WFITN 2015 Abstracts Poster Abstracts

310 Presentation withdrawn

Outcome of Subarachnoid Hemorrhage in our Hospital

AHajime¹, S Hiroaki¹, K Naosuke¹, H Fumihiro¹ and S Shigeo¹

¹Department of Neurosurgery, Tokyo metropolitan police hospital, Japan

Purpose: In 2012 UCAS JAPAN was announced, its data have a large impact. We reports and study cases of subarachnoid hemorrhage which treated in our hospital from April 1st 2013.

Method: From April 1st to October 20th in 2013, 11 subarachnoid hemorrhage patients which surgical treatment was done in our hospital. Brain angiography was done for all patients. We treated 11 aneurysms, and chose the best treatment for its aneurysms. Gender was 2 men, 9 women. Average age was 65.5 years old. The average size of the aneurysm was 5.4 mm. 7 cases was under 5 mm. WFNS grade 1 is 5 cases, 2 was 2 cases, 3 was 1 case, 4 was 2 cases, and 5was 1 case. Aneurysm of the anterior circulation was selected clipping, and coil embolization was performed for aneurysm of the posterior circulation.

Result: A com aneurysm, IC aneurysm, and aneurysm of the posterior circulation was small, and had tendency to rupture. Although the number of the treated patients was small, perhaps in accordance with cases increases, it is believed to have a tendency conforming to UCAS.

Conclusion: We have reported on such treatment and its result in subarachnoid hemorrhage in our hospital.

311

Follow-Up Duration of Unruptured Intracranial Aneurysms

SUAhmed¹, E Barber¹, L Peeling¹, K Meguro¹ and ME Kelly¹

¹Division of Neurosurgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada

Purpose: Natural rate of aneurysm rupture remains controversial, especially for small aneurysms. Centres frequently choose to follow rather than treat aneurysms <7 mm. We aim to study the safety of observation in patients with small UIAs followed in Saskatchewan, and determine the optimal duration of follow-up for small aneurysms.

Methods: We conducted a retrospective review of all patients presenting between July 2008 and February 2015 with unruptured aneurysms. Aneurysm characteristics recorded included size, location, presentation, and follow-up imaging. Multiple aneurysms in a single patient were considered independently.

Results: Of the 203 UIAs <7 mm, 25 were treated, while mean follow-up time was 12.3 months for followed aneurysms, with two incidences of rupture. Of the 88 UIAs ≥ 7 mm, 42 (48%) were treated. Mean follow-up time for followed aneurysms was 8.2 months, and there was one incidence of rupture during follow-up. Overall, follow-up duration for ruptured aneurysms was significantly longer than the mean follow-up duration.

Conclusion: Treatment decision paradigms used in our centre showed low rates of rupture in untreated aneurysms less than <7 mm. Rupture in our cohort of patients occurred at after a longer duration of follow-up than has been previously reported, suggesting that a longer follow-up may be necessary to confirm stability of the aneurysm.

312

Endovascular Treatment of Ophthalmic Artery Aneurysms: Assessing Balloon Test Occlusion and Preservation of Vision in Coil Embolization

JHAhn

Hallym University Sacred Heart Hospital, Anyang, Korea

Purpose: ICA–ophthalmic artery aneurysms have unique configurations corresponding to relative risks of ophthalmologic morbidities. Presented herein are clinical and radiologic outcomes of coil embolization in ophthalmic artery aneurysms.

Materials and Methods: From January 2003 to September 2013, endovascular coiling was performed in 43 consecutive patients with ophthalmic artery aneurysms, each classified by the degree to which the ophthalmic artery was incorporated by the aneurysm and the contiguity between the ophthalmic artery entry and parent ICA. Clinical and radiologic outcomes of this approach were investigated, including the technical aspects of treatment and the efficacy of balloon test occlusion.

Results: Among 14 patients (32.6%, all ophthalmic artery types) undergoing balloon test occlusion before endovascular coiling, patent collaterals between the external carotid artery and ophthalmic artery were demonstrated in 12 (85.7%) and complete compromise of the ophthalmic artery (without affecting vision) occurred in 4 patients during coiling. Steam-shaped S-configured (67.9%) or straight microcatheters (17.8%) facilitated aneurysm selection in most of the superiorly directed ophthalmic artery aneurysms (n = 28), and steam-shaped pigtail microcatheters (85.7%) were useful in medially directed aneurysms (n = 14). Balloon protection (n = 22) was generally used to facilitate coiling, or a stent (n = 9) was alternatively deployed. Satisfactory aneurysmal occlusion was achieved through coil embolization in 37 lesions (86.1%). During follow-up of 35 patients (mean interval, 12.9 ± 9.4 months), only 1 instance (2.9%) of major recanalization was observed.

