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Joonho Chung, Sang Hyun Suh, Chang-Ki Hong, Jin-Yang Joo, Yong Cheol Lim, Yong Sam Shin and Yong Bae Kim

OBJECT

The purpose of this study was to report the authors' preliminary experience using self-expanding closed-cell stents deployed in small arteries (< 2 mm in diameter) to treat intracranial aneurysms.

METHODS

A total of 31 patients were studied. All subjects met the following criteria: 1) they received an Enterprise stent for treatment of a wide-necked aneurysm or a dissecting aneurysm or as part of a stent-salvage procedure; and 2) they had an Enterprise stent deployed in a small parent artery (< 2 mm in diameter) that had no atherosclerotic stenosis. Procedure-related complications and follow-up sizes of the parent arteries were evaluated for safety and patency.

RESULTS

There were 16 ruptured aneurysms and 15 unruptured aneurysms. Three (9.7%) of the 31 patients experienced procedure-related complications, and they all were asymptomatic. Follow-up angiography was performed in 27 patients (87.1%) (at a mean 15.5 months after surgery). Parent arteries with 2 acute angles (n = 4) were occluded in 3 cases (75.0%), and those with no acute angles (n = 13) or 1 acute angle (n = 6) showed 100% patency on follow-up angiography. There was a significant difference between the follow-up sizes (mean 1.72 ± 0.30 mm) of parent arteries and their sizes (mean 1.59 ± 0.26 mm) before treatment (95% CI − 0.254 to − 0.009 mm; p = 0.037, paired-samples t-test).

CONCLUSIONS

In the current series the deployment of self-expanding closed-cell stents in small arteries was safe and resulted in good patency, especially when the stents were deployed in segments of the parent artery with no acute angles or only 1 acute angle.

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Joshua T. Billingsley and Brian L. Hoh

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Joonho Chung, Yong Cheol Lim, Sang Hyun Suh, Yu Shik Shim, Yong Bae Kim, Jin-Yang Joo, Bum-soo Kim and Yong Sam Shin

Object

The purpose of this study was to report the authors' experiences in stent-assisted coil embolization (SAC) of ruptured wide-necked aneurysms in the acute period and to evaluate the incidence of and risk factors for periprocedural complications.

Methods

A total of 72 patients were recruited for this study between March 2007 and June 2012. All patients met the following criteria: 1) the presence of ruptured intracranial wide-necked saccular aneurysms, and 2) the patient underwent SAC for treatment of those aneurysms within 72 hours of rupture. All of the patients with clinically poor grades or acute hydrocephalus underwent external ventricular drainage (EVD) before SAC. The incidence of and risk factors for periprocedural complications were retrospectively evaluated.

Results

Of the 72 patients included in this study, periprocedural complications occurred in 14 (19.4%), including asymptomatic complications in 4 (5.6%) and symptomatic complications in 10 (13.9%); there were symptomatic thromboembolic complications in 5 patients (6.9%), and symptomatic hemorrhagic complications in 5 (6.9%). The authors observed no subacute or delayed thromboembolic complications during the follow-up period of 18.8 months. Use of EVD (OR 1.413, 95% CI 0.088–2.173; p = 0.046) was the only independent risk factor for periprocedural complications on multivariate logistic regression analysis.

Conclusions

The periprocedural complication rate during SAC was 19.4% among 72 patients. Because of the high complication rate, microsurgical clipping or endovascular treatment with another technique (multiple-microcatheter or balloon-assisted technique) may be a more appropriate option for first-line treatment than SAC, especially in patients requiring EVD.

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Sook Young Sim, Yong Sam Shin, Kyung Gi Cho, Sun Yong Kim, Se Hyuk Kim, Young Hwan Ahn, Soo Han Yoon and Ki Hong Cho

Object

The clinical features of blood blister–like aneurysms (BBAs) that arise at nonbranching sites of the internal carotid artery (ICA) differ from those of saccular aneurysms. In this study, the authors attempt to describe optimal treatments for BBAs, which have yet to be clearly established.

Methods

Ten of 483 patients with aneurysmal subarachnoid hemorrhage who had been seen at the authors’ institution between March 2001 and June 2005 had intraoperatively confirmed BBAs at nonbranching sites of the ICA. All ten patients were women between the ages of 37 and 64 years (mean age 49.3 years); five had a history of hypertension. The BBAs were localized to the right side of the ICA in seven cases. All patients were successfully treated; clipping was undertaken in six, clipping combined with wrapping in three, and trapping in one. These methods were used in conjunction with various other surgical techniques such as brain relaxation by draining cerebrospinal fluid, anterior clinoidectomy, exposing the cervical ICA, gentle subpial dissection (for aneurysms that adhered to the frontal lobe), complete trapping of the ICA before clipping, and protecting the brain. Clip slippage occurred at the end of dural closing in two cases; the aneurysm was completely obliterated using multiple clips combined with ICA stenosis in one of these cases and ICA trapping with good collateral flow in the other. An excellent clinical outcome was achieved in eight patients, whereas two patients were disabled from massive vasospasm. The authors retrospectively reviewed radiological and surgical data in all cases to determine which treatment methods produced a favorable outcome.

Conclusions

Blood blister–like aneurysms located at nonbranching sites of the ICA are difficult to treat. Preoperative awareness and careful consideration of these lesions during surgery can prevent poor clinical outcomes.

