@#BST using the Scepter-Atlas combination can provide an effective and safe method for the treatment of dICA aneurysms. Scepters can be used as delivery catheters for Atlas.

Hospital Volume Threshold Associated with Higher Survival after Endovascular Recanalization Therapy for Acute Ischemic Stroke / 대한뇌졸중학회지

Background@#and Purpose Endovascular recanalization therapy (ERT) is becoming increasingly important in the management of acute ischemic stroke (AIS). However, the hospital volume threshold for optimal ERT remains unknown. We investigated the relationship between hospital volume of ERT and risk-adjusted patient outcomes. @*Methods@#From the National Health Insurance claims data in Korea, 11,745 patients with AIS who underwent ERT from July 2011 to June 2016 in 111 hospitals were selected. We measured the hospital’s ERT volume and patient outcomes, including the 30-day mortality, readmission, and postprocedural intracranial hemorrhage (ICH) rates. For each outcome measure, we constructed risk-adjusted prediction models incorporating demographic variables, the modified Charlson comorbidity index, and the stroke severity index (SSI), and validated them. Risk-adjusted outcomes of AIS cases were compared across hospital quartiles to confirm the volume-outcome relationship (VOR) in ERT. Spline regression was performed to determine the volume threshold. @*Results@#The mean AIS volume was 14.8 cases per hospital/year and the unadjusted means of mortality, readmission, and ICH rates were 11.6%, 4.6%, and 8.6%, respectively. The VOR was observed in the risk-adjusted 30-day mortality rate across all quartile groups, and in the ICH rate between the first and fourth quartiles (P<0.05). The volume threshold was 24 cases per year. @*Conclusions@#There was an association between hospital volume and outcomes, and the volume threshold in ERT was identified. Policies should be developed to ensure the implementation of the AIS volume threshold for hospitals performing ERT.

Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time

Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention (NI) team for EVT candidate prior to imaging, NI team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.

Consensus Statements by Korean Society of Interventional Neuroradiology and Korean Stroke Society: Hyperacute Endovascular Treatment Workflow to Reduce Door-to-Reperfusion Time

Recent clinical trials demonstrated the clinical benefit of endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion. These trials confirmed that good outcome after EVT depends on the time interval from symptom onset to reperfusion and that in-hospital delay leads to poor clinical outcome. However, there has been no universally accepted in-hospital workflow and performance benchmark for rapid reperfusion. Additionally, wide variety in workflow for EVT is present between each stroke centers. In this consensus statement, Korean Society of Interventional Neuroradiology and Korean Stroke Society Joint Task Force Team propose a standard workflow to reduce door-to-reperfusion time for stroke patients eligible for EVT. This includes early stroke identification and pre-hospital notification to stroke team of receiving hospital in pre-hospital phase, the transfer of stroke patients from door of the emergency department to computed tomography (CT) room, warming call to neurointervention team for EVT candidate prior to imaging, neurointervention team preparation in parallel with thrombolysis, direct transportation from CT room to angiography suite following immediate decision of EVT and standardized procedure for rapid reperfusion. Implementation of optimized workflow will improve stroke time process metrics and clinical outcome of the patient treated with EVT.

Feasibility, Safety, and Follow-up Angiographic Results of Endovascular Treatment for Non-Selected Ruptured Intracranial Aneurysms Under Local Anesthesia with Conscious Sedation

BACKGROUND: At most centers, general anesthesia (GA) has been preferred for endovascular treatment (EVT) of ruptured intracranial aneurysms (RIAs). In this study, we analyzed procedural results, clinical outcomes, and follow-up angiographic findings for patients undergoing EVT for RIA under local anesthesia (LA) with conscious sedation (CS). METHODS: We retrospectively evaluated 308 consecutive patients who underwent EVT for RIAs at a single institution between June 2009 and February 2017. EVT under LA with CS was considered for all patients with aneurysmal subarachnoid hemorrhage, regardless of Hunt and Hess (HH) scale score. RESULTS: EVT was performed for 320 aneurysms in 308 patients with subarachnoid hemorrhages. The mean patient age was 55.5±12.6 years. Moderate (III) and poor (IV, V) HH grades were observed in 75 (24.4%) and 77 patients (25%), respectively. Complete occlusion immediately after EVT was achieved for 270 (84.4%) of 320 aneurysms. Thromboembolic complications and intraprocedural ruptures occurred in 25 (7.8%) and 14 cases (4.3%), respectively. The morbidity rate at discharge (as defined by a modified Rankin scale score of 3 or greater) was 27.3% (84/308), while the mortality rate was 11.7% (36/308). Follow-up angiographic results were available for 210 (68.1%) of 308 patients. Recanalization was observed in 64 (29.3%) of 218 aneurysms in 210 patients. CONCLUSION: Based on our experience, EVT for RIAs under LA with CS was feasible, regardless of the clinical grade of the subarachnoid hemorrhage. Complication rates and follow-up angiographic results were also comparable to those observed when GA was used to perform the procedure.

