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The flow diversion technique is increasingly used for reconstructive endovascular treatment of fusiform cerebral aneurysms. Double stenting with the Low-profile Visualized Intraluminal Support (LVIS) Blue stent is one of the flow diversion techniques. The aim of this study was to analyze the clinical and angiographic outcomes of LVIS Blue double stenting for fusiform cerebral aneurysms.Between March 2016 and July 2020, double LVIS Blue stenting was attempted in 25 fusiform cerebral aneurysms. Patient medical records and radiological images were carefully reviewed.The technical success rate was 100% (25/25). Six aneurysms (24.0%) were located in the anterior circulation and 19 aneurysms (76.0%) were located in the posterior circulation. Intraprocedural thromboembolic complications occurred in 1 patient (4.0%). During the follow-up period (30.8 ± 14.2 months), there were no deaths or delayed complications. The mean angiographic follow-up duration was 28.2 ± 12.8 months. Follow-up angiography revealed complete obliteration (O'Kelly-Marotta D) in 21 (84.0%) patients and near-complete obliteration (O'Kelly-Marotta C + 2 matched with Kamran-Byrne grade 3) in 2 (8.0%) patients. Two patients (8.0%) showed worsening of obliteration grades. One (4.0%) patient required retreatment. There was no significant in-stent stenosis or branch occlusion covered by stents.Double stenting using LVIS Blue stents for the treatment of fusiform cerebral aneurysms is effective and safe.

Objective: The trend in the initial severity of aneurysmal subarachnoid hemorrhage (SAH) is unclear. This study aimed to evaluate whether there was an improvement in the initial severity of SAH over time.Methods: From January 1, 2005, to December 31, 2020, we identified patients who visited the emergency department of our institution with SAH due to intracranial aneurysm rupture. We identified the Hunt Hess (HH) grade and modified Fisher grade of each patient from the medical records, and the Mann-Kendal method was used to estimate the trend of each grade system.Results: A total of 547 patients with SAH were identified. The mean age of the patients was 59.3 years (standard deviation (SD), 14.6). The mean aneurysm size was 6.9 mm (SD, 4.6 mm). The most frequent aneurysm location was the anterior communicating artery (28.7%). In the Mann-Kendal estimates for the analysis of the trend, there was no statistically significant grade throughout the HH and modified Fisher grades. Similarly, there was no improvement throughout all grades in the modified Fisher grade over time.Conclusions: The initial severity of SAH due to cerebral aneurysm rupture did not improve over time.

Objective : Endovascular treatment of large, wide-necked intracranial aneurysms by coil embolization is often complicated by low rates of complete occlusion and high rates of recurrence. A flow diverter device has been shown to be safe and effective for the treatment of not only large and giant unruptured aneurysms, but small and medium aneurysms. However, in Korea, its use has only recently been approved for aneurysms

Objective : Stent-assisted coil embolization (SAC) has been increasingly used to treat various types of intracranial aneurysms. Delayed thromboembolic complications are major concerns regarding this procedure, so dual antiplatelet therapy with aspirin and clopidogrel is needed. However, clinicians vary the duration of dual antiplatelet therapy after SAC, and no randomized study has been performed. This study aims to compare the safety and efficacy of long-term (12 months) dual antiplatelet therapy and shortterm dual antiplatelet therapy (6 months) after SAC for patients with unruptured intracranial aneurysms (UIAs).Methods : This is a prospective, randomized and multicenter trial to investigate the optimal duration of dual antiplatelet therapy after SAC in patients with UIAs. Subjects will receive dual antiplatelet therapy for 6 months (short-term group) or 12 months (longterm group) after SAC. The primary endpoint is the assessment of thromboembolic complications between 1 and 18 months after SAC. We will enroll 528 subjects (264 subjects in each group) and perform 1 : 1 randomization. This study will involve 14 topperforming, high-volume Korean institutions specializing in coil embolization.Results : The trial will begin enrollment in 2022, and clinical data will be available after enrollment and follow-up.Conclusion : This article describes that the aim of this prospective randomized multicenter trial is to compare the effect of short-term (6 months) and long-term (12 months) dual antiplatelet therapy on UIAs in patients undergoing SAC, and to find the optimal duration.

There are few reports on the preventative value of intensive blood pressure (BP) management for stroke in the literature since the new criteria for hypertension (HTN) were announced by the American College of Cardiology/American Heart Association in 2017. To identify the optimal BP for the primary prevention of stroke in a healthy population aged between 19 and 65 years, we conducted a 10-year observational study on the risk of stroke, subclassified as hemorrhagic stroke (hSTK) and ischemic stroke (iSTK), according to BP categories (e.g., low-normal BP, high-normal BP, elevated BP, stage 1 HTN and stage 2 HTN) using the National Health Insurance Service Database. Of the 8,327,751 participants who had a health checkup in 2008, 949,551 were ultimately enrolled in this study and observed from 2009 to 2018. The risk of hSTK was significantly increased from stage 2 HTN (adjusted hazard ratio (AHR) 3.036 [95% confidence interval (CI), 2.159–4.252]) in men and from stage 1 HTN (AHR 2.972 [95% CI, 2.256–3.897]) in women. The risk of iSTK was significantly increased among both men (AHR 1.404 [95% CI, 1.164–1.693]) and women (AHR 2.012 [95% CI, 1.603–2.526]) with stage 1 HTN. The risk of overall stroke was significantly increased in men (AHR 1.386 [95% CI, 1.180–1.629]) and women (AHR 2.363 [95% CI, 1.973–2.830]) from stage 1 HTN. Therefore, for the primary prevention of overall stroke, adults under the age of 65 should manage their BP from stage 1 HTN.

