Development of Sustained Release System Based on High Water-Absorbable Gel Formation Using Croscarmellose Sodium, Alkaline Excipients and HPMC (ACSH SR System); Novel Application of Croscarmellose Sodium as a Gel Former.

PURPOSE: Croscarmellose sodium, generally used as a superdisintegrant in pharmaceutical formulations, is hydrolyzed to form the gel structure under basic pH conditions. Utilizing this property of croscarmellose sodium, we developed a novel sustained release (SR) system. METHODS: Immediate release (IR) and SR tablets containing croscarmellose sodium, alkaline excipients and/or hydroxypropyl methylcellulose (HPMC) were prepared and examined for wet strength and in vitro drug release behavior. In vivo oral drug absorption was evaluated for IR tablets, HPMC tablets and our novel SR tablets in fasted Beagle dogs. RESULTS: To form the gel structure even under the physiological condition, alkaline excipients were added into the formulation containing croscarmellose sodium. Furthermore, HPMC was used to make the gel structure strong enough against mechanical destructive forces. The novel alkalized croscarmellose sodium-HPMC (ACSH) SR tablet, consisting of croscarmellose sodium, alkaline excipients, and HPMC, successfully sustained the release of acetaminophen, ibuprofen, or nicardipine hydrochloride, compared with the IR tablets. The ACSH SR system provided a better release of acetaminophen than the HPMC tablet without croscarmellose sodium in the release study using a small volume of liquid, suggesting that substantial release and subsequent absorption would be expected in the distal intestinal segments after oral dosing. The in vivo oral absorption study revealed that the ACSH SR system successfully suppressed and prolonged the plasma concentrations of acetaminophen. CONCLUSION: This novel ACSH SR system prepared with croscarmellose sodium, alkaline excipients, and HPMC, would be a promising SR formulation for enabling substantial drug absorption in the distal intestinal segments.

Creation of single molecular conjugates of metal-organic cages and DNA.

Here we report the development of an equimolar conjugate of a metal-organic cage (MOC) and DNA (MOC-DNA). Several MOC-DNA conjugates were assembled into a programmed structure by coordinating with a template DNA having a complementary base sequence. Moreover, conjugation with the MOC drastically enhanced the permeability of DNA through the lipid bilayer, presenting great potential as a drug delivery system.

Large-Vessel Occlusion Stroke Treated by Endovascular Thrombectomy in Patient with Coronavirus Disease 2019.

We report a case of acute ischemic stroke caused by large-vessel occlusion in a patient infected with coronavirus disease 2019 (COVID-19) who was treated by endovascular thrombectomy. The patient was a 41-year-old man hospitalized with moderately severe COVID-19. Fourteen days after the onset of COVID-19, dysarthria and right hemiplegia were observed, and acute occlusion of the left middle cerebral artery was diagnosed. Mechanical thrombectomy was performed with a stent retriever while the patient was under local anesthesia and sedation. The staff involved in the intervention was as minimal as possible. The interventional surgeon wore a disposable surgical gown, an N95 mask, a face shield, and two pairs of gloves, while the patient was fitted with a surgical mask. The intervention involved the usual procedures, such as sheath insertion, catheter manipulation, and stent deployment, and the thrombus was removed with the stent retriever. The time from puncture to recanalization was within 30 minutes. No infection was observed in our staff or inpatients after the intervention. Thus, we were able to perform neuroendovascular treatment without spreading COVID-19 by taking appropriate measures to prevent infection.

Severe Complications After Endovascular Trapping of Vertebral Artery Dissecting Aneurysm: Simultaneous Occurrence of Medullary and Cervical Spinal Cord Infarction.

