Factors influencing discharge against medical advice (DAMA) in traumatic brain injury patients requiring decompressive surgery: a comprehensive analysis.

raumatic brain injury (TBI) is a significant global health concern, particularly affecting young individuals, and is a leading cause of mortality and morbidity worldwide. Despite improvements in treatment infrastructure, many TBI patients choose discharge against medical advice (DAMA), often declining necessary surgical interventions. We aimed to investigate the factors that can be associated with DAMA in TBI patients that were recommended to have surgical treatment. This study was conducted at single tertiary university center (2008-2018), by retrospectively reviewing 1510 TBI patients whom visited the emergency room. We analyzed 219 TBI surgical candidates, including 50 declining surgery (refused group) and the others whom agreed and underwent decompressive surgery. Retrospective analysis covered demographic characteristics, medical history, insurance types, laboratory results, CT scan findings, and GCS scores. Statistical analyses identified factors influencing DAMA. Among surgical candidates, 169 underwent surgery, while 50 declined. Age (60.8 ± 17.5 vs. 70.5 ± 13.8 years; p < 0.001), use of anticoagulating medication (p = 0.015), and initial GCS scores (9.0 ± 4.3 vs. 5.3 ± 3.2; p < 0.001) appeared to be associated with refusal of decompressive surgery. Based on our analysis, factors influencing DAMA for decompressive surgery included age, anticoagulant use, and initial GCS scores. Contrary to general expectations and some previous studies, our analysis revealed that the patients' medical conditions had a larger impact than socioeconomic status under the Korean insurance system, which fully covers treatment for TBI. This finding provides new insights into the factors affecting DAMA and could be valuable for future administrative plans involving national insurance.

Comparison of the efficacy in improving trigeminal neuralgia in petroclival meningioma between microsurgery and radiosurgery: a meta-analysis.

The purpose of this study was to systematically review studies in the literature to assess the superiority between microsurgery and radiosurgery regarding the efficacy in improving petroclival meningioma (PCM)-related trigeminal neuralgia (TN). PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched from the inception until December 08, 2022. The overall proportion of patients with improved TN after treatment in all six included studies was 56% (95% confidence interval [CI], 35-76.9%). Higgins I2 statistics showed significant heterogeneity (I2 = 90%). Subgroup analysis showed that the proportion of improved TN was higher in the microsurgery group than that in the radiosurgery group (89%; 95% CI, 81-96.5% vs. 37%, 95% CI, 22-52.7%, respectively, p < 0.01). Subgroup analysis (for studies that documented the number of posttreatment Barrow Neurological Institute scores 1 and 2) revealed that the proportion of pain-free without medication after treatment was higher in the microsurgery group than that in the radiosurgery group (90.7%; 95% CI, 81-99.7% vs. 34.5%, 95% CI, 21.3-47.7.7%, respectively, p < 0.01). Based on the results of this meta-analysis, we concluded that microsurgery is superior to radiosurgery in controlling PCM-related TN.

Predictor of the Postoperative Swelling After Craniotomy for Spontaneous Intracerebral Hemorrhage: Sphericity Index as a Novel Parameter.

Objective: Spontaneous intracerebral hemorrhage is a serious type of stroke with high mortality and disability rates. Surgical treatment options vary; however, predicting edema aggravation is crucial when choosing the optimal approach. We propose using the sphericity index, a measure of roundness, to predict the aggravation of edema and guide surgical decisions. Methods: We analyzed 56 cases of craniotomy and hematoma evacuation to investigate the correlation between the sphericity index and patient outcomes, including the need for salvage decompressive craniectomy (DC). Results: The patients included 35 (62.5%) men and 21 (37.5%) women, with a median age of 62.5 years. The basal ganglia was the most common location of hemorrhage (50.0%). The mean hematoma volume was 86.3 cc, with 10 (17.9%) instances of hematoma expansion. Cerebral herniation was observed in 44 (78.6%) patients, intraventricular hemorrhage in 34 (60.7%), and spot signs in 9 (16.1%). Salvage DC was performed in 13 (23.6%) patients to relieve intracranial pressure. The median follow-up duration was 6 months, with a mortality rate of 12.5%. The sphericity index was significantly correlated with delayed swelling and hematoma expansion but not salvage DC. Conclusions: The sphericity index is a promising predictor of delayed swelling and hematoma expansion that may aid in the development of surgical guidelines and medication strategies. Further large-scale studies are required to explore these aspects and establish comprehensive guidelines.