Objective The treatment of multiple intracranial aneurysms (MIAs) involves various modalities and sometimes requires staged operations. This study aimed to prove the efficacy and safety of one-stage multiple craniotomies (OSMC) for multiple cerebral aneurysms. Methods We retrospectively reviewed the medical records of the patients who underwent treatment for intracranial aneurysms between May 2003 and April 2020. The surgical results, complications, and lengths of hospital stay were compared between the patients who underwent OSMC and those who underwent multi-stage multiple craniotomies (MSMC). Results The demographic characteristics of the OSMC and MSMC groups (n=82 and 43, respectively) were similar. There were no statistically significant differences between the two groups when the amount of blood transfused, complications, and surgical results were compared (p=n.s. for all); however, the operation time and hospitalization period (353.9 min vs. 490.3 min and 12.3 days vs. 21.8 days, respectively; p=0.001 for both) were shorter in the OSMC group. The treatment cost (17,000 USD vs. 22,000 USD, p=0.001) was lower in the OSMC group. Conclusions OSMC for aneurysm clipping in patients with MIAs is a relatively safe and economical method. Furthermore, it has good clinical outcomes. This new surgical method is worthwhile in that it can be applied to patients who are afraid to undergo multiple surgeries, and we suggest it is an efficient, low-cost option for the treatment of MIAs.

There arefew reports on the preventative value of intensive blood pressure (BP) management for stroke, especially hemorrhagic stroke (hSTK),after new criteria for hypertension (HTN) were announced by theAmerican College of Cardiology/American Heart Association in 2017. To identify the optimal BP for the primary prevention of hSTK in a healthy population aged between 20 and 65 years, we conducted a 10-yearobservational study on the risk of hSTK, subclassified as intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) according to BP categories (e.g.,low normal BP, high normal BP, elevated BP, stage 1 HTN and stage 2 HTN) using the National Health Insurance Service Database. Of the 8,325,579 participants who had a health checkup in 2008, 947,378 were ultimately enrolled in this study and observed from 2009 to 2018. The risk of ICH was significantly increased from stage 2 HTN (adjusted hazard ratio (AHR) 2.002 [95% confidence interval (CI) 1.203-3.332]) and stage 1 HTN (AHR 2.021 [95% CI, 1.251-3.263]) in men and women, respectively. The risk of SAH was significantly increased among both men (AHR 1.637 [95% CI, 1.066-2.514]) and women (AHR 4.217 [95% CI, 2.648-6.715]) from stage 1 HTN. The risk of hSTK was significantly increased among men with stage 2 HTN (AHR 3.034 [95% CI, 2.161-4.260]) and women with stage 1 HTN (AHR 2.976 [95% CI, 2.222-3.986]).Therefore, for the primary prevention of hSTK, including ICH and SAH, adults under the age of 65 should manage their BP from stage 1 HTN.

Objective : Placement of a single transverse stent via the nondominant A1 across the anterior communicating artery (AComA) into the contralateral A2 can provide sufficient neck coverage for wide-necked bifurcation AComA aneurysms. The authors described the feasibility, safety and long-term outcomes of this technique.Methods : Between January 2015 and February 2018, placement of a single transverse stent via the nondominant A1 was attempted in 17 wide-necked bifurcation AComA aneurysms. The authors reviewed the medical records and radiological studies.Results : The technical success rate was 94.1% (16/17). Periprocedural thromboembolic complications occurred in one patient (6.3%) without permanent neurological deficits. The mean clinical follow-up duration was 39.9±9.8 months. No deaths or delayed thromboembolic complications occurred. The mean angiographic follow-up duration was 38.9±9.8 months. The immediate and final follow-up complete occlusion rates were 87.4 and 93.7%, respectively. There was no recanalization during the follow-up period.Conclusion : Placement of a single transverse stent via the nondominant A1 across the AComA into the contralateral A2 is a feasible and relatively safe endovascular technique for the treatment of wide-necked bifurcation AComA aneurysms, with good long-term occlusion rates and a reasonable complication rate, if only the nondominant A1 is applicable.

The recurrence rate of posterior communicating artery (Pcom) aneurysms after endovascular treatment (EVT) is higher than that for aneurysms located in other sites. However, it is still unclear what mechanisms are responsible for the recanalization of cerebral aneurysms. In this investigation, we compared hemodynamic factors related with recanalization of Pcom aneurysms treated by endoluminal coiling using computational fluid dynamics (CFD) with high-resolution three-dimensional digital subtraction angiography images. Twenty patients were enrolled. A double-sinogram acquisition was performed with and without contrast injection after coil embolization to get true blood vessel lumen by relatively complementing the first sinogram with the second. Adaptive Cartesian meshing was performed to produce vascular wall objects for CFD simulation. The boundary condition for inlet (ICA) was set for dynamic velocity according to the cardiac cycle (0.8 s). Hemodynamic parameters were recorded at two specific points (branching point of Pcom and residual sac). The peak pressure, peak WSS, and oscillatory shear index (OSI) were recorded and analyzed. The median age was 61.0 years, and 18 patients (90%) were female. During a median follow-up of 12 months, seven (35%) treated aneurysms showed recanalization. The median aneurysm volume was significantly higher, and aneurysm height and neck sizes were significantly longer in the recanalization group than those in the stable group. At the branching point of the Pcom, the peak pressure, peak WSS, or OSI did not significantly differ between the two groups. The only statistically significant hemodynamic parameter related with recanalization was the OSI at the aneurysm point. Multivariate logistic regression showed that with an increase of 0.01 OSI at the aneurysm point, the odds ratio for the aneurysm recanalization was 1.19. A higher OSI is related with recanalization after coil embolization for a Pcom aneurysm.

Objective To analyze the incidence and treatment trends of hemorrhagic stroke (HS), according to HS subtypes, using nationwide data in Korea from January 2008 to December 2016. Methods We used data from the national health-claim database provided by the National Health Insurance Service for 2008–2016 using the International Classification of Diseases. The crude incidence and age-standardized incidence of each disease associated with HS, which included intracranial aneurysm (IA), hypertensive intracerebral hemorrhage (ICH), and arteriovenous malformation (AVM), were calculated and additional analysis was conducted according to age and sex. Changes in trends in treatment methods and number of treatments were analyzed for each cerebrovascular disease using the Korean Classification of Diseases procedure codes. Results In 2016, the total number of newly diagnosed adult patients with HS was 24169, showing a decrease by 7.0% since 2008; the age-standardized incidence of HS was 46.2 per 100000 person-years. The age-standardized incidence of unruptured IA (UIA) in adults was 71.4 per 100000 person-years—increased by 2.6-fold since 2008—while that of ruptured IA (RIA) was 12.6 per 100000 person-years, which had decreased at a rate of 20.3% since 2008. The number of coil embolization (CE) for UIA increased by 3.4-fold over 9 years and exceeded that of clipping since 2008. With respect to RIA, CE increased by 2.0-fold over 9 years and exceeded that of clipping from 2014. As for spontaneous ICH in adults, the age-standardized incidence was 31.3 per 100000 person-years in 2016—decreased by 34.7% since 2008—and 14.6% of patients diagnosed with ICH were treated in 2016, which was not significantly different from the proportion of patients treated since 2008. The age-standardized incidence of unruptured AVM (UAVM) was 2.0 per 100000 person-year in 2016, while that of ruptured AVM (RAVM) was 2.4 per 100000 person-years in 2016, showing a decreasing rate of 17.2% from 2008. The total number of treated patients with AVM declined since 2014. Conclusion In Korea, age-related cerebral vascular diseases, such as RIA, ICH, and RAVM, demonstrated a declining trend in agestandardized incidence; meanwhile, UIA and UAVM demonstrated an increased trend in both crude incidence and age-standardized incidence for 9 years. The increase in the elderly population, management of hypertension, and development of diagnostic and endovascular techniques appear to have influenced this trend.

