Short-term outcomes of a multicentre randomized clinical trial comparing laparoscopic pylorus-preserving gastrectomy with laparoscopic distal gastrectomy for gastric cancer (the KLASS-04 trial).

BACKGROUND: There remain concerns about the safety and functional benefit of laparoscopic pylorus-preserving gastrectomy (LPPG) compared with laparoscopic distal gastrectomy (LDG). This study evaluated short-term outcomes of a randomized clinical trial (RCT) comparing LPPG with LDG for gastric cancer. METHODS: The Korean Laparoendoscopic Gastrointestinal Surgery Study (KLASS)-04 trial was an investigator-initiated, open-label, parallel-assigned, superiority, multicentre RCT in Korea. Patients with cT1N0M0 cancer located in the middle third of the stomach at least 5 cm from the pylorus were randomized to undergo LPPG or LDG. Participants, care givers and those assessing the outcomes were not blinded to group assignment. Outcomes were 30-day postoperative morbidity rate and death at 90 days. RESULTS: Some 256 patients from nine institutions were randomized (LPPG 129 patients, LDG 127 patients) between July 2015 and July 2017 and outcomes for 253 patients were analysed. Postoperative complications within 30 days were seen in 19.3 and 15.5 per cent in the LPPG and LDG groups respectively (P = 0·419). Postoperative pyloric stenosis was observed in nine (7.2 per cent) and two (1·5 per cent) patients in the LPPG and LDG groups (P = 0·026) respectively. In multivariable analysis higher BMI was a risk factor for postoperative complications (odds ratio 1·17, 95 per cent c.i. 1·04 to 1·32; P = 0·011). Death at 90 days was zero in both groups. CONCLUSION: Postoperative complications and mortality was comparable in patients undergoing LPPG and LDG. Registration number: NCT02595086 (http://www.clinicaltrials.gov).

Long-Term Outcomes of Patients with Stent Tips Embedded into Internal Carotid Artery Branches during Aneurysm Coiling.

BACKGROUND AND PURPOSE: During stent-assisted coiling of ICA aneurysms, stent tips are sometimes unintentionally embedded into ICA branches. Stent tips can be visualized because they have radiopaque markers. Concerns regarding stent tip misplacement include risks of artery perforation and occlusion. The aim of this study was to evaluate the long-term outcomes of ICA branches with embedded stent tips. MATERIALS AND METHODS: ICA branches with embedded stent tips were identified among 35 patients with unruptured ICA aneurysms treated with stent-assisted coiling between November 2003 and November 2014. Patient clinical and angiographic outcomes associated with the embedded stent tip were analyzed. RESULTS: Most of the 35 studied aneurysms were paraclinoid ICA aneurysms (n = 30). The most commonly involved ICA branch was the posterior communicating artery (26 patients, 74.3%), followed by the anterior choroidal artery (8 patients, 22.9%) and ophthalmic artery (1 patient, 2.9%). During the follow-up period (38.6 ± 17.9 months), no new neurologic deficits developed. Neither hemorrhagic nor thromboembolic events occurred. Angiography was performed during the final follow-up evaluation at a mean of 32.7 ± 18.0 months, and all ICA branches with embedded stent tips showed patent blood flow without severe luminal narrowing. CONCLUSIONS: In our experience, placement of a stent tip into ICA branches during stent-assisted coiling was not associated with any major adverse events.

Prophylactic Antiplatelet Medication in Endovascular Treatment of Intracranial Aneurysms: Low-Dose Prasugrel versus Clopidogrel.

