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To assess clinical outcomes of ruptured vertebral artery dissecting aneurysms, focusing on comparing parent artery occlusion (PAO) with stent-assisted treatments, and to identify risk factors for unfavorable outcomes and postprocedural complications.This retrospective review included 36 ruptured vertebral artery dissecting aneurysms treated between February 2009 and April 2020. Treatment modalities included PAO without stent and stent-assisted treatments. Stent-assisted treatments included PAO with posterior inferior cerebellar artery (PICA) stenting and stent-assisted coiling. Univariate and multivariate analyses were conducted to evaluate risk factors for unfavorable outcomes and postprocedural complications.Patients were treated with PAO only (24, 66.7%), PAO with PICA stenting (4, 11.1%), and PAO with stent-assisted coiling (8, 22.2%). There were only fusiform aneurysms with PICA involvement in the PAO with PICA stenting group. In the stent-assisted coiling group, 4 aneurysms incorporated PICA, and 4 aneurysms involved dominant vertebral artery. Old age (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.01-1.56, P = 0.044) and poor Hunt-Hess grade (OR = 537.99, 95% CI = 6.73-42994.1, P = 0.005) were significantly associated with unfavorable clinical outcomes after a mean follow-up of 37.5 ± 32.8 months. Fusiform dilatation shape (OR = 15.97, 95% CI = 1.52-167.38, P = 0.021) and PICA involvement (OR = 13.71, 95% CI = 1.29-145.89, P = 0.030) were independent risk factors for ischemic complications.Unfavorable clinical outcomes were significantly related to old age and poor Hunt-Hess grade. There were no significant differences between treatment groups in clinical outcomes or ischemic complications. Stent-assisted treatments might be effective and safe methods for ruptured vertebral artery dissecting aneurysms.

We aimed to compare clinical outcomes of acute ischemic stroke (AIS) due to internal carotid artery (ICA) occlusion following mechanical thrombectomy (MT), focusing on occlusion types.We retrospectively reviewed 67 AIS patients who had an ICA occlusion on computed tomography angiography and underwent MT in a single tertiary center. ICA occlusion types were categorized as (1) true cervical ICA (cICA) occlusion (true occlusion), (2) pseudo-occlusion of the cICA (pseudo-occlusion), and (3) distal ICA (dICA) occlusion. We compared the clinical characteristics and their outcomes according to the ICA occlusion type.Fourteen patients were diagnosed with true occlusion, 32 with pseudo-occlusion, and 21 with dICA occlusion. The main etiologies were atherothrombotic in true occlusion (64.3%) and cardioembolic in pseudo-occlusion (81.3%) and dICA occlusion (71.4%) (P0.001). Pseudo-occlusion showed lower rates of successful reperfusion (37.5%, P = 0.009, 78.6% in true occlusion and 71.4% in dICA occlusion) and poor functional outcome at 3 months (18.8%, P = 0.037, 50% in true occlusion and 47.6% in dICA occlusion) with statistical significance. The infarction volume (169.4 ± 154.4 mL, P = 0.004, 29.2 ± 52.7 mL in true occlusion and 105.8 ± 13.4 mL in dICA occlusion) was significantly higher in pseudo-occlusion. On multivariate logistic analysis, pseudo-occlusion (odds ratio [OR]: 4.84, 95% confidence interval [CI] 1.02-22.87, P = 0.023) was an independent risk factor for poor reperfusion, which was significantly associated with a poor functional prognosis (OR: 22.04, 95% CI 1.99-243.83, P = 0.012).Patients with pseudo-occlusion showed poorer clinical outcomes compared with other ICA occlusion types, possibly due to a poor reperfusion rate after MT.

OBJECTIVEVisual deterioration is one of the disabling complications that can occur after carotid angioplasty and stenting (CAS). The purpose of this study was to evaluate the risk factors for newly developed visual symptoms after CAS, focusing on ophthalmic artery (OA) flow pattern and etiology of visual loss.METHODSA retrospective review of 127 patients with 138 internal carotid artery (ICA) stenosis lesions that were treated with CAS from February 2009 to October 2017 in a single institution was performed. The flow pattern of the OA was evaluated with digital subtraction angiography and classified into 3 types: type I, antegrade OA flow before and after CAS; type II, antegrade OA flow reversal after CAS; and type III, retained nonantegrade OA flow after CAS.RESULTSThe degree of ipsilateral ICA stenosis was significantly higher in the nonantegrade group than that in the antegrade group (81.73% ± 9.87% vs 75.74% ± 10.27%, p = 0.001). Independent risk factors for newly developed visual symptoms after CAS were visual symptoms before CAS (OR 65.29, 95% CI 5.14–827.2; p = 0.001) and type III OA flow pattern (OR 55.98, 95% CI 2.88–1088.0; p = 0.008). The post-CAS visual symptoms in 10 patients were related to acute elevation of intraocular pressure in 6 patients and retinal artery occlusion in 3 patients.CONCLUSIONSMaintained retrograde or undetected OA flow after CAS and initial visual symptoms before CAS were related to post-CAS visual symptoms. Thus, careful attention is needed for these patients during the perioperative period, and immediate evaluation and management are required for patients with post-CAS visual loss.

This study aimed to compare the treatment outcomes of large (15–25 mm) and giant (> 25 mm) intracranial aneurysms (IAs), according to different treatment modalities. In total, 112 patients with large and giant IAs treated with various treatment modalities between January 2009 and December 2018 were retrospectively reviewed. Clinical and radiological parameters were analyzed and correlated with the treatment modality. A total of 141 procedures were performed on 112 patients. We initially treated 47 cases with coil embolization, 39 with flow diverter (FD), 13 with direct clipping, and 13 with parent artery occlusion (PAO). Recurrence (46.8%) and retreatment (31.9%) rates were significantly higher in the coiling group (p < 0.001). Complete occlusion rate (36.3%) was significantly lower in the coiling group (p = 0.027). PAO could achieve a high complete occlusion rate (90.9%) with low complication rate (12.5%). The total complication rate was 17%. In the multivariate logistic regression analysis, FD (OR 3.406, p = 0.036) and direct clipping (OR 5.732, p = 0.017) showed a significantly higher complication rate than coiling. The overall mortality rate was 8% (8/139 procedures). At the last follow-up (mean 30.6 ± 26.4 months), 70 of 96 patients (72.9%) showed complete or near-complete occlusion. Good functional outcome (mRS ≤ 2) was observed in 90 of 112 (80.3%) patients at the last follow-up (mean 33.2 ± 30.5 months). Good clinical and radiologic outcomes with acceptable complication and mortality rates can be achieved by various treatment modalities. The selection of appropriate modality should be individualized based on the angiographic findings and clinical symptoms.

