Chang-Ki Hong

Reconstructive Endovascular Treatment of Intracranial Fusiform Aneurysms: A 1-Stage Procedure with Stent and Balloon

BACKGROUND AND PURPOSE: Intracranial fusiform aneurysms, which incorporate the branch vessel and require salvaging of the parent vessel, are difficult to manage. The goal of this study was to evaluate the efficacy of reconstructive endovascular treatment of intracranial fusiform aneurysms by using a 1-stage procedure with a stent and balloon. MATERIALS AND METHODS: During a 3-year period, 20 patients with 20 intracranial fusiform aneurysms were treated by using a 1-stage procedure involving a balloon and stent. Subarachnoid hemorrhage was present in 15 patients. Five aneurysms were located in the anterior circulation and 15, in the posterior circulation. Clinical outcomes and periprocedural complications were evaluated in all patients. The extent of coil packing was evaluated by control angiography after embolization and classified as either complete occlusion or partial occlusion. Angiography was performed 6, 12, and 24 months after embolization to evaluate stent patency and coil packing. RESULTS: The 1-stage procedure by using a combination of balloon and stent was technically successful in all patients. There were no complications related to the procedure, complete occlusion was obtained in 16 patients, and partial occlusion, in 4 patients. All patients recovered well except for 2 who died due to causes unrelated to the procedure. Clinical follow-up was performed in all surviving patients at a mean of 12.3 months (range, 7–24 months), and angiography showed that the patent parent arteries were free of aneurysm recanalization or in-stent stenosis. CONCLUSIONS: This 1-stage procedure may provide a feasible and safe treatment strategy for the management of intracranial fusiform aneurysms that are not amenable to deconstructive embolization.

Management of Anterior Inferior Cerebellar Artery Aneurysms: Endovascular Treatment and Clinical Outcome

BACKGROUND AND PURPOSE: AICA aneurysms are rare and a challenge to treat surgically. We present our experience of the angiographic results and the clinical outcomes for 9 AICA aneurysms treated by EVT. MATERIALS AND METHODS: Between 1997 and 2009, EVT was attempted for 9 AICA aneurysms. Six patients presented with SAH, and 3 aneurysms were found incidentally. The location of the aneurysms was the proximal AICA in 7 and the distal AICA in 2. Five aneurysms originated from an AICA-PICA variant. Clinical outcomes and procedural complications were evaluated, and angiography was performed 6, 12, and 24 months after embolization to confirm recanalization of the coiled aneurysm. RESULTS: EVT was technically successful in 7 patients (78%). Surgical trapping was performed in 1 patient after failure of EVT, and another aneurysm occluded spontaneously, along with the parent artery during EVT. In 7 patients, the AICAs had good patency on postoperative angiography. Stent-assisted coiling was performed in 3 patients. Follow-up angiographies were performed in 7 patients and showed no evidence of recanalization or progressive occlusion with further thrombosis except in 1 patient. There was no evidence of aneurysm rupture during the follow-up period, and 8 patients were able to perform all usual activities (mRS score, 0–1). CONCLUSIONS: EVT may provide a feasible and safe option as an alternative, though a microsurgical option is initially considered for the management of AICA aneurysms. Further follow-up and more experience are also necessary.

Clinical Risk Factors Affecting Procedure-Related Major Neurological Complications in Unruptured Intracranial Aneurysms

Purpose The operative risk and natural history rupture risk for the treatment of unruptured intracranial aneurysms (UIAs) should be evaluated. The purpose of this study was to report our experience with treating UIAs and to outline clinical risk factors associated with procedure-related major neurological complications. Materials and Methods We treated 1158 UIAs in 998 patients over the last 14 years. All patients underwent operation performed by a single microvascular surgeon and two interventionists at a single institution. Patient factors, aneurysm factors, and clinical outcomes were analyzed in relation to procedure-related complications. Results The total complication rate was 22 (2.2%) out of 998 patients. Among them, complications developed in 14 (2.3%) out of 612 patients who underwent microsurgery and in 8 (2.1%) out of 386 patients who underwent endovascular procedures. One patient died due to intraoperative rupture during an endovascular procedure. The procedure-related complication was highly correlated with age (p=0.004), hypertension (p=0.002), and history of ischemic stroke (p<0.001) in univariate analysis. The multivariate analysis revealed previous history of ischemic stroke (p=0.001) to be strongly correlated with procedure-related complications. Conclusion A history of ischemic stroke was strongly correlated with procedure-related major neurological complications when treating UIAs. Accordingly, patients with UIAs who have a previous history of ischemic stroke might be at risk of procedure-related major neurological complications.

