A novel predictor of ischemic complications in the treatment of ruptured middle cerebral artery aneurysms: Neck-branching angle

Objective

The risk factors of procedural cerebral ischemia (CI) in ruptured middle cerebral artery (MCA) aneurysms are unclear. This study proposed the neck-branching angle (NBA), a simple quantitative indicator of the aneurysm neck and branch vessels, and analyzed its usefulness as a predictor of procedural CI in ruptured MCA aneurysms.

Methods

We retrospectively analyzed 128 patients with ruptured saccular MCA aneurysms who underwent surgical or endovascular treatment between January 2014 and June 2021. We defined the NBA as the angle formed by the MCA aneurysm neck and M2 superior or inferior branch vessel line. The superior and inferior NBA were measured on admission via three-dimensional computed tomography angiography on admission. We divided the patients into clipping (106 patients) and coiling (22 patients) groups according to the treatment. Risk factors associated with procedural CI were analyzed in each group.

Results

Both groups showed that an enlarged superior NBA was a significant risk factor for procedural CI (clipping, P < 0.0005; coiling group, P = 0.007). The receiver operating characteristic curve showed the closed thresholds of the superior NBA with procedural CI in both groups (clipping group, 128.5°, sensitivity and specificity of 0.667 and 0.848, respectively; coiling group, 130.9°, sensitivity and specificity of 1 and 0.889, respectively).

Conclusion

The NBA can estimate the procedural risk of ruptured MCA aneurysms. In addition, an enlarged superior NBA is a risk factor for procedural CI in both clipping and coiling techniques.

Thromboelastography 6s for assessment of platelet function during coil embolization of unruptured intracranial aneurysms

OBJECTIVES

Methods for assessing platelet function in patients with neurovascular disease remain controversial and poorly studied. This study aimed to assess associations between thromboelastography 6s (TEG6s) measurements and postoperative ischemic complications in patients with unruptured intracranial aneurysms (UIAs) treated by coil embolization.

METHODS

Eighty-four patients with UIAs taking a combined aspirin and clopidogrel protocol were retrospectively reviewed from January 2021 to May 2022. Blood samples were obtained for TEG6s to assess platelet function on the day of coil embolization. To identify acute ischemic complications, diffusion-weighted imaging (DWI) was performed within 24 h after coil embolization. Multivariate logistic regression analysis was conducted to identify potential risk factors for postoperative positive DWI (DWI (+)) lesions.

RESULTS

Forty-three of the 84 patients (51%) with DWI (+) lesions were identified. Compared with patients without DWI (+) lesions, Adenosine diphosphate (ADP)-induced platelet-fibrin clot strength (MA_ADP) was significantly higher (53.6 mm [Interquartile range (IQR): 48.3-58.3 mm] vs 46.7 mm [IQR: 36.8-52.2 mm]; p=0.001) and ADP inhibition rate (ADP%) was significantly lower (19% [IQR: 11-31%] vs 31% [IQR: 21-44%]; p=0.001) in DWI (+) patients. Multivariate analysis identified MA_ADP, ADP%, and procedure time as significant independent predictors of subsequent DWI (+) lesions (odds ratios: 1.07, 0.96, and 1.02, respectively). Based on receiver operating characteristic curve analysis, MA_ADP >50.9 mm and ADP% <28.8% were associated with postoperative DWI (+) lesions in patients undergoing coil embolization for UIAs.

CONCLUSIONS

MA_ADP and ADP% as assessed by TEG6s can offer reliable parameters to predict postoperative ischemic complications after coil embolization of UIAs. Lower MA_ADP values and higher ADP% may decrease the risk of postoperative ischemic complications.

Complications and risk factors after digital subtraction angiography: 1-year single-center study

OBJECTIVE

Digital subtraction angiography (DSA) is an imaging technique used to diagnose and confirm abnormal lesions of cerebral blood vessels in various situations. Several complications such as cerebral infarction, contrast-induced allergy, and angio-site hematoma or infection can occur after DSA. We investigated complication rates and risk factors related to DSA.

METHODS

All patients who underwent DSA at Incheon St. Mary's Hospital from January to December 2021 were included. Those who underwent emergency DSA due to stroke or who underwent endovascular surgery within 1 week after DSA were excluded. Complications that occurred within 1 week after DSA were included in the study and was classified into three categories (neurologic complications, contrast-induced allergy, and wound complications).

