[Exposure level of neonicotinoid pesticides and their metabolites in pregnant women in the suburb of Shanghai]

In 2021, a total of 151 pregnant women were selected from the suburb of Shanghai. A questionnaire survey was conducted to obtain data about maternal age, gestational week, total annual household income, education level and passive smoking among pregnant women and one spot urine was collected. The concentrations of eight neonicotinoid pesticides and four metabolites in urine were measured by ultra-high performance liquid chromatography-tandem quadrupole time-of-flight mass spectrometry. The differences in detection frequencies and concentrations of neonicotinoid pesticides and their metabolites among pregnant women with different characteristics were compared, and the influencing factors of the detection of neonicotinoid pesticides in urine were analyzed. The results showed that at least one neonicotinoid pesticide was detected in 93.4% (141 samples) of urine samples. The detection frequencies of N-desmethyl-acetamiprid, clothianidin, thiamethoxam, and N-desmethyl-clothianidin were high, about 78.1% (118 samples), 75.5% (114 samples), 68.9% (104 samples), and 44.4% (67 samples), respectively. The median concentration of the sum of all neonicotinoid pesticides was 2.66 μg/g. N-desmethyl-acetamiprid had the highest detection concentration with a median concentration of 1.04 μg/g. A lower urinary detection frequency of imidacloprid and its metabolites was seen in pregnant women aged 30-44 years [OR (95%CI): 0.23 (0.07-0.77)]. A higher detection frequency of clothianidin and its metabolites was seen in pregnant women with per capita annual household income≥100, 000 yuan [OR (95%CI): 6.15 (1.56-24.28)]. There was widespread exposure to neonicotinoid pesticides and their metabolites in pregnant women from the suburb of Shanghai, which might pose potential health risks to pregnant women, and maternal age and household income were potential influencing factors of the exposure to neonicotinoid pesticides.

[Temporal trend of antibiotic use among primary school children in Shanghai, 2017-2020]

To investigate the temporal trend of antibiotic use among children in Shanghai from 2017 to 2020. The stratified cluster sampling method was used to establish a dynamic cohort of healthy children based on primary schools in Changning District, Shanghai. In the cohort, there were 282 children from 2017, 287 children from 2018, 294 from 2019 and 301 from 2020. A total of 700 children aged 7-11 years were included in the study. The basic information and antibiotic use of children were investigated by questionnaire every year, and their height and weight were measured at the same time. Chi-square test was used to analyze the difference of antibiotic use rate in each year and generalized estimation equation was used to analyze the temporal trend of antibiotic use. The results showed that the use rates of all antibiotics, cephalosporins, azithromycin and other antibiotics (including penicillin, lincomycin, quinolones, etc.) of children between 2017 and 2020 were 15.6%, 10.5%, 2.7%, and 2.4%, respectively. In 2017, 2018, 2019, and 2020, there were significant differences for the use rates of total antibiotics and other antibiotics in children (P=0.033, P=0.040), and there were no significant differences for the use rates of cephalosporins and azithromycin (P=0.274, P=0.455). After adjusting for children's basic characteristics, the generalized estimation equation showed that the annual use rate of all antibiotics, cephalosporins, and other antibiotics decreased over time.

Changes in Muscle Mass after Botulinum Toxin Injection in Children with Spastic Hemiplegic Cerebral Palsy

We aimed to evaluate muscle mass changes after injection of botulinum toxin (BoNT) in children with spastic hemiplegic cerebral palsy (CP). Children aged between 2 and 12 years who were diagnosed with hemiplegic CP with spastic equinus foot were prospectively recruited and administered BoNT in the affected leg. Lean body mass (LBM) of both legs and total limbs was measured by dual-energy X-ray absorptiometry (DXA) preinjection and 4 and 12 weeks after injection. A total of 15 children were enrolled into the study. LBM of both legs and total limbs increased significantly over 12 weeks of growth. The ratio of LBM of the affected leg to total limbs and to the unaffected leg significantly reduced at 4 weeks after injection compared with preinjection but significantly increased at 12 weeks after injection compared with 4 weeks after injection. In conclusion, the muscle mass of the affected leg after BoNT injection in children with hemiplegic spastic CP decreased at 4 weeks after BoNT injection but significantly recovered after 12 weeks after injection.

[Progress of research on the relations between bipolar disorder and type 2 diabetes mellitus]

Both risks of type 2 diabetes mellitus (T2DM) in patients with bipolar disorder (BD) and of BD in patients with T2DM are both significantly higher than the general population, indicating the two disorders may share the common pathogenesis. Patients with BD and co-morbid T2DM behave poorly on managing their own behavior on health, thus increased risks of outcomes on related complications, disability and mortality. The article reviewed the epidemiologic features, health hazards, relations and possible mechanisms between BD and T2DM. Strategies and measures on intervention of BD and T2DM were also involved in the text to improve the awareness and research ability of the researchers.

Clinical features of subungual melanoma according to the extent of Hutchinson's nail sign: a retrospective single-centre study

BACKGROUND

Hutchinson's nail sign (HS) is among the diagnostic criteria for subungual melanoma (SUM). However, there is minimal evidence supporting the overall clinical significance of HS in SUM.

OBJECTIVES

To identify clinicopathological features of SUM according to the extent of HS.

METHODS

Retrospective cohort study was performed with consecutive SUM patients at a single centre from January 2006 to December 2017. The extent of HS was defined by the number of affected nail folds (range 0-4). Comparison groups were organized as follows: patients with HS (affecting ≥1 nail folds) vs. without HS; patients with HS affecting ≥2 nail folds vs. HS affecting <2 nail folds; patients with HS affecting ≥3 nail folds vs. HS affecting <3 nail folds. Clinicopathological characteristics of SUM were compared between the groups.

RESULTS

Sixty-one SUM patients were included. Forty-six (75.4%) exhibited HS; 22 (47.8%) on a toe and 24 (52.2%) on a finger. In multivariate analysis, nail destruction [hazard ratio (HR), 10.00; 95% confidence interval (CI), 2.61-38.30; P = 0.001] was significantly associated with the presence of HS and amputation was significantly associated with HS affecting ≥2 nail folds (HR, 4.75; 95% CI, 1.36-16.61; P = 0.015). High T stage (HR, 1.85; 95% CI, 1.20-2.85; P = 0.005, Fig. 2) was significantly associated with HS appearing in ≥3 nail folds.

CONCLUSION

Besides its value of detecting SUM, HS provides useful clinical information. The number of nail folds exhibiting HS could be a useful clinical clue for planning therapeutic strategies for SUM.

Korean language specific dysarthria associated with idiopathic peripheral facial palsy

To investigate the patterns of dysarthria in Korean patients with idiopathic peripheral facial palsy.Seventy-eight patients diagnosed with idiopathic peripheral facial palsy within the onset of symptom to 7 day time frame were prospectively enrolled. The initial symptom of facial palsy was examined by the House-Brackmann scale. All patients were tested by Urimal-Test of Articulation and Phonology-2 (U-TAP-2), which is specialized for the evaluation of dysarthria in Korean language - Hangeul - when the patients first visited and were followed up at 4 weeks after the onset, respectively. The facial electromyography was performed after 7 days, since the presentation of the first symptom. Electric stimulation therapy and simple facial exercise education were performed in all patients as routine treatments for facial palsy with or without dysarthria. The patterns of dysarthria were analyzed by initial and follow-up U-TAP-2 results, respectively.Among 78 patients, 50 patients (64.1%) had dysarthria in the first assessment. The 6 consonants and 3 vowels were errored in U-TAP-2 test. The bilabial consonants "&#x3143;"[p] or "&#x0314D;" [p] were substituted with labiodental consonant [f], and palate-alveolar consonants were replaced by alveolar consonants - "&#x314A;"[t(Equation is included in full-text article.)] to "&#x314C;"[t]. Bilabial consonant "&#x3141;"[m] was replaced by velar nasal consonant "&#x3147;"[ŋ]. Liquid consonant was altered to nasal sound. For example, "&#x3139;"[r] is replace by "&#x3134;"[n]. The velar consonant "&#x3132;"[k] was pronounced as "&#x314B;" [k]. The diphthong vowels "&#x315F;"[[Latin Small Letter Turned H]i], "&#x315A;"[ø], or "&#x3158;"[wa] were pronounced as monothong "&#x3163;" [i], "&#x3150;"[ε], or "&#x314F;"[a], and "&#xBABB;"[mot] is slowly pronounced. After 4 weeks, 14 patients still showed pronunciation errors in 5 consonants and 3 vowels. The most common error was substitution.Among 78 patients with idiopathic peripheral facial palsy, 50 patients had dysarthria and 14 out of 50 patients with dysarthria lasted more than 4 weeks. Five consonants ("&#x3141;", "&#x314A;", "&#x314D;", "&#x3139;", "&#x3132;") and 3 vowels ("&#x3158;", "&#x3157;", "&#x315F; or &#x315A;") were still mispronounced after 4 weeks, and most common error was substitution. Therefore, speech evaluation and speech therapy specialized for errors in high frequency of consonants and vowels are needed in patients with idiopathic peripheral facial palsy, in Korea.

Suspected Metallic Embolization Distal to Coiled Intracranial Aneurysms Detectable by Susceptibility-Weighted MR Imaging

BACKGROUND AND PURPOSE

After endovascular coiling of intracranial aneurysms, round dark parenchymal lesions believed to be particulate metal are sometimes encountered in MR imaging studies of the brain. We used SWI to assess the frequency of such occurrences, in addition to exploring likely causes and clinical implications.

