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Background: To evaluate the association between retinal artery/arteriole occlusion (RAO) and unruptured intracranial aneurysm (UIA)., Methods: Incident UIA patients from a nationwide cohort (n=253 240) were categorised into three groups based on subsequent treatment: observation (n=208 993), microsurgical clipping (n=14 168) and endovascular treatment (EVT) groups (n=30 079). The incidence and the incident time of RAO were analysed. HRs of RAO and associated risk factors were evaluated. Additionally, a hospital cohort comprising 2569 consecutive UIA patients treated at a tertiary hospital was analysed with detailed clinical information of UIAs., Results: In the nationwide cohort analysis, the incidence of RAO was significantly higher in EVT group than in observation and clipping groups, especially within 60 days (early RAO (within 60 days): HR=4.00, 95% CI: 2.44 to 6.56); delayed RAO (after 60 days): HR=1.74, 95% CI: 1.13 to 2.68). Multivariable analysis showed that the presence of chronic kidney disease (p=0.009) and use of a balloon microcatheter during the procedure (p=0.013) were associated with a higher risk of RAO. In hospital cohort analysis, 11 (0.8%) cases of RAO occurred after EVT, whereas none occurred after microsurgical clipping (p<0.001). Patients with RAO were younger and received balloon microcatheters more frequently than their counterparts. Ten cases of RAO (90.9%) occurred in paraclinoid aneurysms, where EVT was preferred over microsurgical clipping., Conclusions: Performing EVT for UIA may increase the risk of subsequent RAO. Care should be taken when treating paraclinoid aneurysms with balloon microcatheters., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To report the long-term clinical and angiographic outcomes of the endovascular treatment of large/giant basilar tip aneurysms (BTAs) in our institutions., Methods: We retrospectively reviewed cases of BTA larger than 10 mm that received endovascular treatment between January 2009 and December 2019. Data on the demographic and clinical characteristics and radiologic severity were obtained from the patients' medical records. The collected clinical follow-up data included neurological evaluation. Magnetic resonance angiography (MRA) was performed 6 to 12 months after the procedure, followed by once every 1 to 2 years as needed., Results: A total of 12 patients with BTA were included in this study. The median age was 60.08 years (27-80 years), and the mean clinical follow-up was 66.78 months (19.00-142.87 months). Almost half of the patients presented with unruptured BTAs (58.33%, n = 7). The median maximum aneurysm diameter was 13.00 mm (10.46-20.90 mm) and the mean neck size was 8.34 mm (4.82-13.04 mm). A Modified Raymond Roy Classification (MRRC1) of 1 or 2 was observed in 66.67% of the patients (n = 8) immediately after the first procedure. Procedural morbidity and mortality were 33.33% and 8.33%, respectively. Major recanalization occurred in two patients, one of whom underwent additional coiling with the other being merely observed due to older age., Conclusion: It is very difficult to cure a large BTA completely at once and recanalization occurred often after endovascular treatment. Conducting long-term follow-up studies at short intervals is warranted, as well as improving existing treatment methods and developing new approaches., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Endovascular treatment (EVT) of posterior communicating artery aneurysms (PcomA) is challenging because of posterior communicating artery (Pcom) architecture. Additionally, these aneurysms have a high risk of recanalization compared with those located elsewhere., Methods: The radiographic findings of 171 patients treated with EVT at two institutions were retrospectively reviewed. Univariate and multivariate analyses were performed, and subgroup analyses were performed based on Pcom characteristics., Results: Recanalization of PcomAs occurred in 53 patients (30.9%). Seven patients (4.0%) were retreated (six endovascularly and one with microsurgical clipping). The mean follow-up duration was 27.7 months (range: 3.5-78.6). The maximum diameter (odds ratio [OR] 1.23, P = .006, 95% CI 1.07-1.44), a Raymond-Roy classification of grade II or III (OR 2.26, P = .03, 95% CI 1.08-4.82), and the presence of reinforcement (balloon or/and stent, OR 0.44, P = .03, 95% CI 0.20-0.91) were associated with recanalization using multivariate logistic regression. Significant differences were found in maximum aneurysm diameter (P = .03) between normal- and fetal-type Pcoms on analysis of variance., Conclusions: The recanalization rate of PcomAs after EVT was 30.9%; the retreatment rate was 4.0%. Maximum diameter, Raymond-Roy classification, and presence of reinforcement were significantly associated with recanalization but not associated with fetal-type Pcom. Aneurysm size was larger in patients with a fetal-type Pcom than in those with a normal Pcom. Pcom size was not related to recanalization rate., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Austria, part of Springer Nature.)

