[Coil Embolization for Very Small Intracranial Aneurysms with Diameter Less than 3mm:A Case Series of 14 Patients and Literature Review]

INTRODUCTION

Many studies describe aneurysms measuring ≤3mm as "very small" or "tiny, " with a risk of intraoperative rupture higher than that of most cerebral aneurysms. We evaluated the results of endovascular coil embolization for very small aneurysms with diameter ≤3mm.

MATERIAL AND METHODS

The same interventional neurosurgeon performed coil embolization for 14 tiny aneurysms in 14 patients(8male and 6 females)at our institution between May 2015 and June 2017. Patient age range was 42-88 years(average 65.6 years). Five aneurysms had ruptured and 9 were unruptured. Of the 9 unruptured aneurysms, 3 were associated with a previous ruptured aneurysm. We assessed the procedural complications, type of microcatheter and coils used, total number and length of coils, and angiographic results immediately after the procedure.

RESULTS

In 14 aneurysm cases, 8 used only 1 pre-shaped microcatheter, 4 used 2, and 2 used 3;cases using multiple microcatheters added final shaping. Only one case used a helical first coil and the remaining 13 cases used a 3-dimensional coil. The number of coils used was 1 in 3 cases, 2 in 7 cases, 3 in 2 cases, and 4 in 2 cases. The total length of coils inserted was <5 cm in 5 cases, 5-10 cm in 5 cases, and >10 cm in 4 cases. The total length of coils used was <10cm in 70% of cases. Immediately after coil embolization, complete occlusion and a neck remnant were achieved in 11 and 3 cases, respectively. Ballooning was induced by intentionally introducing a balloon-assist technique during surgery in 7 cases, and the balloon was actually inflated in 4 cases. Complications were seen in 2 ruptured cases;1 had an intraoperative rupture, the other had parent artery occlusion, and both patients recovered.

CONCLUSION

Coil embolization for tiny aneurysms can be performed comparatively safely by understanding the pitfalls and by using appropriate procedures and tools. Placing the catheter tip at the aneurysm neck is the first step and endovascular treatment is usually performed with ≤3 coils measuring ≤10 cm in total length. Complete embolization should be attempted, but even incomplete embolization is acceptable. More delicate coil embolization is required.

Signatures of a jet cocoon in early spectra of a supernova associated with a γ-ray burst

Long γ-ray bursts are associated with energetic, broad-lined, stripped-envelope supernovae^1,2 and as such mark the death of massive stars. The scarcity of such events nearby and the brightness of the γ-ray burst afterglow, which dominates the emission in the first few days after the burst, have so far prevented the study of the very early evolution of supernovae associated with γ-ray bursts³. In hydrogen-stripped supernovae that are not associated with γ-ray bursts, an excess of high-velocity (roughly 30,000 kilometres per second) material has been interpreted as a signature of a choked jet, which did not emerge from the progenitor star and instead deposited all of its energy in a thermal cocoon⁴. Here we report multi-epoch spectroscopic observations of the supernova SN 2017iuk, which is associated with the γ-ray burst GRB 171205A. Our spectra display features at extremely high expansion velocities (around 115,000 kilometres per second) within the first day after the burst^5,6. Using spectral synthesis models developed for SN 2017iuk, we show that these features are characterized by chemical abundances that differ from those observed in the ejecta of SN 2017iuk at later times. We further show that the high-velocity features originate from the mildly relativistic hot cocoon that is generated by an ultra-relativistic jet within the γ-ray burst expanding and decelerating into the medium that surrounds the progenitor star^7,8. This cocoon rapidly becomes transparent⁹ and is outshone by the supernova emission, which starts to dominate the emission three days after the burst.

Impact of Body Mass Index on Activities of Daily Living in Inpatients with Acute Heart Failure

OBJECTIVES

To investigate the impact of body mass index on activities of daily living in inpatients with acute heart failure.

DESIGN

A retrospective cohort study.

SETTING

A hospital-based database contains Diagnosis Procedure Combination survey data from 100 participating acute-care hospitals.

PARTICIPANTS

11,301 inpatients aged 20 year or older who were admitted to the participating hospitals with a diagnosis of acute heart failure.

