A Comparison between Mechanical Thrombectomy and Intra-arterial Fibrinolysis in Acute Basilar Artery Occlusion: Single Center Experiences / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Recent advances in intra-arterial techniques and thrombectomy devices lead to high rate of recanalization. However, little is known regarding the effect of the evolvement of endovascular revascularization therapy (ERT) in acute basilar artery occlusion (BAO). We compared the outcome of endovascular mechanical thrombectomy (EMT) versus intra-arterial fibrinolysis (IAF)-based ERT in patients with acute BAO. METHODS: After retrospectively reviewed a registry of consecutive patients with acute ischemic stroke who underwent ERT from September 2003 to February 2015, 57 patients with acute BAO within 12 hours from stroke onset were enrolled. They were categorized as an IAF group (n=24) and EMT group (n=33) according to the primary technical option. We compared the procedural and clinical outcomes between the groups. RESULTS: The time from groin puncture to recanalization was significantly shorter in the EMT group than in the IAF group (48.5 [25.3 to 87.8] vs. 92 [44 to 179] minutes; P=0.02) The rate of complete recanalization was significantly higher in the EMT group than in the IAF group (87.9% vs 41.7%; P<0.01). The good outcome of the modified Rankin Scale score≤2 at 3 months was more frequent in the EMT group than in the IAF group, but it was not statistically significant (39.4% vs 16.7%; P=0.06). CONCLUSIONS: EMT-based ERT in patients with acute BAO is superior to IAF-based ERT in terms of the reduction of time from groin puncture to recanalization and the improvement of the rate of complete recanalization.

Reappraisal of Anatomic Outcome Scales of Coiled Intracranial Aneurysms in the Prediction of Recanalization

OBJECTIVE: Several scales are currently used to assess occlusion rates of coiled cerebral aneurysms. This study compared these scales as predictors of recanalization. METHODS: Clinical data of 827 patients harboring 901 aneurysms treated by coiling were retrospectively reviewed. Occlusion rates were assessed using angiographic grading scale (AGS), two-dimensional percent occlusion (2DPO), and volumetric packing density (vPD). Every scale had 3 categories. Followed patients were dichotomized into either presence or absence of recanalization. Kaplan-Meier analysis was conducted, and Cox proportional hazards analysis was performed to identify surviving probabilities of recanalization. Lastly, the predictive accuracies of three different scales were measured via Harrell's C index. RESULTS: The cumulative risk of recanalization was 7% at 12-month, 10% at 24-month, and 13% at 36-month of postembolization, and significantly higher for the second and third categories of every scale (p<0.001). Multivariate-adjusted hazard ratios (HRs) of the second and third categories as compared with the first category of AGS (HR : 3.95 and 4.15, p=0.004 and 0.001) and 2DPO (HR : 4.87 and 3.12, p<0.001 and 0.01) were similar. For vPD, there was no association between occlusion rates and recanalization. The validated and optimism-adjusted C-indices were 0.50 [confidence (CI) : -1.09-2.09], 0.47 (CI : -1.10-2.09) and 0.44 (CI : -1.10-2.08) for AGS, 2DPO, and vPD, respectively. CONCLUSION: Total occlusion should be reasonably tried in coiling to maximize the benefit of the treatment. AGS may be the best to predict recanalization, whereas vPD should not be used alone.

Bilateral Approach for Stent-assisted Coiling of Posterior Inferior Cerebellar Artery Aneurysms: Two Cases

Aneurysms of the posterior inferior cerebellar artery (PICA) are rarely encountered. In particular, due to frequent anatomic complexity and the presence of nearby critical structures, PICA origin aneurysms are difficult to treat. However, recent reports of anecdotal cases using advanced endovascular instruments and skills have made the results of endovascular treatment rather outstanding. PICA preservation is the key to a successful endovascular treatment, based on the premise that a PICA origin aneurysm is well occluded. To secure PICA flow, stenting into the PICA would be the best method, however, it is nearly impossible technically via the ipsilateral vertebral artery (VA) if the PICA arose at an acute angle from the sac. In such a case, a bilateral approach for stent-assisted coiling can be a creative method for achievement of two goals of both aneurysm occlusion and PICA preservation: ipsilateral approach for coil delivery and contralateral cross-over approach for stent delivery via a retrograde smooth path into the PICA.

Evidence-Based Changes in Devices and Methods of Endovascular Recanalization Therapy / 신경중재치료의학

The devices and methods of endovascular recanalization therapy (ERT) have been rapidly developed and changed since PROACT II trial. Emerging as a treatment option in addition to intravenous or intra-arterial thrombolysis, mechanical thrombectomy is currently being further developed and investigated as a potential first-line and stand-alone treatment. This review highlights and summarizes the recent clinical series and trials of the available devices and methods of ERT focusing on the multimodal approach.