Background: Discriminating a junctional dilatation from a true saccular aneurysm is clinically important., Purpose: To evaluate the usefulness of high-resolution three-dimensional proton density-weighted turbo spin-echo magnetic resonance imaging (PD MRI) in distinguishing a junctional dilatation from an aneurysm of the posterior communicating artery (PcomA)., Methods: Eighty-two consecutive patients with 83 PcomA lesions, which were evaluated by time-of-flight (TOF) MR angiography (MRA), PD MRI, and digital subtraction angiography (DSA), were enrolled. These radiologic data were retrospectively and independently reviewed by two neurosurgeons, and each diagnosis based on TOF MRA, PD MRI, and DSA was compared. The diagnostic efficacy (interobserver agreement, intermodality agreement, and diagnostic performance) of PD MRI was compared with that of TOF MRA., Results: PD MRI showed higher AC1 (Gwet's agreement coefficient, PD MRI: 0.8942, 95% CI 0.8204 to 0.968; TOF MRA: 0.7185, 95% CI 0.5753 to 0.8617) and prevalence-adjusted bias-adjusted kappa coefficient (PABAK) (PD MRI: 0.8554, TOF MRA: 0.5904) than TOF MRA for interobserver agreement. For intermodality agreement, PD MRI also showed higher AC1 (PD MRI: 0.9069, 95% CI 0.8374 to 0.9764; TOF MRA: 0.7983, 95% CI 0.6969 to 0.8996) and PABAK (PD MRI: 0.8735, TOF MRA: 0.7289) than TOF MRA. The diagnostic performance of PD MRI was statistically superior to that of TOF MRA in sensitivity, specificity, positive predictive value, and negative predictive value., Conclusions: PD MRI could provide excellent diagnostic accuracy and better information in distinguishing a junctional dilatation from a true saccular aneurysm of the PcomA compared with TOF MRA., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The purpose of this study was to report our preliminary experience of stent-assisted coiling (SAC) of wide-necked intracranial aneurysms with a single microcatheter in patients with parent arteries that were small-caliber, with stenosis, or a very tortuous course., Methods: Between March 2018 and December 2018, we treated 394 aneurysms in 359 patients with endovascular treatment. Among 197 aneurysms treated by SAC, there were 16 cases (all wide-necked unruptured aneurysms) treated by SAC with a single microcatheter and a Neuroform Atlas stent. Follow-up angiography was performed at 6 to 12 months after SAC, and clinical follow-up was performed from 6 to 12 months in all patients., Results: The reasons for SAC with a single 0.0165-in. microcatheter were small-caliber (n = 4), stenosis (n = 2), and very tortuous course (n = 10) of the parent arteries. There was no complication related to delivering or deploying the Neuroform Atlas stent as well as no failure of selecting aneurysm by cell-through technique. All patients had a modified Rankin score of 0 at discharge and at follow-up. Initial angiographic results showed six cases (37.5%) of complete occlusion. In follow-up angiographies, 12 cases (75.0%) achieved compete occlusion., Conclusion: When performing SAC of wide-necked intracranial aneurysms in parent arteries with small-caliber, stenosis, or a very tortuous course, cell-through SAC using a single microcatheter and a Neuroform Atlas stent within a 5 Fr- (or smaller) guiding or intermediate catheter might be a useful option.

Background: Little has been reported about the feasibility and durability of a Low-profile Visualized Intraluminal Support Junior (LVIS Jr) Y-stenting device for wide-neck bifurcation aneurysms., Purpose: To evaluate the feasibility and durability of LVIS Jr Y-stenting for coiling of unruptured wide-neck bifurcation aneurysms., Methods: We identified patients in whom LVIS Jr Y-stenting was attempted for unruptured wide-neck bifurcation aneurysms from a prospectively maintained registry of a referral hospital. Procedural success rate, treatment-related morbidity, and clinical and angiographic outcomes were retrospectively assessed., Results: LVIS Jr Y-stenting was attempted for a total of 21 aneurysms in 21 patients (mean age 60±8.9 years; M:F=6:15): nine basilar artery, six anterior communicating artery, four middle cerebral artery, one internal carotid artery, and one vertebrobasilar fenestration aneurysms. The mean dome and neck size were 7.9±2.7 mm and 5.7±1.8 mm, respectively. All attempts were successful. Treatment-related morbidity occurred in one individual with a modified Rankin Scale (mRS) score of 2. Immediate postprocedural angiograms showed complete occlusion in 15 (71.4%) and neck remnant in 6 (28.6%) patients. All 21 patients had good outcomes (mRS score 0-2) for a mean of 12 months' follow-up (range 6-27 months); mRS score 0 in 20 patients and mRS score 2 in one patient, respectively. Follow-up imaging over a mean of 11 months (range 6-18 months) was available in 18 patients (85.7%). All aneurysms showed complete occlusion at follow-up., Conclusions: LVIS Jr Y-stenting and coiling for wide-neck bifurcation aneurysms seems to be feasible with acceptable safety and to provide durable aneurysm occlusion for wide-neck bifurcation aneurysms., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: We report the results of a pilot clinical study that evaluated the safety and efficacy of a newly-developed, retrievable flow diverter (FloWise; Taewoong Medical) for the treatment of internal carotid artery (ICA) aneurysm., Materials and Methods: A total of 10 patients were enrolled. Inclusion criteria were 1) unruptured aneurysm with a dome size of ≥ 8 mm and a neck size of ≥ 4 mm at the ICA, or 2) two or more unruptured aneurysms of any size able to be spanned by a single FloWise at the ICA. Co-primary effectiveness end points were technical success of FloWise placement, and a 50% or greater decrease in aneurysm volume at the 6-month follow-up angiogram. The primary safety end point was the new development of neurological deficits persisting for more than 1-month post-treatment., Results: Ten patients harboring 14 ICA aneurysms (median diameter, 9.4 mm; range, 2.3-31.0 mm) were enrolled between January 2016 and July 2017. FloWise placement was successful in all patients. There were no newly-developed neurological deficits during the 6-month clinical follow-up period. One patient did not receive follow-up imaging due to pregnancy. Nine patients with 12 aneurysms received a 6-month angiographic follow-up. Ten aneurysms (83.3%) showed decreases in volume greater than 50% (mean volume decrease, 82.8 ± 32.9%), of which 8 (66.7%, 95% confidence interval, 35.4-98.0%) showed complete occlusion. One patient was retreated due to mass symptom aggravation., Conclusions: In this pilot study, FloWise appeared to be safe and effective for ICA aneurysm treatment. A prospective multicenter study to validate the effectiveness and safety of FloWise would be worthwhile., Competing Interests: The authors have no financial conflicts of interest., (Copyright © 2019 The Korean Society of Radiology.)