Endovascular trapping of vertebral artery dissecting aneurysm (VADA) can lead to ischemic complications, including medullary infarction due to obstruction of perforating arteries, and cervical spinal cord infarction caused by ischemia of spinal arteries branching from the affected vertebral artery (VA). This report describes a rare case of concomitant medullary and spinal cord infarction following internal trapping of ruptured VADA. A 47-year-old male presented with severe subarachnoid hemorrhage and neurological pulmonary edema, and a vertebral angiogram demonstrated VADA. A small-sized posterior inferior cerebellar artery (PICA) was found proximal to the affected vessel. The anterior spinal artery (ASA) branched distal to a dilated portion. Perforating arteries were insufficiently visualized due to image quality. Internal trapping was performed, and complete occlusion of VADA was achieved, preserving the origin of ASA. Postoperative magnetic resonance imaging (MRI) revealed ischemic lesions in the lateral medulla oblongata and upper cervical spinal cord. The patient presented with severe neurological symptoms, including lower cranial neuropathy due to medulla infarction, respiratory dysfunction, and tetraparesis due to cervical spinal cord infarction. The modified Rankin scale at three months was grade 5. Various factors, including perforating artery ischemia, unstable general condition, and insufficient antithrombotic therapy, were considered the cause. Therefore, evaluating the tiny perforating and spinal arteries branching from the VA should be especially considered to avoid these complications. Furthermore, advances in angiographic apparatus and workstations should provide a high-resolution radiological image and adequate treatment strategy.

A Case of Puncture-Site Giant Pseudoaneurysm Following Recanalization Therapy for Acute Ischemic Stroke: Marked Growth and Rupture of a Femoral Artery Pseudoaneurysm.

Objective: We report a case of the marked growth and rupture of a giant femoral artery pseudoaneurysm at the puncture site that developed after recanalization therapy for acute basilar artery occlusion. Case Presentation: A 79-year-old woman developed acute ischemic stroke due to atherosclerotic basilar artery occlusion. Endovascular intervention was performed and recanalization of the affected vessel was achieved. However, she developed brainstem infarction and consciousness disturbance persisted. The femoral access site was treated using a vascular closure device at the end of the procedure. A right femoral artery pseudoaneurysm of approximately 5 cm in size was found 2 weeks after onset during the examination for deep venous thrombosis with right lower extremity edema. Manual compression did not achieve thrombotic occlusion of the aneurysm due to obesity and leg edema. Considering the severe neurological status of the patient, the pseudoaneurysm was followed up without surgical treatment. Dual antiplatelet therapy and direct oral anticoagulant agents were administered. Four weeks after onset, the pseudoaneurysm presented rapid growth, and on the 35th day after onset, it exceeded 15 cm in size and ruptured, causing hemorrhagic shock with massive femoral hematoma. Pseudoaneurysm resection and hematoma removal were performed surgically, and the patient recovered. However, improvement of neurological manifestations was poor and the modified Rankin Scale at 90 days after onset was 5. Conclusion: A case of giant femoral artery pseudoaneurysm following recanalization therapy for acute ischemic stroke was reported. Pseudoaneurysms at the puncture site can rupture after significant growth. Curative treatment is required without delay.

A Case of Segmental Arterial Mediolysis: Hemoperitoneum with Hemorrhagic Shock due to Rupture of a Visceral Artery Aneurysm Following Subarachnoid Hemorrhage.

Objective: Segmental arterial mediolysis (SAM) is a non-inflammatory and non-atherosclerotic vascular disease characterized by segmental medial defect/necrosis of muscular arteries as a result of mediolysis. SAM affects the visceral and intracranial arteries, and causes arterial dissection and aneurysm. We report a case of aneurysmal subarachnoid hemorrhage (SAH) followed by hemoperitoneum due to a ruptured visceral artery aneurysm. Case Presentation: A 54-year-old man developed SAH from a ruptured anterior communicating artery aneurysm, which was clipped on the same day. Thereafter, he was treated to prevent cerebral vasospasm. Six days after onset, he developed acute anemia and his blood pressure decreased, suggesting hemorrhagic shock. Hemoperitoneum was detected on computed tomography and abdominal angiography was performed. Irregular and stenotic arterial findings, and an unusual aneurysm with contrast stasis were found in a branch vessel from the right gastroepiploic artery. SAM was diagnosed based on the clinical course and angiographic characteristics. Endovascular treatment consisted of embolization of the visceral artery aneurysm with liquid embolic material. after embolization, the vital signs stabilized and he recovered from shock. Acute treatment for SAH was continued. Although the patient did not develop vasospasm-related sequelae, he was transferred to the rehabilitation hospital 7 weeks after onset and his modified Rankin Scale score at 3 months after onset was 2. Conclusion: Visceral artery aneurysm associated with SAM should be considered as the cause of hemoperitoneum with hemorrhagic shock during the acute phase of SAH.