Endovascular Treatment of Wide-necked Cerebral Aneurysms with an Acute Angle Branch Incorporated into the Sac: Novel methods of Branch Access in 8 Aneurysms / 신경중재치료의학

PURPOSE: The optimal management of geometrically complex aneurysms remains challenging. The aim of this retrospective study was to evaluate the safety and feasibility of branch-selective technique (BT) in wide-necked aneurysms with an acute angle branch incorporated into the sac. MATERIALS AND METHODS: Eight consecutive patients harboring wide-necked cerebral aneurysms with an incorporated, acute angle branch (mean, 30.4degrees) underwent coiling over an 18-month period. Dome-to-neck ratio ranged from 0.9 to 1.8 (mean, 1.2). Every procedure utilized BT, i.e., stent- or catheter-assisted coiling through the incorporated branch. RESULTS: Technical success was achieved in all cases. With the aim to avoid the risk of aneurysmal rupture during struggling intraaneurysmal wire navigation, a 'looping method' and retrograde approach of a preshaped 0.014' microcatheter (C or J) was used for branch access in five cases and a 'looping method' and antegrade approach in one case. In the remaining one, just the C-preshape was enough to directly enter the branch without intraaneurysmal wire navigation. Overall, stent-assisted coiling was performed in seven cases, while catheter-assisted coiling was undertaken in one. The only complication was thrombotic posterior inferior cerebellar artery occlusion in one case, which was recanalized after tirofiban infusion. New neurological deficits were not identified in any cases. CONCLUSION: BT seems safe and feasible for wide-necked aneurysms with an acute angle branch incorporated into the sac. The looping method may offer safe access to the incorporated, acute angle branch and should be considered for replacement of the fearful intra-aneurysmal wire navigation.

Subarachnoid Hemorrhage from a Dissecting Aneurysm of the Posterior Cerebral Artery in a Child : Rebleeding after Stent-Assisted Coiling Followed by Stent-Within-Stent Technique

Pediatric patients with dissecting aneurysms usually present with ischemia rather than bleeding. We report a case of a 15-year-old boy with a dissecting aneurysm of the posterior cerebral artery (PCA) presenting with hemorrhage. He was first treated with stent-assisted coil embolization, in an attempt to avoid trapping of the PCA and preserve the perforators. After the procedure, he recovered well from general anesthesia, but rebleeding occurred from the same lesion 6 hours after the procedure, therefore endovascular segmental occlusion of the parent artery was performed secondarily. Apparently, a reconstructive method of stent-assisted coiling is worth trying to preserve the parent vessel and perforators, but it is not always efficient and durable for dissecting aneurysms.

Concurrent Hypertensive Intracerebral Hemorrhage and Rupture of a Previously Clipped Intracranial Aneurysm / 대한뇌혈관외과학회지

Simultaneous occurrence of remote intracerebral hemorrhage (ICH) and intracranial aneurysmal subarachnoid hemorrhage is very rare. We report on a case of concurrent hypertensive ICH at the left thalamus and rupture of an intracranial aneurysm at the bifurcation of the single A2 segment of the anterior cerebral artery in a 64-year-old woman, which was clipped previously, with review of the literature. To our knowledge, this is the first case report demonstrating bleeding of previously clipped aneurysm with simultaneous hypertensive ICH. Hypertensive crisis following ICH seems to have provoked rupture of the residual aneurysm.

Dural Arteriovenous Fistula at the Foramen Magnum with Holocord Myelopathy: Case Report / 신경중재치료의학

We report a case of dural arteriovenous fistula at the foramen magnum with a diagnostic delay of 10 months from initial myelopathic symptoms. A 59-year-old male with urinary incontinence and progressive ascending weakness of the extremities was transferred through two other hospitals to our institution with no tentative or established diagnosis. A correct diagnosis was not made until 10 months after initial symptoms: follow-up MR images revealed diffuse edema involving the holocord and lower brain stem, and engorged veins around the spinal cord. Cerebral angiography confirmed a dural arteriovenous fistula drained by perimedullary venous plexus. That fistula was occluded by transarterial embolization using NBCA (n-butyl cyanoacrylate). However, it seemed hard to expect any improvement in the clinical condition of the patient due to considerable diagnostic delay. To avoid missing a chance of treatment for this potentially reversible disease, early diagnosis is mandatory and it requires a high-level suspicion.

A Case of Dural Arteriovenous Fistula of the Anterior Condylar Vein / 신경중재치료의학

We present a rare case of dural arteriovenous fistula of the anterior condylar vein presenting with conjunctival injection and proptosis, and pulsatile tinnitus on the right side. A two-session transvenous and transarterial embolization, using fibered pushable coils and n-butyl cyanoacrylate, respectively, resulted in complete obliteration of the fistula without complication. The angioarchitecture, pathophysiology, and management of the fistula will be discussed.

