Treatment Results of Carotid Artery Stenting with an Open-Cell Stent: Analysis of 734 Consecutive Cases at a Single Center.

OBJECTIVE: In carotid artery stenting (CAS) for internal carotid artery stenosis, the stent is often selected according to the plaque properties and arterial tortuosity. In our institute, an open-cell stent is used as the first-line stent regardless of the characteristics of the lesion. This study was performed to examine the outcome of CAS with an open-cell stent as the real-world results. METHODS: In total, 811 CAS procedures using open-cell stents were performed for internal carotid artery stenosis from April 2002 to December 2019. Of these patients, we excluded those with hyperacute conditions for which CAS was performed within 3 days of onset, those in whom acute mechanical thrombectomy was performed simultaneously with CAS, and those with stenosis due to arterial dissection. Thus, 734 patients were retrospectively analyzed. Perioperative and long-term outcomes and risk factors for perioperative infarction were investigated. RESULTS: The periprocedural stroke rate and mortality rate were 3.7% (27/734) and 0.4% (3/734), respectively. Low-echoic plaque was a significant risk factor for periprocedural stroke in both univariate (P < 0.03) and multivariate (odds ratio, 2.69; 95% confidence interval, 1.14-6.66; P = 0.02) analyses. Cerebral infarction and high grade restenosis were observed in 15 (2.0%) and 17 (2.3%) patients during a median 50-month follow-up. CONCLUSIONS: CAS with open-cell stents showed good results in terms of both the postoperative stroke incidence and long-term severe restenosis rate. However, low-echoic plaque was a risk factor for perioperative stroke incidence, which should be considered when deciding on the indication for CAS with an open-cell stent.

Incidence and Outcomes of Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Registry-based Descriptive Trial in Kobe City.

The current study aims to evaluate the incidence and results of aneurysmal subarachnoid hemorrhage (aSAH) throughout Kobe City. Based on a multicenter retrospective registry-based descriptive trial involving all 13 primary stroke centers in Kobe City, patients with aSAH treated between October 2017 and September 2019 were studied. A total of 334 patients were included, with an estimated age-adjusted incidence of 11.12 per 100,000 person-years. Curative treatment was given to 94% of patients, with endovascular treatment (51%) preferred over surgical treatment (43%). Of the patients, 12% were treated by shunt surgery for sequential hydrocephalus with a worse outcome at 30 days or discharge (14% vs. 46%, odds ratio (OR): 0.19, 95% confidence interval (CI): 0.088-0.39, p-value <0.001). As for vasospasm and delayed cerebral ischemia, most patients were given intravenous fasudil infusion (73%), with endovascular treatment for vasospasm in 24 cases (7.2%). The fasudil group had more good outcomes (42% vs. 30%, OR: 1.64, 95% CI: 0.95-2.87, p-value = 0.075) and significantly less death (3.3% vs. 35%, OR: 0.064, 95% CI: 0.024-0.15, p-value <0.001) at 30 days or discharge. Mortality rose from 12% at 30 days or discharge to 17% at 1 year, but neurological function distribution improved over time (modified Rankin Scale 0-2 was 39% at 30 days or discharge, 53% at 60 days, and 63% at 1 year). Our retrospective registered trial presented various statistics on aSAH, summarizing the current treatment status and prognosis.

Cerebral hyperperfusion syndrome after stenting for revascularization of intracranial internal carotid artery dissection.

Cerebral hyperperfusion syndrome (CHS) is one of the complications of cerebral revascularization. The main pathophysiology of CHS was considered to be cerebral autoregulation impairment due to long-standing cerebral hypoperfusion. Herein, we describe the case of a 40-year-old man with symptomatic intracranial arterial dissection (IAD) related to internal carotid artery stenosis. The patient underwent intracranial stenting 11 days after onset due to severe cerebral hypoperfusion presenting with neurological symptoms, and CHS presenting with intracerebral hemorrhage, post-operatively. The present case indicated not only the potential risk of CHS after intracranial stenting in IAD-related stenosis but also that cerebral hypoperfusion-even in a short period-might lead to CHS.

