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

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

Standards for Endovascular Neurosurgical Training and Certification of the Society of Korean Endovascular Neurosurgeons 2013

The need for standard endovascular neurosurgical (ENS) training programs and certification in Korea cannot be overlooked due to the increasing number of ENS specialists and the expanding ENS field. The Society of Korean Endovascular Neurosurgeons (SKEN) Certification Committee has prepared training programs and certification since 2010, and the first certificates were issued in 2013. A task force team (TFT) was organized in August 2010 to develop training programs and certification. TFT members researched programs and systems in other countries to develop a program that best suited Korea. After 2 years, a rough draft of the ENS training and certification regulations were prepared, and the standard training program title was decided. The SKEN Certification Committee made an official announcement about the certification program in March 2013. The final certification regulations comprised three major parts: certified endovascular neurosurgeons (EN), certified ENS institutions, and certified ENS training institutions. Applications have been evaluated and the results were announced in June 2013 as follows: 126 members received EN certification and 55 hospitals became ENS-certified institutions. The SKEN has established standard ENS training programs together with a certification system, and it is expected that they will advance the field of ENS to enhance public health and safety in Korea.

The Difference of Each Angiographic Finding After Multiple Stent According to Stent Type in Bilateral Vertebral Artery Dissection

We report a case of spontaneous bilateral intracranial vertebral artery dissecting aneurysms with subarachnoid hemorrhage. One dissecting lesion was treated with a coronary balloon-mounted stent (BMS) technique; however, due to differences in access route tortuosity, the other lesion was treated with a self-expandable stent (SES) technique. After 2 months, the angiographic outcome showed complete healing of the dissected segment on the side that was treated with BMS; in contrast, the dissection lesion appeared to be re-growing on the side that was treated with SES. Complete treatment of the aggravated lesion was achieved by additional deployment of BMSs. Therefore, we have provided a discussion of the possible reasons for this difference in outcome according to the stent type.

The Difference of Each Angiographic Finding After Multiple Stent According to Stent Type in Bilateral Vertebral Artery Dissection

We report a case of spontaneous bilateral intracranial vertebral artery dissecting aneurysms with subarachnoid hemorrhage. One dissecting lesion was treated with a coronary balloon-mounted stent (BMS) technique; however, due to differences in access route tortuosity, the other lesion was treated with a self-expandable stent (SES) technique. After 2 months, the angiographic outcome showed complete healing of the dissected segment on the side that was treated with BMS; in contrast, the dissection lesion appeared to be re-growing on the side that was treated with SES. Complete treatment of the aggravated lesion was achieved by additional deployment of BMSs. Therefore, we have provided a discussion of the possible reasons for this difference in outcome according to the stent type.

Endovascular Treatment of Blood Blister-Like Aneurysms Using Multiple Self-Expanding Stents

The surgical as well as endovascular treatment of blood-blister-like aneursysms (BBAs) is extremely difficult because of these pathological natures, such as small and the fragile necks. The optimal treatment of BBAs has remained uncertain. Stents are known to divert blood flow and induce thrombosis of intracranial aneurysms. We report 3 cases of successful obliteration of BBAs after multiple stents placement.

Changes in Bypass Flow during Temporary Occlusion of Unused Branch of Superficial Temporal Artery

OBJECTIVE: Some neurosurgeons intentionally ligate the branches of the superficial temporal artery (STA) that are not used in standard STA-to-middle cerebral artery (MCA) anastomosis for the purpose of improving the flow rate in the bypass graft. We investigated changes in bypass flow during temporary occlusion of such unused branches of the STA. METHODS: Bypass blood flow was measured by a quantitative microvascular ultrasonic flow probe before and after temporary occlusion of branches of the STA that were not used for anastomosis. We performed measurements on twelve subjects and statistically assessed changes in flow. We also examined all the patients with digital subtraction angiography in order to observe any post-operative changes in STA diameter. RESULTS: Initial STA flow ranged from 15 mL/min to 85 mL/min, and the flow did not change significantly during occlusion as compared with pre-occlusion flow. The occlusion time was extended by 30 minutes in all cases, but this did not contribute to any significant flow change. CONCLUSION: The amount of bypass flow in the STA seems to be influenced not by donor vessel status but by recipient vessel demand. Ligation of the unused STA branch after completion of anastomosis does not contribute to improvement in bypass flow immediately after surgery, and furthermore, carries some risk of skin necrosis. It is better to leave the unused branch of the STA intact for use in secondary operation and to prevent donor vessel occlusion.

