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Purpose Here, we presented our early experience with flow diversion procedures using the Surpass Evolve flow diverter (SE, Stryker) and reported the feasibility and safety profile compared to those of a control group treated with other types of flow diverters. Methods We included 31 and 53 consecutive flow diversion procedures performed using the SE and other commercial flow diverters, respectively, to treat intracranial aneurysms at our institution. We used two commercial flow diversion systems in the comparison group: the pipeline embolization device and Surpass Streamline. Results In the SE group, technical failures occurred in three (9.7%) cases, due to either incomplete wall apposition ( n  = 1, 3.2%) or stent migration ( n  = 2, 6.5%). Major complications occurred in four (12.9%) cases: delayed rupture of the target aneurysm ( n  = 1, 3.2%), major ischemic stroke ( n  = 1, 3.2%), sudden death from an unidentified cause ( n  = 1, 3.2%), and parent artery occlusion with stent thrombosis ( n  = 1, 3.2%). Balloon angioplasty was performed in eight (25.8%) cases. On post-procedure MRI, a DWI-positive lesion was detected in three (9.7%) cases. After multivariate adjustment, the SE group was independently associated with less procedural time of ≥ 90 min (adjusted OR, 0.09; 95% CI, 0.03–0.29; p  < 0.001), balloon angioplasty (adjusted OR, 0.22; 95% CI, 0.07–0.75; p  = 0.015), and DWI-positive lesions (adjusted OR, 0.04; 95% CI, 0.01–0.19; p  < 0.001). Conclusion The SE is safe and easy to deploy.

BackgroundEndovascular treatment for vertebral artery dissecting aneurysms (VADAs) includes overlapping stents and flow diverters. This study compared the safety and effectiveness of overlapping stents and flow diverters for unruptured VADAs.MethodsWe retrospectively enrolled patients with unruptured VADAs who underwent overlapping stents or flow diverters at two tertiary hospitals in South Korea. The primary clinical outcome was the occurrence of stroke. The primary angiographic outcomes (>12 months) were categorized as regression, no decrease in size, recanalization, or stent occlusion, of which only regression was defined as a favorable angiographic outcomes.ResultsOf the 146 patients with VADAs, 25 (17.1%) had flow diverters and 121 (82.9%) had overlapping stents. For the primary angiographic outcomes over 12 months, the rate of favorable angiographic outcomes for flow diverters was 81.8% and for overlapping stents (triple stents) was 98.8% (P=0.006). In the multivariale analysis, after adjusting for partially thrombosed aneurysms, aneurysm shape, non-dominant vessel, posterior inferior cerebellar artery involvement, and procedure type, overlapping stents (triple stents) was not associated with favorable angiographic outcomes compared with flow diverters (OR 7.040, 95% CI 0.549 to 90.294; P=0.134), but partially thrombosed aneurysms was inversely associated with favorable angiographic outcomes (OR 0.056, 95% CI 0.005 to 0.589; P=0.016). The primary clinical outcome followed up to the last angiography did not occur in all patients.ConclusionThere was no difference in safety and effectiveness between overlapping stents and flow diverters in unruptured VADAs. Further endovascular treatment studies are needed regarding the association of partially thrombosed aneurysms with unfavorable angiographic outcomes.

Moyamoya disease (MMD) is a rare cerebrovascular disease characterized by progressive stenosis of large intracranial arteries and a hazy network of basal collaterals called moyamoya vessels. A polymorphism (R4810K) in the Ring Finger Protein 213 ( RNF213 ) gene, at chromosome 17q25.3, is the strongest genetic susceptibility factor for MMD in East Asian populations. MMD was regarded prevalent in childhood and in East Asian populations. However, the so-called MMD could represent only the tip of the iceberg. MMD is increasingly reported in adult patients and in Western populations. Moreover, the RNF213 variant was recently reported to be associated with non-MMD disorders, such as intracranial atherosclerosis and systemic vasculopathy (e.g., peripheral pulmonary artery stenosis and renal artery stenosis). In this review, we summarize the spectrums of RNF213 vasculopathy in terms of clinical and genetic phenotypes. Continuous efforts are required for pathophysiology-based diagnoses and treatment, which will benefit from collaboration between clinicians and researchers, and between stroke and vascular physicians.