BACKGROUND AND PURPOSE: Prophylactic antiplatelet medication is beneficial in decreasing thromboembolic complications during endovascular treatment of unruptured intracranial aneurysms. The efficacy may be limited by variability of individual response to antiplatelet medication, especially clopidogrel. We compared the efficacy of 2 antiplatelet medications, low-dose prasugrel and clopidogrel, in patients undergoing endovascular treatment of unruptured aneurysms. MATERIALS AND METHODS: From November 2014 to July 2015, 194 patients with a total of 222 unruptured aneurysms underwent endovascular treatment at a single institution. Laboratory and clinical data from the prospectively maintained registry were used in this study. Antiplatelet medication was given the day before endovascular treatment (prasugrel 20 mg or 30 mg or clopidogrel 300 mg). Response to the antiplatelet medication was measured by the VerifyNow system. Periprocedural adverse event rates between the 2 groups were compared. RESULTS: There were no significant differences in the baseline characteristics of patients and aneurysms between the 2 groups. The P2Y12 reaction unit values were lower (clopidogrel group versus prasugrel group, 242.7 ± 69.8 vs 125.7 ± 79.4; P < .0001) and percentage inhibition values were higher (22.1% ± 19.7% vs 60.2 ± 24.7%; P < .0001) in the prasugrel group. There were no thromboembolic events, but there was 1 procedural bleed in each group, without any clinical consequences. CONCLUSIONS: The prasugrel group showed more effective and consistent platelet inhibition. We may omit the antiplatelet response assay with the low-dose prasugrel premedication before the endovascular treatment of patients with unruptured aneurysms. Further study is required to determine whether there is benefit of this strategy regarding clinical outcome.

MRI findings of spinal arteriovenous fistulas: focusing on localisation of fistulas and differentiation between spinal dural and perimedullary arteriovenous fistulas.

AIM: To investigate the magnetic resonance imaging (MRI) findings of spinal arteriovenous fistulas (AVFs) to predict their locations and types. MATERIALS AND METHODS: Patients who underwent spinal angiography for suspected spinal AVF between April 2003 and April 2013 were enrolled. Spine MRI images were analysed by two radiologists in consensus focusing on the distribution patterns of flow void pial vessels (FVPVs): longitudinal distribution pattern along the spinal level (even or uneven, with description of the most crowded level in uneven cases) and axial distribution pattern in relation to the cord (ventral, dorsal, or co-dominance). Spinal angiography served as the reference standard for the locations and types of fistulas. RESULTS: Thirty-two patients (M:F=24:8, mean age, 53 years; range, 2-74 years) were included. There were 18 patients with spinal dural AVFs (SDAVFs), seven with perimedullary AVFs, four with epidural AVFs, and three diagnosed as normal. In 12 of 15 longitudinally uneven AVFs, the most crowded levels of FVPVs corresponded to the true fistulous levels within two-level differences. While dorsal dominance was predominant in SDAVFs (13/18), ventral dominance was predominant in perimedullary AVFs (5/7; p<0.01). CONCLUSION: Fistulous levels may be predicted to be within two levels of the most crowded levels of FVPVs. The dorsal dominance pattern of FVPVs favours SDAVFs, whereas ventral dominance suggests perimedullary AVFs.

Prognostic value of tumor-infiltrating lymphocytes in Epstein-Barr virus-associated gastric cancer.

BACKGROUND: This study explored the prognostic impact of tumor-infiltrating lymphocytes (TILs) and investigated whether three histologic subtypes (lymphoepithelioma-like carcinoma, carcinoma with Crohn's disease-like lymphoid reaction, and conventional-type adenocarcinoma) could stratify a prognostic subset for patients with Epstein-Barr virus (EBV)-associated gastric cancer (EBVaGC). MATERIALS AND METHODS: After reviewing 1318 consecutive cases of surgically resected or endoscopic submucosal dissected gastric cancers, 120 patients were identified as EBV-positive using EBV-encoded RNA in situ hybridization. The evaluation of the percentage of intratumoral (iTu-) and stromal (str-) TILs was carried out, and the cases were also subclassified into three histologic subtypes as noted above. RESULTS: Among the 120 patients, 73 patients (60.8%) and 60 patients (50.0%) were determined as str-TIL-positive and iTu-TIL-positive, respectively. In a univariate analysis, str-TIL-positivity was significantly associated with longer recurrence-free survival (RFS; P = 0.002) and disease-free survival (DFS; P = 0.008), yet not overall survival (OS; P = 0.145). While iTu-TIL-positivity has a tendency of favorable outcome indicator for DFS and OS, but statistically significant differences were not shown, respectively (RFS, P = 0.058; DFS, P = 0.151; OS, P = 0.191). In a multivariate analysis using a Cox proportional hazard model adjusted for age, pTNM stage, lymphatic invasion, perineural invasion, and venous invasion; histologic subtype, WHO classification, and str-TIL-positivity were independently or tentatively associated with favorable RFS (hazard ratio [HR] = 12.193, 95% confidence interval [95% CI] 1.039-143.055, P = 0.047) or DFS (HR = 4.836, 95% CI 0.917-25.525, P = 0.063). CONCLUSION: The histologic subclassification and TILs can be used to predict RFS and DFS for patients with EBVaGC.