Conclusion: If one tailors technical strategies, ophthalmic artery aneurysms are amenable to safe and effective endovascular coil embolization, which tends to be stable in follow-up. Balloon test occlusion may be helpful in devising treatment strategies to preserve vision when coiling ophthalmic artery aneurysms (especially those incorporating an ophthalmic artery origin) is done.

313

Different Approaches in Reconstructive Endovascular Treatment of Large and Giant Intracranial Aneurysms

SArustamyan¹, A Bocharov¹, E Bukharin¹, P Dorokhov¹, K Mikeladze¹, E Vinogradov¹ and S Yakovlev¹

¹N.N. Burdenko Neurosurgery Institute, Moscow, Russian Federation

Purpose: To estimate effectiveness of endovascular treatment of large and giant intracranial aneurysms using stent-assisted coiling and flow-diverter stenting.

Methods: 237 patient with 244 large and giant intracranial aneurysms, were operated. There were 61 men and 176 women aged from 18 to 77 years. Share of giant aneurysms was 59%.

Aneurysms demonstrated ICH at 13% of pts, in 55% cases they had pseudo-tumorous current. 204 aneurysms were localized on ICA, 40 – in vertebro-basilar basin. 92 aneurysms kept thrombotic mass. In 207 cases it is used Pipeline (PED), in 37 – stent-assisting coiling (SAC). Medication support included 75 mg of Plavix or 90 mg Ticagrelor and 100 mg of aspirin within 3 days before and 6 months after operation.

Results: Technical success has been reached in 95% of aneurysms. In early postoperative period morbidity\mortality has made 2.7%/3.3 % in cases with using PED and 2.7%/2.7% in cases with using SAC thereafter.

Long-term results were evaluated at 63% of pts within 4 to 50 months after operation. Total and subtotal aneurysms occlusion was detected at 85% of cases. Disappearance of clinical symptoms is noted in 39% of cases. Morbidity\mortality has made 4.9%/2.5% in PED group and 10.7%/3.5% in SAC group conformably.

Conclusion: PED is very effective device for remodeling parent artery lumen in cases of large and giant intracranial aneurysms. SAC technics can be recommended in cases of aneurysm with diverticulums, bifurcation aneurysms and ruptured aneurysms in acute period of SAH.

314

Aneurysm Coil Embolization Using 1.5 F Marathon® Catheter

TAsano¹, J Sakurai¹, H Saito¹, R Kobayashi¹, T Kobayashi¹, S Takebayashi¹, K Takizawa¹ and K Houkin²

¹Asahikawa Red Cross Hospital, Asahikawa, Hokkaido, Japan

²Hokkaido University, Sapporo, Hokkaido, Japan

Purpose: Marathon® catheter (Covidien, CA, USA) is a flow directed microcatheter designed mainly for delivering liquid embolic agent to brain AVMs and dural AVFs. The authors report their clinical experience of aneurysmal embolization using Marathon® catheter and asses the usefulness of this method.

Methods: 10 patients with intracranial aneurysms underwent coil embolization using Marathon catheter in our institutions. In all cases, ED extrasoft® coils (Kaneka, Osaka, Japan) were used as embolic agents.

Results: All embolization procedures were successfully accomplished and satisfactory occlusion was achieved without any new neurological symptom in all cases. Marathon® catheter not only showed superior navigability and operability during treatment of distally located small aneurysms, but showed lower reluctance in crossing stent struts.

Conclusion: Aneurysm coil embolization using Marathon® catheter is feasible, and has a certain role especially in treating small aneurysms which is located distally, beyond tortuous vessels or those needs trans-cell access.

315

Spontaneous Resolution of Unruptured Fusiform Aneurysm on Middle Cerebral Artery by Taking Antiplatelet Agent Only

KCCha¹ and SH Park²

¹Department of Neurosurgery, Pohang St. Mary’s Hospital, Pohang, Korea

²Department of Neurology, Pohang St. Mary’s Hospital, Pohang, Korea

Purpose: Little is known about the etiology and clinical course of fusiform compared with saccular aneurysms in middle cerebral artery. We report a case of unruptured fusiform aneurysm on M2 portion of right middle cerebral artery, which was spontaneously resolved after conservative treatment by taking antiplatelet agent for one year.

