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In coil embolization of cerebral aneurysms, inadequate packing is known to increase the probability of recanalization. Even tightly embolized aneurysms may be recanalized, but predictive factors for recanalization have not been fully investigated. This retrospective study aimed to identify risk factors for recanalization of treated aneurysms with a volume embolization ratio (VER) ≥ 25%. A total of 301 unruptured aneurysms in 248 patients who underwent coil embolization between March 2012 and January 2021 were analyzed. Cases involving dissecting aneurysm, intraluminal thrombosis, parent artery occlusion, intraoperative rupture, re-treatment, rupture the day after surgery, postoperative coil migration, and postoperative parent artery occlusion were excluded due to the inaccuracy of VER. A total of 105 aneurysms (34.9%) treated with VER ≥ 25% were extracted. Clinical features (age, sex, medical history, family history), anatomical features (shape, location, aneurysm size, inflow angle, and volume), procedural features (stent-assisted, Raymond-Roy occlusion classification [RROC] immediately after treatment, re-treatment rate), and follow-up period were compared between Recanalization and Non-recanalization groups. Predictors of recanalization were determined using logistic regression and receiver operating characteristic (ROC) curve analyses. Eleven aneurysms were recanalized. In multivariate analysis, RROC class 3 (odds ratio [OR] 11.0; 95% confidence interval [CI] 2.03-59.4) and aneurysm volume (OR 1.005; 95%CI 1.001-1.008) were independent predictors of recanalization. ROC curve analysis showed optimal cutoff values for aneurysm volume of 69.5 mm

Objectives: Long term outcome of large / giant unruptured intracranial aneurysms (LG-UIAs) after endovascular therapy is still unknown. We retrospectively analyzed long-term results of patients with LG-UIAs who were followed up more than 5 years after endovascular therapy. Methods: We included patients from our complete database with UIAs greater than 10mm and treated at our hospital from January 2003 to December 2013. Retreatment rate of targeted aneurysms, rupture rate, and the modified Rankin scale (mRS) at last visit were evaluated till December 2018. Results: From 142 patients treated during the period were excluded 3 patients with perioperative rupture and 38 patients with less than 5 years follow-up period, finally analyzing 101 patients. The median aneurysm size was 12.0 mm (IQR 10.8-15). The median follow-up period was 9.4 years (IQR: 7-11), the longest being 13.3 years. Retreatment was performed on 36 patients (35.6%). Comparing cumulative re-treatment rates in groups with aneurysm sizes 20 mm, it was predominantly higher for aneurysms> 20 mm (P = 0.02, Figure1 ). Rupture of targeted aneurysms was observed in 2 cases (1.98%, Figure2 ), and the longest period from last treatment was up to 12 years. The mRS 0-1 at the first treatment and the final visit were 98% and 93%, respectively, and mRS deterioration remained at 5%. Conclusion: The retreatment rate tended to increase in proportion to the size of the aneurysm, however the final neurological outcome was favorable when considering the natural history of these aneurysms. Since aneurysmal rupture could occur after 12 years of treatment, long-term follow-up should be considered for LG-UIAs.

A 40-year-old man presented with a severe headache, lower back pain, and lower abdominal pain 1 month after a head injury caused by falling. Computed tomography (CT) of the head demonstrated bilateral chronic subdural hematoma (CSDH) with a significant amount in the left frontoparietal region. At the same time, magnetic resonance imaging (MRI) of the lumbar spine also revealed CSDH from L2 to S1 level. A simple drainage for the intracranial CSDH on the left side was performed. Postoperatively, the headache was improved; however, the lower back and abdominal pain persisted. Aspiration of the liquefied spinal subdural hematoma was performed by a lumbar puncture under fluoroscopic guidance. The clinical symptoms were dramatically improved postoperatively. Concomitant intracranial and spinal CSDH is considerably rare so only 23 cases including the present case have been reported in the literature so far. The etiology and therapeutic strategy were discussed with a review of the literature. Therapeutic strategy is not established for these two concomitant lesions. Conservative follow-up was chosen for 14 cases, resulting in a favorable clinical outcome. Although surgical evacuation of lumbosacral CSDH was performed in seven cases, an alteration of cerebrospinal fluid (CSF) pressure following spinal surgery should be reminded because of the intracranial lesion. Since CSDH is well liquefied in both intracranial and spinal lesion, a less invasive approach is recommended not only for an intracranial lesion but also for spinal lesion. Fluoroscopic-guided lumbar puncture for lumbosacral CSDH following burr hole surgery for intracranial CSDH could be a recommended strategy.