Background We aimed to analyze outcomes of clipping and coiling in treating unruptured intracranial aneurysms (UIAs) in elderly patients and to identify the age at which perioperative risk increases based on national cohort data in South Korea. Methods The incidence of perioperative intracranial hemorrhage (ICRH), perioperative cerebral infarction (CI), mortality, and moderate to severe disability data of the patients who underwent coiling or clipping for UIAs were retrieved. Estimated breakpoint (EBP) was calculated to identify the age at which the risk of treatment increases. Results A total of 38,207 patients were treated for UIAs. Among these, 22,093 (57.8%) patients underwent coiling and 16,114 (42.2%) patients underwent clipping. The incidence of ICRH, requiring a secondary operation, within 3 months in patients ≥ 65 years that underwent coiling and clipping was 1.13% and 4.81%, respectively, and that of both groups assessed were significantly higher in patients ≥ 75 years (coiling, P = 0.013, relative risk (RR) 1.81; clipping, P = 0.015) than younger patients. The incidence of CI within 3 months in patients aged ≥ 65 was 13.90% and 9.19% in the coiling and clipping groups, respectively. The incidence of CI after coiling in patients aged ≥ 75 years (P < 0.001, RR 1.96) and after clipping in patients aged ≥ 70 years (P < 0.001, RR 1.76) was significantly higher than that in younger patients. The mortality rates within 1 year in patients with perioperative ICRH or CI were 2.41% and 3.39% for coiling and clipping groups, respectively, in patients ≥ 65. These rates increased significantly at age 70 in the coiling group and at age 75 for the clipping group (P = 0.012 and P < 0.001, respectively). Conclusion The risk of treatment increases with age, and this risk increases dramatically in patients aged ≥ 70 years. Therefore, the treatment decisions in patients aged ≥ 70 years should be made with utmost care., Graphical Abstract

Objective To analyze the angiographic features and clinical course, including treatment outcomes and the natural course, of fusiform middle cerebral artery aneurysms (FMCAAs) according to their location, size, and configuration. Methods We reviewed the literature on adult cases of FMCAAs published from 1980 to 2018; from 25 papers, 112 FMCAA cases, for which the location, size, and configuration could be identified, were included in this study. Additionally, 33 FMCAA cases in our hospital were included, from which 16 were assigned to the observation group. Thus, a total of 145 adult FMCAA cases were included. We classified the FMCAAs according to their location (l-type 1, beginning from prebifurcation; l-type 2, beginning from bifurcation; l-type 3, beginning from postbifurcation), size (small

Objective Since less invasive endovascular treatment was introduced to South Korea in 1994, a considerable proportion of endovascular treatments have been performed by neuroradiology doctors, and endovascular treatments by vascular neurosurgeons have recently increased. However, few specific statistics are known regarding how many endovascular treatments are performed by neurosurgeons. Thus, authors compared endovascular treatments collaboratively performed by vascular neurosurgeons with all cases throughout South Korea from 2013 to 2017 to elucidate the role of neurosurgeons in the field of endovascular treatment in South Korea. Methods The Society of Korean Endovascular Neurosurgeons (SKEN) has issued annual reports every year since 2014. These reports cover statistics on endovascular treatments collaboratively or individually performed by SKEN members from 2013 to 2017. The data was requested and collected from vascular neurosurgeons in various hospitals. The study involved 77 hospitals in its first year, and 100 in its last. National statistics on endovascular treatment from all over South Korea were obtained from the Healthcare Bigdata Hub website of the Health Insurance Review & Assessment Service based on the Electronic Data Interchange (EDI) codes (in the case of intra-arterial (IA) thrombolysis, however, statistics were based on a combination of the EDI and I63 codes, a cerebral infarction disease code) from 2013 to 2017. These two data sets were directly compared and the ratios were obtained. Results Regionally, during the entire study period, endovascular treatments by SKEN members were most common in Gyeonggido, followed by Seoul and Busan. Among the endovascular treatments, conventional cerebral angiography was the most common, followed by cerebral aneurysmal coiling, endovascular treatments for ischemic stroke, and finally endovascular treatments for vascular malformation and tumor embolization. The number of endovascular treatments performed by SKEN members increased every year. Conclusion The SKEN members have been responsible for the major role of endovascular treatments in South Korea for the recent 5 years. This was achieved through the perseverance of senior members who started out in the midst of hardship, the establishment of standards for the training/certification of endovascular neurosurgery, and the enthusiasm of current SKEN members who followed. To provide better treatment to patients, we will have to make further progress in SKEN.