Antibiotics Prophylaxis for Endoscopic Endonasal Approach for Skull Base Tumor Surgery: A Meta-Analysis.

BACKGROUND: The regimen of prophylactic antibiotic for endoscopic endonasal skull base surgery (EE-SBS) varies considerably depending on surgeons and their institutes. The purpose of the present meta-analysis is to assess the effect of antibiotic regimens on EE-SBS surgery for anterior skull base tumor. METHODS: The PubMed, Embase, Web of Science, and Cochrane clinical trial databases were systematically searched through October 15, 2022. RESULTS: The 20 included studies were all retrospective. The studies included a total of 10,735 patients who underwent EE-SBS for skull base tumor. The proportion of patients with postoperative intracranial infection across all 20 studies was 0.9% (95% confidence interval [CI] 0.5%-1.3%). The proportion of postoperative intracranial infection in the multiple antibiotics group did not show statistically significant difference to that of the single antibiotic agent group (proportion: 0.6%, 95% CI 0%-1.4% vs. proportion: 1%, 95% CI 0.6%-1.5%, respectively, P = 0.39). The ultra-short duration maintenance group showed lower incidence of postoperative intracranial infection, although it did not reach statistical significance (ultra-short group: 0.7%, 95% CI 0.5%-0.9%; short duration: 1.8%, 95% CI 0.5%-3%; and long duration: 1%, 95% CI 0.2%-1.9%, P = 0.22) The combination of the multiple antibiotics group did not show meaningful low incidence of postoperative intracranial infection (antibiotics combination group: 0.6%, 95% CI 0%-1.4%; cefazolin single group: 0.8%, 95% CI 0%-1.6%; and single antibiotics other than cefazolin: 1.2%, 95% CI 0.7%-1.7%, P = 0.22). CONCLUSIONS: Multiple antibiotics did not show superiority compared with single antibiotic agent. Also, long maintenance duration of antibiotics did not reduce the incidence of postoperative intracranial infection.

Middle meningeal artery embolization for chronic subdural hematoma in elderly patients at high risk of surgical treatment.

OBJECTIVE: The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate. METHODS: We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated. RESULTS: The mean follow-up period was 160 days (range, 46-311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case. CONCLUSIONS: MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.

Clinical features and treatment strategies for vertex epidural hematoma: a systematic review and meta-analysis from individual participant data.

Vertex epidural hematoma (VEDH) is a rare extradural hematoma and often misdiagnosed because of its variety of clinical symptoms and characteristic location. Determining optimal timing and technique for VEDH surgery is difficult because of its midline location and atypical clinical course. This study aims to understand the clinical manifestations and current treatment strategies for VEDH. We searched the published literature regarding VEDH through PubMed and Google Scholar, and individual patient data (IPD) were obtained from the eligible articles. A systematic review and IPD meta-analysis were conducted. In total, 70 patients' individual participant data were gathered. Most patients were male (87%), and traffic-related accidents were the most common injury mechanism (49%). Approximately half the patients (47%) were neurologically intact with nonspecific symptoms such as headache, dizziness, and vomiting at admission. Motor weakness alone (17%) and symptoms related to cranial nerve dysfunction such as anosmia, blurred vision, or diplopia (10%) were also noted. A surgical approach was initially chosen for 20 patients (28%), but eventually chosen for 20 more (total 40, 57%) during the observation period (average delay to surgery, 5 days). Patients who received surgery showed significantly poorer neurological status and larger hematoma size. Totally, two patients (3%) died, but most patients (94%) had a favorable outcome scoring 5 on the Glasgow Outcome Scale. Although VEDH generally showed favorable outcomes, clinicians must be aware of a high rate of delayed neurological deterioration during the observation period, which can be fatal due to central downward herniation.

Correlation of Aneurysmal Wall Enhancement of Unruptured Intracranial Aneurysms on High-Resolution Vessel-Wall Imaging With Clinical Indices and Surgical Findings.

