Longitudinal changes in the ganglion cell complex thickness in acute central serous chorioretinopathy using spectral-domain optical coherence tomography

In this retrospective longitudinal cohort study, we investigated the temporal changes in the peripapillary retinal nerve fiber layer (pRNFL) and inner retinal thickness in patients with acute central serous chorioretinopathy (CSC) using spectral-domain optical coherence tomography (SD-OCT). We followed up with these patients for 6 months, and during this period, the thickness of the pRNFL and the ganglion cell complex (GCC) in CSC patients were compared with the eyes of normal healthy individuals. The study also examined the correlation between the pRNFL thickness, GCC thickness, and visual acuity. The research sample consisted of 67 patients (43 male and 24 female) with an average age of 49.72 ± 9.87 years. The initial findings showed no significant differences in the pRNFL and GCC thickness between the study and fellow eye, study and normal healthy eyes, and fellow and normal healthy eyes. There was no significant difference in the pRNFL and GCC thickness when comparing the study eye with the fellow eye for 6 months. In the study eye, no significant difference was observed when comparing the initial GCC and pRNFL thickness with those at 1, 3, and 6 months. Visual acuity improved significantly from 0.18 ± 0.23 logMAR to 0.04 ± 0.06 logMAR (p < 0.001). The GCC and pRNFL thickness did not significantly affect visual acuity. In conclusion, acute CSC patients did not show significant changes in the pRNFL and inner retinal thickness, suggesting that the GCC and pRNFL do not substantially influence the short-term visual prognosis in these patients.

Long-Term Changes in Retinal Nerve Fiber Layer Thickness after Vitrectomy for Epiretinal Membrane Using Optical Coherence Tomography Images

This study investigated the long-term effects of epiretinal membrane (ERM) surgery on peripapillary retinal nerve fiber layer (RNFL) thickness using optical coherence tomography (OCT) images. We included 30 patients with idiopathic ERM who underwent a vitrectomy for ERM removal with internal limiting membrane peeling. The patients were followed up for 5 years after surgery, and their medical records were reviewed for best-corrected visual acuity (BCVA) and OCT parameters. The study population comprised 24 females (80.0%), and the mean age was 65.4 ± 7.2 years. The baseline BCVA significantly improved from 0.28 ± 0.24 to 0.12 ± 0.09 logMAR (p < 0.001) 1 year after surgery and continued to improve for 5 years after surgery. The peripapillary RNFL thickness initially increased after surgery and then gradually decreased. The peripapillary RNFL thicknesses of the global and temporal sectors showed significant reductions 2 years after surgery, whereas those of the nasal sectors did not significantly change. The peripapillary RNFL thickness was thinner in the global and temporal areas of the operated eyes than in those of the fellow eyes 4 and 5 years after surgery. In conclusion, peripapillary RNFL thicknesses decreased in the global and temporal areas after ERM surgery, whereas peripapillary RNFL thicknesses in the nasal sectors did not change significantly during the long-term follow-up.

Neovascular Glaucoma Associated with Chronic Rhegmatogenous Retinal Detachment

PURPOSE

To demonstrate the clinical features and natural course of chronic retinal detachment-associated neovascular glaucoma.

METHODS

Ten patients, diagnosed with chronic retinal detachment-associated neovascular glaucoma during 2007-2016 were retrospectively investigated. Besides chronic retinal detachment, no patients had any neovascular glaucoma-predisposing conditions, such as carotid artery disease. Retinal perfusion status was evaluated from the fundus fluorescein angiography images.

RESULTS

The mean age of patients was 57.5 years (range, 22-78 years). Complete retinal reattachment was achieved in three eyes, while partial or total chronic retinal detachment persisted in seven eyes. Wide-angle fundus fluorescein angiography revealed peripheral retinal capillary obstruction and severe nonperfusion. Neovascular glaucoma developed 213.4 months (range, 17-634 months) after retinal detachment. Three eyes received Ahmed valve implantation, while five eyes received intravitreal bevacizumab injection. Intraocular pressure was controlled in 10 eyes. Two eyes developed phthisis bulbi during follow-up.

CONCLUSIONS

In eyes with a chronic retinal detachment history, iris neovascularization and neovascular glaucoma can develop due to retinal capillary obstruction and chronic retinal ischemia, even after achieving retinal reattachment. We suggest regular follow-up examinations for patients with chronic retinal detachment, particularly for eyes with retinal nonperfusion, as detected on fundus fluorescein angiography.

LONG-TERM ANALYSIS OF INTRASCLERAL FIXATION OF INTRAOCULAR LENS: Trocar-Cannula-Based Sutureless Intrascleral Fixation Versus Sutured Scleral Fixation

PURPOSE

To compare the long-term outcomes of sutureless intrascleral fixation of the intraocular lens versus sutured scleral fixation.

METHODS

The authors retrospectively analyzed the medical records of patients who underwent intrascleral fixation of the intraocular lens using two different techniques: trocar-cannula-based sutureless fixation and sutured scleral fixation. Clinical outcomes were compared before and 1-, 3-, 6-, and 12-month follow-ups after the operation.

RESULTS

A total of 51 patients were followed over a 12-month period after the operation, including 28 eyes in the sutureless group and 23 eyes in the sutured group. Best-corrected visual acuity and spherical equivalent values reached targeted values faster in the sutureless scleral fixation of the intraocular lens. However, no significant difference was observed between the two groups. For intraocular lens capture, there was a statistically significant difference observed in the incidence of postoperative complications, which was demonstrated by one eye in the sutureless group and seven in the sutured group ( P = 0.009). To exclude the effect of corneal astigmatism, surgically induced astigmatism was calculated based on the astigmatism value 1 year after surgery. It was found that the sutureless technique significantly reduced the occurrence of astigmatism (2.43 ± 1.42 vs. 1.65 ± 0.94, P = 0.031).

CONCLUSION

In a 1-year follow-up period, the trocar-cannula-based sutureless technique was reliable and effective. Sutureless fixation was associated with fewer postoperative complications and lower surgically induced astigmatism values than those with sutured fixation.

A deep learning-based framework for retinal fundus image enhancement

PROBLEM

Low-quality fundus images with complex degredation can cause costly re-examinations of patients or inaccurate clinical diagnosis.

AIM

This study aims to create an automatic fundus macular image enhancement framework to improve low-quality fundus images and remove complex image degradation.

METHOD

We propose a new deep learning-based model that automatically enhances low-quality retinal fundus images that suffer from complex degradation. We collected a dataset, comprising 1068 pairs of high-quality (HQ) and low-quality (LQ) fundus images from the Kangbuk Samsung Hospital's health screening program and ophthalmology department from 2017 to 2019. Then, we used these dataset to develop data augmentation methods to simulate major aspects of retinal image degradation and to propose a customized convolutional neural network (CNN) architecture to enhance LQ images, depending on the nature of the degradation. Peak signal-to-noise ratio (PSNR), structural similarity index measure (SSIM), r-value (linear index of fuzziness), and proportion of ungradable fundus photographs before and after the enhancement process are calculated to assess the performance of proposed model. A comparative evaluation is conducted on an external database and four different open-source databases.

RESULTS

The results of the evaluation on the external test dataset showed an significant increase in PSNR and SSIM compared with the original LQ images. Moreover, PSNR and SSIM increased by over 4 dB and 0.04, respectively compared with the previous state-of-the-art methods (P < 0.05). The proportion of ungradable fundus photographs decreased from 42.6% to 26.4% (P = 0.012).

CONCLUSION

Our enhancement process improves LQ fundus images that suffer from complex degradation significantly. Moreover our customized CNN achieved improved performance over the existing state-of-the-art methods. Overall, our framework can have a clinical impact on reducing re-examinations and improving the accuracy of diagnosis.