Comparison of Symptomatic Vasospasm after Surgical Clipping and Endovascular Coiling.

Vasospasm, initial neurological damage, rebleeding, and periprocedural complications are associated prognostic factors for clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH). In this study, factors related to delayed ischemic neurological deficit (DIND) are evaluated using data from our institute for the last 18 years. Data from 2001 to 2018 of patients with aneurysmal SAH who underwent surgical clipping (SC) or endovascular coiling (EC) within 7 days of onset were retrospectively analyzed. Cases of mortality within 5 days after treatment were excluded. Multivariate analysis was used to identify the risk factors for DIND. In total, 840 cases of SAH were assessed; among these cases, 384 (45.7%) and 456 (54.3%) were treated with SC and EC, respectively. The frequency of DIND in the EC group was significantly less than that in the SC group (11.8% vs. 17.7%; p = 0.016). In the results of multivariate analysis, internal carotid artery (ICA) aneurysm and hemorrhagic complications were the risk factors for DIND. Cilostazol administration and EC were significant factors for vasospasm prevention after aneurysmal SAH (odds ratio of ICA aneurysm: 1.59, hemorrhagic complications: 1.76, SC: 1.51, and cilostazol administration: 0.51, respectively). Cilostazol administration was also a significant factor in patients who were treated with EC. ICA aneurysm, treatment strategy, hemorrhagic complications, and cilostazol administration were associated with DIND. Oral administration of cilostazol and avoiding hemorrhagic complications were effective in DIND prevention. If both treatments are available for ruptured aneurysms, clinicians should choose EC on the basis of its ability to prevent DIND.

A Damp-and-Push Technique for the Copolymer (Onyx) Embolization of Dural Arteriovenous Fistula.

BACKGROUND: Copolymer (Onyx) embolization is an effective treatment for dural arteriovenous fistula (dAVF), however, some dAVFs have multiple, high-flow feeding vessels, resulting in insufficient embolization. For the treatment of such patients, we have developed a novel flow-control technique, the 'damp-and-push technique'. The purpose of this study was to evaluate the technical efficiency and safety of this technique. METHODS: Seven patients who had been diagnosed with intracranial dAVF were treated by transarterial Onyx embolization using the damp-and-push technique between 2016 and 2019. This technique was designed to reduce blood flow to the shunt site using a balloon catheter in the major feeding vessel other than the one injected with Onyx, leading to better Onyx penetration and enabling more controlled embolization of complex dAVFs. Retrospectively collected data were reviewed to assess the occlusion rates and clinical outcomes. RESULTS: The dAVF was at a transverse sinus-sigmoid sinus junction in four patients, in the superior sagittal sinus in two, and in the tentorium in one. Five cases were Cognard type Ⅱb and two cases were Cognard type Ⅳ. All the patients were treated by transarterial Onyx injection via the main feeding vessel, combined with flow reduction in the other main feeding vessel using a balloon catheter. Complete occlusion was achieved in six patients and elimination of cerebral venous reflux was achieved in all the patients. There were no immediate or delayed post-interventional complications. CONCLUSIONS: Transarterial Onyx embolization of dAVF using the damp-and-push technique is safe and yields a high complete occlusion rate.

Candidate drugs for preventive treatment of unruptured intracranial aneurysms: A cross-sectional study.