We report the case of a patient with a spinal extradural arteriovenous fistula (AVF) associated with Cowden syndrome (CS) that was successfully treated by endovascular surgery. CS is an autosomal dominant disorder associated with diverse symptoms caused by a deleterious mutation in the phosphatase and tensin homolog (PTEN) gene. A 67-year-old woman was diagnosed with CS based on her medical history of multiple cancers for which she underwent abdominal surgery, macrocephaly, Lhermitte-Duclos disease, and facial papules. Her genetic testing demonstrated a PTEN mutation. She presented with progressive paraparesis and her MRI of the thoracolumbar spine showed the spinal cord edema along with flow voids. A spinal angiogram demonstrated a spinal extradural AVF with the perimedullary drainage. The AVF was successfully treated by endovascular surgery. The PTEN mutation can accelerate angiogenesis; thus, vascular anomalies are one of the diagnostic criteria of CS. However, only two cases of vascular anomalies involving the spinal cord in patients with CS have been reported previously. As the present case, both cases had a history of abdominal or retroperitoneal cancer. The PTEN mutation accompanied with abdominal surgery might have caused this vascular anomaly as the consequences of venous congestion around the thoracolumbar spine. A spinal extradural AVF should be considered in patients with CS who present with myelopathy, especially when the patient has a history of abdominal or retroperitoneal surgery. Regarding the treatment strategy, endovascular surgery should be considered because surgical insult could prompt secondary vascular anomalies resulting from neovascularization due to the PTEN mutation.

Background: Radiation-induced aneurysms have been previously reported; however, multiple and repeated de novo aneurysm formation chronologically and anatomically during long-term follow-up have not yet been observed. The pathogenesis of persistent radiation-induced vasculopathy is not fully understood. Case Description: A 31-year-old woman presented with intraventricular hemorrhage due to rupture of a right internal carotid artery (ICA) aneurysm that developed 17 years after surgical resection of a low-grade glioma in the right frontal lobe and postoperative radiotherapy (focal, 50 Gy/25 fractions). During glioma follow-up, salvage surgery with adjuvant gamma knife therapy and chemotherapy (ranimustine, vincristine, temozolomide) were performed for recurrence of the glioma. The aneurysm was treated with endovascular coil embolization. However, she experienced repeated intraventricular hemorrhages, and angiography revealed a de novo ICA aneurysm. The de novo aneurysms were treated with endovascular surgery using coil embolization and stenting. At 2 years after the third hemorrhage, the surgical wound became dehiscent, probably due to wound infection, thus epicranial soft tissue reconstruction using vascularized skin flap was performed. Despite multistaged endovascular surgery for the ICA aneurysm, she experienced repeated subarachnoid and intraventricular hemorrhages. Angiography revealed a de novo aneurysm of the right posterior cerebral artery and basilar trunk. She underwent coil embolization and stenting. Despite active management with endovascular surgery and close follow-up, she died after an eighth consecutive intraventricular and intracerebral hemorrhage caused by a de novo large aneurysm of the posterior cerebral artery. Conclusions: To the best of our knowledge, the present study is the first to report on of refractory and recurring de novo aneurysms treated by multistaged endovascular surgery during a long-term follow-up after radiotherapy and multistaged craniotomy for glioma. Key words: De novo aneurysm, Low-grade glioma, Multistaged craniotomy, Occult wound infection, Radiation-induced aneurysm