Summary of case: 51-year old female had visited to outpatient department of neurosurgery in our hospital due to recurrent left arm weakness. Neurologic examination showed no definite focal neurologic deficit and brain image revealed no remarkable acute intracranial lesion. However, conventional cerebral angiography showed fusiform dilatation on M2 portion of right middle cerebral artery, superior trunk, without visuable double lumen or Pearl & String sign. She had taken dual antiplatelet agents, aspirin 100 mg and clopidogrel 75 mg per day, for one month and, after that, the single agent only, aspirin 100 mg per day. Magnetic resonance angiogram, one year after, showed a complete spontaneous resolution of MCA fusiform aneurysm.

Conclusion: We report a case of spontaneously resolved unruptured fusiform aneurysm on middle cerebral artery by conservative treatment only.

316

Rare Case of Monozygotic Twins with Concurrent Intracranial and Abdominal Aneurysms

FCharvát, J Vrána, V Beneš and V Charvátová

Military University Hospital Prague, Praha, Czech Republic

Purpose: Pathophysiology and genetics of different types of aneurysms suggest some common mechanisms in their genesis, supporting observational studies of familial aggregation of intracranial aneurysms (IA), aortic abdominal aneurysms (AAA) and aneurysms in other locations. Until now 33 reports of IA in both monozygotic twins were identified.

We report case of monozygotic twins from affected family, both treated for IA and AAA.

Methods: The patients, monozygotic twins JS and PS, born 1949 had family history of aneurysms in mother and sister (fatal abdominal bleeding). Patient JS was diagnosed with incidental unruptured giant (15×19 mm) aneurysm of right middle cerebral artery (MCA) in 11/2013. Aneurysm was subsequently stented (2/2014), coiled (3/2014) and recoiled (12/2014) with successful exclusion without complications. Patient JS was treated for unruptured AAA in other hospital in 7/2012 without complications. Patient JS’s comorbidities include implanted defibrillator, diabetes mellitus, dyslipidemia and aortobiiliac bypass.

Results: The twin, patient PS, underwent screening CT angiography with finding of small (8×4 mm) aneurysm of right MCA (identical location to JS). Patient PS’s lesion was stented in 3/2014, complicated by in stent thrombosis, treated successfully by intravascular mechanical and pharmacological thrombolysis. The aneurysm was finally coiled in 5/2014. PS had stentgraft implanted for unruptured AAA in other hospital in 8/2007 without complications. Patient PS’s history includes multiple myeloma, myocardial infarction, hypertension, dyslipidemia, COPD and phlebothrombosis with subsequent pulmonary embolism.

Conclusion: According to literature review, we present probably the first case of monozygotic twins with concurrent AAA’s and IA’s in both siblings. Our cases support the need for screening of asymptomatic monozygotic twins (and other close relatives) of patients with aneurysms not only for aneurysms in similar locations but also in other common sites.

317

Endovascular Treatment of Ruptured Vertebral Artery Dissecting Aneurysms

HChikuie¹, O Hamasaki¹, M Takano¹, N Obayashi², M Nakaoka², K Yahara², S Nabika², F Ikawa³, T Hidaka³ and Y Kurokawa³

¹Department of Neurosurgery, Miyoshi Central Hospital; Miyoshi, Hiroshima, Japan

²Department of Neurosurgery, Matsue Red Cross Hospital; Matsue, Shimane, Japan

³Department of Neurosurgery, Shimane Prefectural Central Hospital; Izumo, Shimane, Japan

Purpose: Neuroendovascular therapy is emerged as first-line therapy for ruptured vertebral artery dissecting aneurysms (VADAs), but the location of VADA relative to the posterior inferior cerebellar artery (PICA) and development of the PICA affect the treatment strategy.

Method: We studied 21 patients (16 men, 5 women, mean age, 54.7 years) with ruptured VADAs, treated between 1999 and 2014 at three hospitals.

Results: 16 patients underwent internal endovascular trapping, 4 patients underwent proximal endovascular occlusion, and one underwent distal endovascular occlusion in the acute stage and internal endovascular trapping four days later due to reruptured VADA. The location of ADA relative to the ipsilateral PICA were proximal to PICA (pP), PICA involved (Pi), distal to PICA (dP), and no PICA (nP) in 2, 5, 10, and 4 patients, respectively. The developments and locations of PICA were bilateral anterior inferior cerebellar artery (AICA)-PICA, ipsilateral AICA-PICA, extradural, and intradural in 1, 3, 2, and 15 patients, respectively. The number of favorable outcome (modified Rankin Scale, mRS 0 to 2) on discharge was 13 (61.9%).