The effect of intravitreal brolucizumab on choroidal thickness in patients with neovascular age-related macular degeneration

In this study we evaluated the effect of intravitreal brolucizumab injections on choroidal thickness in patients with neovascular age-related macular degeneration (nAMD) who previously showed an incomplete response to anti-vascular endothelial growth factor treatment. A total of thirty-four eyes from 34 patients were included in this study. The patients received an average of 2.4 ± 1.1 brolucizumab injections with the mean follow-up period of 4.9 ± 2.0 months. After their first brolucizumab treatment, the central foveal thickness (CFT) and subfoveal choroidal thickness (SFCT) were significantly decreased from 431.6 ± 190.0 μm and 193.9 ± 75.1 μm to 274.6 ± 109.4 μm (P < 0.001) and 169.4 ± 71.1 μm (P < 0.001), respectively. However, there were no improvements in visual acuity. Patients were divided into three subgroups according to the number of brolucizumab treatments: one, two, and three or more injections. In all three subgroups, the CFT and SFCT were significantly reduced compared to baseline at all time points of brolucizumab injections. In conclusion, choroidal thickness was significantly reduced after intravitreal brolucizumab injections as a switching treatment in patients with nAMD.

Risk factors for myopic choroidal neovascularization-related macular atrophy after anti-VEGF treatment

Purpose

The study aimed to evaluate risk factors for macular atrophy (MA) associated with myopic choroidal neovascularization (mCNV) during long-term follow-up after intravitreal anti-vascular endothelial growth factor (VEGF) treatment in highly myopic eyes.

Methods

The medical records of patients who received intravitreal injection of anti-VEGF agents as mCNV treatment and were followed-up for more than 36 months were retrospectively reviewed. The risk factors for the development of mCNV-MA, which is the fovea-involving patchy atrophy lesion adjacent to mCNV, were investigated using the Cox proportional hazard model.

Results

A total of 82 eyes (74 patients) were included in the study. The mean age at anti-VEGF treatment was 56.3 ± 12.5 years (range, 26–77), and the mean follow-up period was 76.3 ± 33.5 months (range, 36–154). During follow-up, mCNV-MA developed in 27 eyes (32.9%), and its occurrence was estimated to be 24.5% at 3 years and 37.3% at 5 years after the first anti-VEGF treatment. Old age (hazard ratio [HR] = 1.054, 95% confidence interval [CI]: 1.018–1.091; P = 0.003) and greater CNV size at baseline (HR = 2.396, CI: 1.043–5.504; P = 0.040) were significant factors for mCNV-MA development. Eyes with a thinner subfoveal choroid were more likely to show faster enlargement of the mCNV-MA during follow-up.

Conclusions

In mCNV eyes treated with intravitreal anti-VEGF agents, older age and greater mCNV size at baseline were risk factors for the development of MA during long-term follow-up, which was associated with a poor visual prognosis.

Unilateral Cilioretinal Artery and Advanced Age-Related Macular Degeneration: A Retrospective Cross-Sectional Study

PURPOSE

To investigate the association between the presence of a cilioretinal artery (CRA) and advanced age-related macular degeneration (AMD), including the prevalence of choroidal neovascularization (CNV) and geographic atrophy (GA).

DESIGN

Retrospective cross-sectional study.

METHODS

This was a single-center study. A total of 738 patients with AMD who underwent optical coherence tomography angiography (OCTA) were included in the study. Fundus photographs were reviewed to determine the presence of the CRA. In patients with a unilateral CRA, paired tests were performed between eyes with and without the CRA to compare AMD severity and prevalence of CNV and GA. The main outcomes of interest were AMD stage and prevalence of CNV and GA. Macular vasculature, including vessel density, perfusion density, and foveal avascular zone, were examined using OCTA.

RESULTS

A total of 174 eyes from 87 patients with a unilateral CRA were examined. A total of 27.8% and 8.1% of patients had a CRA in 1 eye and both eyes, respectively. Eyes with a CRA showed lower AMD stage (4-step AREDS category; P = .037) and a lower prevalence of CNV (23.0% vs 41.4%; P = .024) than those without a CRA. The prevalence of GA and macular vessel density, perfusion density, and foveal avascular zone measured by OCTA were similar in both groups.

CONCLUSIONS

In the eyes with a CRA, AMD stage and prevalence of CNV were lower than those in the eyes without a CRA. However, the effect of the CRA on the macular vascular system remains unclear.

Comparison of surgical outcomes after removal of epiretinal membrane associated with retinal break and idiopathic epiretinal membrane

PURPOSE

To compare the surgical outcomes of epiretinal membranes (ERMs) associated with retinal break and idiopathic ERMs.

METHODS

This retrospective study included patients with an idiopathic ERM or an ERM associated with retinal break, who were followed up for ≥ 6 months after ERM removal. The postoperative functional and anatomical outcomes were compared between the groups.

RESULTS

A total of 160 and 38 eyes (198 patients) were in the idiopathic and retinal break groups, respectively. There was no significant difference in the baseline anatomical and functional parameters between the groups. At 6 months after surgery and at the final follow-up, best-corrected visual acuity, central foveal thickness, and ectopic inner foveal layer improved significantly in both groups, but there was no significant difference between the groups. In latter 49.0% of patients, tests for metamorphopsia and aniseikonia were performed. There was a significant improvement in the scores of metamorphopsia (0.40 ± 0.38 to 0.27 ± 0.28; p < 0.001) and aniseikonia (6.07 ± 4.46 to 4.11 ± 3.52; p < 0.001) in the idiopathic group at 6 months after surgery, but not in the retinal break group. The idiopathic group had significantly greater circularity of ERM extent compared to the retinal break group (p = 0.025).

CONCLUSION

Visual and anatomical improvements after removal of ERMs associated with retinal break and idiopathic ERMs were comparable. However, metamorphopsia and aniseikonia improved only after removal of idiopathic ERMs.

Influence of postoperative ectopic inner foveal layer on visual function after removal of idiopathic epiretinal membrane

Purpose

To investigate the functional and anatomical parameters and their postoperative changes according to the ectopic inner foveal layer (EIFL) staging scheme for idiopathic epiretinal membrane (ERM).

Methods

In this prospective study, patients with idiopathic ERM underwent pars plana vitrectomy and ERM removal, and were followed-up for 6 months. The associations of EIFL with pre- and postoperative functional and anatomical parameters were analyzed.

Results

A total of 84 eyes (84 patients) were included: 39 (46.4%), 33 (39.3%), and 12 (14.3%) as EIFL stages 2, 3, and 4, respectively. At 6 months after surgery, the mean best-corrected visual acuity (BCVA) significantly improved in all EIFL stages (P ≤ 0.003); however, metamorphopsia improved only in eyes with EIFL stage 2 (P = 0.039) and 3 (P = 0.011). The aniseikonia and foveal avascular zone (FAZ) area showed no significant postoperative changes in any of the EIFL stages. Both preoperatively and during 6 months after surgery, the EIFL stage showed a significant correlation with BCVA (P ≤ 0.033), metamorphopsia (P ≤ 0.008), central macular thickness (P < 0.001), and FAZ parameters (P ≤ 0.016) at each time point, but not with aniseikonia. Significant correlations of EIFL thickness with BCVA (P = 0.028) and metamorphopsia (P = 0.006) before surgery were not persistent after surgery.

Conclusion

Both pre- and postoperatively, the staging of EIFL, rather than its thickness, is a simple and adequate surrogate marker for visual acuity and metamorphopsia in eyes with idiopathic ERM.

Initial Experience With Hand-Assisted Laparoscopic Living Donor Nephrectomy: Training and Clinical Practice as a General Surgeon

BACKGROUND

To analyze our initial results of hand-assisted laparoscopic living donor nephrectomy, executed by a skilled gastrointestinal surgeon.

METHODS

A total of 22 consecutive patients underwent the hand-assisted laparoscopic living donor nephrectomy between December 2014 and January 2017. We retrospectively analyze the patient's perioperative clinical data, which were collected prospectively.

RESULTS

The right kidney was harvested in 12 patients. The mean operative time and intraoperative blood loss was 241.0 ± 43.4 minutes (range, 140-310 min) and 293.2 ± 203.1 mL (range, 50-700 mL), respectively. The mean warm ischemic time was 288.4 ± 103.4 seconds (range, 179-610 s). Postoperative complications included chyle leakage in 2 patients who were left kidney donors and oliguria in 1 patient who was a right kidney donor. All patients recovered with conservative care, and the mean hospital stay was 7.5 ± 1.7 days. The mean creatinine level was 0.7 ± 0.2 mg/dL before surgery, 1.1 ± 0.3 mg/dL at postoperative day (POD) 1, and 1.0 ± 0.2 mg/dL after discharge. The mean glomerular filtration rate was 97.9 ± 18.2 mL/min/1.73 m² before surgery, 60.7 ± 10.4 at POD 1, and 67.3 ± 11.1 after discharge. Operation time was not associated with patient body mass index and case number. No significant differences, other than postoperative complications, were found in the perioperative data for the side of kidney donation.

