Flow Diversion Therapy of Remnant and Recurrent Intracranial Aneurysms Treated Surgically.

AIM: To evaluate the safety and efficacy of flow diverter stents (FDSs) for treating remnant or recurrent intracranial aneurysms that were treated surgically. MATERIAL AND METHODS: The patients who were treated with FDSs due to remnant or recurrent intracranial aneurysms after microsurgery were included in the study. The patients' demographics, treatment histories, aneurysm features, complications associated with flow diversion, and neurological and angiographic follow-up findings were evaluated. RESULTS: Twenty patients (eight males) with 20 aneurysms were included in the study. Of 20 aneurysms, 18 (90%) were in the anterior, and two (10%) were in the posterior circulation. The initial treatment methods were clipping in 17 (85%) and wrapping in three (15%) aneurysms. The endovascular procedure was successful in all patients. In three patients (15%), periprocedural and postprocedural complications were encountered. No hemorrhagic complications were detected on cone-beam computed tomography. One patient with a basilary aneurysm died because of brain stem ischemia. The total morbimortality was 5%. The mean length of follow-up was 13.7 ± 7.3 months in 18 patients. The first angiographic follow-up (3-6 months) revealed the complete occlusion in 7 of 11 aneurysms (63.6%). By contrast, 16 aneurysms (94.1%) were occluded at the last angiographic follow-up, one aneurysm (5.9%) was still filling. CONCLUSION: An FDS seems effective, safe, and extremely attractive in treating remnant and recurrent intracranial aneurysms treated surgically.

The impact of visual and motor skills on ideational apraxia and transcortical sensory aphasia.

BACKGROUND: Patients with extensive left hemisphere damage frequently have ideational apraxia (IA) and transcortical sensory aphasia (TSA). Difficulty with action coordination, phonological processing, and complex motor planning may not be indicative of higher-order motor programming or higher-order complex formation. We report on the effects of IA and TSA on the visual and motor skill of stroke patients. PURPOSE: The study aims to address the question of whether IA and TSA in bilingual individuals are the results of an error of motor function alone or due to a combined motor plus and cognitive dysfunction effect. METHOD: Twelve bilingual patients (seven males, and five females) were diagnosed with IA and TSA, and are divided into two groups of six patients. Then, 12 healthy bilingual controls were evaluated for comparing with both groups. Bilingual aphasia testing (BAT) and appropriate behavioral evaluation were used to assess motor skills, including coordination, visual-motor testing, and phonological processing. RESULTS: Findings (pointing skills) show that the performance of the L1 and L2 languages are consistently significant (p < 0.001) in healthy individuals compared to the IA and TSA groups. Command skills for L1 and L2 languages were significantly higher in healthy individuals compared to IA and TSA controls (p < 0.001). Further, the orthographic skills of IA and TSA vs controls in both groups were significantly reduced (p < 0.01). Visual skills in the L1 language were significantly improved (p < 0.05) in IA and TSA patients compared to healthy controls after 2 months. Unlike orthographic skills which were improved in IA and TSA patients, languages in bilingual patients did not simultaneously improve. CONCLUSION: Dyspraxia is a condition that affects both motor and visual cognitive functions, and patients who have it often have less referred motor skills. The current dataset shows that accurate visual cognition requires both cognitive-linguistic and sensory-motor processes. Motor issues should be highlighted, and skills and functionality should be reinforced along with the significance of treatment between IA and TSA corresponding to age and education. This can be a good indicator for treating semantic disorders.

Structural changes in the side branches and the circle of Willis following the use of flowdiverting stents.

BACKGROUND: This study aimed to evaluate the diameter and flow changes in the circle of Willis and side branches following the use of FDSs extending from the middle cerebral artery (MCA) to the internal carotid artery (ICA) for the treatment of aneurysms in the terminal segment of ICA, and the clinical results. METHODS: This study was conducted in a single center between January 2012 and April 2018 in patients with the anterior choroidal artery (AChoA), the posterior communicating artery (PComA), and the ICA terminal segment aneurysms treated with the FDSs. The changes in aneurysm size, arterial structures covered by the FDSs, and changes in the diameter and flow in arteries forming the circle of Willis were retrospectively analyzed. RESULTS: Fourteen patients with a total of 25 aneurysms treated with FDSs extending from MCA to ICA were evaluated. The mean aneurysm fundus size was 5.14 mm (range 1.5-22 mm). Before treatment, the anterior communicating artery (AComA) was patent in all patients. Implanted FDSs covered the anterior cerebral artery (ACA) and AChoA in all patients (100%), nonhypoplasic PComA in two patients (14.28%), and the ophthalmic artery in nine (64.3%). The mean follow-up time was 36.78 ± 22.44 months. In follow-up, there was a decrease in the mean ipsilateral ACA A1 segment diameter from 1.99 ± 0.58 cm to 1.81 ± 0.31 cm (p = 0.01). The mean contralateral A1 segment diameter increased from 1.66 ± 0.48 cm to 1.93 ± 0.42 cm (p = 0.004). All aneurysms were totally occluded. DISCUSSION: If the AComA is patent, ipsilateral anterior circulation can be compensated through modifications in the contralateral ACA A1 segment in patients with ICA terminal segment aneurysms treated with FDSs extended from MCA to ICA and covering ACA. Although covering the anterior choroidal and lenticulostriate arteries by FDSs, ischemic complications may not occur frequently. Thus, this effective therapy can be applied more safely.