RESULTS

The mean age was 57.7±13.2 years old and the female was dominant at 63.9%. The overall complication rate was 5% (n=20/407). Regarding neurologic complications, the presence of malignancy (p<0.01), and a longer procedure time (>15 minutes, p=0.04) were statistically significant factors. Contrast-induced allergy did not show any statistically significant difference in any parameter. The wound complication rate was higher in men (p=0.02), trans-femoral approach (p=0.02), frequent alcohol drinkers (p=0.04), those taking anticoagulants (p=0.03), and longer procedure time (>15 minutes, p<0.01).

CONCLUSIONS

DSA is an invasive diagnostic modality and can cause several complications. Patients with cancer should be more careful about the occurrence of cerebral infarction, and men taking anticoagulants or drinking frequently should be more careful about the occurrence of angio-site hematomas.

Symptomatic ischemic complications following endovascular treatment of vertebral artery dissecting aneurysms

PURPOSE

The aim of this study is to investigate the clinical and radiological features related to the symptomatic ischemic complications of vertebral artery dissecting aneurysm (VADA) following endovascular treatment (EVT).

METHODS

The clinical and radiological features of 127 VADAs, which were treated in a single tertiary institute between September 2008 and December 2020, were retrospectively reviewed. We defined a thrombosed aneurysm as being one which the thrombus was in the aneurysm in magnetic resonance imaging (MRI). Symptomatic ischemic complication was defined as a case in which acute infarction was confirmed on diffusion weighted image after EVT with associated clinical symptoms. Univariate and multivariate analyses were executed to demonstrate the associations between symptomatic ischemic complication and characteristics of VADA.

RESULTS

The rate of symptomatic ischemic complication was 13.4% (17 of 127). The thrombosed aneurysms were observed in 24.4% (31 of 127) and posterior inferior cerebellar artery (PICA) involvement was shown in 38.6% (49 of 127). Multivariate logistic regression analysis demonstrated that thrombosed aneurysms (odds ratio [OR] = 8.54, 95% confidence interval [CI] 1.98-36.87, p = 0.004) and PICA involvement (OR = 4.26, 95% CI 1.03-17.68, p = 0.046) were significantly associated with symptomatic ischemic complications following EVT.

CONCLUSION

This study showed that the VADAs with intra-aneurysmal thrombose and PICA involvement may be independent risk factors for symptomatic ischemic complications following EVT. Therefore, when the thrombosed VADAs with PICA involvement are observed, practitioners may consider close postoperative monitoring for early detection of ischemic complications.

Recurrent pyogenic liver abscess after pancreatoduodenectomy caused by common hepatic artery injury: A case report

BACKGROUND

Pancreaticoduodenectomy (PD) has been increasingly performed as a safe treatment option for periampullary malignant and benign disorders. However, the operation may result in significant postoperative complications. Here, we present a case that recurrent pyogenic liver abscess after PD is caused by common hepatic artery injury in atypical celiac axis anatomy.

CASE SUMMARY

A 56-year-old man with a 1-d history of fever and shivering was diagnosed with hepatic abscess. One year and five months ago, he underwent PD at a local hospital to treat chronic pancreatitis. After the operation, the patient had recurrent intrahepatic abscesses for 4 times, and the symptoms were relieved after percutaneous transhepatic cholangial drainage combining with anti-inflammatory therapy in the local hospital. Further examination showed that the recurrent liver abscess after PD was caused by common hepatic artery injury due to abnormal abdominal vascular anatomy. The patient underwent percutaneous drainage but continued to have recurrent episodes. His condition was eventually cured by right hepatectomy. In this case, preoperative examination of the patient’s anatomical variations with computed tomography would have played a pivotal role in avoiding arterial injuries.

CONCLUSION

A careful computed tomography analysis should be considered mandatory not only to define the operability (with radical intent) of PD candidates but also to identify atypical arterial patterns and plan the optimal surgical strategy.