CONCLUSION

A skilled surgeon with experience in laparoscopic abdominal surgery (such as gastrectomy or colectomy) might safely perform hand-assisted donor nephrectomy. However, we could not identify a clear case number to complete the learning curve.

Adjuvant Coil Assisted Glue Embolization of Vein of Galen Aneurysmal Malformation in Pediatric Patients

Purpose

Adjuvant coils may offer advantages in flow control during glue embolization of high flow vein of Galen aneurysmal malformation (VGAM) patients but involves specific issues such as feasibility, durability and coil mass effect. The purpose of this study is to assess the outcome of adjuvant coils in addition to transarterial glue embolization for treatment of these patients.

Materials and Methods

Five pediatric VGAM patients (age range; 11 weeks to 2 yrs 2 mos) with high flow fistulous angioarchitecture were treated with adjuvant coils 1) in the distal feeding artery and/or 2) in the vein of Galen followed by glue embolization of the shunt. The angiographic / clinical outcomes were assessed.

Results

Adjuvant coils were deployed in the distal feeding artery (n=3), vein of Galen pouch plus distal feeding artery (n=2). Additional transarterial glue embolization of the fistulae was successfully performed (n=4). Complete occlusion was achieved with coils in one case. Complete occlusion was achieved for all mural type cases (n=4). Residual feeders remained in a case of choroidal type of VGAM. No complications were noted related to the treatment. All patients showed normal development on follow up (range: 7.6 to 88.8 mo, mean 49.3 mo). Initial hydrocephalus improved on follow up despite coil mass effect in dilated vein of Galen.

Conclusion

Adjuvant coils for flow control with glue embolization may be a safe and effective treatment method for VGAM patients with high flow fistulous feeders.

Current Concepts in Lymphatic Malformation

A lymphatic malformation (LM) is the most common form of congenital vascular malformation (CVM). The new Hamburg classification of CVM distinguishes the truncular (T) form from the extratruncular (ET) form of LMs. Both are consequences of a developmental arrest at the different stages of lymphangiogenesis as a result of defective genes. The purpose of this review was to evaluate the current management results of both forms of LMs. A retrospective review of the clinical data of 315 patients with a diagnosis of LMs treated between September 1994 and December 2001 was performed. Lymphoscintigraphy was the most frequent diagnostic test. The patients with the ET form were treated with sclerotherapy with OK-432 and/or ethanol. Combinations of CDP (complex decongestive physiotherapy) and/or compressotherapy were used to treat all the T-form patients. In addition, surgery, either reconstructive or ablative, was offered to patients with the T form who failed to respond to the proper CDP. A multidisciplinary team performed the management of LM, and the results were evaluated every 6 months.

Among 797 patients with CVM, 315 were confirmed to have LMs, either as the T form (226) or the ET form (89). Another 66 LMs were diagnosed with hemolymphatic malformations (HLM). Most of the ET forms (89/315) were the cystic type (70/89), while the T forms included aplasia and/or an obstruction (204/226). The ET form was most frequent in the head, neck, and thorax (69/89). The T form was located most frequently to the extremities (202/226), mostly to the lower limb (180/202). Two hundred and twenty-six T forms belonged to the various clinical stages: stages I-32, II-104, III-48, IV-18, and an unclear stage-24. The ET form was treated with sclerotherapy using OK-432 (108/120) and absolute ethanol (12/120). Among the 11 patients with the multiple ET form, 7 patients underwent perioperative sclerotherapy with OK-432 and a subsequent surgical excision. The clinical response of the T form at the extremity to CDP was excellent to good in a majority of clinical stages I to II (121/136) but decreased to a good to fair degree in stages III to IV (31/66). The additional surgical therapy, either reconstructive (10/19) or ablative (9/19), provided limited success in improving CDP efficacy, owing mainly to poor compliance. The long-term outcome of the initial success through self-motivated home-maintenance care during the follow-up period of up to 48 months was totally dependent on patient compliance. OK-432 sclerotherapy to 51 ET forms has shown excellent results on 88.9% of the cystic type (40/45) and 50% (3/6) of the cavernous type (minimum follow-up for 24 months). Seventeen ET forms in 7 patients were treated with a preoperative OK-432 sclerotherapy and a subsequent surgical excision, which provided good to excellent results in 14 for a minimum of 24 months.

Primary lymphedema, which is the T form of LMs, can be managed safely by a combination of CDP with compressotherapy. Patients with good compliance can benefit from additional surgical therapy, either reconstructive or ablative. The ET form, particularly the cystic type, can be treated with various scleroagents that are preferably less toxic as the primary therapy. A surgical excision with or without perioperative sclerotherapy provides good results for patients with the localized cavernous type of the ET form. A multidisciplinary team approach is essential for the proper care of LM.

Critical role of duplex ultrasonography for the advanced management of a venous malformation

Objectives: Duplex ultrasonography was assessed for its advanced role as a contemporary guide for the safer management of venous malformation (VM) at the lower extremities through a comparison study with matching magnetic resonance imaging (MRI) and/or ascending phlebography findings.

Methods: A retrospective review of 50 patients with a VM in the lower extremities was performed using the duplex scan findings on the initial diagnosis and the subsequent follow-up assessment of the treatment response. The screening findings of deep vein thrombosis (DVT) development following ethanol sclerotherapy on 40 patients were also included. A marginal vein (lateral embryonal) compression test was also performed on 10 patients, who were candidates for a resection preoperatively, in order to assess its value in predicting the response to the subsequent resection. The duplex scan findings were compared with the available ascending phlebography results in 38 patients, and also with the MRI findings available for all 50 patients.

Results: The duplex scan on the 50 patients confirmed the existence of a normal deep vein system in the lower extremities in 43 patients as the true-positive test findings. One false-negative test finding was subsequently confirmed by an angiographic evaluation. The duplex scan also confirmed the absence of a normal deep vein system in four patients as a true-negative test. MRI subsequently confirmed two false-positive findings in one patient, and angiography confirmed two false-positive findings in another (sensitivity − 97.8%, specificity − 66.7%, positive predictive value − 95.6%, and negative predictive value − 80%). Among a total of 40 patients who received ethanol sclerotherapy, the duplex scan identified DVT in three patients, and also screened out properly in 37 patients through a total of 185 ethanol sclerotherapy sessions. The compression test predicted the surgical outcome successfully in the majority (7/8). The duplex scan appears to have comparable reliability to MRI and/or angiography for diagnosing and managing VM.

Conclusions: The duplex scan can provide the critical haemodynamic information of both the deep venous system and VM lesions quite effectively with the cost-effectiveness of a non-invasive test. In particular, the duplex scan is an excellent test for the safe management of VM of the lower extremity, including the early detection of DVT through multi-session ethanol sclerotherapy.

Glycerol-3-phosphate acyltransferase-1 upregulation by O-GlcNAcylation of Sp1 protects against hypoxia-induced mouse embryonic stem cell apoptosis via mTOR activation

Oxygen signaling is critical for stem cell regulation, and oxidative stress-induced stem cell apoptosis decreases the efficiency of stem cell therapy. Hypoxia activates O-linked β-N-acetyl glucosaminylation (O-GlcNAcylation) of stem cells, which contributes to regulation of cellular metabolism, as well as cell fate. Our study investigated the role of O-GlcNAcylation via glucosamine in the protection of hypoxia-induced apoptosis of mouse embryonic stem cells (mESCs). Hypoxia increased mESCs apoptosis in a time-dependent manner. Moreover, hypoxia also slightly increased the O-GlcNAc level. Glucosamine treatment further enhanced the O-GlcNAc level and prevented hypoxia-induced mESC apoptosis, which was suppressed by O-GlcNAc transferase inhibitors. In addition, hypoxia regulated several lipid metabolic enzymes, whereas glucosamine increased expression of glycerol-3-phosphate acyltransferase-1 (GPAT1), a lipid metabolic enzyme producing lysophosphatidic acid (LPA). In addition, glucosamine-increased O-GlcNAcylation of Sp1, which subsequently leads to Sp1 nuclear translocation and GPAT1 expression. Silencing of GPAT1 by gpat1 siRNA transfection reduced glucosamine-mediated anti-apoptosis in mESCs and reduced mammalian target of rapamycin (mTOR) phosphorylation. Indeed, LPA prevented mESCs from undergoing hypoxia-induced apoptosis and increased phosphorylation of mTOR and its substrates (S6K1 and 4EBP1). Moreover, mTOR inactivation by rapamycin (mTOR inhibitor) increased pro-apoptotic proteins expressions and mESC apoptosis. Furthermore, transplantation of non-targeting siRNA and glucosamine-treated mESCs increased cell survival and inhibited flap necrosis in mouse skin flap model. Conversely, silencing of GPAT1 expression reversed those glucosamine effects. In conclusion, enhancing O-GlcNAcylation of Sp1 by glucosamine stimulates GPAT1 expression, which leads to inhibition of hypoxia-induced mESC apoptosis via mTOR activation.

