Sung-Chul Jin

Endovascular Strategies for Vertebrobasilar Dissecting Aneurysms

BACKGROUND AND PURPOSE: Dissecting vertebrobasilar aneurysms are challenging to treat, and standard treatment modalities remain controversial. We retrospectively evaluated our experience using endovascular techniques to treat these aneurysms. MATERIALS AND METHODS: From February 1997 to December 2007, 42 patients with intradural vertebrobasilar dissecting aneurysms underwent endovascular treatment. Twenty-nine patients had ruptured aneurysms, and 13 patients had unruptured dissecting aneurysms. The endovascular modalities for vertebrobasilar dissecting aneurysms were the following: 1) trapping (n = 30), 2) proximal occlusion (n = 3), 3) stent with coil (n = 6), and 4) stent alone (n = 3). RESULTS: Seventeen of the 29 patients with ruptured vertebrobasilar dissecting aneurysms had successful outcomes without procedural complications following endovascular treatment. Procedure-related complications were the following: 1) rebleeding (n = 3), 2) posterior inferior cerebellar artery (PICA) territory infarction (n = 6), 3) brain stem infarction (n = 2), and 4) thromboembolism-related multiple infarctions (n = 1). Clinical outcomes were favorable in 32 patients (76.1%). There were 3 (7.1%) procedure-related mortalities due to rebleeding, and 1 (2.4%) non-procedure-related mortality due to pneumonia sepsis. All 13 patients with unruptured vertebrobasilar dissecting aneurysms had favorable clinical and radiologic outcomes without procedure-related complications. CONCLUSIONS: Endovascular procedures for treatment of unruptured symptomatic dissecting aneurysms resulted in favorable outcomes. Ruptured vertebrobasilar dissecting aneurysms are associated with a high risk of periprocedural complications. Risks can be managed by using appropriate endovascular techniques according to aneurysm location, configuration, and relationship with the PICA.

Comparison of 2-year angiographic outcomes of stent- and nonstent-assisted coil embolization in unruptured aneurysms with an unfavorable configuration for coiling.

BACKGROUND AND PURPOSE: Stents are known to have hemodynamic and biologic effects in addition to their mechanical scaffold effect. To determine whether stents affect long-term outcomes after coiling of unruptured aneurysms, we compared angiographic outcomes at 2 years postembolization for stent- and nonstent-assisted coiled unruptured aneurysms. MATERIALS AND METHODS: Stent-assisted coiling was used in unruptured aneurysms unfavorable for simple coiling (neck size >4 mm and dome-to-neck ratio <1.5) in our practice. Therefore, 126 coiled unruptured aneurysms in total (40 [31.7%] stent group and 86 [68.3%] nonstent group) with these conditions were selected for this study. The nonstent group aneurysms were treated with multiple microcatheter technique (53 cases) or balloon-assisted technique (33 cases). Self-expandable stents were used for coiling in stent group aneurysms. No significant difference in aneurysmal characteristics (aneurysm type [sidewall/bifurcation], diameter, neck size, and dome-to-neck ratio) or angiographic outcome at embolization (packing attenuation, obliteration grade, and contrast filling) were observed between the 2 study groups. RESULTS: At 2-year follow-up visits, rates of progressive occlusion (stent group, 17/40 [42.5%] versus nonstent group, 34/86 [39.5%]) and recanalization (7/40 [17.5%] versus 18/86 [21.0%]) did not show a statistically significant difference between the 2 groups (P = .895). CONCLUSIONS: The present study did not show that additional hemodynamic and biologic effects of stents designed for neck remodeling were enough to enhance progressive occlusion and prevent the recanalization of unruptured aneurysms. Our finding suggests that stent placement provides no better long-term angiographic outcomes for unruptured aneurysms with an unfavorable configuration for coiling.

