Hyun Ho Choi, Young Dae Cho, Dong Hyun Yoo, Su Hwan Lee, Eung Koo Yeon, Hyun-Seung Kang, Won-Sang Cho, Jeong Eun Kim, and Moon Hee Han
In the presence of symmetric A1 flow, the safety and efficacy of compromising the anterior communicating artery (ACoA) during coil embolization of ACoA aneurysms has yet to be evaluated. Herein, the authors describe their experience, focusing on procedural safety.
Between October 2012 and July 2017, 285 ACoA aneurysms with symmetric A1 flows were treated at the authors’ institution by endovascular coil embolization. Clinical and angiographic outcome data were subjected to binary logistic regression analysis.
ACoA compromise was chosen in the treatment of 71 aneurysms (24.9%), which were completely (n = 15) or incompletely (n = 56) compromised. In the remaining 214 lesions, the ACoA was preserved. Although 9 patients (3.2%) experienced procedure-related thromboembolisms (compromised, 4; preserved, 5), all but 1 patient (with ACoA compromise) were asymptomatic. In multivariate analysis, subarachnoid hemorrhage at presentation was the sole independent risk factor for thromboembolism (OR 15.98, p < 0.01), with ACoA compromise being statistically unrelated. In 276 aneurysms (96.8%) with follow-up of > 6 months (mean 20.9 ± 13.1 months, range 6–54 months), recanalization was confirmed in 21 (minor, 15; major, 6). A narrow (≤ 4 mm) saccular neck (p < 0.01) and ACoA compromise (p = 0.04) were independently linked to prevention of recanalization.
During coil embolization of ACoA aneurysms, the ACoA may be compromised without serious complications if A1 flows are symmetric. This approach may also confer some long-term protection from recanalization, serving as a valid treatment option for such lesions.
Eung Koo Yeon, Young Dae Cho, Dong Hyun Yoo, Su Hwan Lee, Hyun-Seung Kang, Jeong Eun Kim, Won-Sang Cho, Hyun Ho Choi, and Moon Hee Han
The authors conducted a study to ascertain the long-term durability of coiled aneurysms completely occluded at 36 months’ follow-up given the potential for delayed recanalization.
In this retrospective review, the authors examined 299 patients with 339 aneurysms, all shown to be completely occluded at 36 months on follow-up images obtained between 2011 and 2013. Medical records and radiological data acquired during the extended monitoring period (mean 74.3 ± 22.5 months) were retrieved, and the authors analyzed the incidence of (including mean annual risk) and risk factors for delayed recanalization.
A total of 5 coiled aneurysms (1.5%) occluded completely at 36 months showed recanalization (0.46% per aneurysm-year) during the long-term surveillance period (1081.9 aneurysm-years), 2 surfacing within 60 months and 3 developing thereafter. Four showed minor recanalization, with only one instance of major recanalization. The latter involved the posterior communicating artery as an apparent de novo lesion, arising at the neck of a firmly coiled sac, and was unrelated to coil compaction or growth. Additional embolization was undertaken. In a multivariate analysis, a second embolization for a recurrent aneurysm (HR = 22.088, p = 0.003) independently correlated with delayed recanalization.
Almost all coiled aneurysms (98.5%) showing complete occlusion at 36 months postembolization proved to be stable during extended observation. However, recurrent aneurysms were predisposed to delayed recanalization. Given the low probability yet seriousness of delayed recanalization and the possibility of de novo aneurysm formation, careful monitoring may be still considered in this setting but at less frequent intervals beyond 36 months.
Dong Hyun Yoo, Chul-Ho Sohn, Young Dae Cho, Hyun-Seung Kang, Chul-Kee Park, Jin Wook Kim, and Jae Hyoung Kim
Superselective pseudocontinuous arterial spin labeling (ss-pCASL) is an MRI technique in which individual vessels are labeled to trace their perfusion territories. In this study, the authors assessed its merit in defining feeding vessels and gauging preoperative embolization feasibility for patients with meningioma, using digital subtraction angiography (DSA) as the reference method.
Thirty-one consecutive patients with meningiomas were prospectively recruited, each undergoing DSA (and embolization, if feasible) before resection. All ss-pCASL imaging studies were performed 1 day prior to DSA. Two neuroradiologists independently reviewed ss-pCASL images, rating the contribution of each labeled vessel to tumor blood supply as none, minor, or major. Two neuroradiologists also gauged the feasibility of embolization in each patient, based on ss-pCASL images. Interobserver and intermodality agreement were determined using Cohen’s kappa statistic. The diagnostic performance of ss-pCASL was assessed in terms of discerning tumor blood supply and the potential for embolization.
Interobserver agreement in the rating of blood supply by ss-pCASL was very good (κ = 0.817, 95% CI 0.771–0.863), and intermodality agreement (consensus ss-pCASL readings vs DSA findings) was good (κ = 0.688, 95% CI 0.632–0.744). In delineating tumor blood supply, ss-pCASL showed high sensitivity (87.1%) and specificity (87.2%). The positive and negative predictive values for embolization feasibility were 85.2% and 100%, respectively.
In patients with meningiomas, feeding vessels are reliably predicted by ss-pCASL. This noninvasive approach, involving no iodinated contrast or radiation exposure, is particularly beneficial if there are no prospects of embolization.
Chang Hwan Pang, Soo Eon Lee, Chang Hyeun Kim, Jeong Eun Kim, Hyun-Seung Kang, Chul-Kee Park, Sun Ha Paek, Chi Heon Kim, Tae-Ahn Jahng, Jin Wook Kim, Yong Hwy Kim, Dong Gyu Kim, Chun Kee Chung, Hee-Won Jung, and Heon Yoo
There is inconsistency among the perioperative management strategies currently used for chronic subdural hematoma (cSDH). Moreover, postoperative complications such as acute intracranial bleeding and cSDH recurrence affect clinical outcome of cSDH surgery. This study evaluated the risk factors associated with acute intracranial bleeding and cSDH recurrence and identified an effective perioperative strategy for cSDH patients.
A retrospective study of patients who underwent bur hole craniostomy for cSDH between 2008 and 2012 was performed.
A consecutive series of 303 cSDH patients (234 males and 69 females; mean age 67.17 years) was analyzed. Postoperative acute intracranial bleeding developed in 14 patients (4.57%) within a mean of 3.07 days and recurrence was observed in 37 patients (12.21%) within a mean of 31.69 days (range 10–104 days) after initial bur hole craniostomy. The comorbidities of hematological disease and prior shunt surgery were clinical factors associated with acute bleeding. There was a significant risk of recurrence in patients with diabetes mellitus, but recurrence did not affect the final neurological outcome (p = 0.776). Surgical details, including the number of operative bur holes, saline irrigation of the hematoma cavity, use of a drain, and type of postoperative ambulation, were not significantly associated with outcome. However, a large amount of drainage was associated with postoperative acute bleeding.
Bur hole craniostomy is an effective surgical procedure for initial and recurrent cSDH. Patients with hematological disease or a history of prior shunt surgery are at risk for postoperative acute bleeding; therefore, these patients should be carefully monitored to avoid overdrainage. Surgeons should consider informing patients with diabetes mellitus that this comorbidity is associated with an increased likelihood of recurrence.