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BACKGROUND AND PURPOSE: With the increasing use of the Pipeline Embolization Device for the treatment of aneurysms, predictors of clinical and angiographic outcomes are needed. This study aimed to identify predictors of incomplete occlusion at last angiographic follow-up. MATERIALS AND METHODS: In our retrospective, single-center cohort study, 105 ICA aneurysms in 89 subjects were treated with Pipeline Embolization Devices. Patients were followed per standardized protocol. Clinical and angiographic outcomes were analyzed. We introduced a new morphologic classification based on the included angle of the parent artery against the neck location: outer convexity type (included angle, 200°), and lateral wall type (160° ≤ included angle ≤200°). This classification reflects the metal coverage rate and flow dynamics. RESULTS: Imaging data were acquired in 95.3% of aneurysms persistent at 6 months. Complete occlusion was achieved in 70.5%, and incomplete occlusion, in 29.5% at last follow-up. Multivariable regression analysis revealed that 60 years of age or older (OR, 5.70; P = .001), aneurysms with the branching artery from the dome (OR, 10.56; P = .002), fusiform aneurysms (OR, 10.2; P = .009), and outer convexity–type saccular aneurysms (versus inner convexity type: OR, 30.3; P

BACKGROUND AND PURPOSE: Recanalization after coil embolization is widely studied. However, there are limited data on how recanalized aneurysms rupture. Herein, we describe our experience with the rupture of recanalized aneurysms and discuss the type of recanalized aneurysms at greatest rupture risk. MATERIALS AND METHODS: A total of 426 unruptured aneurysms and 169 ruptured aneurysms underwent coil embolization in our institution between January 2009 and December 2017. Recanalization occurred in 38 (8.9%) of 426 unruptured aneurysms (unruptured group) and 37 (21.9%) of 169 ruptured aneurysms (ruptured group). The Modified Raymond-Roy classification on DSA was used to categorize the recanalization type. Follow-up DSA was scheduled until 6 months after treatment, and follow-up MRA was scheduled yearly. If recanalization was suspected on MRA, DSA was performed. RESULTS: In the unruptured group, the median follow-up term was 74.0 months. Retreatment for recanalization was performed in 18 aneurysms. Four of 20 untreated recanalized aneurysms (0.94% of total coiled aneurysms) ruptured. In untreated recanalized aneurysms, class IIIb aneurysms ruptured significantly more frequently than class II and IIIa (P = .025). In the ruptured group, the median follow-up term was 28.0 months. Retreatment for recanalization was performed in 16 aneurysms. Four of 21 untreated recanalized aneurysms (2.37% of total coiled aneurysms) ruptured. Class IIIb aneurysms ruptured significantly more frequently than class II and IIIa (P = .02). CONCLUSIONS: The types of recanalization after coil embolization may be predictors of rupture. Coiled aneurysms with class IIIb recanalization should undergo early retreatment because of an increased rupture risk.

IntroductionIn our institute, most cases of carotid artery stenosis are treated by carotid artery stenting (CAS) with an open-cell stent and double-balloon protection, even if plaques are unstable. This study was performed to examine the outcome of CAS with an open-cell stent and double-balloon protection for unstable plaques.MethodsA total of 184 CAS procedures in our institute between October 2010 and February 2018 were assessed. Ultrasonography findings of low-echo plaques, plaque ulceration, or both were defined as unstable plaques. A plaque-to-muscle ratio (PMR) of >1.8 on T1-weighted black blood imaging using spin-echo was also defined as an unstable plaque. Seventy-four unstable plaques on ultrasonography and 86 unstable plaques evaluated by PMR were included. Open-cell stents and double-balloon protection (proximal balloon protection during lesion crossing and distal balloon protection after lesion crossing) were used in all cases.ResultsOn ultrasonography, perioperative asymptomatic thromboembolization was significantly more frequent in the unstable plaque group (39/74, 52.7%) than in the stable plaque group (41/110, 37.3%, p=0.0384). Asymptomatic thromboembolization was also significantly more frequent in the PMR >1.8 group (44/86, 51.2%) than in the PMR ConclusionsThe outcomes of CAS with an open-cell stent and double-balloon protection are acceptable. This method is effective and safe, even if carotid artery stenosis comprises unstable plaques.