A rare case of multiple pituitary adenomas in an adolescent Cushing disease presenting as a vertebral compression fracture

Cushing disease in children and adolescents, especially with multiple pituitary adenomas (MPAs), is very rare. We report 17-year-old boy with MPAs. He presented with a vertebral compression fracture, weight gain, short stature, headache, and hypertension. On magnetic resonance imaging (MRI), only a left pituitary microadenoma was found. After surgery, transient clinical improvement was observed but headache and hypertension were observed again after 3 months later. Follow-up MRI showed a newly developed right pituitary microadenoma 6 months after the surgery. The need for careful clinical and radiographic follow-up should be emphasized in the search for potential MPAs in patients with persistent Cushing disease.

Pipeline Embolization Device for Large/Giant or Fusiform Aneurysms: An Initial Multi-Center Experience in Korea / 신경중재치료의학

PURPOSE: The purpose of this study was to assess the safety and early outcomes of the Pipeline device for large/giant or fusiform aneurysms. MATERIALS AND METHODS: The Pipeline was implanted in a total of 45 patients (mean age, 58 years; M:F=10:35) with 47 large/giant or fusiform aneurysms. We retrospectively evaluated the characteristics of the treated aneurysms, the periprocedural events, morbidity and mortality, and the early outcomes after Pipeline implantation. RESULTS: The aneurysms were located in the internal carotid artery (ICA) cavernous segment (n=25), ICA intradural segment (n=11), vertebrobasilar trunk (n=8), and middle cerebral artery (n=3). Procedure-related events occurred in 18 cases, consisting of incomplete expansion (n=8), shortening-migration (n=5), transient occlusion of a jailed branch (n=3), and in-stent thrombosis (n=2). Treatment-related morbidity occurred in two patients, but without mortality. Both patients had modified Rankin scale (mRS) scores of 2, but had an improved mRS score of 0 at 1-month follow-up. Of the 19 patients presenting with mass effect, 16 improved but three showed no changes in their presenting symptoms. All patients had excellent outcomes (mRS, 0 or 1) during the follow-up period (median, 6 months; range, 2-30 months). Vascular imaging follow-up (n=31, 65.9%; median, 3 months, range, 1-25 months) showed complete or near occlusion of the aneurysm in 24 patients (77.4%) and decreased sac size in seven patients (22.6%). CONCLUSION: In this initial multicenter study in Korea, the Pipeline seemed to be safe and effective for large/giant or fusiform aneurysms. However, a learning period may be required to alleviate device-related events.

Susceptibility-Weighted Imaging for Detection of Thrombus in Acute Cardioembolic Stroke / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Susceptibility-weighted imaging (SWI) can show an intravascular thrombus as a hypointense susceptibility vessel sign (SVS). In this study, we investigated the usefulness of SWI in the detection of an intravascular thrombus in acute cardioembolic stroke by comparing the SVS on SWI to the vessel status on time-of-flight magnetic resonance angiography (MRA). METHODS: We consecutively enrolled patients with cardioembolic stroke in the anterior circulation within 3 days from stroke onset. The frequency and location of the SVS on SWI were compared with those of occlusion on MRA. RESULTS: One hundred and twenty-two patients were conclusively enrolled in this study. The SVS was observed in 75.4% (92/122) of the enrolled patients. MRA showed occlusion in 57% (70/122) of the enrolled patients. The SVS was identified in all 70 patients with occlusion on MRA. The SVS was observed in 22 (42.3%) of 52 patients without occlusion on MRA (P<0.001), which was identified mainly in post-bifurcation segments of the middle cerebral artery: the M2 segment in 4 patients, M3 segment in 10 patients, M4 segment in 4 patients, A3 segment in 1 patient, and multiple segments in 2 patients. The mean length of the SVS in the M1 segment was 13.65 mm (median: 12.39 mm, length range: 2.70-39.50 mm). CONCLUSIONS: SWI can provide useful information about the thrombus location, the presence of a single thrombus or multiple thrombi especially in distal intracranial arteries, and the thrombus burden, all in acute cardioembolic stroke.