Cerebral proliferative angiopathy accompanied by cerebral cavernous malformation: A case report.

Cerebral Proliferative Angiopathy (CPA) is a rare vascular malformation that is distinguished from classical brain arteriovenous malformations (AVM) in its imaging findings and clinical progression but more importantly in its pathophysiology. Here we report the case of a 37-year-old male patient with CPA accompanied by Cerebral Cavernous Malformation (CCM) in hopes to expand the inquiry into the pathophysiology of this rare lesion. A patient with progressive headache, right-sided weakness, and impaired speech were evaluated at our medical center. Neuroimaging studies were performed, and the patient was diagnosed with CPA. The patient has been followed up with conservative management and periodic neuroradiological evaluation for 5 years. Digital subtraction angiography (DSA) showed a vascular malformation diffusely covering the left hemisphere that is consistent with CPA. In addition, 2 sequential CCMs were detected in the right hemisphere. Also, the patients' familial history included two brothers with CCMs. The coexistence of CPA with CCM and patients' familial history of CCM could suggest the possibility of a common pathophysiological element.

Flow diverter stents in the treatment of recanalized intracranial aneurysms.

BACKGROUND: We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly. MATERIALS & METHODS: Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients' demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded. RESULTS: Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3-6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero. CONCLUSION: The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.

Flow Diverter Stents in the Treatment of Cerebral Aneurysms Less than 5 mm.

AIM: To evaluate the safety and efficacy of flow diverter (FD) stents in the treatment of intracranial aneurysms less than 5 mm. MATERIAL AND METHODS: We treated 66 aneurysms in 43 patients with aneurysms less than 5 mm. Of the patients, 29 were females and 14 males (mean age: 50.2 years). Headache was the most frequent symptom. In 8 patients, the aneurysms were recanalized and these had been treated with coils or stent-assisted coiling. All aneurysms were in the anterior circulation. In the treatment, one of the SILK, Pipeline, Derivo or FRED FD stents was used for each patient. Neurointerventional stent medication (double antiplatelet) was used. All patients were investigated for new ischemic lesions with diffusion-weighted imaging one day later. The first follow-up angiogram was planned 3-6 months later. RESULTS: The treatment was technically successful in all patients. Minor complications occurred in 3 patients (7%). In one patient, thrombus inside the SILK was seen and was relieved with tirofiban. The second patient bled from the right common femoral artery entrance, which was operated on. In the third patient, the complication was technical. All patients were discharged without any neurological deficit. The mean follow-up period was 26 (6-52) months. Of the aneurysms, 64 (97.0%) were completely closed. CONCLUSION: The FD treatment of cerebral, anterior circulation small aneurysms less than 5 mm is effective and safe.

Effects of Arginine Vasopressin and V1 Receptor Antagonist on Cerebral Vasospasm Secondary to Subarachnoid Hemorrhage: An Experimental Study.

AIM: To examine morphological, radiological and biochemical effects of arginine vasopressin (AV) and V1 receptor antagonist on cerebral vasospasm (CVS) after subarachnoid hemorrhage (SAH) in rabbits. MATERIAL AND METHODS: Forty male New Zealand white rabbits were randomly divided into four groups comprising 10 rabbits each. The groups were; 1) Control group, 2) SAH group, 3) SAH+AV group, 4) SAH+V1 antagonist group. Diameters of the basilar artery in all groups were measured on angiograms. All animals were sacrificed two days following basilar angiography and tissue samples of basilar artery were obtained under microscope immediate after craniectomy for ultrastructural and biochemical examinations. RESULTS: The artery diameters were found to be 50% and 50% at the 30th minute in the groups 2 and 3 respectively. In group 3, CVS was 13% more in comparison with the 2nd group. In group 4, vascular constriction was 34.5% at the 30th minute and about 30.9% at the 300th minute. Despite the increase in regional blood flow, AV did not provide morphological change. Histological appearance was related to vascular stenosis due to CVS. Histological outcome was the best in group 4 because of less CVS. CONCLUSION: Arginine vasopressin plays an important role in CVS. We detected morphological and radiological recovery in basilar artery, besides moderate improvement due to AV receptor antagonist in CVS.