Background Although most neurovascular diseases can be treated either by microsurgical or endovascular means, a subset of patients may require a combined approach. Patient transfer from the operating room (OR) to the angiosuite has been a fundamental drawback of this type of approach. Objective The purpose of this study is to report our clinical experience performing combined surgical and endovascular procedures for neurovascular diseases in the hybrid OR. Methods 29 patients with neurovascular diseases underwent combined endovascular and surgical procedures in a single session: 16 were scheduled combined treatment and 13 were emergency combined procedures. Of the emergency cases, three were rescue surgeries after endovascular complications. Three patients had ruptured intracranial aneurysms, eight had unruptured intracranial aneurysms, eight had arteriovenous malformations and eight had arteriovenous fistulae; two patients had either a spinal tumor or dural arteriovenous fistulae. Results All combined procedures were performed in a single session without changing the patient9s surgical position. In cases of ruptured arteriovenous malformations or aneurysms with hematoma, an emergency embolization was performed to assist the surgical procedure. Combined superficial temporal artery–middle cerebral artery (STA–MCA) bypass followed by endovascular parent artery trapping were successfully performed for complex large or giant aneurysms. There were two periprocedural ischemic complications. Of the three patients who underwent surgical rescue after endovascular complications, two remained intact and one died despite immediate surgical procedures. Conclusion A combined endovascular and surgical approach conducted in a hybrid OR provides a new strategy for the treatment of complex neurovascular diseases.

Background Intraventricular hemorrhages (IVHs) caused by ruptured cerebral aneurysms often have poor outcomes. Treatment challenges include comorbidities, increased intracranial pressure caused by IVH, and risk of rebleeding. Case Description Two cases of severe IVH accompanied by acute hydrocephalus caused by ruptured aneurysm were treated with coil embolization followed by endoscopic hematoma evacuation as a single treatment session in a hybrid operating room (OR) equipped with a multipurpose angio biplane system. The first case was an 84-year-old woman with a ruptured basilar top aneurysm, who presented with Hunt and Hess (H&H) grade 5 subarachnoid hemorrhage (SAH) with packed IVH. The second case was a 43-year-old man with a ruptured anterior communicating artery aneurysm who presented with H&H grade 5 SAH with packed IVH. In both cases, endovascular coil embolization was performed first to prevent intraoperative bleeding. The coiled aneurysms suddenly appeared on the screen of the endoscope during the hematoma removal, which could have led to massive rebleeding if not treated previously. Neither patient needed a reinsertion of the ventricular drainage or developed chronic hydrocephalus during hospitalization. The hybrid OR enabled the 2 treatment approaches to be performed without the need to transfer the patient, thereby minimizing the transition time between the modalities. Intraoperative cone-beam computed tomography contributed to the evaluation of residual clots. Conclusions A hybrid OR may contribute to a combined neuroendoscopic and endovascular treatment for ruptured cerebral aneurysms with severe intraventricular hemorrhage.

BACKGROUND AND PURPOSE: The natural history and therapeutic management of dissecting vertebrobasilar aneurysms without ischemic or hemorrhagic stroke (nonstroke dissecting vertebrobasilar aneurysms) are not well-established. We conservatively followed patients with nonstroke dissecting vertebrobasilar aneurysms and evaluated the factors related to clinical and morphologic deterioration. MATERIALS AND METHODS: One hundred thirteen patients were enrolled and divided by clinical presentation at diagnosis: asymptomatic (group 1, n = 52), pain only (group 2, n = 56), and mass effect (group 3, n = 5). Patients were conservatively managed without intervention and antithrombotic therapy. Clinical outcomes and morphologic changes were analyzed. RESULTS: A total of 113 patients who were diagnosed with nonstroke dissecting vertebrobasilar aneurysm had a mean follow-up of 2.9 years (range, 27 days to 8 years). Throughout that period, 1 patient in group 1 (1.9%) and 1 patient in group 2 (1.8%) showed clinical deterioration due to mass effect, and 1 patient in group 3 (20%) developed ischemic stroke followed by subarachnoid hemorrhage. Most patients (97.3%) were clinically unchanged. Three patients who had clinical deterioration showed aneurysm enlargement (P < .001). Aneurysms remained morphologically unchanged in 91 patients (80.5%). Aneurysm enlargement was seen in 5 patients (4.4%); risk of enlargement was significantly associated with either maximum diameter (hazard ratio = 1.30; 95% CI, 1.11–11.52; P = .001) or aneurysm ≥10 mm (hazard ratio = 18.0; 95% CI, 1.95–167; P = .011). CONCLUSIONS: The natural course of these lesions suggests that acute intervention is not always required and close follow-up without antithrombotic therapy is reasonable. Patients with symptoms due to mass effect or aneurysms of >10 mm may require treatment.

