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Purpose: Here, we presented our early experience with flow diversion procedures using the Surpass Evolve flow diverter (SE, Stryker) and reported the feasibility and safety profile compared to those of a control group treated with other types of flow diverters. Methods: We included 31 and 53 consecutive flow diversion procedures performed using the SE and other commercial flow diverters, respectively, to treat intracranial aneurysms at our institution. We used two commercial flow diversion systems in the comparison group: the pipeline embolization device and Surpass Streamline. Results: In the SE group, technical failures occurred in three (9.7%) cases, due to either incomplete wall apposition (n = 1, 3.2%) or stent migration (n = 2, 6.5%). Major complications occurred in four (12.9%) cases: delayed rupture of the target aneurysm (n = 1, 3.2%), major ischemic stroke (n = 1, 3.2%), sudden death from an unidentified cause (n = 1, 3.2%), and parent artery occlusion with stent thrombosis (n = 1, 3.2%). Balloon angioplasty was performed in eight (25.8%) cases. On post-procedure MRI, a DWI-positive lesion was detected in three (9.7%) cases. After multivariate adjustment, the SE group was independently associated with less procedural time of ≥ 90 min (adjusted OR, 0.09; 95% CI, 0.03–0.29; p < 0.001), balloon angioplasty (adjusted OR, 0.22; 95% CI, 0.07–0.75; p = 0.015), and DWI-positive lesions (adjusted OR, 0.04; 95% CI, 0.01–0.19; p < 0.001). Conclusion: The SE is safe and easy to deploy. [ABSTRACT FROM AUTHOR]

Recently, the treatment of intracranial aneurysms entered a new phase due to safe surgical tool such as neurophysiologic monitoring and challenged by endovascular treatment. To determine the safety of clipping surgery in the modern era, we reviewed our experiences of simple unruptured anterior circulation aneurysm surgery which is commonly performed in many places. We retrospectively reviewed 610 consecutive patients who were treated with surgical clipping under motor evoked potential (MEP) monitoring for a tiny to large anterior circulation aneurysm in a single institute between 2008 and 2012. MEP changes were identified in 40 cases (6.6 %). MEP deterioration was associated with remote site epidural hematoma ( n = 1), anesthesia ( n = 2), temporary clipping ( n = 21), and permanent clipping ( n = 16). Despite that no persistent MEP deterioration was noted after prompt corrective measures, 56 (9.2 %) patients showed symptomatic ( n = 14) and asymptomatic ( n = 42) radiologic abnormalities. Anterior cerebral artery (ACA) aneurysm was associated with a higher radiologic complication rate (Fisher's exact test, P < 0.05). Two (0.3 %) patients showed severe morbidity (mRS >2) at latest follow-up. MEP monitoring can be helpful in preventing postoperative motor deterioration but seems to have some limitations. Although the permanent morbidity rate was low, a significant clinical (2.3 %) or radiologic (9.2 %) abnormality rate was identified even in simple aneurysm clipping that should be taken into account when performing interdisciplinary treatment planning and patient counseling. Also, direct vascular monitoring or new neurophysiologic monitoring techniques are needed to reduce surgical complications, especially in ACA aneurysm surgery. [ABSTRACT FROM AUTHOR]

Objectives: To identify the incidence of thromboembolic complications based on magnetic resonance imaging (MRI) and to explore the potential risk factors for thromboembolism (TE) during the periprocedural period of elective coil embolization for unruptured intracranial aneurysms. Methods: We retrospectively reviewed all aneurysm cases treated with coil insertion between January 2008 and March 2011. Two hundred eighty-two coiling procedures for unruptured aneurysms were included in this study. The patients' demographic characteristics were documented and records reviewed for abnormalities in diffusion-weighted imaging (DWI) seen on post-procedure MRI, intraoperative thrombus formation, and clinical signs of stroke. Results: Overall, there were 87 (30.9 %) procedure-related complications in 282 aneurysms treated: 2 (0.7 %) procedural ruptures, 5 (1.8 %) symptomatic infarctions, and 80 (28.3 %) asymptomatic infarctions. Thromboembolic events during the procedure were observed more often in the the hyperlipidemia group (32/71 aneurysms, 45.1 %) than in the normal lipid profile group (39/196 aneurysms, 25.6 %; p = 0.002; chi-squre test). The coiling technique and size of the aneurysm were also associated with TE ( p < 0.001 and p = 0.004). Conclusion: Hyperlipidemia seems to be associated with a significant increase in the rate of thromboembolic events. In preventive procedures, modifiable risk factors should be managed to reduce complications. Although permanent deficits are rare, the high rate of thromboembolic events suggests that improvements in the technique, such as the addition of antiplatelet agents and the development of new embolic materials, are necessary. [ABSTRACT FROM AUTHOR]

