Yong Cheol Lim

Reconstructive treatment of ruptured blood blister-like aneurysms with stent and coil.

BACKGROUND Controversy remains about the optimal treatment for blood blister--like aneurysms (BBAs). OBJECTIVE To evaluate clinical and angiographic outcomes after reconstructive treatment for BBA with stent and coil. METHODS Thirty-four patients (6 men, 28 women; mean age, 47.3 years) with ruptured BBAs underwent reconstructive treatment with stent and coil. Posttreatment courses and outcomes were retrospectively evaluated. RESULTS Initial treatments were ≥ 2 overlapping stents with or without coiling (n = 28) and single stent with coiling (n = 6). Three BBAs rebled on days 9, 11, and 15 after treatment, resulting in 1 death. Except for 3 patients who died early, 31 patients were followed up for 7 to 80 months (median, 32 months). One patient recovered completely but died of complications of systemic lupus erythematosus at 25 months. Of the remaining 30 patients, 25 had favorable outcomes (modified Rankin scale, 0-2) and 5 had unfavorable outcomes. Angiographic follow-up was available in the 32 BBAs. Eight (25.0%) recurred, all within 5 weeks. In the multiple stents group (n = 26), 22 BBAs showed improvement or complete healing, but 4 (15.4%, 2 rebleedings) had recurrence. In the single stent with coiling group (n = 6), 2 BBAs were stable but 4 (66.7%, 1 rebleeding) had recurrence. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence (P < .05). CONCLUSION Reconstructive treatment with stent and coil appears a viable option for BBAs. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence. Follow-up angiography should be considered mandatory soon after treatment. ABBREVIATIONS BBA, blood blister--like aneurysmICA, internal carotid arterymRS, modified Rankin ScaleSAH, subarachnoid hemorrhage.

Forced Arterial Suction Thrombectomy with the Penumbra Reperfusion Catheter in Acute Basilar Artery Occlusion: A Retrospective Comparison Study in 2 Korean University Hospitals

BACKGROUND AND PURPOSE: A performance of forced arterial suction thrombectomy was not reported for the treatment of acute basilar artery occlusion. This study compared revascularization performance between intra-arterial fibrinolytic treatment and forced arterial suction thrombectomy with a Penumbra reperfusion catheter in patients with acute basilar artery occlusion. MATERIALS AND METHODS: Fifty-seven patients with acute basilar artery occlusion were treated with intra-arterial fibrinolysis (n = 25) or forced arterial suction thrombectomy (n = 32). Baseline characteristics, successful revascularization rate, and clinical outcomes were compared between the groups. RESULTS: Baseline characteristics, the frequency of patients receiving intravenous recombinant tissue plasminogen activator, and mean time interval between symptom onset and femoral puncture did not differ between groups. The forced arterial suction thrombectomy group had a shorter procedure duration (75.5 minutes versus 113.3 minutes, P = .016) and higher successful revascularization rate (88% versus 60%, P = .017) than the fibrinolysis group. Fair outcome, indicated by a modified Rankin Scale 0–3, at 3 months was achieved in 34% of patients undergoing forced arterial suction thrombectomy and 8% of patients undergoing fibrinolysis (P = .019), and the mortality rate was significantly higher in the fibrinolysis group (25% versus 68%, P = .001). Multiple logistic regression analysis identified the forced arterial suction thrombectomy method as an independent predictor of fair outcome with adjustment for age, sex, initial NIHSS score, and the use of intravenous recombinant tissue plasminogen activator (odds ratio, 7.768; 95% CI, 1.246–48.416; P = .028). CONCLUSIONS: In acute basilar artery occlusion, forced arterial suction thrombectomy demonstrated a higher revascularization rate and improved clinical outcome compared with traditional intra-arterial fibrinolysis. Further clinical trials with the newer Penumbra catheter are warranted.

Newly suggested surgical method of decompressive craniectomy for patients with middle cerebral artery infarction.

ObjectivesThe purpose of this study is to suggest the landmarks for decompressive craniectomy so that surgery can be standardized to achieve adequate decompression in patients with malignant middle cerebral artery infarction. We also analyzed the efficacy and safety of this newly suggested surgical method. MethodsEleven patients (group A) underwent this newly suggested decompressive surgery. The bony landmarks for decompressive craniectomy are described. The area of the bone flap and the brain volume protruding out of the skull surface were measured. The outcomes were evaluated 3 months after the surgery. All the results were compared with that of 13 patients (group B) who were treated with conventional surgical methods. ResultsThe mean area of craniectomy was larger in group A (399.9±50.9 cm2) than that in group B (308.5±50.5 cm2, P=0.021). The brain volume protruding out of the skull surface was 161.8±101.7 cm3 in group A and 106.3±55.1 cm3 in group B, indicating that more decompression was performed in group A (P=0.034). Six (54.5%) of 11 patients in group A had favorable outcomes (modified Rankin Scale 0 to 3) without mortality, whereas 2 (15.4%) of 13 patients in group B had favorable outcomes and 3 (23.1%) patients in group B expired. ConclusionDecompressive craniectomy using the newly suggested method is feasible and safe, and it may be more beneficial, compared with conventional craniectomy, for patients with malignant middle cerebral artery infarction. Furthermore, it may be easier to perform by training neurosurgeons.