Other Hospital-onset Acute Ischemic Stroke Due to Large Vessel Occlusion Treated by Mechanical Thrombectomy after Inter-hospital Transfer.

The purpose of this study was to investigate the in-hospital acute ischemic stroke due to large vessel occlusion (LVO) that developed in another thrombectomy-incapable hospital, treated by mechanical thrombectomy after inter-hospital transfer. In eight other hospital-onset LVO patients, clinical characteristics, treatment results, and the timeline of thrombectomy were retrospectively investigated and compared to the results of 17 patients developed LVO at our own hospital and 18 developed in the community. In the analysis of timeline, the mean recognition-to-arrival time in other hospital-onset patients was 169 ± 78 min, significantly longer than for the community-onset patients (79 ± 78 min). Arrival-to-puncture time was 42 ± 19 min, significantly shorter than for the own hospital-onset patients (166 ± 80 min) and the community-onset patients (155 ± 76 min). Recognition-to-puncture times for the other hospital-onset patients, the own hospital-onset patients, and the community-onset patients were 212 ± 74, 166 ± 80, and 216 ± 83 min, respectively, and recognition-to-recanalization times were 285 ± 73, 200 ± 81, and 275 ± 125 min. Both these times were shorter for the own hospital-onset patients. The rates of modified Rankin Scale (mRS) of 0-2 in the three groups were 12%, 30%, and 23%, respectively. The rate of mRS 0-2 was lowest in the other hospital-onset patients. In conclusion, the other hospital-onset patients required additional time for their initial management and inter-hospital transfer although arrival-to-puncture time was shorter. Favorable outcomes were observed less frequently in them. Improving inter-hospital cooperation systems and to educate the medical staff in a thrombectomy-incapable hospital concerning stroke management is important measures for other hospital-onset stroke with LVO.

Newly Developed Aneurysm at the Anastomosis Site of a Superficial Temporal Artery to Middle Cerebral Artery Bypass Successfully Treated by Endovascular Embolization.

BACKGROUND: The superficial temporal artery (STA) to middle cerebral artery (MCA) bypass is an effective treatment procedure for steno-occlusive severe ischemic disease of the anterior circulation. The formation of an aneurysm at the anastomosis site is a rare complication, and the mechanism underlying this condition and the appropriate treatment strategy, have not yet been established. We describe a case of an unruptured anastomosis aneurysm that was treated by endovascular embolization 7 years after bypass surgery. CASE DESCRIPTION: A 62-year-old woman presented with slurred speech, with magnetic resonance imaging and angiography showing multiple infarctions in her left cerebral hemisphere and severe stenosis in the left internal carotid artery and left MCA. An STA-MCA anastomosis was performed without neurologic sequelae. Five years later, follow-up magnetic resonance imaging showed that an aneurysm had formed at the MCA side of the anastomosis site. After 2 years, the saccular aneurysm had grown and was embedded in the brain parenchyma. Because the patient had experienced repeated problems with surgical wound healing, an endovascular intervention was performed, achieving obliteration of the aneurysm by coil embolization. CONCLUSIONS: Endovascular treatment is a feasible and efficacious treatment option for an aneurysm at the anastomosis site of an STA-MCA bypass.

[Tentorial Dural Arteriovenous Fistula with Bithalamic Lesions and Bilateral Basal Ganglia Hemorrhage:A Case Report].

OBJECTIVE: We report an unusual case of tentorial dural arteriovenous fistula(DAVF)with bithalamic lesions and bilateral intracranial hemorrhage. CASE PRESENTATION: A 73-year-old man presented with lethargy and progressive cognitive decline. Imaging demonstrated bithalamic edematous lesions and bilateral basal ganglia hemorrhage in the right putamen and left internal capsule. Angiography revealed tentorial DAVF fed by both the internal and external carotid arteries. A shunted pouch was present in the superior petrosal sinus, and retrograde reflux drainage was see in the deep venous system, including the basal vein, vein of Galen, and internal cerebral veins with congestion. Initially, transarterial embolization was palliatively performed, and subsequently, a microsurgery achieved obliteration of the tentorial DAVF. Postoperatively, the bilateral thalamic changes disappeared, although sequela of the intracranial hemorrhage persisted. CONCLUSION: Deep venous congestion due to tentorial DAVF induced unusual bithalamic lesions and bilateral basal ganglia hemorrhage. Tentorial DAVF was treated with combined endovascular and surgical operations. Tentorial AVF is an aggressive vascular disease, and prompt diagnosis and treatment are necessary.