A 46-year-old woman was admitted with generalized convulsion and deep coma which occurred 3 weeks after sudden onset of severe headache and pyrexia. Initial computed tomography did not reveal any abnormal findings except for an arachnoid cyst in the right middle fossa. Three weeks later repeat computed tomography showed intracystic hematoma in the arachnoid cyst with uncal herniation. Angiography revealed a right internal carotid-posterior communicating artery aneurysm. The neck of the aneurysm was clipped successfully, but hemiparesis was persistent postoperatively. Angiography is required for investigation of intracystic hematoma of an arachnoid cyst, especially in the absence of head injury, to avoid delayed diagnosis of any ruptured aneurysm.

[Introduction] In stent-assisted coil embolization for brain aneurysms, precise deployment of the delivered stent is essential to achieve optimal angiographical outcome. However, it is frequently difficult to predict where the proximal end of the delivered stent lands due to complicated 3D structure of the target artery. A new software “Virtual Stent (VS) (Siemens AG, Forchheim, Germany)”, is designed to simulates the location of proximal and distal ends of the delivered-stent based on the 3D angiogram, thereby the program help an interventionalist to choose the best suitable profile of the stent before delivery. To evaluate the accuracy of the program, retrospective analysis of the previously treated patients using VS was performed. [Methods] We retrospectively applied VS to post-treatment 3D DSA images in 44 aneurysm patients who were treated with stent-assisted coiling using Enterprise Stent®. Distal marker of VS was aligned to that of EP, and discrepancy between the proximal marker of VS and EP was measured. The mean/maximal discrepancy was calculated in three groups with different length of EP, and evaluation was performed. [Results] In all cases, VS was successfully applied on each 3D DSA image. Overall avarage discrepancy between the proximal marker of VS and that of EP was 1.20mm. The mean/maximum discrepancy varied among the 3 groups with different EP length, 22mm (8 cases): 2.29mm/3.7mm, 28mm (32 cases): 0.93mm/2.5mm, 37mm (4 cases): 1.21mm/1.8mm. In the anterior circulation cases, the mean/maximum discrepancy were 1.33mm/3.7mm respectively, while in the posterior circulation the discrepancy was 0.91mm/2.34mm. In every case, it was considered that the discrepancy between the EP and VS was minimal and the VS could be a good predictor of the final positioning of a delivered EP. [Conclusion] For stent assisted coil embolization of the brain aneurysms, VS simulation provides acceptable accuracy for planning the stent size and its positioning.