Tapered Flow Diverters in the Treatment of Intracranial Aneurysms.

AIM: To report the initial experience of cerebral aneurysm treatment with Tapered flow diverters (TFDs). MATERIAL AND METHODS: Thirty patients with 34 aneurysms underwent cerebral aneurysm treatment with TFD (Silk, Balt, Montmorency, France) between March 2011 and March 2016. Procedural findings, complications, clinical and imaging follow-up were assessed retrospectively. RESULTS: The patients" mean age was 48±14.5 years (range, 16-74; 25 females). Aneurysms size ranged from 3 to 35 mm with an average diameter of 13.9±8.8 mm and a median diameter of 10.5 mm. Technical success rate was 96.6%. Technically, deployment of the device was similar to the non-tapered version and subjectively, it appeared to be easier in the paraophthalmic segment. Permanent morbidity and mortality rates secondary to the procedure were 0%. On clinical follow-up (29 patients, mean 9.3±9.1 months) there were no clinical untoward events. Imaging follow-up was at or after 6 months (20 patients, mean 12.3±10 months). Angiographic occlusion rate was 80%. CONCLUSION: TFD is safe to use and effective for the treatment of intracranial aneurysms in this series. The occlusion rate is higher with respect to the previous reports and experience using the non-tapered version. Maintenance of porosity at the transition zone may be the factor underlying the higher occlusion rate. TFD may be preferred especially for arterial segments aneurysms where there is considerable discrepancy in size between the distal and proximal parent artery.

A Patient with Eight Intracranial Aneurysms: Endovascular Treatment in Two Sessions.

The frequency of multiple intracranial aneurysms seen in patients with or without subarachnoid hemorrhage is high. The advancement of the endovascular technique and devices has ensured that endovascular treatment of intracranial aneurysms is the first choice in most cases, especially in unruptured ones. Different combinations of treatment modalities and techniques can be used in the management of multiple aneurysms. But in selected patients without subarachnoid hemorrhage, treatment of all aneurysms in one or more sessions with endovascular techniques is less traumatic than that with surgery. In the literature, the maximum number of aneurysms in one patient treated endovascularly and/or surgically is seven. In this case report, we present, with a review of the literature, a patient with eight intracranial aneurysms, all of which were treated in two sessions with various endovascular techniques. A 40-year-old female patient was admitted due to headache. Angiography showed eight aneurysms in the posterior circulation and, bilaterally, in the anterior circulation. All aneurysms were treated endovascularly in two sessions. In the treatment of the aneurysms, different endovascular techniques were used including flow diverters stents, stent-assisted coiling, Y-stent-assisted coiling, and coiling alone.

The DERIVO Embolization Device in the Treatment of Intracranial Aneurysms: Short- and Midterm Results.

OBJECTIVE: The DERIVO embolization device (DED) is a new nitinol flow diverter stent manufactured for the treatment of intracranial aneurysms. In this study, we evaluated the safety and efficacy of the DED in the treatment of intracranial aneurysms and present the short- and midterm results. METHODS: We treated 34 aneurysms using 26 devices in 24 patients with wide-necked, mostly medium-sized, and fusiform aneurysms. Fourteen of the patients included in the study were women and the other 10 were men. Headache was the most frequent symptom. Although 31 (91.2%) aneurysms were in the anterior circulation, 3 (8.8%) were in the posterior. Intracranial stent medication was accomplished in all patients. All patients were evaluated 1 day later for any ischemic lesion with diffusion-weighted imaging. The first and second follow-up angiograms were planned to be performed after 3 and 9 months. RESULTS: In all patients, the treatment was successful. No hemorrhagic complication was seen on computed tomography scan performed immediately after the procedure. All patients were discharged without any neurologic deficit. Although 20 (71.4%) of 28 aneurysms in 20 patients were totally closed on the 3-month follow-up angiogram, 14 (77.8%) of 18 aneurysms in 9 patients were totally closed on the 9-month follow-up. General morbidity was 8.4%, and mortality was 4.3%. CONCLUSIONS: The DED seems effective and safe in the treatment of different kinds of intracranial aneurysms.