Growing Thrombosed Dissecting Aneurysm of the Vertebral Artery after Endovascular Proximal Artery Occlusion: the Role of the Vasa Vasorum / 신경중재치료의학

Proximal artery occlusion is one of several treatment methods for ruptured vertebral artery dissecting aneurysm (rVADA). However, that treatment may be incomplete and the risk of rebleeding should not be ignored. By contrast, mass effect, such as symptoms and signs of brain stem compression, ensuing after that treatment and rVADA occlusion, has not been reported in English literature. We experienced such a rare case of brain stem compression ensuing 3 months after VADA occlusion by endovascular proximal artery occlusion. To reduce the mass effect, surgery was performed with surgical specimen processed histologically. The clinical and radiological data of the case, its probable mechanism, and histological findings will be described and discussed here.

Spinal Dural Arteriovenous Fistulas: Clinical Experience with Endovascular Treatment as a Primary Therapeutic Modality

OBJECTIVE: The aim of this study was to evaluate the efficacy of endovascular therapy as a primary treatment for spinal dural arteriovenous fistula (DAVF). METHODS: The authors reviewed 18 patients with spinal DAVFs for whom endovascular therapy was considered as an initial treatment at a single institute between 1993 and 2006. NBCA embolization was considered the primary treatment of choice, with surgery reserved for patients in whom endovascular treatment failed. RESULTS: Surgery was performed as the primary treatment in one patient because the anterior spinal artery originated from the same arterial pedicle as the artery feeding the fistula. Embolization was used as the primary treatment modality in 17 patients, with an initial success rate of 82.4%. Two patients with incomplete embolization had to undergo surgery. One patient underwent multiple embolizations, which failed to completely occlude the fistula but relieved the patient's symptoms. Spinal DAVF recurred in two patients (one collateral development and one recanalization) during the follow-up period. The collateral development was obliterated by repeated embolization, but the patient with recanalization refused further treatment. The overall clinical status improved in 15 patients (83.3%) during the follow-up period. CONCLUSION: Endovascular therapy can be successfully used as a primary treatment for the majority of patients with spinal DAVFs. Although it is difficult to perform in some patients, endovascular embolization should be the primary treatment of choice for spinal DAVF.

Delayed Subarachnoid Hemorrhage from an Embolized Unruptured Intracranial Aneurysm with Minor Recanalization: A Case Report / 신경중재치료의학

Endovascular treatment of cerebral aneurysm is known to be safe and effective in terms of periprocedural complication and rebleeding rates. However, the risk of recanalization in embolized aneurysms necessitates regular follow-ups. We present here a case of subarachnoid hemorrhage from an embolized unruptured aneurysm with stable minor recanalization shown on follow-up images.

Aspiration Clot Removal by Mannual Compression of Common Carotid Artery for Acute Internal Carotid Occlusion: a Case Report / 신경중재치료의학

Acute occlusion of the intracranial internal carotid artery (ICA) bifurcation, so-called "carotid T occlusion," extends from distal portion of the internal carotid into the proximal segments of the middle and anterior cerebral arteries. This carotid T occlusion has been associated with low recanalization rates and poor prognosis. An 83-year-old man underwent successful transarterial suction thrombectomy using manual compression of ipsilateral common carotid artery for the treatment of acute carotid T-occlusion. Herein, we report this case and discuss the technical aspect.

Spinal Epidural Arteriovenous Fistula Presented with Subdural Hematoma: a Case of Transarterial Embolization Using NBCA / 신경중재치료의학

We present a patient with spinal epidural arteriovenous fistula presented with subdural hematoma and progressive myelopathy. Transarterial embolization using NBCA results in complete obliteration of fistula without complication. The pathophysiology, angioarchitexture of the lesion and strategy for its cure would be discussed.

Phase III Clinical Trial Comparing Iopamidol 250 mgI/mL and Iopamidol 300mgI/mL in Cerebral Angiography: Multicenteric, Randomized and Double Blind Study

PURPOSE: To evaluate and compare the safety, tolerance and the image quality of cerebral angiography images with the use of the nonionic monomeric contrast agent, iopamidol at 250 mgI/mL or 300 mgI/mL. MATERIALS AND METHODS: This study was approved by the institutional review board and was performed from December 2005 to March 2006. A total of 90 patients undergoing an elective cerebral angiography were studied during a phase III clinical trial to compare the safety and diagnostic efficacy of iopamidol at 250 mgI/ml and 300 mgI/ml. The overall quality of cerebral angiography images was independently graded into three categories: good, bad and nondiagnostic by two radiologists. RESULTS: The image quality of the cerebral angiography was good in 100% of the patients in both groups. A total of 4.44% of the patients experienced adverse events (4.44% in the iopamidol 250 group and 4.44% in the iopamidol 300 group). No statistically significant differences were observed between the two studied groups for either the proportion of patients with one or more adverse events or the intensity of the adverse events. CONCLUSION: The safety and efficacy (quality of the radiographic diagnostic visualization) of Iopamidol at 250 and 300 mg I/ml did not reveal any significant differences and thus are comparable.