Susceptibility-Weighted Imaging for Detection of Thrombus in Acute Cardioembolic Stroke / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Susceptibility-weighted imaging (SWI) can show an intravascular thrombus as a hypointense susceptibility vessel sign (SVS). In this study, we investigated the usefulness of SWI in the detection of an intravascular thrombus in acute cardioembolic stroke by comparing the SVS on SWI to the vessel status on time-of-flight magnetic resonance angiography (MRA). METHODS: We consecutively enrolled patients with cardioembolic stroke in the anterior circulation within 3 days from stroke onset. The frequency and location of the SVS on SWI were compared with those of occlusion on MRA. RESULTS: One hundred and twenty-two patients were conclusively enrolled in this study. The SVS was observed in 75.4% (92/122) of the enrolled patients. MRA showed occlusion in 57% (70/122) of the enrolled patients. The SVS was identified in all 70 patients with occlusion on MRA. The SVS was observed in 22 (42.3%) of 52 patients without occlusion on MRA (P<0.001), which was identified mainly in post-bifurcation segments of the middle cerebral artery: the M2 segment in 4 patients, M3 segment in 10 patients, M4 segment in 4 patients, A3 segment in 1 patient, and multiple segments in 2 patients. The mean length of the SVS in the M1 segment was 13.65 mm (median: 12.39 mm, length range: 2.70-39.50 mm). CONCLUSIONS: SWI can provide useful information about the thrombus location, the presence of a single thrombus or multiple thrombi especially in distal intracranial arteries, and the thrombus burden, all in acute cardioembolic stroke.

Reversible Cerebellar Ataxia Related to Extrapontine Myelinolysis without Hyponatremia after Cisplatin-Based Chemotherapy for Cholangiocarcinoma / Journal of the Korean Cancer Association, 대한암학회지

A 60-year-old woman presented with cerebellar signs including dysarthria and ataxia, after intravenous infusion of cisplatin-based chemotherapy. Several blood tests showed mild neutropenia, normocytic normochromic anemia, but no evidence of a marked hyponatremia. Brain magnetic resonance imaging with diffusion-weighted sequences showed hyper-intense signal abnormalities in the extrapontine region, sparing the basis pontis. Here, we report on the case of a patient with reversible cerebellar ataxia related to extrapontine myelinolysis without hyponatremia after treatment with cisplatin-based chemotherapy for cholangiocarcinoma and discuss the literature on cerebellar ataxia in patients who underwent recent chemotherapy for malignancy.

Recurrent arteriovenous malformation on palate after embolization combined surgical resection: preoperative magnetic resonance features and intraoperative angiographic findings

Angiography is the gold standard for the diagnosis and complete resection of arteriovenous malformations (AVMs). The absence of residual AVM after surgery is commonly believed to reduce the risk of future hemorrhage. However, AVMs can recur after proven complete angiographic resection can occur, albeit rarely, especially in the pediatric population. We report a rare case of a recurrent AVM two years after complete resection in an adult patient. This case report shows that AVMs in adults can recur despite their rarity and despite postoperative angiography confirming complete removal. Moreover, in this case, the recurrent AVM involved a new feeding vessel that was not involved with the initial lesion.

Perfusion-Weighted Imaging Finding in Lateral Medullary Infarction With Negative Diffusion-Weighted Imaging

No abstract available.

Susceptibility-Weighted Imaging Finding in Patient With Deep Cerebral Vein Thrombosis

No abstract available.

Simultaneous Occurrence of Cerebral Infarction and Subarachnoid Hemorrhage due to Anterior Cerebral Artery Dissection Treated by Bypass Surgery and Coil Embolization

Anterior cerebral artery (ACA) dissection with simultaneous subarachnoid hemorrhage (SAH) and cerebral infarction is very rare and its treatment continues to be debates. We present a case of simultaneous SAH and cerebral infarction caused by dissection of the ACA that was successfully treated by bypass surgery and an endovascular procedure.

Cauda Equina Syndrome Caused by Spinal Dural Arteriovenous Fistula

Spinal dural arteriovenous fistula (SDAVF) is rare but still the most commonly encountered vascular malformation of the spinal cord. A 31-year-old male developed gait disturbance due to weakness of his lower extremities, voiding difficulty and sexual dysfunction with a progressive course since 3 months. He showed areflexia in both knees and ankles. Electromyographic findings were suggestive of multiple root lesions involving bilateral L2 to S4 roots of moderate degree. Magnetic resonance images showed high signal intensity with an ill-defined margin in T2-weighted images and intensely enhanced by a contrast agent through the lumbosacral spinal cord. Selective spinal angiography confirmed a dural arteriovenous fistula with a nidus at the L2 vertebral level. After selective endovascular embolization, his symptoms drastically improved except sexual dysfunction. We report a rare case of cauda equina syndrome due to spinal arteriovenous fistula with drastic improvement after endovascular embolization.