OBJECTIVEBrain arteriovenous malformation (BAVM) is a rare cerebrovascular disease that causes intracranial hemorrhage. Although several reports have demonstrated the epidemiological features of BAVM in Western countries, no epidemiological investigations regarding BAVM have been reported in Korea. The authors aimed to investigate the national epidemiology of ruptured BAVM in a Korean population.METHODSThe authors used data from the National Health Insurance Service–National Sample Cohort (NHIS-NSC). The original cohort included approximately 1 million individuals (2% of the Korean population) with 12-year claim data (2002–2013). To construct an initial cohort for investigation, the authors selected 1,016,820 registered individuals in 2005. Subjects with a history of cerebrovascular disease (code I6xx) and BAVM (Q282) between 2002 and 2004 were washed-out to identify incident cases. During the 9-year follow-up (2005–2013), the incidence of BAVM was calculated using the earliest date of diagnosis of ruptured or unruptured BAVM. Direct standardization was applied to the crude incidence. Mortality and disability were evaluated using registration data. Related diagnostic procedures were also analyzed.RESULTSA total of 8,802,696 person-years of observation were noted. During observation, 308 patients were diagnosed with a ruptured BAVM. The crude incidence of ruptured BAVM was 3.5 per 100,000 person-years. There was no sex difference in incidence. The mortality rate for patients with a ruptured BAVM 1 month after diagnosis was 12.7%. At 1-year and 5-year follow-up examinations, mortality rates were 17.2% and 22.1%, respectively. Severe disability–free survival rates of patients with ruptured AVMs were 75.3% and 69.8% at 1-year and 5-year follow-up, respectively.CONCLUSIONSThe standardized incidence of ruptured BAVMs was 3.6 per 100,000 person-years in Korea. Ruptured BAVMs resulted in high mortality and disability rates.

Background Recently, innovative attempts have been made to identify moyamoya disease (MMD) by focusing on the morphological differences in the head of MMD patients. Following the recent revolution in the development of deep learning (DL) algorithms, we designed this study to determine whether DL can distinguish MMD in plain skull radiograph images. Methods Three hundred forty-five skull images were collected as an MMD-labeled dataset from patients aged 18 to 50 years with definite MMD. As a control-labeled data set, 408 skull images of trauma patients were selected by age and sex matching. Skull images were partitioned into training and test datasets at a 7:3 ratio using permutation. A total of six convolution layers were designed and trained. The accuracy and area under the receiver operating characteristic (AUROC) curve were evaluated as classifier performance. To identify areas of attention, gradient-weighted class activation mapping was applied. External validation was performed with a new dataset from another hospital. Findings For the institutional test set, the classifier predicted the true label with 84·1% accuracy. Sensitivity and specificity were both 0·84. AUROC was 0·91. MMD was predicted by attention to the lower face in most cases. Overall accuracy for external validation data set was 75·9%. Interpretation DL can distinguish MMD cases within specific ages from controls in plain skull radiograph images with considerable accuracy and AUROC. The viscerocranium may play a role in MMD-related skull features. Fund This work was supported by grant no. 18-2018-029 from the Seoul National University Bundang Hospital Research Fund.

BackgroundThe role of the inhibition rate of VerifyNow in assessing the thromboembolic risk of coil embolization for unruptured intracranial aneurysms is unclear.ObjectiveTo carry out a retrospective study to determine whether the inhibition rate could provide additional help in predicting thromboembolic events when it was used for patients with a P2Y12 reaction unit (PRU) level of 220 or lower.MethodsPatients who underwent coil embolization for unruptured aneurysms with an appropriate PRU level (PRU 220 or lower) between January 1, 2015 and December 31, 2018 were analyzed. A total of 954 patients with 1020 aneurysms were included in this study. The primary outcome was the thromboembolic events occurring within 30 days after coil embolization. The receiver operating characteristic (ROC) curve and the area under the curve (AUC) were obtained to determine the quantitative predictive ability of the inhibition rate. The optimal cut-off value was derived using the Youden index.ResultsThromboembolic events developed in 11 patients (1.08% of 1020 procedures). The AUC of the ROC curve was 0.83. The optimal cut-off value of the inhibition rate derived using the maximum Youden index was 22.0%. A sensitivity test using a multiple logistic regression analysis demonstrated that the inhibition rate was a significant variable for predicting thromboembolic events.ConclusionsThe inhibition rate can be used to determine high thromboembolic risks for patients with PRU levels of 220 or lower. The optimal cut-off value of the inhibition rate was 22.0% when the PRU level was 220 or less.

Objective : Drug-eluting stents and balloons are occasionally used to reduce restenosis in medically intractable intracranial atherosclerotic stenosis. The authors aimed to determine whether such drugs can cause neurotoxicity due to local effects in a rat model.Methods : Intra-arterial catheters were placed in the right common carotid artery of rats. Mannitol was injected to transiently open the brain-blood barrier (BBB), followed by high-dose drug (paclitaxel and rapamycin) injection. The optimal time interval of transient BBB opening for maximal drug penetration was determined to be 10 minutes. Paclitaxel and rapamycin were intraarterially administered in various doses. All the rats were neurologically evaluated, and their brain tissues were histologically examined.Results : Neither neurological deficits nor histological abnormalities were observed in all the rats.Conclusion : Paclitaxel and rapamycin did not cause neurotoxicity in a rat model with transient BBB opening.

The treatment of multiple intracranial aneurysms (MIAs) involves various modalities and sometimes requires staged operations. This study aimed to prove the efficacy and safety of one-stage multiple craniotomies (OSMC) for multiple cerebral aneurysms. We retrospectively reviewed the medical records of the patients who underwent surgical clipping of an intracranial aneurysm at Seoul National University Bundang Hospital between 2003 and April 2020. The surgical results, complications, and lengths of hospital stay were compared between the patients who underwent OSMC and those who underwent multi-stage multiple craniotomies (MSMC). The demographic characteristics of the OSMC and MSMC groups (n = 82 and 43, respectively) were similar. There were no statistically significant differences between the two groups when the amount of blood transfused, complications, and surgical results were compared (p = 0.925, p = 0.528, and p = 0.898, respectively); however, the operation time and hospitalization period (353.9 min vs. 490.3 min and 12.3 days vs. 21.8 days, respectively; p

