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BackgroundMechanical thrombectomy (MT) is a primary endovascular modality for acute intracranial large vessel occlusion. However, further treatment, such as rescue stenting, is occasionally necessary for refractory cases. We aimed to investigate the efficacy and safety of rescue stenting in first-line MT failure and to identify the clinical factors affecting its clinical outcome.MethodsA multicenter prospective registry was designed for this study. We enrolled consecutive patients who underwent rescue stenting for first-line MT failure. Endovascular details and outcomes, follow-up patency of the stented artery, and clinical outcomes were summarized and compared between the favorable and unfavorable outcome groups.ResultsA total of 78 patients were included. Intracranial atherosclerotic stenosis was the most common etiology for rescue stenting (97.4%). Seventy-seven patients (98.7%) were successfully recanalized by rescue stenting. A favorable outcome was observed in 66.7% of patients. Symptomatic intracranial hemorrhage and mortality were observed in 5.1% and 4.0% of patients, respectively. The stented artery was patent in 82.1% of patients on follow-up angiography. In a multivariable analysis, a patent stent on follow-up angiography was an independent factor for a favorable outcome (OR 87.6; 95% CI 4.77 to 1608.9; p=0.003). Postprocedural intravenous maintenance of glycoprotein IIb/IIIa inhibitor was significantly associated with the follow-up patency of the stented artery (OR 5.72; 95% CI 1.45 to 22.6; p=0.013).ConclusionsIn this multicenter prospective registry, rescue stenting for first-line MT failure was effective and safe. For a favorable outcome, follow-up patency of the stented artery was important, which was significantly associated with postprocedural maintenance of glycoprotein IIb/IIIa inhibitors.

Objective We investigated the effectiveness of a right hemispheric surgical approach in treating unruptured anterior communicating artery aneurysms. Methods Between January 2005 and June 2012, 305 patients with anterior communicating artery (Acom) aneurysms were treated using the pterional approach. Among them, 113 who underwent microsurgery with an unruptured Acom aneurysm were enrolled in this study. Every patient was evaluated with digital subtraction angiography preoperatively and CT scans were taken several times postoperatively. Surgical outcomes and complications were evaluated at discharge using the Glasgow Outcome Scale and at 6 months after surgery with CT angiography. Results Enrolled patients included 55 males and 58 females with a mean age of 56.3 years (range: 30–75 years). The mean diameter of the aneurysm was 5.8 mm (range: 1.9–24.1). Left A1 dominancy was found in 71 patients (62.8%) whereas right A1 dominancy was found in 20 patients (17.7%), and right pterional craniotomies were performed in 92 patients (81.4%) while left pterional craniotomies were performed in 21 patients (18.6%). Complete clip application was achieved in 94.9% of patients (74 of 78) in right-side approach group but in only 81.3% of patients (13 of 16) in left-side approach group. Despite a left A1 dominancy and approached from the right, more than 90% of the patients had an excellent outcome at discharge (GOS 5) and more than 90% a complete aneurysm clipping at the 6-month follow-up CT angiography although it was not statistically significant. Conclusion Microsurgical clipping of the unruptured Acom aneurysm through a right-side surgical approach showed favorable postoperative clinical and anatomical outcomes, especially aneurysms smaller than 10 mm.

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.

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.

Objective To analyze the interspinous distance and the height, length, and thickness of the lumbar spinous process for interspinous device implantation in Korean patients. Methods Morphometric data obtained from plain radiographs of the lumbar and sacral spine were analyzed. The study included 60 matched subjects who visited an outpatient clinic for back pain. Exclusion criteria included collapsed intervertebral disc, lumbarization, and sacralization. There were 34 men and 26 women; age range was the 20s to 70s, with 10 subjects in each decade. The interspinous distance and height, length, and thickness of the lumbar spinous process were obtained on lateral radiographs using an image analysis program (M-view 5.4; Marotech). Results The largest interspinous distance was at L2-3, with a mean of 12 mm (range 6–22 mm), and the smallest distance was at L5-S1, with a mean of 8 mm (range 3–16 mm). The interspinous distance became shorter from L1-2 to L5-S1. A negative correlation was noted between age and interspinous distance in the L1-5 levels (L1-2, y=−0.11x + 17.27, r 2 = 0.34, P r 2 = 0.12, P = 0.0058; L3-4, y=−0.08x + 14.39, r 2 = 0.27, P r 2 = 0.096, P = 0.0158; L5-S1, y=−0.02x + 9.25, r 2 = 0.028, P = 0.1982). Conclusions There is a decreasing trend in the interspinous distance in the L1-5 levels with advancing years. Taking progressive collapse of the interspinous distance with the aging process into consideration, interspinous implants should be carefully selected in younger patients.