Frequency of concomitant ischemic heart disease and risk factor analysis for an early postoperative myocardial infarction after elective abdominal aortic aneurysm repair

Purpose

We aimed to see the frequency of concomitant ischemic heart disease (IHD) in Korean patients with abdominal aortic aneurysm (AAA) and to determine risk factors for an early postoperative acute myocardial infarction (PAMI) after elective open or endovascular AAA repair.

Methods

We retrospectively reviewed a database of patients who underwent elective AAA repair over the past 11 years. Patients were classified into 3 groups: control group; group I, medical IHD treatment; group II, invasive IHD treatment. Rates of PAMI and mortality at 30 days were compiled and compared between groups according to the type of AAA repair.

Results

Six hundred two elective repairs of infrarenal or juxtarenal AAAs were enrolled in this study. The patients were classified into control group (n = 398, 66.1%), group I (n = 73, 12.1%) and group II (n = 131, 21.8%). PAMI developed more frequently after open surgical repair (OSR) than after endovascular aneurysm repair (EVAR) (5.4% vs. 1.3%, P = 0.012). In OSR patients (n = 373), PAMI developed 2.1% in control group, 18.0% in group I and 7.1% in group II (P < 0.001). In EVAR group (n = 229), PAMI developed 0.6% in control group, 4.3% in group I and 2.2% in group II (P = 0.211). On the multivariable analysis of risk factors of PAMI, PAMI developed more frequently in patients with positive functional stress test.

Conclusion

The prevalence of concomitant IHD was 34% in Korean AAA patients. The risk of PAMI was significantly higher after OSR compared to EVAR and in patients with IHD compared to control group. Though we found some risk factors for PAMI, these were not applied to postoperative mortality rate.

A New Flow-Diverter (the FloWise): In-Vivo Evaluation in an Elastase-Induced Rabbit Aneurysm Model

OBJECTIVE

We aimed to evaluate the efficacy and safety of a newly developed, partially retrievable flow-diverter (the FloWise) in an elastase-induced rabbit aneurysm model.

MATERIALS AND METHODS

We developed a partially retrievable flow diverter composed of 48 strands of Nitinol and platinum wire. The FloWise is compatible with any microcatheter of 0.027-inch inner diameter, and is retrievable up to 70% deployment. The efficacy and safety of the FloWise were evaluated in the elastase-induced rabbit aneurysm model. The rate of technical success (full coverage of aneurysm neck) and assessment of aneurysm occlusion and stent patency was conducted by angiograms and histologic examinations at the 1-month, 3-month, and 6-month follow-up. The patency of small arterial branches (intercostal or lumbar arteries) covered by the FloWise were also assessed in the 5 subjects.

RESULTS

We attempted FloWise insertion in a total of 32 aneurysm models. FloWise placement was successful in 31 subjects (96.9%). Two stents (6.2%) were occluded at the 3-month follow-up, but there was no evidence of in-stent stenosis in other subjects. All stented aneurysms showed progressive occlusion: grade I (complete aneurysm occlusion) in 44.4% and grade II (aneurysm occlusion > 90%) in 55.6% at 1 month; grade I in 90% and II in 10% at 3 months; and grade I in 90% and II in 10% at 6 months. All small arterial branches covered by the FloWise remained patent.

CONCLUSION

A newly developed, partially retrievable flow-diverter seems to be a safe and effective tool of aneurysm occlusion, as evaluated in the rabbit aneurysm model.

National Priority Setting of Clinical Practice Guidelines Development for Chronic Disease Management

By November 2013, a total of 125 clinical practice guidelines (CPGs) have been developed in Korea. However, despite the high burden of diseases and the clinical importance of CPGs, most chronic diseases do not have available CPGs. Merely 83 CPGs are related to chronic diseases, and only 40 guidelines had been developed in the last 5 yr. Considering the rate of the production of new evidence in medicine and the worsening burden from chronic diseases, the need for developing CPGs for more chronic diseases is becoming increasingly pressing. Since 2011, the Korean Academy of Medical Sciences and the Korea Centers for Disease Control and Prevention have been jointly developing CPGs for chronic diseases. However, priorities have to be set and resources need to be allocated within the constraint of a limited funding. This study identifies the chronic diseases that should be prioritized for the development of CPGs in Korea. Through an objective assessment by using the analytic hierarchy process and a subjective assessment with a survey of expert opinion, high priorities were placed on ischemic heart disease, cerebrovascular diseases, Alzheimer's disease and other dementias, osteoarthritis, neck pain, chronic kidney disease, and cirrhosis of the liver.

Development of Quality Management Systems for Clinical Practice Guidelines in Korea

This study introduces the Clinical practice guidelines (CPGs) appraisal system by the Korean Academy of Medical Sciences (KAMS). Quality management policies for CPGs vary among different countries, which have their own cultures and health care systems. However, supporting developers in guideline development and appraisals using standardized tools are common practices. KAMS, an organization representing the various medical societies of Korea, has been striving to establish a quality management system for CPGs, and has established a CPGs quality management system that reflects the characteristics of the Korean healthcare environment and the needs of its users. KAMS created a foundation for the development of CPGs, set up an independent appraisal organization, enacted regulations related to the appraisals, and trained appraisers. These efforts could enhance the ability of each individual medical society to develop CPGs, to increase the quality of the CPGs, and to ultimately improve the quality of the information available to decision-makers.

Outcomes and prognostic factors after emergent carotid artery stenting for hyperacute stroke within 6 hours of symptom onset

BACKGROUND

The optimal treatment for hyperacute stroke attributable to cervical internal carotid artery (C-ICA) occlusion remains controversial.

OBJECTIVE

This study sought to evaluate clinical outcomes and prognostic factors after carotid artery stenting (CAS) in patients with hyperacute stroke within 6 hours of onset.

METHODS

Forty-seven patients with hyperacute stroke attributable to atherosclerotic C-ICA occlusion underwent emergent CAS. Forty-two patients (89.4%) had tandem intracranial artery occlusion (TIO). When patients showed remnant M1 or proximal M2 occlusions after CAS, intracranial recanalization therapy was performed by using pharmacologic thrombolysis and mechanical thrombectomy with a Solitaire stent. Clinical and radiologic data were compared between patients with favorable (modified Rankin scale, 0-2) and unfavorable outcomes. Binary logistic regression analysis was used to find independent prognostic factors.

RESULTS

Emergent CAS was successful in all but 1 patient. Seven (16.7%) of 42 patients with TIO did not need further treatment, because thrombolysis in cerebral ischemia ≥2b was achieved immediately after CAS. Of the 35 patients who underwent intracranial recanalization therapy for remnant TIO, thrombolysis in cerebral ischemia ≥2b was achieved in 71.4% (25 of 35). Twenty-six patients (55.3%) had favorable outcomes, and mortality was 6.4% at 3 months. Time from symptom onset to carotid recanalization was inversely and independently associated with a favorable outcome for all patients and for those with TIO (P < .05).

CONCLUSION

In our patient group, emergent CAS for hyperacute stroke caused by atherosclerotic C-ICA occlusion seemed to be effective and safe. Time to carotid recanalization was inversely and independently associated with a favorable outcome.

Combination of Multicatheter Plus Stent or Balloon for Treatment of Complex Aneurysms

BACKGROUND AND PURPOSE

Coiling of complex aneurysms is still difficult even with current adjuvant techniques. This study sought to evaluate the safety and effectiveness of a combination of multicatheter plus stent or balloon for the treatment of complex aneurysms.