BACKGROUND AND PURPOSE: Establishment of drug therapy to prevent rupture of unruptured intracranial aneurysms (IAs) is needed. Previous human and animal studies have gradually clarified candidate drugs for preventive treatment of IA rupture. However, because most of these candidates belong to classes of drugs frequently co-administered to prevent cardiovascular diseases, epidemiological studies evaluating these drugs simultaneously should be performed. Furthermore, because drugs included in the same class may have different effects in terms of disease prevention, drug-by-drug assessments are important for planning intervention trials. MATERIALS AND METHODS: We performed a cross-sectional study enrolling patients diagnosed with IAs between July 2011 and June 2019 at our institution. Patients were divided into ruptured or unruptured groups. The drugs investigated were selected according to evidence suggested by either human or animal studies. Univariate and multivariate logistic regression analyses were performed to assess the association of drug treatment with rupture status. We also performed drug-by-drug assessments of the association, including dose-response relationships, with rupture status. RESULTS: In total, 310 patients with ruptured and 887 patients with unruptured IAs were included. Multivariate analysis revealed an inverse association of statins (odds ratio (OR), 0.54; 95% confidence interval (CI) 0.38-0.77), calcium channel blockers (OR, 0.41; 95% CI 0.30-0.58), and angiotensin II receptor blockers (ARBs) (OR, 0.67; 95% CI 0.48-0.93) with ruptured IAs. Moreover, inverse dose-response relationships with rupture status were observed for pitavastatin and rosuvastatin among statins, benidipine, cilnidipine, and amlodipine among calcium channel blockers, and valsartan, azilsartan, candesartan, and olmesartan among ARBs. Only non-aspirin non-steroidal anti-inflammatory drugs were positively associated with ruptured IAs (OR, 3.24; 95% CI 1.71-6.13). CONCLUSIONS: The present analysis suggests that several types of statins, calcium channel blockers, and ARBs are candidate drugs for preventive treatment of unruptured IAs.

Initial Results of Percutaneous Transluminal Angioplasty/Stenting for Vertebrobasilar Occlusion due to Atherothrombotic Disease during Acute Phase.

Objective: The efficacy and safety of acute percutaneous transluminal angioplasty or stenting (PTA/PTAS) for vertebrobasilar artery occlusion with atherothrombotic brain infarction (ATBI) have not been confirmed despite the resistance to medical therapy alone. There are few reports about this disease and its treatment. Therefore, the treatment outcomes at our hospital were summarized to evaluate the efficacy and safety. Methods: This was a retrospective study of acute PTA/PTAS for vertebrobasilar artery occlusion due to atherosclerotic change in 19 consecutive patients with a modified Rankin Scale (mRS) score of 0-2 before stroke between March 2010 and December 2018. The factors related to prognosis were investigated. Outcomes were assessed at 90 days of follow-up. Results: Of 19 patients with acute vertebrobasilar artery occlusion treated by PTA/PTAS, 8 had good outcomes (mRS 0-2) and 11 had poor outcomes (mRS 3-6). There were no differences in the clinical or patient background except for the National Institutes of Health Stroke Scale (NIHSS) score between groups. The good outcome group had a lower NIHSS score than the poor outcome group (median: 9.5 vs 35, p <0.001). The Thrombolysis in Cerebral Ischemia (TICI) 2b-3 group had a slightly more favorable outcome than the TICI0-2a group (p = 0.10). There were no differences in outcome between PTA and PTAS groups (p = 0.65). Conclusion: Reperfusion of the posterior circulation by PTA/PTAS may be necessary for a good outcome. Although acute stenting must be performed under careful observation, a stent can be placed when recurrence in the early phase is estimated with high probability.

Stroke Systems of Care During the COVID-19 Epidemic in Kobe City.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) outbreak raised concerns over healthcare systems' ability to provide suitable care to stroke patients. In the present study, we examined the provision of stroke care in Kobe City during the COVID-19 epidemic, where some major stroke centers ceased to provide emergency care. METHODS: This was a cross-sectional study. The Kobe Stroke Network surveyed the number of stroke patients admitted to all primary stroke centers (PSCs) in the city between March 1 and May 23, 2020, and between March 3 and May 25, 2019. In addition, online meetings between all PSC directors were held regularly to share information. The survey items included emergency response system characteristics, number of patients with stroke hospitalized within 7 days of onset, administered treatment types (IV rt-PA, mechanical thrombectomy, surgery, and endovascular therapy), and stroke patients with confirmed COVID-19. RESULTS: During the period of interest in 2020, the number of stroke patients hospitalized across 13 PSCs was 813, which was 15.5% lower than that during the same period of 2019 (p = 0.285). The number of patients admitted with cerebral infarction, intracerebral hemorrhage, and subarachnoid hemorrhage decreased by 15.4% (p = 0.245), 16.1% (p = 0.659), and 14.0% (p = 0.715), respectively. However, the rates of mechanical thrombectomy and surgery for intracerebral hemorrhage were slightly increased by 12.1% (p = 0.754) and 5.0% (p = 0.538), respectively. PSCs that ceased to provide emergency care reported a decrease in the number of stroke cases of 65.7% compared with the same period in 2019, while other PSCs reported an increase of 0.8%. No case of a patient with stroke and confirmed COVID-19 was reported during the study period. CONCLUSION: Kobe City was able to maintain operation of its stroke care systems thanks to close cooperation among all city PSCs and a temporal decrease in the total number of stroke cases.