Endovascular Treatment of Cerebral Aneurysms: Coiling Techniques / 신경중재치료의학

For an effective and durable occlusion of cerebral aneurysm, the aneurysmal sac should be packed by detachable coils as densely as technically possible. Navigating microcatheters, coil framing, and packing of the sac are the major technical steps of aneurismal embolization. There are several additional techniques and devices for dealing with wide-necked aneurysms. This paper reviews and describes various techniques for safe navigation of microcatheters including tip shaping, selection of the shapes for initial coil framing, selection of coil sizes techniques for packing, and techniques of balloon- or stent-assisted coiling for embolization of wide-necked lesions.

Microcatheter-assisted Coil Embolization of Distal Vertebral Artery Wide-Necked Aneurysm: A Case Report / 신경중재치료의학

Endovascular treatment of wide-necked intracranial aneurysms remains challenging despite continuing instrumental and technical advances. A 67-year-old woman visited us for an asymptomatic unruptured aneurysm at the right distal vertebral artery and was planned to undergo endovascular coil embolization. During a second coil placement through a single microcatheter, the first coil frame was deformed and protruded into the parent artery. We decided to jack-up the protruded coil using an additional microcatheter because the tortuous vertebral artery path didn't allow a balloon or stent device to approach this aneurysm for parent artery protection. Using that microcatheter-assisted technique, the parent artery could be preserved and the aneurysm could, moreover, be excluded.

Endovascular Treatment of Dural Sinus Malformation in Infant: A Case Report / 신경중재치료의학

Dural sinus malformation (DSM) with arteriovenous fistula (AVF) is very rare in pediatric group. We experienced one case of DSM and treated AVF by endovascular embolization. Herein we report this rare case occurred in infant.

Mid-term Outcomes Comparison of Intracranial Aneurysms Treated with Polyglycolic Acid/Lactide Copolymer-Coated Coils Versus Bare Platinum Coils / 신경중재치료의학

PURPOSE: A coated coil system, covered with a bioabsorbable polymeric material (polyglycolic acid/lactide copolymer, PGLA), was developed to accelerate intra-aneurysmal clot organization and fibrosis, and thereby to reduce aneurysm recanalization. As a continuation of a previously published study that included analysis of short-term outcomes of endosaccular coil embolization of intracranial saccular aneurysm within 6 months, the purpose of this study was to evaluate the mid-term results of PGLA-coated coils in patients with intracranial aneurysms and to compare results with those of bare platinum coils. PATIENTS AND METHODS: Fifty-one patients harboring 56 intracranial aneurysms underwent endovascular embolization with PGLA-coated coils. The control group included 78 consecutive patients, harboring 87 aneurysms, who underwent coil embolization with bare platinum coils. The authors compared mid-term follow-up results in these two groups retrospectively. RESULTS: The median follow-up interval for radiologic evaluation was 12 months (range 5 to 18 months) and 14 months (range 6 to 30 months) in the PGLA-coil group and the bare-coil group, respectively. Major aneurysm recanalization occurred in 9 of 43 aneurysms (20.9%) in the PGLA-coil group and in 13 of 64 aneurysms (20%) in the bare-coil group. Notably, the rate of major recanalization (46.2%) in the PGLA coil group with a packing density of <25% was significantly higher than that of the bare coil group (17.8%). CONCLUSION: In spite of a similar incidence of recanalization between the PGLA-coated coil and bare platinum coil groups, the major recanalization rate of this group was significantly higher than that of the bare coil group, if packing density of more than 25% was not achieved using PGLA-coated coils. So we can conclude that dense packing is more likely to have an effect on treatment result rather than does biological effect of PGLA in case of endosaccular coil embolization using PGLA-coated coils.

Successful Treatment of Intracranial Small Pial Single-Channel Arteriovenous Fistula Using N-butyl Cyanoacrylate: Report of 2 Cases / 신경중재치료의학

Intracranial pial single-channel arteriovenous fistula is a rare vascular lesion distinct from plexiform arteriovenous malformation. We report 2 cases of intracranial small pial single-channel arteriovenous fistula which was successfully treated with n-butyl cyanoacrylate.