Objectives: Therapeutic strategies for residual or recurrent aneurysm (RRA) after microsurgical clipping have not been well established. The purpose of this study was to report our retreatment experiences with previously clipped aneurysms and to demonstrate retreatment strategies for these RRAs., Patients and Methods: From 1996-2016, we treated 68 RRAs after previous clipping. Among them, 34 patients underwent microsurgical retreatment, and the other 34 underwent endovascular retreatment. Radiographic images and clinical data were reviewed retrospectively to determine the treatment efficacy, clinical outcomes, and important factors for selecting the proper treatment modality., Results: The most common aneurysm location was the middle cerebral artery (50%) in the microsurgery group and the internal carotid artery (47.1%) in the endovascular surgery group (p =  0.001). In the microsurgery group, 16 (47.1%) patients had additional clipping without removal of previous clips, 17 (50.0%) had clipping with removal of previous clips, and 1 (2.9%) had bypass surgery with trapping. In the endovascular surgery group, 28 (82.4%) patients had simple coiling, 5 (14.7%) had stent-assisted coiling, and 1 (2.9%) had a flow diverter. Procedure-related complications during retreatment occurred in 4 (5.9%) patients. Complete obliteration was achieved in 51 (75.0%) patients (microsurgery group, 82.4% and endovascular surgery group, 67.6%; p =  0.002)., Conclusions: In properly selected cases, treatment of RRAs could be safely performed either by microsurgery or endovascular surgery and result in a good clinical outcome with acceptable morbidity. The decision to choose the treatment modality for RRAs after clipping is not easy but should be considered to lower the risk of retreatment., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Objective: The purpose of this study was to report the authors' experience with endovascular treatment (EVT) of ophthalmic artery (OA) aneurysms and to investigate risk factors for visual complications of EVT for unruptured OA aneurysms., Methods: Fifty-four patients with unruptured OA aneurysms subjected to EVT were recruited for this study from March 2010 to December 2017. The clinical and angiographic outcomes of all 54 patients were investigated and analyzed retrospectively., Results: Of the 54 patients included in this study, 5 patients (9.3%) had visual complications, including asymptomatic unintended OA occlusion in 2 patients (3.7%) and symptomatic complications in 3 patients (5.6%); 2 patients (3.7%) had transient visual complications, and 1 (1.9%) had a permanent complication. No subacute or delayed visual complications occurred during the 20.8-month follow-up period. OA incorporation by the aneurysm (odds ratio [OR], 3.471; 95% confidence interval [CI], 1.115-9.184; P = 0.038) and intentional OA occlusion (OR, 1.820; 95% CI, 1.248-6.221; P = 0.044) were independent risk factors for visual complications in a multivariate logistic regression analysis., Conclusions: The visual complication rate was 9.3% when performing EVT for unruptured OA aneurysms. OA aneurysms with OA incorporation by the aneurysm might be at higher risk of visual complications when performing EVT. Intentional OA occlusion should be performed with caution, even though a patient may have favorable collaterals during balloon test occlusion., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Foreign body emboli during endovascular treatment (EVT) may cause delayed enhancing lesions (DELs)., Objective: To report our experiences of this complication in patients treated for cerebral aneurysms and to investigate the cause of the lesions by benchtop analyses., Methods: Three patients with DELs on MRI after EVT were retrospectively investigated. Unusual friction had occurred in the midst of coil delivery in two patients. The imaging findings, cause of the lesions due to the devices used for the procedure, treatment, and follow-up results were assessed. Two benchtop analyses were performed. First, a microcatheter that showed similar unusual friction during coiling was retrieved and dissected at the point of friction. Second, the EVT procedure was simulated with multiple coil advancement and withdrawal maneuvers within an acutely angulated microcatheter to identify downstream foreign body material emboli., Results: The DELs were identified 27-37 days (mean 32.7) after the procedure. The patients presented with left arm weakness, headache, and no other symptoms. The lesions were located in the hemisphere corresponding to the treatment. The symptoms subsided after conservative therapy. The dissected microcatheter showed whitish semitransparent material adherent to the inner lumen. Similar material was sieved after multiple coil advancement and withdrawal maneuvers., Conclusions: DELs may be caused by fragmentation and emboli of the inner coating wall of the microcatheter. Development of unusual friction during coil delivery may be a sign of damage of the microcatheter inner wall and the device should be discarded., Competing Interests: Competing interests: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Objective: Few studies have investigated treatment strategies for brain tumor with a coexisting unruptured intracranial aneurysm (cUIA). The purpose of this study was to evaluate the safety and efficacy of preoperative coiling for cUIA, and subsequent brain tumor surgery., Materials and Methods: A total of 19 patients (mean age, 55.2 years; M:F = 4:15) underwent preoperative coiling for 23 cUIAs and subsequent brain tumor surgery. Primary brain tumors were meningiomas (n = 7, 36.8%), pituitary adenomas (n = 7, 36.8%), gliomas (n = 3, 15.8%), vestibular schwannoma (n = 1, 5.3%), and Rathke's cleft cyst (n = 1, 5.3%). cUIAs were located at the distal internal carotid artery (n = 9, 39.1%), anterior cerebral artery (n = 8, 34.8%), middle cerebral artery (n = 4, 17.4%), basilar artery top (n = 1, 4.3%), and posterior cerebral artery, P1 segment (n = 1, 4.3%). The outcomes of preoperative coiling of cUIA and subsequent brain tumor surgery were retrospectively evaluated., Results: Single-microcatheter technique was used in 13 cases (56.5%), balloon-assisted in 4 cases (17.4%), double-microcatheter in 4 cases (17.4%), and stent-assisted in 2 cases (8.7%). Complete cUIA occlusion was achieved in 18 cases (78.3%), while residual neck occurred in 5 cases (21.7%). The only coiling-related complication was 1 transient ischemic attack (5.3%). Neurological deterioration did not occur in any patient during the period between coiling and tumor surgery. At the latest clinical follow-up (mean, 29 months; range, 2-120 months), 15 patients (78.9%) had favorable outcomes (modified Rankin Scale, 0-2), while 4 patients (21.1%) had unfavorable outcomes due to consequences of brain tumor surgery., Conclusion: Preoperative coiling and subsequent tumor surgery was safe and effective, making it a reasonable treatment option for patients with brain tumor and cUIA.