MATERIALS AND METHODS

We reviewed 700 MR imaging studies performed between September 2018 and March 2019 at our institution as follow-up monitoring of coiled intracranial aneurysms. Any sizeable (>5 mm) rounded dark-signal lesions encountered were presumed to be metallic. The magnitudes and locations of such lesions were recorded. In patients with these lesions, pertinent procedural documentation was screened for devices used, including coils, microcatheters, microguidewires, and stents. Medical records were also examined to determine whether any related symptoms ensued.

RESULTS

Twenty patients (2.8%) exhibited a total of 25 lesions on SWI. Diameters ranged from 5 to 11 mm (median, 8 mm). All except 2 lesions were located in brain regions downstream from aneurysms, but all lesions occupied vascular territories of vessels used to place guiding catheters. Other than the Synchro 14, which was routinely deployed, no device was regularly used in patients with SWI-detectable lesions; and none of the affected patients developed focal neurologic symptoms as a consequence.

CONCLUSIONS

Although the origins remain unclear, distal embolization of particulate metal distal to coiled cerebral aneurysms is occasionally observed on follow-up MR imaging studies. Such lesions, however, seem to have no apparent clinical impact.

Bilateral idiopathic neuralgic amyotrophy involving selective branches of peripheral nerves with a stepwise progression: A case report

RATIONALE

This is a report about a rare case of idiopathic neuralgic amyotrophy (INA) involving selective peripheral nerve branches of bilateral upper extremities, which exhibited a stepwise progression.

PATIENT CONCERN

A 66-year-old woman presented with paresis of selective branches of bilateral median nerves, followed by paresis of bilateral posterior interosseous nerve (PIN) 8 weeks later.

DIAGNOSES

We diagnosed it as INA involving the selective motor branches of bilateral median nerves and bilateral PINs. Forearm magnetic resonance imaging combined with electrodiagnostic testing helped accurately identify the affected regions, and ultrasonography demonstrated a severe constriction of the left PIN.

INTERVENTIONS

Intravenous methylprednisolone partially relieved the pain and paralysis. Surgical neurolysis of the constricted left PIN was done for persistent paralysis.

OUTCOMES

The muscle power of the bilateral median nerve territories was recovered to nearly normal, but the muscle power of the left PIN territories remained at grade 1.

LESSONS

This case indicates that INA can manifest as a multiple mononeuropathy involving individual fascicular levels of peripheral nerve branches with focal constriction, and electrodiagnostic study combined with forearm MRI and ultrasonography can help in identifying affected lesion and predicting the prognosis.

Contralateral Approach to Coil Embolization of Proximal A1 Aneurysms Using the Anterior Communicating Artery

BACKGROUND AND PURPOSE

Aneurysms arising from the proximal A1 segment of the anterior cerebral artery are rare, and their distinctive configurations often pose technical challenges during endovascular embolization. Herein, we present 11 patients with proximal A1 aneurysms requiring a contralateral approach (via the anterior communicating artery) to coil embolization.

MATERIALS AND METHODS

From a prospectively collected data repository, we retrieved records of 11 patients consecutively treated for proximal A1 aneurysms between January 2011 and March 2018. In each instance, coil embolization was performed by the contralateral route. Outcomes were analyzed in terms of morphologic features and clinical status.

RESULTS

Aneurysms in all 11 patients were directed posteriorly and were small (<5 mm). A contralateral approach (via the anterior communicating artery) was used after ipsilateral attempts at aneurysm selection failed in each instance, despite using a variety of microcatheters. Single punctures and single guiding catheters sufficed in 9 patients, but 2 patients required dual punctures and 2 guiding catheters. All endovascular treatments ultimately yielded excellent outcomes. Although 1 symptomatic infarct was manifested in the course of ipsilateral treatment, no morbidity or mortality resulted from the contralateral access.

CONCLUSIONS

Due to angio-anatomic constraints, a contralateral strategy for coil embolization of proximal A1 aneurysms is acceptable if ipsilateral access is technically prohibitive and the vessels (contralateral A1 and anterior communicating artery) are amenable to the passage of microdevices.

Comparison of Clinical Outcomes of Intracranial Aneurysms: Procedural Rupture versus Spontaneous Rupture

BACKGROUND AND PURPOSE

Procedural rupture of an intracranial aneurysm is a devastating complication in endovascular treatment. The purpose of this study was to evaluate the clinical outcomes of patients with procedural rupture of unruptured saccular intracranial aneurysms compared with those with spontaneously ruptured aneurysms.

MATERIALS AND METHODS

A retrospective review was performed for 1340 patients with 1595 unruptured saccular intracranial aneurysms that underwent endovascular coil embolization between February 2010 and December 2014. The clinical outcomes of patients with procedural rupture of unruptured saccular intracranial aneurysms were compared with those of 198 patients presenting with spontaneously ruptured aneurysms.

RESULTS

In this series, procedural rupture developed in 19 patients (1.4% per patient and 1.2% per aneurysm), and the morbidity related to procedural rupture was 26.3% (95% confidence interval, 8.5%-61.4%) with no mortality. Hunt and Hess scale grades and hospitalization days of patients with procedural rupture were equivalent to those of patients presenting with spontaneous aneurysm rupture. Subsequent treatment procedures after hemorrhage (including lumbar drainage, extraventricular drainage, decompressive craniectomy, and permanent shunt) showed no difference between the 2 groups. The hemorrhage volumes were smaller in the procedural-rupture group (P = .03), and the endovascular vasospasm therapies tended to be more frequently required in the spontaneous aneurysm-rupture group (P = .08). At postictus 6 months, the proportion of modified Rankin Scale scores of ≥2 were lower in the procedural-rupture group (5.3% versus 26.8%, P = .049). In multivariate analysis, spontaneous aneurysm rupture was a significant risk factor for worse clinical outcome (OR = 14.9; 95% CI, 1.2-193.1; P = .039).

CONCLUSIONS

This study showed better clinical outcomes in the procedural-rupture group. Even though there is a potential chance of aneurysm rupture during treatment, the clinical outcomes after procedural bleeds seem to be more favorable than those of spontaneous rupture.

Risk Factor Analysis of Recanalization Timing in Coiled Aneurysms: Early versus Late Recanalization

BACKGROUND AND PURPOSE

Long-term documentation of anatomic and angiographic characteristics pertaining to the timing of recanalization in coiled aneurysms has been insufficient. Our intent was to analyze and compare early and late-phase recanalization after coiling, identifying respective risk factors.

MATERIALS AND METHODS

A total of 870 coiled saccular aneurysms were monitored for extended periods (mean, 30.8 ± 8.3 months). Medical records and radiologic data were also reviewed, stratifying patients as either early (n = 128) or late (n = 52) recanalization or as complete occlusion (n = 690). Early recanalization was equated with confirmed recanalization within 6 months after the procedure, whereas late recanalization was defined as verifiable recanalization after imaging confirmation of complete occlusion at 6 months. A multinomial regression model served to assess potential risk factors, the reference point being early recanalization.

RESULTS

Posterior circulation (P = .009), subarachnoid hemorrhage at presentation (P = .011), second attempt for recanalized aneurysm (P < .001), and aneurysm size >7 mm (P < .001) emerged as variables significantly linked with early recanalization (versus complete occlusion). Late (versus early) recanalization corresponded with aneurysms ≤7 mm (P = .013), and in a separate subanalysis of lesions ≤7 mm, aneurysms 4-7 mm showed a significant predilection for late recanalization (P = .008). However, the propensity for complete occlusion in smaller lesions (≤7 mm) increased as the size diminished.

CONCLUSIONS

Although long-term complete occlusion after coiling was more likely in aneurysms ≤7 mm, such lesions were more prone to late (versus early) recanalization, particularly those of 4-7 mm in size. Long-term follow-up imaging is thus appropriate in aneurysms >4 mm to detect late recanalization of those formerly demonstrating complete occlusion.

Influence of systemic bone mineral density on atlantoaxial subluxation in patients with rheumatoid arthritis

Osteopenia and osteoporosis were independent predictive factors for higher atlantoaxial subluxation occurrence in patients with lower body mass index. Our findings suggest that patients with rheumatoid arthritis with osteopenia or osteoporosis, particularly those with lower body mass index (BMI), should be screened regularly to determine the status of their cervical spines.

INTRODUCTION

Cervical spine involvement in rheumatoid arthritis (RA) patients may cause serious adverse effects on quality of life and overall health. This study aimed to evaluate the association between atlantodental interval (ADI), atlantoaxial subluxation (AAS), and systemic bone mineral density (BMD) based on BMI variations among established patients with RA.

METHODS

The ADI was transformed to the natural log scale to normalize distributions for all analyses. Multivariable linear regression analyses were used to identify independent predictive factors for ADI based on each BMD classification. Multivariate Cox regression analyses were also performed to identify independent predictive factors for the risk of AAS, which were classified by tertile groups of BMI.