Carotid artery stenting before surgery for carotid artery occlusion associated with acute type A aortic dissection: Two case reports.

BACKGROUND: We experienced two cases of ischemic stroke resulting from carotid artery occlusion associated with acute type A aortic dissection (ATAAD), in which carotid artery stenting before the surgery for ATAAD resulted in good clinical outcomes.Case 1 description: A 63-year-old woman was hospitalized for conscious disturbance, right hemiparesis, and total aphasia. Computed tomography of the head showed no abnormal findings. Computed tomography angiography showed ATAAD and bilateral common carotid artery occlusion. Surgery was not indicated for ATAAD because of a poor prognosis of ischemic stroke. However, carotid artery stenting of the left common carotid artery occlusion was successfully performed, and her neurological findings improved. The patient underwent hemiarch replacement for ATAAD on the day after carotid artery stenting. Her final modified Rankin Scale was 1. Case 2 Description: A 57-year-old woman was hospitalized for mild left hemiparesis. Magnetic resonance imaging showed right watershed infarction and right common carotid artery occlusion. Computed tomography angiography showed ATAAD. After hospitalization, conscious disturbance appeared and left hemiparesis worsened. Ischemic stroke indicated a poor prognosis for revascularization by surgery for ATAAD. Thus, carotid artery stenting of the right common carotid artery occlusion was performed. The patient's neurological findings improved and she underwent hemiarch replacement for ATAAD at 19 days after carotid artery stenting. Her final modified Rankin Scale was 1. CONCLUSIONS: In the present cases, although ischemic stroke was serious and precluded surgical indication for ATAAD, carotid artery stenting before surgery for ATAAD resulted in good clinical outcomes. Performing carotid artery stenting before surgery for ATAAD is challenging but achievable, and is a valid treatment option depending on the individual cases.

Outcomes of Endovascular Therapy versus Microsurgical Treatment for Aneurysmal Subarachnoid Hemorrhage in Patients ≥70 Years of Age.

Purpose: This retrospective research aimed to compare the efficacy of endovascular therapy (EVT) versus microsurgical treatment (MST) for elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods: Elderly (>70 years) patients with aSAH who underwent aneurysm obliteration during 2007-2017 were selected from our hospital database and enrolled in this retrospective study. We reviewed each patient's background, the severity of the aSAH, and aneurysmal characteristics that compelled EVT or microsurgery treatment and then compared the two treatment groups. A favorable primary outcome was defined by a modified Rankin scale (mRS) score of 0-3 at hospital discharge. The 78 patients formed two cohorts (39 patients each) based on their propensity scores for EVT or MST. We estimated the adjusted odds ratio, followed by a sensitivity analysis of the original 201 patients (118 with EVT and 83 with MST). Results: In the propensity score-matched cohorts, favorable outcomes were observed in 33.3% and 7.7% of patients in the EVT and MST groups, respectively (p = 0.01). Results of the sensitivity analysis were similar to the main results. Conclusion: The clinical outcomes for the elderly aSAH patients were better in the EVT group than in MST group.

A Case of Subarachnoid Hemorrhage with Dissecting Aneurysm of the Anterior Choroidal Artery.

