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We introduce a new imaging technique to improve visualisation of stent apposition after endovascular treatment of brain aneurysms employing high-resolution cone beam CT and three-dimensional digital subtraction angiography. After performing a stent-assisted coil embolisation of brain aneurysm, the image datasets were processed with a metal artefact reduction software followed by the automated image fusion programmes. Two patients who underwent aneurysm coiling using a Neuroform stent were evaluated. The reconstructed 3D images showed a detailed structure of the stent struts and identified malappositions of the deployed stents. Case 1 showed good apposition on the outer curvature side of the carotid siphon, while the inner curvature side showed prominent malapposition. Case 2, with multiple aneurysms, showed good apposition on both outer and inner curvature sides, although inward prolapse of the struts was observed. This new imaging technique may help evaluate stent apposition after the endovascular aneurysm treatment.

Purpose Incomplete stent apposition after the treatment of brain aneurysm can increase the risk of thromboembolic complications and remains to be the major concern during the procedure. Utilizing the high resolution cone-beam CT (HR-CBCT) and metal artifact reduction software (MAR), the metal artifact produced by the coil mass is reduced and the visualization of the deployed stent is optimized. After combining with the 3D digital subtraction angiography (3D-DSA), the resulting image is used for the evaluation of the stent apposition in the artery. Initial clinical experience of this novel imaging method is reported. Methods A total of 24 aneurysm patients who underwent the stent assisted coil embolization was selected for this study. All patients were treated using either Neuroform® stent or Enterprise® stent system. Artis PURE® Platform (Siemens) was used in this study. Acquisition protocols are follows. A HR-CBCT acquisition was performed to obtain the image of stent and coil mass. The dataset was then reconstructed using MAR. A 3 D DSA acquisition was performed for the visualization of the vasculature. The two datasets were combined using a dedicated software. A 3D volume rendering (VR) image was created and the stent apposition of each treated patient was evaluated. Results All 24 patients underwent the image acquisition successfully. Relationship between the deployed stent and the wall of the parent artery was well visualized in every patient although partial image defect of the stent due to the metal artifact was observed in the relatively large aneurysms. The incomplete stent apposition was frequently seen near the carotid siphon, especially at the inner curve of the target vessel. Conclusion Combination of high resolution cone-beam CT and 3D DSA for the evaluation of intracranial stents provided sufficient visualization of the deployed stent and parent artery. This imaging method can be used for the evaluation of stent apposition during/after the treatment of brain aneurysms. Disclosures I. Yuki: 1; C; Siemens Grant. S. Hataoka: None. T. Ishibashi: 1; C; Siemens Grant. C. Dahmani: 5; C; Employee of Siemens Healthcare. A. Ikemura: None. Y. Kambayashi: None. I. Kan: None. Y. Abe: None. S. kaku: None. K. Nishimura: None. T. Kodama: None. Y. Sasaki: None. Y. Murayama: 1; C; Siemens Grant.

Purpose Fastest decision making for cerebral stroke is absolutely imperative to raise the chance of patient good recovery. With the increasing demand for immediately diagnosis and treatment of stroke, the telemedicine has become one of the most important tools to access the fast and immediate communication, and support the efforts of stroke team. ‘JOIN’ has been developed to maximize the communication by rapidly accessing diagnostic images and clinical information, taking advantage of today most common communication format: social network/SMS. Methods ‘JOIN’ was created to maximize the sharing and communication of patient data and images between hospital systems and paramedical staff members in and out of the hospital, through the today’s most common device: smartphones. ‘JOIN’ can transfer information such as clinical data, CT, MR, Angiographic and intraoperative images, as well as having on-fly expert opinion and real-time discussion inside of same chat room, making ‘JOIN’ the single and ultimate hub for the professionals to access ‘what’s going on’ with the patient.. The system is specially maximized for the communication in emergencies. Results A new pilot run of ‘JOIN’ in our hospital showed adequate performance and proper information flow, resulting in proper diagnosis and management of all stroke patients. The ‘JOIN’ system was introduced to our institution in August 2014, for communication with our affiliated hospitals. Conclusions The ‘JOIN’ is an efficient tool of appropriate standard management in most time demanding treatments of stroke. It is our belief that adoption of this app with smartphone will allow us to help and save the lives of more patients with cerebral stroke. Disclosures H. Takao: 1; C; NTT DOCOMO, INC.. T. Ishibashi: None. I. Yuki: None. S. Kaku: None. I. Kan: None. K. Nishimura: None. R. Mori: None. M. Watanabe: None. Y. Kanbayashi: None. Y. Yeh: None. K. Irie: None. T. Sakano: None. H. Arita: 5; C; NTT DOCOMO INC. T. Oobatake: 5; C; NTT DOCOMO INC. Y. Murayama: 1; C; NTT DOCOMO, INC.

