Hae Woong Jeong

Onyx Embolization of Dural Arteriovenous Fistula, using Scepter C Balloon Catheter: a Case Report

We report our experience using Onyx for embolization of dural arteriovenous fistula (DAVF) under dual lumen balloon catheter flow arrest. Transfemoral cerebral angiography revealed a superior sagittal sinus (SSS) DAVF that was supplied via multiple branches of the external carotid arteries, the right anterior cerebral arteries, and the meningeal branches of the internal carotid artery. There was no anterograde venous drainage through the SSS, and venous drainage was almost retrograde through the medullary and cortical veins. Under general anesthesia, a transvenous approach was utilized to place the microcatheter close to the fistula site. After intravenous embolization with various coils, DAVF was partially occluded; Balloon catheter gained access to the DAVF via the right middle meningeal artery. We injected Onyx through the Scepter C catheter, after which DAVF was nearly completely occluded. Balloon-assisted Onyx embolization is a feasible and effective approach for the management of DAVF.

Clinical Practice Guideline for the Management of Intracranial Aneurysms

Purpose An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture. Materials and Methods We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN). Results We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method. Conclusion This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.

Adjuvant Tirofiban Injection Through Deployed Solitaire Stent As a Rescue Technique After failed Mechanical Thrombectomy in Acute Stroke.

Purpose We present our experiences of intra-arterial tirofiban injection through a deployed Solitaire stent as a rescue therapy after failed mechanical thrombectomy in patients with acute ischemic stroke. Materials and Methods Data on 18 patients treated with adjunctive tirofiban injection through a temporarily deployed Solitaire stent after failed mechanical thrombectomy were retrospectively reviewed. Solitaire stent was used as a primary thrombectomy device in 16 of 18 patients. Two patients received manual aspiration thrombectomy initially. If initial mechanical thrombectomy failed, tirofiban was injected intra-arterially through the deployed Solitaire stent and then subsequent Solitaire thrombectomy was performed. Results Fourteen patients had occlusions in the middle cerebral artery, 2 in the distal internal carotid artery, and 2 in the basilar artery. Successful recanalization was achieved in 14 patients (77.7%) after intra-arterial injection of tirofiban and subsequent Solitaire thrombectomy. Three patients without successful recanalization after rescue method received angioplasty with stenting. Overall, successful recanalization (TICI grades 2b and 3) was achieved in 17 (94.4%) of 18 patients. Periprocedural complications occurred in 5 patients: distal migration of emboli in 5 patients and vessel perforation in 1. Three patients died. Good functional outcome (mRS ≤ 2) was achieved in 9 patients (50.0%) at 3 months. Conclusion Rescue intra-arterial injection of tirofiban through a temporarily deployed Solitaire stent may facilitate further recanalization in cases of failed mechanical thrombectomy in patients with acute ischemic stroke.

Multibanded Anterior Talofibular Ligaments in Normal Ankles and Sprained Ankles Using 3D Isotropic Proton Density–Weighted Fast Spin-Echo MRI Sequence

OBJECTIVE The purpose of this study is to evaluate the frequency and MRI characteristics of multibanded anterior talofibular ligaments in normal ankles and to characterize the tear types of multibanded anterior talofibular ligaments in sprained ankles using a 3D isotropic proton density (PD)-weighted fast spin-echo (FSE) MRI sequence. SUBJECTS AND METHODS In the first session, 3D PD-weighted FSE MRI of 33 ankles was obtained from 20 asymptomatic volunteers. The number of bands in the anterior talofibular ligaments, the locations of the anterior talofibular ligaments on orthogonal planes of the 3D PD-weighted FSE images, and the signal intensity, depth, and width of each band on their multiplanar reformatted images parallel to the orientation of each band of the anterior talofibular ligament were evaluated by two readers. In the second session, 3D PD-weighted FSE MRI of 51 sprained ankles was evaluated by two readers for determining the number of bands in the anterior talofibular ligaments and the presence of tears in each band. RESULTS In the first session, three anterior talofibular ligaments were single banded, 27 were double banded, and three were triple banded. In double-banded anterior talofibular ligaments, the superior band was about two times wider and thicker than the inferior band. The depth, width, and location of single-banded anterior talofibular ligaments and the superior band of double-banded anterior talofibular ligaments were not statistically significantly different. In the second session, the most common type of injury in double-banded anterior talofibular ligaments was a two-band tear. CONCLUSION In an evaluation using the 3D PD-weighted FSE sequence, most anterior talofibular ligaments consisted of two bands, and tears in both bands were the most common type of injury in double-banded anterior talofibular ligaments.