A retrieval thrombectomy technique with the Solitaire stent in a large cerebral artery occlusion

BackgroundTo describe preliminary experiences and the procedural details of retrieval thrombectomy using a self-expanding and fully retrievable Solitaire stent (ev 3 Inc., CA, USA) in acute ischemic stroke (AIS) patients with large artery occlusions.MethodsEight patients with AIS were treated by mechanical thrombectomy using a self-expanding, fully retrievable stent (Solitaire, ev 3 Inc., CA, USA). The stent was deployed to cover the whole intra-arterial clot and then it was slowly retrieved while occluding the internal cerebral artery (ICA) with a balloon guiding catheter. Additionally, continuous negative pressure was applied through the balloon guiding catheter with a specially designed gun device. Occlusion sites were M1 in six cases including one combined supraclinoid ICA occlusion and the other combined M2 occlusion, M2 in 1 case and one basilar artery top.ResultsComplete recanalization was achieved in all patients. Procedure time was 45 min or less in seven cases and 70 min in one case. Distal emboli occurred in one case in which the balloon guide catheter was not used. Only in this case was intraarterial fibrinolytics infusion necessary. There was no post-operative intracranial hemorrhage.ConclusionsIn our experience, retrieval thrombectomy with the Solitaire stent was a simple and effective method for reopening large cerebral arteries in AIS patients.

Intra-Arterial Infusion of a Glycoprotein IIb/IIIa Antagonist for the Treatment of Thromboembolism During Coil Embolization of Intracranial Aneurysm: A Comparison of Abciximab and Tirofiban

BACKGROUND AND PURPOSE: Abciximab and tirofiban are commonly used for the treatment of thromboembolisms that form during coiling of intracranial aneurysms; however, it is not known which of these inhibitors is safer and more effective. We report the safety and the recanalization rates for intra-arterial abciximab and intra-arterial tirofiban infusion for the treatment of thromboembolisms that form during coiling. MATERIALS AND METHODS: Between March 2004 and April 2011, 346 intracranial aneurysms were treated with coiling. Thromboembolisms developed in 22 of these patients and were treated by use of intra-arterial tirofiban (n = 11) or abciximab (n = 11) infusion. RESULTS: In the abciximab group, the thromboembolisms were completely (n = 1) or partially (n = 7) resolved in 8 cases (72.7%) at the time of the final control angiography. Complete (n = 9) or partial (n = 2) resolution was achieved in all cases at the time of follow-up angiography (<3 days after the procedure). In the tirofiban group, thromboembolisms were completely (n = 4) or partially (n = 6) resolved in 10 cases (90.9%) at the time of the final control angiography. Complete (n = 9) or partial (n = 2) resolution was observed in all cases at the time of the follow-up angiography. There were no statistically significant differences between the 2 groups with respect to thrombus resolution (final angiography, P = .311; follow-up angiography, P = .707). No hemorrhagic complications developed in either group. CONCLUSIONS: These results suggest that tirofiban is more effective than abciximab for the immediate resolution of thromboembolisms, with no statistical significance. Both intra-arterial tirofiban and abciximab exhibited similar safety and recanalization rates.

The Characteristics and Risk Factors of Headache Development after the Coil Embolization of an Unruptured Aneurysm

Little is known about headaches post-aneurysm coiling. These authors treated 90 patients with unruptured aneurysms and no headaches. Nearly 56% developed headaches within 72 hours of treatment and all headaches resolved shortly thereafter. Only coil-packing attenuation was associated with presence of headaches. The authors concluded that though headaches were common, these were nearly always benign and resolved spontaneously. High packing attenuation may induce stretching of the aneurysm and inflammation that can result in headaches. BACKGROUND AND PURPOSE: Development of a headache after aneurysm coil embolization is not uncommon but has received little attention. The authors prospectively analyze the characteristics and risk factors of a headache after coiling in patients treated for an unruptured cerebral aneurysm. MATERIALS AND METHODS: Ninety patients treated for an unruptured cerebral aneurysm over a period of 1 year, and without a headache history within a month before coiling, were enrolled in this study. All coilings were successfully performed without neurologic complications. After coiling, headache development and intensities were recorded. RESULTS: Fifty (55.6%) patients experienced a headache (VAS score, 4.5 ± 2.02) at 7.9 (range, 0–72) hours, on average, after coiling, and all headaches resolved within an average of 73.0 (range, 3–312) hours. Univariate analysis showed that the following were significantly associated with the development of a headache: age ≤50 years (OR 4.636, 95% CI, 1.414–15.198), hypertension (OR 0.232, 95% CI, 0.095–0.571), a packing attenuation of >25% (OR 3.619, 95% CI, 1.428–9.174), and a previous headache history (OR 2.769, 95% CI, 1.120–6.849). However, binary logistic regression showed that only a packing attenuation of >25% (P = .013, adjusted OR 3.774, 95% CI, 1.320–10.790) and no history of hypertension (P = .019, adjusted OR 3.515, 95% CI, 1.233–10.021) were independently associated with the development of a headache. CONCLUSIONS: A headache frequently developed after the coiling of unruptured aneurysms. However, headaches were relatively benign and resolved within several days. The present study shows that no hypertension history and a packing attenuation of >25% are risk factors of headache development.