MATERIALS AND METHODS

All complex aneurysms that underwent coiling with the combination technique were identified from prospectively maintained neurointerventional data bases. "Complex aneurysm" was defined as a wide-neck aneurysm with branch incorporation into or a deep lobulation of the sac. The clinical and angiographic outcomes were retrospectively analyzed.

RESULTS

Sixty-two complex aneurysms (12 ruptured, 50 unruptured) in 62 patients (mean age, 57 years; male/female ratio, 12:50) were treated with a combination technique by using a multicatheter plus stent (n = 42, 3 ruptured) or balloon (n = 20, 9 ruptured). Treatment-related morbidity (grade 3 hemiparesis) occurred in 1 patient (1.6%). Except for 1 patient who had treatment-related morbidity, none of the other patients with unruptured aneurysms developed new neurologic symptoms at discharge. Nine of the 12 patients with ruptured aneurysms had good outcomes (Glasgow Outcome Score, 4 or 5) at the latest follow-up (mean, 32 months; range, 6-72 months), and 1 patient died from an initial SAH. Posttreatment control angiograms revealed complete occlusion in 27, neck remnant in 34, and incomplete occlusion in 1 aneurysm. At least 1 follow-up catheter or MR angiogram was available in 80.6% (n = 50) (mean, 21 months; range, 6-65 months). There were 4 minor and 3 major recurrences (14.0%).

CONCLUSIONS

In this case series, the combination technique by using multicatheter plus stent or balloon seemed safe and effective for the treatment of complex aneurysms.

Impact of temporary opening using a stent retriever on clinical outcome in acute ischemic stroke

Background

Stent retriever has a distinct ability to restore blood flow temporarily before achieving final reperfusion. There has been a limited report regarding the clinical impact of it. We investigated if temporary opening of occluded vessels using a stent retriever before final reperfusion might improve clinical outcome in acute ischemic stroke patients who received the endovascular reperfusion treatment.

Methods

We enrolled consecutive ischemic stroke patients who had an initial occlusive lesion in the anterior circulation and achieved final reperfusion (Thrombolysis In Cerebral Infarction [TICI] ≥2) by endovascular treatment. Temporary opening was defined as the presence of ante grade flow (TICI≥2) during deployment of a stent retriever. Favorable outcome was defined as a modified Rankin scale score≤2 at 90 day.

Results

A total of 98 patients were included in the study and temporary opening was achieved in 49 (50%). Temporary opening was associated with favorable outcome (odds ratio, 7.825; 95% confidence interval, 1.592–38.461; p = 0.011) in the multivariate analysis. The probability of having a favorable outcome tended to decrease as time from onset to final reperfusion increased in patients without temporary opening. However, this trend was not evident in the patient with temporary opening. The beneficial effect of temporary opening on clinical outcome seemed to be present in patients with good collaterals but not in patients with poor collaterals.

Conclusions

Temporary opening of occluded vessel using a stent retriever may be beneficial for improving clinical outcome in acute ischemic stroke patients.

Self-Expanding Stent Placement for Anterior Circulation Intracranial Artery Dissection Presenting With Ischemic Symptoms

BACKGROUND:

The prognosis of ischemic anterior circulation intracranial dissection (AC-ICD) is poor and its optimal management is still controversial.

OBJECTIVE:

To evaluate the safety and efficacy of a self-expanding stent for ischemic AC-ICD.

METHODS:

Eight patients (mean age, 36 years) underwent self-expanding stenting for ischemic AC-ICD. Imaging findings of ischemic AC-ICD, the reason for stenting, and the clinical and angiographic outcomes were retrospectively evaluated.

RESULTS:

AC-ICD involved intracranial internal carotid artery to middle cerebral artery (MCA) in 2, intracranial internal carotid artery alone in 3, and MCA alone in 3 patients. Six AC-ICDs showed complete or near occlusions while 2 had a severe degree of stenosis. Six AC-ICDs showed an intimal flap and 3 had intramural hematomas. Six patients underwent emergent stenting for acute stroke within 6 hours (n = 2) or crescendo-type stroke within 24 hours (n = 4), while 2 patients had stenting for recurrent ischemia on dual antiplatelet and/or anticoagulation after the initial attack. The mean dissection-related stenosis improved from 93.1% to 20.3% after stenting (P &lt; .05). The mean National Institutes of Health Stroke Scale score improved from 7.5 to 1.4 (P &lt; .05). All patients had excellent or favorable outcomes at 3 months: modified Rankin Scale score, 0 in 3, 1 in 3, and 2 in 1 patient(s). No patients had subarachnoid hemorrhage or ischemic symptom recurrence during the clinical follow-up (mean, 27 months). All stented arteries were patent without significant in-stent stenosis on angiographic follow-up (range, 3–12 months).

CONCLUSION:

Self-expanding stents seem to be safe and effective for AC-ICD presenting with acute/crescendo-type stroke or recurrent ischemia despite adequate medication.

Jostent covered stent placement for emergency reconstruction of a ruptured internal carotid artery during or after transsphenoidal surgery

OBJECT

Internal carotid artery (ICA) rupture during transsphenoidal surgery (TSS) is an extremely difficult complication to treat. This study aimed to evaluate the immediate and long-term outcomes of covered stent placement for emergency reconstruction of ruptured ICAs during or after TSS.

METHODS

Seven patients underwent covered stent placement for emergency reconstruction of a ruptured ICA during or after TSS. The safety and effectiveness of covered stent placement for emergency reconstruction of ruptured ICAs were retrospectively analyzed.

RESULTS

Pretreatment angiography showed active bleeding in 6 patients (5 intraoperative and 1 postoperative) and a pseudoaneurysm in 1 patient. Of the 6 patients with active bleeding, 5 were treated with a successive operation to control active bleeding. The other patient was treated just after cardiopulmonary resuscitation due to massive nasal bleeding 20 days after revision of TSS. All active bleeding was controlled immediately after covered stent insertion in these 6 patients. One patient showed a gap between the covered stent and ICA wall without active bleeding 30 minutes after glycoprotein IIb/IIIa inhibitor administration due to in-stent thrombosis. The gap was occluded with coil embolization after completion of the temporarily suspended TSS. The seventh patient, whose ICA tear was treated with surgical suture, underwent covered stent placement for a pseudoaneurysm detected on postoperative Day 2. During a mean follow-up period of 46 months (range 12-85 months), all patients had excellent outcomes (modified Rankin Scale score of 0). All the stented ICAs were patent on vascular imaging follow-up at a mean of 34 months (range 12-85 months).

CONCLUSIONS

Covered stents appear to be a safe and effective option for emergency reconstruction of ruptured ICAs during or after TSS.

NLRP3 inflammasome activation by mitochondrial ROS in bronchial epithelial cells is required for allergic inflammation

Abnormality in mitochondria has been suggested to be associated with development of allergic airway disorders. In this study, to evaluate the relationship between mitochondrial reactive oxygen species (ROS) and NLRP3 inflammasome activation in allergic asthma, we used a newly developed mitochondrial ROS inhibitor, NecroX-5. NecroX-5 reduced the increase of mitochondrial ROS generation in airway inflammatory cells, as well as bronchial epithelial cells, NLRP3 inflammasome activation, the nuclear translocation of nuclear factor-κB, increased expression of various inflammatory mediators and pathophysiological features of allergic asthma in mice. Finally, blockade of IL-1β substantially reduced airway inflammation and hyperresponsiveness in the asthmatic mice. These findings suggest that mitochondrial ROS have a critical role in the pathogenesis of allergic airway inflammation through the modulation of NLRP3 inflammasome activation, providing a novel role of airway epithelial cells expressing NLRP3 inflammasome as an immune responder.

Incidence and risk factors for diffusion-weighted imaging (+) lesions after intracranial stenting and its relationship with symptomatic ischemic complications

BACKGROUND AND PURPOSE

Little is known about high-signal lesions in magnetic resonance diffusion-weighted imaging (DWI [+]) after stenting for intracranial atherosclerotic stenosis. This study aimed to evaluate the incidence, distribution, risk factors, and clinical implications of DWI (+) after intracranial stenting.

METHODS

A total of 123 patients (male:female=88:35, mean age, 64.1 years) with symptomatic intracranial atherosclerotic stenosis (mean stenosis, 76.1±7.7%) underwent both stenting and poststenting DWI. The incidence, distribution (embolic-alone versus stenosis-associated perforator/mixed), and risk factors of DWI (+) and its relationship with symptomatic ischemic complications (SIC, including stroke or transient ischemic attack) were retrospectively evaluated.