[Current Status of Thrombectomy Calls for Acute Ischemic Stroke for a Single Neurointerventionist in a Regional Hospital].

OBJECTIVE: The purpose of this study was to investigate the current status of thrombectomy calls for acute ischemic stroke for a single neurointerventionist in a regional hospital. METHODS: We retrospectively evaluated patients with thrombectomy calls for a neurointerventionist from January to November 2016 in our hospital, where a single board-certified neurointerventionist conducts endovascular interventions. Number, frequency, and time of thrombectomy calls were analyzed. Patients ineligible for revascularization were still used in analysis even though the neurointerventionist did not perform thrombectomy. RESULTS: Over 11 months(334 days), there were 105 calls, of which 48 were during duty hours and 57 during off-duty hours. The neurointerventionist was called once every 3.2 days in total, once every 4.7 days during duty hours, once every 5.7 days during off-duty hours of working days, and once every 6.2 days during holidays. Thrombectomies were performed in 37 cases(35%). Thrombectomies were performed once every 9.1 days and once every 2.8 calls. Twenty-four patients presented with ischemic stroke with large vessel occlusion, but they were determined to be ineligible for thrombectomy because of progressed ischemia in 7 patients, poor clinical condition in 7, or symptom recovery or recanalization in 10. Diagnoses of 42 patients who were not indicated for thrombectomy included ischemic stroke without major artery occlusion in 24 patients and intracerebral hemorrhage in 14. CONCLUSION: In a regional hospital with a single neurointerventionist, the frequency of thrombectomy calls was about once in every 3 days, and approximately half of them occurred during off-duty hours. A thrombectomy was performed about once every 9 days and about once every 3 thrombectomy-calls. Measures should be taken to reduce the burden on neurointerventionists in stroke centers, especially in understaffed institutes.

Experimental study of coil delivery wire insertion force in intracranial aneurysm embolization: force discrepancy generated inside the microcatheter through that coil delivery wire passes.

In endovascular coil embolization for intracranial aneurysms, as coils are filled in the aneurysm and the stage of procedure is advanced, the force to push forward the coil delivery wire (insertion force) increases. However, the coil insertion force that interventionist's felt at his fingertips does not directly reflect the stress of the aneurysm and is affected by the resistance generated inside the microcatheter through that the wire passes. The authors evaluated this force discrepancy by subtracting the loading force at the tip of delivery wire from the insertion force of delivery wire and examined the relationship among them. Experiments were performed with the device that applies a constant loading force to the delivery wire tip with the coil removed. A force gauge was connected to the end-tip of the delivery wire to measure the insertion force. The force was measured by changing delivery wire in different coil brands and the conditions of microcatheter (straight or bent position). The results demonstrated that force discrepancy generated inside the microcatheter increased as the loading force increased in a linear relationship. Different coil delivery wires produced differences in the way that force discrepancy changed, thus reflecting the properties of each wire. Microcatheters with more curvature were associated with a higher force discrepancy. In conclusions, as the loading force increases, the force discrepancy increases, and it means that the coil insertion force that the interventionist feels at his fingertips also increases. This force discrepancy is impacted by the delivery wire properties and microcatheter curvature.

Experimental study of the characteristics of various types of filling coils for intracranial aneurysm embolisation.

Background In endovascular embolisation for an intracranial aneurysm, after framing coil deployment, soft coils (often called filling coils) are usually selected to fill inside the cage of previous coils. Various kinds of filling coils are available, although each coil has its own characteristics. Understanding their differences to ensure proper coil selection is important to achieve successful embolisation. The purpose of this study was to investigate the characteristics of various filling coils. Materials and methods The authors developed a radiolucent coil to evaluate the performance of coils under conditions simulating the course of embolisation. Experimental embolisation was performed by using a silicone aneurysm filled with radiolucent coils. Indices including area, circularity, centroid position and coefficient of variation were investigated by analysing the figures of the filling coils after being inserted into the radiolucent coil under fluoroscopy. Results The characteristics of each coil depended on the coil design. The helical coil had the highest circularity and centroid position scores and lowest area score. Therefore, it tended to develop a compacted mass. The low shape-memory coil had the lowest circularity, second-highest centroid position and highest coefficient of variation scores. Therefore, it tended to develop irregularly shaped distribution with low reproducibility. Complex coils generally had higher area and circularity scores. Therefore, they tended to provide a balanced distribution with relatively expanded mass and less small compartmentation. Conclusions The evaluated characteristics of various filling coils should be useful for appropriate selection of filling coils.