Both intracranial atherosclerotic stenosis (ICAS) and moyamoya disease (MMD) are prevalent in Asians. We hypothesized that the Ring Finger protein 213 gene polymorphism (RNF213), a susceptibility locus for MMD in East Asians, is also a susceptibility gene for ICAS in patients whose diagnosis had been confirmed by conventional angiography (absence of basal collaterals) and high-resolution MRI (HR-MRI, presence of plaque). We analyzed 532 consecutive patients with ischemic events in the middle cerebral artery (MCA) distribution and relevant stenotic lesion on the distal internal carotid artery or proximal MCA, but no demonstrable carotid or cardiac embolism sources. Additional angiography was performed on 370 (69.5%) patients and HR-MRI on 283 (53.2%) patients. Based on angiographic and HR-MRI findings, 234 patients were diagnosed with ICAS and 288 with MMD. The RNF213 variant was observed in 50 (21.4%) ICAS patients and in 119 (69.1%) MMD patients. The variant was observed in 25.2% of patients with HR-MRI-confirmed ICAS. Similarly, 15.8% of ICAS patients in whom MMD was excluded by angiography had this variant. Among the ICAS patients, RNF213 variant carriers were younger and more likely to have a family history of MMD than non-carriers were. Multivariate testing showed that only the age of ICAS onset was independently associated with the RNF213 variant (odds ratio, 0.97; 95% CI, 0.944-0.99). RNF213 is a susceptibility gene not only for MMD but also for ICAS in East Asians. Further studies are needed on RNF213 variants in ICAS patients outside East Asian populations.

Both Moyamoya disease (MMD) and intracranial atherosclerotic stenosis (ICAS) are more prevalent in Asians than in Westerners. We hypothesized that a substantial proportion of patients with adult-onset MMD were misclassified as having ICAS, which may in part explain the high prevalence of intracranial atherosclerotic stroke in Asians. We analyzed 352 consecutive patients with ischemic events within the MCA distribution and relevant intracranial arterial stenosis, but no demonstrable carotid or cardiac embolism sources. Conventional angiography was performed in 249 (70.7%) patients, and the remains underwent MRA. The occurrence of the c.14429G>A (p.Arg4810Lys) variant in ring finger protein 213 (RNF213) was analyzed. This gene was recently identified as a susceptibility gene for MMD in East Asians. The p.Arg4810Lys variant was observed in half of patients with intracranial stenosis (176 of 352, 50.0%), in no healthy control subjects (n = 51), and in 3.2% of stroke control subjects (4 of 124 patients with other etiologies). The presence of basal collaterals, bilateral involvement on angiography, and absence of diabetes were independently associated with the presence of the RNF213 variant. Among 131 patients who met all three diagnostic criteria and were diagnosed with MMD, three-fourths (75.6%) had this variant. However, a significant proportion of patients who met two criteria (57.7%), one criterion (28.6%), or no criteria (20.0%) also had this variant. Some of them developed typical angiographic findings of MMD on follow-up angiography. Careful consideration of MMD is needed when diagnosing ICAS because differential therapeutic strategies are required for these diseases and due to the limitations of the current diagnostic criteria for MMD.

Background/Objectives: Target tetra detachable coils (TTDCs) aid in achieving effective framing during the coil embolization of small intracranial aneurysms by maintaining a tetrahedral conformation within the aneurysm sac. We aimed to report the initial experience of patients treated for intracranial aneurysms using TTDCs, with a specific focus on efficacy and safety. Methods: We retrospectively reviewed the medical records of 41 patients who underwent the coil embolization of intracranial aneurysms sized ≤10 mm with TTDCs between April and May 2023. Post-procedural angiographic and clinical results were reviewed. Results: Of the 46 aneurysms (45 unruptured and 1 ruptured), 33 (71.7%) were treated with the stent-assisted technique and 13 (28.3%) using the simple coil embolization technique. Post-procedural angiography showed complete occlusion in 41 aneurysms (89.1%), neck remnants in 1 (2.2%), and residual aneurysms in 4 (8.7%). The mean packing density was 34.7% (19.3–46.8%), with TTDC coil length comprising a mean of 88.5% of the total coil length. No major device- or procedure-related complications were observed. During the follow-up, 40 aneurysms (93.0%) demonstrated complete occlusion, while neck remnants were observed in 1 (2.3%), and residual aneurysms in 2 (4.7%). No cases of recanalization were observed. Conclusions: The TTDC is a safe and effective device for the endovascular treatment of intracranial aneurysms. Follow-up studies are required to establish long-term results.

Stem cell-based therapeutics are amongst the most promising next-generation therapeutic approaches for the treatment of spinal cord injury (SCI), as they may promote the repair or regeneration of damaged spinal cord tissues. However, preclinical optimization should be performed before clinical application to guarantee safety and therapeutic effect. Here, we investigated the optimal injection route and dose for adult human multipotent neural cells (ahMNCs) from patients with hemorrhagic stroke using an SCI animal model. ahMNCs demonstrate several characteristics associated with neural stem cells (NSCs), including the expression of NSC-specific markers, self-renewal, and multi neural cell lineage differentiation potential. When ahMNCs were transplanted into the lateral ventricle of the SCI animal model, they specifically migrated within 24 h of injection to the damaged spinal cord, where they survived for at least 5 weeks after injection. Although ahMNC transplantation promoted significant locomotor recovery, the injection dose was shown to influence treatment outcomes, with a 1 × 106 (medium) dose of ahMNCs producing significantly better functional recovery than a 3 × 105 (low) dose. There was no significant gain in effect with the 3 × 106 ahMNCs dose. Histological analysis suggested that ahMNCs exert their effects by modulating glial scar formation, neuroprotection, and/or angiogenesis. These data indicate that ahMNCs from patients with hemorrhagic stroke could be used to develop stem cell therapies for SCI and that the indirect injection route could be clinically relevant. Moreover, the optimal transplantation dose of ahMNCs defined in this preclinical study might be helpful in calculating its optimal injection dose for patients with SCI in the future.