Preoperative predictive value of the necessity for anterior clinoidectomy in posterior communicating artery aneurysm clipping.

OBJECTIVEResection of the anterior clinoid process (ACP) for the clipping of an internal carotid–posterior communicating artery aneurysm is rarely needed. However, preoperative awareness of the necessity of anterior clinoidectomy is essential for safe clipping of the lesions. We investigated the preoperative predictive value for anterior clinoidectomy in treating internal carotid–posterior communicating artery aneurysms. METHODSWe retrospectively reviewed all patients with a posterior communicating artery aneurysm treated with clipping in the past 5 years. Only the patients who underwent both computed tomographic angiography and 4-vessel digital subtraction angiography were included in this study. We measured several angles and distances on these images, and compared the parameters measured between an anterior clinoidectomy group and a non–anterior clinoidectomy group. A P value of less than 0.05 was considered significant. RESULTSWe examined 94 cases of posterior communicating artery aneurysms treated with clipping. The ACP was resected in 6 of the 94 cases. In the anterior clinoidectomy group, there were 3 factors that were statistically significant. First, the calculated real distance between the ACP and the aneurysmal neck was shorter (mean, 4.4 ± 0.7 versus 7.2 ± 1.4 mm). Second, the angle between vertical line to cranial base and communicating segment of the internal carotid artery (ICA) was larger (mean, 62.5 ± 4.6 versus 50.9 ± 10.7 degrees). Third, the angle between the communicating segment and the ophthalmic segment of the ICA was smaller (mean, 66.5 ± 15.1 versus 84.6 ± 20.4 degrees). CONCLUSIONThe anterior clinoidectomy group showed a more tortuous course of intracranial ICA around the ACP than the nonclinoidectomy group. Therefore, measurement of the distal ICA angle is helpful in predicting the necessity of anterior clinoidectomy.

Ideal Internal Carotid Artery Trapping Technique without Bypass in a Patient with Insufficient Collateral Flow

Internal carotid artery (ICA) trapping can be used for treating intracranial giant aneurysm, blood blister-like aneurysms and ICA rupture during the surgery. We present a novel ICA trapping technique which can be used with insufficient collaterals flow via anterior communicating artery (AcoA) and posterior communicating artery (PcoA). A patient was admitted with severe headache and the cerebral angiography demonstrated a typical blood blister-like aneurysm at the contralateral side of PcoA. For trapping the aneurysm, the first clip was placed at the ICA just proximal to the aneurysm whereas the distal clip was placed obliquely proximal to the origin of the PcoA to preserve blood flow from the PcoA to the distal ICA. The patient was completely recovered with good collaterals filling to the right ICA territories via AcoA and PcoA. This technique may be an effective treatment option for trapping the aneurysm, especially when the PcoA preservation is mandatory.

Incidence and Risk Factors for Rebleeding during Cerebral Angiography for Ruptured Intracranial Aneurysms

Purpose The purpose was to evaluate the incidence and risk factors for rebleeding during cerebral angiography in ruptured intracranial aneurysms. Materials and Methods Among 1896 patients with ruptured intracranial aneurysms between September 2006 and December 2013, a total of 11 patients who experienced rebleeding of the ruptured aneurysms during digital subtraction angiography (DSA) were recruited in this study. Results There were 184 patients (9.7%) who had suffered rebleeding prior to the securing procedure. Among them, 11 patients experienced rebleeding during DSA and other 173 patients at a time other than DSA. Eight (72.7%) of the 11 patients experienced rebleeding during three-dimensional rotational angiography (3DRA). The incidence of rebleeding during DSA was 0.6% in patients with ruptured intracranial aneurysms. Multivariate logistic regression analysis showed that aneurysm location in anterior circulation [odds ratio=14.286; 95% confidence interval (CI), 1.877 to 250.0; p=0.048] and higher aspect ratio (odds ratio=3.040; 95% CI, 1.896 to 10.309; p=0.041) remained independent risk factors for rebleeding during DSA. Conclusion Ruptured aneurysms located in anterior circulation with a high aspect ratio might have the risk of rebleeding during DSA, especially during 3DRA.

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.

The Role of Endovascular Treatment for Ruptured Distal Anterior Cerebral Artery Aneurysms: Comparison with Microsurgical Clipping

The purpose of this study was to compare clinical outcomes and treatment‐related complications between coiling and clipping for ruptured distal anterior cerebral artery (DACA) aneurysms.