Objective: Dissecting aneurysms of the anterior choroidal artery (AchoA) are extremely rare, with only a few reported cases. Herein, we report an extremely rare case of subarachnoid hemorrhage with dissecting aneurysm of the AchoA. Case Presentation: A 68-year-old man was hospitalized for sudden onset of headache, progressive consciousness disorder, and right hemiparesis. He had a prior medical history of systemic lupus erythematosus (SLE), and was taking prednisolone (50 mg/day) for 15 months. CT showed subarachnoid hemorrhage in the left side of the basal cistern and Sylvian fissure. Left internal carotid artery (ICA) angiography revealed a fusiform aneurysm of the AchoA. He was diagnosed with a ruptured dissecting aneurysm of the AchoA because the shape of aneurysm was fusiform and there was laminar flow inside the aneurysm. Parent artery occlusion (PAO) was performed to prevent re-hemorrhage on the day of onset. Although ventricular drainage for acute hydrocephalus was performed after AchoA occlusion, his consciousness disorder did not improve. Postoperative angiography at 1-week recovery from the procedure revealed disappearance of the AchoA, including the dissecting aneurysm. However, he died following septic shock caused by pneumonia at 1 month after the procedure. Conclusion: We report an extremely rare case of subarachnoid hemorrhage with a dissecting aneurysm of the AchoA. Vasculitis caused by SLE and a vulnerability of the vessel wall following chronic steroid use are potential causes of the dissecting aneurysm of the AchoA.

Safety and efficacy of an open-cell stent and double-balloon protection for unstable plaques: analysis of 184 consecutive carotid artery stentings.

INTRODUCTION: In our institute, most cases of carotid artery stenosis are treated by carotid artery stenting (CAS) with an open-cell stent and double-balloon protection, even if plaques are unstable. This study was performed to examine the outcome of CAS with an open-cell stent and double-balloon protection for unstable plaques. METHODS: A total of 184 CAS procedures in our institute between October 2010 and February 2018 were assessed. Ultrasonography findings of low-echo plaques, plaque ulceration, or both were defined as unstable plaques. A plaque-to-muscle ratio (PMR) of >1.8 on T1-weighted black blood imaging using spin-echo was also defined as an unstable plaque. Seventy-four unstable plaques on ultrasonography and 86 unstable plaques evaluated by PMR were included. Open-cell stents and double-balloon protection (proximal balloon protection during lesion crossing and distal balloon protection after lesion crossing) were used in all cases. RESULTS: On ultrasonography, perioperative asymptomatic thromboembolization was significantly more frequent in the unstable plaque group (39/74, 52.7%) than in the stable plaque group (41/110, 37.3%, p=0.0384). Asymptomatic thromboembolization was also significantly more frequent in the PMR >1.8 group (44/86, 51.2%) than in the PMR <1.8 group (36/98, 36.7%, p=0.0489). However, symptomatic thromboembolization was rare (n=5, 2.7%), and all of these patients had minor stroke. During the 4-year follow-up, the risk of ipsilateral stroke was 0.28% and 0.27% per year in patients with symptomatic and asymptomatic lesions, respectively. CONCLUSIONS: The outcomes of CAS with an open-cell stent and double-balloon protection are acceptable. This method is effective and safe, even if carotid artery stenosis comprises unstable plaques.

[Treatment Strategies for Unruptured Multiple Intracranial Aneurysms].

OBJECTIVE: Unruptured aneurysms are often discovered incidentally on MRI. In some patients, multiple aneurysms cannot be treated with only craniotomy or endovascular surgery. When both craniotomy and endovascular surgery are deemed necessary, craniotomy is generally performed first because of the use of antiplatelet agents involved, followed by endovascular surgery several months later. However, no clear criteria for this treatment policy have been elicited. We investigated therapeutic outcomes in patients with aneurysms treated by craniotomy followed by endovascular surgery at our hospital. PATIENTS AND METHODS: This was a retrospective study including patients undergoing craniotomy clipping of one or more unruptured aneurysms at one site and endovascular surgery for those at a different site, between January 2012 and May 2018 in our hospital. The types of treatment, interval between treatments, complications, and other factors were analyzed. RESULTS: This study included 22 patients who underwent a total of 25 craniotomies and 23 endovascular surgeries. The mean time from final craniotomy to initial endovascular surgery was 118 days. Although treatment-related complications occurred in three patients, they were not associated with the time interval between craniotomy and endovascular surgery or the timing of the start of the antiplatelet therapy. CONCLUSIONS: The treatment was successful and was carried out safely and appropriately by first performing the craniotomy, followed by a set interval of time before starting the antiplatelet therapy, and then performing the endovascular surgery. Further studies analyzing more cases are required to establish the criteria better, such as the appropriate interval time between treatments.