Problem Based Approach in Acute Ischemic Stroke / 신경중재치료의학

Ischemic strokes result from thrombotic or embolic occlusion of one of the vessels that supply blood to the brain. The primary constituents of the initial thrombus are platelets and fibrin, with erythrocytes and other blood cells becoming trapped as thrombosis continues. Therefore, the recent improvements in therapy have focused on inhibiting platelets and dissolving fibrin. A new generation of thrombolytic agents (plasminogen activators) has been developed over the last decade. However, the clinical improvement has at best been marginal and the frequency of serious intracranial hemorrhage remains unchanged. Therefore, we have extensively reviewed the medical literature to determine the reason for the unsatisfactory clinical outcomes with current pharmacological therapies.

Sclerotherapy in the Treatment of Congenital Venous and Lymphatic Malformation: Efficacy and Safety with Long-term Follow-up / 대한피부과학회지

BACKGROUND: Surgical excision and alcohol sclerotherapy have been used to treat congenital vascular malformations (CVM) with a significant success rate but the methods have also left marked morbidity. The alternative, sclerotherapy using ordinary sclerosants, although resulting in trivial complications, has a relatively low cure rate and is rarely used in Korea for CVM management. OBJECTIVE: To evaluate the effects and side effects of sclerotherapy using ordinary sclerosants such as polidocanol (POL) and sodium tetradecyl sulfate (STS) for the treatment of CVM of a venous and lymphatic type. METHODS: To confirm the long-term effects and safety with at least a 3-year follow-up, we chose a total of 26 patients who had undergone sclerotherapy between 2000 to 2004. There were 22 venous malformations (VMs) and 4 lymphatic malformations (LMs) which were rather small and superficial, not beyond muscular fascia. Sclerotherapy using POL and STS was performed by blind intraluminal and/or intralesional injection without the aid of imaging methods such as ultrasound examination. The results were evaluated by the patients' subjective satisfaction, physical examination, comparison of photographs and/or radiological examinations, then they were classified into 4 groups; excellent (improvement >75%), good (50~75%), fair (25~49%) and poor (<25%). RESULTS: Twenty two VMs comprised 14 in the excellent group (66.7%), 6 in the good group (25.0%), 1 in the fair group (4.2%) and 1 in the poor group (4.2%). Two LMs of macrocystic type revealed excellent results but the other two showing microcystic type revealed poor results. The dose of sclerosant was 0.1 to 2 ml in every session and a total of 1 to 6 sessions (average: 2.2) were performed. Only one VM showed hyperpigmentation as a side effect. CONCLUSION: Sclerosants for ordinary varicose vein eradication can be used on the treatment of small and superficial venous malformations and macrocystic-lymphatic malformations with relative efficacy and safety.

Thromboembolic Events after Coil Embolization of Cerebral Aneurysms: Prospective Study with Diffusion-Weighted Magnetic Resonance Imaging Follow-up

OBJECTIVE: In order to assess the incidence of thromboembolic events and their clinical presentations, the present study prospectively examined routine brain magnetic resonance images (MRI) taken within 48 hours after a coil embolization of cerebral aneurysms. METHODS: From January 2006 to January 2008, 163 cases of coil embolization of cerebral aneurysm were performed along with routine brain MRI, including diffusion-weighted magnetic resonance (DW-MR) imaging, within 48 hours after the embolization of the aneurysm to detect the silent thromboembolic events regardless of any neurological changes. If any neurological changes were observed, an immediate brain MRI follow-up was performed. High-signal-intensity lesions in the DW-MR images were considered as acute thromboembolic events and the number and locations of the lesions were also recorded. RESULTS: Among the 163 coil embolization cases, 98 (60.1%) showed high-signal intensities in the DW-MR imaging follow-up, 66 cases (67.0%) involved the eloquent area and only 6 cases (6.0%) showed focal neurological symptoms correlated to the DW-MR findings. The incidence of DW-MR lesions was higher in older patients (> or =60 yrs) when compared to younger patients (<60 yrs) (p=0.002, odd s ratio=1.043). The older patients also showed a higher incidence of abnormal DW-MR signals in aneurysm-unrelated lesions (p=0.0003, odd's ratio=5.078). CONCLUSION: The incidence of symptomatic thromboembolic attacks after coil embolization of the cerebral aneurysm was found to be lower than that reported in previous studies. While DW-MR imaging revealed a higher number of thromboembolic events, most of these were clinically silent and transient and showed favorable clinical outcomes. However, the incidence of DW-MR abnormalities was higher in older patients, along with unpredictable thromboembolic events on DW-MR images. Thus, in order to provide adequate and timely treatment and to minimize neurological sequelae, a routine DW-MR follow-up after coil embolization of cerebral aneurysms might be helpful, especially in older patients.