Background and Purpose— The clinical course of acute ischemic stroke with large vessel occlusion (LVO) is a multifactorial process with various prognostic factors. We aimed to model this process with machine learning and predict the long-term clinical outcome of LVO before endovascular treatment and to compare our method with previously developed pretreatment scoring methods. Methods— The derivation cohort included 387 LVO patients, and the external validation cohort included 115 LVO patients with anterior circulation who were treated with mechanical thrombectomy. The statistical model with logistic regression without regularization and machine learning algorithms, such as regularized logistic regression, linear support vector machine, and random forest, were used to predict good clinical outcome (modified Rankin Scale score of 0–2 at 90 days) with standard and multiple pretreatment clinical variables. Five previously reported pretreatment scoring methods (the Pittsburgh Response to Endovascular Therapy score, the Stroke Prognostication Using Age and National Institutes of Health Stroke Scale index, the Totaled Health Risks in Vascular Events score, the Houston Intra-Arterial Therapy score, and the Houston Intra-Arterial Therapy 2 score) were compared with these models for the area under the receiver operating characteristic curve. Results— The area under the receiver operating characteristic curve of random forest, which was the worst among the machine learning algorithms, was significantly higher than those of the standard statistical model and the best model among the previously reported pretreatment scoring methods in the derivation (the area under the receiver operating characteristic curve were 0.85±0.07 for random forest, 0.78±0.08 for logistic regression without regularization, and 0.77±0.09 for Stroke Prognostication using Age and National Institutes of Health Stroke Scale) and validation cohorts (the area under the receiver operating characteristic curve were 0.87±0.01 for random forest, 0.56±0.07 for logistic regression without regularization, and 0.83±0.00 for Pittsburgh Response to Endovascular Therapy). Conclusions— Machine learning methods with multiple pretreatment clinical variables can predict clinical outcomes of patients with anterior circulation LVO who undergo mechanical thrombectomy more accurately than previously developed pretreatment scoring methods.

Background Eagle syndrome with stroke onset is a rare condition. Carotid stenting of dissected arteries and/or surgical resection of the elongated styloid process are frequently performed; however, there are no definitive criteria for selecting these treatments. Case Description A 46-year-old man presented with left hemiplegia. Acute infarction in the right frontal and parietal lobes and bilateral internal carotid artery (ICA) dissection due to the elongated styloid process were diagnosed via magnetic resonance imaging and computed tomography angiography. He was treated with stenting of the left ICA dissection, with observation of the right ICA dissection. However, the right ICA dissection deteriorated 4 days after the initial event, and additional stenting was performed. He underwent bilateral prophylactic styloidectomy with an extraoral approach 8 months after symptom onset. At >3 years after the styloidectomy, he has not experienced recurrence of the infarction. Conclusions Stenting in the acute phase prevented the recurrence of stroke, and styloid process resection in the chronic phase cured vascular Eagle syndrome. This staged therapy could be beneficial in the treatment of vascular Eagle syndrome.