Radiological Imaging Findings of Patients with Congenital Totally Hearing Loss.

OBJECTIVE: The aim of this study was to determine and classify inner ear abnormalities in patients who had cochlear implants because of congenital sensorineural hearing loss using preoperative temporal bone computed tomography and magnetic resonance imaging. MATERIALS AND METHODS: Patients in the otolaryngology department who had cochlear implants because of congenital sensorineural hearing loss between January 2011 and December 2013 were included in the study. There were 167 male and 133 female patients, a total of 300. All of the patients were evaluated with 4-detector-row computed tomography and 1.5 Tesla magnetic resonance imaging. RESULTS: Inner ear abnormalities were found in 136 of 600 ears (20.3%). There were six ears with incomplete partition-II (4.4%), five ears with incomplete partition-I (3.6%), two ears with Michel deformity (1.4%), two ears with cochlear hypoplasia (1.4%), two ears with cochlear otosclerosis (1.4%), and one ear with common cavity deformity (0.7%). Dilatation of the internal acoustic canal was found in 42 ears (30.9%); also, 21 ears with cochlear nerve aplasia/hypoplasia (15.4%), 5 ears with internal acoustic canal aplasia, and 1 ear with internal acoustic canal hypoplasia (0.73%) were detected. There were 10 ears with posterior semicircular canal (7.3%), 10 ears with lateral semicircular canal (7.4%), 8 ears with superior semicircular canal aplasia/hypoplasia (5.9%), and 8 ears with lateral semicircular canal-vestibular dysplasia. An enlarged vestibular aqueduct was found in 16 ears (11.7%). High jugular bulbs were found in 21 ears; however, this variation was not considered to be an inner ear abnormality. CONCLUSION: Computed tomography and magnetic resonance imaging are essential for the evaluation, determination, and classification of inner ear abnormalities in patients with congenital sensorineural hearing loss who are candidates for cochlear implant operations. Also, these radiological instruments aid in determining contraindications and predicting intraoperative difficulties. Computed tomography and magnetic resonance imaging findings for these patients should be evaluated by an experienced radiologist before the operation.

A New Concept for Carotid Artery Stenting: Coating the Atherosclerotic Plaque by Covered Stent before Bare Stent Implantation.

In carotid artery stenting (CAS) procedures, distal embolism, periprocedural stent thrombosis, and 30-day stroke due to the plaque fragmentation and protrusion caused by stent implantation and balloon dilation are frequent complications. In this technical case report, a case is presented of extracranial carotid artery stenosis treated with a covered stent and subsequent implantation of a bare stent. In addition, the possibility is discussed that this new technique prevents the distal microembolic complications, periprocedural stent thrombosis, and 30-day stroke of extracranial CAS.

Flow Diversion in Middle Cerebral Artery Aneurysms: Is It Really an All-Purpose Treatment?

BACKGROUND AND OBJECTIVE: The outcome of flow diversion for middle cerebral artery (MCA) aneurysms, one of the most common sites for intracranial aneurysms, has not been defined thoroughly. We assessed our outcomes in MCA aneurysms (MCAAs) treated by flow diversion, i.e., with either dedicated flow diverters or telescopic stents. METHODS: Patients with MCAAs were treated by flow diversion if surgical or other endovascular treatment modalities had failed or were deemed likely to fail. Angiographic and clinical outcome of these patients was assessed retrospectively. Aneurysm location on MCA was defined as M1 segment, "true bifurcation" (classical bifurcation of MCA into superior and inferior trunks), "variant bifurcation" (bifurcation of early frontal or early/distal temporal branches), or M2 segment. Aneurysm morphology was classified as saccular versus dissecting/fusiform. RESULTS: Treatment was attempted in 29 MCAAs. Technical failure rate was 3.4% (1/29). Thirteen of aneurysms were fusiform. Of the bifurcation aneurysms, most (10/16) were the variant type. Overall and procedure-related mortality/permanent morbidity rates were 10.3% (3/29) and 3.5% (1/29). Total occlusion rates (mean angiographic follow-up 10.3 months) for saccular and fusiform aneurysms were 40% and 75%, respectively. In bifurcation aneurysms, occlusion was strongly associated with side-branch occlusion (P < 0.005). CONCLUSIONS: In this series, flow diversion for the treatment of MCAAs was safe, was effective in the treatment of fusiform MCAAs, and was not as effective at mid-term for MCA bifurcation aneurysms. Unsatisfactory occlusion rate in bifurcation aneurysms likely results from residual filling of the aneurysms in cases in which the jailed side branch remains patent.

