H.W. Pyun

Intracranial Stenting of Severe Symptomatic Intracranial Stenosis: Results of 100 Consecutive Patients

BACKGROUND AND PURPOSE: There are a few reports regarding the outcome evaluation of balloon-expandable intracranial stent placement (BEICS). The purpose of our study was to evaluate the outcome and factors related to the adverse events (AEs) of BEICS. MATERIALS AND METHODS: We evaluated 100 consecutive patients who underwent BEICS. We assessed the procedural success (residual stenosis <50%), AEs (minor strokes, major strokes, and death), clinical outcome, and restenosis (>50%) at 6 months. We also analyzed 18 factors including symptom patterns related to AE rate. Symptom patterns revealed 1) stable patients (n = 73) with improving, stationary, or resolved symptoms; and 2) unstable patients (n = 27) with gradual worsening or fluctuating symptoms (National Institutes of Health Stroke Scale [NIHSS] ≥4) within 2 days before stent placement. RESULTS: The procedural success rate was 99%. Overall, there were 10 (10%) AEs within the 6 months: 4 (4%) minor strokes, 3 (3%) major strokes, and 3 (3%) deaths including a death from myocardial infarction. AE rate was 4.1% in stable and 25.9% in unstable patients. Restenosis at 6 months revealed 0% (0/59). Good outcome (modified Rankin Scale ≤2) at 6 months was 97% (71/73) in stable and 67% (18/27) in unstable patients. Stepwise logistic regression model revealed that symptom pattern (unstable versus stable) was the only significant risk factor (OR, 8.167; 95% CI, 1.933–34.500; P = .004). CONCLUSION: BEICS revealed a low AE and good outcome rate at 6 months, especially in the stable patients. Midterm outcome was also favorable in the unstable patient group.

Placement of Covered Stents for Carotid Blowout in Patients with Head and Neck Cancer: Follow-up Results after Rescue Treatments

BACKGROUND AND PURPOSE: Placement of a covered stent to control carotid blowout (CB) in malignant tumors of the head and neck has been reported to be an effective treatment. However, it is not uncommon to encounter recurrent hemorrhage. The purpose of this study was to evaluate the follow-up results of patients treated with covered stents. MATERIALS AND METHODS: We retrospectively reviewed the results of 7 consecutive patients who underwent placement of a covered stent to control CB. Most of them had poor wound healing because of previous irradiation, surgery, or both. The initial procedures were successful in all patients. Their clinical course was reviewed for rebleeding, additional endovascular treatments in recurrent cases, and outcomes. RESULTS: Recurrence developed in 6 of 7 patients. The interval between the first procedure and the hemorrhagic event was from 3 to 44 days. In 6 patients who had a recurrent CB, 4 had rebleeding from the previous site of the stent, whereas 2 other patients experienced recurrent bleeding in a different area from the site of the stent. Additional endovascular treatments were carried out in all affected patients by another insertion of a covered stent (n = 3), coil embolization (n = 2), or insertion of a covered stent followed by permanent arterial occlusion (n = 1). CONCLUSION: Placement of a covered stent in patients with head and neck cancer who sustain CB showed frequent rebleeding despite favorable initial rescue results. Recurrent CB at the previous stent site developed frequently in patients with uncontrolled wound infection. Concomitant or short-interval arterial trapping should be considered selectively in those conditions.

Concomitant Multiple Revascularizations in Supra-Aortic Arteries : Short-Term Results in 50 Patients

BACKGROUND AND PURPOSE: The outcome for simultaneous revascularization of more than 1 supra-aortic arterial stenosis has not been evaluated because of concerns regarding the increased risk of additional procedures. We evaluated the feasibility and safety of concomitant multiple supra-aortic arterial revascularizations (CMSAR). MATERIALS AND METHODS: We retrospectively evaluated 50 consecutive patients who underwent CMSARs with angioplasty and stent placement. The study included a separate lesion group (LG) (n = 28), ipsilateral LG (n = 17) including adjacent (n = 6) and remote (n = 11) tandem lesions, and triple LG (n = 5). We assessed the procedural success (defined as residual stenosis <30%) and periprocedural event rate (ER) (minor or major stroke, and death). We compared the ERs in the lesion (ipsilateral vs separate) and symptom (unstable vs stable) pattern groups with the Fisher exact test. RESULTS: Procedural success was achieved in all patients (50/50). Periprocedural events within 30 days were noted in 5 (10%). ER within 2 days after the procedure was higher in the ipsilateral LG (4/17) than in the separate LG (0/28) (P = .016). Major events consisting of a major stroke and a death occurred in 2 patients in the unstable group (4%) and was more common in the unstable (2 of 7) than in the stable group (0/38) (P = .029). During the mean 11-month follow-up period, there was 1 symptomatic recurrence. CONCLUSION: CMSARs are feasible with a high procedural success rate resulting in a favorable short-term outcome. However, they must be carefully performed in ipsilateral LG, especially in patients in the unstable group.