Association between CYP2C19 genotype and the additional effect of cilostazol to clopidogrel resistance in neuroendovascular therapy.

We investigated the association between CYP2C19 genotype and additional effect of cilostazol on clopidogrel resistance (CR) in neuroendovascular therapy. Between January 2012 and January 2016, 447 consecutive patients were administered with 75-mg cilostazol/day. The VerifyNow System was used for evaluating P2Y12 reaction units (PRU) > 230 and/or percentage inhibition of platelet function (% Inhibition) ≤ 20 as CR. Among 158 patients with CR, 31 were administered with additional 100- or 200-mg cilostazol/day and their platelet function was evaluated. According to CYP2C19 genotypes revealed using the Spartan RX and DNeasy Blood & Tissue Kit, patients were classified into three phenotypic groups: extensive metabolizer (EM, three patients), intermediate metabolizer (IM, 12 patients), and poor metabolizer (PM, 16 patients). Administration of additional cilostazol decreased PRU (EM group: 160.7 ± 85.2 after vs 278.3 ± 40.1 before, P = 0.15; IM group: 205.6 ± 74.0 vs 254.3 ± 35.0, P = 0.02; and PM group: 227.8 ± 52.2 vs 282.1 ± 30.4, P = 0.003), and increased % Inhibition (EM group: 40.0 ± 27.9 vs 9.3 ± 3.8, P = 0.25; IM group: 31.4 ± 18.0 vs 11.8 ± 8.2, P = 0.001; and PM group: 24.6 ± 15.0 vs 10.4 ± 9.3, P = 0.001). However, the rate of normalized-clopidogrel response, thromboembolic lesions, and bleeding complications were not significantly different among the three groups. Thus, the addition of cilostazol was effective on CR in terms of PRU, % Inhibition, rate of change of normalized-clopidogrel response, thromboembolic events, and bleeding complications irrespective of phenotype.

High-resolution cone beam CT for evaluation of vascular channel in intracranial partial thrombosed aneurysm.

The authors present a 60-year-old man with a partially thrombosed, intracranial vertebral artery aneurysm. A vascular channel in intra-aneurysmal thrombus was effectively identified with high-resolution cone beam CT (DynaCT Micro: Siemens Medical Solutions, Erlangen, Germany). Pre-procedural vertebral angiogram implied a perforating artery arising from near neck of the aneurysm and DynaCT Micro performed before approaching to the lesion demonstrated a vascular channel running in intra-aneurysmal thrombus which could not be distinguished from perforators with other imaging modalities. It was confirmed that perforators around the aneurysm were not identified and safely treated the aneurysm with stent-assisted coil embolization. High-resolution cone beam CT is enable to sharply visualize vessel lumens, thrombus, and intra-thrombus structures, and is useful to identify a vascular channel in intracranial partially thrombosed aneurysm.

Evaluation for shunted pouches of cavernous sinus dural arteriovenous fistula and the treatment outcome of transvenous embolization.