RESULTS

A total of 1220 patients with RA who had undergone at least one or more cervical radiography and BMD assessments were identified and enrolled. We found that the association between BMD and ADI (β, -0.029; 95% CI, -0.059 to 0.002; p = 0.070) fell short of achieving statistical significance. However, the ADI showed a 3.6% decrease per 1 BMI increase in the osteoporosis group (β, -0.036; 95% CI, -0.061 to -0.011; p = 0.004). The osteopenia and osteoporosis groups showed about a 1.5-fold and a 1.8-fold increased risk of AAS occurrence among the first tertile of the BMI group.

CONCLUSIONS

Our study showed a possible association between lower BMD and AAS occurrence in patients with RA with lower BMI. Further studies are needed to confirm our findings.

Antiangiogenic Effect of Bevacizumab: Application of Arterial Spin-Labeling Perfusion MR Imaging in a Rat Glioblastoma Model

BACKGROUND AND PURPOSE

The usefulness of arterial spin-labeling for the evaluation of the effect of the antiangiogenic therapy has not been elucidated. Our aim was to evaluate the antiangiogenic effect of bevacizumab in a rat glioblastoma model based on arterial spin-labeling perfusion MR imaging.

MATERIALS AND METHODS

DSC and arterial spin-labeling perfusion MR imaging were performed by using a 9.4T MR imaging scanner in nude rats with glioblastoma. Rats were randomly assigned to the following 3 groups: control, 3-day treatment, and 10-day treatment after bevacizumab injection. One-way analysis of variance with a post hoc test was used to compare perfusion parameters (eg, normalized CBV and normalized CBF from DSC MR imaging and normalized CBF based on arterial spin-labeling) with microvessel area on histology. The Pearson correlations between perfusion parameters and microvessel area were also determined.

RESULTS

All of the normalized CBV from DSC, normalized CBF from DSC, normalized CBF from arterial spin-labeling, and microvessel area values showed significant decrease after treatment (P < .001, P < .001, P = .005, and P < .001, respectively). In addition, normalized CBV and normalized CBF from DSC and normalized CBF from arterial spin-labeling strongly correlated with microvessel area (correlation coefficient, r = 0.911, 0.869, and 0.860, respectively; P < .001 for all).

CONCLUSIONS

Normalized CBF based on arterial spin-labeling and normalized CBV and normalized CBF based on DSC have the potential for evaluating the effect of antiangiogenic therapy on glioblastomas treated with bevacizumab, with a strong correlation with microvessel area.

Prophylactic Antiplatelet Medication in Endovascular Treatment of Intracranial Aneurysms: Low-Dose Prasugrel versus Clopidogrel

BACKGROUND AND PURPOSE

Prophylactic antiplatelet medication is beneficial in decreasing thromboembolic complications during endovascular treatment of unruptured intracranial aneurysms. The efficacy may be limited by variability of individual response to antiplatelet medication, especially clopidogrel. We compared the efficacy of 2 antiplatelet medications, low-dose prasugrel and clopidogrel, in patients undergoing endovascular treatment of unruptured aneurysms.

MATERIALS AND METHODS

From November 2014 to July 2015, 194 patients with a total of 222 unruptured aneurysms underwent endovascular treatment at a single institution. Laboratory and clinical data from the prospectively maintained registry were used in this study. Antiplatelet medication was given the day before endovascular treatment (prasugrel 20 mg or 30 mg or clopidogrel 300 mg). Response to the antiplatelet medication was measured by the VerifyNow system. Periprocedural adverse event rates between the 2 groups were compared.

RESULTS

There were no significant differences in the baseline characteristics of patients and aneurysms between the 2 groups. The P2Y12 reaction unit values were lower (clopidogrel group versus prasugrel group, 242.7 ± 69.8 vs 125.7 ± 79.4; P < .0001) and percentage inhibition values were higher (22.1% ± 19.7% vs 60.2 ± 24.7%; P < .0001) in the prasugrel group. There were no thromboembolic events, but there was 1 procedural bleed in each group, without any clinical consequences.

CONCLUSIONS

The prasugrel group showed more effective and consistent platelet inhibition. We may omit the antiplatelet response assay with the low-dose prasugrel premedication before the endovascular treatment of patients with unruptured aneurysms. Further study is required to determine whether there is benefit of this strategy regarding clinical outcome.

Fate of Coiled Aneurysms with Minor Recanalization at 6 Months: Rate of Progression to Further Recanalization and Related Risk Factors

BACKGROUND AND PURPOSE

Minor recanalization in coiled aneurysms may remain stable with time or may progress to major recanalization. Our aim was to monitor the aneurysms displaying minor recanalization in imaging studies at 6 months, gauging major recanalization rates and related risk factors through extended follow-up.

MATERIALS AND METHODS

Sixty-five aneurysms (in 65 patients) showing minor recanalization in follow-up imaging at 6 months were reviewed retrospectively. Medical records and radiologic data accruing during extended monitoring (mean, 24.8 ± 8.2 months) were assessed. Univariate and multivariate analyses were conducted to identify risk factors for progression from minor-to-major recanalization.

RESULTS

Progression to major recanalization was observed in 24 (36.9%) of the initially qualifying aneurysms during a follow-up of 112.5 aneurysm-years, for an annual rate of 17.84% per aneurysm-year. Progression was determined chronologically as follows: 14 (58.3%) at 6 months, 8 (33.3%) at 18 months, and 2 (8.4%) at 30 months. Stent deployment significantly decreased the occurrence of major recanalization (OR = 0.22, P = .03), whereas antiplatelet therapy (OR = 0.82, P = .75), posterior location (OR = 0.24, P = .20), and second coiling for recanalized aneurysms (OR = 0.96, P = .96) were unrelated.

CONCLUSIONS

Our analysis determined a 36.9% rate of major recanalization during a follow-up of 112.5 aneurysm-years in coiled aneurysms showing minor recanalization at 6 months. Stent deployment alone conferred a protective effect, preventing further recanalization without additional treatment. Given the fair probability of late major recanalization, aneurysms showing minor recanalization at 6 months should be monitored diligently, particularly in the absence of stent placement.

Do Contrast-Fill Patterns Immediately After Coil Embolization of Small Saccular Aneurysms Impact Long-Term Results?

PURPOSE

It is generally accepted that filling of a saccular aneurysm with contrast immediately after coil embolization predisposes to later recanalization. However, not all such scenarios evolve similarly over time. We investigated outcomes of small (≤ 7 mm) aneurysms with contrast-filled sacs immediately after coil embolization, evaluating the impact of pattern and degree of filling on subsequent recanalization.

METHODS

Between January, 2008 and December, 2010, 186 small (≤ 7 mm) saccular aneurysms that retained contrast after coil embolization accrued for this study. Lesions were categorized by pattern (eccentric vs. concentric) and degree of filling on working projections. Clinical and morphologic factors were also analyzed to assess impact on subsequent recanalization. Morphologic outcomes at 6 months or more were assessed.

RESULTS

In 93.5 % (174/186) of aneurysms with visible contrast retention, complete occlusion was evident on follow-up imaging studies at 6 months. Multiple logistic regression analysis indicated that eccentric (vs. concentric) contrast filling carried greater risk of subsequent recanalization (p = 0.020). Stent placement and progressive occlusion were also linked, falling short of statistical significance (p = 0.089). Of 166 progressively occluded aneurysms followed for more than 12 months (mean, 30.8 ± 7.3 months), 158 (95.2 %) exhibited stable occlusion.

CONCLUSION

Small (≤ 7 mm) aneurysms that retain contrast immediately after coil embolization are more likely to become completely occluded over time through progressive thrombosis. However, an eccentric fill pattern may predispose to recanalization.

Correlation of Asymmetry Indices Measured by Arterial Spin-Labeling MR Imaging and SPECT in Patients with Crossed Cerebellar Diaschisis

BACKGROUND AND PURPOSE

Crossed cerebellar diaschisis, not only a secondary result of supratentorial infarction but also an indicator of clinical outcomes, has frequently been reported on PET and SPECT but has been rarely described with arterial spin-labeling MR imaging. The purpose of this study was to determine the ability of arterial spin-labeling MR imaging to evaluate crossed cerebellar diaschisis compared with that of SPECT. To our knowledge, this is the first study to validate arterial spin-labeling in crossed cerebellar diaschisis by using SPECT as a reference standard.

MATERIALS AND METHODS

This study included 16 patients in whom crossed cerebellar diaschisis was shown on SPECT and 10 control subjects in whom crossed cerebellar diaschisis was not shown on SPECT. During the qualitative analysis, asymmetric cerebellar perfusion on arterial spin-labeling was divided into 1 of the following 3 grades by 2 blinded observers: the affected cerebellum was isointense compared with the unaffected cerebellum (grade I), it was slightly hypointense (grade II), or it was markedly hypointense (grade III). In the quantitative analysis, asymmetry indices were calculated by using SPECT and arterial spin-labeling images. For statistical analysis, κ statistics, the interobserver correlation coefficient, the independent t test, Pearson correlation, and linear regression analysis were used.

RESULTS

Almost all the diagnoses of crossed cerebellar diaschisis on SPECT were noted on arterial spin-labeling in both qualitative and quantitative analyses with good interobserver agreement (κ = 0.961; interobserver correlation coefficient, 0.806). The mean asymmetry index of arterial spin-labeling (26.06 ± 9.00) was significantly larger than that for SPECT (15.28 ± 5.34; P < .001). There was a significant positive correlation between the asymmetry indices obtained for SPECT and those for arterial spin-labeling (r = 0.77 [95% CI, 0.443-0.916]; P < .001). The relationship of asymmetry indices between SPECT and arterial spin-labeling (x, y) was calculated as y = 6.2131 + 1.2986x (R(2) = 0.592; P < .001).