ENDOVASCULAR TREATMENT CAVERNOUS CAROTID ANEURYSM WITH PIPELINE FLEX EMBOLIZATION DEVICE: 1-YEAR FOLLOW UPABSTRACTAsymptomatic intracranial aneurysms are usually detected accidentally through neuroimaging. However, a large intracranial aneurysm (15-24mm) is more likely to manifest clinically due to its mass effect. Aneurysms in the cavernous segment of carotid artery generally exhibit occulomotor nerve palsy, headache and dizziness. The selection of endovascular therapy depends on the type and morphology of the aneurysm. Currently, the treatment options were stent-assisted coil and pipeline embolization device (PED). We reported two cases of large symptomatic unruptured cavernous carotid aneurysm (CCA), treated with the flow diverter technique using a pipeline flex embolization device (PED flex) the second generation of PED. The first case was a 59-year-old woman with complaint of diplopia and headache. Computed Tomography (CT) angiography and 3 dimensional (D) brain imaging revealed bilateral aneurysms, one was in the right cavernous carotid (16.1x16.6mm) and the other was in the left cavernous carotid (9.2x6.5mm). In second case a 67-year-old woman with complaint of headache. Magnetic resonance angiography (MRA) revealed a 15mm aneurysm in the right cavernous carotid. Both aneurysms were treated using PED flex (4.75mm diameter/25mm length and 4mm diameter/25mm length, respectively), except the left cavernous carotid aneurysm in the first case. Six month and one year follow up angiograms were obtained, and showed complete occlusion of aneurysms. Flow diverter technique using PED flex is a feasible and effective treatment for large symptomatic unruptured carotid cavernous aneurysms.Keywords: Embolization, flow-diverter, large cavernous carotid aneurysms, pipeline flex embolization device (PED flex)ABSTRAKAneurisma intrakranial asimptomatik biasanya terdeteksi secara tidak sengaja melalui pemeriksaan pencitraan neuroradiologis. Akan tetapi aneurisma intrakranial yang besar (15-24mm) cenderung memberikan gejala klinis akibat efek massa yang ditimbulkan. Apabila aneurisma terletak di arteri karotis segmen kavernosa, penderita dapat mengalami paresis nervus okulomotor dan juga terkadang memberikan gejala nyeri kepala serta rasa pusing. Pemilihan terapi endovaskuler bergantung pada tipe dan morfologi dari aneurisma. Saat ini, pemilihan terapi endovaskuler dapat berupa stent-assisted coiling dan alat embolisasi pipeline. Kami melaporkan dua kasus aneurisma karotis kavernosa (AKK) tidak pecah berukuran besar simptomatik dengan teknik flow-diverter menggunakan pipeline flex embolization device (PED flex) yang merupakan generasi kedua dari alat embolisasi pipeline. Pada kasus pertama wanita 59 tahun dengan keluhan diplopia dan nyeri kepala, pemeriksaan Computed Tomography (CT) angiografi dan 3 dimensi (D) otak ditemukan aneurisma pada karotis kavernosa bilateral, yang masing-masing berukuran (16,1x16,6mm) pada sisi kanan dan (9,2x6,5mm) pada sisi kiri. Pada kasus kedua, wanita 67 tahun dengan keluhan nyeri kepala. Pemeriksaan MRA otak ditemukan aneurisma berukuran 15mm pada karotis kavernosa sebelah kanan. Masing-masing aneurisma diterapi dengan PED flex (4,75mm diameter/25mm panjang dan 4mm diameter/25mm panjang), kecuali aneurisma pada karotis kavernosa sebelah kiri pada kasus pertama. Follow-up pada enam bulan dan satu tahun kemudian, dengan pemeriksaan angiografi, menunjukkan oklusi komplet pada masing- masing aneurisma. Terapi endovaskular dengan teknik flow-diverter menggunakan PED flex merupakan modalitas terapi yang efektif dan dapat dilaksanakan untuk aneurisma karotis kavernosa berukuran besar bergejala.Kata kunci: Aneurisma karotis kavernosa besar, embolisasi, flow-diverter, pipeline flex embolization device (PED flex)

BackgroundNeuromuscular block (NMB) used during general anesthesia induces transient skeletal muscle paralysis, but patient movements during endovascular coiling still occur to some degree. Compared with moderate NMB, deep NMB may further improve the intervention condition during endovascular coiling for unruptured cerebral aneurysms; however, little research has focused on the angiographic image quality.MethodsThis prospective, randomized, double-blind clinical trial included 58 patients treated for unruptured cerebral aneurysms with endovascular coiling under general anesthesia. Patients were randomly allocated to either the deep NMB group (post-tetanic count 1 or 2) or the moderate NMB group (train-of-four 1 or 2). The primary outcome was the proportion of patients with a satisfactory intervention condition assessed by surgeons after the procedure using a 5-point intervention condition rating scale (ICRS) from 1 (unable to obtain image) to 5 (optimal); ICRS 5 was defined as satisfactory.ResultsThere were significantly more cases of satisfactory intervention condition in the deep NMB group than in the moderate NMB group (82.1% vs 51.7%, p=0.015). The frequency of each ICRS score was significantly different between the groups (ICRS 5/4/3/2/1: 23/5/0/0/0 vs 15/9/2/3/0, p=0.035). The incidence of major patient movement requiring rescue muscle relaxant was 10.3% in the moderate NMB group and 0% in the deep NMB group (p=0.237). The drugs used to maintain hemodynamic stability were not significantly different between the two groups.ConclusionsDeep NMB improves the intervention condition during endovascular coiling by improving the image quality.

Proximal middle cerebral artery (M1 segment) aneurysms are relatively deeply located in neighboring lenticulostriate arteries, which make them unsuitable for microsurgery. We aimed to investigate the clinical and radiological outcomes of endovascular coiling of M1 segment aneurysms. Between January 2003 and December 2014, we retrospectively reviewed the medical records of 52 patients (52 aneurysms) from four institutions who underwent endovascular coiling of M1 segment aneurysms. Patients who underwent clinical and radiologic follow-up for more than a year after the procedure were evaluated. The aneurysms were located in the early frontal branch, early temporal branch, and lenticulostriate artery in 28, 15, and nine patients, respectively. Endovascular coiling was achieved in 51 cases and failed in one case. Of these 51 cases, 46 (90.2%) and five (9.8%) were non-ruptured and ruptured aneurysms, respectively. Initial angiographic results revealed complete occlusion in 26 (51.0%), residual neck in 16 (31.4%), and residual sac in nine (17.6%) cases. One failed case had a symptomatic procedural complication of thromboembolism. However, there was no permanent morbidity or mortality. Two major recanalization cases (3.9%) were retreated by endovascular coiling. On multivariable logistic regression analysis, aneurysmal recurrence was significantly related to aneurysm height (OR, 1.887; 95% CI, 1.107 to 3.217; p = 0.020), width (OR, 1.836; CI, 1.127 to 2.992; p = 0.015), and neck (OR, 4.017; CI, 1.220 to 13.232, p = 0.022). Endovascular coiling of M1 segment aneurysms appeared to be a feasible treatment option with a relatively low-retreatment rate. Aneurysm size was statistically significantly associated with recurrence.