Role of moesin in HMGB1-stimulated severe inflammatory responses.

Sepsis is a life-threatening condition that arises when the body's response to infection causes systemic inflammation. High-mobility group box 1 (HMGB1), as a late mediator of sepsis, enhances hyperpermeability, and it is therefore a therapeutic target. Despite extensive research into the underlying mechanisms of sepsis, the target molecules controlling vascular leakage remain largely unknown. Moesin is a cytoskeletal protein involved in cytoskeletal changes and paracellular gap formation. The objectives of this study were to determine the roles of moesin in HMGB1-mediated vascular hyperpermeability and inflammatory responses and to investigate the mechanisms of action underlying these responses. Using siRNA knockdown of moesin expression in primary human umbilical vein endothelial cells (HUVECs), moesin was found to be required in HMGB1-induced F-actin rearrangement, hyperpermeability, and inflammatory responses. The mechanisms involved in moesin phosphorylation were analysed by blocking the binding of the HMGB1 receptor (RAGE) and inhibiting the Rho and MAPK pathways. HMGB1-treated HUVECs exhibited an increase in Thr558 phosphorylation of moesin. Circulating levels of moesin were measured in patients admitted to the intensive care unit with sepsis, severe sepsis, and septic shock; these patients showed significantly higher levels of moesin than healthy controls, which was strongly correlated with disease severity. High blood moesin levels were also observed in cecal ligation and puncture (CLP)-induced sepsis in mice. Administration of blocking moesin antibodies attenuated CLP-induced septic death. Collectively, our findings demonstrate that the HMGB1-RAGE-moesin axis can elicit severe inflammatory responses, suggesting it to be a potential target for the development of diagnostics and therapeutics for sepsis.

Angle change of the parent arteries after stent-assisted coil embolization of wide-necked intracranial bifurcation aneurysms.

AIM: To investigate the angle changes of the parent arteries after stent-assisted coil embolization of wide-necked intracranial bifurcation aneurysms. MATERIALS AND METHODS: The adjacent parent arterial angles before and after stent-assisted coil embolization were measured in 38 patients with aneurysms of the anterior communicating artery (ACoAA) and 41 patients with bifurcation aneurysms of the middle cerebral artery (MCABA). Variables were analysed in relation to the angle changes. RESULTS: Vascular angles of the parent arteries significantly increased by 27.8° (±18.5°) immediately after stent-assisted coil embolization in 79 cases (p < 0.001), with 25.7° (±14.8°) in ACoAA and 29.7° (±21.4°) in MCABA, respectively. In 51 (64.6%) cases with follow-up angiography (mean interval 13.5 ± 4.1 months), vascular angles increased by 27.2° (±17.1°) immediately after treatment and further increased by 20.7° (±14.3°) at the last follow-up (all p < 0.001). More acute pre-stent angles of the parent arteries correlated with greater post-stent angle changes (p = 0.006). Younger age tended to be inversely related to post-stent angle changes (p = 0.091). CONCLUSION: Stent placement during coil embolization induced significant changes in the aneurysm-parent artery relationship. Further study is needed to elicit the association between angle change of the parent arteries and aneurysmal stability after coil embolization.

Coil protection using small helical coils for wide-neck intracranial aneurysms: a novel approach.

BACKGROUND AND PURPOSE: A number of remodeling or protective techniques available to treat wide-neck intracranial aneurysms are increasingly being used, provided that the shape/type of aneurysm, vessel diameter, and inherent course of the vessel are conducive to their use. The purpose of this study was to describe a novel method using coil protection for treatment of wide-neck aneurysms. MATERIALS AND METHODS: This technique involves sequential maneuvers to the aneurysm and affected branch artery. A microcatheter is first introduced into the aneurysmal sac, and another microcatheter is introduced into the entrance of the branch artery, followed by partial deployment of a small helical coil into the branch artery. A framing coil is then placed within the aneurysmal sac, under the protection of the helical coil. After completion of the first coil insertion, the helical coil should be retrieved to confirm the stability of the framing coil. The helical coil can also serve as a filler. RESULTS: This technique was successfully applied to 12 intracranial saccular aneurysms of the MCA bifurcation (5 patients); anterior communicating artery (3 patients); and A1 and M1 segments, distal ACA, and basilar tip (1 patient each). Selective endovascular treatment was successfully performed and resulted in excellent outcomes in all patients. There were no complications directly related to coil protection. CONCLUSIONS: Our small study suggests that coil protection can be a safe alternative to traditional remodeling or protective techniques when those techniques have failed or are not possible due to vascular geometry. It is particularly suited for the treatment of wide-neck aneurysms arising from small and acutely angulated branching vessels.