Background Stent-assisted coil embolization (SAC) for treating anterior communicating artery (AcomA) aneurysms is safe and effective. Straightening of parent vessels by stent placement can lead to progressive thrombosis. We describe our experience with SAC for AcomA aneurysms and demonstrate the effect of straightening the parent vessels. Methods A total of 26 patients with AcomA aneurysms were treated using SAC in our institute between July 2010 and December 2017. Follow-up digital subtraction angiography was performed 6 months after treatment, magnetic resonance angiography was performed every year, and outcomes were analyzed. Results From all aneurysms (n = 24), 12 (50.0%) were neck remnant, and 12 (50.0%) were dome-filling types immediately after the procedure. At the 6-month digital subtraction angiography follow-up (n = 22), 13 (59.1%) aneurysms were complete obliteration, 8 (36.4%) were neck remnant, and 1 (4.5%) was dome filling. The median parent vessel angle was measured preoperatively at 98.1°, increased to 124.8° immediately after stent deployment, and further increased to 149.6° at the 6-month follow-up. Progressive thrombosis was observed in 13 of 22 (59.1%) aneurysms. The parent vessel angle change immediately after stent deployment in the progressive thrombosis group tended to be larger than that observed in the no thrombosis group; this change was significant at the 6-month follow-up. The median follow-up term was 18 months. No patients required retreatment. Conclusions Good SAC outcomes were achieved for AcomA aneurysms, and hemodynamic changes related to straightening of the parent vessels is a consideration in SAC.

IntroductionWe have observed that aneurysms treated by insufficient coil embolization and filled with contrast agent immediately after the procedure are often completely occluded at follow-up. However, there are limited studies showing progressive thrombosis of aneurysms after coil embolization. Herein, we describe our experience with coil embolization for aneurysms, and discuss the factors involved in progressive thrombosis.MethodsA total of 255 aneurysms treated by coil embolization in our institute between January 2011 and June 2017 and observed >6 months were included. ‘Progressive thrombosis’ indicated that aneurysms that were neck remnant (NR) or dome filling (DF) immediately after coil embolization changed to complete obliteration (CO) at the 6-month follow-up digital subtraction angiography. The factors involved in progressive thrombosis were assessed.ResultsIn all aneurysms (n=255), 24 (9.4%) were CO, 82 (32.2%) were NR, and 149 (58.4%) were DF immediately after the procedure. At 6-month digital subtraction angiography, 123 (48.2%) were CO, 95 (37.3%) were NR, and 37 (14.5%) were DF. Retreatment for major recanalization was performed in eight cases (3.1%). One hundred and three aneurysms showed progressive thrombosis. There were significant differences in aneurysm location (P=0.0002), aneurysm dome diameter (P=0.0015), aneurysm neck diameter (P=0.0068), volume embolization ratio (P=0.0054), and endovascular procedure with stent (P=0.0264) between the progressive thrombosis and no thrombosis groups.ConclusionsProgressive thrombosis can occur in aneurysms after coil embolization depending on aneurysm location and size, and stent use. Thus, the degree of coil embolization and combination with a stent should be adjusted depending on aneurysm type.

Background Copolymer (Onyx) embolization is an effective treatment for dural arteriovenous fistula (dAVF), however, some dAVFs have multiple, high-flow feeding vessels, resulting in insufficient embolization. For the treatment of such patients, we have developed a novel flow-control technique, the ‘damp-and-push technique’. The purpose of this study was to evaluate the technical efficiency and safety of this technique. Methods Seven patients who had been diagnosed with intracranial dAVF were treated by transarterial Onyx embolization using the damp-and-push technique between 2016 and 2019. This technique was designed to reduce blood flow to the shunt site using a balloon catheter in the major feeding vessel other than the one injected with Onyx, leading to better Onyx penetration and enabling more controlled embolization of complex dAVFs. Retrospectively collected data were reviewed to assess the occlusion rates and clinical outcomes. Results The dAVF was at a transverse sinus-sigmoid sinus junction in four patients, in the superior sagittal sinus in two, and in the tentorium in one. Five cases were Cognard type Ⅱb and two cases were Cognard type Ⅳ. All the patients were treated by transarterial Onyx injection via the main feeding vessel, combined with flow reduction in the other main feeding vessel using a balloon catheter. Complete occlusion was achieved in six patients and elimination of cerebral venous reflux was achieved in all the patients. There were no immediate or delayed post-interventional complications. Conclusions Transarterial Onyx embolization of dAVF using the damp-and-push technique is safe and yields a high complete occlusion rate.