Diagnostic impact of monitoring transcranial motor-evoked potentials to prevent ischemic complications during endovascular treatment for intracranial aneurysms

The present study aimed to determine the incidence of intraprocedural motor-evoked potential (MEP) changes and to correlate them with intraprocedural ischemic complications and postprocedural neurological deficits in patients after endovascular intracranial aneurysm treatment. This study analyzed data from 164 consecutive patients who underwent endovascular coil embolization to treat intracranial aneurysms under transcranial MEP monitoring. We analyzed associations between significant changes in MEP defined as > 50% decrease in amplitude, and intraprocedural complications as well as postoperative neurological deficits. Factors associated with postprocedural neurological deficits were also assessed. The treated aneurysms were predominantly located in the anterior circulation (71%). Fourteen (9%) were located at perforators or branches that supplied the pyramidal tract. Intraprocedural complications developed in eight (5%) patients, and four of eight (50%) patients occurred postprocedural neurological deficits. Significant intraprocedural MEP changes occurred during seven of eight endovascular procedures associated with intraprocedural complications and salvage procedures were performed immediately. Among these changes, four transient MEP changes, recovered within 10 min, were not associated with postprocedural neurological deficits, whereas three permanent MEP changes were associated with postprocedural neurological deficits and mRS ≥ 1 at discharge. Aneurysms located at perforators/branches supplying the pyramidal tract, and permanent intraprocedural MEP changes were associated with postprocedural neurological deficits. We conclude that intraprocedural transcranial MEP monitoring can reliably identify ischemic changes and can initiate prompt salvage procedures during endovascular aneurysm treatment.

Effect of high-dose strong statin for preventing periprocedural ischemic complications of carotid artery stenting

Statin therapy has been shown to induce carotid atherosclerotic plaque regression and reduce the periprocedural ischemic complications of carotid artery stenting (CAS). This study assessed the safety and usefulness of pretreatment using a high-dose strong statin (HDSS) to reduce the periprocedural ischemic complications of CAS. We analyzed 117 carotid lesions treated by CAS that were evaluated with magnetic resonance imaging (MRI) within 48 h after the procedure. For 67 lesions, an HDSS (rosuvastatin 20 mg or atorvastatin 40 mg daily) were prescribed from at least 14 days before CAS to at least 14 days after procedure (HDSS group). Clinical and angiographic data, as well as in-hospital outcomes, of the HDSS group were retrospectively compared with 50 lesions with conventional treatment without an HDSS (non-HDSS group). There were no significant differences in the baseline clinical and procedural characteristics between the two groups. There was no side effect related to the HDSS. Stroke rates were similar between the two groups (3.0% in HDSS group vs 8.0% in non-HDSS group, p = 0.22). All were minor strokes. Compared to the non-HDSS group, the HDSS group had a lower frequency of new lesions on diffusion-weighted imaging (DWI) with MRI (25.4% vs 44.0%, p = 0.0345). New ipsilateral DWI-positive rate in the HDSS group was significantly lower than in the non-HDSS group (16.4% vs 34.0%, p = 0.0275). Nonipsilateral (contralateral or posterior circulation) DWI-positive rates were similar between the two groups (13.4% vs 20.0%, p = 0.34). Pretreatment with an HDSS might reduce the periprocedural ischemic complications of CAS.

Transient Cerebral Vasospasm After Carotid Artery Stenting: A Case Report and Literature Review

BACKGROUND

Cerebral embolism after carotid artery stenting (CAS) is a well-known complication, but cerebral ischemia owing to cerebral vasospasm after CAS is rare and has seldom been reported. We describe a patient with transient ischemic complications owing to reversible cerebral vasospasm of the middle cerebral artery after CAS.

CASE DESCRIPTION

A 74-year-old man presented with right hemiparesis caused by acutely scattered brain infarction in the left cerebral hemisphere. Magnetic resonance angiography showed severe stenosis of the left cervical internal carotid artery origin. CAS under a distal filter protection was performed without any intraprocedural complications, but 12 hours later, the patient had aphasia and Gerstmann syndrome. Urgent magnetic resonance imaging revealed no evidence of an intracranial hemorrhage or new cerebral infarction. However, magnetic resonance angiography showed diffuse vasospasm of the left middle cerebral artery. His symptoms and imaging findings improved gradually with conservative treatment. The patient was discharged without new neurologic deficit or recurrent attack 3 weeks after CAS.

CONCLUSIONS

In a patient with delayed neurologic symptoms after CAS, the possibility of cerebral vasospasm should be kept in mind to select appropriate treatment.

Intraoperative neuromonitoring during microsurgical clipping for unruptured anterior choroidal artery aneurysm

OBJECTIVE

To investigate the safety and unexpected finding of the intraoperative neuromonitoring (IONM) including somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) during microsurgical clipping of an unruptured anterior choroidal artery (AChA) aneurysm.