Conclusions: Neuroendovascular therapy for VADAs using internal endovascular trapping is proper treatment, except in the Pi type. Treatment of the Pi type is controversial. Poor grade subarachnoid hemorrhage and postoperative medullary infarction are associated with unfavorable outcome.

318

Isolated Abducens Nerve Palsy Following Ruptured Anterior Circulation Aneurysm

CSCho, JH Ko and YJ Kim

Department of Neurosurgery, Dankook University Hospital, College of Medicine, Cheon-an, Korea

Isolated abducens nerve palsies associated with intracranial aneurysms have rarely been reported. Their association with anterior commnunicating artery is even rarer. We report two cases of isolated unilateral abducens nerve palsies occurring after subarchnoid hemorrhage due to the rupture of an intracranial aneurysm. It is speculated that the main causes of palsies are compression and stretching of abducens nerves by a thick clot in the prepontine cistern. Although most of the abducens palsies may be reversible and have good prognosis, it is important that the kept in mind as isolated symptoms of subarchnoid hemorrhage.

319

Microembolic Signal Monitoring and the Prediction of Thromboembolic Events Following Coil Embolization of Unruptured Intracranial Aneurysms: Diffusion-weighted Imaging Correlation

JHCho¹, DH Kang^2,4, JC Park², YW Kim³ and YS Kim⁴

¹Department of Neurosurgery, Pohang SM Christianity Hospital, Pohang, Republic of Korea

²Department of Neurosurgery, Kyungpook National University Hospital, Daegu, Republic of Korea

³Department of Neurology, Kyungpook National University Hospital, Daegu, Republic of Korea

⁴Department of Radiology, Kyungpook National University Hospital, Daegu, Republic of Korea

Purpose: Microembolic signal (MES) monitoring with transcranial Doppler ultrasonography (TCD) may allow for early prediction of thromboembolisms following endovascular coiling of unruptured intracranial aneurysms (UIAs). However, the method has not gained widespread use and may benefit from correlation with diffusion-weighted imaging (DWI) of acute ischemic lesions after coiling. This purposed to evaluate the relationship between MESs and DWI-positive lesions more precisely.

Methods: We conducted a prospective study on 45 consecutive patients. TCD was performed over the artery that is dependent on the site of aneurysm. Consequently, 38 patients were available to detect MESs immediately (MES-1) and 24 h (MES-2) after coiling for UIAs. We also checked DWI 1 day after the coiling and analyzed correlations between the TCD and DWI findings.

Results: MES-1 and MES-2 were positive in 25 (65.7%) and 14 (36.8%) patients, respectively. DWI-positive lesions were seen in 20 (52.6%) patients, and only 1 (2.6%) patient was symptomatic. MES-1 and MES-2 were strongly correlated with the number of DWI-positive lesions (Spearman’s correlation coefficient = 0.79 and 0.70, P < 0.01 and P < 0.01, respectively). Additionally, there was a significant correlation between MES-1 and MES-2 (Spearman’s correlation coefficient = 0.70).

Conclusion: Based upon the significant correlation between MES and DWI findings, MES may have a role for early detection of ischemic complications after coiling of UIAs.

320

Do Contrast-Fill Patterns Immediately After Coil Embolization of Small Saccular Aneurysms Impact Long-Term Results?

YDCho and MH Han

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

Purpose: It is generally accepted that filling of a saccular aneurysm with contrast immediately after coil embolization predisposes to later recanalization. However, not all such scenarios evolve similarly over time. We investigated outcomes of small (≤7 mm) aneurysms with contrast-filled sacs immediately after coil embolization, evaluating the impact of pattern and degree of filling on subsequent recanalization.

Methods: Between January, 2008 and December, 2010, 186 small (≤7 mm) saccular aneurysms that retained contrast after coil embolization accrued for this study. Lesions were categorized by pattern (eccentric vs concentric) and degree of filling on working projections. Clinical and morphologic factors were also analyzed to assess impact on subsequent recanalization. Morphologic outcomes at 6 months or more were assessed.