Background We experienced two cases of ischemic stroke resulting from carotid artery occlusion associated with acute type A aortic dissection (ATAAD), in which carotid artery stenting before the surgery for ATAAD resulted in good clinical outcomes. Case 1 description: A 63-year-old woman was hospitalized for conscious disturbance, right hemiparesis, and total aphasia. Computed tomography of the head showed no abnormal findings. Computed tomography angiography showed ATAAD and bilateral common carotid artery occlusion. Surgery was not indicated for ATAAD because of a poor prognosis of ischemic stroke. However, carotid artery stenting of the left common carotid artery occlusion was successfully performed, and her neurological findings improved. The patient underwent hemiarch replacement for ATAAD on the day after carotid artery stenting. Her final modified Rankin Scale was 1. Case 2 Description: A 57-year-old woman was hospitalized for mild left hemiparesis. Magnetic resonance imaging showed right watershed infarction and right common carotid artery occlusion. Computed tomography angiography showed ATAAD. After hospitalization, conscious disturbance appeared and left hemiparesis worsened. Ischemic stroke indicated a poor prognosis for revascularization by surgery for ATAAD. Thus, carotid artery stenting of the right common carotid artery occlusion was performed. The patient’s neurological findings improved and she underwent hemiarch replacement for ATAAD at 19 days after carotid artery stenting. Her final modified Rankin Scale was 1. Conclusions In the present cases, although ischemic stroke was serious and precluded surgical indication for ATAAD, carotid artery stenting before surgery for ATAAD resulted in good clinical outcomes. Performing carotid artery stenting before surgery for ATAAD is challenging but achievable, and is a valid treatment option depending on the individual cases.

The use of human induced pluripotent stem cells (hiPSCs) eliminates the ethical issues associated with fetal or embryonic materials, thus allowing progress in cell therapy research for ischemic stroke. Strict regulation of cell therapy development requires the xeno-free condition to eliminate clinical complications. Maintenance of hiPSCs with feeder-free condition presents a higher degree of spontaneous differentiation in comparison with conventional cultures. Therefore, feeder-free derivation might be not ideal for developing transplantable hiPSC derivatives. We developed the feeder-free condition for differentiation of cortical neurons from hiPSCs. Then, we evaluated the cells' characteristics upon transplantation into the sham and focal brain ischemia on adult male Wistar rats. Grafts in lesioned brains demonstrated polarized reactivity toward the ischemic border, indicated by directional preferences in axonal outgrowth and cellular migration, with no influence on graft survival. Following the transplantation, forelimb asymmetry was better restored compared with controls. Herein, we provide evidence to support the use of the xeno-free condition for the development of cell therapy for ischemic stroke.

The purification of pluripotent stem cell-derived cortico-fugal projection neurons (PSC-CFuPNs) is useful for disease modeling and cell therapies related to the dysfunction of cortical motor neurons, such as amyotrophic lateral sclerosis (ALS) or stroke. However, no CFuPN-specific surface markers for the purification are known. Recently, microRNAs (miRNAs) have been reported as alternatives to surface markers. Here, we investigated this possibility by applying the miRNA switch, an mRNA technology, to enrich PSC-CFuPNs. An array study of miRNAs in mouse fetal brain tissue revealed that CFuPNs highly express miRNA-124-3p at E14.5 and E16.5. In response, we designed a miRNA switched that responds to miRNA-124-3p and applied it to mouse embryonic stem cell (ESC)-derived cortical neurons. Flow cytometry and quantitative polymerase chain reaction (qPCR) analyses showed the miRNA-124-3p switch enriched CFuPN-like cells from this population. Immunocytechemical analysis confirmed vGlut1/Emx1/Bcl11b triple positive CFuPN-like cells were increased from 6.5 to 42%. Thus, our miRNA-124-3p switch can uniquely enrich live CFuPN-like cells from mouse ESC-derived cortical neurons.