Background and Purpose: Coil packing density (PD) can be calculated via a formula (PDF ) or software (PDS ). Two types of PD can be different from each other for same aneurysm. This study aimed to evaluate the interobserver agreement and relationships between the 2 types of PD relative to aneurysm size., Methods: Consecutive 420 saccular aneurysms were treated with coiling. PD (PDF , [coil volume]/[volume calculated by formula] and PDS, [coil volume]/[volume measured by software]) was calculated and prospectively recorded. Interobserver agreement was evaluated between PDF and PDS . Additionally, the relationships between PDF and PDS relative to aneurysm size were subsequently analyzed., Results: Interobserver agreement for PDF and PDS was excellent (Intraclass correlation coefficient, PDF ; 0.967 and PDS ; 0.998). The ratio of PDF and PDS was greater for smaller aneurysms and converged toward 1.0 as the maximum dimension (DM ) of aneurysm increased. Compared with PDS , PDF was overestimated by a mean of 28% for DM < 5 mm, by 17% for 5 mm ≤ DM < 10 mm, and by 9% for DM ≥ 10 mm (P < 0.01)., Conclusions: Interobserver agreement for PDF and PDS was excellent. However, PDF was overestimated in smaller aneurysms and converged to PDS as aneurysm size increased., (Copyright © 2014 by the American Society of Neuroimaging.)

Background and Purpose: 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., Methods: Eighty-four consecutive patients (M:F = 36:48; mean 53.8 years) with ruptured DACA aneurysms were treated by either clipping (n = 46, 54.8%) or coiling (n = 38, 45.2%). The clinical outcomes and procedure-related complications were evaluated and compared between the two groups., Results: Procedure-related complications tend to occur more frequently in the clipping (n = 6, 13.0%) than coiling group (n = 1, 2.6%) (P = .121). At discharge, 51 patients (60.7%) had favorable outcomes (Glasgow outcome scale [GOS], 4 or 5). There was no significant difference between the two groups in favorable outcome (63.2% vs. 58.7%; P = .677). Hunt and Hess (HH) grade (P < .001; 95% CI, 3.354-29.609) and treatment modality (P = .044; 95% CI, 1.039-16.325) were independent risk factors for poor outcome (GOS, 1-3)., Conclusions: Coiling was more favorable to clipping in clinical outcomes and incidence of treatment-related complications for ruptured DACA aneurysms., (Copyright © 2013 by the American Society of Neuroimaging.)