Results: In 93.5% (174/186) of aneurysms with visible contrast retention, complete occlusion was evident on follow-up imaging studies at 6 months. Multiple logistic regression analysis indicated that eccentric (vs concentric) contrast filling carried greater risk of subsequent recanalization (p = 0.020). Stent placement and progressive occlusion were also linked, falling short of statistical significance (p = 0.089). Of 166 progressively occluded aneurysms followed for >12 months (mean, 30.8 ± 7.3 months), 158 (95.2%) exhibited stable occlusion.

Conclusion: Small (≤7 mm) aneurysms that retain contrast immediately after coil embolization are more likely to become completely occluded over time through progressive thrombosis. However, an eccentric fill pattern may predispose to recanalization.

321 Presentation withdrawn

Effect of Stenting on Progressive Thrombosis of Small Unruptured Saccular Intracranial Aneurysms Incompletely Occluded Directly After Coil Embolization: A Propensity-Score Analysis

YDCho and MH Han

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

Purpose: The rate of incomplete occlusion in intracranial aneurysms, despite every effort, is still approximately 10%. Increasingly, self-expanding stents have been used to intensify packing density and divert flow. Nevertheless, the effect of protective stenting on progressive thrombosis of small and incompletely occluded unruptured intracranial aneurysms (UIAs) ≤10 mm in size remains unclear due to confounding factors related to stent deployment probability. In this setting, we examined the effect of stenting on progressive thrombosis using a propensity score-matched case-controlled analysis.

Methods: A total of 715 small UIAs consecutively treated by coiling between 2008 and 2010 were eligible for study. Time-of-flight magnetic resonance angiography and/or catheter angiography were used to estimate extent of saccular occlusion after coil embolization. Complete occlusion at 6 months postembolization of a sac filled with contrast immediately after coiling constituted progressive thrombosis. A propensity score-matched analysis was conducted, based on probability of stent deployment.

Results: Ultimately, 206 (28.8%) small UIAs showed incomplete saccular occlusion directly after coiling. Of these, 182 (88.3%) displayed progressive thrombosis at 6 months. Aneurysm size (p < 0.01), neck size (p < 0.01), and embolization attempt (p < 0.01) differed significantly for stented and non-stented lesions, but incidence of progressive thrombosis did not differ (p = 0.78) between groups. After 1:1 propensity-score matching, however, the rate of complete occlusion in stented subjects (97.5%) surpassed that of non-stented counterparts (OR = 9.75; p = 0.01).

Conclusion: Small UIAs incompletely occluded after coiling showed a complete occlusion rate of 88.3% at 6 months postembolization. Stent deployment seems to promote complete occlusion in such lesions by progressive thrombosis.

322

Triple Microcatheter Use in Endovascular Treatment of Wide-Necked Intracranial Aneurysms: Single Center Experience

YDCho and MH Han

Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

Purpose: Dual microcatheter technique is common practice in coil embolization of wide-necked aneurysm, owing to unique safety and efficacy benefits. Still, technical limitations of some complex configurations may necessitate additional microcatheters to bolster coil stability, compact coil packing, or protective effect. Described herein is a triple microcatheter technique for endovascular management of wide-necked intracranial aneurysms.

Methods: Data accruing prospectively between January, 2006 and October, 2014 on simultaneously executed triple microcatheter coil embolization procedures done in 38 saccular aneurysms were reviewed. Clinical and morphologic outcomes were assessed, with emphasis on technical aspects of treatment.

Results: Triple microcatheter technique was successfully applied in all 38 saccular aneurysms, involving posterior communicating artery (n = 13), middle cerebral artery (n = 10), basilar tip (n = 7), anterior cerebral artery (n = 5), or internal carotid artery (n = 3). Stent protection was added in four patients and balloon remodeling in one. Dual microcatheters (n = 24) were usually deployed for coil delivery within sacs of aneurysms, adding another microcatheter for protection. Otherwise, triple microcatheters were deployed expressly for coil delivery (n = 11) or coils were delivered via single microcatheter, with dual microcatheters deployed for protection (n = 3). Successful aneurysmal occlusion was achieved in 89.5%, with no procedure-related morbidity or mortality. At final follow-up (mean interval, 30.2 ± 22.7 months), stable aneurysmal occlusion was sustained in 72.2% (26/36).

Conclusion: Outcomes of this limited study suggest that a triple microcatheter technique may be an effective and safe therapeutic option in wide-necked aneurysms, using technical strategies tailored to complex angio-anatomic configurations.