RESULTS

Forty-three patients (35.0%) had DWI (+). Middle cerebral artery, smaller distal parent artery, and treatment-related dissection were independent risk factors for DWI (+) (P<0.05). SIC occurred in 4 patients (3.3%), all of whom had DWI (+). Of the patients with DWI (+), neither the number nor the volume of DWI (+) differed significantly between SIC and asymptomatic patients: median number/patient, 3.5 (range, 2-11) versus 2.0 (range, 1-11) and median volume/patient, 329.8 mm(3) (range, 76-883.5 mm(3)) versus 119.5 mm(3) (range, 32.5-873.0 mm(3)). However, SIC occurred more frequently in the stenosis-associated perforator/mixed type (3/11, 27.3%) than in the embolic-alone type (1/32, 3.1%; P<0.05).

CONCLUSIONS

The incidence of DWI (+) after intracranial stenting for intracranial atherosclerotic stenosis was 35.0%. Middle cerebral artery, smaller distal parent artery, and treatment-related dissection were independent risk factors for DWI (+). SIC occurred more frequently in the stenosis-associated perforator/mixed type than in the embolic-alone type.

Treatment of multiple intracranial aneurysms with 1-stage coiling

BACKGROUND AND PURPOSE

Although multiple intracranial aneurysms are frequent, determining treatment strategy and methods for them is often complicated. The aim of this study was to evaluate the safety and effectiveness of 1-stage coiling for multiple intracranial aneurysms.

MATERIALS AND METHODS

All patients who underwent 1-stage coiling for ≥2 aneurysms were identified from a prospectively registered neurointerventional data base during 10 years. The patient characteristics and clinical and angiographic outcomes at discharge and follow-up were retrospectively evaluated.

RESULTS

One hundred sixty-seven patients (male/female ratio, 30:137; mean age, 58 years) with multiple aneurysms (418 aneurysms; mean, 2.5 aneurysms/patient) underwent attempted 1-stage coiling for ≥2 aneurysms (359 aneurysms; mean, 2.1 aneurysms/patient). In 131 patients (78.4%), all detected aneurysms were treated with coiling only. Treatment-related morbidity and mortality at discharge were 1.8% and 0.6% per patient, respectively. Of the 132 patients without subarachnoid hemorrhage, 129 (97.7%) had favorable outcomes (mRS 0-2) at discharge; of the 35 patients with SAH, 27 (77.1%) had favorable outcomes at discharge. Of the 162 patients (97%) for whom clinical follow-up was available (mean, 35.8 months), 154 patients (95.1%) had favorable outcomes. Immediate posttreatment angiography showed complete occlusion in 186 (51.8%) aneurysms, neck remnants in 134 (37.3%), sac remnants in 33 (9.2%), and failure in 6 (1.7%). Of the 262 (73.9%) aneurysms that underwent follow-up imaging (mean, 24.8 months), 244 (93.1%) showed a stable or improved state, with 12 (4.6%) minor and 6 (2.3%) major recurrences.

CONCLUSIONS

One-stage coiling of multiple aneurysms seems to be safe and effective, with low morbidity and mortality.

Prognostic value of lymphoscintigraphy in patients with gynecological cancer-related lymphedema

BACKGROUND AND OBJECTIVES

We investigated the prognostic value of qualitative lymphoscintigraphy in gynecological cancer-related lymphedema, which is a common complication after treatment.

METHODS

All 152 patients underwent (99m) Tc tin-colloid lymphoscintigraphy before complex decongestive therapy (CDT). We analyzed the uptake patterns of the inguinal lymph nodes, main lymphatic vessel and collateral lymphatic vessels, as well as dermal back flow. We compared these lymphoscintigraphic findings and other clinical variables between good and poor therapeutic responders using Pearson's Chi-squared test, Fisher's exact test and multiple logistic regression analysis.

RESULTS

Eighty-nine patients (58.6%) had a poor therapeutic response to CDT. In univariate analysis, there were significant differences between good and poor responders in clinical stage (P < 0.001), therapy compliance (P < 0.001), main lymphatic vessel uptake pattern (P < 0.01), collateral lymphatic vessel uptake pattern (P < 0.01) and severity of dermal back flow (P < 0.001). After multivariate analysis, only severity of dermal back flow (P < 0.005), clinical stage (P < 0.05) and therapy compliance (P < 0.001) were found to be independent predictors of therapeutic response.

CONCLUSIONS

Lymphoscintigraphy may be useful to predict the outcome of patients with gynecological cancer-related lymphedema undergoing CDT along with clinical stage and compliance.

The role of endovascular treatment for ruptured distal anterior cerebral artery aneurysms: comparison with microsurgical clipping

BACKGROUND AND PURPOSE

The purpose of this study was to compare clinical outcomes and treatment-related complications between coiling and clipping for ruptured distal anterior cerebral artery (DACA) aneurysms.

METHODS

Eighty-four consecutive patients (M:F = 36:48; mean 53.8 years) with ruptured DACA aneurysms were treated by either clipping (n = 46, 54.8%) or coiling (n = 38, 45.2%). The clinical outcomes and procedure-related complications were evaluated and compared between the two groups.

RESULTS

Procedure-related complications tend to occur more frequently in the clipping (n = 6, 13.0%) than coiling group (n = 1, 2.6%) (P = .121). At discharge, 51 patients (60.7%) had favorable outcomes (Glasgow outcome scale [GOS], 4 or 5). There was no significant difference between the two groups in favorable outcome (63.2% vs. 58.7%; P = .677). Hunt and Hess (HH) grade (P < .001; 95% CI, 3.354-29.609) and treatment modality (P = .044; 95% CI, 1.039-16.325) were independent risk factors for poor outcome (GOS, 1-3).

CONCLUSIONS

Coiling was more favorable to clipping in clinical outcomes and incidence of treatment-related complications for ruptured DACA aneurysms.

Quantitative analysis of vascular calcification

Vascular calcification is a prominent feature of atherosclerosis. The mineral composition and quantity within calcified arterial plaques remains unelucidated; therefore, the aim of this study was to analyze the mineral composition of such plaques. Calcified arterial plaques were obtained from patients with abdominal aortic aneurysms (AAAs) and carotid artery stenoses. Calcified aneurysmal plaques were obtained during the routine open repair of AAAs, while calcified carotid plaques were collected from patients who underwent carotid endarterectomy (CEA). Following the appropriate preparation of each sample, inductively coupled plasma atomic emission spectrometry (ICP-AES) was used to analyze the calcium and phosphate levels, while flame atomic absorption spectrometry (FAAS) was used to analyze the levels of iron and zinc. The levels of these mineral components were evaluated. In the aortic and carotid plaques, the mean calcium concentration was 9.83 and 11.94 wt.%, respectively, and the mean phosphate concentration was 4.31 and 6.08 wt.%, respectively. It was not possible to analyze the absolute concentration of iron in the carotid plaques due to the concentration being below the measurement limit. The zinc concentration was variable between samples. In conclusion, the main components of aortic and carotid plaques are calcium and phosphate. The mineral concentrations of the plaques in the present study may be used as reference values for further studies on vascular calcification. More studies are required to elucidate the correlation between the mineral components and vascular calcification.

Hypoglossal canal dural arteriovenous fistula: incidence and the relationship between symptoms and drainage pattern

Object

The purpose of this study was to evaluate the incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of hypoglossal canal dural arteriovenous fistula (HC-dAVF).

Methods

During a 16-year period, 238 patients underwent endovascular treatment for cranial dAVF at a single center. The incidence, radiographic findings, relationship between presenting symptoms for treatment and drainage pattern, and treatment outcomes of HC-dAVF were retrospectively evaluated.