Background: This study aimed to evaluate clinical and angiographic outcomes of Y-configuration double-stent-assisted (Y-stent) coiling using two closed-cell stents for wide-necked basilar tip aneurysm (BTA)., Materials: A total of 25 patients underwent Y-stent coiling using two closed-cell stents as a first-time treatment in 18 (3 ruptured) BTAs, retreatment in 2 BTAs and as a third treatment in 5 wide-necked BTAs. Clinical and angiographic outcomes were evaluated retrospectively., Results: Treatment-related complications were three (12.0 %) thromboembolic infarctions due to two acute in-stent thromboses and one embolism. Twenty-two (88 %) patients had favorable outcomes (modified Rankin scale score [mRS], 0-2) during the follow-up period (mean, 30 months; range, 6-54 months). Two patients died: one from initial subarachnoid hemorrhage and the other from intracerebral hemorrhage due to underlying Moyamoya disease. Post-treatment angiograms showed complete occlusion in nine aneurysms, residual neck in 11 aneurysms and residual sac in five aneurysms. Follow-up angiograms were available at least once between 5 to 34 months (mean, 16 months) in 21 patients. Nineteen patients showed improved or stable states (complete occlusion, n = 17; residual neck, n = 2). Major recurrences occurred in two BTAs (9.5 %). Those two major recurrent aneurysms had been large-sized aneurysms at the initial coiling procedure. Both showed not only coil compaction but also progressive growth to giant-sized aneurysms and intra-aneurysmal thrombus formation at the Y-stent coiling as a third-time treatment., Conclusions: Y-stent coiling using two closed-cell stents is a safe and durable treatment option for wide-necked BTA, but may have limited efficacy for large/giant sized and thrombosed aneurysms.

Background: Overwide and undertall small intracranial aneurysms remain a challenge for coil embolization. The purpose of this study is to evaluate the feasibility and results of intrasaccular double microcatheter endovascular coil embolization of overwide and undertall small intracranial aneurysms., Methods: Small (<7 mm), overwide (dome-to-neck ratio [DNR] ≤1.2), and undertall (ASPECT ratio ≤1.2) aneurysms which were treated with double microcatheter technique were selected. For the double microcatheter technique, two microcatheters were selected simultaneously into the aneurysm sac and coil insertion was performed alternatingly. The initial results, ASPECT, DNR ratios, complications, and follow-up results were assessed., Results: Twenty small (mean, 3.8 mm), overwide (mean DNR, 1.1), and undertall (mean ASPECT, 1.0) aneurysms were treated with the double microcatheter technique. Overall, complete or near complete occlusion was achieved in 19/20 cases. This was achieved with only the double microcatheter technique in 16/20 cases (ASPECT mean, 1.0; DNR mean, 1.1). Adjuvant balloon remodeling was performed in 4/20 cases (ASPECT mean, 0.8; DNR mean, 1.1). The ASPECT ratio was significantly lower in the adjuvant balloon remodeling cases (p = 0.027). Coiling failed in one patient with both DNR and ASPECT ratio <1.0. Overall, one patient developed a focal visual field defect after the procedure. No other patients developed neurologically significant complications., Conclusions: Double microcatheter technique may be a safe and effective method for the treatment of overwide and undertall small intracranial aneurysms.

Objective: A new double-lumen balloon catheter was being developed for the treatment of cerebral aneurysms. The purpose of this study is to report our initial experience of a double-lumen balloon catheter for the treatment of wide-necked aneurysms., Materials and Methods: Seventeen patients (mean age, 63 years; range, 45-80 years) with wide-necked, with or without a branch-incorporated aneurysms, (10 ruptured and 9 unruptured) were treated with balloon-assisted coil embolization using a double-lumen balloon catheter (Scepter C™ or Scepter XC™) for 7 months after being introduced to our country. Locations of the aneurysms were posterior communicating artery (n = 7), anterior communicating artery or A2 (n = 7), middle cerebral artery (MCA) bifurcation (n = 3), basilar artery tip (n = 1) and anterior choroidal artery (n = 1). The initial clinical and angiographic outcomes were retrospectively evaluated., Results: Coil embolization was successfully completed in all 19 aneurysms, resulting in complete occlusions (n = 18) or residual neck (n = 1). In one procedure, a thrombus formation was detected at the neck portion of the ruptured MCA bifurcation aneurysm near to the end of the procedure. It was completely resolved with an intra-arterial infusion of Glycoprotein IIb/IIIa inhibitor (Tirofiban, 1.0 mg) without any clinical sequela. There were no treatment-related events in the remaining 18 aneurysms. At discharge, functional neurological state improved in 11 patients (10 patients with ruptured aneurysm and 1 with unruptured aneurysm presenting with mass symptoms) and 6 patients with unruptured aneurysms had no newly developed symptoms., Conclusion: In this preliminary case series, the newly developed double-lumen Scepter balloon appears to be a safe and convenient device for coil embolization of wide-necked aneurysms.

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.

Background and Purpose: The aims of this study are to evaluate the risk factors for symptomatic ischemic complication (symptomatic ischemic complication [SIC], transient ischemic attack, or stroke) and microembolisms detected as MR diffusion-weighted imaging (MR-DWI)-positive (DWI(+)) lesions, and the relationship between DWI(+) and SIC after coiling of unruptured intracranial aneurysm., Methods: Between March 2009 and November 2011, 382 unruptured intracranial aneurysms in 343 patients underwent both coiling and posttreatment MR-DWI. The incidence of and risk factors for SIC and DWI(+), and the relationship between DWI(+) and SIC were retrospectively analyzed., Results: The incidence of SIC was 4.1%. The incidence of DWI(+) was 54.5%. The number of DWI(+) lesions was significantly larger in the SIC group, than in the asymptomatic one (12.1±10.4 versus 5.0±8.7, P<0.00). The cutoff value of DWI(+) for predicting SIC was ≥6 (sensitivity 85.7%, specificity 70.7%). The patients with DWI(+) ≥6 was 28.6%. Of the patients with SIC, the patients with DWI(+) ≥6 was 78.6%. Patients aged≥65 years had a trend for SIC, and it was the only independent risk factor for DWI(+) ≥cutoff (n=6; 95%CI, 1.167-3.083)., Conclusions: The number of DWI(+) lesions was significantly larger in the SIC group than in the asymptomatic one after coiling of unruptured intracranial aneurysm. Patients aged≥65 had a trend for SIC, and it was the only independent risk factor for the number of DWI(+) ≥cutoff value (n=6) for predicting SIC.