MEASUREMENTS

The Barthel Index score at discharge and hospital death.

RESULTS

The number of patients with a body mass index of <18.5 kg/m2 (underweight), 18.5-22.9 kg/m2 (low-normal weight), 23.0-24.9 kg/m2 (high-normal weight), 25.0-29.9 kg/m2 (overweight), and ≥30.0 kg/m2 (obesity) were 1689 (15%), 4715 (42%), 1809 (16%), 2306 (20%), and 782 (7%), respectively. Median Barthel Index scores at admission and discharge were 65 and 100, respectively. Hospital death occurred in 101 (0.9%) patients. Lower body mass index was associated with lower Barthel Index score at discharge and higher mortality. Multivariable analysis adjusted for body mass index, age, sex, New York Heart Association classification, Barthel Index score at admission, the updated Charlson Comorbidity Index, length of hospital stay, number of drugs administered, and rehabilitation during hospitalization revealed that body mass index was independently associated with Barthel Index score at discharge (beta: 0.354; 95% confidence interval: 0.248-0.461) and hospital death (odds ratio: 0.926, 95% confidence interval: 0.877-0.978).

CONCLUSION

Overweight and obese inpatients showed greater independence in activities of daily living at discharge and lower rates of mortality, indicating the obesity paradox. A combination of rehabilitation and improved nutrition seems to be important in underweight patients with acute heart failure.

Burden of Premorbid Consumption of Texture Modified Diets in Daily Life on Nutritional Status and Outcomes of Hospitalization

OBJECTIVES

Due to the water-rich cooking process required to soften texture modified diets (TMDs), TMDs may have poorer nutrition. The aim of this study was to investigate the associations between daily premorbid TMD consumption and nutritional status at the time of hospitalization, and its burden on hospitalization outcomes.

DESIGN

Retrospective observational study.

SETTING

An academic hospital.

PARTICIPANTS

The cohort comprised 3,594 older adult patients aged ≥65 years admitted to the hospital.

MEASUREMENTS

Patients were interviewed on admission using a premorbid daily consumption meal form to determine whether the patient ate a TMD. Nutritional status was examined using nutritional screening tools (Mini-Nutritional Assessment Short Form [MNA-SF], Malnutrition Universal Screening Tool [MUST], Geriatric Nutritional Risk Index [GNRI]) and the European Society of Clinical Nutrition and Metabolism (ESPEN)-defined criteria of malnutrition at admission. Length of hospital stay (LOS) and in-hospital mortality were considered outcomes of hospitalization. Multivariate analyses were performed to detect associations between premorbid TMD consumption and nutritional status and outcomes.

RESULTS

The mean age of the subjects was 75.9±7.0 years, including 58% males. Overall, 110 (3.1%) patients consuming a premorbid TMD were identified. They were older (p<0.001), had poor nutritional status (lower MNA-SF score [p<0.001] and GNRI value [p<0.001], higher MUST score [p<0.001], and more prevalent ESPEN-defined malnutrition [61.8% vs. 14.0%, p<0.001] than did patients without a TMD. The mortality rate and LOS of patients with TMD was higher (7.3% vs. 2.9%, p=0.017) and longer (19 days vs. 8 days, p<0.001) than those without TMD. Multivariate analyses showed that TMD consumption was independently associated with poor nutritional status and prolonged LOS after adjusting confounders.

CONCLUSION

Daily consumption of a TMD during the premorbid period affects nutritional status at the time of hospitalization and outcomes. Further studies are necessary to investigate whether nutritional intervention can improve outcomes for people on a TMD.

Novel microguidewire-assist (MGA) manoeuver for coil embolisation of an unruptured middle cerebral artery aneurysm

We describe here a novel yet very simple technique, called microguidewire-assist (MGA) manoeuvre, for coil embolisation of unruptured intracranial aneurysms. A 79-year-old woman with a small, broad-necked middle cerebral artery (MCA) bifurcation aneurysm that incorporated the orifice of the acute-angled M2 superior trunk underwent coil embolisation. Since the balloon assist technique was not feasible, we inserted and retained only the microguidewire through M1 to the M2 superior trunk; subsequently, with appropriate use of the microguidewire, coil embolisation was completed. The MGA manoeuvre resulted in slight vessel straightening and subsequent changes in the angulation of the aneurysmal neck, with which stable placement of the platinum coil was successfully accomplished. For coil embolisation of small, broad-necked MCA aneurysms that partially straddle the M2 trunk, this manoeuvre might provide an effective therapeutic alternative if other techniques are not feasible.