Reversible Aggravation of Neurological Deficits after Steroid Medication in Patients with Venous Congestive Myelopathy Caused by Spinal Arteriovenous Malformation

Steroids are empirically used to medicate patients with myelopathy of unknown etiology. We report the reversible aggravation of neurological status after steroid administration in a patient with venous congestive myelopathy (VCM). We retrospectively evaluated 36 patients with angio-graphically confirmed spinal arteriovenous malformation (SAVM) from a prospectively collected neurointerventional database. We evaluated steroid medication and neurological aggravation using Aminoff grading and analyzed using Fishers exact test whether steroid medication is related to neurological aggravation and spinal cord edema as demonstrated on MR T2-WI. Among 26 patients who had been treated with steroids, ten had aggravated neurological deficits. The aggravation in these ten patients was related to the steroid medication (P = 0.039 in all patients) and only marginally to VCM with spinal cord edema as seen on T2-WI (P = 0.074). Aggravation caused by using a high intravenous dose (250–1000 mg) of methylprednisolone or dexamethasone at 8–20 mg/day slowly decreased after stopping the steroid medication. Steroids were reversibly detrimental in patients with VCM caused by SAVM. A history of neurological aggravation after the use of steroids may suggest the diagnosis of SAVM associated with VCM.

Internal carotid artery stenosis with ipsilateral persistent hypoglossal artery presenting as a multiterritorial embolic infarction: a case report

Persistent hypoglossal artery (PHA) is a relatively rare vascular anomaly of persistent carotid-basilar anastomosis. We have treated a patient with stenosis of the internal carotid artery which was combined with PHA and who presented with multiple small embolic infarcts in multiple vascular territories. It is important to know that a persistent carotid-basilar anastomosis could be one of the causes bringing about acute infarction in both the anterior and posterior vascular territories, mimicking cardioembolism.

Incidental Saccular Aneurysms on Head MR Angiography: 5 Years' Experience at a Single Large-Volume Center

Background and Purpose The diagnostic accuracy for unruptured intracranial aneurysms has increased, and incidental asymptomatic aneurysms have come to represent a substantial clinical burden because of their controversial natural history. However, their prevalence may be attributable to variations in evaluation methods and demographics. We therefore describe the prevalence and magnetic resonance angiography (MRA) findings of incidental intracranial saccular aneurysms over a 5-year period at a single large-volume center. Methods MRA images from 18,237 patients obtained between January 2001 and December 2005 were retrieved from the radiology report database. Patients diagnosed with incidental intracranial saccular aneurysms were identified and their MRA data were reviewed. Imaging and clinical follow-up data were evaluated. Results During the study period, 366 incidental intracranial saccular aneurysms were identified in 330 patients (prevalence, 1.8%; 95% confidence interval, 1.63%-2.01%; 115 men and 215 women; age range, 22-82 years; median age, 63 years). The prevalence was higher in women (215/8,112) than in men (115/10,125; P=0.02). The prevalence increased with age in women (P<0.01), but not in men (P=0.30). Aneurysm size ranged from 1.5 mm to 13 mm, with a median size of 4 mm. The most common location was the bifurcation of the middle cerebral artery (131/366; 35.8%). Conclusions Our real world experience indicated a slightly lower overall prevalence of incidental intracranial saccular aneurysms than previously reported. The prevalence increased with age in women but not in men.

Covered stent application of a repeatedly regrowing iatrogenic subclavian artery pseudoaneurysm at the origin of the vertebral artery.

Formation of an iatrogenic subclavian artery pseudoaneurysm while attempting central venous access through the internal jugular vein is relatively uncommon. However, management of a subclavian artery pseudoaneurysm remains a challenge because of its growing tendency and its relation to the origin of the vertebral artery (VA). We report a strategy for using a covered stent as for the endovascular treatment of a patient with a repeatedly regrowing subclavian artery pseudoaneurysm at the origin of the VA.

Dissecting aneurysm of the basilar arterial trunk presenting with pontine infarction. Coil obliteration of the dissecting aneurysm including the diseased basilar arterial segment.

Dissecting basilar aneurysms have rarely been reported but are associated with high morbidity and mortality. Therefore, controversy exists as to the proper management of such lesions because their natural course is not well understood. We describe a 50-year-old man with a dissecting aneurysm involving the lower basilar trunk who presented with pontine infarction corresponding to the aneurysmal sac location. We obliterated the dissecting basilar aneurysm by coil embolization of the aneurysmal sac as well as the diseased segment of the basilar trunk after confirmation of collateral filling of the basilar artery through the posterior communicating artery. The patient recovered without any procedural complication. Eight month follow-up revealed complete disappearance of the aneurysm without symptom recurrence together with preservation of collateral flow in the distal basilar artery. Obliteration of the parent artery as well as the aneurysmal sac with coils could be considered in a lower basilar aneurysm of a dissecting nature.