Background and Purpose: Differentiation between pseudo-occlusion and true occlusion of internal carotid artery (ICA) is important in treatment planning for acute ischemic stroke patients. We compared the findings of multiphasic computed tomography angiography between cervical ICA pseudo-occlusion and true occlusion at the cervical ICA in patients with anterior circulation acute ischemic stroke to determine their diagnostic value. Methods: Thirty patients with nonvisualization of the proximal ICA were included. Diagnosis of pseudo- or true occlusion of the ICA was made based on digital subtraction angiography. Diagnostic performances of multiphasic computed tomography angiography findings—(1) a flame-shaped stump and (2) delayed contrast filling at the cervical ICA— were evaluated and compared. The Fisher exact test, χ 2 test, or Wilcoxon rank-sum test and McNemar test were used in the data analysis. Results: Twelve patients had true proximal ICA occlusion and 18 had pseudo-occlusion. Delayed contrast filling at the cervical ICA on multiphasic computed tomography angiography was found in all patients with pseudo-occlusion of the ICA, while 1 case of true occlusion showed delayed contrast filling ( P Conclusions: We demonstrated that the delayed filling sign on multiphasic computed tomography angiography could be a useful and readily available finding for differentiating proximal ICA pseudo-occlusion from true occlusion.

Background Cerebral angiosarcoma is an extremely rare malignant tumor that originates from vascular endothelial cells of the brain or meninges. Especially, primary brainstem angiosarcoma has not been reported. Case Description A 64-year-old man presented with left subjective weakness, hypesthesia, and dizziness. Brain imaging showed a multistage hemorrhagic mass in the right dorsal pons, which was initially misdiagnosed as a cavernous malformation. The patient's neurologic status suddenly deteriorated over a few months, and the mass grew rapidly. Surgical resection was performed, and the final pathology showed brainstem angiosarcoma. Conclusions To our knowledge, this is the first case of brainstem angiosarcoma confirmed by pathology after surgical resection. This report highlights that clinicians need to consider angiosarcoma as part of the differential diagnosis for rare hemorrhagic lesions in the brainstem when both imaging findings and neurologic deterioration indicate rapid progression.

Objective The purpose of this study was to analyze treatment outcomes according to treatment modality for elderly patients over 75 years with unruptured intracranial aneurysm. Methods Fifty-four elderly patients treated in a single tertiary institute between January 2010 and December 2018 were retrospectively reviewed. We compared clinical outcome, radiological results, and complications between the coiling and clipping groups. Results A total of 55 procedures were performed in 54 patients. Of 55 aneurysms, 44 were treated endovascularly and 11 were treated surgically. There was no significant difference in patient baseline characteristics including mean age, sex, and preexisting co-morbidity between the two groups. Even though there was no significant difference (p=0.373), procedure-related symptomatic complication occurred only in coiling group (3 out of 44 patients, 6.6%). Mortality rate was significantly higher in clipping group (1 out of 11 patients, 9.1%) than in coiling group (0%, p=0.044). Good clinical outcome (modified Rankin Scale 0-2) at 90 days was achieved in 43 cases treated with coiling (97.7%), and 10 cases with clipping (90.9%, p=0.154). Conclusions Clipping is more invasive procedure and takes longer operation time, which might lead to unpredictable mortality in elderly patients. Coiling might have high procedure-related stroke rate due to tortuous vessels with atherosclerosis. Therefore, aggressive treatment of elderly patients should be carefully considered based on patient's medical condition and angiographic findings.

The aim of this study is to investigate the clinical and radiological features related to the symptomatic ischemic complications of vertebral artery dissecting aneurysm (VADA) following endovascular treatment (EVT).The clinical and radiological features of 127 VADAs, which were treated in a single tertiary institute between September 2008 and December 2020, were retrospectively reviewed. We defined a thrombosed aneurysm as being one which the thrombus was in the aneurysm in magnetic resonance imaging (MRI). Symptomatic ischemic complication was defined as a case in which acute infarction was confirmed on diffusion weighted image after EVT with associated clinical symptoms. Univariate and multivariate analyses were executed to demonstrate the associations between symptomatic ischemic complication and characteristics of VADA.The rate of symptomatic ischemic complication was 13.4% (17 of 127). The thrombosed aneurysms were observed in 24.4% (31 of 127) and posterior inferior cerebellar artery (PICA) involvement was shown in 38.6% (49 of 127). Multivariate logistic regression analysis demonstrated that thrombosed aneurysms (odds ratio [OR] = 8.54, 95% confidence interval [CI] 1.98-36.87, p = 0.004) and PICA involvement (OR = 4.26, 95% CI 1.03-17.68, p = 0.046) were significantly associated with symptomatic ischemic complications following EVT.This study showed that the VADAs with intra-aneurysmal thrombose and PICA involvement may be independent risk factors for symptomatic ischemic complications following EVT. Therefore, when the thrombosed VADAs with PICA involvement are observed, practitioners may consider close postoperative monitoring for early detection of ischemic complications.

Severe intracranial atherosclerotic stenosis (ICAS) is a major cause of stroke. Although percutaneous transluminal angioplasty and stenting (PTAS) treatment methods have increased over the last decade as alternative therapies, there is debate regarding the best method of treatment, with medical and surgical therapies often suggested.We analyzed the long-term follow-up results from 5 years of intracranial stenting for intracranial stenosis from three stroke centers. The primary endpoints were early stroke complications or death within 30 days after stent insertion, and the secondary endpoint was a recurrent stroke between 30 days and 60 months. Correlating factors and Kaplan-Meier survival curves for recurrent stroke and in-stent restenosis (ISR) were also obtained.Seventy-three PTAS in 71 patients were examined in this study. The primary and secondary endpoints were all 8.2% (n = 6), and restenosis was 13.7% (n = 10) during the 5-year follow-up. The primary endpoints were significantly frequent in the high National Institutes of Health Stroke Scale (NIHSS) and early stent (≤ 7 days after dual antiplatelet medication) groups. Secondary endpoint and ISR were identically frequent in the younger age group and in the presence of tandem stenosis in other major intracranial arteries. The cumulative probability of recurrent stroke and ISR at 60 months was 16.4% and 14.1%, respectively.This study shows that PTAS is safe and effective for major ICAS. Reducing the early complication rate is still an important factor, despite the fact that long-term stroke recurrence was low.