Patient Radiation Exposure During Diagnostic and Therapeutic Procedures for Intracranial Aneurysms: A Multicenter Study

Purpose To assess patient radiation doses during cerebral angiography and embolization of intracranial aneurysms across multi-centers and propose a diagnostic reference level (DRL). Materials and Methods We studied a sample of 490 diagnostic and 371 therapeutic procedures for intracranial aneurysms, which were performed at 23 hospitals in Korea in 2015. Parameters including dose-area product (DAP), cumulative air kerma (CAK), fluoroscopic time and total angiographic image frames were obtained and analyzed. Results Total mean DAP, CAK, fluoroscopy time, and total angiographic image frames were 106.2 ± 66.4 Gy-cm2, 697.1 ± 473.7 mGy, 9.7 ± 6.5 minutes, 241.5 ± 116.6 frames for diagnostic procedures, 218.8 ± 164.3 Gy-cm2, 3365.7 ± 2205.8 mGy, 51.5 ± 31.1 minutes, 443.5 ± 270.7 frames for therapeutic procedures, respectively. For diagnostic procedure, the third quartiles for DRLs were 144.2 Gy-cm2 for DAP, 921.1 mGy for CAK, 12.2 minutes for fluoroscopy times and 286.5 for number of image frames, respectively. For therapeutic procedures, the third quartiles for DRLs were 271.0 Gy-cm2 for DAP, 4471.3 mGy for CAK, 64.7 minutes for fluoroscopy times and 567.3 for number of image frames, respectively. On average, rotational angiography was used 1.5 ± 0.7 times/session (range, 0-4; n=490) for diagnostic procedures and 1.6 ± 1.2 times/session (range, 0-4; n=368) for therapeutic procedures, respectively. Conclusion Radiation dose as measured by DAP, fluoroscopy time and image frames were lower in our patients compared to another study regarding cerebral angiography, and DAP was lower with fewer angiographic image frames for therapeutic procedures. Proposed DRLs can be used for quality assurance and patient safety in diagnostic and therapeutic procedures.

Angiographic and clinical result of endovascular treatment in paraclinoid aneurysms.

Purpose The purpose of this study was to analyze the results of an immediate and mid-term angiographic and clinical follow-up of endovascular treatment for paraclinoid aneurysms. Materials and Methods From January 2002 to December 2012, a total of 113 consecutive patients (mean age: 56.2 years) with 116 paraclinoid saccular aneurysms (ruptured or unruptured) were treated with endovascular coiling procedures. Clinical and angiographic outcomes were retrospectively evaluated. Results Ninety-three patients (82.3%) were female. The mean size of the aneurysm was 5.5 mm, and 101 aneurysms (87.1%) had a wide neck. Immediate catheter angiography showed complete occlusion in 40 aneurysms (34.5%), remnant sac in 51 (43.9%), and remnant neck in 25 (21.6%). Follow-up angiographic studies were performed on 80 aneurysms (69%) at a mean period of 20.4 months. Compared with immediate angiographic results, follow-up angiograms showed no change in 38 aneurysms, improvement in 37 (Fig. 2), and recanalization in 5. There were 6 procedure-related complications (5.2%), with permanent morbidity in one patient. Conclusion Out study suggests that properly selected patients with paraclinoid aneurysms can be successfully treated by endovascular means.

Preoperative Embolization of Cerebellar Hemangioblastoma with Onyx: Report of Three Cases

Hemangioblastoma is a benign and highly vascular tumor. Complete surgical resection of highly vascular tumor such as hemangioblastoma may be challenging due to excessive bleeding. Preoperative embolization of these lesions may decrease the intraoperative blood loss and facilitate excision. We report three cases of cerebellar hemangioblastomas that were embolized using Onyx.