The optimal duration of dual-antiplatelet therapy (DAPT) for preventing delayed thromboembolic events (DTEs) remains unclear. We aimed to determine whether longer DAPT provides improved protection against delayed DTEs.This retrospective cohort study included 507 stent-assisted coil embolization procedures using a single stent for unruptured intracranial aneurysms. We performed coarsened exact matching according to the duration of maintenance DAPT. DTEs were defined as any neurologic symptoms concerning the stented vascular territory and occurring at 1 month or later after the procedure. After stratification according to DAPT duration (short-term,9 months; long-term, ≥9 months), the log-rank test and Z-analysis were performed to evaluate the efficacy of long-term DAPT for preventing DTEs.Of 507 treated patients (median follow-up, 44 months), 25 (4.9%) experienced DTEs at 1 month after the procedure. Among all DTEs, 9 (1.8%) were infarctions confirmed on magnetic resonance imaging. Permanent neurologic deficit (modified Rankin Scale score ≥2) occurred in 2 (0.4%) patients. On procedure-to-event analysis, long-term DAPT was not superior for preventing DTEs. Most events occurred within 1 month of switching from DAPT to single-antiplatelet therapy, regardless of DAPT duration. The longest time from the procedure to DTE occurrence was 22 months. Age older than 54.5 years was identified as independent risk factor for DTE-stroke.Compared with short-term DAPT, long-term DAPT delays the occurrence of DTEs but does not lower their incidence. Longer-term DAPT (9 months) should be considered after stent-assisted coil embolization for unruptured intracranial aneurysms, although its efficacy remains to be clarified.

BackgroundThe long-term outcomes of endovascular coiling and surgical clipping for the treatment of unruptured intracranial aneurysms are unclear.MethodsWe performed a nationwide retrospective cohort study using claims data from the Korean Health Insurance Review and Assessment Service on patients undergoing surgical clipping or endovascular coiling from 2008 to 2014. Inverse probability treatment weighting for average treatment effect on the treated and the multiple imputation method were used to balance covariates and handle missing values. The primary outcome was all-cause mortality at 7 years.ResultsWe identified 26 411 patients of whom 11 777 underwent surgical clipping and 14 634 underwent endovascular coiling. After adjustment with the use of inverse probability treatment weighting for average treatment effect on the treated, all-cause mortality rates at 7 years were 3.8% in the endovascular coiling group and 3.6% in the surgical clipping group (HR 1.05; 95% CI 0.86 to 1.28; P=0.60, log-rank test). The adjusted probabilities of aneurysm rupture at 7 years were 0.9% after endovascular coiling and 0.7% after surgical clipping (HR 0.9; 95% CI 0.61 to 1.34; P=0.63, log-rank test). The probabilities of retreatment at 7 years after adjustment were 4.9% in the endovascular coiling group and 3.2% in the surgical clipping group (HR 1.52; 95% CI 1.28 to 1.81; PConclusionsAll-cause mortality at 7 years was similar between the elective surgical clipping and endovascular coiling groups in patients with unruptured aneurysms who had no history of subarachnoid hemorrhage due to aneurysm rupture.

BACKGROUND AND PURPOSE: During stent-assisted coiling of ICA aneurysms, stent tips are sometimes unintentionally embedded into ICA branches. Stent tips can be visualized because they have radiopaque markers. Concerns regarding stent tip misplacement include risks of artery perforation and occlusion. The aim of this study was to evaluate the long-term outcomes of ICA branches with embedded stent tips. MATERIALS AND METHODS: ICA branches with embedded stent tips were identified among 35 patients with unruptured ICA aneurysms treated with stent-assisted coiling between November 2003 and November 2014. Patient clinical and angiographic outcomes associated with the embedded stent tip were analyzed. RESULTS: Most of the 35 studied aneurysms were paraclinoid ICA aneurysms (n = 30). The most commonly involved ICA branch was the posterior communicating artery (26 patients, 74.3%), followed by the anterior choroidal artery (8 patients, 22.9%) and ophthalmic artery (1 patient, 2.9%). During the follow-up period (38.6 ± 17.9 months), no new neurologic deficits developed. Neither hemorrhagic nor thromboembolic events occurred. Angiography was performed during the final follow-up evaluation at a mean of 32.7 ± 18.0 months, and all ICA branches with embedded stent tips showed patent blood flow without severe luminal narrowing. CONCLUSIONS: In our experience, placement of a stent tip into ICA branches during stent-assisted coiling was not associated with any major adverse events.

Background: Blood pressure variability (BPV) is associated with target organ damage progression and increased cardiovascular events, including stroke. The aim of this study was to evaluate the associations between short-term BPV during acute periods and recanalization degree, early neurological deterioration (END) occurrence, and functional outcomes in acute ischemic stroke patients who had undergone intra-arterial thrombectomy (IAT). Methods: We retrospectively analyzed 303 patients with large vessel occlusive stroke who underwent IAT. The following BPV parameters, measured over 24 and 48 h after IAT, were compared: the mean, SD, coefficient of variation (CV), variation independent of the mean (VIM) for both the systolic BP (SBP) and diastolic BP, and the proportion of nocturnal SBP risers. Results: BPV parameters decreased with higher recanalization degree. The mean SBP (SBPmean) over 24 and 48 h after IAT, and the SD of SBP (SBPSD), CV of SBP (SBPCV), and VIM of SBP (SBPVIM) during the 48 h following the procedure had significant associations with recanalization degree. Patients with END had higher BPV than that of those without END, and the difference was more evident for incomplete recanalization. Increased BPV was associated with a shift toward poor functional outcome at 3 months after adjustment, including recanalization degree (OR range for significant parameters, 1.26–1.64, p = 0.006 for 48 h SBPmean, p = 0.003 for 48 h SBPCV, otherwise p < 0.002). Conclusions: Short-term BPV over 24 and 48 h after IAT in acute ischemic stroke patients was related to recanalization degree, and END occurrence, and may be an independent predictor of clinical outcome.