Objective: To evaluate if the MRI image findings of carotid arterial plaques using Magnetization-Prepared Rapid Acquisition with Gradient Echo (MPRAGE) is associated with the risk of thromboembolic event during carotid artery stenting (CAS). Methods: A total of 109 carotid stenting was performed on 99 patients. Correlation between the Pre-operative MRI findings of carotid arterial plaque using MPRAGE and the procedure related thromboembolic event was assessed. Distal protection devices were used in all cases including a balloon protection device (Guardwire) and filter devices (AngioguardXP, Filterwire EZ). All lesions were classified into three types according to the intensities on MPRAGE: high intensity (group A), intermediate intensity (group B) and iso-intensity groups (group B). Procedure related morbidity within 30days of procedure was evaluated using Modified Rankin Scale (MRS). Results: Neurological ischemic events associated with the carotid stenting occurred in 11 out of 109 procedures (10.1%). Two (1.8%) cases showed persistent neurological deficit and six (5.5%) showed transient neurological events. Ocular ischemia occurred in 3 cases (2.8%). Thromboembolic events in group A (n=40), group B (n=36) and group C (n=30) were 7 (23.3%), 4 (11.1%) and 0 (0%), respectively. The incidence of thromboembolic events was significantly higher in the combined group A and B as compared to that in group C (P=0.006). Thromboembolic events of CAS with use of Guardwire, Angioguard and Filterwire were 12.1%, 14.3% and 0%, respectively. In CAS for high intensity plaque (n=66), incidence of thromboembolic event with use of Angioguard (4 of 15, 26.7%) was higher than that of Guardwire (7 of 38, 18.4%). In group A, none of the cases (n=20) treated with filter wire showed procedure related ischemic event. Conclusions: High intensity plaque on MPRAGE can be related to high rate of thromboembolic events during CAS.

A 46-year-old woman was admitted with generalized convulsion and deep coma which occurred 3 weeks after sudden onset of severe headache and pyrexia. Initial computed tomography did not reveal any abnormal findings except for an arachnoid cyst in the right middle fossa. Three weeks later repeat computed tomography showed intracystic hematoma in the arachnoid cyst with uncal herniation. Angiography revealed a right internal carotid-posterior communicating artery aneurysm. The neck of the aneurysm was clipped successfully, but hemiparesis was persistent postoperatively. Angiography is required for investigation of intracystic hematoma of an arachnoid cyst, especially in the absence of head injury, to avoid delayed diagnosis of any ruptured aneurysm.

A 87-year old male was admitted to our hospital due to generalized convulsion with loss of consiousness. He was afebrile and his blood sampling was not infectious. Computed tomography scan suspected left chronic subdural hematoma. Burr hole drainage was performed to remove the hematoma, but the abscess was aspirated in the subdural space. Infected subdural hematoma is rare. We discuss the clinical presentation, diagnosis and. treatment, and also briefly review the literature.

Purpose Stent assisted coil embolization recently became a common treatment strategy for the wide neck aneurysms. Normal digital subtraction angiography (DSA), however, does not allow visualization of the deployed stents. With a combination of novel Metal Artefact Removal software (MAR) and C-arm CT, the coil mass, stent, and contrast material can be differentiated. In this study, experimental aneurysms were treated with stent assisted coil embolization and image analysis was performed using the C-arm CT and MAR. I. V. injection of the contrast to obtain the images was also performed. Methods A total of 12 experimental aneurysms were created in 6 swine. The aneurysms were treated with coil embolization using stent assisted technique. High Resolution (HR) C-arm CT with intra-arterial injection of the contrast dye (20%) was performed immediately after the treatment and obtained images were processed with MAR. Intra venous contrast injection (non-diluted) from femoral vein was also performed in 3 swine. Visualization of the residual aneurysms as well as coil loops protruded into the stent lumen was evaluated. Two patients previously treated with stent assisted coil embolization underwent the same image acquisition protocol, and the obtained images were evaluated. Results Coil loops protruded into the stent lumen, which were not visible before the MAR due to the significant metal artefact, were well visualised after the MAR. Likewise, Contrast filling into the residual aneurism was observed after the MAR in every aneurysm. Intravenous injection of the contrast material reproduced similar image quality as compared to the intra arterial injections. The C-arm CT images of the two patients showed remarkable reduction of the metal artefacts after the MAR processing. Conclusions The combination of the C-arm CT and MAR enables the differentiation of the coil mass, stent and contrast material by markedly reducing the metal artefact produced by the coils. This novel image modality may contribute to the evaluation of aneurysms treated with stent assisted coil embolization. Disclosures I. Yuki: 1; C; Siemens Grant. Y. Kambayashi: 1; C; Siemens Grant. A. Ikemura: 1; C; Siemens Grant. I. Kan: 1; C; Siemens Grant. Y. Abe: None. A. Mohamed: 5; C; Siemens Japan KK. C. Dahmani: 5; C; Siemens Japan KK. T. Ishibashi: 1; C; Siemens Grant. I. Kajiwara: 1; C; Siemens Grant. K. Nishimura: 1; C; Siemens Grant. Y. Murayama: 1; C; Siemens Grant.