Results

The incidence of HC-dAVF was 4.2% (n = 10). Initial symptoms were tinnitus with headache (n = 6), tinnitus only (n = 1), ocular symptoms (n = 1), otalgia (n = 1), and congestive myelopathy (n = 1). Presenting symptoms requiring treatment included ocular symptoms (n = 4), hypoglossal nerve palsy (n = 4), aggravation of myelopathy (n = 1), and aggravation of tinnitus with headache (n = 1). While the affected HC was widened in 4 of 10 patients, hypersignal intensity on source images was conspicuous in all 7 patients who underwent MR angiography (MRA). All ocular symptoms and congestive myelopathy were associated with predominant drainage to superior ophthalmic or perimedullary veins due to antegrade drainage restriction. All patients who underwent transvenous coil embolization (n = 8) or transarterial N-butyl cyanoacrylate (NBCA) embolization (n = 1) improved without recurrence. One patient who underwent transarterial particle embolization had a recurrence 12 months posttreatment and was retreated with transvenous embolization.

Conclusions

The incidence of HC-dAVF was 4.2% of all cranial dAVF patients who underwent endovascular treatment. Source images of MRA helped to accurately diagnose HC-dAVF. More aggressive symptoms may develop as a result of a change in the predominant drainage route due to the development of venous stenosis or obstruction over time. Transvenous coil embolization appears to be the first treatment of choice.

Repeated thrombolytic therapy in patients with recurrent acute ischemic stroke

Background and Purpose

Widespread use of thrombolytic treatments, along with improved chances of survival after an initial ischemic stroke, increases the possibility of repeated thrombolysis. There are few reports, however, regarding repeated thrombolysis in patients who have suffered acute ischemic stroke. We explored the number and outcome of patients with repeated thrombolytic therapy in the era of multimodal thrombolytic treatments.

Methods

We investigated patients with acute ischemic stroke who had received thrombolytic treatments for a period of 10 years. Number of thrombolysis was determined in each patient. Recanalization was defined as Thrombolysis in Cerebral Infarction grading ≥2a. Symptomatic hemorrhagic transformation was defined as any increase in the National Institutes of Health Stroke Scale score that could be attributed to intracerebral hemorrhage. A good outcome was defined as a modified Rankin scale score ≤2.

Results

Of the 437 patients who received thrombolytic treatments, only 7 underwent repeated thrombolysis (1.6%). The median age at the time of repeated thrombolytic therapy was 71 years old; 4 of the patients were female. All patients had 1 or more potential sources of cardiac embolism. Recanalization was achieved in all patients, in both the first and the second thrombolysis. No symptomatic intracranial hemorrhage occurred after repeated thrombolytic treatments. Five patients (71.4%) showed good outcomes at 3 months.

Conclusions

Repeated thrombolysis for recurrent acute ischemic stroke appears to be safe and feasible. Among patients who experience recurrent acute ischemic stroke, thrombolytic therapy could be considered even if the patient has had previous thrombolytic treatments.

Reconstructive Treatment of Ruptured Blood Blister–like Aneurysms With Stent and Coil

BACKGROUND:

Controversy remains about the optimal treatment for blood blister--like aneurysms (BBAs).

OBJECTIVE:

To evaluate clinical and angiographic outcomes after reconstructive treatment for BBA with stent and coil.

METHODS:

Thirty-four patients (6 men, 28 women; mean age, 47.3 years) with ruptured BBAs underwent reconstructive treatment with stent and coil. Posttreatment courses and outcomes were retrospectively evaluated.

RESULTS:

Initial treatments were ≥ 2 overlapping stents with or without coiling (n = 28) and single stent with coiling (n = 6). Three BBAs rebled on days 9, 11, and 15 after treatment, resulting in 1 death. Except for 3 patients who died early, 31 patients were followed up for 7 to 80 months (median, 32 months). One patient recovered completely but died of complications of systemic lupus erythematosus at 25 months. Of the remaining 30 patients, 25 had favorable outcomes (modified Rankin scale, 0-2) and 5 had unfavorable outcomes. Angiographic follow-up was available in the 32 BBAs. Eight (25.0%) recurred, all within 5 weeks. In the multiple stents group (n = 26), 22 BBAs showed improvement or complete healing, but 4 (15.4%, 2 rebleedings) had recurrence. In the single stent with coiling group (n = 6), 2 BBAs were stable but 4 (66.7%, 1 rebleeding) had recurrence. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence (P &lt; .05).

CONCLUSION:

Reconstructive treatment with stent and coil appears a viable option for BBAs. Single stent with coiling and Hunt and Hess grade ≥ 4 were 2 independent risk factors for recurrence. Follow-up angiography should be considered mandatory soon after treatment.

Incidence of embolism associated with carotid artery stenting: open-cell versus closed-cell stents

Object

Carotid artery stenting (CAS) can be an alternative option for carotid endarterectomy in the prevention of ischemic stroke caused by carotid artery stenosis. The purpose of this study was to evaluate the influence of stent design on the incidence of procedural and postprocedural embolism associated with CAS treatment.

Methods

Ninety-six symptomatic and asymptomatic patients, consisting of 79 males and 17 females, with moderate to severe carotid artery stenosis and a mean age of 69.0 years were treated with CAS. The stent type (48 closed-cell and 48 open-cell stents) was randomly allocated before the procedure. Imaging, procedural, and clinical outcomes were assessed and compared. The symptomatic subgroup (76 patients) was also analyzed to determine the influence of stent design on outcome.

Results

New lesions on postprocedural diffusion-weighted imaging (DWI) were significantly more frequent in the open-cell than in the closed-cell stent group (24 vs 12, respectively; p = 0.020). The 30-day clinical outcome was not different between the 2 stent groups. In the symptomatic patient group, stent design (p = 0.017, OR 4.173) and recent smoking history (p = 0.036, OR 4.755) were strong risk factors for new lesions on postprocedural DWI.

Conclusions

Stent design may have an influence on the risk of new embolism, and selecting the appropriate stent may improve outcome.

Initial experience with the new double-lumen scepter balloon catheter for treatment of wide-necked aneurysms

Objective

A new double-lumen balloon catheter was being developed for the treatment of cerebral aneurysms. The purpose of this study is to report our initial experience of a double-lumen balloon catheter for the treatment of wide-necked aneurysms.

Materials and Methods

Seventeen patients (mean age, 63 years; range, 45-80 years) with wide-necked, with or without a branch-incorporated aneurysms, (10 ruptured and 9 unruptured) were treated with balloon-assisted coil embolization using a double-lumen balloon catheter (Scepter C™ or Scepter XC™) for 7 months after being introduced to our country. Locations of the aneurysms were posterior communicating artery (n = 7), anterior communicating artery or A2 (n = 7), middle cerebral artery (MCA) bifurcation (n = 3), basilar artery tip (n = 1) and anterior choroidal artery (n = 1). The initial clinical and angiographic outcomes were retrospectively evaluated.

Results

Coil embolization was successfully completed in all 19 aneurysms, resulting in complete occlusions (n = 18) or residual neck (n = 1). In one procedure, a thrombus formation was detected at the neck portion of the ruptured MCA bifurcation aneurysm near to the end of the procedure. It was completely resolved with an intra-arterial infusion of Glycoprotein IIb/IIIa inhibitor (Tirofiban, 1.0 mg) without any clinical sequela. There were no treatment-related events in the remaining 18 aneurysms. At discharge, functional neurological state improved in 11 patients (10 patients with ruptured aneurysm and 1 with unruptured aneurysm presenting with mass symptoms) and 6 patients with unruptured aneurysms had no newly developed symptoms.

Conclusion

In this preliminary case series, the newly developed double-lumen Scepter balloon appears to be a safe and convenient device for coil embolization of wide-necked aneurysms.

Coil-protected embolization technique for a branch-incorporated aneurysm

OBJECTIVE

A small branch-incorporated aneurysm is an aneurysm with a small branch incorporated into the sac or the neck. It is one of the most difficult aneurysms to treat with coil embolization. The aim of this study was to evaluate the safety and effectiveness of the coil-protected embolization technique for small-branch incorporated aneurysm.

MATERIALS AND METHODS

Fourteen aneurysms (2 ruptured and 12 unruptured) in 12 patients (mean age, 56 years, range, 40-73 years; 6 men and 6 women) were treated with the coil-protected embolization technique during the period between February 2007 and October 2011. Clinical and angiographic outcomes were retrospectively evaluated.