Objective: A small branch-incorporated aneurysm is an aneurysm with a small branch incorporated into the sac or the neck. It is one of the most difficult aneurysms to treat with coil embolization. The aim of this study was to evaluate the safety and effectiveness of the coil-protected embolization technique for small-branch incorporated aneurysm., Materials and Methods: Fourteen aneurysms (2 ruptured and 12 unruptured) in 12 patients (mean age, 56 years, range, 40-73 years; 6 men and 6 women) were treated with the coil-protected embolization technique during the period between February 2007 and October 2011. Clinical and angiographic outcomes were retrospectively evaluated., Results: All aneurysms were successfully treated without any complications during the procedure. Immediate post-treatment angiographies demonstrated complete or near complete occlusion in 12 and incomplete occlusion in 2 patients. Two patients had a delayed small embolic infarction in the relevant posterior circulation territory and middle cerebral artery territory 10 days and 14 days later, respectively, but both recovered completely or almost completely (modified Rankin scale score [mRS score], 0 and 1, respectively). During the clinical follow-up period (mean, 21 months; range: 2-58 months), all patients reported an mRS score of 0 (n = 10) or 1 (n = 2). Vascular imaging follow-up (catheter angiography: n = 3 and MR angiography: n = 8) was available in 11 aneurysms at 6-12 months. All 11 aneurysms showed complete occlusion except for 1 minor neck recurrence that did not require further treatment., Conclusion: In this series of cases, the coil-protected embolization technique seems to be feasible and effective in the treatment of small-branch incorporated aneurysms.

Background and Purpose: The incidence and risk factors for recurrence after endovascular treatment of intracranial vertebrobasilar dissecting aneurysms (VBDAs) have not been studied. We aimed to evaluate the incidence and risk factors for recurrence after endovascular treatment of VBDAs., Methods: A total of 111 patients (mean age, 45±10 years) underwent endovascular treatment for 119 VBDAs (ruptured/unruptured=73:46). Incidence and risk factors for recurrence were retrospectively evaluated., Results: Sixty-two VBDAs were treated by a reconstructive technique by using 1 to 3 overlapping stents with or without coiling, and 57 VBDAs were treated by a deconstructive technique by using proximal occlusion or internal trapping at the dissected segment of the parent artery. Follow-up angiography was available for 97 VBDAs (81.5%) in 89 patients at 3 days to 48 months (median, 13 months) after treatment. There were 13 recurrences: 6 had rebleeding but 7 had no rebleeding. All 6 hemorrhagic recurrences had initially presented with a ruptured form. Ten recurrences were confirmed by angiography, but 3 recurrences with rebleeding did not receive follow-up angiography. The rate of post-treatment recurrence did not differ between reconstructive and deconstructive treatments. Involvement of the posterior inferior cerebellar artery origin (odds ratio=8.026; 95% confidence interval, 1.561 to 41.259; P=0.013) was the only independent risk factor for recurrence., Conclusions: There was a 13% recurrence after endovascular treatment of VBDAs. Posterior inferior cerebellar artery origin involvement was the only independent risk factor for recurrence after endovascular treatment of VBDAs.

Background: Since the International Subarachnoid Aneurysmal Trial, endovascular coiling has been increasingly used as primary treatment option for ruptured or unruptured aneurysms that are feasible for coiling., Objective: To evaluate the feasibility and clinical and angiographic outcomes of coiling for unruptured middle cerebral artery aneurysms., Methods: The records of 70 consecutive patients with 76 unruptured middle cerebral artery aneurysms who underwent coiling were retrospectively evaluated., Results: Thirty-one aneurysms were treated by single-catheter, 18 by multicatheter, 11 by balloon-assisted, 13 by stent-assisted, and 3 by a combination of multicatheter and balloon-assisted techniques. Coiling was accomplished in 75 but failed in 1 aneurysm. One patient died of consequences of subarachnoid hemorrhage occurring 9 hours after coiling. One intraprocedural aneurysm rupture occurred, which was controlled by further coil insertions and left no sequelae. There were 1 cortical infarction and 1 basal ganglia infarction, both of which recovered completely. Treatment-related permanent morbidity and mortality rates were 0% and 1.4%, respectively. Postembolization control angiography revealed 40 complete, 30 neck remnant, and 5 incomplete occlusions. Clinical follow-up was available in all patients (mean, 25 months; range, 7-105 months). There was no subarachnoid hemorrhage during follow-up, but 1 death resulting from acute myocardial infarction occurred 3 months after coiling. None of the surviving patients had any neurological deterioration. Follow-up angiography was available in 69 aneurysms at 6 to 24 months (mean, 12 months). Three major and 6 minor recurrences were detected. All 3 major recurrent aneurysms were re-treated by coiling without any complications., Conclusion: Most unruptured middle cerebral artery aneurysms could be safely treated by coiling with acceptable short-term to midterm outcomes. Our results warrant further study with a longer follow-up period in a larger population.