Basilar Artery Occlusion with "Seizures" as a Presenting Symptom: Three Cases Treated Using Mechanical Thrombectomy

BACKGROUND

Basilar artery occlusion (BAO) is a rare, potentially fatal cause of ischemic stroke. It is often challenging to diagnose, especially when the presenting symptom is "seizures". We present 3 cases of patients with BAO presenting with seizures.

CASE DESCRIPTION

The first patient was a 53-year-old man with clonic convulsions. On angiography, BAO was detected and mechanical thrombectomy (MT) was performed. The modified Rankin Scale score at 3 months after treatment was 1. The second patient was a 64-year-old man with generalized convulsions. He was diagnosed with BAO and vertebral artery dissection and was treated with MT, percutaneous transluminal angioplasty, and stenting. The modified Rankin Scale score at 3 months after treatment was 3. The third patient was a 77-year-old man with tonic convulsions. He was diagnosed with BAO and treated with MT. However, he did not survive.

CONCLUSIONS

BAO is devastating; however, it is a treatable disease. Our report suggests that BAO should be suspected in patients presenting with initial convulsive seizures.

A case of delayed distal coil migration after coil embolization of an unruptured distal azygos anterior cerebral artery aneurysm: A case report and literature review

Intraprocedural coil migration during endovascular treatment for an aneurysm that might carry serious ischemic complications is well known. On the other hand, delayed coil migration after endovascular treatment for an aneurysm is very rare. A 77-year-old woman was incidentally diagnosed with unruptured aneurysm associated with distal azygos anterior cerebral artery (ACA). The aneurysm was located at the distal bifurcation of the azygos ACA and was wide necked (approximately 7 mm in diameter). Endovascular coil embolization was selected and the aneurysm was occluded successfully, but 29 days after endovascular therapy, follow-up computed tomography (CT) and magnetic resonance (MR) angiography revealed distal coil migration in the peripheral portion of the ACA. In addition, CT on day 57 after therapy revealed the migrated coil had moved more distally. Fortunately, in the course of these events, the patient remained asymptomatic. To the best of our knowledge, this represents the first case of delayed distal coil migration associated with relatively rare azygos ACA aneurysm, and also the first report confirming more distal coil movement over time. In the future, a large number of patients could develop this complication as more aneurysms are aggressively treated with endovascular treatment. Knowledge regarding the possibility of delayed coil migration is thus important.

A surge of light at the birth of a supernova

It is difficult to establish the properties of massive stars that explode as supernovae. The electromagnetic emission during the first minutes to hours after the emergence of the shock from the stellar surface conveys important information about the final evolution and structure of the exploding star. However, the unpredictable nature of supernova events hinders the detection of this brief initial phase. Here we report the serendipitous discovery of a newly born, normal type IIb supernova (SN 2016gkg), which reveals a rapid brightening at optical wavelengths of about 40 magnitudes per day. The very frequent sampling of the observations allowed us to study in detail the outermost structure of the progenitor of the supernova and the physics of the emergence of the shock. We develop hydrodynamical models of the explosion that naturally account for the complete evolution of the supernova over distinct phases regulated by different physical processes. This result suggests that it is appropriate to decouple the treatment of the shock propagation from the unknown mechanism that triggers the explosion.

Abstract WP12: Mechanical Thrombectomy for Basilar Artery Occlusion

Background and Purpose: Basilar artery occlusion (BAO) is an infrequent cause of stroke, accounting for 1.1% of acute ischemic stroke cases. The natural history of patients with BAO is devastating, with morbidity rates of up to 80%. No previous randomized controlled studies on the efficacy of recanalization therapy have been reported.