PATIENTS AND METHODS

From January 2011 to March 2018, the neurophysiological, clinical, and radiological data of 115 patients who underwent microsurgical clipping for an unruptured AChA aneurysm under IONM were retrospectively analyzed. The incidence of ischemic complications after microsurgical clipping of unruptured AChA aneurysms as well as the false-negative rate, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of IONM during surgery were calculated.

RESULTS

Ischemic complications after the microsurgical clipping of an AChA aneurysm under IONM occurred in 7 of 115 patients (6.08%). Among them, 3 were symptomatic (2.6%). The false-negative rate of IONM for ischemic complications was 6.08% (7 patients). High specificity; 100% (95% confidence interval [95% CI] = 0.972-1.000), PPVs; 100% (95% CI = 0.055-1.000), and NPVs; 93% (95% CI = 0.945-0.973) with low sensitivity; 11.1% (95% CI = 0.006-0.111) were calculated.

CONCLUSIONS

IONM including transcranial MEP during microsurgical clipping of unruptured AChA aneurysm might have limited usefulness. Therefore, other MEP monitoring using direct cortical stimulation or modified transcranial methodology should be considered to compensate for it.

A case report: Feasibility of a near infrared ray vision system (Photo dynamic eye®) for the postoperative ischemic complication of gallbladder carcinoma

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Radical resection with or without preserving extra-hepatic bile duct has shown similar prognoses for gallbladder carcinoma.

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In the case of ischemic biliary complications of gallbladder carcinoma, whether to preserve the extrahepatic bile duct is a critical issue.

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Authentic indocyanine green near-infrared imaging is feasible for the estimation of the correct blood flow in postoperative ischemic biliary complications.

Introduction

Radical resection with or without preserving extra-hepatic bile duct has shown similar prognoses for gallbladder carcinoma (GB ca), although aggressive resection is essential. In preserving bile duct, ischemic complications are serious, life-threatening serious problems. Correct evaluation of the blood flow to the biliary tract is crucial.

Case presentation

A case of gallbladder ca in a 62-year-old man was reported. The patient was diagnosed with stage Ⅱ GB ca (T2, N0, M0) by ultrasonography, computed tomography, magnetic resonance imaging, and endoscopic ultrasonography. Cholecystectomy and intraoperative frozen section examination were planned. After recognition of invasion to subserosa and negative cystic duct margin, radical dissection of the lymph nodes in the hepatoduodenal ligament with preserving biliary tract was performed. Three days after the operation, biliary peritonitis was revealed. Emergency laparotomy showed ischemic bile leakage. Proper blood flow of the biliary system was realized by a near-infrared ray vision system (Photo Dynamic Eye®: HAMAMATSU Photonics) using indocyanine green. Primary suture of the extra-hepatic biliary duct and T-tube drainage were selected. No stricture of the bile system nor recurrence was recognized for two years after surgery.

Discussion

In the case of ischemic biliary complications, whether to preserve the extrahepatic bile duct is a critical issue for the surgeons. In this case study, the feasibility of authentic indocyanine green near-infrared imaging was shown for postoperative ischemic biliary situations.

Conclusions

Authentic indocyanine green near-infrared imaging was feasible for the estimation of the blood flow to the postoperative ischemic biliary complication.

Unpredictable postoperative global cerebral infarction in the patient of williams syndrome accompanying moyamoya disease

We report a rare case of Williams syndrome accompanying moyamoya disease in whom postoperative global cerebral infarction occurred unpredictably. Williams syndrome is an uncommon hereditary disorder associated with the connective tissue abnormalities and cardiovascular disease. To our knowledge, our case report is the second case of Williams syndrome accompanying moyamoya disease. A 9-year-old boy was presented with right hemiparesis after second operation for coarctation of aorta. He was diagnosed as having Williams syndrome at the age of 1 year. Brain MRI showed left cerebral cortical infarction, and angiography showed severe stenosis of bilateral internal carotid arteries and moyamoya vessels. To reduce the risk of furthermore cerebral infarction, we performed indirect anastomosis successfully. Postoperatively, the patient recovered well, but at postoperative third day, without any unusual predictive abnormal findings the patient's pupils were suddenly dilated. Brain CT showed the global cerebral infarction. Despite of vigorous treatment, the patient was not recovered and fell in brain death one week later. We suggest that in this kind of labile patient with Williams syndrome accompanying moyamoya disease, postoperative sedation should be done with more thorough strict patient monitoring than usual moyamoya patients. Also, we should decide the revascularization surgery more cautiously than usual moyamoya disease. The possibility of unpredictable postoperative ischemic complication should be kept in mind.