A Self-expanding Nitinol Stent (Enterprise) for the Treatment of Wide-necked Intracranial Aneurysms: Angiographic and Clinical Results in 40 Aneurysms

Objective Self-expanding stents are increasingly used for the treatment of complex intracranial aneurysms. The purpose of this study was to evaluate the usefulness and safety of a self-expanding nitinol stent (Enterprise) in the treatment of wide-necked intracranial aneurysms. Methods This was a retrospective study of 39 patients with 40 wide-necked intracranial aneurysms who were enrolled in a single-center registry of patients treated with the Enterprise between June 2009 and December 2011. Thirty patients were asymptomatic, four had cerebrovascular accident sequelae, and five had suffered subarachnoid hemorrhage. One aneurysm had reopened after prior coil embolization, while 39 had not been treated. Clinical charts, procedural data, and angiographic results, including both immediate post-procedural angiograms and follow-up imaging, were reviewed. Results The mean neck size of the aneurysms was 5.58 mm (range 3-15.1 mm). Embolization was successful in all patients. There were five procedure-related events. There were no fatalities, but one procedure-related morbidity was noted. The immediate angiographic results included eight complete occlusions (20%), six remnant necks (15%), and 26 remnant sacs (65%). At angiographic follow-up (mean: 11.3 months), out of 18 of the aneurysms treated with stent-assisted coiling, there were 13 (72.2%) complete occlusions, four (22.2%) remnant necks, and one recanalization (5.6%). Conclusion Stent-assisted coiling using the Enterprise is effective for the treatment of wide-necked intracranial aneurysms. Further angiographic and clinical follow-up investigation will be needed for evaluation of the long-term outcomes.

Mechanical Solitaire Thrombectomy with Low-Dose Booster Tirofiban Injection.

Purpose Mechanical thrombectomy using a Solitaire stent has been associated with a high recanalization rate and favorable clinical outcome in intra-arterial thrombolysis. To achieve a higher recanalization rate for mechanical Solitaire thrombectomy, we used an intra-arterial low-dose booster tirofiban injection into the occluded segment after stent deployment. We report the safety and recanalization rates for mechanical Solitaire thrombectomy with a low-dose booster tirofiban injection. Materials and Methods Between February and March 2013, 13 consecutive patients underwent mechanical Solitaire thrombectomy with low-dose booster tirofiban injection. The occlusion sites included the proximal middle cerebral artery (5 patients), the internal carotid artery (5 patients), the top of the basilar artery (2 patients) and the distal middle cerebral artery (M2 segment, 1 patient). Six patients underwent bridge treatment, including intravenous tissue plasminogen activator. Tirofiban of 250 µg was used in all patients except one (500 µg). All occluded vessels were recanalized after 3 attempts at stent retrieval (1 time, n=9; 2 times, n=2; 3 times, n=2). Results Successful recanalization was achieved in all patients (TICI 3, n=8; TICI 2b, n=5). Procedural complications developed in 3 patients (subarachnoid hemorrhage, n=2; hemorrhagic transformation, n=1). Mortality occurred in one patient with a basilar artery occlusion due to reperfusion brain swelling after mechanical Solitaire thrombectomy with low-dose booster tirofiban injection. Favorable clinical outcome (mRS≤2) was observed in 8 patients (61.5%). Conclusion Our modified mechanical Solitaire thrombectomy method using a low-dose booster tirofiban injection might enhance the recanalization rate with no additive hemorrhagic complications.

Endovascular Treatment of Intracranial Vertebral Artery Dissecting Aneurysms: Follow up Angiographic and Clinical Results of Endovascular Treatment in Serial Cases.

Purpose To report angiographic and clinical results of endovascular treatment in 45 intracranial vertebral artery dissecting aneurysms (VADAs). Materials and Methods From July 2002 to September 2013, a total of 42 patients with 45 VADAs received endovascular treatment. Endovascular treatment consisted of internal trapping with detachable coils, stent-assisted coiling, and stenting only. Immediate and follow-up angiographic findings and clinical outcome were retrospectively reviewed. Results There were 17 ruptured VADAs and 28 unruptured VADAs. Overall, 26 VADAs were treated with internal trapping, 14 with stent-assisted coil embolization, and 5 with stenting only. Immediate angiographic results revealed complete occlusion in 31 cases and incomplete occlusion in 14 cases. Follow-up imaging studies were available in 31 cases. On follow-up imaging, antegrade recanalization occurred in 2 of 16 cases treated with internal trapping. Aneurysmal recurrence occurred in one case treated with stent-assisted coiling. Procedural complications occurred in 8 patients. In cases of unruptured VADA, favorable outcome (mRS 0 and 1) was achieved in 26 cases and poor outcome (mRS 2-5) in 2 cases. There was no mortality in patients with unruptured VADAs. Conclusion Endovascular treatment of intracranial VADA appears to be safe and effective. Follow-up angiographic study is needed because parent artery recanalization or aneurysmal recurrence can occur.