Methods: In the present single-center study, consecutive BAO patients were treated with mechanical thrombectomy (MT) using the stent retriever and the Penumbra system. Computed tomography perfusion was used for patient evaluation. Clinical outcomes were correlated with demographic, clinical, and radiographic findings.

Results: Between October 2011 and March 2017, MT was performed in 37 patients with BAO (mean age 70.1±10.9). Mean baseline National Institutes of Health Stroke Scale was 23±11. Recanalization rate (≧thrombolysis in cerebral infarction 2b) was 100%. Mean onset to recanalization time (OTR) was 226.3±117.8minutes. Favorable outcome at 90 days (modified Rankin scale≦2) was 60.6%. Mortality rate at 90 days was 10.8%. In an univariate analysis, IV rt-PA use, and OTR were significantly associated with favorable outcomes. In a multivariate logistic regression model, IV rt-PA use and lower NIHSS score were significantly related to favorable outcomes.

Conclusions: Multimodal endovascular therapy using the Penumbra system and/or stent retriever demonstrated high recanalization rates and improved outcomes in BAO. Both devices were feasible and effective in the treatment of BAO. An approach combining MT with IV thrombolysis provided better recanalization rates and improved clinical outcomes.

[Five Cases of Neuroendovascular Treatment Using the Goose Neck Snare for Inducing and Holding the Guiding Catheter]

The stabilization of a guiding catheter is a very important factor for successful endovascular treatment. However, it is sometimes difficult to obtain sufficient stabilization because of the tortuosity of the approach route. A Goose Neck Snare is useful for the retrieval of intravascular foreign bodies and can be used to hold the guiding catheter. We describe five cases of endovascular treatment performed while using the Goose Neck Snare via the brachial artery to hold the guiding catheter. We discuss the utility of this strategy.

Increased metabolite production by deletion of an HDA1-type histone deacetylase in the phytopathogenic fungi, Magnaporthe oryzae (Pyricularia oryzae) and Fusarium asiaticum

Histone deacetylases (HDACs) play an important role in the regulation of chromatin structure and gene expression. We found that dark pigmentation of Magnaporthe oryzae (anamorph Pyricularia oryzae) ΔMohda1, a mutant strain in which an orthologue of the yeast HDA1 was disrupted by double cross-over homologous recombination, was significantly stimulated in liquid culture. Analysis of metabolites in a ΔMohda1 mutant culture revealed that the accumulation of shunt products of the 1,8-dihydroxynaphthalene melanin and ergosterol pathways were significantly enhanced compared to the wild-type strain. Northern blot analysis of the ΔMohda1 mutant revealed transcriptional activation of three melanin genes that are dispersed throughout the genome of M. oryzae. The effect of deletion of the yeast HDA1 orthologue was also observed in Fusarium asiaticum from the Fusarium graminearum species complex; the HDF2 deletion mutant produced increased levels of nivalenol-type trichothecenes. These results suggest that histone modification via HDA1-type HDAC regulates the production of natural products in filamentous fungi.

SIGNIFICANCE AND IMPACT OF THE STUDY

Natural products of fungi have significant impacts on human welfare, in both detrimental and beneficial ways. Although HDA1-type histone deacetylase is not essential for vegetative growth, deletion of the gene affects the expression of clustered secondary metabolite genes in some fungi. Here, we report that such phenomena are also observed in physically unlinked genes required for melanin biosynthesis in the rice blast fungus. In addition, production of Fusarium trichothecenes, previously reported to be unaffected by HDA1 deletion, was significantly upregulated in another Fusarium species. Thus, the HDA1-inactivation strategy may be regarded as a general approach for overproduction and/or discovery of fungal metabolites.

A case with coil embolization for ruptured aneurysm associated with fenestration of the posterior inferior cerebellar artery

An 87-year-old man hospitalized for subarachnoid hemorrhage showed a ruptured aneurysm arising from fenestration of the posterior inferior cerebellar artery. Endovascular treatment was selected and the aneurysm and superior limb were embolized completely using three coils. Fenestration of the posterior cerebellar artery is exceedingly rare. In addition, we present a first case of aneurysm as fenestration of the posterior inferior cerebellar artery that was definitively identified as a cause of bleeding.