Objective.—The objective of this study is to determine the incidence, character, and outcome of headache in patients with unruptured intracranial aneurysms who had been treated to avoid the risk of rupture. Background.—There are a variety of clinical manifestations associated with unruptured intracranial aneurysms. Among them, chronic headache is the most common presenting and/or accompanying symptom. Methods.—Among the 137 patients with unruptured aneurysms who had been treated, we collected 81 patients excluding 30 on the basis of inclusion criteria. Twenty-six patients were lost to follow-up. We collected data by medical record review and a telephone survey. Included in the information collected was the analysis of presenting symptom, location and size of each aneurysm, location, quality, intensity and duration of headaches, associated symptoms, triggering and alleviating factors, and precipitating events. Results.—Forty-nine patients (60.5%) of 81 had chronic headaches before the diagnosis of unruptured intracranial aneurysm. Forty-four patients (89.8%) answered that their headaches were improved slightly (12 patients) or markedly (32 patients) ( P <.05). The clinical pattern of the headache worsened in only 1 patient and did not change in 4 patients. When the surgical group (40 patients) and the coil embolization group (41 patients) were compared, there was no significant difference observed in outcome ( P >.05). Conclusion.—Either by employing the technique of clipping or by coil embolization, treatment of unruptured intracranial aneurysms resulted in relief of headaches in majority of patients who had headaches pre-operatively. [ABSTRACT FROM AUTHOR]

This study aimed to evaluate the clinical course after flow diversion (FD) treatment with a focus on aneurysms with remnant sac filling, by analyzing angiographic outcomes, aneurysm volume, and clinical events. We retrospectively reviewed the medical records of 61 patients who underwent FD for intracranial aneurysms between July 2014 and June 2021. The majority of aneurysms (52.5%) were located in the internal carotid artery, with a median diameter of 16.6 mm and neck size of 9.3 mm. Remnant filling was observed in 17 aneurysms (27.9%) more than 18 months after FD, 10 (16.4%) of these aneurysms underwent enlargement, which occurred only in cases with subtotal filling or entry remnant states. Eleven patients experienced major adverse events, and three exhibited unfavorable functional outcomes. The incidence of major adverse events and unfavorable functional outcomes was significantly higher in the aneurysm enlargement group than that in the no-filling or stable remnant filling groups (P < 0.001). Aneurysmal diameter and the presence of incorporated branches were independent predictors of aneurysm enlargement, while the presence of incorporated branches was the only independent predictor of persistent remnant filling. Aneurysm enlargement after FD is not uncommon, particularly when the aneurysm is large, has incorporated vessels, or does not undergo occlusion within 12 months, often culminating in major adverse events and unfavorable functional outcomes. In addition to investigating angiographic results, it is necessary to evaluate the changes in aneurysm size and clinical events when assessing the efficacy of FD. [ABSTRACT FROM AUTHOR]

A response to by Je Young Yeon, Jong-Soo Kim and Seung-Chyul Hong to a letter to the editor about their article which discusses the role of U.S. foreign aid temporary clipping in perforator damage during middle cerebral aneurysm surgery, is presented.