OBJECTIVE The aim of this study was to investigate the clinical and radiological factors associated with the rupture of a vertebral artery dissecting aneurysm (VADA) and to evaluate whether the stagnation sign is a significant risk factor for rupture of VADA. METHODS Clinical and radiological variables of 117 VADAs treated in a tertiary hospital from September 2008 to December 2020 were retrospectively reviewed. The stagnation sign is defined as the finding of contrast agent remaining in the lesion until the venous phase of angiography. Univariate and multivariate analyses were executed to reveal the associations between rupture status and VADA characteristics. RESULTS The rate of ruptured VADAs was 29.1% (34 of 117) and the stagnation sign was observed in 39.3% (46 of 117). Fusiform shape (OR 5.105, 95% CI 1.591–16.383, p = 0.006), irregular surface (OR 4.200, 95% CI 1.412–12.495, p = 0.010), posterior inferior cerebellar artery (PICA) involvement (OR 3.788, 95% CI 1.288–11.136, p = 0.016), and the stagnation sign (OR = 3.317, 95% CI 1.131–9.732, p = 0.029) were significantly related to rupture of VADA in multivariate logistic regression analysis. CONCLUSIONS This study showed that fusiform shape, irregular surface, PICA involvement, and the stagnation sign may be independent risk factors for the rupture of VADA. Therefore, when the potential risk factors are observed in unruptured VADA, more aggressive treatment rather than follow-up or medical therapy may be considered.

Objectives To identify predictors of atherosclerotic change in aneurysms and parent arteries, and to retrospectively analyze outcomes from clipped aneurysms that showed atherosclerotic changes. Methods Between May 2017 and April 2018, we collected a total of 151 clipping cases and reviewed records of operation videos to classify atherosclerosis by location (dome, neck of aneurysm, or parent artery). To identify predictors of atherosclerotic change in aneurysms, we analyzed baseline demographic characteristics, preoperative images, and Framingham Risk Scores (FRS). We also analyzed incomplete clipping cases according to atherosclerosis presence and location. Result This study cohort included 110 women (mean age, 59.3 ± 7.1 years) and 41 men (mean age, 55.9 ± 9.6 years). Atherosclerotic change was seen in 77 cases. FRS, diabetes mellitus, and aneurysm size were identified as independent risk factors for atherosclerotic change in multivariate logistic regression analysis. There were 11 incomplete clipping cases (7.2%). Among the 30 cases with atherosclerotic change in the neck were 10 cases of incomplete clipping (P Conclusions FRS, diabetes mellitus, and aneurysm size as predictors of atherosclerosis in patients undergoing aneurysm surgery can help guide surgical decisions and performance.

Objective Since less invasive endovascular treatment was introduced to South Korea in 1994, a considerable proportion of endovascular treatments have been performed by neuroradiology doctors, and endovascular treatments by vascular neurosurgeons have recently increased. However, few specific statistics are known regarding how many endovascular treatments are performed by neurosurgeons. Thus, authors compared endovascular treatments collaboratively performed by vascular neurosurgeons with all cases throughout South Korea from 2013 to 2017 to elucidate the role of neurosurgeons in the field of endovascular treatment in South Korea. Methods The Society of Korean Endovascular Neurosurgeons (SKEN) has issued annual reports every year since 2014. These reports cover statistics on endovascular treatments collaboratively or individually performed by SKEN members from 2013 to 2017. The data was requested and collected from vascular neurosurgeons in various hospitals. The study involved 77 hospitals in its first year, and 100 in its last. National statistics on endovascular treatment from all over South Korea were obtained from the Healthcare Bigdata Hub website of the Health Insurance Review & Assessment Service based on the Electronic Data Interchange (EDI) codes (in the case of intra-arterial (IA) thrombolysis, however, statistics were based on a combination of the EDI and I63 codes, a cerebral infarction disease code) from 2013 to 2017. These two data sets were directly compared and the ratios were obtained. Results Regionally, during the entire study period, endovascular treatments by SKEN members were most common in Gyeonggido, followed by Seoul and Busan. Among the endovascular treatments, conventional cerebral angiography was the most common, followed by cerebral aneurysmal coiling, endovascular treatments for ischemic stroke, and finally endovascular treatments for vascular malformation and tumor embolization. The number of endovascular treatments performed by SKEN members increased every year. Conclusion The SKEN members have been responsible for the major role of endovascular treatments in South Korea for the recent 5 years. This was achieved through the perseverance of senior members who started out in the midst of hardship, the establishment of standards for the training/certification of endovascular neurosurgery, and the enthusiasm of current SKEN members who followed. To provide better treatment to patients, we will have to make further progress in SKEN.

Posterior communicating artery (PcomA) aneurysm can be classified into sidewall or bifurcation types based on the anatomical variation of fetal-type posterior cerebral artery (fPCA). The aims of this study were to investigate the significance of fPCA as an independent risk factor for the rupture of PcomA aneurysm and to evaluate other associated morphological and clinical risk factors. We retrospectively reviewed clinical and radiological findings of 255 patients with PcomA aneurysms, which were treated in a single tertiary institute between January 2009 and December 2016. Univariate and multivariate analyses were performed to evaluate the associations between morphological and clinical variables and rupture status. Subgroup analysis was also performed based on the aneurysms with and without fPCA. Fifty-five out of 255 PcomA aneurysms (21.6%) were associated with fPCA. Multivariate logistic regression analysis showed that the superior direction of aneurysm dome (OR 9.106, p = 0.007), the presence of a bleb (OR 4.780, p

Coil embolization with multiple overlapping stents was performed as an alternative treatment option for blood blister-like aneurysms (BBAs). However, coil placement into the BBAs has the inherent risks of rupture and regrowth. We describe a safe dense coil packing technique into and just proximal of BBAs using a semi-jailing technique for the treatment of BBAs of the internal carotid artery (ICA) and report the long-term clinical outcomes.The technique involves the partial deployment of a self-expanding and retrievable stent from the ICA bifurcation to the mid-portion of a BBA followed by coil embolization with gradual unsheathing of the stent from the BBA to its just proximal portion. Seventeen patients were treated using this technique (10 women; mean age, 47.9 ± 11 years; overall mean clinical follow-up period, 42.3 ± 22.8 months). Technique safety and feasibility, and follow-up angiographic results and clinical outcomes (modified Rankin Scale, mRS) were evaluated.Procedures were successfully applied without any procedure-related complications. Immediate post-treatment angiograms showed total obliteration of the BBAs in all 17 patients. Follow-up angiograms, which were available in 15 (88.2%) patients, showed complete resolution of BBAs. Fourteen (82.4%) of 17 patients achieved favorable clinical outcomes (mRS ≤ 2).Forward deployed coil embolization with multiple overlapping stents offers a safe and effective reconstructive endovascular technique for the treatment of the BBAs.