Background and Purpose Double catheter coil embolisation (DCC) technique has been used for the treatment of wide neck aneurysms. Unlike Stent assisted Coil Embolisation (SAC), DCC does not require long term post-treatment anti-platelet therapy. Whether or not DCC can reduce the procedure related complications in SAC is not clear. In this series, consecutive unruptured wide neck aneurysm patients were treated primarily with the DCC. SAC was only used as a rescue therapy when the coil mass in the aneurysm was considered to be unstable. Clinical as well as angiographical outcomes of those who treated with DCC were reviewed. Methods A total of 597 unruptured aneurysm patients were treated in our institution between 2006 and 2012. Of these, 144 patients with wide neck (neck size >4.0 or dome-neck ratio Results A total of 129 patients were treated with DCC only, and 5 patients were shifted to the SAC based on the intra-procedural findings. The average neck size and the average dome-neck ratio of the treated aneurysms were 6mm and 1.3 respectively. Every aneurysm treated with DCC was successfully embolised. Intra-operative hemorrhagic event occurred in 2 cases. There was no intra-operative thrombo-embolic event. During the average follow up period of 809 days, post operative symptomatic ischaemic events were seen in two cases (1.6%) and post operative hemorrhagic event (procedure unrelated) was seen in 1 case (0.8%). Permanent morbidity and mortality throughout was 2.4% and 0.8% respectively. Recanalisation that required re-treatment was seen in 14.7% but there was no procedure related complication during the re-treatment. Conclusion The angiographic outcomes of the aneurysms treated with DCC in this series were comparable to the historical controls of the wide neck aneurysms treated with other adjunctive techniques. To minimise procedure related ischaemic/haemorrhagic event associated with the SAC, DCC may be a potential candidate of alternative treatment. Disclosures I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Misaki: None. K. Nishimura: None. A. Ikemura: None. T. Abe: None. Y. Murayama: None.

Purpose To improve the visualisation of residual neck in the aneurysms treated with coil embolisation utilising the time-resolved contrast enhanced magnetic resonance angiography (4D MRA). Materials and Methods A total of 11 patients who underwent coil embolisation of brain aneurysm underwent 1.5 Tesla 4D MRA one year after the procedure. Of these, 6 patients were treated with stent assisted technique. The image information obtained from the 4D MRA was re-processed utilising a 3D Neuroimaging software (TeraRecon, Inc.) and compared to the images obtained from the cerebral angiograms. Results Six patients showed major recanalisation and five patients showed minimal residual neck of the treated aneurysm in the cerebral angiogram. The 4D MRA images obtained from each patient was consistent with the images from the cerebral angiogram. The susceptibility artifact induced by the coils and stents was significantly reduced as compared to the images of contrast enhanced time of flight (CE-TOF) images. The re-processed 3D images of 4D MRA in the Neuroimaging software showed great reproducibility of angiographical findings obtained from the cerebral angiograms. Conclusion The combination of the 4D MRA and utilisation of the 3D Neuroimaging software showed great visualisation of residual aneurysm. This imaging method can be a good alternative for the post-procedure follow up angiograms in the patients who underwent coil embolisation. Disclosures A. Ikemura: None. I. Yuki: None. T. Ishibashi: None. H. Arakawa: None. K. Irie: None. H. Takao: None. I. Kajiwara: None. K. Nishimura: None. I. Kan: None. Y. Murayama: None.