BACKGROUND: Many physicians consider aneurysmal wall enhancement (AWE) on high resolution-vessel wall imaging (HR-VWI) as an imaging biomarker of unstable unruptured intracranial aneurysms (UIAs). OBJECTIVE: To evaluate the clinical value of different AWE signal intensities (SIs) by assessing the correlation between the AWE SIs and surgical findings and rupture risk assessment tools. METHODS: Twenty-six patients with 34 aneurysms who underwent surgical clipping were included. The corrected AWE SI was calculated by comparing T1-weighted images with post-gadolinium enhanced T1-weighted images. The correlation of AWE with the population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, site of aneurysm (PHASES) and earlier subarachnoid hemorrhage, location of the aneurysm, age >60 years, population, size of the aneurysm, shape of the aneurysm (ELAPSS) scores was evaluated using correlation and linear regression analysis. To quantify the surgical findings, the average color value of the aneurysms expressed in the CIELCh system was measured. Δh, color difference from yellow, was used for statistical analysis. RESULTS: The mean age of the patients and aneurysm size were 64.08 yr and 6.95 mm, respectively. The mean AWE SI, PHASES and ELAPSS scores, and Δh were 22.30, 8.41, 20.32, and 41.36, respectively. The coefficients of correlation of AWE SI with the PHASES and ELAPSS scores and Δh were 0.526, 0.563, and -0.431. We found that the AWE SI affected the PHASES (ß = 0.430) and ELAPSS scores (ß = 0.514) and Δh (ß = -0.427) in simple linear regression analysis. CONCLUSION: The AWE on HR-VWI was correlated with the PHASES and ELAPSS scores and the color. The stronger the AWE, the higher were the PHASES and ELAPSS scores and the more abnormal was the color. The AWE might indicate the degree of inflammation.

Hemodynamic Features of Microsurgically Identified, Thin-Walled Regions of Unruptured Middle Cerebral Artery Aneurysms Characterized Using Computational Fluid Dynamics.

BACKGROUND: Thin-walled regions (TWRs) of aneurysm surfaces observed in microscopic surgery are thought to be vulnerable areas for growth and rupture of unruptured intracranial aneurysms (UIAs). OBJECTIVE: To identify hemodynamic features of TWRs of aneurysms by using computational fluid dynamics (CFD) analyses of unruptured middle cerebral artery bifurcation (MCAB) aneurysms. METHODS: Nine patients with 11 MCAB aneurysms were enrolled, and their TWRs were identified. CFD analysis was performed using 3 parameters: pressure, wall shear stress (WSS), and WSS divergence (WSSD). Each parameter was evaluated for its correspondence with TWR. RESULTS: Among 11 aneurysms, 15 TWRs were identified. Corresponding matches with CFD parameters (pressure, WSS, and WSSD) were 73.33, 46.67, and 86.67%, respectively. CONCLUSION: WSSD, a hemodynamic parameter that accounts for both magnitude and directionality of WSS, showed the highest correspondence. High WSSD might correspond with TWR of intracranial aneurysms, which are likely high-risk areas for rupture.

Unexpected Daily Changes in Tumor Volume during Fractionated Gamma Knife Radiosurgery for Solitary Intraventricular Metastatic Renal Cell Carcinoma: A Case Report.

For most fractionated stereotactic radiosurgery treatment plans, daily imaging is not routinely performed, because there is little expectation that lesions will change significantly in the short term. However, here, we present the case of an abrupt increase and decrease in tumor volume during fractionated gamma knife radiosurgery (GKRS) for metastatic brain cancer. A 65-year-old man with a history of nephrectomy due to renal cell carcinoma was admitted to our hospital because of mild cognitive disorder and gait disturbance. An initial MRI of the brain demonstrated a 5 × 3 × 4.5 cm-sized, heterogeneously well-enhanced tumor with a large cystic component compressing the left thalamus and corpus callosum near the lateral ventricle. Owing to its large size and proximity to critical structures, we decided to perform 3 fractionated GKRSs over 3 consecutive days. After the first fraction of 9 Gy with 50% isodose, follow-up MRI the next day revealed an unexpected increase in tumor volume up to 30%. Therefore, the radiosurgical plan was adjusted, and GKRS was performed again using the same dose for the second fraction. The image taken on the third day showed rapid shrinkage of the tumor volume. This case shows that a tumor may change its shape and volume unexpectedly even during the short period of a fractionated GKRS session. Hence, for optimal fractionated GKRS treatment of tumors with the likelihood of an abrupt change in the short term, interval imaging should be considered.

Clinical Features of Patients With Spontaneous Intracranial Hypotension Complicated With Bilateral Subdural Fluid Collections.