Is Transradial Cerebral Angiography Feasible and Safe? A Single Center's Experience

OBJECTIVE: Although a transradial angiography is accepted as the gold standard for cardiovascular procedures, cerebral angiography has been performed via transfemoral approach in most institutions. The purpose of this study is to present our experience concerning the feasibility, efficacy, and safety of a transradial approach to cerebral angiography as an alternative to a transfemoral approach. METHODS: Between February 2007 and October 2009, a total of 1,240 cerebral angiographies were performed via a transradial approach in a single center. The right radial approach was used as an initial access route. The procedure continued only after the ulnar artery was proven to provide satisfactory collateral perfusion according to two tests (a modified Allen's test and forearm angiography). RESULTS: The procedural success rate was 94.8% with a mean duration of 28 minutes. All supra-aortic vessels were successfully catheterized with a success rate of 100%. The success rates of selective catheterization to the right vertebral artery, right internal carotid artery, left internal carotid artery, and left vertebral artery were 96.1%, 98.6%, 82.6% and 52.2%, respectively. The procedure was performed more than twice in 73 patients (5.9%), including up to 4 times in 2 patients. The radial artery occlusion was found in 4 patients (5.4%) on follow-up cerebral angiography, but no ischemic symptoms were observed in any of the cases. CONCLUSION: This study suggests that cerebral angiography using a transradial approach can be performed with minimal risk of morbidity. In particular, this procedure might be useful for follow-up angiographies and place less stress on patients.

The Expansion of Cervical Synovial Cyst after Trauma : A Case Report and Literature Review

We report a rare case that showed aggravation of neurological symptoms due to expansion of the synovial cyst at C7/T1 after several month of trauma and present the consideration of proper prevention and management. A 64-year old male was admitted by right arm weakness(GIV+) after a pedestrian traffic accident. According to computed tomography(CT) scan and electromyography(EMG), a brachial plexus injury was diagnosed and he was treated conservatively. After 7 months, he was re-admitted by the left side weakness(GIV-) with severe pain and magnetic resonance image(MRI) revealed the expanded cystic lesion at C7/T1 level which compressed the cord from left side. After administration of steroid, surgical resection was performed via posterior approach and partial laminectomy. The dural expansion was observed after total removal of cyst which was diagnosed as a pathologist and symptoms were completely recovered. Because of its possibility of expansion of the synovial cyst and critical myelopathic symptoms can be induced in cervical spine, immobilization should be in consideration for acute period of post-trauma, especially, in old-aged patients with degenerative facet joints. And surgical procedure should not be delayed if symptoms developed.

Delayed Carotid Wallstent Shortening Resulting in Restenosis Following Successful Carotid Artery Angioplasty and Stenting

Carotid angioplasty and stenting (CAS) for carotid stenosis has been increasingly used as an alternative treatment in patients not eligible for surgery. Even though CAS can be performed relatively simply in many cases, various complications can occur. We report four cases of CAS using the Carotid Wallstent, which were complicated by delayed shortening of the stent, resulting in restenosis after successful CAS.

Minimally Invasive and Tailored Surgical Approach to the Anterior Circulation Aneurysms / 대한뇌혈관외과학회지

OBJECTIVES: Supraorbital route through eyebrow incision, mini-pterional craniotomy, and midline interhemispheric route are most generally used methods for key hole surgery on anterior circulation aneurysm. Surgical route is determined according to aneurysm architecture and patient status. The approaching route can be selected according to the findings of 3-dimensional computed tomography (CT) angiography simulation. Prospective decision-making protocol, surgical technique of key hole surgery, and the results are presented in this paper. METHODS: 173 patients with anterior circulation aneurysms were treated by direct surgical neck clipping during last two years. Twenty patients of poor grade (Hunt-Hess grade IV,V) were treated by craniectomy with clipping. Decision making protocol was applied to 153 unruptured and good grade ruptured aneurysm patients. Simulation of key hole surgery was conducted by CT work station using conventional software InSpace (Siemens, Germany), and direction and shape of aneurysm was observed from the perspective of microsurgery. RESULTS: 113 ruptured and 40 unruptured aneurysms were secured through one of the three approaching routes. Supraorbital approach had been performed in 82 cases (unruptured 24, ruptured 58) while 64 cases were treated by mini-pterional craniotomy. Midline key hole surgery were carried out in seven distal anterior circulation aneurysms (DACA) using brain navigation system. After locating the aneurysm, supraorbital approach was applied to 46 cases involving anterior cerebral artery (ACA), 16 in internal carotid artery (ICA) and 20 in middle cerebral artery (MCA). Mini-pterional craniotomy was carried out in aneurysms located in ACA (9), ICA (18), and MCA (37). In most cases, the results of clipping were good. The average follow-up time was 16.7months (ranging 2 to 32months) and the results were cosmetically excellent. CONCLUSION: Simulating surgical approaches with 3-D CT angiography is a highly useful method for determining various surgical routes in anterior circulation aneurysm treatment. Therefore, minimally invasive and tailored surgical approaches are recommended since optimal route can be found through simulation. Thus, minimal invasive and tailored surgical approach is available through this method. These procedures have clear advantages; shorter surgical time and hospital stay, less operative trauma, reduced costs and less pain, and better cosmetic outcomes compared to standard craniotomy. Optimal surgical results are expected from minimally invasive and tailored surgical craniotomy.