Five overlapping enterprise stents in the internal carotid artery-to-middle cerebral artery to treat a ruptured blood blister-like aneurysm

Ruptured blood blister-like aneurysms (BBAs) are rare and very difficult to treat. The optimal treatment of BBAs has yet to be clearly established. Reconstructive endovascular treatment (EVT) of this type of lesion has been recently tried with multiple stents together with or without coiling, and this is expected to have a flow diversion effect [1–3]. Herein, we report on a case with repeated recurrence of a BBA after initial treatment with three overlapping Enterprise stents (Codman Neurovascular, Miami Lake, FL, USA) and coiling, and the lesion was finally completely obliterated using five Enterprise stents with coiling. To the best of our knowledge, this is the first case that five overlapping stents were deployed in the same site of the intracranial vessel with 1-year follow-up. A 41-year-old woman was admitted to our institute with severe, sudden-onset headache. She was alert without any neurological deficit. Brain computed tomography revealed bilateral sylvian obliteration and a magnetic resonance image showed subarachnoid hemorrhage on the FLAIR image. Right internal carotid artery (ICA) angiography demonstrated a small hemispherical bulge at the anterolateral wall of the communicating segment of the ICA (Fig. 1a). Because of its typical location and shape, this lesion was diagnosed as a BBA. Initially, we discussed performing segmental occlusion of the right ICA, which was bearing the BBA. However, this option was abandoned because of the poor collateral circulation and the patient’s intolerance to a right ICA occlusion test. Other treatment options such as microsurgical clipping, wrapping and/or trapping with bypass were dropped out because of the high risk of intraoperative bleeding and the difficulty of the technique. Thus, we planned to perform stentassisted coil embolization with multiple overlapping stents. At the beginning of the procedure, loading doses of clopidogrel 300 mg and aspirin 200 mg were given orally. A 6-Fr guiding catheter (Envoy; Codman Neurovascular) was positioned at the distal cervical portion of the right ICA. The right middle cerebral artery (MCA) was navigated using a microcatheter (Prowler Select Plus; Codman Neurovascular) and a microwire. A 4.5 mm 9 28 mm Enterprise stent was loaded through the catheter and it was ready for deployment. A second microcatheter (Excelsior; Boston Scientific, Natick, MA, USA) was then placed into the BBA. After the stent was fully deployed, two coils were inserted into the BBA. An additional Enterprise stent (4.5 mm 9 22 mm) was introduced and positioned, such that it overlapped the previous stent for remodeling the blood flow away from the BBA. Three more coils were inserted into the BBA. Finally, the third Enterprise stent (4.5 mm 9 28 mm) was deployed to further reinforce the flow diversion effect away from the BBA. Right ICA angiography showed near complete obliteration of the BBA (Fig. 1b). The 6-day follow-up angiography showed a neck recurrence (Fig. 1c), which was retreated with further coiling on the same day, and this resulted in complete obliteration (Fig. 1d). Follow-up angiography 2 weeks after the second treatment revealed no evidence of recanalization J. Chung Department of Neurosurgery, Yonsei University College of Medicine, Gangnam Severance Hospital, Seoul, Republic of Korea

Comparison of the Incidence of Parenchymal Hematoma and Poor Outcome in Patients with Carotid Terminus Occlusion Treated with Intra-Arterial Urokinase Alone or with Combined IV rtPA and Intra-Arterial Urokinase

BACKGROUND AND PURPOSE: Patients with acute CTO generally have a poor prognosis, despite IV or IA thrombolytic treatment. The goal of this study was to analyze the results of patients with CTO who had IA urokinase treatment with or without initial IV rtPA based on a bridging protocol. MATERIALS AND METHODS: Sixteen consecutive patients with acute ischemic stroke due to CTO who had combined IV and IA or a single IA thrombolytic treatment were enrolled. The baseline characteristics and prognosis were described. The patients who did and did not develop a PH shortly after treatment were compared. RESULTS: The mean age was 66.4 years, and the median initial NIHSS score was 17. The median dose of IA urokinase was 320,000 U, and recanalization (TICI grade II-III) was achieved in 12 patients (75%). However, 5 patients died and 10 patients had poor prognosis with mRS 5–6 at discharge. Six patients (37.5%) with a PH had a higher NIHSS score 1 day after treatment (26.7 versus 13.6, P = .002), and they had more frequent mortality (66.7% versus 10.0%, P = .018) and worse prognosis (mRS 5–6; 100% versus 40%, P = .016) at discharge than patients without PH. CONCLUSIONS: Patients with CTO who received IA urokinase treatment based on a bridging protocol had a poor prognosis. The development of PH might affect this outcome.