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Sang Hyun Suh, Byung Moon Kim, Sung Il Park, Dong Ik Kim, Yong Sam Shin, Eui Jong Kim, Eun Chul Chung, Jun Seok Koh, Hyun Cheol Shin, Chun Sik Choi and Yu Sam Won

Object

A ruptured dissecting aneurysm of the vertebrobasilar artery (VBA-DA) is a well-known cause of acute subarachnoid hemorrhage (SAH) with a high rate of early rebleeding. Internal trapping of the parent artery, including the dissected segment, is one of the most reliable techniques to prevent rebleeding. However, for a ruptured VBA-DA not suitable for internal trapping, the optimal treatment method has not been well established. The authors describe their experience in treating ruptured VBA-DAs not amenable to internal trapping of the parent artery with stent-assisted coil embolization (SAC) followed by a stent-within-a-stent (SWS) technique.

Methods

Eleven patients—6 men and 5 women with a mean age of 48 years and each with a ruptured VBA-DA not amenable to internal trapping of the parent artery—underwent an SAC-SWS between November 2005 and October 2007. The feasibility and clinical and angiographic outcomes of this combined procedure were retrospectively evaluated.

Results

The SAC-SWS was successful without any treatment-related complications in all 11 patients. Immediate posttreatment angiograms revealed complete obliteration of the DA sac in 3 patients, near-complete obliteration in 7, and partial obliteration in 1. One patient died as a direct consequence of the initial SAH. All 10 surviving patients had excellent clinical outcomes (Glasgow Outcome Scale Score 5) without posttreatment rebleeding during a follow-up period of 8–24 months (mean follow-up 15 months). Angiographic follow-up at 6–12 months after treatment was possible at least once in all surviving patients. Nine VBA-DAs showed complete obliteration; the other aneurysm, which had appeared partially obliterated immediately after treatment, demonstrated progressive obliteration on 2 consecutive follow-up angiography studies. There was no in-stent stenosis or occlusion of the branch or perforating vessels.

Conclusions

The SAC-SWS technique seems to be a feasible and effective reconstructive treatment option for a ruptured VBA-DA. The technique may be considered as an alternative therapeutic option in selected patients with ruptured VBA-DAs unsuitable for internal trapping of the parent artery.

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Tae-Young Jung, Shin Jung, Hyang-Hwa Ryu, Young-Il Jeong, Yong-Hao Jin, Shu-Guang Jin, In-Young Kim, Sam-Suk Kang and Hyung-Seok Kim

Object

Galectin-1 is highly expressed in motile cell lines. The authors investigated whether galectin-1 actually modulates the migration and invasion of human glioblastoma multiforme (GBM) cell lines, and whether its expression with respect to invasion and prognosis is attributable to certain glioma subgroups.

Methods

In the human GBM cell lines U343MG-A, U87MG, and U87MG-10′, the RNA differential display was evaluated using Genefishing technology. The results were validated by reverse transcription polymerase chain reaction and Northern blot analysis to detect possible genetic changes as the determining factors for the motility of the malignant glioma. The migration and invasion abilities were investigated in human GBM cell lines and galectin-1 transfectant using an in vitro brain slice invasion model and a simple scratch technique. The morphological and cytoskeletal (such as the development of actin and vimentin) changes were examined under light and confocal microscopy. Galectin-1 expression was assessed on immunohistochemical tests and Western blot analysis.

Results

Endogenous galectin-1 expression in the human GBM cell lines was statistically correlated with migratory abilities and invasiveness. The U87-G-AS cells became more round than the U87MG cells and lacked lamellipodia. On immunohistochemical staining, galectin-1 expression was increased in higher-grade glioma subgroups (p = 0.027).

Conclusions

Diffuse gliomas demonstrated higher expression levels than pilocytic astrocytoma in the Western blot. Galectin-1 appears to modulate migration and invasion in human glioma cell lines and may play a role in tumor progression and invasiveness in human gliomas.

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Kyung-Sub Moon, Shin Jung, Seung-Kwon Seo, Tae-Young Jung, In-Young Kim, Hyang-Hwa Ryu, Yong-Hao Jin, Shu-Guang Jin, Young-Il Jeong, Kyung-Keun Kim and Sam-Suk Kang

Object

The authors evaluated the clinical manifestations and surgical results in patients with cystic vestibular schwannoma (VS), and investigated the matrix metalloproteinase (MMP) expression of the cyst fluid and wall in an attempt to elucidate the pathogenesis and characteristics of this disease.

Methods

The clinical and neuroimaging features, perioperative findings, and surgical outcomes in 24 cases of cystic VS and 82 cases of solid VS, all of which were treated using the suboccipital approach, were retrospectively compared. To evaluate the role of MMP in cystic VS, gelatin zymography and immunohistochemical studies of the cyst fluid, wall, and solid portion were performed in nine cases of this disease.

The mean duration of symptoms was shorter (14.0 months compared with 26.1 months; p = 0.04) and the mean size of the tumor was larger (43.8 mm compared with 34.2 mm; p = 0.048) in the cystic than the solid VS group. Although gross-total resection was easier to accomplish in this group (100% compared with 84.1%), adhesion to the facial nerve was more frequent (62.5% compared with 48.8%; p = 0.042). On gelatin zymography studies, MMP-2 expression was ubiquitously observed in all cyst fluids. Immunohistochemical analysis of the cyst wall showed that MMP-2 was apparently localized to the tumor cells on the luminal inner surface, adjacent to the cyst cavity.

Conclusions

Resection of cystic VS is complicated by severe adhesion of the tumor capsule to the facial nerve and the large size of the lesion. The authors believe that MMP-2 may be involved in the pathogenesis of cyst formation or in its enlargement and may aggravate adhesion to the facial nerve, either by promoting the enlargement of the tumor or engendering the degradation of the tumor–nerve barrier proteolytically.