Effect of Direct Neurologic Evaluation on Outcomes During Treatment of Unruptured Intracranial Aneurysms Under Local Anesthesia.

OBJECTIVE: The greatest advantage of local anesthesia (LA) in endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is that direct neurologic evaluation can be performed during the procedure, unlike with general anesthesia. However, the usefulness of such direct evaluation has not been established. In this study, we attempted to assess the effects of direct neurologic evaluation by identifying the causes, management, and outcomes of clinical symptoms during the procedure and procedure-related events during EVT under LA. METHODS: We retrospectively evaluated the medical and radiologic data of 1000 patients (1015 UIAs) who had undergone coil embolization under LA from 2008 to 2016. RESULTS: Clinical symptoms were identified in 62 patients (6.2%) during the procedure. The symptoms improved during the procedure in 27 of these patients (44%) and after the procedure in another 28 (45%). One month after the procedure, 55 patients (89%) had good outcomes and 7 (11%) had poor outcomes. Procedure-related events occurred in 67 patients (6.7%); of these 67 events, 39 were symptomatic and 28 were asymptomatic. Thirty-five of the 39 symptomatic events (90%) [13 of 13 (100%) ruptures, 6 of 10 (60%) thrombus formations, and 16 of 16 (100%) thromboembolisms] were detected on the basis of clinical symptoms before angiographic changes were identified, and they were managed promptly. All 28 patients with asymptomatic events were managed safely without further complications before symptoms developed. CONCLUSIONS: We demonstrated that appropriate management of clinical symptoms and procedure-related events under LA led to favorable outcomes of EVT of UIAs.

PulseRider-Assisted Coil Embolization for Treatment of Intracranial Bifurcation Aneurysms: A Single-Center Case Series with 24-Month Follow-up.

BACKGROUND: Although endovascular coiling of unruptured aneurysms is widely accepted, the endovascular treatment of wide-neck bifurcation aneurysms remains one of the most challenging morphologies. Our purpose was to describe our experience with 24-month follow-up for the treatment of unruptured intracranial bifurcation aneurysms using the PulseRider (Cerenovus, New Brunswick, NJ). METHODS: This study is a single-center, single-arm registry performed under institutional review board control to evaluate efficacy and safety of the PulseRider. Patients with bifurcation aneurysms were identified and enrolled prospectively. Angiography immediately after treatment and at 6 months, and magnetic resonance imaging and magnetic resonance angiography at 12- and 24-month follow-up were retrospectively analyzed. A modified Rankin score was obtained prior to procedure, at discharge, and at 6-, 12- and 24-month follow-up visits. RESULTS: Eight patients with a mean age of 66 years were treated with the PulseRider. All patients had bifurcation aneurysms (2 anterior communicating, 2 carotid terminus, and 4 basilar apex). The aneurysm diameters ranged from 4.6 to 13.6 mm (mean 7.4 mm) with dome/neck ratio ranging from 1.4 to 2.2 (mean 1.6). In all cases, the PulseRider was successfully deployed. Complete occlusion was demonstrated at 6-month follow-up on 6 of 8 (75%), near complete occlusion in 1 of 8 (12.5%), and residual aneurysm in 1 of 8 (12.5%) patients. There was no change or recurrence on magnetic resonance angiography, nor clinical complication after the procedure through 24-month follow-up. CONCLUSIONS: Our experience with 24-month follow-up demonstrated favorable efficacy in the treatment of intracranial wide-neck bifurcation aneurysms using the PulseRider.

Successful Reperfusion with Endovascular Therapy Has Beneficial Effects on Long-Term Outcome Beyond 90 Days.