Microsurgical Clipping of Unruptured Middle Cerebral Artery Bifurcation Aneurysms: Incidence of and Risk Factors for Procedure-Related Complications

OBJECTIVEnTo report our experiences in microsurgical clipping of unruptured middle cerebral artery (MCA) bifurcation aneurysms and to evaluate the incidence of and risk factors for procedure-related complications.nnnMETHODSnThe study comprised 416 patients treated between March 2003 and February 2014. All patients met the following criteria: 1) microsurgical clipping of an unruptured MCA bifurcation aneurysm was performed, and 2) clinical and radiographic follow-up data were available including preoperative digital subtraction angiography. The incidence of and risk factors for procedure-related complications were retrospectively evaluated.nnnRESULTSnProcedure-related complications occurred in 15 (3.6%) patients, including asymptomatic complications in 10 (2.4%) patients and symptomatic complications in 5 (1.2%) patients. Multivariate logistic regression analysis showed that posteroinferior projection of the aneurysm (odds ratioxa0= 2.814, 95% confidence intervalxa0= 0.995-6.471, Pxa0=xa00.042), distance between the internal carotid artery bifurcation and the MCA bifurcation (Dt) in a linear line (odds ratioxa0= 1.813, 95% confidence intervalxa0= 0.808-6.173, Pxa0= 0.043), and horizontal angle between the vertical line toxa0the base of the skull and Dt (odds ratioxa0= 2.046, 95% confidence intervalxa0= 1.048-10.822, Pxa0= 0.048) were independent risk factors for procedure-related complications.nnnCONCLUSIONSnWhen performing clipping of unruptured MCA bifurcation aneurysms, the procedure-related complication rate was 3.6%. Patients with MCA bifurcation aneurysms with posteroinferior projection, shorter Dt,xa0and larger horizontal angle may be at a higher risk of procedure-related complications when performing microsurgical clipping.

Benefits of Surgical Treatment for Unruptured Intracranial Aneurysms in Elderly Patients

OBJECTIVEnDue to longer life spans, patients newly diagnosed with unruptured intracranial aneurysms (UIAs) are increasing in number. This study aimed to evaluate how management of UIAs in patients age 65 years and older affects the clinical outcomes and post-procedural morbidity rates in these patients.nnnMETHODSnWe retrospectively reviewed 109 patients harboring 136 aneurysms across 12 years, between 1997 and 2009, at our institute. We obtained the following data from all patients : age, sex, location and size of the aneurysm(s), presence of symptoms, risk factors for stroke, treatment modality, and postoperative 1-year morbidity and mortality. We classified these patients into three groups : Group A (surgical clipping), Group B (coil embolization), and Group C (observation only).nnnRESULTSnAmong the 109 patients, 56 (51.4%) underwent clipping treatment, 25 (23%) patients were treated with coiling, and 28 observation only. The overall morbidity and mortality rates were 2.46% and 0%, respectively. The morbidity rate was 1.78% for clipping and 4% for coiling. Factors such as hypertension, diabetes mellitus, hypercholesterolemia, smoking, and family history of stroke were correlated with unfavorable outcomes. Two in the observation group refused follow-up and died of intracranial ruptured aneurysms. The observation group had a 7% mortality rate.nnnCONCLUSIONnOur results show acceptable favorable outcome of treatment-related morbidity comparing with the natural history of unruptured cerebral aneurysm. Surgical clipping did not lead to inferior outcomes in our study, although coil embolization is generally more popular for treating elderly patients. In the treatment of patients more than 65 years old, age is not the limiting factor.

The Course of Headache in Patients With Moderate-to-Severe Headache Due to Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cross-Sectional Study

The purpose of this study was to evaluate the course of headache in patients with moderate‐to‐severe headache due to aneurysmal subarachnoid hemorrhage (aSAH) and to identify its predisposing factors.