CONCLUSIONS

Arterial spin-labeling can be a noninvasive alternative to SPECT for evaluating crossed cerebellar diaschisis.

Clinical utility of arterial spin-labeling as a confirmatory test for suspected brain death

Diagnosis of brain death is made on the basis of 3 essential findings: coma, absence of brain stem reflexes, and apnea. Although confirmatory tests are not mandatory in most situations, additional testing may be necessary to declare brain death in patients in whom results of specific components of clinical testing cannot be reliably evaluated. Recently, arterial spin-labeling has been incorporated as part of MR imaging to evaluate cerebral perfusion. Advantages of arterial spin-labeling include being completely noninvasive and providing information about absolute CBF. We retrospectively reviewed arterial spin-labeling findings according to the following modified criteria based on previously established confirmatory tests to determine brain death: 1) extremely decreased perfusion in the whole brain, 2) bright vessel signal intensity around the entry of the carotid artery to the skull, 3) patent external carotid circulation, and 4) "hollow skull sign" in a series of 5 patients. Arterial spin-labeling findings satisfied the criteria for brain death in all patients. Arterial spin-labeling imaging has the potential to be a completely noninvasive confirmatory test to provide additional information to assist in the diagnosis of brain death.

Aneurysm Recurrence Volumetry Is More Sensitive than Visual Evaluation of Aneurysm Recurrences

PURPOSE

Considerable inter-observer variability in the visual assessment of aneurysm recurrences limits its use as an outcome parameter evaluating new coil generations. The purpose of this study was to compare visual assessment of aneurysm recurrences and aneurysm recurrence volumetry with an example dataset of HydroSoft coils (HSC) versus bare platinum coils (BPC).

METHODS

For this retrospective study, 3-dimensional time-of-flight magnetic resonance angiography datasets acquired 6 and 12 months after endovascular therapy using BPC only or mainly HSC were analyzed. Aneurysm recurrence volumes were visually rated by two observersas well as quantified by subtraction of the datasets after intensity-based rigid registration.

RESULTS

A total of 297 aneurysms were analyzed (BPC: 169, HSC: 128). Recurrences were detected by aneurysm recurrence volumetry in 9 of 128 (7.0 %) treated with HSC and in 24 of 169 (14.2 %) treated with BPC (odds ratio: 2.39, 95 % confidence interval: 1.05-5.48; P = 0.039). Aneurysm recurrence volumetry revealed an excellent correlation between observers (Cronbach's alpha = 0.93). In contrast, no significant difference in aneurysm recurrence was found for visual assessment (3.9 % in HSC cases and 4.7 % in BPC cases). Recurrences were observed in aneurysms smaller than the sample median in 10 of 33 (30.3 %) by aneurysm recurrence volumetry and in 1 of 13 (7.7 %) by visual assessment.

CONCLUSIONS

Aneurysm recurrences were detected more frequently by aneurysm recurrence volumetry when compared with visual assessment. By using aneurysm recurrence volumetry, differences between treatment groups were detected with higher sensitivity and inter-observer validity probably because of the higher detection rate of recurrences in small aneurysms.

Endovascular treatment of ophthalmic artery aneurysms: assessing balloon test occlusion and preservation of vision in coil embolization

BACKGROUND AND PURPOSE

ICA-ophthalmic artery aneurysms have unique configurations corresponding to relative risks of ophthalmologic morbidities. Presented herein are clinical and radiologic outcomes of coil embolization in ophthalmic artery aneurysms.

MATERIALS AND METHODS

From January 2003 to September 2013, endovascular coiling was performed in 43 consecutive patients with ophthalmic artery aneurysms, each classified by the degree to which the ophthalmic artery was incorporated by the aneurysm and the contiguity between the ophthalmic artery entry and parent ICA. Clinical and radiologic outcomes of this approach were investigated, including the technical aspects of treatment and the efficacy of balloon test occlusion.

RESULTS

Among 14 patients (32.6%, all ophthalmic artery types) undergoing balloon test occlusion before endovascular coiling, patent collaterals between the external carotid artery and ophthalmic artery were demonstrated in 12 (85.7%) and complete compromise of the ophthalmic artery (without affecting vision) occurred in 4 patients during coiling. Steam-shaped S-configured (67.9%) or straight microcatheters (17.8%) facilitated aneurysm selection in most of the superiorly directed ophthalmic artery aneurysms (n = 28), and steam-shaped pigtail microcatheters (85.7%) were useful in medially directed aneurysms (n = 14). Balloon protection (n = 22) was generally used to facilitate coiling, or a stent (n = 9) was alternatively deployed. Satisfactory aneurysmal occlusion was achieved through coil embolization in 37 lesions (86.1%). During follow-up of 35 patients (mean interval, 12.9 ± 9.4 months), only 1 instance (2.9%) of major recanalization was observed.

CONCLUSIONS

If one tailors technical strategies, ophthalmic artery aneurysms are amenable to safe and effective endovascular coil embolization, which tends to be stable in follow-up. Balloon test occlusion may be helpful in devising treatment strategies to preserve vision when coiling ophthalmic artery aneurysms (especially those incorporating an ophthalmic artery origin) is done.

The heterogeneity of ventral tegmental area neurons: Projection functions in a mood-related context

The ventral tegmental area (VTA) in the brain's reward circuitry is composed of a heterogeneous population of dopamine, GABA, and glutamate neurons that play important roles in mediating mood-related functions including depression. These neurons project to different brain regions, including the nucleus accumbens (NAc), the medial prefrontal cortex (mPFC), and the amygdala. The functional understanding of these projection pathways has been improved since the extensive use of advanced techniques such as viral-mediated gene transfer, cell-type-specific neurophysiology and circuit-probing optogenetics. In this article, we will discuss the recent progress in understanding these VTA projection-specific functions, focusing on mood-related disorders.

Posterior Communicating Artery Compromise in Coil Embolization of Posterior Communicating Artery Aneurysms

PURPOSE

Whether the posterior communicating artery (PcomA) can be safely compromised during endovascular treatment of a PcomA aneurysm is a matter of debate. Here we present clinical and radiologic outcomes, given this scenario.

METHODS

From data prospectively accrued between January 2004 and December 2012, records of 44 patients harboring 46 PcomA aneurysms were retrieved. All had suffered PcomA compromise in the course of endovascular coil embolization. Patients/aneurysms were stratified into those with complete (Group A) and incomplete (Group B) compromise depending on the degree of PcomA flow limitation documented by postembolization ipsilateral internal carotid artery angiography. Clinical and radiologic outcomes were accordingly assessed.

RESULTS

All affected vessels were hypoplastic PcomA variants (PcomA/P1 ratio, ≤ 1.0), with exception of a single dominant PcomA (PcomA/P1 ratio, 1.1). In Group A (23 patients, 23 aneurysms), no PcomA compromise-related infarction was evident, whereas in Group B (21 patients, 23 aneurysms), two ischemic events occurred. One patient suffered thalamic infarction, although patency of the PcomA was adequate in a follow-up angiogram, and another experienced a transient ischemic attack.

CONCLUSION

Our findings suggest that obstructed flow in hypoplastic PcomA variants during coil embolization of PcomA aneurysms carries no major consequence. However, incomplete compromise of the PcomA may be a source of delayed thromboembolic infarction.

Potential for the use of the Solitaire stent for recanalization of middle cerebral artery occlusion without a susceptibility vessel sign

BACKGROUND AND PURPOSE

Absence of the MCA susceptibility vessel sign (negative MCA susceptibility vessel sign) on gradient recalled-echo MR imaging in acute stroke is commonly associated with in situ stenosis and thrombotic occlusion. We evaluated the effectiveness and safety of the Solitaire stent as the first-line device for the recanalization of MCA occlusion with a negative MCA susceptibility vessel sign.

MATERIALS AND METHODS

Thirty-eight consecutive patients presenting with acute ischemic stroke due to MCA occlusion were treated by using the Solitaire AB stent alone or combined with thrombolytic drugs. Among these patients, 11 (7 men and 4 women; median age, 70 years; range, 49-89 years) who underwent multimodal stroke MR imaging before the endovascular procedure and had no MCA susceptibility vessel sign on the initial gradient recalled-echo MR imaging were included in this study. The primary end point was the recanalization of the occluded artery evaluated by the arterial occlusive lesion score. Clinical outcome was assessed at discharge and 90 days, as was the degree of residual MCA stenosis or reocclusion.

RESULTS

Successful recanalization (arterial occlusive lesion score ≥ II) without balloon angioplasty was obtained in 9 patients (81.8%). Six patients (54.5%) had an mRS score of ≤2 at 90 days. After a median of 147 days, no patient showed reocclusion on follow-up imaging. There were no symptomatic intracerebral hemorrhages.

CONCLUSIONS

The Solitaire stent is a feasible tool as the first-line device for multimodal endovascular recanalization therapy in acute ischemic stroke with a negative MCA susceptibility vessel sign. It has a good rate of successful and complete recanalization and is a fast yet safe procedure.