Objective To determine clinical and radiologic outcomes of vertebral artery dissecting aneurysms involving posterior inferior cerebellar artery according to different types of endovascular treatment. Methods This study included 18 vertebral artery dissecting aneurysms (6 ruptured and 12 unruptured) involving posterior inferior cerebellar artery treated from January 2009 to December 2016. Treatments were multiple stenting, stent-assisted coil embolization, vertebral artery trapping with vertebral artery–posterior inferior cerebellar artery stenting, and Pipeline embolization. Clinical and radiologic information were obtained from retrospective chart review and radiologic review. Results Subarachnoid hemorrhage was diagnosed initially in 6 of 18 patients, and infarction was diagnosed initially in 2 patients. Multiple stenting was performed in 4 patients, including 1 (25%) who had cerebellar infarction and 1 (25%) who had recurrence. Stent-assisted coil embolization was performed in 8 patients, including 1 (12.5%) who had postoperative cerebellar infarction and 2 (25%) who had recurrence. Vertebral artery trapping with vertebral artery–posterior inferior cerebellar artery stenting was performed in 4 patients, including 1 (25%) who had postoperative cerebellar infarction. There was no recurrence (0%). Pipeline embolization was performed in 2 patients, including 1 (50%) who had recurrence. There was no postoperative infarction (0%). No subarachnoid hemorrhage occurred during follow-up. Deterioration in modified Rankin Scale score was found only in the stent-assisted coil embolization group (1/8; 12.5%). Conclusions Vertebral artery trapping with vertebral artery–posterior inferior cerebellar artery stenting showed the lowest rate of aneurysm recurrence with high rate of minor infarction and favorable neurologic outcome. Stent-assisted coil embolization showed high recurrence rates with possible fatal disabling infarction.

BackgroundBasilar artery (BA) trunk aneurysms are rare, and the clinical characteristics and outcomes of endovascular treatment (EVT) remain unclear. The purpose of this study was to report clinical and angiographic outcomes of BA trunk aneurysm treated with EVT and to analyze risk factors for unfavorable outcomes.MethodsFrom October 2004 to December 2020, a total of 40 patients with BA trunk aneurysms underwent EVT. Clinical characteristics and outcomes were evaluated retrospectively from a prospectively collected database. Of the 40 enrolled patients, nine were treated by coiling without stents, 17 were treated by stent-assisted coiling, six by stent only, five by flow diverters, and three by vertebral artery occlusion.ResultsIn total, 27 (67.5%) patients had subarachnoid hemorrhage as an initial presentation, and 20 (50.0%) had large/giant aneurysms. Procedure-related complications occurred in five patients (12.5%); favorable clinical outcome was achieved in 27 patients (67.5%); and six patients (15.0%) died. Favorable angiographic outcome was achieved in 26 (83.9%) of 31 patients who underwent follow-up angiography. Poor initial Hunt-and-Hess grade (OR 7.67, 95% CI 1.55 to 37.80; p=0.018) was the only independent risk factor for unfavorable clinical outcome. Large/giant aneurysm (OR 8.14, 95% CI 1.88 to 27.46; p=0.047) and long lesion (OR 14.25, 95% CI 1.48 to 69.80; p=0.013) were independent risk factors for unfavorable angiographic outcomes during follow-up.ConclusionsEVT might be a feasible option for this rare disease entity. Unfavorable angiographic outcome might be expected in a large/giant aneurysm or a long lesion. It can be difficult to treat BA trunk aneurysms by EVT, needing multiple procedures or various techniques due to diverse clinical and angiographic features.

This study aimed to identify the association between the number of anterior choroidal arteries (AchoAs) and procedure-related ischemic complications in microsurgical clipping of unruptured AchoA aneurysms. We retrospectively reviewed the clinical, radiological, and intraoperative findings of 153 patients with unruptured AchoA aneurysms treated with microsurgical clipping between January 2012 and November 2020 in a single tertiary institution. Intraoperative video clips were reviewed, and the AchoA type was categorized into two according to the number of AchoAs: (1) single-type group with single origin and single branch and (2) multiple-type group with duplicated origin or divided multiple branches. Uni- and multivariate analyses were performed to assess the relationship between clinical and radiological factors and perioperative ischemic complications. Of the 153 patients, 52 (34%) were categorized as multiple-type group. The frequency of perioperative ischemic complications, including decreased intraoperative motor evoked potential (MEP), silent infarction, and postoperative ischemic symptoms, was significantly higher in the multiple-type group than in the single-type group (13 [25%] vs 6 [5.9%], p = 0.001). Multivariate logistic regression analysis showed that multiple-type group (odds ratio [OR], 3.725; 95% confidence interval [CI], 1.171–11.845, p = 0.026) and multilobulated shape (OR, 9.512; 95% CI, 2.093–43.224; p = 0.004) were significantly associated with perioperative ischemic complications. Among 9 patients with decreased MEP, postoperative ischemic symptoms developed in 2 patients after clip adjustment. Multiple-type AchoA aneurysms and multilobulated shape are significantly correlated with perioperative ischemic complications. Postoperative ischemic complications can be minimized by recognizing these variations and using multimodal approach with MEP monitoring.

Purpose: Three-dimensional (3D) measurement of intracranial aneurysms is important in planning endovascular treatment, and 3D rotational angiography (RA) is effective in accurate measurement. The purpose of this study was to evaluate the feasibility of low dose 3D RA (5 seconds 0.10 μGy/frame) in measuring an intracranial aneurysm using an in vitro phantom.Materials and Methods: We investigated an in vitro 3D phantom of an intracranial aneurysm with 10 acquisitions of 3D RA with a conventional dose (5 seconds 0.36 μGy/frame) and 10 acquisitions with a low-dose (5 seconds 0.10 μGy/frame). 3D size and neck diameters of the aneurysm were measured and compared between the 2 groups (conventional and low-dose) using noninferiority statistics.Results: The aneurysm measurements were well-correlated between the 2 readers, and noninferiority in the measurement of aneurysmal size of low-dose 3D RA was demonstrated, as the upper margin of the 1-sided 97.5% confidence interval did not cross the pre-defined noninferiority margin of 0.2 mm by the 2 readers.Conclusion: Low-dose (5 seconds 0.10 μGy/frame) cerebral 3D RA is technically feasible and not inferior in in vitro 3D measurement of an intracranial aneurysm. Thus, low-dose 3D RA is promising and needs further evaluation for its clinical utility in the planning of endovascular treatment of an intracranial aneurysm.