Purpose To evaluate the potential advantages and limitations of 4D-DSA image acquisition, the acquired images on the patients with arteriovenous malformations (AVMs) and aneurysms were reviewed and analyzed. Methods Brain arteriovenous malformation (AVM) and brain aneurysm patients who underwent 4D-DSA during the pre and post assessment for the endovascular / surgical treatment were included. The obtained source image information of the 4D-DSA was transferred to a dedicated workstation and reconstructed using a software, “Syngo Dyna4D © ”. The results were reviewed and interpretation of each image finding was evaluated. The radiation dose required for each examination was calculated, and compared with that required for conventional 5-second 3D-DSA acquisitions. Results 10 aneurysm patients and 4 AVM patients underwent 4D-DSA. One patient had both an intracranial aneurysm and an AVM. 6 aneurysm patients underwent 6-second acquisition protocol. 12-second acquisition was used for all AVM patients as well as 4 aneurysm patients. For aneurysm evaluation, with a temporal sampling of 28.7-volumes/sec and a region of interest (ROI) of 42 cm x× 42 cm, the quality of the image was not sufficient to evaluate contrast flow patterns in the aneurysm although the sizes of all aneurysms were less than 10 mm in the largest diameter. With 12-second acquisition, anatomical information of both arteries and veins were simultaneously obtained in one scan, which was useful for the pre-operative evaluation of surgical clipping. For AVMs, temporal change in the appearance of each feeding artery clearly differentiated the different feeding patterns of each artery to the nidus component. Detailed anatomical structures, e.g. a stenosis in the main drainer which was not detected in the 2D-DSA and difficult to see in the conventional 3D angiogram, were better depicted in the 4D-DSA images. Average surface dose of the radiation was 115 mGy in the 6-second acquisition, 225 mGy in the 12-second acquisition and 105 mGy in the conventional 3D angiogram. Conclusions 4D-DSA provides useful information for the treatment planning of AVM patients by depicting the temporal change in the 3D-DSA. Current temporal resolution was not sufficient for the evaluation of contrast flow patterns in the small aneurysms. The 12-second acquisition which covers the entire arterial phase to the venous phase required approximately double the radiation dose of the conventional 5-second 3D-DSA. However, the dose required for the 6-second acquisition, which mainly covers the arterial phase, was similar to the conventional 3D-DSA. Disclosures I. Yuki: 1; C; Siemens Grant. T. Ishibashi: None. A. Ikemura: 1; C; Siemens Grant. Y. Kambayashi: None. I. Kan: None. Y. Abe: None. C. Dahmani: 5; C; Siemens K. K.. S. Kaku: None. K. Nishimura: None. Y. Murayama: 1; C; Siemens Grant.

Purpose Stent assisted coil embolization recently became a common treatment strategy for the wide neck aneurysms. Normal digital subtraction angiography (DSA), however, does not allow visualization of the deployed stents. With a combination of novel Metal Artefact Removal software (MAR) and C-arm CT, the coil mass, stent, and contrast material can be differentiated. In this study, experimental aneurysms were treated with stent assisted coil embolization and image analysis was performed using the C-arm CT and MAR. I. V. injection of the contrast to obtain the images was also performed. Methods A total of 12 experimental aneurysms were created in 6 swine. The aneurysms were treated with coil embolization using stent assisted technique. High Resolution (HR) C-arm CT with intra-arterial injection of the contrast dye (20%) was performed immediately after the treatment and obtained images were processed with MAR. Intra venous contrast injection (non-diluted) from femoral vein was also performed in 3 swine. Visualization of the residual aneurysms as well as coil loops protruded into the stent lumen was evaluated. Two patients previously treated with stent assisted coil embolization underwent the same image acquisition protocol, and the obtained images were evaluated. Results Coil loops protruded into the stent lumen, which were not visible before the MAR due to the significant metal artefact, were well visualised after the MAR. Likewise, Contrast filling into the residual aneurism was observed after the MAR in every aneurysm. Intravenous injection of the contrast material reproduced similar image quality as compared to the intra arterial injections. The C-arm CT images of the two patients showed remarkable reduction of the metal artefacts after the MAR processing. Conclusions The combination of the C-arm CT and MAR enables the differentiation of the coil mass, stent and contrast material by markedly reducing the metal artefact produced by the coils. This novel image modality may contribute to the evaluation of aneurysms treated with stent assisted coil embolization. Disclosures I. Yuki: 1; C; Siemens Grant. Y. Kambayashi: 1; C; Siemens Grant. A. Ikemura: 1; C; Siemens Grant. I. Kan: 1; C; Siemens Grant. Y. Abe: None. A. Mohamed: 5; C; Siemens Japan KK. C. Dahmani: 5; C; Siemens Japan KK. T. Ishibashi: 1; C; Siemens Grant. I. Kajiwara: 1; C; Siemens Grant. K. Nishimura: 1; C; Siemens Grant. Y. Murayama: 1; C; Siemens Grant.