Single-stage extracranial carotid artery stenting and intracranial aneurysm coiling: technical feasibility and clinical outcome

The coexistence of carotid artery stenosis and cerebral aneurysm in a patient presents challenges for treatment decision-making. The purpose of this study was to evaluate the technical feasibility and clinical outcome after single-stage extracranial carotid artery stenting (CAS) and ipsilateral intracranial aneurysm coiling in a single institution. From March 2005 to February 2011, 17 patients with 21 aneurysms underwent single-stage CAS and coiling for ipsilateral aneurysms. There were symptomatic atherosclerotic carotid stenoses with unruptured aneurysms in eight, ruptured or symptomatic aneurysms with simultaneous asymptomatic carotid stenoses in two and asymptomatic lesions in seven. CAS was followed by aneurysm coiling in all 17 patients. Clinical and radiological data were reviewed. There were two procedure-related complications: acute in-stent thrombosis in one and premature aneurysmal rupture in the other. After aneurysm coiling, complete occlusion was demonstrated in 17 aneurysms and near-total occlusion in four. No neurological deficit was found at discharge and follow-up outcomes were excellent in all the patients (mean, 32.9 months). Follow-up imaging studies were performed in all the patients, including neck CT angiography in 14 (mean, 26.1 months), brain MR angiography in 14 (mean, 31.2 months), and conventional angiography in three (mean, 14.7 months). They revealed two asymptomatic, mild carotid re-stenoses and one major aneurysmal recanalization requiring re-coiling. A single-stage CAS and coiling procedure appears to be feasible and the complication rate seems to be reasonable. We suggest that there is no need for separate therapeutic procedures when a patient has carotid artery stenosis and accompanying ipsilateral intracranial aneurysm.

Stent-assisted coil embolization of posterior communicating artery aneurysms

BACKGROUND AND PURPOSE

Use of protective stents may not be effective in coil embolization of wide-neck aneurysms involving the posterior communicating artery. Successful implementation depends on the caliber of the vessel, its angle of origin, and the manner in which its orifice is incorporated into the aneurysm. Presented here are the results (clinical and radiographic) of coil embolization in aneurysms of the ICA-posterior communicating artery junction, variably aided by stents. The primary focus is angiographic configurations that impact stent placement.

MATERIALS AND METHODS

From a prospective data repository, we retrieved records of 32 consecutive patients with 33 posterior communicating artery aneurysms, all of which were treated by stent-assisted coil embolization between June 2008 and August 2012. Outcomes were analyzed in terms of aneurysm configuration and clinical status.

RESULTS

Stents were positioned entirely in the ICA (n = 26), from the ICA to the posterior communicating artery (n = 2), in the posterior communicating artery only (n = 3), and retrograde from the posterior communicating artery to the ICA terminus (n = 2). Procedure-related complications occurred in 3 patients (9.1%), but only 1 (3.0%) had mild neurologic sequelae (Glasgow Outcome Score 4). Using coil embolization, we achieved successful occlusion in 24 aneurysms (72.7%), and in 9 others, subtotal occlusion was conferred. During a mean follow-up of 15.7 ± 10.7 months, imaging of 27 aneurysms documented stable occlusion in 19 (70.4%), whereas angiography of 15 aneurysms (39.5%) disclosed 2 instances of in-stent stenosis (13.3%) and a solitary occurrence of stent migration (6.7%).

CONCLUSIONS

In posterior communicating artery aneurysms, stent protection during coil embolization is feasible by adjusting the procedural strategy to accommodate differing configurations of the aneurysm and its vascular source.

Coil protection using small helical coils for wide-neck intracranial aneurysms: a novel approach

BACKGROUND AND PURPOSE

A number of remodeling or protective techniques available to treat wide-neck intracranial aneurysms are increasingly being used, provided that the shape/type of aneurysm, vessel diameter, and inherent course of the vessel are conducive to their use. The purpose of this study was to describe a novel method using coil protection for treatment of wide-neck aneurysms.

MATERIALS AND METHODS

This technique involves sequential maneuvers to the aneurysm and affected branch artery. A microcatheter is first introduced into the aneurysmal sac, and another microcatheter is introduced into the entrance of the branch artery, followed by partial deployment of a small helical coil into the branch artery. A framing coil is then placed within the aneurysmal sac, under the protection of the helical coil. After completion of the first coil insertion, the helical coil should be retrieved to confirm the stability of the framing coil. The helical coil can also serve as a filler.

RESULTS

This technique was successfully applied to 12 intracranial saccular aneurysms of the MCA bifurcation (5 patients); anterior communicating artery (3 patients); and A1 and M1 segments, distal ACA, and basilar tip (1 patient each). Selective endovascular treatment was successfully performed and resulted in excellent outcomes in all patients. There were no complications directly related to coil protection.

CONCLUSIONS

Our small study suggests that coil protection can be a safe alternative to traditional remodeling or protective techniques when those techniques have failed or are not possible due to vascular geometry. It is particularly suited for the treatment of wide-neck aneurysms arising from small and acutely angulated branching vessels.

Embolization of intracranial aneurysms with HydroSoft coils: results of the Korean multicenter study

BACKGROUND AND PURPOSE

Various modifications of detachable coils have been attempted to reduce recurrence rates in aneurysmal coil embolization and HydroSoft coil is one of them. The authors report their experience using HydroSoft coils in the treatment of cerebral aneurysms.

MATERIALS AND METHODS

The present study is a prospective multicenter observational series of 127 aneurysms in 120 patients treated with HydroSoft coils.

RESULTS

Ten centers participated in this study, and there were 92 (72%) unruptured and 35 ruptured aneurysms. Aneurysm volumes were ≥ 100 mm³ in 21 (17%) and < 100 mm³ in 106 (83%) (mean, 56 mm³; range, 5-249 mm³). The average percentage length of HydroSoft coils detached in treated aneurysms was 67% (range, 42%-100%). Immediate postprocedural angiography demonstrated complete aneurysm occlusion in 69% (87/127 aneurysms), residual neck in 20% (25/127), and residual sac in 12% (15/127). Procedure-related adverse events occurred in 4.7% (6/127 aneurysms), including procedural bleeding (5/127) and thromboembolism (2/127), and immediate procedure-related morbidity and mortality rates were 0.8% and 0%. Conventional angiography or MRA follow-up was performed in 83% (105/127) at ≥ 6 months after treatment (mean interval, 11 months; range, 6-24 months). The overall recanalization rate was 3% (3/105 aneurysms; 2 major and 1 minor recanalizations). Progression to complete aneurysmal occlusion was noted in 20 of 27 aneurysms (74%) during the follow-up.

CONCLUSIONS

The safety profile of HydroSoft coils appears acceptable. In terms of initial occlusion rates and durability, embolization by using HydroSoft coils seems to be favorable compared with most large series of pure platinum or coated coils.

Comparison of 2-year angiographic outcomes of stent- and nonstent-assisted coil embolization in unruptured aneurysms with an unfavorable configuration for coiling

BACKGROUND AND PURPOSE

Stents are known to have hemodynamic and biologic effects in addition to their mechanical scaffold effect. To determine whether stents affect long-term outcomes after coiling of unruptured aneurysms, we compared angiographic outcomes at 2 years postembolization for stent- and nonstent-assisted coiled unruptured aneurysms.

MATERIALS AND METHODS

Stent-assisted coiling was used in unruptured aneurysms unfavorable for simple coiling (neck size >4 mm and dome-to-neck ratio <1.5) in our practice. Therefore, 126 coiled unruptured aneurysms in total (40 [31.7%] stent group and 86 [68.3%] nonstent group) with these conditions were selected for this study. The nonstent group aneurysms were treated with multiple microcatheter technique (53 cases) or balloon-assisted technique (33 cases). Self-expandable stents were used for coiling in stent group aneurysms. No significant difference in aneurysmal characteristics (aneurysm type [sidewall/bifurcation], diameter, neck size, and dome-to-neck ratio) or angiographic outcome at embolization (packing attenuation, obliteration grade, and contrast filling) were observed between the 2 study groups.

RESULTS

At 2-year follow-up visits, rates of progressive occlusion (stent group, 17/40 [42.5%] versus nonstent group, 34/86 [39.5%]) and recanalization (7/40 [17.5%] versus 18/86 [21.0%]) did not show a statistically significant difference between the 2 groups (P = .895).

CONCLUSIONS

The present study did not show that additional hemodynamic and biologic effects of stents designed for neck remodeling were enough to enhance progressive occlusion and prevent the recanalization of unruptured aneurysms. Our finding suggests that stent placement provides no better long-term angiographic outcomes for unruptured aneurysms with an unfavorable configuration for coiling.

Matrix² coils in embolization of intracranial aneurysms: 1-year outcome and comparison with bare platinum coil group in a single institution

BACKGROUND AND PURPOSE

The endosaccular occlusion by using BPC has been useful in the treatment of intracranial aneurysms, but its limited durability remains a deep-seated drawback. The Matrix² coil, one of the bioactive-coated coils, had been developed to improve this limited durability. To evaluate durability of Matrix² coils after embolization of intracranial aneurysms, we retrospectively compared 1-year outcomes with that of BPC groups.

MATERIALS AND METHODS

A group of 121 aneurysms in 114 patients were embolized by using Matrix² coils between April 2006 and September 2008. The BPC group consisted of 151 aneurysms in 137 patients embolized by using BPCs alone between October 2007 and October 2008. The initial outcomes including packing densities, occlusion grades, and periprocedural complications, and the 1-year outcomes on MR angiography were retrospectively compared between the 2 groups.