The characteristics and risk factors of headache development after the coil embolization of an unruptured aneurysm.

BACKGROUND AND PURPOSE: Development of a headache after aneurysm coil embolization is not uncommon but has received little attention. The authors prospectively analyze the characteristics and risk factors of a headache after coiling in patients treated for an unruptured cerebral aneurysm. MATERIALS AND METHODS: Ninety patients treated for an unruptured cerebral aneurysm over a period of 1 year, and without a headache history within a month before coiling, were enrolled in this study. All coilings were successfully performed without neurologic complications. After coiling, headache development and intensities were recorded. RESULTS: Fifty (55.6%) patients experienced a headache (VAS score, 4.5 ± 2.02) at 7.9 (range, 0-72) hours, on average, after coiling, and all headaches resolved within an average of 73.0 (range, 3-312) hours. Univariate analysis showed that the following were significantly associated with the development of a headache: age ≤ 50 years (OR 4.636, 95% CI, 1.414-15.198), hypertension (OR 0.232, 95% CI, 0.095-0.571), a packing attenuation of >25% (OR 3.619, 95% CI, 1.428-9.174), and a previous headache history (OR 2.769, 95% CI, 1.120-6.849). However, binary logistic regression showed that only a packing attenuation of >25% (P = .013, adjusted OR 3.774, 95% CI, 1.320-10.790) and no history of hypertension (P = .019, adjusted OR 3.515, 95% CI, 1.233-10.021) were independently associated with the development of a headache. CONCLUSIONS: A headache frequently developed after the coiling of unruptured aneurysms. However, headaches were relatively benign and resolved within several days. The present study shows that no hypertension history and a packing attenuation of >25% are risk factors of headache development.

Clinical implications of internal carotid artery flow impairment caused by filter occlusion during carotid artery stenting.

BACKGROUND AND PURPOSE: Membrane filters are EPDs, which preserve ICA flow during CAS. However, ICA flow arrest may occur with filter use. This report describes the angiographic, clinical, and histopathologic features of the filter occlusion. MATERIALS AND METHODS: Sixty-one consecutive patients with cervical carotid stenosis treated by CAS by using a single type of filter device were evaluated. All patients were on dual antiplatelet treatment and fully heparinized. Prestent dilation was performed in all patients. Poststent dilation was performed in 15 patients. Control angiograms were obtained and evaluated after each step of the CAS procedure. All filters were inspected for debris, and if present, histology was obtained. RESULTS: CAS was successfully performed in all cases with <20% residual stenosis. Filter occlusion occurred in 6 patients (9.8%). It developed immediately after stent deployment in 4, and after a second prestent dilation in 2. Five of the 6 had severe carotid stenosis. In all patients, filter withdrawal led to immediate and complete restoration of ICA flow. In 1 patient, acute embolic M1 occlusion occurred immediately after filter withdrawal but was successfully treated with thrombolysis. None of filter-occlusion group had permanent neurologic deficits. Gross and microscopic examinations demonstrated that the pores of the filters were occluded mainly by fibrin. Postoperative diffusion MR imaging revealed no difference between filter-occlusion and non-filter-occlusion groups. CONCLUSIONS: ICA flow arrest due to filter occlusion during CAS is relatively common and occurs more frequently in severe stenosis. It resolves rapidly after filter removal and does not appear to worsen outcome.

Comparison of 2-year angiographic outcomes of stent- and nonstent-assisted coil embolization in unruptured aneurysms with an unfavorable configuration for coiling.

