OBJECTIVEThe safety of the stent-assisted coil embolization (SAC) technique for acutely ruptured aneurysms has not been established yet. SAC is believed to be associated with a high risk of thromboembolic and hemorrhagic complications in acute subarachnoid hemorrhage (SAH). The aim of this study was to evaluate the safety and efficacy of the SAC technique in the setting of acutely ruptured aneurysm.METHODSA total of 102 patients who received endovascular treatment for acute SAH between January 2011 and December 2017 were enrolled. The SAC technique was performed in 38 of these patients, whereas the no-stent coil embolization (NSC) technique was performed in 64. The safety and efficacy of the SAC technique in acute SAH was evaluated as compared with the NSC technique by retrospective analysis of radiological and clinical outcomes.RESULTSThere were no significant differences in clinical or angiographic outcomes between the SAC and NSC techniques in patients with acute SAH. The rate of ventriculostomy-related hemorrhagic complications was higher in the SAC group than that in the NSC group (63.6% vs 12.5%; OR 12.25, 95% CI 1.78–83.94, p = 0.01). However, all these complications were asymptomatic and so small that they were only able to be diagnosed with imaging.CONCLUSIONSRuptured wide-necked aneurysms could be effectively and safely treated with the SAC technique, which showed clinical and angiographic outcomes similar to those of the NSC technique. Hence, the SAC technique with dual-antiplatelet drugs may be a viable option even in acute SAH.

We report a rare case of a ruptured distal anterior inferior cerebellar artery (possibly dissecting) aneurysm of the caudal trunk, successfully treated by endovascular occlusion. A 41-year-old man presented with sudden severe headache and drowsiness. On the day of ictus, conventional angiography was performed to make the above diagnosis, followed by endovascular occlusion of the sac and the parent artery. The patient recovered completely without any neurologic deficit after treatment. Endovascular occlusion could be a safe and effective treatment option in a case of a ruptured distal AICA aneurysm of the caudal trunk.

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<b><i>Background:</i></b> Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. <b><i>Aims:</i></b> We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. <b><i>Methods:</i></b> Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. <b><i>Results:</i></b> In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. <b><i>Conclusions:</i></b> Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

The prevalence of aneurysm formation in adults with Moyamoya disease (MMD) is higher than that in the general population. The treatment strategy is often individualized based on the patient's disease characteristics. A 22-year-old man was diagnosed with MMD after presenting a small thalamic intracerebral and subarachnoid hemorrhage in the quadrigeminal cistern. Cerebral angiography revealed a small aneurysm (2.42 mm) in the left anterior choroidal artery. Since the hemodynamics in the left hemisphere was compromised, an indirect bypass surgery was performed. The patient's condition deteriorated postoperatively because of poor perfusion of the internal carotid artery, and massive hydration was required. During neurocritical care, the aneurysm increased in size (5.33 mm). An observation strategy was adopted because of the distal aneurysmal location and the high risk involved. Subsequently, the patient recovered, and newly developed collateral flow appeared from the external carotid artery. Additionally, a dramatic size reduction of the aneurysm (1.51 mm) was noticed. Our case suggests that MMD-related dissecting aneurysms on a distal cerebral artery, which present a high risk of embolization, could be managed by indirectly reducing the hemodynamic burden. Massive hydration in such cases should be avoided or balanced to avoid the risk of rapid growth and aneurysm rupture.