We investigated the association between early recanalization degree after intravenous thrombolysis (IVT), occurrence of hemorrhagic transformation, and functional outcome. We also evaluated whether recombinant tissue plasminogen activator (rTPA) dosing error could influence the outcome. Patients with ischemic stroke with major vessel occlusion (n=256) who underwent IVT were included. Recanalization status (no recanalization, partial recanalization, and complete recanalization) was confirmed by subsequent magnetic resonance or conventional angiography. Association between early recanalization degree and favorable outcome (modified Rankin Scale score ≤2) was evaluated using logistic regression analysis. Early partial recanalization was achieved in 33 (12.9%), and complete recanalization in 7 (2.7%) patients. Patients with the highest quintile of rTPA dosage achieved complete recanalization more frequently than the lower four quintiles (8.0% vs 2.0%, P=0.03). Hemorrhagic transformation tended to occur more frequently in patients with complete recanalization as compared with patients with partial recanalization (57.1% vs 21.2%, P=0.15). The proportion of favorable outcome was significantly lower in patients with the highest quintile of rTPA dosage used as compared with the patients with lower four quintiles (40.8%, 57.0%, P=0.04). In multivariable analysis, partial recanalization was significantly associated with favorable outcome (adjusted odds ratio, 3.15; 95% CI, 1.06-9.35), but complete recanalization was not. Early partial recanalization after IVT may be an indicator of favorable outcome with low occurrence of any hemorrhagic transformation.

Background: Several endovascular techniques and devices are presently available for the non-surgical treatment of basilar-tip aneurysms in dedicated neurovascular departments. However, the revolving drawback to treatment to angiographic approach remains the long-term coil-mass durability and less patent published results regarding treatment outcome and long-term efficacy. We aim to share our experience of selected endovascular techniques for treating basilar-tip aneurysms and its long-term clinical and angiographic outcome. Material and methods: We retrospectively reviewed 109 patients basilar-tip aneurysm who had endovascular treatment in our department from 2003 to 2014. Three groups were based on treatment method: single microcatheter (SM), multiple microcatheters (MM), and stent-assisted (SA) coiling techniques. All procedural-related complications and outcomes were followed and analyzed. Angiographic follow-up with accompanying skull-series review were evaluated from initial coil-mass occlusion time to the last follow-up outpatient attendance. Results: In our study, sac size (p 11 mm (p 4 mm (p = 0.006). Conclusion: Small aneurysms particularly those with a small-neck size can be treated with SM or MM approach. Medium-large sized aneurysm can be treated effectively by combined MM and SA techniques.

Summary Background and purpose To determine whether status of dominant vertebral artery could affect clinical outcome in patients with symptomatic basilar artery occlusion (BAO). Methods We reviewed patients with symptomatic BAO who underwent endovascular treatment at the institute between January 2007 and July 2014. Patients were categorized into 2 groups according to functional outcome and baseline characteristics, treatment related factors were compared. Variables including clinical and imaging parameters were also compared according to the dominant V1 lesion. Results Fifty-nine of 101 patients underwent endovascular treatment and 23 patients (39.0%) showed favorable outcome (modified Rankin score ≤3 at 3 month). Younger age, male sex, lower baseline NIHSS score, higher PC-ASPECTS, absence of hemorrhagic transformation, shorter procedure time, and complete recanalization were associated with favorable outcome. Procedure time tended to be longer in patients with dominant V1 lesion (130.0; range, 105.0–179.0 vs. 101.5; range, 48.0–138.0, P = 0.05). Among patients with large artery disease (LAD), higher initial NIHSS, and clinical manifestation of decreased mental status were significantly associated with dominant V1 lesion. Endovascular procedure time tended to be longer, distal basilar occlusion tended to be more frequent, and proportion of the patients with complete recanalization tended to be less in patient with dominant V1 lesion. Poor outcome tended to be more frequent in dominant V1 lesion with LAD (88.9% vs. 42.9%, P = 0.05). These findings were comparable in patients who underwent mechanical thrombectomy. Conclusion Dominant V1 steno-occlusion may be associated with poor functional outcome in patients with the symptomatic BAO. Status of dominant VA and various treatment strategy should be considered when performing endovascular treatment for recanalization in patients with symptomatic BAO.

OBJECTIVE For patients with unruptured intracranial aneurysms (UIAs), the information transfer that precedes informed consent needs to be in-depth and detailed, as most patients with a UIA have no symptoms, yet the risks related to treatment are relatively high. Thus, in this study an educational and interactive program was proposed for patients with UIAs to improve the informed consent process and assess the level of comprehension. METHODS A total of 110 patients with UIAs underwent the proposed educational and interactive informed consent (EIIC) process and were enrolled in this study. The EIIC process combines patient education using information booklets, a cartoon book, a video, an initial physician-patient interview, answering a questionnaire, a second physician-patient interview based on the questionnaire results, and finally consent. After the first physician-patient interview that provides the patient with specific information, including his or her angiographic characteristics, medical condition, and recommended treatment, the patient is requested to answer a questionnaire composed of 3 parts: demographic information, including the patient's age, sex, and years of education; 13 medical questions to assess the patient's knowledge about his or her UIA; and an evaluation of the usefulness of the educational resources. The control group consisted of 65 patients from 3 other tertiary university hospitals where the EIIC process was not used. RESULTS The questionnaire scores of the EIIC group ranged from 7 to 13 (mean ± SD: 11.9 ± 1.3) and were significantly higher than those for the controls (10.2 ± 1.9, p < 0.001). The better comprehension of the patients in the EIIC group was remarkable as they were significantly older than those in the control group (62.7 ± 8.3 years vs 55.9 ± 10.5 years, respectively; p < 0.001). For both the EIIC group and the control group, a Pearson correlation analysis revealed a positive correlation (r = 0.232 for the EIIC group, r = 0.603 for controls) between the years of education and the questionnaire score (p = 0.015 for the EIIC group, p < 0.001 for the controls), whereas no correlation was found between the patient age and the questionnaire score. For the EIIC group, the verbal information from the attending physician was selected by 90 patients (81.8%) as the most useful and informative educational method, while the most effective reinforcement of this verbal communication was the video (n = 86; 78.2%), information booklets (n = 16; 14.5%), the Internet (n = 7; 6.4%), and the cartoon book (n = 1; 0.9%). CONCLUSIONS The proposed standardized EIIC process resulted in good patient comprehension about UIAs. The verbal information from the attending physician was the most informative, and the video was the most effective reinforcement of the verbal communication. The patient level of comprehension was shown to be correlated with years of education.