The incidence of aneurysmal subarachnoid hemorrhage (SAH) increases with age. Aged patients of SAH are thought to have higher risk for complications and poorer prognosis. We retrospectively reviewed the consecutive medical records of ruptured intracranial aneurysm patients over 75 years old (y/o), who were admitted to our hospital, where endovascular treatment was adopted as the first option between April 2004 and July 2010. Thirty-eight patients (6 males and 32 females) ranging from 75 to 90 (average 82.1) y/o were enrolled. They were divided into a course observation (CO) group (n=7), clipping (CL) group (n=13) and coil embolization (CE) group (n=18). Among these 3 groups, we evaluated the clinical characteristics, Hunt & Kosnik (H&K) grade on admission, and modified Rankin Scale (mRS) and Glasgow Outcome Scale (GOS) 3 months after ictus as the outcomes. Furthermore, we analyzed the main cause leading to unfavorable outcomes. According to the location of radically treated aneurysms, all MCA aneurysms were clipped and all VBA aneurysms were coil embolized, while ACoA aneurysms were more likely to be treated with coil embolization. Although it was necessary in some cases to alter the approach route from trans-femoral to trans-brachial or trans-carotid due to atherosclerotic tortuosity, every coil embolization was successful without procedure-related complications. Moreover, neither re-rupture nor re-growth requiring further treatment occurred during follow-up period (range, 6 months–6 years). Among the CL group and CE group, 20 (64.5%) of 31 resulted in mRS 3–6 despite aggressive treatment. However, the results of the CO group were much worse than those of the CL group and CE group. All 7 patients in the CO group died of primary brain damage (PBD) 3, re-rupture 3, pneumonia 1, respectively. There was no significant difference between the CL group and CE group in age distribution or H&K grade. Nevertheless, the proportion of mRS 0 and 1 in the CE group was larger than that in the CL group (44.4% vs. 23.1%), although there was no statistical difference. No vegetative survival (V) was found in this study, so we regarded severely disabled (SD) and dead (D) as unfavorable outcomes. There were 6 SD and 3 D of 13 in the CL group, whereas there were 7 SD and 3 D of 18 in the CE group. As the main cause of unfavorable outcomes, PBD, systematic complications such as pneumonia, pre-existing comorbidities etc. were named, but above all, vasospasm was strongly correlated with SD in the CL group (4 of 6) compared with the CE group (2 of 7). Though there were inherent limitations and biases in this study and the overall results were unsatisfactory, we validated the usefulness of coil embolization for ruptured aneurysm in elderly patients. Because coil embolization was effective against re-rupture, it might be a preferred alternative for aneurysms not amenable to clipping. Optimum treatment should be considered individually when both microsurgical and endovascular treatment modalities are available. Furthermore, intensive peri-procedural management of patients’ clinical conditions especially focused on preventing vasospasm as well as greater skill in both treatments are important to improve outcomes.

We investigated the current state of and problems in patients with subarachnoid hemorrhage initially diagnosed and treated by general physicians at a local referring hospital and subsequently transferred to our hospital for neurosurgical treatment. We studied 37 consecutive patients with subarachnoid hemorrhage over a 7-year period from April 2001 to March 2008. A total of 7 men and 30 women aged 50 to 89 years (average: 71.2±9.5 years) were included in this study. Thirteen patients (35.1%) were referred to our hospital with diagnoses other than subarachnoid hemorrhage. Twenty-three of 27 patients who had CT scans were diagnosed correctly in the referring hospital, while only 1 of 10 patients was correctly diagnosed without CT. Time from the onset to admission to our hospital ranged from 85 minutes to 144 hours (average: 15.3±29 hours). The reasons of delay in patients who took more than 12 hours to reach us were patients’ delay in visiting the referring hospital in 3 cases and uncertain initial diagnosis in 6. All 6 cases complained of sudden headache, but did not undergo CT. All patients were transferred by an ambulance car, and the duration of transfer ranged from 60 to 120 minutes (average: 85.4±15.7 minutes). None of the patients experienced rebleeding during transfer. Subarachnoid hemorrhage can be diagnosed correctly at the local primary hospital with CT, allowing appropriate primary treatments. Initial misdiagnosis is the major cause of delay in transferring patients to neurosurgical facilities.