Balloon-assisted coiling (BAC) is an endovascular treatment that may be associated with increased complications and thromboembolic events compared with other coiling techniques. We compared clinical outcomes of endovascular treatment (simple coiling, stent-assisted coiling, and BAC) in patients with unruptured intracranial aneurysms at the internal carotid artery and assessed risk factors that could cause cerebral infarction in patients who underwent BAC.We retrospectively reviewed the records of 528 patients with 544 aneurysms who underwent endovascular treatment for unruptured intracranial aneurysms between January 2013 and November 2019. Demographic features, clinical information, balloon inflation time, fetal posterior cerebral artery, anterior cerebral artery (ACA) variants, and angiographic results were analyzed to determine risk factors for cerebral infarction.There were no significant differences among the 3 groups in terms of general characteristics. In the BAC group, 14 of 39 patients showed a significantly higher incidence of cerebral infarction on diffusion magnetic resonance imaging compared with the stent-assisted coiling (37/238) and simple coiling (21/267) groups (P 0.001). There was no significant difference between the ACA variants (normal vs. hypoplasia or aplasia) and cerebral infarction in the simple coiling and stent-assisted coiling groups, but the proportion of aplasia or hypoplasia in the BAC group was significantly higher (P = 0.001).There is a significant association between anatomic ACA variants and cerebral infarction occurrence after BAC. Identifying the variant of the anatomic ACA using digital subtraction angiography would help to predict cerebral infarction after BAC.

This study aimed to evaluate the image quality and dose reduction of low-dose three-dimensional (3D) rotational angiography (RA) for evaluating intracranial aneurysms.We retrospectively evaluated the clinical data and 3D RA datasets obtained from 146 prospectively registered patients (male:female, 46:100; median age, 58 years; range, 19-81 years). The subjective image quality of 79 examinations obtained from a conventional method and 67 examinations obtained from a low-dose (5-seconds and 0.10-µGy/frame) method was assessed by two neurointerventionists using a 3-point scale for four evaluation criteria. The total image quality score was then obtained as the average of the four scores. The image quality scores were compared between the two methods using a noninferiority statistical testing, with a margin of -0.2 (i.e., score of low-dose group - score of conventional group). For the evaluation of dose reduction, dose-area product (DAP) and air kerma (AK) were analyzed and compared between the two groups.The mean total image quality score ± standard deviation of the 3D RA was 2.97 ± 0.17 by reader 1 and 2.95 ± 0.20 by reader 2 for conventional group and 2.92 ± 0.30 and 2.95 ± 0.22, respectively, for low-dose group. The image quality of the 3D RA in the low-dose group was not inferior to that of the conventional group according to the total image quality score as well as individual scores for the four criteria in both readers. The mean DAP and AK per rotation were 5.87 Gy-cm² and 0.56 Gy, respectively, in the conventional group, and 1.32 Gy-cm² (Low-dose 3D RA was not inferior in image quality and reduced the radiation dose by 70%-77% compared to the conventional 3D RA in evaluating intracranial aneurysms.

The aim of this study was to evaluate clinical and morphological factors associated with recurrence in anterior communicating artery (AcomA) aneurysms after clipping or coiling. We retrospectively reviewed the clinical and radiologic features of consecutive 214 patients with AcomA aneurysms treated between January 2012 and December 2016 in a single tertiary institute. Univariate and multivariate analyses were performed to identify the relationship between clinical and morphological variables and recurrence. Of 214 patients, 166 were unruptured aneurysms and 109 were treated with coiling. Overall recurrence rate was 13% (28 out of 214 aneurysms) during mean 36.9 ± 18.4-month follow-up. Multivariate logistic regression analysis showed that size greater than 10 mm (OR = 5.651; 95% CI, 1.317–24.242; p = 0.020), smoking (OR = 3.474; 95% CI, 1.342–8.996; p = 0.010), coiling (OR = 2.98; 95% CI, 1.005–8.832; p = 0.049), and anterior direction of aneurysm (OR = 3.77; 95% CI, 1.12–12.66; p = 0.032) were significantly associated with recurrence of AcomA aneurysms after treatment. The results of this study demonstrated that coiling, large aneurysm, anterior direction, and smoking history may be independent risk factors for the recurrence of AcomA aneurysms. Therefore, careful follow-up should be needed especially in large AcomA aneurysms with anterior direction after coiling.

Background We hypothesized that the immediate postoperative imaging features would be associated with early regression of flow-diverted aneurysms. We compared the imaging features from digital subtraction angiography and spin echo T2-weighted magnetic resonance imaging between those with early total regression and partial regression. Methods A total of 30 consecutive patients with large and giant aneurysms were treated with pipeline embolization devices and divided into 2 groups according to the follow-up angiographic findings at 3–6 months. Of the 30 patients, 20 had had total or near total regression and 10 had had partial regression of the aneurysmal sac. The baseline characteristics, percent area of stagnated iodine contrast agent on anteroposterior and lateral angiographic views just after installation of the pipeline device, and median, minimal, and 10-percentile signal intensity of the aneurysmal sac on T2-weighted spin echo images 1 day after the procedure were compared between the 2 groups. Results A comparison of the demographic data between the 2 groups showed no significant differences. The volume of the treated aneurysmal sac also did not differ significantly (2559.28 ± 3021.45 mm3 vs. 2551.76 ± 6550.58 mm3; P = 0.455). The total or near total regression group had a larger percent area of iodine stagnation on the lateral angiographic view compared with the partial regression group (52.26% vs. 23.35%; P = 0.002). The median, minimal, and 10-percentile signal intensity of the volume of interest were higher in the total or near total regression group than in the partial regression group (1.29 vs. 0.93 [P = 0.025]; 0.07 vs. 0.00 [P = 0.042]; 0.57 vs. 0.24 [P = 0.005]). Conclusions The percent area of contrast media stagnation on lateral angiograms and the median, minimal, and 10th-percentile signal intensity of the volume of interest of treated aneurysmal sacs on T2-weighted images can be used to predict early regression of aneurysmal sacs.

The purpose of this study was to report the author's experiences in treating large (10-25 mm) and giant (25 mm) intracranial aneurysms (IAs) using a single Flow Re-direction Endoluminal Device (FRED) without assistant coiling, with a focus on procedure-related complications.A total of 33 patients who were treated with FRED between January 2018 and July 2020 were retrospectively reviewed. The timing of procedure-related complications was chronologically categorized as acute (within 7 days), subacute (8 to 21 days), and delayed (after 21 days) periods. Follow-up angiography was performed at 2 to 27 months (mean 9.7 months), and clinical follow-up was performed at 1 to 31 months (mean 14.1 months) in all patients.Six (18.2%) patients experienced procedure-related complications, including 2 (6.1%) in acute period, 1 (3.0%) in subacute period, and 3 (9.1%) in delayed period. Thromboembolic complications occurred in 5 (15.2%) patients and hemorrhagic complications in 1 (3.0%). Permanent morbidity and mortality rates were 3.0% each. Non-internal carotid artery (ICA) location of IAs (odds ratio 6.532; 95% confidence interval, 1.335-17.816;The procedure-related complication rate was 18.2% in this study. Procedure-related complications might increase when treating large and giant IAs located on a non-ICA, especially on the middle cerebral artery. Therefore, it may be suggested that neurointerventionists and endovascular neurosurgeons should pay attention to the location of IAs when treating large and giant IAs with a single FRED.