BACKGROUND AND PURPOSE: Stents are known to have hemodynamic and biologic effects in addition to their mechanical scaffold effect. To determine whether stents affect long-term outcomes after coiling of unruptured aneurysms, we compared angiographic outcomes at 2 years postembolization for stent- and nonstent-assisted coiled unruptured aneurysms. MATERIALS AND METHODS: Stent-assisted coiling was used in unruptured aneurysms unfavorable for simple coiling (neck size >4 mm and dome-to-neck ratio <1.5) in our practice. Therefore, 126 coiled unruptured aneurysms in total (40 [31.7%] stent group and 86 [68.3%] nonstent group) with these conditions were selected for this study. The nonstent group aneurysms were treated with multiple microcatheter technique (53 cases) or balloon-assisted technique (33 cases). Self-expandable stents were used for coiling in stent group aneurysms. No significant difference in aneurysmal characteristics (aneurysm type [sidewall/bifurcation], diameter, neck size, and dome-to-neck ratio) or angiographic outcome at embolization (packing attenuation, obliteration grade, and contrast filling) were observed between the 2 study groups. RESULTS: At 2-year follow-up visits, rates of progressive occlusion (stent group, 17/40 [42.5%] versus nonstent group, 34/86 [39.5%]) and recanalization (7/40 [17.5%] versus 18/86 [21.0%]) did not show a statistically significant difference between the 2 groups (P = .895). CONCLUSIONS: The present study did not show that additional hemodynamic and biologic effects of stents designed for neck remodeling were enough to enhance progressive occlusion and prevent the recanalization of unruptured aneurysms. Our finding suggests that stent placement provides no better long-term angiographic outcomes for unruptured aneurysms with an unfavorable configuration for coiling.

Intra-arterial nimodipine infusion for cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage.

This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.

Endovascular treatment for unruptured intracranial aneurysms in elderly patients: single-center report.

BACKGROUND AND PURPOSE: The optimal management of patients with unruptured intracranial aneurysms remains controversial in elderly populations. The aim of this study was to evaluate technical results and clinical outcomes in a single center of consecutive elderly patients with unruptured intracranial aneurysms treated with endovascular embolization. MATERIALS AND METHODS: Between May 2003 and February 2010, 96 patients older than 70 years (men, 16 patients; women, 80 patients; mean age, 73 years) with 122 saccular unruptured intracranial aneurysms were treated in our hospital with an endovascular approach. The endovascular procedures and technique, angiographic follow-up, and complications were evaluated. RESULTS: Successful embolizations without complications were completed in 95.9%. Five patients had procedure-related events, including thromboembolism in 1 patient, aneurysm perforation during the procedure in 1, and 3 postoperative transient minor symptoms (headache, otalgia, and trigeminal pain) in 3. The degree of occlusion of the treated aneurysm was complete in 46.7%; there was a small neck remnant in 40.9% and residual filling in 12.2%. Imaging (MR angiography) follow-up was performed in 68.7% of the patients. The mean follow-up duration was 19.4 months (range, 5-57 months). Fifty-five patients (93.9%) showed no interval change of the residual neck. Four (6%) demonstrated recanalizations, all of which were successfully recoiled. CONCLUSIONS: Endovascular treatment of unruptured intracranial aneurysms in patients older than 70 years of age appears to be safe. Favorable outcomes with low morbidities may replace surgery or conservative treatment as an active management alternative.

Dysregulation of upstream binding factor-1 acetylation at K352 is linked to impaired ribosomal DNA transcription in Huntington's disease.

Huntington's disease (HD) is an autosomal-dominant neurological disorder caused by expanded CAG repeats in the Huntingtin (Htt) gene, but it is not known how this mutation causes neurodegeneration. Herein, we found that dysfunction of upstream binding factor-1 (UBF-1) is linked to reduced ribosomal DNA (rDNA) transcription in HD. We identified that UBF1 acetylation at Lys (K) 352 by CREB binding protein (CBP) is crucial for the transcriptional activity of rDNA. UBF1 mutation (K352A, K352Q, and K352R) decreased rDNA transcriptional activity. Moreover, both CBP-dHAT mutant and knockdown of CBP by siRNA reduced acetylation of UBF1 and resulted in the decreased transcription of rDNA into rRNA. ChIP analysis showed a significant reduction of UBF1 occupancy in the promoter of rDNA in STHdh(Q111) cell line model of HD. These results demonstrate that abnormal activity of UBF1 and its acetylation by CBP are linked to impaired rDNA transcription in HD. This novel mechanism suggests that modulation of UBF-mediated rDNA synthesis by CBP may be a therapeutic target for improving neuronal rDNA transcription in HD.