Endovascular and Microsurgical Treatment of Superior Cerebellar Artery Aneurysms

Objective Superior cerebellar artery (SCA) aneurysms are regarded as being as difficult to treat surgically as posterior circulation aneurysms. We describe here a series of 33 of these aneurysms treated with microsurgery or embolization. Methods Between June 1997 and August 2007, 33 patients (9 men, 24 women; age, 29 to 76 years) with SCA aneurysms underwent microsurgical (n = 12) or endovascular (n = 21) treatment. Twenty two patients presented with subarachnoid hemorrhage. Thirty aneurysms were located in the junction between the SCA and the basilar artery (BA), two in the proximal SCA (S1) and one in the distal SCA (S2-3). Results Of the 29 SCA aneurysms, located in the junction between the SCA and BA, which were available on conventional angiography, 20 were lateral-superior, six lateral-horizontal, two lateral inferior, and one posterior type. Of the 12 patients treated microsurgically, eight had clinically excellent or good outcomes. Causes of poor outcomes included initial poor clinical status (n = 2), infarction due to parent artery compromise (n = 1), and artery of Heubner injury due to surgery for a coexisting anterior communicating artery aneurysm (n = 1). Of the 21 patients treated endovascularly, 17 had clinical good or excellent outcomes. Causes of clinically poor outcomes included initial poor clinical status (n = 2) and infarction due to thrombosis of exposed coil mesh (n = 1). One patient underwent embolization resulted in death due to vasospasm. Three patients required additional embolization for coil compaction. Conclusion There was no morbidity related to perforator injury, regardless of the treatment modality. Embolization or microsurgery is an effective modality, with relatively low procedural morbidity and mortality rates.

Endovascular Treatment for Unruptured Intracranial Aneurysms in Elderly Patients: Single-Center Report

BACKGROUND AND PURPOSE: The optimal management of patients with unruptured intracranial aneurysms remains controversial in elderly populations. The aim of this study was to evaluate technical results and clinical outcomes in a single center of consecutive elderly patients with unruptured intracranial aneurysms treated with endovascular embolization. MATERIALS AND METHODS: Between May 2003 and February 2010, 96 patients older than 70 years (men, 16 patients; women, 80 patients; mean age, 73 years) with 122 saccular unruptured intracranial aneurysms were treated in our hospital with an endovascular approach. The endovascular procedures and technique, angiographic follow-up, and complications were evaluated. RESULTS: Successful embolizations without complications were completed in 95.9%. Five patients had procedure-related events, including thromboembolism in 1 patient, aneurysm perforation during the procedure in 1, and 3 postoperative transient minor symptoms (headache, otalgia, and trigeminal pain) in 3. The degree of occlusion of the treated aneurysm was complete in 46.7%; there was a small neck remnant in 40.9% and residual filling in 12.2%. Imaging (MR angiography) follow-up was performed in 68.7% of the patients. The mean follow-up duration was 19.4 months (range, 5–57 months). Fifty-five patients (93.9%) showed no interval change of the residual neck. Four (6%) demonstrated recanalizations, all of which were successfully recoiled. CONCLUSIONS: Endovascular treatment of unruptured intracranial aneurysms in patients older than 70 years of age appears to be safe. Favorable outcomes with low morbidities may replace surgery or conservative treatment as an active management alternative.

A technical strategy for carotid artery stenting: suboptimal prestent balloon angioplasty without poststenting balloon dilatation.