A new Low-profile Visualized Intraluminal Support device (LVIS Blue) is a braided stent that provides a higher degree of metal coverage. This stent may be beneficial for complete obliteration of an aneurysm due to not only its support of a higher occlusion rate using coils inside of the aneurysm but also its flow-diverting effect. We introduce and describe a new flow-diversion technique using an LVIS Blue stent within an Enterprise stent for patients with vertebral artery (VA) dissecting aneurysms. A 6-Fr guiding catheter was positioned in the ipsilateral VA. A microcatheter with an inner diameter of 0.021 inches was navigated and positioned across the dissecting segment of the VA. An Enterprise stent was then deployed and used to cover the dissecting segment by pushing the pusher wire of the stent while simultaneously unsheathing the microcatheter. The microcatheter was navigated along the remaining pusher wire to the distal VA through the Enterprise stent. An LVIS Blue stent was introduced and positioned such that it overlapped the previous stent in order to divert blood flow away from the dissecting segment. We present a case in which this technique was used to successfully obliterate a dissecting aneurysm while maintaining the VA patency with vessel wall remodeling. The LVIS Blue stent-within-an-Enterprise stent technique may be an effective treatment option for patients with VA dissecting aneurysms as an alternative technique to flow diverters.

Background Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) provides additional benefits remains controversial. We aimed to compare clinical and radiologic outcomes between IVT+MT and MT alone groups. Methods We retrospectively reviewed the clinical and radiological features of patients from the prospectively collected database who sustained anterior circulation stroke due to large vessel occlusion (LVO) and were treated with MT within 8 hours of symptom onset. We compared rates of successful reperfusion, functional independence and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) as clinical endpoints between the 2 groups. Results The 81 patients included in this study included 38 (46.9%) in the MT alone group (mean age, 72.6 ± 14.1 years; 17 males [44.7%]) and 43 in the IVT+MT group (mean age, 68.9 ± 12.8 years; 29 males [67.4%]). There were no significant differences in patient baseline characteristics between the 2 groups except for a male predominance in the IVT+MT group. The mean interval from onset to groin puncture (221.6 ± 110.5 minutes vs. 204.7 ± 63.7 minutes; P = 0.472) and the rate of successful reperfusion rate (thrombolysis in cerebral infarction 2b/3, 60.5% vs. 58.1%; P = 0.827) did not differ significantly between the MT and IVT+MT groups. The rate of favorable functional outcome, as determined by a modified Rankin Scale score 0–2 (36.8% vs. 51.2%; P = 0.263) and mortality at 90 days (18.4% vs. 9.3%; P = 0.332), and the rate of sICH (5.3% vs. 4.6%; P = 1.000) were also not significantly different between the 2 groups. Conclusions This study suggests that previous IVT might not facilitate successful reperfusion and favorable functional outcomes in patients with anterior circulation stroke treated with MT. MT alone can be a safe and effective treatment modality in patients who are ineligible for IVT for various reasons.

The purpose of this study was to investigate the risk factors associated with recurrence of posterior communicating artery aneurysms after treatment and to evaluate the significance of fetal-type posterior cerebral artery as an independent risk factor for recurrence of posterior communicating artery aneurysms.The clinical and radiological findings of 220 posterior communicating artery aneurysms treated between January 2009 and December 2016 in a single tertiary institute were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the association between clinical and radiological variables and recurrence.Of 220 posterior communicating artery aneurysms, 148 aneurysms were unruptured and 82 aneurysms were treated with surgery. Forty-six out of 220 aneurysms (20.9%) were associated with fetal-type posterior cerebral artery. Overall recurrence rate was 19% (42 out of 220 aneurysms) during mean 54.6 ± 29.8 months follow-up. Multivariate logistic regression analysis showed that size (OR=1.238; 95% CI, 1.087-1.409, p = 0.001), ruptured status (OR=2.699; 95% CI, 1.179-6.117, p = 0.019), endovascular treatment (OR=3.803; 95% CI, 1.330-10.875, p = 0.013), incomplete occlusion (OR=4.699; 95% CI, 1.999-11.048, p = 0.001) and fetal-type posterior cerebral artery (OR=3.533; 95% CI, 1.373-9.089, p = 0.009) were significantly associated with recurrence after treatment.The results demonstrated that fetal-type posterior cerebral artery may be an independent risk factor for the recurrence of posterior communicating artery aneurysms. Therefore, fetal-type posterior cerebral artery can be considered as an important risk factor for the recurrence of posterior communicating artery aneurysms, along with other known risk factors such as size, ruptured status, endovascular treatment, and incomplete occlusion.

We aimed to evaluate the correlation between aspirin or clopidogrel resistance and the risk of thromboembolic events (TEs). Between June 2011 and April 2015, we reviewed clinical and angiographic characteristics, and TEs in the patients undergoing stent-assisted coil embolization (SAC) of unruptured intracranial aneurysms (UIA) at our institution. We did not modify antiplatelet medication in patients with resistance. The relationships between antiplatelet resistance and the occurrence of acute symptomatic TEs, any diffusion-positive lesions, multiple diffusion-positive lesions, or delayed TEs were investigated. Ninety-nine endovascular treatments with stent-assisted technique were performed on 99 patients. The prevalence of aspirin resistance was 12% and clopidogrel resistance was 62.6%. Acute symptomatic TEs were demonstrated in 4 patients (4%). Diffusion-positive lesions were found in 82 patients [82.1%; 36 patients were group I (≤5) and 46 patients were group II (>5)]. Delayed TEs were demonstrated in 10 patients (10.1%). Neither aspirin resistance nor clopidogrel resistance was relevant to the development of acute symptomatic TEs, any diffusion-positive lesions, multiple diffusion-positive lesions, and delayed TEs (P logistic = not available, 0.448, 0.362, and 0.829 for aspirin resistance and P logistic = 0.607, 0.367, 0.278, and 0.245 for clopidogrel resistance). Without modification of antiplatelet medication, we demonstrated 4% of acute symptomatic TEs and 10% of delayed TEs. Aspirin or clopidogrel resistance did not show significant relationships with acute and delayed TEs in the SAC of UIA.