Hybrid, Y-configured, dual stent-assisted coil embolization in the treatment of wide-necked bifurcation aneurysms.

In Y-stenting, stabilization of the first stent may be problematic as in some cases it migrates during second stent insertion. This report evaluates the safety and effectiveness of the technique and presents the long-term results of hybrid, Y-configured, dual stent-assisted coil embolization in the treatment of wide-necked bifurcation aneurysms. We retrospectively evaluated the patients treated endovascularly due to cerebral aneurysms. Twenty patients treated with hybrid Y-stent-assisted coil embolization were enrolled in the study. In hybrid stenting, an open-cell intracranial stent (Neuroform) was used as a first stent to prevent stent migration. A closed-cell stent (Enterprise or Acclino) was used as a second stent and the aneurysm was embolized with coils between the stent struts. In all patients, hybrid Y-stenting and coil embolization were accomplished successfully. No stent migration occurred. Clinically, neither symptomatic neurologic complication nor death was seen. Of 20 wide-necked bifurcation aneurysms, nine were at the basilar tip, while seven were at the middle cerebral artery and three at the anterior communicating artery. In one patient, the aneurysm was at the A2-3 junction of the anterior cerebral artery. One of the patients had a subarachnoid hemorrhage. The mean angiographic follow-up was 25.6 months. No in-stent stenosis was seen in any of the patients and recanalization in only one. Hybrid, Y-configured, dual stent-assisted coil embolization is a safe and effective method in the treatment of wide-necked bifurcation aneurysms to prevent stent migration and aneurysm recanalization, and is a viable alternative to microsurgery.

Extrarenal pseudoaneurysm of the arterial anastomosis in a renal transplant: endovascular coil embolization with balloon remodeling technique.

Anastomotic pseudoaneurysms of transplanted kidneys are a very rare complication and encountered in less than 1% of such operations. They may be devastating and cause functional impairment and even loss of the graft. In this report, we present the first case of treatment of extrarenal pseudoaneurysm of arterial anastomosis in a renal transplant patient with endovascular coil embolization with the balloon remodeling technique. This method is mostly used in the treatment of wide-neck intracranial aneurysms.

Face skin necrosis following embolization for arteriovenous malformations: a case report.

INTRODUCTION: Arteriovenous malformations (AVMs) are rare in the oral and maxillofacial regions. DISCUSSION: AVMs may induce severe complications such as uncontrollable bleeding. Superselective intra-arterial embolization is an effective method for this bleeding that is refractory to conservative treatment. Arterial embolization may cause ischemic complications. We report the case of a patient who developed face skin necrosis following bilateral facial artery embolization.

Iliac artery stenosis as a cause of posttransplant renal failure and claudication.

Iliac artery stenosis (IAS) is a rare complication after renal transplantation. We demonstrate a case of ipsilateral external IAS proximally to anastomosis in a kidney recipient, which manifested with renal failure and claudication, and was successfully treated with endovascular stent placement.

Estimation of the ratio of renal artery stenosis with magnetic resonance angiography using parallel imaging technique in suspected renovascular hypertension.

BACKGROUND: Renovascular hypertension, which may lead to end-stage renal failure, necessitates prompt diagnosis and medication. Although various diagnostic tools exist for evaluation of renal arteries, magnetic resonance angiography (MRA), with the improvement of hardware and software systems, has become a very promising technique in screening patients with suspected renal hypertension. In this study, we aimed to assess renal artery stenosis on MRA in patients with suspected renovascular disease using a parallel imaging technique which allows faster scanning with higher resolution. METHODS: Eighty-four patients with hypertension underwent MRA and digital angiography. RESULTS: MRA detected renal artery stenosis with a sensitivity rate ranging from 69.3 to 100% and specificity rate ranging from 85.7 to 96%. CONCLUSION: Contrast-enhanced MRA of renal arteries is very effective in the demonstration of renal artery stenoses and assessment of stenosis ratio. Furthermore, parallel imaging technology has improved this procedure by reducing the scan time. Renal MRA, as a diagnostic tool, can accurately direct patients with renovascular disease to intravascular treatment.

Chondromas of the falx cerebri and dural convexity: report of two cases and review of the literature.

Intracranial chondromas usually arise from the base of the skull. They rarely originate from the convexity dura and falx. Here we describe two cases of intracranial chondroma located at the convexity dura and falx, discuss the genesis, radiologic, histologic features and review the literature.