RESULTS

The Matrix² coil group and BPC group with similar baseline demographic characteristics revealed comparable initial outcomes. The rates of overall recurrence, major recanalization, and retreatment were 17.4%, 14.0%, and 10.7% versus 7.3%, 5.3%, and 4.6%, respectively (P = .066). However, the rates of subgroups with aneurysm volumes between 50 and 200 mm³ were 23.7%, 13.1%, and 10.5% versus 2.2%, 0%, and 0% (P = .022), respectively. The rates of subgroups with packing attenuation <30% were 38.3%, 31.9%, and 23.4% versus 13.3%, 11.7%, and 10% (P = .025), respectively. There were no differences in packing attenuation (P = .152), initial occlusion grade (P = .098), and 1-year outcomes (P = .209) according to the length of Matrix² coils used.

CONCLUSIONS

Overall, initial and 1-year outcomes of the Matrix² coil group were comparable to those of the BPC group. However, in certain subgroups of aneurysm volume and packing attenuation, the 1-year durability of Matrix² coils was inferior to that of the BPC group.

Is fasting necessary for elective cerebral angiography?

BACKGROUND AND PURPOSE

In order to prevent unexpected events such as aspiration pneumonia, cerebral angiography has been performed under fasting in most cases. We investigated prospectively the necessity of fasting before elective cerebral angiography.

MATERIALS AND METHODS

The study is an open-labeled clinical trial without random allocation. In total, 2554 patients who underwent elective cerebral angiography were evaluated on development of nausea, vomiting, and pulmonary aspiration during and after angiography. Potential risks and benefits associated with fasting were provided in written documents and through personal counseling to patients before the procedure. The patients chose their fasting or nonfasting option. No restriction in diet was given after angiography. The patients were observed for 24 hours. Nausea and vomiting during and within 1 hour after angiography was considered as a positive event associated with cerebral angiography.

RESULTS

The overall incidence of nausea and vomiting during and within 1 hour after angiography was 1.05% (27/2554 patients). There was no patient with pulmonary aspiration. No statistical difference in nausea and vomiting development between the fasting and the diet groups was found.

CONCLUSIONS

The incidence of nausea and vomiting associated with cerebral angiography is low and not affected by diet or fasting. Pulmonary aspiration had no difference between the diet and the fasting group. Our study suggests that fasting may not be necessary for patients who undergo elective cerebral angiography.

Endovascular treatment of wide-neck intracranial aneurysms using a microcatheter protective technique: results and outcomes in 75 aneurysms

BACKGROUND AND PURPOSE

The microcatheter protective technique positions an additional microcatheter in the parent or side-branching artery to protect it during coil embolization. The purpose of this study was to describe this method and to evaluate its efficacy and safety as an alternative to a multiple-microcatheter or balloon- or stent-assisted technique for wide-neck aneurysms.

MATERIALS AND METHODS

A retrospective review of 74 patients (43 women; mean age, 59.6 years) with 75 wide-neck aneurysms treated with the microcatheter protective technique between January 2003 and April 2010 was performed. Immediate postembolization angiograms were evaluated by using a conventional angiographic scale, and clinical evaluation was performed by using the GOS. Clinical and imaging follow-up were available in 57 (76%) patients, with a mean of 14.7 months.

RESULTS

Postembolization angiograms demonstrated total occlusion in 45 of 75 (60%) aneurysms, a neck remnant in 17 (22.7%), and body filling in 13 (17.3%). The technique-related complication rate was 17.4% (13/75), and the procedural-related morbidity rate was 1.3% (1/74). All patients, except 3 complicated cases with a GOS of <4, had a GOS of 5 at the end of the study period. Of the 57 aneurysms with follow-up, recanalization developed in 5 (8.8%) aneurysms, and 3 (5.3%) cases of major recanalization were re-treated endovascularly.

CONCLUSIONS

The microcatheter protective technique is feasible and safe for coil embolization of wide-neck aneurysms, especially in cases that are not suitable for multiple catheter or balloon- or stent-assisted techniques.

Two-year follow-up of contrast stasis within the sac in unruptured aneurysm coil embolization: progressive thrombosis or enlargement?

BACKGROUND AND PURPOSE

The fate of contrast stasis within an aneurysmal sac after coiling has not been established. We followed and evaluated the potential risks of recanalization of unruptured aneurysms embolized with BPCs for 2 years.

MATERIALS AND METHODS

A total of 301 unruptured aneurysms in 252 patients were treated with BPCs. Contrast stasis was observed on initial postembolization angiograms in 104 (34.6%) of these aneurysms. For follow-up, skull images by an angiographic unit (at 3, 9, 15, and 21 months), CE-MRA including TOF source images (at 6, 12, and 18 months), and DSA (at 24 months) were used.

RESULTS

In 89 (85.6%) of the 104 aneurysms with contrast stasis, the stasis disappeared on 6-month MRAs and occlusions remained unchanged without recanalization for 2 years. In the remaining 15 (14.4%), recanalization occurred during follow-up. The presence of contrast stasis was not found to be associated with the obliteration rate (P = .641) or packing attenuation (aneurysms without contrast stasis 30.7% ± 11.18 versus aneurysms with contrast stasis 33.0% ± 12.11, P = .113). Contrast stasis was not found to be a risk factor for recanalization (15/104 [14.4%] versus 29/197 [14.7%], P = 1.000).

CONCLUSIONS

Contrast stasis is a benign angiographic finding that can disappear within 6 months on follow-up MRA. In addition, contrast stasis was not found to be associated with a low obliteration rate or packing attenuation or to be a risk factor for recanalization. The present study shows that aneurysms with contrast stasis on initial postembolization angiograms are no more likely to recanalize than aneurysms without contrast stasis.

Intracranial stent placement for recanalization of acute cerebrovascular occlusion in 32 patients

BACKGROUND AND PURPOSE

Stents have been reported as an option for improvement of the recanalization rate in AIS. The authors have also used intracranial stents in failed cases of IAT with pharmacologic and mechanical methods since 2004. We retrospectively reviewed our cases of intracranial stent use for IAT of AIS for recanalization and as a rescue procedure for iatrogenic intracranial vascular dissection during IAT.

MATERIALS AND METHODS

Thirty-two patients, who were diagnosed with AIS, were treated with intracranial stents (28 balloon-mounted and 7 self-expandable stents) at our neurovascular center between April 2004 and December 2008. The stent use for all 32 patients was the final attempt to recanalize occluded vessels after various trials of pharmacologic or mechanical thrombolysis or to treat iatrogenic vascular dissection.

RESULTS

Among the 32 patients, immediate poststenting angiographic recanalization was achieved in 100% with TIMI/TICI 2 (15 of 32 lesions, 46.9%) or TIMI/TICI 3 (17 of 32 lesions, 53.1%). However, complication rates were also high. Major symptomatic intracerebral hemorrhage (1 case of procedural symptomatic hemorrhage and 3 cases of delayed symptomatic hemorrhage) occurred in 4 (12.5%); intracranial vascular dissection, in 4 (12.5%); extracranial vascular dissection, in 3 (9.4%); immediate IST, in 4 (12.5%); subacute (within 1 week) IST, in 2; late (>1 week) IST, in 1, and 1 case of in-stent restenosis occurred twice (at 5 and 17 months).

CONCLUSIONS

Intracranial stent placement for AIS management has an excellent recanalization rate. However, it is associated with high complication risks as our series showed. We believe that the decision to treat AIS with intracranial stent placement should be made after careful consideration of potential benefits and risks.

Intraosseous cranial dural arteriovenous fistula treated with transvenous embolization

BACKGROUND AND PURPOSE

We analyzed the angiographic architecture of intraosseous dural arteriovenous fistulas (DAVFs) and evaluated the use of transvenous embolization for curative treatment.

MATERIALS AND METHODS

The study population consisted of 6 patients with intraosseous DAVFs from 3 hospitals. In all of these patients, we retrospectively reviewed the medical records and images, and we were able to confirm the lesions in all patients from CT, MR imaging, and angiographic images. 3D rotational angiographic coronal source images clearly demonstrated the presence of an intraosseous DAVF in 2 patients.

RESULTS

An intraosseous DAVF was located at the upper clivus in 1, the petrous apex in 1, and the lower clivus adjacent to the hypoglossal canal in 4 cases. All of the cases showed the presence of a dilated venous pouch, manifest as an osteolytic lesion on CT and as an intraosseous signal-intensity void on MR images. All patients were treated with transvenous embolization by targeting the dilated venous pouch and its connecting tributaries. Four intraosseous DAVFs were immediately completely embolized. One patient had a residual shunt, but the shunt disappeared 1 month later. One patient presented with a simultaneous DAVF in the ipsilateral cavernous sinus without a significant amount of shunt. None of the patients had procedural complications, and 5 patients recovered from the presenting symptoms.

CONCLUSIONS

An intraosseous DAVF could be completely cured with transvenous embolization. For curative treatment, the intraosseous dilated venous pouch can be the target lesion for endovascular treatment.

Endovascular coil embolization of 435 small asymptomatic unruptured intracranial aneurysms: procedural morbidity and patient outcome

BACKGROUND AND PURPOSE

Whether treatment of small asymptomatic aneurysms is appropriate or not remains controversial. We performed a retrospective study on the procedural morbidity and mortality of coil embolization of small asymptomatic unruptured intracranial aneurysms (UIAs) to obtain a more generalized estimate of procedural risk.