Objective: To evaluate the postprocedural hemorrhagic complications associated with stent-remodeled coil embolization of intracranial aneurysms., Methods: From the database of 163 cases of stent-remodeled therapy for wide-neck intracranial aneurysms, patients who showed intracranial hemorrhagic complications on follow-up brain imaging were selected. The initial presentation, antithrombotic medication, hemorrhagic type, location, amount, association with ventriculostomy, symptomatic involvement, and outcome were assessed., Results: Ten patients (6.1%) developed intracranial hemorrhagic complications (range; 0-422 days; mean; 56 days). The hemorrhagic complication rate was higher in patients with acute subarachnoid hemorrhage (20%, 6 of 30 patients) than in patients with unruptured aneurysms (3%, 4 of 133 patients). Nine of the 10 patients were on dual-antiplatelet therapy at the time of hemorrhage development. Seven of the hemorrhages developed in patients with ventriculostomies (intraparenchymal, n=4; subdural hematoma, n=3). Three patients who did not receive a ventriculostomy also developed intracranial hemorrhage (n=1) or intraparenchymal hemorrhage (n=2). Hemorrhagic transformation in the recently infarcted brain tissue seemed to be the cause of nonventriculostomy related intraparenchymal hemorrhage. The hemorrhages were accompanied by symptomatic aggravation in 6 of 10 cases, with 5 cases resulting in moribund clinical outcome., Conclusion: Postprocedural intracranial hemorrhage may be a risk of stent-remodeled therapy while the patient is on dual-antiplatelet medication. Extra caution is warranted especially in patients with acute subarachnoid hemorrhage requiring ventriculostomy or with underlying recent brain infarction.

Objective: To evaluate clinical presentation, safety, techniques, clinical and angiographic outcomes, and prognostic factors of coiling for remnant/recurred aneurysm after clipping., Methods: Twenty-four consecutive patients (11 men and 13 women; mean age, 52 years) with 24 recurred/remnant aneurysms after clipping underwent coil embolization between September 2000 and December 2008. Clinical presentations of remnant/recurred aneurysms, safety, techniques, clinical and angiographic outcomes, and prognostic factors of coil embolization were retrospectively evaluated., Results: Twenty-two aneurysms initially presented with subarachnoid hemorrhage and the other two, with mass effect. Eight aneurysms presented with rebleeding and 16 aneurysms were found on follow-up CT angiogram (n = 12) or catheter angiogram (n = 4). The interval between clipping and coiling ranged from 8 days to 114 months (mean, 31 months). Twelve were treated by using single-catheter, 6 by stent-assisted, 4 by multicatheter, 1 by both balloon- and catheter-assisted, and 1 by balloon-in-stent technique. Immediate postembolization angiogram revealed complete obliteration (n = 19) or residual neck (n = 5). Procedure-related permanent morbidity and mortality rates were 4.2% (1 of 24) and 0%, respectively. There was no rebleeding during clinical follow-up for 3 to 82 months (mean, 24 months). Presentation with rupture after clipping was the only significant predictor of poor outcome (P < .05)., Conclusion: Coiling seems to be a safe and effective retreatment option for remnant/ recurred aneurysm after clipping. Presentation with rupture after clipping is the only predictor of poor outcome. For routine/regular follow-up after clipping, CT angiography may be the imaging modality advisable for detection of remnant/recurred aneurysm.

Purpose: The influences of a stent on the outcome of embolized aneurysms are not well known. The purpose of this study is to assess and compare the angiographic follow-up (FU) results of stent-remodeled (StR) and non-remodeled (nonR) coil embolization of intracranial aneurysms., Methods: Thirty-seven StR patients with FU digital subtraction angiography (DSA) were matched with 37 nonR patients according to presentation (ruptured or unruptured), location of the aneurysm (sidewall or bifurcation), initial sac occlusion (complete/near complete or incomplete/failure), and the sac size (largest diameter/less than 2 mm difference). The baseline clinical and aneurysm characteristics, initial/FU treatment success rates, and FU DSA findings between the StR and nonR groups with regard to the morphologic features (size and location) of the aneurysms were assessed and compared., Results: The StR group showed more frequent progressive thrombosis compared to the nonR group (56.8 vs. 27.0%; p < 0.05). These differences were more prominent for small aneurysms (70 vs. 25%; p < 0.05). Small aneurysms showed a lower rate of FU recanalization in the StR group compared to the nonR group (0 vs. 25%; p < 0.05). Sidewall aneurysms also showed a higher rate of progressive thrombosis in the StR group (61.1 vs. 27.8%; p < 0.05)., Conclusions: Coil embolization is an effective treatment method for intracranial aneurysms, however, changes on follow-up may affect the long-term outcome. Stent remodeling may aid in preserving and enhancing the treatment durability especially in small aneurysms.