Background This study aimed to evaluate the detailed location and the number (single or multiple) of cavernous sinus dural arteriovenous fistula (CSDAVF) shunted pouches as well as the relationship between the characteristics of shunted pouch(es) and the treatment outcome of transvenous embolization for CSDAVF. Methods A total of 23 consecutive patients with CSDAVFs who underwent angiogram and transvenous embolization were retrospectively analyzed. Shunted pouches were assessed using three-dimensional angiogram and multiplanar reformatted image obtained from the rotational angiogram data. Results Of the 23 patients with CSDAVFs, 40 shunted pouches were identified. Twelve CSDAVFs had a single shunted pouch, and 11 had multiple shunted pouches. The mean CSDAVF with multiple shunted pouches was 2.5. The shunted pouches were more often found in the posterior compartment of the CS, which was connected with the intercavernous sinus (23/40; 57.5%). In 12 CSDAVFs with a single shunted pouch, 10 were treated with selective embolization and complete occlusion was achieved during the follow-up. Two CSDAVFs with single shunted pouch were just observed without intervention, and DAVFs disappeared spontaneously during the follow-up period. In 11 CSDAVFs with multiple shunted pouches, eight were treated with selective embolization and three with sinus embolization. In six of eight (75%), complete occlusion was achieved following selective embolization, but two of eight (25%) recurred and required retreatment. Conclusions Rotational angiography data suggested that the shunted pouches of CSDAVFs were mostly located in the posterior compartment of the CS connected with the intercavernous sinus. Selective embolization for CSDAVFs with a single shunted pouch is the first-line treatment alternative to sinus packing, and selective embolization with multiple shunted pouches will be a considerable treatment option.

Contrast-induced Encephalopathy Following Embolization of Intracranial Aneurysms in Hemodialysis Patients.

Contrast-induced encephalopathy is a very rare complication associated with endovascular treatment of intracranial aneurysms. Patients with renal dysfunction may be prone to developing contrast medium neurotoxicity as a result of delayed elimination of the contrast medium in renal metabolism. This article focuses on our experience with contrast-induced encephalopathy in patients with end-stage renal disease requiring hemodialysis. The authors retrospectively reviewed five patients diagnosed with contrast-induced encephalopathy who underwent aneurysm coil embolization at their institution from January 2006 to December 2015. During the 10-year period, embolization was performed in 755 cases, among which contrast-induced encephalopathy occurred in five patients (0.66%). Three of the five patients were undergoing dialysis for chronic renal failure (one male and two female; mean age 66.7). Embolization for hemodialysis patients was performed in eight during the same period and the incidence of contrast-induced encephalopathy in hemodialysis patients is quite high in our series (3 of 8; 38%). Procedures were performed in one for recurrence of unruptured anterior-communicating artery aneurysm and in two for unruptured basilar-tip aneurysm. Mean approximately 220 ml of contrast media was used among three hemodialysis patients. All three patients showed an improvement or a control in symptoms soon after hemodialysis. Recovery of neurological symptoms was complete in two and almost normal in one within 1 week after intervention. Contrast-induced encephalopathy should be kept in mind as an expected complication of aneurysm embolization in hemodialysis patients. In hemodialysis patients with contrast-induced encephalopathy, performing hemodialysis is an effective treatment to improve symptoms early.

Clinical Application of Insertion Force Sensor System for Coil Embolization of Intracranial Aneurysms.

INTRODUCTION: In endovascular embolization for intracranial aneurysms, it is important to properly control the coil insertion force. However, the force can only be subjectively detected by the subtle feedback experienced by neurointerventionists at their fingertips. The authors envisioned a system that would objectively sense and quantify that force. In this article, coil insertion force was measured in cases of intracranial aneurysm using this sensor, and its actual clinical application was investigated. METHODS: The sensor consists of a hemostatic valve (Y-connector). A little flexure was intentionally added in the device, and it creates a bend in the delivery wire. The sensor measures the change in the position of the bent wire depending on the insertion force and translates it into a force value. Using this, embolization was performed for 10 unruptured intracranial aneurysms. RESULTS: The sensor adequately recorded the force, and it reflected the operators' usual clinical experience. The presence of the sensor did not affect the procedures. The sensor enabled the operators to objectively note and evaluate the insertion force and better cooperative handling was possible. Additionally, other members of the intervention team shared the information. Force records demonstrated the characteristic patterns according to every stage of coiling (framing, filling, and finishing). CONCLUSIONS: The force sensor system adequately measured coil insertion force in intracranial aneurysm coil embolization procedures. The safety of this sensor was demonstrated in clinical application for the limited number of patients. This system is useful adjunct for assisting during coil embolization for an intracranial aneurysm.

Evaluation of the characteristics of various types of finishing coils for the embolization of intracranial aneurysms in an experimental model with radiolucent coils.