RESULTS

All aneurysms were successfully treated without any complications during the procedure. Immediate post-treatment angiographies demonstrated complete or near complete occlusion in 12 and incomplete occlusion in 2 patients. Two patients had a delayed small embolic infarction in the relevant posterior circulation territory and middle cerebral artery territory 10 days and 14 days later, respectively, but both recovered completely or almost completely (modified Rankin scale score [mRS score], 0 and 1, respectively). During the clinical follow-up period (mean, 21 months; range: 2-58 months), all patients reported an mRS score of 0 (n = 10) or 1 (n = 2). Vascular imaging follow-up (catheter angiography: n = 3 and MR angiography: n = 8) was available in 11 aneurysms at 6-12 months. All 11 aneurysms showed complete occlusion except for 1 minor neck recurrence that did not require further treatment.

CONCLUSION

In this series of cases, the coil-protected embolization technique seems to be feasible and effective in the treatment of small-branch incorporated aneurysms.

Abstract TP428: Microsurgical and Endovascular Treatment of Ruptured Distal Anterior Cerebral Artery Aneurysms

Introduction: Distal anterior cerebral artery (DACA) aneurysms are less common and surgical morbidity has been reported relatively high due to intraoperative rupture and narrow surgical field. Endovascular treatment can be alternative to surgery. This study investigated the efficacy and safety of endovascular coiling for ruptured DACA aneurysms comparing with microsurgical clipping.

Patients and Methods: Between January 1999 and March 2012, consecutive 94 patients with ruptured DACA aneurysm were treated by surgical clipping (n=52, 55.3%) and endovascular coiling (n=42, 44.7%) in five institutions including only 2 cases of recurrence (2.1%, 1 in clip and 1 in coil). The clinical outcomes of patients and procedure-related complications (intraprocedural rupture and any infarction) were evaluated and compared between two groups.

Results: There were 38 males and 56 females (mean age; 55.1 years). Initial Hunt-Hess grade was GII in 25 patients (37.2%), GIII in 36 patients (38.3%), GIV in 12 patients (12.8%), and GV in 11 patients (11.7%), which was significantly higher in coil group (2.77 in clip vs 3.26 in coil, p=0.016). Initial CT scanning showed ruptured DACA aneurysm with ICH (n=35; 37.2%) and hydrocephalus (n=25; 26.6%). Maximal diameter of aneurysm was less than 5mm in 36 (38.3%), 5~10mm in 53 (56.4%), and 10mm and more than in 5 (5.3%). Technical success rate was 100% and complete occlusion or neck remnant of aneurysm was achieved in 87 [92.6%, 49 (96.1%) in clip vs 38 (90.5%) in coil, p=0.404] and incomplete in 6 (6.4%). At discharge, favorable outcome (modified GOS; good and fair) was obtained in 70 [77.8%, 44 (84.6%) in clip vs 26 (68.4%) in coil, p=0.078]. Intraprocedural rupture occurred only in clipping group [6 cases (11.5%), p=0.031]. Any procedure-related infarction occurred in 7 [7.4%, 6 (11.5%) in clip vs 1 (2.4%) in coil, p=0.126]. Intraprocedural thrombus was detected in 5 cases of coil group and most of them were restored by thrombolytic therapy. There was one case of acute rebleeding in coiling group and this patient died.

Conclusions: Endovascular coiling was comparable treatment with clipping for ruptured DACA aneurysms.

Wingspan Stenting for Intracranial Atherosclerotic Stenosis

BACKGROUND:

Intracranial atherosclerotic stenosis (ICAS) is responsible for 9% to 37% of ischemic strokes.

OBJECTIVE:

To evaluate the clinical outcome and risk factors for in-stent restenosis (ISR) after treatment of ICAS with a Wingspan stent.

METHODS:

Seventy-seven patients with 79 total target ICAS &gt; 60% (mean, 79.9 ± 8.4%; symptomatic ICAS, 96.2%) underwent attempted treatment with Wingspan stenting between March 2010 and March 2011. A retrospective review of the prospectively registered data was conducted to assess the risk factors for ISR and the clinical outcomes of these patients.

RESULTS:

The 30-day transient ischemic attack/stroke and death rates were 5.3% (95% confidence interval [CI], 0.1-10.5) and 0%, respectively. All patients but 1 were followed up clinically for a mean of 18.9 months (range, 12–23 months). During the period, cumulative transient ischemic attack/stroke and death rates were 8.1% (95% CI, 1.7-14.5) and 0%, respectively. Only 1 patient suffered a disabling stroke (subarachnoid hemorrhage), which was associated with retreatment of an ISR with a drug-eluting balloon-expandable stent. Follow-up angiography was available in 69 treated vessels (89.6%) at 3 to 24 months (median, 12 months). Binary ISR rate was 24.6%, of which 17.6% (3 of 17 cases) was symptomatic. Rapid balloon inflation (95% CI, 5.490-530.817) and longer length of stenosis (95% CI, 1.093-1.891) were independent risk factors for ISR.

CONCLUSION:

Wingspan stenting may be effective for appropriately selected ICAS patients. Rapid balloon inflation and longer lengths of stenosis were independent risk factors for ISR.

Endovascular treatment of bilateral intracranial vertebral artery dissecting aneurysms presenting with subarachnoid hemorrhage

BACKGROUND

Optimal management of bilateral vertebral artery dissecting aneurysms (bi-VDAs) causing subarachnoid hemorrhage (SAH) remains unclear.

OBJECTIVE

To investigate the treatment methods and outcomes of bi-VDA causing SAH.

METHODS

Seven patients were treated endovascularly for bi-VDA causing SAH. Treatment methods and outcomes were evaluated retrospectively.

RESULTS

Two patients were treated with 2 overlapping stents for both ruptured and unruptured VDAs, 2 with 2 overlapping stents and coiling for ruptured VDA and with conservative treatment for unruptured VDA, 1 with internal trapping (IT) for ruptured VDA and stent-assisted coiling for unruptured VDA, 1 with IT for ruptured VDA and 2 overlapping stents for unruptured VDA, and 1 with IT for ruptured VDA and a single stent for unruptured VDA. None had rebleeding during follow-up (range, 15-48 months). All patients had favorable outcomes (modified Rankin Scale score, 0-2). On follow-up angiography at 6 to 36 months, 9 treated and 2 untreated VDAs revealed stable or improved state, whereas 3 VDAs in 2 patients showed regrowth. Of the 3 recurring VDAs, 1 was initially treated with IT but recurred owing to retrograde flow to the ipsilateral posterior inferior cerebellar artery (PICA), the second was treated with single stent but enlarged, and the last was treated with 2 overlapping stents and coiling but recurred from the remnant sac harboring the PICA origin. All 3 recurred VDAs were retreated with coiling with or without stent insertion.

CONCLUSION

Bilateral VDAs presenting with SAH were safely treated with endovascular methods. However, endovascular treatment may be limited for VDAs with PICA origin involvement.

Clinical and angiographic characteristics of multiple dural arteriovenous shunts

BACKGROUND AND PURPOSE

The pathogenesis and characteristics of multiple DAVSs are not well-known. The purpose of this study was to evaluate the angiographic and clinical characteristics of patients with multiple DAVSs with an emphasis on the pathomechanism.

MATERIALS AND METHODS

One hundred seventy-nine patients with DAVS were reviewed. Patients with ≥ 2 fistulas at anatomically separate sites were included. Multiple DAVSs were categorized into synchronous (simultaneous multiplicity) or metachronous (temporal sequential development of multiplicity) types. The angiographic and clinical characteristics of these lesions were analyzed.

RESULTS

Fourteen patients were diagnosed with multiple DAVSs (7.8%; synchronous, n = 7; metachronous, n = 7). Thirteen of the 14 patients showed CVR (93%, Borden type II/III). Multiple DAVSs were frequently associated with dural sinus thrombosis (71.4%, n = 10). Synchronous DAVSs developed in association with an occluded sinus (n = 5). De novo metachronous lesions developed in association with thrombosis of a previously patent dural sinus (n = 3) or reopening of an occluded sinus (n = 2). Multiplicity was associated with aggressive initial symptoms in 64.3% (n = 9). The newly developed lesions in the metachronous types were accompanied by hemorrhage (n = 1), neurologic deficit (n = 1), worsening of the initial benign symptoms (n = 2), and incidental detection (n = 3). The mean time interval between the initial diagnosis and de novo lesion detection was 31.3 ± 29.8 months (range, 12-92 months).

CONCLUSIONS

Multiplicity of DAVSs is associated with poor angiographic and clinical prognosis, requiring an aggressive treatment and management strategy. Sinus thrombosis has a prominent role in the pathomechanism of DAVSs.