BACKGROUND:Traditional carotid artery stenting (CAS) consists of predilatation, optional deployment of embolic protection devices, stenting, and poststent angioplasty. Each step carries a risk of thromboembolism. OBJECTIVE:To design a new and simplified procedural protocol, suboptimal balloon angioplasty without routine poststenting balloon dilatation, and to describe the efficacy this protocol in terms of procedural risks and angiographic and clinical outcomes. METHODS:Over a period of 6 years, 161 carotid artery stenoses in 156 consecutive patients were treated by CAS with embolic protection devices. Among them, 110 lesions in 107 patients (68.3%) were treated by our simplified method (symptomatic, > 50% stenosis; asymptomatic, > 70% stenosis). Overall, 98 lesions (88.3%) had severe stenosis (> 70%). RESULTS:The mean stenosis was reduced from 77% to 10% after CAS. A persistent neurological deficit developed in 2 patients from thromboembolism. Hemodynamic insufficiency developed in 14 lesions during CAS (12.7%). The ipsilateral stroke and mortality rate was 4.5% within 1 month after CAS (asymptomatic, 3.6%; symptomatic, 4.8%). Over a mean of 19 months of follow-up, additive angioplasty was performed in 2 patients as a result of progressive restenosis (≥ 50%). A comparison of the balloon sizes of the prestent angioplasty for group 1 (balloon, ≤ 4 mm) and group 2 (balloon, ≥ 5 mm) showed no difference in restenosis between the groups at 15 months of follow-up after CAS. CONCLUSION:Our CAS technique with suboptimal prestenting angioplasty without routine use of poststenting dilatation is safe, simple, and efficient with acceptable risks.

Epilepsy After Bypass Surgery in Adult Moyamoya Disease

BACKGROUND:Postoperative seizure, well-known in association with other pathologies, has been rarely discussed in adult moyamoya disease. OBJECTIVE:We evaluated postoperative seizures in adult patients with moyamoya undergoing revascularization surgery. METHODS:From 2001 to 2007, 43 adult patients with moyamoya disease underwent 53 revascularization surgeries, consisting of direct bypass with or without indirect bypass. Incidence and profile of postoperative seizures were investigated, with evaluation of influencing factors. Multivariable analysis using a generalized estimation equation was performed to determine which factors were related to postoperative seizure. RESULTS:Seizures developed in 10 sides (18.9%) after revascularization for moyamoya disease, including immediate (<24 hours, n = 0), early (1-7 days, n = 5), late (8-30 days, n = 0), and delayed seizures (≥1 month, n = 7). Early and subsequent delayed seizures developed in the same lesions in 2 patients. Seizures developed only in the patients with combined direct and indirect revascularization. Postoperative temporary neurological deficits with imaging abnormalities were significantly related to postoperative nondelayed seizures (P = .02). Delayed seizures were significantly different according to the location of the recipient artery (P = .03), especially with the frontal branches. By multivariable analysis, revascularization using frontal branches trended toward increased incidence of delayed postoperative seizure, with adjusted odds ratio of 13.78 (95% confidence interval, 1.7-114.1). CONCLUSION:In adult patients with moyamoya disease, the incidence of delayed postoperative seizure seems to be higher than that of other pathologies. The delayed, pronounced formation of synangiosis in moyamoya disease may be related to the development of such delayed postoperative seizures, especially when the location of the recipient artery is frontal.

Detachable Coil Embolization for Saccular Posterior Inferior Cerebellar Artery Aneurysms

OBJECTIVE Surgical treatment of posterior inferior cerebellar artery (PICA) aneurysms is challenging due to limited surgical accessibility. Endovascular approach has a benefit of avoiding direct injury to the brainstem or lower cranial nerves. Therefore, it has recently been considered an alternative or primary modality for PICA aneurysms. We retrospectively assessed outcomes following detachable coil embolization of saccular PICA aneurysms. METHODS From February 1997 to December 2007, we performed endovascular procedures to treat 15 patients with 15 PICA aneurysms. Fourteen patients with 14 PICA aneurysms morphology of which was saccular were reviewed retrospectively. Twelve patients had ruptured aneurysms. The aneurysms arose from the PICA origin site (n = 12), the PICA lateral medullary segment (n = 1), or the PICA tonsilomedullary segment (n = 1). RESULTS Complete aneurysm occlusion was achieved in 10 patients, residual neck in 3, and residual sac in one. Radiological follow-up was performed in 7 patients with mean duration of 34.7 months (range, 1-97 months) and showed stable or complete occlusion in 6 patients. There were no rebleeding or retreatment after endovascular treatment. Thromboembolism was the only procedure-related complication (n = 4 ; 28.6%). Asymptomatic PICA infarction occurred in two patients and symptomatic PICA infarction in two elderly patients with poor clinical grade. Of these procedural PICA infarction cases, 1 symptomatic PICA infarction patient developed ventriculitis and septic shock leading to death. The clinical outcome was good in 10 patients (71.4%). CONCLUSIONS In the present study, detachable coil embolization has shown as an efficient modality for PICA saccular aneurysms challenging indications of microsurgery. However, thromboembolic complications should be considered, especially in poor clinical elderly patients with ruptured aneurysms.