In endovascular coil embolization of intracranial aneurysms, very soft coils, often called "finishing coils," are usually selected in the final stage of coil embolization. The authors developed a radiolucent coil made of thin nylon thread to evaluate the performance of coils under a situation simulating the course of embolization. The characteristics of various types of finishing coils were investigated using radiolucent coils. Experimental embolization was performed with a silicone aneurysm filled with radiolucent coils simulating the final stage of embolization. Three indices, i.e. area, perimeter, and circularity of the inserted coils, were investigated on the X-ray images after coil insertion. The coils used were as follows: Target Ultra Helical, MicroPlex Hypersoft, Axium Helix, ED Coil Extrasoft, and DeltaPlush. In the analysis of area and perimeter, there were significant differences in multiple comparisons. There was no significant difference in circularity, although it was generally ranked in order by coil brand. Target Ultra and MicroPlex Hypersoft had higher scores for area and perimeter and lower scores for circularity, in contrast to DeltaPlush, which had lower scores for area and perimeter and a higher score for circularity. Based on these results, the finishing coils were divided into three groups: Target Ultra Helical and MicroPlex Hypersoft; Axium Helix and ED Coil Extrasoft; DeltaPlush. They are better for use in early, midst, and end of finishing, respectively. The characteristics of various finishing coils were evaluated, and the results obtained reflected actual clinical experience and provide useful information to appropriately select finishing coils.

Innovations in Endovascular Treatment Strategies for Large Carotid Cavernous Aneurysms-The Safety and Efficacy of a Flow Diverter.

BACKGROUND: The efficacy for the treatment of large carotid cavernous aneurysms (CCAs) was compared between conventional endovascular treatments, stent-assisted coiling (SAC), parent artery occlusion (PAO), and the flow diverter (FD). METHODS: Between January 2001 and December 2015, 49 patients with large, broad-necked, unruptured CCA underwent endovascular treatment at our institution. We performed PAO in 22 patients, SAC in 18 patients, and FD in 9 patients. Safety and efficacy were assessed in all patients by periodic clinical and radiological examinations during a 6-month follow-up. RESULTS: All 22 aneurysms treated with PAO disappeared immediately after treatment, but in the SAC-treated group, complete occlusion was obtained in only 5 of the 18 patients. All aneurysms in the FD group resulted in body filling. Perioperative ipsilateral temporary ischemic events occurred in 6 cases (PAO 4, SAC 2, FD 0). Delayed deterioration or new onset of cranial nerve symptoms was observed in 10 cases (PAO 3, SAC 3, FD 4), almost all of which recovered within 3 months. During the 6-month follow-up, all aneurysms treated with PAO showed a decrease in size without recanalization. In the SAC group, 12 aneurysms showed neck remnants, and marked recanalization occurred in 4 cases. Six of the 9 aneurysms in the FD group were completely occluded. CONCLUSIONS: The FD provided excellent final results despite transient worsening of symptoms. Although further long-term follow-up is essential, from a cost-effective and time-saving viewpoint, FD is a relatively safe and reliable method for the treatment of large CCAs.

Relationship between low response to clopidogrel and periprocedural ischemic events with coil embolization for intracranial aneurysms.

OBJECTIVES: Low response to antiplatelet drugs is one of the risk factors for ischemic events. We examined the influence of low response to clopidogrel on symptomatic ischemic events and new ischemic MRI lesions with endovascular intracranial aneurysmal coil embolization. MATERIALS AND METHODS: Between August 2010 and July 2013, 189 procedures in 181 consecutive patients who underwent endovascular coiling and received clopidogrel before treatment were investigated retrospectively. Platelet aggregation activity was examined by VerifyNow analysis. Low response to clopidogrel was defined as P2Y12 reaction units ≥230 in this study. Symptomatic ischemic complications within 30 days and postoperative new ischemic lesions on MRI-diffusion weighted imaging were evaluated. RESULTS: 66 of 189 (34.9%) cases were low responders to clopidogrel. Ischemic complications occurred in 2 of 66 (3.0%) low responders compared with 6 of 123 (4.9%) responders (p=0.72). A new high intensity spot larger than 5 mm was significantly more frequent in low responders (26 of 66; 39.4%) than in responders (26 of 121; 21.2%; p=0.01). On multivariate analysis, independent risk factors for larger new ischemic lesions were low response to clopidogrel, smokers, posterior location, and aneurysms with a larger neck. CONCLUSIONS: Low response to clopidogrel had little effect on clinical outcome although it increased asymptomatic large ischemic lesions in this cohort.