For most fractionated stereotactic radiosurgery treatment plans, daily imaging is not routinely performed, because there is little expectation that lesions will change significantly in the short term. However, here, we present the case of an abrupt increase and decrease in tumor volume during fractionated gamma knife radiosurgery (GKRS) for metastatic brain cancer. A 65-year-old man with a history of nephrectomy due to renal cell carcinoma was admitted to our hospital because of mild cognitive disorder and gait disturbance. An initial MRI of the brain demonstrated a 5 × 3 × 4.5 cm-sized, heterogeneously well-enhanced tumor with a large cystic component compressing the left thalamus and corpus callosum near the lateral ventricle. Owing to its large size and proximity to critical structures, we decided to perform 3 fractionated GKRSs over 3 consecutive days. After the first fraction of 9 Gy with 50% isodose, follow-up MRI the next day revealed an unexpected increase in tumor volume up to 30%. Therefore, the radiosurgical plan was adjusted, and GKRS was performed again using the same dose for the second fraction. The image taken on the third day showed rapid shrinkage of the tumor volume. This case shows that a tumor may change its shape and volume unexpectedly even during the short period of a fractionated GKRS session. Hence, for optimal fractionated GKRS treatment of tumors with the likelihood of an abrupt change in the short term, interval imaging should be considered.

BACKGROUND Many physicians consider aneurysmal wall enhancement (AWE) on high resolution-vessel wall imaging (HR-VWI) as an imaging biomarker of unstable unruptured intracranial aneurysms (UIAs). OBJECTIVE To evaluate the clinical value of different AWE signal intensities (SIs) by assessing the correlation between the AWE SIs and surgical findings and rupture risk assessment tools. METHODS Twenty-six patients with 34 aneurysms who underwent surgical clipping were included. The corrected AWE SI was calculated by comparing T1-weighted images with post-gadolinium enhanced T1-weighted images. The correlation of AWE with the population, hypertension, age, size of aneurysm, earlier subarachnoid hemorrhage from another aneurysm, site of aneurysm (PHASES) and earlier subarachnoid hemorrhage, location of the aneurysm, age &gt;60 years, population, size of the aneurysm, shape of the aneurysm (ELAPSS) scores was evaluated using correlation and linear regression analysis. To quantify the surgical findings, the average color value of the aneurysms expressed in the CIELCh system was measured. Δh, color difference from yellow, was used for statistical analysis. RESULTS The mean age of the patients and aneurysm size were 64.08 yr and 6.95 mm, respectively. The mean AWE SI, PHASES and ELAPSS scores, and Δh were 22.30, 8.41, 20.32, and 41.36, respectively. The coefficients of correlation of AWE SI with the PHASES and ELAPSS scores and Δh were 0.526, 0.563, and –0.431. We found that the AWE SI affected the PHASES (β = 0.430) and ELAPSS scores (β = 0.514) and Δh (β = –0.427) in simple linear regression analysis. CONCLUSION The AWE on HR-VWI was correlated with the PHASES and ELAPSS scores and the color. The stronger the AWE, the higher were the PHASES and ELAPSS scores and the more abnormal was the color. The AWE might indicate the degree of inflammation.

Background Physicians can find it challenging to decide whether confirmative digital subtraction angiography (DSA) should be performed in patients who present with "suspicious small aneurysmlike structures" on magnetic resonance angiography (MRA). Factors associated with "false positive aneurysms on MRA" (FPAMs)," which are finally confirmed as negative on DSA, have rarely been reported. This study aimed to identify the clinical or radiologic clues indicative of FPAM on DSA. Methods Patients who had undergone DSA between 2016 and 2019 for suspicious aneurysm-like structures < 5 mm in size on MRA were enrolled. Patient demographics and the details regarding the geometry of the structures were retrospectively reviewed. Univariate and multivariate logistic regression analyses were conducted to identify the associated factors. Receiver operating characteristic curve analysis was performed to assess the clinical implications. Results Of the 107 suspicious structures, 46 were indicated as being false positive on DSA (42.96%). Location (positive on C7 and negative on C5-6 ICA) and lower dome to neck ratio were found to be significant parameters in the multivariate analysis. The dome to neck ratio threshold value was 0.99. Conclusion Suspicious aneurysm-like structures located not on C5-6 but on C7 ICA and having wide neck morphologies (dome to neck ratio < 0.99) are highly likely to be negative on DSA.