Is fasting necessary for elective cerebral angiography?

BACKGROUND AND PURPOSE: In order to prevent unexpected events such as aspiration pneumonia, cerebral angiography has been performed under fasting in most cases. We investigated prospectively the necessity of fasting before elective cerebral angiography. MATERIALS AND METHODS: The study is an open-labeled clinical trial without random allocation. In total, 2554 patients who underwent elective cerebral angiography were evaluated on development of nausea, vomiting, and pulmonary aspiration during and after angiography. Potential risks and benefits associated with fasting were provided in written documents and through personal counseling to patients before the procedure. The patients chose their fasting or nonfasting option. No restriction in diet was given after angiography. The patients were observed for 24 hours. Nausea and vomiting during and within 1 hour after angiography was considered as a positive event associated with cerebral angiography. RESULTS: The overall incidence of nausea and vomiting during and within 1 hour after angiography was 1.05% (27/2554 patients). There was no patient with pulmonary aspiration. No statistical difference in nausea and vomiting development between the fasting and the diet groups was found. CONCLUSIONS: The incidence of nausea and vomiting associated with cerebral angiography is low and not affected by diet or fasting. Pulmonary aspiration had no difference between the diet and the fasting group. Our study suggests that fasting may not be necessary for patients who undergo elective cerebral angiography.

Genetic variation of the HIV-1 integrase region in newly diagnosed anti-retroviral drug-naïve patients with HIV/AIDS in Korea.

The survival time of HIV/AIDS patients in Korea has increased since HAART (highly active anti-retroviral therapy) was introduced. However, the occurrence of drug-resistant strains requires new anti-retroviral drugs, one of which, an integrase inhibitor (INI), was approved by the US Food and Drug Administration (FDA) in 2007. INIs have been used for therapy in many countries and are about to be employed in Korea. Therefore, it is important to identify basic mutant variants prior to the introduction of INIs in order to estimate their efficacy. To monitor potential drug-resistant INI mutations in Korean HIV/AIDS patients, the polymorphism of the int gene was investigated together with the pol gene using a genotypic assay for 75 randomly selected Korean HIV-1 patients newly diagnosed in 2007. The drug-resistant mutation sequences were analysed using the Stanford HIV DB and the International AIDS Society resistance testing-USA panel (IAS-USA). Seventy strains of Korean subtype B were compared with foreign subtype-B strains, and there were no significantly different variants of the int gene region in the study population. Major mutation sites in the integrase (E92Q, F121Y, G140A/S, Y143C/R, Q148H/R/K and N155H) were not detected, and only a few minor mutation sites (L74M, V151I, E157Q, V165I, I203M, S230N and D232N) were identified in 21 strains (28%). Resistance due to mutations in the pol gene was observed in a single strain (1.3%) resistant to protease inhibitors (PIs) and in four strains (5.3%) resistant to reverse transcriptase inhibitors (RTIs). In summary, this demonstrates that INIs will be susceptible to drug naïve HIV/AIDS patients in Korea.

Two-year follow-up of contrast stasis within the sac in unruptured aneurysm coil embolization: progressive thrombosis or enlargement?

BACKGROUND AND PURPOSE: The fate of contrast stasis within an aneurysmal sac after coiling has not been established. We followed and evaluated the potential risks of recanalization of unruptured aneurysms embolized with BPCs for 2 years. MATERIALS AND METHODS: A total of 301 unruptured aneurysms in 252 patients were treated with BPCs. Contrast stasis was observed on initial postembolization angiograms in 104 (34.6%) of these aneurysms. For follow-up, skull images by an angiographic unit (at 3, 9, 15, and 21 months), CE-MRA including TOF source images (at 6, 12, and 18 months), and DSA (at 24 months) were used. RESULTS: In 89 (85.6%) of the 104 aneurysms with contrast stasis, the stasis disappeared on 6-month MRAs and occlusions remained unchanged without recanalization for 2 years. In the remaining 15 (14.4%), recanalization occurred during follow-up. The presence of contrast stasis was not found to be associated with the obliteration rate (P = .641) or packing attenuation (aneurysms without contrast stasis 30.7% ± 11.18 versus aneurysms with contrast stasis 33.0% ± 12.11, P = .113). Contrast stasis was not found to be a risk factor for recanalization (15/104 [14.4%] versus 29/197 [14.7%], P = 1.000). CONCLUSIONS: Contrast stasis is a benign angiographic finding that can disappear within 6 months on follow-up MRA. In addition, contrast stasis was not found to be associated with a low obliteration rate or packing attenuation or to be a risk factor for recanalization. The present study shows that aneurysms with contrast stasis on initial postembolization angiograms are no more likely to recanalize than aneurysms without contrast stasis.