Stent salvage using the Enterprise stent for procedure-related complication during coil embolization of ruptured intracranial aneurysms

BackgroundDespite accumulated experience and improved understanding of the tools, endovascular treatment of intracranial aneurysms continues to have risks linked to the technique itself, and induces procedure-related complications. The purpose of this study was to report our series of stent salvage using the Enterprise stent for procedure-related complication during coil embolization in patients with ruptured intracranial aneurysms.MethodsParent artery thrombosis, parent artery dissection, and coil protrusion were considered to be the procedure-related complications. There were 18 consecutive cases (3 unruptured and 15 ruptured aneurysms) with procedure-related complications rescued by the Enterprise stent from December 2008 to December 2011. Follow-up angiography was performed in 14 of the 15 patients with ruptured aneurysms between 6 and 30xa0months (mean 14.6xa0months) after the procedure.ResultsThe procedure-related complications were parent artery dissection (nu2009=u20091), parent artery thrombosis (nu2009=u20094), and coil protrusion (nu2009=u200910). There was no complication related to delivering or deploying of the Enterprise stent. Initial radiographic results showed 8 cases of complete occlusion and 7 cases of neck remnant. There was no change in the angiographic results during the follow-up periods.ConclusionsFacing with procedure-related complications during coil embolization of ruptured intracranial aneurysms, the closed-cell designed Enterprise stent might be a useful option for the salvage technique by restoring blood flow and minimizing thromboembolic events.

The course of headache in patients with moderate-to-severe headache due to mild traumatic brain injury: a retrospective cross-sectional study

BackgroundLittle is known about the long-term course of headache in patients with moderate-to-severe headache due to traumatic brain injury ufeff(TBI). We evaluated the course of headache in patients with moderate-to-severe headache due to mild TBI.MethodsSince September 2009, patients with TBI prospectively rated their headache using a numeric rating scale (NRS). From the database containing 935 patients with TBI between September 2009 and December 2013, 259 patients were included according to following criteria: (1) newly onset moderate-to-severe headache (NRSu2009≥u20094) due to head trauma; (2) ageu2009≥u200915xa0years; (3) Glasgow Coma Scaleu2009≥u200913; (4) transient loss of consciousnessu2009≤u200930xa0min; and (5) radiographic evaluation, such as computed tomography or magnetic resonance image. We evaluated initial and follow-up NRS scores to determine the significance of NRS changes and identified risk factors for moderate-to-severe headache at 36-month follow-up.ResultsAt 36-month follow-up, 225 patients (86.9%) reported improved headache (NRSu2009≤u20093) while 34 (13.1%) reported no improvement. The NRS scores were significantly decreased within a month (Pu2009<u20090.001). The follow-up NRS scores at 12-, 24-, and 36-months were lower than those at one month (Pu2009<u20090.001). Multiple logistic regression analysis showed that post-traumatic seizure (odds ratio, 2.162; 95% CI, 1.095–6.542; Pu2009=u20090.041) and traumatic intracranial hemorrhage (odds ratio, 2.854; 95% CI, 1.241–10.372; Pu2009=u20090.024) were independent risk factors for moderate-to-severe headache at 36-month follow-up.ConclusionsThe course of headache in patients with mildxa0TBI continuously improved until 36-month follow-up. However, 13.1% of patients still suffered from moderate-to-severe headache at 36-month follow-up, for whom post-traumatic seizure and traumatic intracranial hemorrhage might be risk factors.

Headache After Cerebral Angiography: Frequency, Predisposing Factors, and Predictors of Recovery

Headache after cerebral angiography is frequent but has received little attention. The purpose of this study was to evaluate the incidence and risk factors of headache after cerebral angiography. This study also addressed the predisposing factors that facilitate headache recovery.

Characteristics and Management of Residual or Slowly Recurred Intracranial Aneurysms

OBJECTIVEnResidual aneurysm from incomplete clipping or slowly recurrent aneurysm is associated with high risk of subarachnoid hemorrhage. We describe complete treatment of the lesions by surgical clipping or endovascular treatment.nnnMETHODSnWe analyzed 11 patients of residual or recurrent aneurysms who had undergone surgical clipping from 1998 to 2009. Among them, 5 cases were initially clipped at our hospital. The others were referred from other hospitals after clipping. The radiologic and medical records were retrospectively analyzed.nnnRESULTSnAll patients presented with subarachnoid hemorrhage at first time, and the most frequent location of the ruptured residual or recurrent aneurysm was in the anterior communicating artery to posterior-superior direction. Distal anterior cerebral artery, posterior communicating artery, and middle cerebral artery was followed. Repositioning of clipping in eleven cases, and one endovascular treatment were performed. No residual aneurysm was found in postoperative angiography, and no complication was noted in related to the operations.nnnCONCLUSIONnThese results indicate the importance of postoperative or follow up angiography and that reoperation of residual or slowly recurrent aneurysm should be tried if such lesions being found. Precise evaluation and appropriate planning including endovascular treatment should be performed for complete obliteration of the residual or recurrent aneurysm.