BACKGROUND: Subdural hygromas are often found bilaterally in spontaneous intracranial hypotension (SIH). They frequently progress to chronic subdural hematomas (CSDHs), and if the hematomas are formed, it is difficult to consider SIH as an underlying cause. Whether SIH is underlying or not among the patients presenting bilateral subdural fluid collections (hygromas or CSDHs) is clinically important because the treatment strategy should be different between them. OBJECTIVES: We designed a retrospective case-control study to figure out differential clinical features of the patients presenting bilateral symptomatic subdural fluid collections owing to SIH. METHODS: Sixty-two patients with bilateral symptomatic subdural fluid collections were enrolled, and their data on general demographics, clinical courses, radiological findings, treatments, and outcomes were collected. The patients were divided into "SIH" and "Non-SIH" groups, and a simple logistic regression analysis was performed to clarify the differences between the groups. The consequent receiver operating characteristics (ROC) curve analyses were performed with the significant predictors. RESULTS: Eight patients (13%) were diagnosed with SIH. Young age (odds ratio [OR] = 0.831, 95% confidence interval [CI]: 0.743-0.929, P = .0012), no underlying disease (OR = 0.062, 95% CI: 0.007-0.544, P = .0121), radiological features of brain sagging (OR = 10.36, 95% CI: 0.912-93.411, P = .0017), pseudo-subarachnoid hemorrhage (OR = 15.6, 95% CI: 2.088-116.52, P = .0074), and small amount of fluid collections (OR = 0.719, 95% CI: 0.579-0.893, P = .0029) were significantly associated with SIH group. ROC curve analyses were performed in parameters of age and amount of fluid collection and the cut-off values for each parameter were ≤55 years old and ≤22.08 mm, respectively. Patients diagnosed with SIH underwent epidural blood patches and showed good results, except 1 patient who underwent burr-hole trephinations. CONCLUSION: Bilateral subdural fluid collections due to underlying SIH is associated with young age (≤55 years old), no underlying diseases, smaller amount of fluid collections (≤22.08 mm of depth), and radiological findings of brain sagging or pseudo-subarachnoid hemorrhages.

Selective Temporary Stent-Assisted Coil Embolization for Intracranial Wide-Necked Small Aneurysms Using Solitaire AB Retrievable Stent.

OBJECTIVE: Stent-assisted coil embolization of intracranial wide-necked aneurysm requires long-term postoperative antiplatelet therapy to prevent in-stent thrombosis. This study aimed to demonstrate results of temporary stent placement for coiling wide necked small intracranial aneurysms, which eliminated need for antiplatelet agents, and to discuss its feasibility and safety. METHODS: Data of 156 patients who underwent stent-assisted coil embolization between 2011 and 2014 were retrospectively analyzed. Thirteen cases of temporary stent-assisted coil embolization were included, and their clinical and radiological results were evaluated. RESULTS: The aneurysms treated were all unruptured except one case. All of them had wide neck with mean dome-to-neck ratio of 0.96 and were small-sized aneurysms with mean maximal diameter of 4.2 mm. There was no technical failure in retrieval of stent after completion of embolization of the target aneurysm. Immediate angiography revealed 11 complete and two partial embolization (one residual neck and one residual aneurysm). Two cases encountered thrombosis complication, and they were managed without neurological sequelae. The mean follow-up period was 43 months, angiographic follow-up revealed two cases with minor recurrence, and clinical outcome was good with modified Rankin scale score of 0. CONCLUSION: Temporary stent-assisted coil embolization of small wide-necked intracranial aneurysm using fully retrievable stent appears safe and effective. Further application and evaluation of this technique in more cases with larger size aneurysm is warranted.

Analysis of Complications After Cranioplasty with a Customized Three-Dimensional Titanium Mesh Plate.

OBJECTIVE: To report outcomes of cranioplasty (CP) with a customized three-dimensional (3D) titanium mesh plate and identify the relationship between various clinical variables and complications after CP. METHODS: Twenty patients who underwent surgery with customized 3D titanium mesh plates and had follow-up for >6 months from January 2015 to December 2017 were enrolled. Complications related to CP were retrospectively reviewed. Patients were divided into 2 groups (no complication group and complication group), and clinical variables related to complications were compared between the 2 groups. Correlation analysis was performed to identify the clinical variable significantly correlated with complications after CP with a customized 3D titanium mesh plate. RESULTS: Of 20 patients, 11 developed complications, including extrusion, intracranial infection, severe operative site pain, and wound dehiscence. Among the clinical variables, only the presence of a ventriculoperitoneal shunt was significantly correlated with the overall complication rate (odds ratio = 18.66; 95% confidence interval, 1.56-222.92; P = 0.021). CONCLUSIONS: A customized 3D titanium mesh plate is associated with a lower risk of intracranial infection, but the rate of postoperative complications, mainly cosmetic problems, such as forehead mesh extrusion and dehiscence, was high at 55%. A ventriculoperitoneal shunt was significantly correlated with the overall complication rate after CP with a customized 3D titanium mesh plate.