Intracranial stent placement for recanalization of acute cerebrovascular occlusion in 32 patients.

BACKGROUND AND PURPOSE: Stents have been reported as an option for improvement of the recanalization rate in AIS. The authors have also used intracranial stents in failed cases of IAT with pharmacologic and mechanical methods since 2004. We retrospectively reviewed our cases of intracranial stent use for IAT of AIS for recanalization and as a rescue procedure for iatrogenic intracranial vascular dissection during IAT. MATERIALS AND METHODS: Thirty-two patients, who were diagnosed with AIS, were treated with intracranial stents (28 balloon-mounted and 7 self-expandable stents) at our neurovascular center between April 2004 and December 2008. The stent use for all 32 patients was the final attempt to recanalize occluded vessels after various trials of pharmacologic or mechanical thrombolysis or to treat iatrogenic vascular dissection. RESULTS: Among the 32 patients, immediate poststenting angiographic recanalization was achieved in 100% with TIMI/TICI 2 (15 of 32 lesions, 46.9%) or TIMI/TICI 3 (17 of 32 lesions, 53.1%). However, complication rates were also high. Major symptomatic intracerebral hemorrhage (1 case of procedural symptomatic hemorrhage and 3 cases of delayed symptomatic hemorrhage) occurred in 4 (12.5%); intracranial vascular dissection, in 4 (12.5%); extracranial vascular dissection, in 3 (9.4%); immediate IST, in 4 (12.5%); subacute (within 1 week) IST, in 2; late (>1 week) IST, in 1, and 1 case of in-stent restenosis occurred twice (at 5 and 17 months). CONCLUSIONS: Intracranial stent placement for AIS management has an excellent recanalization rate. However, it is associated with high complication risks as our series showed. We believe that the decision to treat AIS with intracranial stent placement should be made after careful consideration of potential benefits and risks.

Spinal intraosseous arteriovenous fistula in the fractured vertebral body.

A 68-year-old woman presenting with progressive paraparesis was diagnosed with an AVF involving a previously fractured L1 vertebral body on which feeders from multiple segmental arteries converged. The most distinctive feature in our patient was that the fistula was located in the vertebral body. Transarterial embolization of the segmental arteries with coils and glue resulted in total obliteration of the fistula, which in turn resulted in symptom improvement.

Intraosseous cranial dural arteriovenous fistula treated with transvenous embolization.

BACKGROUND AND PURPOSE: We analyzed the angiographic architecture of intraosseous dural arteriovenous fistulas (DAVFs) and evaluated the use of transvenous embolization for curative treatment. MATERIALS AND METHODS: The study population consisted of 6 patients with intraosseous DAVFs from 3 hospitals. In all of these patients, we retrospectively reviewed the medical records and images, and we were able to confirm the lesions in all patients from CT, MR imaging, and angiographic images. 3D rotational angiographic coronal source images clearly demonstrated the presence of an intraosseous DAVF in 2 patients. RESULTS: An intraosseous DAVF was located at the upper clivus in 1, the petrous apex in 1, and the lower clivus adjacent to the hypoglossal canal in 4 cases. All of the cases showed the presence of a dilated venous pouch, manifest as an osteolytic lesion on CT and as an intraosseous signal-intensity void on MR images. All patients were treated with transvenous embolization by targeting the dilated venous pouch and its connecting tributaries. Four intraosseous DAVFs were immediately completely embolized. One patient had a residual shunt, but the shunt disappeared 1 month later. One patient presented with a simultaneous DAVF in the ipsilateral cavernous sinus without a significant amount of shunt. None of the patients had procedural complications, and 5 patients recovered from the presenting symptoms. CONCLUSIONS: An intraosseous DAVF could be completely cured with transvenous embolization. For curative treatment, the intraosseous dilated venous pouch can be the target lesion for endovascular treatment.