MATERIALS AND METHODS

A total of 435 small (maximum diameter < or = 7 mm) asymptomatic UIAs in 370 patients were treated by coil embolization. Aneurysm sizes were determined by using 3D angiograms. We assessed procedure-related morbidity and mortality, immediate postprocedural angiographic results, short-term imaging follow-up results, and clinical outcomes.

RESULTS

Initial aneurysm occlusion was complete in 334 aneurysms, near complete in 78, and incomplete in 22. One internal carotid artery (ICA) aneurysm that ruptured during the procedure was treated with parent artery occlusion. Two hundred wide-neck aneurysms were coiled with the aid of various neck-remodeling techniques. The 44 procedure-related complications were the following: 24 thromboembolisms, 11 coil protrusions or prolapses into the parent vessel, 4 intraprocedural ruptures, 3 device-related complications, and 2 femoral-access complications. We had a total of 44 (10.1%) procedure-related complications with only 1 leading to persistent neurologic deficit. Procedure-related permanent morbidity and mortality were 0.27% (1/370) and 0%, respectively.

CONCLUSIONS

In this series of small unruptured asymptomatic aneurysms, endovascular treatment was achieved with good short-term angiographic outcome and low permanent neurologic impairment. The goal of this study was not to provide a conclusion about treatment guidelines for small UIA but rather to help guide future recommendations by presenting a more generalized estimate of endovascular treatment risk than is currently available.

Successful endovascular occlusion of a ruptured distal anterior inferior cerebellar artery aneurysm of the caudal trunk: case report

SUMMARY

We report a rare case of a ruptured distal anterior inferior cerebellar artery (possibly dissecting) aneurysm of the caudal trunk, successfully treated by endovascular occlusion. A 41-yearold man presented with sudden severe headache and drowsiness. On the day of ictus, conventional angiography was performed to make the above diagnosis, followed by endovascular occlusion of the sac and the parent artery. The patient recovered completely without any neurologic deficit after treatment. Endovascular occlusion could be a safe and effective treatment option in a case of a ruptured distal AICA aneurysm of the caudal trunk.

Aseptic meningitis after embolization of cerebral aneurysms using hydrogel-coated coils: report of three cases

SUMMARY

We report the development of aseptic meningitis in 3 patients with aneurysms treated with hydrogel-coated coils. Patients presented with febrile meningeal syndromes during the 24 hours following the procedures and responded to corticosteroids. One of them developed delayed hydrocephalus that required treatment with a ventriculoperitoneal shunt. Aseptic meningitis is one of the important complications related to hydrogel-coated coils that should be recognized. More information based on the posttreatment surveillance after use of hydrogel-coated coils is required.

Pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions: differentiation using MRI

AIMS

To determine the differential magnetic resonance imaging (MRI) features of pituitary adenoma, craniopharyngioma, and Rathke cleft cyst involving both intrasellar and suprasellar regions.

MATERIALS AND METHODS

The MRI images of 64 patients with pituitary adenoma (n=38), craniopharyngioma (n=13), or Rathke cleft cyst (n=13) were retrospectively reviewed by three neuroradiologists. The following characteristics were evaluated: shape, volume, extent, component characteristics, signal intensities of solid portions on T2-weighted images, signal intensities of cystic portions on T1-weighted images, and enhancement patterns of solid portions and cyst walls of tumours. Fisher's exact test applied with Bonferroni correction was used for multiple comparison. A flowchart for differential diagnosis was constructed based on statistical analysis of the results.

RESULTS

A snowman shape, solid characteristics, and homogeneous enhancement of the solid portion were more common in pituitary adenomas (p<0.017). A superiorly lobulated shape, third ventricle compression by superior tumour extension, mixed solid and cystic characteristics, and reticular enhancement of the solid portion were more common in craniopharyngiomas (p<0.017). Finally, an ovoid shape, a small tumour volume, cystic characteristics, and no or thin cyst wall enhancement were more common in Rathke cleft cysts (p<0.017). The flowchart yielded diagnostic accuracies as follows: 92.1% in pituitary adenoma; 92.3% in craniopharyngioma; 92.3% in Rathke cleft cyst; and 92.2% overall.

CONCLUSION

A combination of MRI findings is helpful in the differential diagnosis of the three tumours involving both intrasellar and suprasellar regions.

Anterior spinal artery as a collateral channel in cases of bilateral vertebral arterial steno-occlusive diseases

BACKGROUND AND PURPOSE

We report 6 cases of retrograde flow through the anterior spinal artery (ASA) from cervical vertebral artery (VA) to intracranial distal VA because the perfusion from bilateral vertebral arteries was tenuous. Its hemodynamic and clinical implications are discussed.

METHODS

In association with bilateral steno-occlusive disease of vertebral arteries, 6 cases of retrograde flow through ASA were reviewed in terms of clinical and angiographic characteristics. All 6 patients presented with stroke in the posterior fossa and underwent conventional angiography as part of diagnostic evaluation and/or therapeutic intervention.

RESULTS

On the angiography, 2 patients showed bilateral VA occlusion, and the other 4 patients showed VA occlusion on 1 side and severe stenosis in the other VA. Distal perfusion by ASA was prominent in 2, and not prominent in 4. Reversal or disappearance of the retrograde flow through ASA was observed after successful recanalization of the occluded VA in 4 patients. In 1 patient, increased perfusion through ASA was observed because the stenosed VA was completely occluded.

CONCLUSION

When the vertebral arteries were occluded bilaterally or when a single VA was occluded and the other carried a severe stenosis and, as a result, the basilar arterial blood supply was tenuous, retrograde flow through ASA could be observed. This is a potentially important source of collateral supply to the posterior fossa neural contents. The degree and extent of perfusion via this collateral channel varied depending on presence of other collateral routes and patency of the vertebrobasilar junction.

Embolization of wide-necked aneurysms with using three or more microcatheters

BACKGROUND

A new and relatively simple endovascular technique, in which more than three microcatheters are used for endovascular treatment of cerebral aneurysms for the first time, is described.

METHOD

Eight patients with wide necked aneurysms were successfully treated with detachable coils using the multiple microcatheter technique. Three patients presented with subarachnoid haemorrhage and five were unruptured. The aneurysm locations were superior hypophyseal artery (2), posterior communicating artery (2), middle cerebral artery bifurcation (1), distal anterior cerebral artery (1), basilar artery (1) and vertebral artery (1). The average neck size was 7.4 +/- 2.8 mm (3.5-12 mm), average width of the aneurysms was 10.6 +/- 5.7 mm (6.2-23 mm) and depth was 8.9 +/- 5.8 mm (3-22 mm). Three microcatheters (7 patients) and four microcatheters (1 patient) were introduced and used for coil delivery. Three or four coils were deployed and intermingled to stabilize the whole coil mass as well as to occupy the aneurysmal sac. When a relatively stable coil frame was formed, one coil was detached and subsequent coils were inserted. After the coil mass became more stable, other coils were also detached and all microcatheters were used for subsequent coil deployment.

FINDINGS

All aneurysms were successfully treated without complications. Postemboilzation angiograms showed no contrast filling in 5 cases (100% occlusion) and a very small residual neck in 3 cases. There was no procedure related complication.

CONCLUSION

The multiple microcatheter technique can be one technical option for the endovascular treatment of wide necked aneurysms.

Mechanically-induced proximal arterial occlusion and stent-within-a-stent technique for the treatment of bilateral vertebral artery dissecting aneurysms

Several endovascular approaches have been used in the treatment of dissecting aneurysms of the vertebrobasilar system. We present a case of a bilateral spontaneous vertebral artery (VA) dissecting aneurysms presenting with a subarachnoid haemorrhage. The dominant left VA aneurysm was treated with a stent-within-a-stent construct and the contralateral VA aneurysm was proximally occluded, with no complications, by an unintentional mechanically-induced arterial occlusion.

3T 1H-MR spectroscopy in grading of cerebral gliomas: comparison of short and intermediate echo time sequences

BACKGROUND AND PURPOSE

Echo time (TE) can have a large influence on the spectra in proton MR spectroscopy ((1)H-MR spectroscopy). The purpose of this study was to comparatively assess the diagnostic value of 3T single-voxel (1)H-MR spectroscopy with short or intermediate TEs in grading cerebral gliomas.

METHODS

Single voxel (1)H-MR spectroscopy was performed at 3T in 35 patients with cerebral glioma. The spectra were obtained with both short (35 ms) and intermediate TEs (144 ms). Metabolite ratios of choline (Cho)/creatine (Cr), Cho/N-acetylaspartate (NAA), lipid and lactate (LL)/Cr and myo-inositol (mIns)/Cr were calculated and compared between short and intermediate TEs in each grade. After receiver operating characteristic curve analysis, diagnostic accuracy for each TE in differentiating high-grade glioma from low-grade glioma was compared.

RESULTS

At short TE, Cho/Cr and Cho/NAA ratios were significantly lower, and LL/Cr and mIns/Cr were significantly higher, compared with those at intermediate TE, regardless of tumor grade. Lactate inversion at intermediate TE was found in only 2 patients. At both TEs, there were significant differences in Cho/Cr and LL/Cr ratios between low- and high-grade gliomas. Diagnostic accuracy was slightly higher at short TE alone or combined with intermediate TE than intermediate TE alone (85.7% versus 82.9%).