Introduction: Distal anterior cerebral artery (DACA) aneurysms are less common and surgical morbidity has been reported relatively high due to intraoperative rupture and narrow surgical field. Endovascular treatment can be alternative to surgery. This study investigated the efficacy and safety of endovascular coiling for ruptured DACA aneurysms comparing with microsurgical clipping. Patients and Methods: Between January 1999 and March 2012, consecutive 94 patients with ruptured DACA aneurysm were treated by surgical clipping (n=52, 55.3%) and endovascular coiling (n=42, 44.7%) in five institutions including only 2 cases of recurrence (2.1%, 1 in clip and 1 in coil). The clinical outcomes of patients and procedure-related complications (intraprocedural rupture and any infarction) were evaluated and compared between two groups. Results: There were 38 males and 56 females (mean age; 55.1 years). Initial Hunt-Hess grade was GII in 25 patients (37.2%), GIII in 36 patients (38.3%), GIV in 12 patients (12.8%), and GV in 11 patients (11.7%), which was significantly higher in coil group (2.77 in clip vs 3.26 in coil, p=0.016). Initial CT scanning showed ruptured DACA aneurysm with ICH (n=35; 37.2%) and hydrocephalus (n=25; 26.6%). Maximal diameter of aneurysm was less than 5mm in 36 (38.3%), 5~10mm in 53 (56.4%), and 10mm and more than in 5 (5.3%). Technical success rate was 100% and complete occlusion or neck remnant of aneurysm was achieved in 87 [92.6%, 49 (96.1%) in clip vs 38 (90.5%) in coil, p=0.404] and incomplete in 6 (6.4%). At discharge, favorable outcome (modified GOS; good and fair) was obtained in 70 [77.8%, 44 (84.6%) in clip vs 26 (68.4%) in coil, p=0.078]. Intraprocedural rupture occurred only in clipping group [6 cases (11.5%), p=0.031]. Any procedure-related infarction occurred in 7 [7.4%, 6 (11.5%) in clip vs 1 (2.4%) in coil, p=0.126]. Intraprocedural thrombus was detected in 5 cases of coil group and most of them were restored by thrombolytic therapy. There was one case of acute rebleeding in coiling group and this patient died. Conclusions: Endovascular coiling was comparable treatment with clipping for ruptured DACA aneurysms.

OBJECTIVE Residual aneurysm from incomplete clipping or slowly recurrent aneurysm is associated with high risk of subarachnoid hemorrhage. We describe complete treatment of the lesions by surgical clipping or endovascular treatment. METHODS We analyzed 11 patients of residual or recurrent aneurysms who had undergone surgical clipping from 1998 to 2009. Among them, 5 cases were initially clipped at our hospital. The others were referred from other hospitals after clipping. The radiologic and medical records were retrospectively analyzed. RESULTS All patients presented with subarachnoid hemorrhage at first time, and the most frequent location of the ruptured residual or recurrent aneurysm was in the anterior communicating artery to posterior-superior direction. Distal anterior cerebral artery, posterior communicating artery, and middle cerebral artery was followed. Repositioning of clipping in eleven cases, and one endovascular treatment were performed. No residual aneurysm was found in postoperative angiography, and no complication was noted in related to the operations. CONCLUSION These results indicate the importance of postoperative or follow up angiography and that reoperation of residual or slowly recurrent aneurysm should be tried if such lesions being found. Precise evaluation and appropriate planning including endovascular treatment should be performed for complete obliteration of the residual or recurrent aneurysm.