Cerebral Venous Thrombosis (CVT) is a relatively uncommon but important cause of stroke that tends to affect young adults, especially women. Head trauma with or without skull fracture was reported to be triggering factors for CVT, but the underlying pathophysiology was not well elucidated. Endothelial injury and coexistent hypercoagulability were supposed to contribute to CVT after head trauma without skull fracture. We report a 49-year-old female patient who presented with headache with vomiting after head trauma and was initially diagnosed as post-traumatic Intracerebral Hemorrhage (ICH), but subsequently, progressed to CVT that resulted in cerebral venous infarction with hemorrhagic transformation. Magnetic Resonance brain Venography (MRV) confirmed CVT in superior sagittal sinus as well as right transverse and sigmoid sinuses. She was treated with endovascular mechanical thrombectomy followed by anticoagulation. The coagulopathy panel was checked both in hospital and in outpatient clinic for evaluating the etiology underlying post-traumatic nonpyogenic CVT. Persistently elevated level of plasma Factor VIII was identified. We should consider that patients with recent head trauma history without skull fracture and coexistent hypercoagulability could develop CVT resulting in cerebral venous infarction with hemorrhagic transformation even when the patient showed no definite focal neurologic deficit or the patient’s initial CT scan revealed no intracranial hemorrhage.

Background The embryological relationship between cerebellar arteries originating directly from the cavernous segment of the internal carotid artery and persistent trigeminal artery is not well understood. Purpose To evaluate the incidence and pattern of cerebellar arteries originating from the internal carotid artery and persistent trigeminal artery, and to discuss their probable embryological relationship. Material and Methods We reviewed 5113 angiographic studies from 5093 patients at our institution over the last eight years, searching for patients with persistent trigeminal artery and cerebellar arteries originating from a cavernous segment of internal carotid artery (persistent trigeminal artery variant). Results Of the 5093 patients, 27 patients had persistent trigeminal artery or persistent trigeminal artery variant (0.53%). Twenty patients (6 men, 14 women; median age = 54 years) had persistent trigeminal artery (0.39%). Seven patients (2 men, 5 women, age range = 37–72 years; median age = 57 years) had a persistent trigeminal artery variant with persistent trigeminal artery terminating in a cerebellar artery without direct connection to the basilar artery (persistent trigeminal artery variant; 0.14%). The terminal branch of the persistent trigeminal artery variant was an anterior inferior carotid artery in five patients and a superior cerebellar artery in two patients. Of the seven patients having persistent trigeminal artery variant, four patients had another artery from the basilar artery to the anterior inferior carotid artery territory. In 6/20 patients with persistent trigeminal artery, there was an anterior inferior carotid artery arising from the persistent trigeminal artery. One of these patients showed another arterial branch from the basilar artery to the anterior inferior carotid artery territory. Conclusion Persistent trigeminal artery variant and cerebellar arteries originating from the persistent trigeminal artery are both believed to be a spectrum of incomplete fusion of the longitudinal neural arteries. Understanding the precise anatomy is important in diagnostic and therapeutic settings for related vascular disease.

Large intracranial aneurysm is challenging for both surgical and endovascular treatment. High recurrence and retreatment rates are still limitations for endovascular treatment. Analysing risk factors of recurrence after endovascular treatment can be useful for planning future treatment strategies. We retrospectively reviewed patients with intracranial saccular aneurysm (≥ 8 mm) who underwent endovascular treatment from 2008 to 2017 at our institution. The demographic features, clinical information and angiographic results were analysed to reveal the risk factors for recurrence and retreatment. Subgroup analysis was performed according to packing density (PD) and stent insertion status. The total recurrence and retreatment rates were 25.7% (44/171) and 10.5% (18/171), respectively. Independent risk factors for recurrence after endovascular treatment were larger aneurysm size (OR 1.32; 95% CI 1.17–1.51; p

Possible Neurological Deterioration (ND) of patients with Traumatic Brain Injury (TBI) is difficult to identify especially the mild and moderate injuries. When ND happens, death or lifelong disability is prevalent. Early prediction of possible ND would allow medical and healthcare institutions to provide the needed medical treatment. This paper presents the results that show Machine Learning (ML) can be used to create predicative models with high prediction rates even with a small set of patient records (219 patient records with 54 variables). From the patient records, 20 randomized data sets with preconditions on the testing and training data were created and fed to selected Artificial Neural Network (ANN) and Classification Algorithms. Preconditions on testing and training data can affect the prediction models created by the different algorithms. The best prediction models created by the ANN algorithms (multilayer perceptron (MLP), recurrent neural network (RNN), and long short-term memory (LSTM)) and two classification algorithms (linear regression and logistic regression algorithms) are considered acceptable and could be applied as medical decision support to identify patients that may potentially have ND. Early prediction of a possible ND of a patient can now be easily carried out as soon as his or her records and medical test results are ready and match the 54 variables needed for prediction.

Although transarterial embolization (TAE) with Onyx has become popular for the treatment of dural arteriovenous fistulas (DAVFs), transvenous embolization (TVE), surgery, and radiosurgery have continued to have a role. The aim of the present study was to compare the treatment outcomes stratified by the different treatment modalities.The data from 92 patients with DAVFs treated from January 2009 to June 2018 were retrospectively reviewed. The treatment strategies were decided by a multidisciplinary team according to the patient's clinical status and angiographic findings. The clinical and radiologic data were analyzed and correlated with the treatment modality.A total of 101 procedures were performed in the 92 patients. TAE, TVE, surgery, and radiosurgery were performed in 31, 49, 12, and 9 procedures, respectively. Complete and near complete occlusion was achieved in 13 cases treated with TAE (41.9%), 41 treated with TVE (83.7%), and 10 with surgery (83.3%), as shown on immediate postprocedural angiography (P0.001). Retreatment was needed in 9 patients in the TAE group and none in the TVE or surgery groups (P0.001). Surgery (n = 1), TVE (n = 3), TAE (n = 1), and radiosurgery (n = 4) were used for patients requiring retreatment. At the last follow-up examination (mean, 26.5 ± 23.9 months), 66 of 72 DAVFs (91.6%) showed angiographic complete occlusion. Clinically, the initial symptoms had disappeared or improved in 87 of 90 patients (96.7%) at the last follow-up evaluation (mean, 26.4 ± 26.8 months).Even in the Onyx era, other treatment modalities still have important roles, as shown in the present study. Therefore, the selection of the appropriate treatment modality should be individualized by the angiographic findings and clinical symptoms.