CONCLUSION

Metabolite ratios were significantly different between short and intermediate TE. Cho/Cr and LL/Cr ratios at either TE were similarly useful in differentiating high-grade gliomas from low-grade gliomas. If only a single spectroscopic sequence can be acquired, short TE seems preferable because of poor lactate inversion at intermediate TE on 3T single-voxel (1)H-MR spectroscopy.

Simultaneous Bilateral Carotid Stenting under the Circumstance of Neuroprotection Device. A Retrospective Analysis

SUMMARY

In this study, in order to evaluate the feasibility and outcomes of simultaneous bilateral carotid artery stenting (CAS) with the use of neuroprotection in symptomatic patients, we conducted a retrospective analysis of 27 patients (19 men, eight women; median age, 69.2 years), all of whom had been scheduled to undergo bilateral CAS in a single setting. All patients presented with severe atherosclerotic bilateral carotid stenosis (> 50% for symptomatic side, > 80% for asymptomatic side), exhibiting symptoms of either a cerebrovascular accident or of a transient ischemic attack on at least one side. 48 arteries were treated with self-expandable stents. Neuroprotection devices were utilized for bilateral CAS in 11 patients, and in 16 unilateral CAS patients. We did not perform the second procedure in six patients, in cases in which a patient exhibited (a) hemodynamic instability, (b) a new neurological impairment, or (c) restlessness after a prolonged time for the first CAS. The second procedure was postponed in a staged manner. We achieved a mean residual stenosis of 8.1 +/- 5.0 % in the treated lesions. The mean procedural time for bilateral CAS was three hours and 18 minutes. 17 patients (63%) developed transient bradycardia during the balloon dilatation of one or both of the relevant arteries. Three patients (11%) exhibited persistent bradycardia and hypotension, which required the administration of intravenous vasopressors for several days (2~7 days). None of the patients ultimately required pacemakers, or any further therapy. Two of the patients (7%) developed transient ischemic attack during the periprocedural period, but recovered completely. One patient developed a new minor stroke after the first procedure, and the second procedure was delayed in a staged manner.We observed no periprocedural deaths, major strokes, or myocardial infarctions, nor did we detect any cases of hyperperfusion syndrome within 30 days. In summary, simultaneous bilateral CAS with neuroprotection can be performed in a single setting without increased concerns with regard to hyperperfusion syndrome, hemodynamic instability, thrombo-embolism, or procedure time, when the first CAS has been safely completed with no evidence of complications in a wellmanaged procedure time.

MRI findings and spreading patterns of necrotizing external otitis: Is a poor outcome predictable?

AIM

To evaluate spreading patterns of necrotizing external otitis (NEO) by magnetic resonance imaging (MRI) and to identify spreading patterns related to a poor outcome.

MATERIALS AND METHODS

Fourteen patients with NEO were divided into good and poor outcome groups according to their final clinical outcomes. Initial MRI images were retrospectively reviewed for regional abnormalities, and follow-up MRI images were reviewed for ICA flow void abnormality and for the following five spreading patterns: medial, crossed, anterior, intracranial, and combined. The frequencies of the abnormal flow void or spreading patterns were compared between the good and poor response groups.

RESULTS

Seven (50%) and seven (50%) patients were respectively allocated to the good and poor outcome groups. Retrocondylar fat infiltration was the most commonest finding on initial MRI images (93%). The frequencies of the abnormal flow void and spreading patterns in the good and poor groups, respectively, were: abnormal flow void, 0 and four (57%); anterior, two (29%) and three (43%); medial, six (86%) and seven (100%); crossed, six (86%) and seven (100%); intracranial middle cranial fossa, one (14%) and four (57%); intracranial posterior cranial fossa, four (57%) and six (86%); intracranial foramen magnum, one (14%) and six (86%).

CONCLUSIONS

NEO almost always involves the retrocondylar fat and spreads via various pathways to extracranial or intracranial spaces. The presence of an abnormal flow void and intracranial dural enhancement, particularly in the middle cranial fossa and foramen magnum, may indicate a poor prognosis.

Kaposiform hemangioendothelioma arising from the internal auditory canal

Kaposiform hemangioendothelioma is a rare vascular tumor and locally aggressive endothelial-derived spindle cell neoplasm, which occurs almost exclusively in infants and adolescents. Radiologically, hemangioendothelioma, including Kaposiform hemangioendothelioma, is seen as a highly vascularized well-enhancing tumor, but no characteristic findings differentiate Kaposiform hemangioendothelioma from other soft-tissue tumors, particularly when the tumor is too small to have any locally aggressive features or identifiable large vessels. We present a case of Kaposiform hemangioendothelioma in the internal auditory canal that had no differential features on initial MR images and rapidly grew into a huge mass in a few months.

Clinical analysis of vertebrobasilar dissection

BACKGROUND

The natural history of vertebrobasilar artery dissection (VAD) is not fully known. The purpose of this study was to review the clinical outcome of the patients with VAD, then to propose an appropriate management strategy for VAD.

METHOD

From 1992 to 2004, 35 VAD patients admitted to our institutes were retrospectively reviewed. There were 28 men and 7 women, whose age ranged from 4 to 67 years with a mean age of 44 years. Angiography was assessed to document the shape, and location of the dissecting aneurysm with respect to the posterior inferior cerebellar artery (PICA). A modified Rankin score was assigned for functional outcome. The functional outcome scores were analyzed according to the patient's age, gender, hypertension history, the pattern of initial manifestation, angiographic shape of VAD, angiographic location of VAD, treatment modality.

FINDINGS

There was no statistically significant difference between the functional outcome with age, gender, trauma history and past medical history of hypertension. Of 35 patients, 22 presented with SAH, 11 with ischemic symptoms and 2 were incidentally detected. The patients without SAH had a better functional outcome than those with SAH (p = 0.029). There was statistical significance between Hunt-Hess (H-H) grade and clinical outcome (p = 0.032). The shape and location of VAD was not significantly related to the functional outcome (p = 0.294, 0.840). But all the cases of rebleeding and mortality (except one case with initially poor H-H grade) developed exclusively in patients with aneurysms. There was no statistically significant correlation between the treatment modality and the outcome (p = 0.691).

CONCLUSION

The VAD patients with SAH would be recommended to be managed by either surgical or endovascular treatment, but those without SAH, could be managed conservatively with antiplatelet therapy and/or anticoagulation.

Anatomical and clinical outcomes after endovascular treatment for unruptured cerebral aneurysms. A single-center experience

SUMMARY

To describe the immediate and follow-up anatomical outcomes as well as procedure-related morbidity after endovascular procedures for unruptured cerebral aneurysms, we reviewed 68 patients with 78 unruptured aneurysms treated with detachable coils from may 1996 to february 2002. Angiograms were retrospectively reviewed for the nature of the aneurysms and the degree of therapeutic obliteration. Periprocedural complications, immediate clinical outcome and longterm neurological status were analyzed. Immediate anatomical outcomes were complete in 35 aneurysms (45%); residual neck in 24 (31%), partial contrast filling in 17 (22%), and failed embolization in two (2%). Of 27 aneurysms with follow-up angiography, 12 of the 13 aneurysms that were completely occluded in the initial treatment were still completely occluded at the end of a mean follow-up period of 17 months. Periprocedural complications were thromboembolic (n=6), haemorrhagic (n=3), coil protrusion (n=7) and other unrelated complications (n=3). Only two patients, with thromboembolic complications were moderately disabled with permanent neurological deficits in immediate clinical outcome, and their condition improved to independent in 1.5 and three months each. Small aneurysms and posterior circulation location showed more protective immediate results than aneurysms of large and anterior circulation after endovascular treatment (p values: 0.01 and 0.02). Our experiences of endovascular treatment for unruptured cerebral aneurysms were comparable to the results of recent series. Endovascular treatment for small posteriorly located aneurysms produced significantly better results than for large anteriorly located lesions.

PC-Based 3D Reconstruction of MR Angiography in Evaluation of Intracranial Aneurysms. The Value of Pre-Treatment Planning for Embolization and Post-Treatment Follow-up

SUMMARY

In this study, we present our experiences of personal computer-based 3D reconstructions of MRA for pre-treatment planning and post-treatment follow-up for cerebral aneurysms. Twentynine ruptured or unruptured intracranial aneurysm patients with 36 intracranial aneurysms, who underwent embolization and pretreatment and/or follow up 3D MRA were included in this study. All 29 patients were examined by DSA and MRA before (18 patients, 24 aneurysms) and/or after embolization (16 patients, 17 aneurysms). The MRA source images were transported to a personal computer in DICOM format for viewing, post-processing, and 3D reconstruction. DSA and PC based SSD 3D MRA equally well demonstrated most aneurysms before embolization (17 patients, 22 aneurysms). The depiction of aneurysm morphology, neck evaluation and branch vessel interpretation were much easier on 3D MRA, which has the ability to manipulate images in real time. When the vascular anatomy was complicated by another vascular system, the anterior or posterior circulations were separately reconstructed easily by using PC based reconstruction software. The 3D MRA also well demonstrated post-embolization recurrence or remnant aneurysmal cavities. In one giant aneurysm, the 3D MRA was unable to show the entire aneurysmal sac due to a blood flow saturation effect, but this was resolved by additional contrast material injection. PC-based 3D MRA proved to be a useful tool for the pretreatment planning of embolization procedures and for follow up after treatment in the case of cerebral aneurysms.