Background and Purpose Double catheter coil embolisation (DCC) technique has been used for the treatment of wide neck aneurysms. Unlike Stent assisted Coil Embolisation (SAC), DCC does not require long term post-treatment anti-platelet therapy. Whether or not DCC can reduce the procedure related complications in SAC is not clear. In this series, consecutive unruptured wide neck aneurysm patients were treated primarily with the DCC. SAC was only used as a rescue therapy when the coil mass in the aneurysm was considered to be unstable. Clinical as well as angiographical outcomes of those who treated with DCC were reviewed. Methods A total of 597 unruptured aneurysm patients were treated in our institution between 2006 and 2012. Of these, 144 patients with wide neck (neck size >4.0 or dome-neck ratio Results A total of 129 patients were treated with DCC only, and 5 patients were shifted to the SAC based on the intra-procedural findings. The average neck size and the average dome-neck ratio of the treated aneurysms were 6mm and 1.3 respectively. Every aneurysm treated with DCC was successfully embolised. Intra-operative hemorrhagic event occurred in 2 cases. There was no intra-operative thrombo-embolic event. During the average follow up period of 809 days, post operative symptomatic ischaemic events were seen in two cases (1.6%) and post operative hemorrhagic event (procedure unrelated) was seen in 1 case (0.8%). Permanent morbidity and mortality throughout was 2.4% and 0.8% respectively. Recanalisation that required re-treatment was seen in 14.7% but there was no procedure related complication during the re-treatment. Conclusion The angiographic outcomes of the aneurysms treated with DCC in this series were comparable to the historical controls of the wide neck aneurysms treated with other adjunctive techniques. To minimise procedure related ischaemic/haemorrhagic event associated with the SAC, DCC may be a potential candidate of alternative treatment. Disclosures I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Misaki: None. K. Nishimura: None. A. Ikemura: None. T. Abe: None. Y. Murayama: None.

Purpose To improve the visualisation of residual neck in the aneurysms treated with coil embolisation utilising the time-resolved contrast enhanced magnetic resonance angiography (4D MRA). Materials and Methods A total of 11 patients who underwent coil embolisation of brain aneurysm underwent 1.5 Tesla 4D MRA one year after the procedure. Of these, 6 patients were treated with stent assisted technique. The image information obtained from the 4D MRA was re-processed utilising a 3D Neuroimaging software (TeraRecon, Inc.) and compared to the images obtained from the cerebral angiograms. Results Six patients showed major recanalisation and five patients showed minimal residual neck of the treated aneurysm in the cerebral angiogram. The 4D MRA images obtained from each patient was consistent with the images from the cerebral angiogram. The susceptibility artifact induced by the coils and stents was significantly reduced as compared to the images of contrast enhanced time of flight (CE-TOF) images. The re-processed 3D images of 4D MRA in the Neuroimaging software showed great reproducibility of angiographical findings obtained from the cerebral angiograms. Conclusion The combination of the 4D MRA and utilisation of the 3D Neuroimaging software showed great visualisation of residual aneurysm. This imaging method can be a good alternative for the post-procedure follow up angiograms in the patients who underwent coil embolisation. Disclosures A. Ikemura: None. I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Nishimura: None. I. Kan: None. Y. Murayama: None.