The mechanism of aneurysm growth after isolation from the circulation is not well known. We report a case of a woman who presented with mass effects of a large cavernous internal carotid artery (ICA) aneurysm. The parent vessel harboring the aneurysm was sacrificed but the aneurysm continued to enlarge with propagation of the disease along the vessel wall progressively extending to the middle cerebral artery (MCA) leading to ischemic stroke. This case provides imaging evidence of the role of mural inflammation in the development of certain aneurysms.

Introduction: We retrospectively evaluated the ischemic complications related to the anterior choroidal artery (AChA) and clinical outcome after coiling of AChA aneurysms., Methods: We included 37 patients (27 with subarachnoid hemorrhage, 10 without) harboring 38 AChA aneurysms (23 ruptured, 15 unruptured) who were treated by coiling at four institutions. Ischemic complications related to the AChA and clinical outcomes were retrospectively evaluated., Results: Intraprocedural transient AChA occlusion occurred in five aneurysms, all of which had AChA incorporated into the aneurysm neck. Two of the five patients suffered postprocedural transient contralateral hemiparesis, but recovered completely. The remaining three patients had no postprocedural symptoms. Incidence of transient AChA occlusion was significantly higher in those aneurysms in which the AChA was incorporated into aneurysm neck (group 2) than in those in which the AChA was not incorporated (group 1). Of the 37 patients, 31 (83.8%) had good recoveries (modified Rankin scale score 0-2). Two patients died from the consequences of subarachnoid hemorrhage. During follow-up for a mean of 27 months (range 4-72 months), none of the 35 living patients re-bled. A total of 29 aneurysms in 28 patients were followed-up angiographically. Recurrences were found in 5 of the 29 aneurysms during follow-up (mean 18 months, range 6-45 months). Re-embolization achieved near complete occlusion of two recurrent aneurysms, both of which were still stable at the time of the next two follow-up angiographies. The other three recurrent aneurysms were not retreated due to the small size of the recurrences., Conclusion: Coiling of AChA aneurysms resulted in good outcomes without AChA-related permanent ischemic complications. Transient AChA occlusion, potentially associated with ischemic complications, was significantly more frequent in the aneurysm in which the AChA was incorporated into the aneurysm neck.

The endovascular treatment of cerebral aneurysms with coils poses significant technical challenges, particularly with respect to wide-necked aneurysms. We present the results of our initial experiences in using a stent for endovascular treatment of aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Twenty-three wide-necked aneurysms from 22 patients were treated during the 13-month study period. Seven patients presented with subarachnoid hemorrhage. Aneurysms were located at the internal carotid artery (n=14), the vertebral artery (n=3), the basilar artery (n=5), and the middle cerebral artery (n=1). A Neuroform stent2 was used for stent-assisted procedures. Premedication with antithrombotic agents was available for unruptured cases. Postprocedural antithrombotic medication was prescribed for all patients. Nineteen aneurysms were primarily stented, followed by coil placement. For five of these aneurysms, stenting was performed subsequent to failure of an attempt to frame with an initial coil. Stenting for the remaining four aneurysms was performed as a rescue procedure to prevent the migration of previously placed coils. Complete occlusion was obtained in ten aneurysms, nearly complete occlusion (95% or more occluded) in 11 aneurysms, and partial occlusion (less than 95% occluded) in one aneurysm. In one aneurysm, we failed to navigate the microcatheter into the aneurysmal sac through the interstices of the stent. Stent thrombosis was noted during the procedure in one patient. Hemorrhagic complication on the 25th day after the procedure was noted in one patient. No procedure-related complications were observed during the procedure or during follow-up in the remaining 20 patients, including seven patients who did not receive antithrombotic agents prior to endovascular treatment owing to recent subarachnoid hemorrhage. To overcome the technical limitation in the coiling of wide-necked aneurysms, stent-assisted coil embolization may be a technically feasible and relatively safe method, even though longer periods of follow-up are required.

The primary objective for the treatment of arteriovenous malformations (AVM) of the brain is to reduce the risk of hemorrhage. The risk of hemorrhage is known to increase with the presence of an aneurysm associated with AVM. The purpose of this report is to describe the development of visual complications after the embolization of a hemorrhagic anterior choroidal artery feeding AVM with an associated aneurysm and to describe the possible causes.

Objective: To evaluate the efficacy of endosaccular Guglielmi detachable coil (GDC) treatment of unruptured aneurysms causing cranial nerve (CN) symptoms., Materials and Methods: Among a database of 218 patients whose aneurysms were treated using GDC, seven patients met the criteria for unruptured aneurysms presenting with symptoms and signs of CN palsy. Changes in CN symptoms before and after GDC treatment were reviewed., Results: Aneurysms were located in the internal carotid-posterior communicating artery (n=3), the basilar bifurcation (n=1) and the cavernous internal carotid artery (n=3). CN symptoms included ptosis (n=6), mydriasis (n=2), and extraocular muscle (EOM) disorder (CN III: n=4; CN VI: n=3). Overall, improvement or resolution of CN symptoms after treatment was noted in five patients. CN symptoms in cases involving small (