Defining "early" cranioplasty to achieve lower complication rates of bone flap failure: resorption and infection.

BACKGROUND: Although cranioplasty (CP) is a frequently performed and simple procedure, complications are common, particularly bone flap resorption and infection. The timing of surgery is as an important contributory factor, but the optimal timing has not been clearly determined. OBJECTIVE: We retrospectively investigated bone flap resorption and surgical site infection after CP to determine the optimal timing of surgery for reduction of complications. METHODS: The study enrolled 126 patients who underwent decompressive craniectomy (DC) and subsequent CP. Patients with bone flap resorption or surgical site infection were analyzed as the "complication" group. Receiver operating characteristic curve analysis was performed and the Youden index was used to dichotomize "early CP" and "late CP" groups. Univariate and multivariate survival analyses were performed. RESULTS: The complication group included 42 patients. The Youden index was used to identify a cutoff value for the DC-CP interval of > 44 days, and this was used to define early (< 45 days) and late (≥ 45 days) CP. Late CP was a significant risk factor in univariate and multivariate Cox regression analyses. CONCLUSION: This study showed that early CP before 45 days after DC is associated with a lower rate of bone flap resorption and surgical site infection than late CP.

Aseptic Bone Flap Resorption after Cranioplasty with Autologous Bone: Incidence, Risk Factors, and Clinical Implications.

OBJECTIVES: Aseptic bone flap resorption (ABFR) is a known complication of cranioplasty (CP) with an autologous bone flap. The incidence of ABFR has been reported to be as high as 34.2% in the literature; however, it is underestimated in clinical fields. We retrospectively reviewed 13 years of clinical cases of patients who underwent CP after decompressive craniectomy (DC) to investigate the incidence and risk factors of ABFR. METHODS: Ninety-one patients who underwent DC and CP in Guro Hospital, Korea University Medical Center, were enrolled. ABFR was defined using serial brain computed tomography. To identify possible risk factors for ABFR, univariate and multivariate Cox regression and receiver operating characteristic curve analyses were performed. RESULTS: Of the 91 patients enrolled, ABFR was diagnosed in 32 patients (35.1%). Bone flap size, existence of a shunting system, and the DC-CP interval were significant in the univariate analysis. Bone flap size was statistically significant in the multivariate analysis (P = 0.0189). The cutoff points of the DC-CP interval and bone flap size were 44 days and 110 cm2, respectively. CONCLUSIONS: The incidence of ABFR was remarkably high. Bone flap size, the existence of a shunting system, and the DC-CP interval were shown to be potential risk factors of ABFR after CP.

How to Escape Stentriever Wedging in an Open-cell Carotid Stent during Mechanical Thrombectomy for Tandem Cervical Internal Carotid Artery and Middle Cerebral Artery Occlusion.

We present 2 cases of complicated mechanical thrombectomy involving tandem cervical internal carotid artery and middle cerebral artery occlusion using the Solitaire FR stent and simultaneous carotid stent angioplasty. During the procedures, the Solitaire stents containing the thrombus were wedged into the open-cell carotid stents, which were already deployed for proximal flow restoration. We describe the methods used to avoid and overcome such complications.

An age-dependent alteration of the respiratory exchange ratio in the db/db mouse.

The leptin receptor-deficient db/db mouse is a rodent model of type 2 diabetes and obesity. Diabetes in db/db mice shows an age-dependent progression, with early insulin resistance followed by an insulin secretory defect resulting in profound hyperglycemia. However, there is insufficient data on agedependent changes of energy metabolism in db/db mice. We demonstrated an age-dependent decrease in the respiratory exchange ratio (RER), calculated by a ratio of VO2/VCO2, in db/db mice. The RER determined by indirect calorimetry, was 1.03 in db/db mice under 6 weeks of age, which were similar to those in heterozygote (db/+) and wild-type (+/+) mice. However, RER decreased from approximately 0.9 to 0.8 by 10 weeks of age and subsequently returned to approximately 0.9 at 22 weeks of age. The changes in RER were concurrent with the alterations in body weight and blood glucose level. However, other metabolic indicators such as glucose tolerance, changes in body fat mass, and urinary glucose levels, did not change with age. The results suggested that the energy source utilized in db/db mice changed with the age-related progression of diabetes.

Role of metabolism by intestinal microbiota in pharmacokinetics of oral baicalin.