We aimed to evaluate the efficacy and safety of single-device flow diversion in patients with aneurysms measuring ≥15 mm in diameter. For this retrospective study, we extracted medical record data for patients with unruptured intracranial aneurysms, who underwent flow diversion, at the authors' institution between July 2014 and August 2019. The primary effectiveness outcome was defined as angiographic occlusion of the target aneurysm within 18 months without major (>50%) parent artery stenosis, major adverse events, or additional treatment. Thirty-five aneurysms in 35 patients were analyzed. Most aneurysms (n = 29, 82.9%) involved the anterior circulation. The median aneurysmal diameter was 18.3 mm, and the median neck size was 7.6 mm. Eleven (31.4%) aneurysms were considered giant (≥25 mm). The primary effectiveness outcome was achieved in 20 (57.1%) patients at a median of 10 months (interquartile range, 4.3–12.5) after flow diversion. Major adverse events occurred in 6 (17.1%) patients, including remote intraparenchymal hemorrhages (n = 2), a major ischemic stroke (n = 1), a delayed rupture of the target aneurysm (n = 1), and clinical deterioration caused by aggravated mass effect (n = 2). Multivariate logistic regression analysis found 2 independent predictors of the primary effectiveness outcome: the aneurysmal diameter (odds ratio, 0.71; 95% confidence interval, 0.54–0.86; P = 0.004) and the parent-vessel angle (odds ratio, 0.97; 95% confidence interval, 0.93–0.99; P = 0.017). Single-device flow diversion was shown to be ineffective for large or giant intracranial aneurysms with a high parent vessel angle. [ABSTRACT FROM AUTHOR]

Despite its relative rarity, the potential for loss of productive years makes aneurysmal subarachnoid hemorrhage (SAH) a considerably important entity in young adult patients (20–39 years of age). This study aimed to analyze outcomes of microsurgery (MS) and endovascular treatment (EVT) for saccular intracranial aneurysms (IAs) in young adult patients. A total of 276 young adult patients with 315 IAs, treated with MS or EVT between January 2001 and December 2015, were studied. Major recurrence and treatment-related complications were the primary outcome measures. Functional outcomes in patients with SAH were also assessed. Major recurrence occurred in 21 cases (6.7%). Younger age (adjusted hazard ratio [aHR], 3.77; 95% confidence interval [CI], 1.45–9.83; P = 0.007), ruptured IA (aHR, 6.44; 95% CI, 2.09–19.89; P = 0.001), size (aHR, 1.84; 95% CI, 1.06–3.18; P = 0.030), and EVT (aHR, 7.21; 95% CI, 2.44–21.35; P < 0.001) were independently related to major recurrence. Treatment-related complications occurred in 5 cases (1.6%) and did not differ between the MS and EVT groups (P > 0.999). Unfavorable outcomes (modified Rankin scale score ≥2) were identified in 30 patients (19.6%) with SAH, and only Hunt and Hess grade was independently associated with unfavorable functional outcome. Both MS and EVT are safe for treating IAs in young adult patients. MS showed better durability of treatment and may be preferred over EVT in young patients in view of their longer life expectancy compared with older patients. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of the present study was to evaluate the usefulness of transcranial motor evoked potential (MEP) monitoring and its impact on morbidity after surgical clipping of unruptured intracranial aneurysms. Methods: Motor outcomes were compared before and after the application of MEP monitoring for a one year period. A total intravenous anesthesia was induced and maintained with a continuous infusion of vecuronium. Muscle MEPs were elicited by constant voltage stimulation via subdermal needle electrodes placed at C3 and C4 positions. A more than 50% decrement of MEP amplitudes compared with baseline recordings was regarded as a warning sign and promptly indicated to the surgeon. Results: Before the application of MEP monitoring, a new motor deficit was observed in 3 of 66 patients. However, in 98 patients operated under MEP monitoring, no new motor deficit was found except for one patient who manifested delayed hemiparesis 30h after the operation owing to a cortical vein injury during craniotomy. MEPs deteriorated in 12 patients which were related to hypotension (n =1), temporary clipping (n =7), and permanent clipping (n =4), and recovered in all after prompt corrective measures. After surgical clipping of unruptured aneurysms, the absence of new motor deficits could be reliably anticipated by recovered MEPs as well as unchanged MEPs. Conclusions: Transcranial MEP monitoring is a simple, safe, and reliable tool for the prediction of postoperative motor functions. The ischemic complications can be reduced via prompt corrective measures taken on the basis of MEP changes during aneurysm surgery. [Copyright &y& Elsevier]