Abstract INTRODUCTION There are very limited data on resuming anticoagulation after chronic subdrual hematoma (CSDH), and there are often cases whose resumption of anticoagulation is delayed for more than several weeks after burr-hole drainage. However, patients on anticoagulation typically have a pre-existing risk factor and are at higher risk of a thromboembolic (TE) event, while they are off anticoagulation. It is therefore important to keep a right balance between the TE risk and the bleeding risk. To evaluate the potential safety for early warfarin resumption, we conducted a retrospective matched cohort study. METHODS Between May 2008 and April 2015, we enrolled a series of 187 patients of CSDH who were and were not receiving warfarin therapy at the time of admission. We prospectively treated the warfarin cohort focusing on the discontinuation of warfarin, INR correction, postoperative management, timing of warfarin resumption, and resumption dosage of warfarin. As to the ordinary cohort, retrospective observational study was conducted using medical charts, surgical reports, and CT scan reviews. And then, 2 cohorts were analyzed using propensity score matching. RESULTS Among the 187 patients, 36 patients had been taking warfarin before surgical treatment, and the others had not. The mean time to recurrence was similar in the warfarin cohort (82.7 ± 3.4) compared to the ordinary cohort (82.0 ± 1.8) (log-rank test, P = .878). After propensity score matching, 33 patients in the warfarin corhort and 74 patients in the ordinary cohort were matched. When analyzed using the generalized estimating equation, there was no significance difference in the recurrence rate of CSDH between 2 groups (P = 0.411). In addition, we found that the recurrence of CSDH in warfarin corhort was not related with postoperative INR levels (linear mixed model, P = .332). CONCLUSION There is no strong consensus on the optimal timing for warfarin resumption and therefore each patient should be managed individually based on underlying TE risks and hemorrhagic burden. However, warfarin-related CSDH patients with a strong indication for anticoagulation would benefit from restarting warfarin about 3 d after burr-hore drainage.

Obstructive sleep apnea syndrome (OSAS) is associated with cerebrovascular disease, which can lead to life-threatening outcomes. The purpose of the study was to investigate the relationship between OSAS and comorbid intracranial aneurysms. We retrospectively reviewed 564 patients who underwent a polysomnography and brain magnetic resonance angiography as part of their health checkup. We calculated the prevalence of an intracranial aneurysm and OSAS in patients and measured the size of the intracranial aneurysm if present. The mean patient age was 55.6 ± 8.5 years, and 82.3% of them were men. The prevalence of an intracranial aneurysm in patients with OSAS was 12.1%, which is significantly higher than patients with non-OSAS (5.9%, p = 0.031). Patients with OSAS had a much higher prevalence of intracranial aneurysms, after adjusting all possible confounding factors such as age, sex, smoking status, alcohol drinking, and body mass index (odds ratio: 2.32; 95% confidence interval: 1.07–5.04). Additionally, the OSAS group had noticeably larger aneurysms compared with those of the non-OSAS group (3.2 ± 2.0 mm vs. 2.0 ± 0.4 mm, p = 0.013). We found a significant association between OSAS and intracranial aneurysms. OSAS could be another risk factor for the development of intracranial aneurysms.

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by stenosis of the internal carotid arteries with compensatory development of collateral vessels. Although a founder variant of RNF213, p.Arg4810Lys (c.14429G>A, rs112735431), is a major genetic risk factor for MMD in East Asians, the frequency and disease susceptibility of other variants in this gene remain largely unknown. In the present study, we investigated the association of RNF213 variants with MMD in Korean patients and population controls. For all RNF213 variants listed in the Human Gene Mutation Database (HGMD) as disease-causing or likely disease-causing mutations for MMD, genotyping was performed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. Genetic data from 264 adult patients with MMD were analyzed and compared with two control populations comprised of 622 and 1,100 Korean individuals, respectively. Among the 30 RNF213 variants that were listed in the HGMD, p.Arg4810Lys was identified in 67.4% (178/264) of patients with MMD and showed a significantly higher allele frequency than in the controls, giving an odds ratio of 63.29 (95% confidence interval, 33.11-120.98) for the 622 controls and 48.55 (95% confidence interval, 31.00-76.03) for the 1100 controls. One additional variant, p.Ala5021Val (c.15062C>T, rs138130613), was identified in 0.8% (2/264) of patients; however, the allele frequencies were not significantly different from those in the controls. These results suggest that, in our cohort of Korean patients, the p.Arg4810Lys is the only variant that is strongly associated with MMD among the 30 RNF213 variants listed in the HGMD.