BACKGROUND AND PURPOSE: Recent studies have demonstrated that endovascular reperfusion therapy improves clinical outcomes at 90 days after ischemic stroke. However, the effects on long-term outcomes are not well known. We hypothesized that successful reperfusion might be associated with long-term improvement beyond 90 days after endovascular therapy. To assess the long-term effects beyond 90 days, we analyzed the association of successful reperfusion with a temporal change in modified Rankin Scale (mRS) score from 90 days to 1 year after endovascular therapy. METHODS: We retrospectively analyzed a database of consecutive patients with acute ischemic stroke who received endovascular therapy between April 2006 and March 2016 at 4 centers. We compared the incidences of improvement and deterioration in patients with successful reperfusion (i.e., modified thrombolysis in cerebral infarction score of 2b or 3) with those in patients with unsuccessful reperfusion. We defined improvement and deterioration as decrease and increase on the mRS score by 1 point or more from 90 days to 1 year after endovascular therapy respectively. RESULTS: A total of 268 patients were included in the current study. The rate of patients with improvement tended to be higher in patients with successful reperfusion than in patients with unsuccessful reperfusion (20% [34/167 patients] vs. 12% [12/101], p = 0.07). The rate of patients with deterioration was lower in patients with successful reperfusion than in patients with unsuccessful reperfusion (25% [42/167] vs. 42% [42/101], p < 0.01). After adjustment for confounders, successful reperfusion was associated with improvement (adjusted OR 2.65; 95% CI 1.23-5.73; p < 0.05) and deterioration (adjusted OR 0.33; 95% CI 0.18-0.62; p < 0.01), independent of the 90-day mRS score. CONCLUSIONS: Successful reperfusion has further beneficial legacy effects on long-term outcomes beyond 90 days after stroke.

Progressive thrombosis of unruptured aneurysms after coil embolization: analysis of 255 consecutive aneurysms.

INTRODUCTION: We have observed that aneurysms treated by insufficient coil embolization and filled with contrast agent immediately after the procedure are often completely occluded at follow-up. However, there are limited studies showing progressive thrombosis of aneurysms after coil embolization. Herein, we describe our experience with coil embolization for aneurysms, and discuss the factors involved in progressive thrombosis. METHODS: A total of 255 aneurysms treated by coil embolization in our institute between January 2011 and June 2017 and observed >6 months were included. 'Progressive thrombosis' indicated that aneurysms that were neck remnant (NR) or dome filling (DF) immediately after coil embolization changed to complete obliteration (CO) at the 6-month follow-up digital subtraction angiography. The factors involved in progressive thrombosis were assessed. RESULTS: In all aneurysms (n=255), 24 (9.4%) were CO, 82 (32.2%) were NR, and 149 (58.4%) were DF immediately after the procedure. At 6-month digital subtraction angiography, 123 (48.2%) were CO, 95 (37.3%) were NR, and 37 (14.5%) were DF. Retreatment for major recanalization was performed in eight cases (3.1%). One hundred and three aneurysms showed progressive thrombosis. There were significant differences in aneurysm location (P=0.0002), aneurysm dome diameter (P=0.0015), aneurysm neck diameter (P=0.0068), volume embolization ratio (P=0.0054), and endovascular procedure with stent (P=0.0264) between the progressive thrombosis and no thrombosis groups. CONCLUSIONS: Progressive thrombosis can occur in aneurysms after coil embolization depending on aneurysm location and size, and stent use. Thus, the degree of coil embolization and combination with a stent should be adjusted depending on aneurysm type.

Effect of Straightening the Parent Vessels in Stent-Assisted Coil Embolization for Anterior Communicating Artery Aneurysms.