Background and Purpose— No evidence is available on the benefits of preventive suboccipital decompressive craniectomy (SDC) for patients with cerebellar infarction. The purpose of this matched case–control study was to investigate whether preventive SDC was associated with good clinical outcomes in patients with cerebellar infarction and to evaluate its predisposing factors. Methods— Between March 2007 and September 2015, 28 patients underwent preventive SDC. We performed propensity score matching to establish a proper control group among 721 patients with cerebellar infarction during the same period. Group A (n=28) consists of those who underwent preventive SDC, and group B (n=56) consists of those who did not undergo preventive SDC. We analyzed and compared clinical outcomes between groups. Results— Clinical outcomes were better in group A than in group B at discharge ( P =0.048) and 12-month follow-up ( P =0.030). Group B had more deaths within 12 months than group A (log-rank, P P =0.009) and the absence of brain stem infarction (odds ratio, 2.862; P =0.033) were independently associated with favorable outcomes (modified Rankin Scale score of 0–2) at 12-month follow-up. Conclusions— Favorable clinical outcomes including overall survival can be expected after preventive SDC in patients with a volume ratio between 0.25 and 0.33 and the absence of brain stem infarction. Among these patients, preventive SDC might be better than the best medical treatment alone.

BACKGROUND Surfactant protein D (SPD) is a member of the collectin family that lines the airway epithelial cells with host defense. However, the role of SPD in the pathogenesis of aspirin-exacerbated respiratory disease (AERD) is still unclear. METHODS The serum SPD level was measured in patients with AERD (n = 336), those with aspirin-tolerant asthma (ATA, n = 442), and healthy controls (HC, n = 104). Polymorphisms of SFTPD in the study subjects were analyzed. The effect of LTE4 on SPD production through eosinophil infiltration was investigated in BALB/c mice. The protective function of SPD against eosinophils inducing inflammation and remodeling was assessed in vitro/vivo. The potential efficacy of nintedanib against airway remodeling through the production of SPD was evaluated. RESULTS The serum SPD level was significantly lower (P

Predicting the fate of patients who are given a misdiagnosis of aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. The purpose was to examine factors associated with initial misdiagnosis of aSAH and to investigate the impact of initial misdiagnosis of aSAH on clinical outcomes. Between January 2007 and December 2015, medical records and radiographic data for 3118 consecutive patients with aSAH were reviewed. There were 33 patients who had been documented with an initial misdiagnosis of aSAH, and all met the following criteria: (1) failure to correctly identify aSAH upon initial presentation to health care professionals; and 2) subsequently documented aSAH after the initial misdiagnosis. After applying exclusion criteria, remaining 2898 patients were included in the control group. The most common cause of the misdiagnosis is failure to detect aSAH on the initial radiographic imaging. Misdiagnosis group showed lower initial Glasgow Coma Scale, better Hunt-Hess grade, and lower Fisher’s grade. Logistic regression analysis showed that initial HH grade (OR, 0.216; p = 0.014), initial Fisher’s grade (OR, 0.732; p = 0.036), and hospital type during initial contact (OR, 2.266; p = 0.042) were independently associated with misdiagnosis of aSAH. Patients with initially good HH grade, lower Fisher’s grade, and visiting non-teaching hospital for initial contact were at risk of being misdiagnosed. Misdiagnosis of aSAH in patients with initial good HH grade did affect clinical outcomes negatively. The rebleeding rate was not significantly different between two groups. However, the mortality rate due to rebleeding was higher in MisDx group than in non-MisDx group.

Spontaneous subarachnoid hemorrhage (SAH) is an important cause of stroke. It is associated with high mortality and morbidity. SAH has differing hemorrhagic patterns, clinical course, prognosis, and therapeutic method, depending on the cause of the bleeding. The most common etiology of SAH is a rupture of an aneurysm arising at the intracranial artery. This chapter describes the underlying pathogenesis of aneurysmal formation, growth, and rupture. Not only the initial hemorrhage but also the ways in which pathophysiological processes following aneurysmal SAH may influence the complicated clinical course of survivors. Furthermore, the chapter discusses updated pathophysiology of post-hemorrhagic phenomena, including aneurysmal rebleeding, hydrocephalus, early brain injury, delayed cerebral ischemia, and medical complications. Finally, non-aneurysmal SAH is rare but is associated with diverse etiologies; the chapter summarizes proposed mechanisms of bleeding and clinical characteristics of non-aneurysmal SAH.

The aim of this study is to evaluate the degree of atherosclerotic changes in intracranial arteries by assessing arterial wall thickness using T1-weighted 3D-turbo spin echo (3D-TSE) and time-of-flight MR angiography (TOF-MRA) in patients with acute ischemic stroke as compared with unaffected controls. Thirty-three patients with acute ischemic stroke and 36 control patients were analyzed. Acute ischemic stroke patients were divided according to TOAST classification. At both distal internal carotid arteries and basilar artery without stenosis, TOF-MRA was used to select non-stenotic portion of assessed arteries. 3D-TSE was used to measure the area including the lumen and wall (AreaOuter) and luminal area (AreaInner). The area of the vessel wall (AreaVW) of assessed intracranial arteries and the ratio index (RI) of each patient were determined. AreaInner, AreaOuter, AreaVW, and RI showed good inter-observer reliability and excellent intra-observer reliability. AreaInner did not significantly differ between stroke patients and controls (P = 0.619). However, AreaOuter, AreaVW, and RI were significantly larger in stroke patients (P

The aim of this study was to review our experience with surgical clipping and endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs), with a special focus on complications. We retrospectively analyzed clinical and radiological data from patients who underwent surgery or EVT. Surgery was performed by one neurosurgeon, and EVT was performed by two neurointerventionists according to one hybrid neurosurgeon’s decision. Adverse events included the following: (1) decline of the modified Rankin Scale (mRS) score from 1 to 2 and (2) any unexpected neurological deficit or imaging finding affecting the prognosis and/or requiring additional procedures, medication, or prolonged hospital stay. Of the 1231 UIAs in 1124 patients, 625 (50.7 %) aneurysms were treated with surgery, and 606 (49.3 %) aneurysms were treated with EVT. The overall complication rate of UIA treatment was 3.2 %. The rate of adverse events was 2.4 %, and the rates of morbidity and mortality were 0.6 and 0.2 %, respectively. The rates of adverse events, morbidity, and mortality were not significantly different between surgery and EVT. The rate of hospital use for EVT was stationary over the years of the study. Posterior circulation in surgery, large aneurysms (>15 mm) in EVT, and stent- or balloon-assisted procedures in EVT were associated with the occurrence of complications. Poor clinical outcome (mRS of 3–6) was 0.8 % at hospital discharge. Both UIA treatment modalities decided by one hybrid neurosurgeon showed low complication rates and good clinical outcomes in this study. These results may serve as a point of reference for clinical decision-making for patients with UIA.