Purpose To identify and apply an optimized P2Y12 reaction units (PRU) threshold for implementing modified antiplatelet preparation to prevent thromboembolic events in patients nonresponsive to clopidogrel (clopidogrel nonresponders) undergoing coil embolization of unruptured aneurysms and to evaluate the clinical validity. Materials and Methods The optimal PRU threshold for prediction of thromboembolic events was determined with the Youden index in post hoc analysis of a previous, prospectively enrolled cohort of 165 patients in whom the antiplatelet regimen was not modified. This optimal PRU threshold was used to define clopidogrel nonresponders in a prospective validation study of 244 patients. Standard preparation (aspirin, clopidogrel) was maintained for 126 patients responsive to clopidogrel (clopidogrel responders, 51.6%), and modified preparation (aspirin, prasugrel) was prescribed prior to embolization for 118 clopidogrel nonresponders (48.4%). Fifty-seven clopidogrel nonresponders from the previous cohort who did not receive the modified preparation were included as a historical control group. Thromboembolic and bleeding events were compared among groups by using logistic regression analysis. Results Post hoc analysis from the previous cohort yielded PRU of at least 220 as the optimal threshold for modified preparation selection. The thromboembolic event rate of the clopidogrel responders (one of 126 [0.8%]) was lower than that of the historical control group that received standard preparation (seven of 57 patients [12.3%]; adjusted risk difference [RD], -10.1%; 95% confidence interval [CI]: -18.5, -1.7; P = .015) and was similar to that of clopidogrel nonresponders who received modified preparation (one of 118 [0.8%]; adjusted RD, -0.5%; 95% CI: -3.1, 2.1; P = .001 for noninferiority; P = .699 for superiority). Bleeding event rates did not differ among groups (four of 126 clopidogrel responders [3.2%] vs four of 57 clopidogrel nonresponders that received standard preparation [7.0%] [adjusted RD, -4.5%; 95% CI: -11.1, 3.4; P = .228] vs five of 118 clopidogrel nonresponders that received modified preparation [4.2%] [adjusted RD, -0.6%; 95% CI: -5.8, 4.2; P = .813]). Conclusion Patients undergoing coil embolization of unruptured aneurysms, regardless of clopidogrel responsiveness, had low thromboembolic risk when using PRU of at least 220 as the threshold for implementing modified antiplatelet preparation with prasugrel. © RSNA, 2016 Online supplemental material is available for this article.

Background Ultrasonic flow meters and quantitative magnetic resonance angiography quantitatively assess flow during hemodynamic evaluation of cerebral ischemia. Although their reliability and reproducibility have been verified, their clinical impact in moyamoya disease has rarely been reported. Objective To investigate flow measurement outcomes in moyamoya disease patients pre- and postoperatively through a retrospective observational study. Methods We evaluated 41 patients undergoing their first revascularization surgery who were followed ≥6 mo. Hemodynamic parameters were recorded preoperatively, at 1 and 6 mo postoperatively, and at the last follow-up. Demographic factors, Suzuki stage, and stroke development were also analyzed. Results Patients' median age was 37 yr (interquartile range [IQR], 27-43), and 16 (39.0%) patients were men. During follow-up, 9 (22.0%) patients experienced postoperative stroke (4 major strokes). Hemodynamic status was improved in 34 (82.9%) patients at the 6-mo follow-up. Median intraoperative flow was 41 mL/min (IQR, 25-59). Bypass flow peaked at 6 mo (median, 67 mL/min; IQR, 35-99). At the 1- and 6-mo follow-ups, ipsilateral hemispheric flow was significantly increased. The median proportion of posterior circulation at 6 mo was 44.4%, significantly lower than the preoperative proportion (50.1%). Abundant intraoperative bypass flow was associated with hemodynamic improvement, while low contralateral hemispheric flow was related with immediate postoperative ischemic stroke. Conclusion Ipsilateral hemispheric flow was increased during 6-mo follow-up, and posterior circulation flow burden was diminished. Abundant intraoperative bypass flow was associated with postoperative hemodynamic improvement. Low preoperative contralateral hemispheric flow was related with immediate postoperative ischemic stroke.

Objectives Ischemic complications (ICs) account for 6.7% after microsurgical clipping of unruptured intracranial aneurysms. This study aimed to evaluate the efficacy of somatosensory evoked potential (SSEP) monitoring during microsurgical clipping of unruptured middle cerebral artery (MCA) aneurysms and evaluate the incidence of and risk factors for ischemic complications after clipping of unruptured MCA aneurysms. Patients and methods Herein, 1208 patients with cerebral aneurysms and treated with microsurgical clipping between May 2003 and February 2015 were enrolled. Those with multiple aneurysms, history of head trauma, subarachnoid hemorrhage, bypass and/or endovascular treatment, and intraoperative rupture were excluded. Subsequently, 411 patients with single unruptured MCA aneurysms treated with simple microsurgical clipping were enrolled. Patients were divided into two groups based on the application of SSEP monitoring during surgery. Results The IC rate was 0.9% and 5.6% in the SSEP and non-SSEP groups, respectively. Univariate analysis revealed that age ≥ 62.5 years, aneurysm size ≥ 4.15 mm, temporary clipping, history of hyperlipidemia and stroke, and no-SSEP monitoring were risk factors for ICs. Multivariate logistic regression analysis showed that age ≥ 62.5 years (odds ratio [OR] = 7.7; 95% confidence interval [95% CI] = 1.5–37.7; P = 0.011), previous stroke (OR = 26.8, 95% CI = 2.4–289.2, P = 0.007), and inversely SSEP monitoring (OR = 0.14, 95% CI 0.02–0.72, P = 0.019) were independent risk factors for ICs. Conclusion Clinicians should consider the possibility of IC during microsurgical clipping of unruptured MCA aneurysms in patient ≥62.5 years and/or a history of stroke. Intraoperative SSEP monitoring is an effective and feasible tool for preventing IC.