BACKGROUND: Stent-assisted coil embolization (SAC) for treating anterior communicating artery (AcomA) aneurysms is safe and effective. Straightening of parent vessels by stent placement can lead to progressive thrombosis. We describe our experience with SAC for AcomA aneurysms and demonstrate the effect of straightening the parent vessels. METHODS: A total of 26 patients with AcomA aneurysms were treated using SAC in our institute between July 2010 and December 2017. Follow-up digital subtraction angiography was performed 6 months after treatment, magnetic resonance angiography was performed every year, and outcomes were analyzed. RESULTS: From all aneurysms (n = 24), 12 (50.0%) were neck remnant, and 12 (50.0%) were dome-filling types immediately after the procedure. At the 6-month digital subtraction angiography follow-up (n = 22), 13 (59.1%) aneurysms were complete obliteration, 8 (36.4%) were neck remnant, and 1 (4.5%) was dome filling. The median parent vessel angle was measured preoperatively at 98.1°, increased to 124.8° immediately after stent deployment, and further increased to 149.6° at the 6-month follow-up. Progressive thrombosis was observed in 13 of 22 (59.1%) aneurysms. The parent vessel angle change immediately after stent deployment in the progressive thrombosis group tended to be larger than that observed in the no thrombosis group; this change was significant at the 6-month follow-up. The median follow-up term was 18 months. No patients required retreatment. CONCLUSIONS: Good SAC outcomes were achieved for AcomA aneurysms, and hemodynamic changes related to straightening of the parent vessels is a consideration in SAC.

First-in-man experience of the Versi Retriever in acute ischemic stroke.

OBJECTIVE: To describe our initial experience with the Versi Retriever for mechanical thrombectomy in patients with acute ischemic stroke. METHODS: This study is a single-center, single-arm, first-in-man registry under institutional review board control to evaluate the efficacy and safety of the new stent retriever, the Versi Retriever. Patients with acute ischemic stroke were consecutively enrolled between September and November 2017. The clinical and procedural data were retrospectively analyzed. The angiographic result after the procedure was self-graded based on the Thrombolysis in Cerebral Infarction (TICI) scale by each operator. RESULTS: Eleven patients with a mean age of 69.4 years were treated with the Versi Retriever. Median National Institutes of Health Stroke Scale score on admission was 16 (IQR 10-34). The occluded vessel was located in the anterior circulation in 81.8%. Revascularization rates of TICI 2b-3 and TICI 3 at final angiogram were achieved in 100% and 63.6%, respectively. A favorable functional outcome (modified Rankin Scale 0-2) at 90 days was obtained in 72.7%. No symptomatic intracranial hemorrhage occurred and no procedure-related complication was observed. CONCLUSIONS: Our initial experience suggests that the Versi Retriever is a safe and effective stent retriever for mechanical thrombectomy in patients with acute ischemic stroke. CLINICAL TRIAL REGISTRATION: NCT03366818.

Comparison of practical methods in clinical sites for estimating cerebral blood flow during balloon test occlusion.

OBJECTIVE: The authors sought to compare methods of measurement for venous phase delay (VPD) or mean stump pressure (MSTP) to rank their potential to predict ischemic tolerance during balloon test occlusion in the internal carotid artery, exploring a more correlative and convenient way to measure cerebral blood flow (CBF) that could be utilized even in the acute phase or in institutions not adequately equipped to measure CBF during the test. METHODS: X-ray angiography perfusion analysis using diagnostic digital subtraction angiography (DSA) equipment enables 1-step examination (without any room-to-room transfer of patients) to measure CBF, VPD, and MSTP completely simultaneously, which has not been accomplished by any previous perfusion studies. RESULTS: This analysis was applied to 17 patients and resulted in successful estimation of all 3 parameters in each case. The average VPD of several cortical veins had a strong correlation with relative CBF (rCBF) between bilateral hemispheres with a correlation coefficient of 0.89443, a correlation as strong as that (0.90357) of the "approximate VPD," which is interpreted based on the trend line of the scatterplot of the time to peak contrast opacification in cortical veins and their spatial positioning from the median sagittal plane. MSTP and classic visual determination of VPD have weaker correlation coefficients with rCBF (0.56119 and 0.70048, respectively). Overall, subjective visual determination in combination with the calculation of the trend line to estimate VPD provided a considerably strong correlation with rCBF (R = 0.86660) without any dedicated software or hardware. CONCLUSIONS: VPD has a stronger correlation with rCBF than MSTP. rCBF could be successfully predicted on common DSA equipment, even by visual determination without expensive software, if the trend line is adopted for processing to estimate VPD.