Baicalin (baicalein-7-glucuronide) is a flavonoid purified from Scutellaria baicalensis Georgi that has traditionally been used for treatment of hypertension, cardiovascular diseases, and viral hepatitis. In this study, the effects of intestinal microbiota on the pharmacokinetics of baicalin were investigated in normal and antibiotic-pretreated rats following p.o. administration of 100 mg/kg baicalin by using liquid chromatography/ion trap mass spectrometry. When rats were pretreated orally with cefadroxil, oxytetracycline and erythromycin for 3 days to control the number of intestinal bacteria, the pharmacokinetic parameters of oral baicalin were significantly affected by antibiotics: Cmax, T1/2(ß), Kel and AUC values were significantly changed compared to those in normal rats. These results indicate that intestinal microbiota might play a key role in the oral pharmacokinetics of baicalin.

Successful obliteration of unclippable large and giant middle cerebral artery aneurysms following extracranial-intracranial bypass and distal clip application.

Large to giant middle cerebral artery aneurysm is a challenging disease, especially when incorporating important perforating arteries. Surgical risk increases by perforator infarction and anatomical complexity. In this clinical setting, extensive consideration of surgical options is needed. The two cases described here were unruptured and had rather stable wall. Because of their large and giant size, hardness and incorporated arteries, it was not affordable to isolate them by means of clipping or trapping. The procedure as the alternative to conventional treatment modalities, extracranial-intracranial bypass followed by clipping of only the efferent artery successfully treated the aneurysms.

Angiographic and clinical outcomes of stent-alone treatment for spontaneous vertebrobasilar dissecting aneurysm.

PURPOSE: Spontaneous vertebrobasilar dissecting aneurysm (VBD) is a very challenging disease with an unpredictable clinical course and controversies on treatment strategy. The present study reports radiological and clinical outcomes of stent-alone treatment (SAT) for VBD. METHODS: Twenty-four VBDs treated with SAT are included in the present study. Clinical and angiographic data were reviewed retrospectively. RESULTS: A total of 24 lesions in 22 patients with a mean follow-up period of 16.21 months were included. Of the 24 individual lesions, 23 were intracranial vertebral artery lesions and 1 lesion was located in the basilar artery. There were six cases of ruptured dissections with the other cases having various symptoms. The immediate post-SAT angiographic outcomes included 5 lesions with good remodeling over 90% recovery and 19 poorly remodeled lesions. The latest angiographic outcomes included 17 cases of good remodeling (remodeling rate over 90%), 6 cases of poor remodeling (remodeling rate below 70%), and 1 case with morphological aggravation. The overlapping stent technique was used in seven cases and it was significantly associated with good angiographic results. None of the rupture cases underwent re-rupture post SAT. There was one case of a symptomatic complication of a femoral arteriovenous fistula. CONCLUSIONS: The SAT could be a feasible alternative for the treatment of VBD. The overlapping technique was significantly associated with good angiographic outcome. We expect that technological development of the intracranial stent will allow better procedural outcomes of SAT.

Computed tomography angiography, perfusion computed tomography, and a drug-eluting stent for the treatment of in-stent restenosis of the middle cerebral artery.

The authors report a case of in-stent restenosis (ISR) of the middle cerebral artery (MCA) following bare-metal stent (BMS) deployment and subsequent treatment using a drug-eluting stent (DES). This 65-year-old woman presented with frequent transient ischemic attacks. Initial studies revealed occlusion of the left internal carotid artery and severe stenosis of the right MCA with decreased cerebral perfusion in the bilateral MCA territories. Stent-assisted angioplasty of the right MCA was performed using a BMS, and satisfactory results were obtained with no complications. Six months after the procedure the patient presented with recurrent symptoms, and workups revealed ISR with decreased cerebral perfusion. A DES was successfully placed without complications. Follow-up studies at 3 and 8 months after retreatment showed sustained luminal integrity and cerebral perfusion. A combination of CT angiography and perfusion CT exhibited the anatomical results and hemodynamic status of the stenotic lesion, and these findings coincided with the patient's clinical symptoms and the results of conventional cerebral angiography. In-stent restenosis of the MCA after placement of a BMS can be treated using a DES. A combination of CT angiography and perfusion CT can be an alternative to conventional angiography. Low-profile devices with an amelioration of trackability are essential for the further incorporation of the DES into the field of endovascular neurosurgery. More clinical experiences and long-term follow-ups are mandatory to evaluate the safety, efficacy, and durability of the DES.