323

Multicenter Analysis of Radiation Exposure in Large and Giant Aneurysms with the Penumbra Coil 400 System: A Comparison

AChowdhary¹, B Baxter², O Zaidat³, J Lynch³, A Patel⁴, E Deshaies⁵, K Liu⁶, A Zauner⁷, D Lopes⁸, M Kabbani⁹, K Woodward¹⁰, R Klucznik¹¹, H Moyle¹², O Jansen¹³, V Aletich¹⁴, R von Kummer¹⁵, J Gerber¹⁵, A Xavier¹⁶, A Khaldi¹⁷, P Gailloud¹⁸, A Turk¹⁹, P Schramm²⁰, G Rappard²¹, M Ollenschleger²², R Pergolizzi²³, J Mocco²⁴, R Tawk²⁵, S Prothmann²⁶, J Delgado²⁷, Y Kayan²⁷, S Satti²⁸, T Patankar²⁹, F Hui³⁰, P Jacobson³¹, H Woo³², M Brant-Zawadski³³, C Roth³⁴, C Kazmierczak³⁵, E Mualem³⁶, S Hak³⁶, N Nguyen³⁶, S Sit³⁶ and for the Penumbra ACE Trial Investigators

¹Overlake Hospital, Bellevue, WA, USA

²Erlanger Health System, Chattanooga, TN, USA

³Froedtert Hospital, Milwaukee, WI, USA

⁴Massachusetts General Hospital, Boston, MA, USA

⁵SUNY Upstate Medical University, Syracuse, NY, USA

⁶University of Virginia Health System, Charlottesville, VA, USA

⁷Cottage Hospital. Santa Barbara, CA, USA

⁸Rush University Medical Center, Chicago, IL, USA

⁹Gundersen Medical Foundation, La Cross, WI, USA

¹⁰Fort Sanders Regional Medical Center, Knoxville, TN, USA

¹¹The Methodist Hospital Research Institute, Houston, TX, USA

¹²Icahn School of Medicine at Mount Sinai, New York, NY, USA

¹³University Hospital Schleswig-Holstein, Kiel, Germany

¹⁴University of Illinois at Chicago Medical Center, Chicago, IL, USA

¹⁵University of Dresden, Dresden, Germany

¹⁶McLaren Health Center, Flint, MI, USA

¹⁷WellStar Kennestone Hospital, Marietta, GA, USA

¹⁸Johns Hopkins University, Baltimore, MD, USA

¹⁹Medical University of South Carolina, Charleston, SC, USA

²⁰University Medical Center Göttingen, Göttingen, Germany

²¹Los Angeles Brain and Spine Institute, Los Angeles, CA, USA

²²Hartford Hospital, Hartford, CT, USA

²³Inova Fairfax Hospital, Falls Church, VA, USA

²⁴Vanderbilt University Medical Center, Nashville, TN, USA

²⁵Mayo Clinic Jacksonville, Jacksonville, FL, USA

²⁶Technical University of Munich, München, Germany

²⁷Northwestern Hospital, Minneapolis, MN, USA

²⁸Christiana Health Care Services, Newark, DE, USA

²⁹Leeds General Infirmary, Leeds, Germany

³⁰Cleveland Clinic, Cleveland, OH, USA

³¹Loma Linda University Health Care, Loma Linda, CA, USA

³²Stony Brook University Hospital, Stony Brook, NY, USA

³³Hoag Hospital, Newport Beach, CA, USA

³⁴Klinikum Bremen-Mitte, Bremen, Germany

³⁵William Beaumont Hospital, Royal Oak, MI, USA

³⁶Penumbra, Inc., Alameda, CA, USA

Purpose: Endovascular coil embolization is highly effective and is routinely used to treat cerebral aneurysms. From recent literature, there is an increased concern regarding radiation exposure from these types of medical procedures. The Penumbra Coil 400™ system (PC400) is a new generation of 0.020” diameter coils designed to enhance filling efficiency, effectiveness, and safety. Reported herein are outcomes from a post-hoc analysis of the PC400 Aneurysm Coiling Efficiency multicenter registry comparing the Pipeline embolization device and conventional coils in a recent published article (Colby et al., 2014) to coiling in large and giant proximal aneurysms (≥10 mm).

Methods: The PC400 registry is a prospective study of patients with intracranial aneurysms who are treated with the PC400 System. Patients with cerebral aneurysms ≥10 mm were included in this analysis.

Results: 100% of Pipeline and conventional coils aneurysms were located in the ICA (N = 37 and N = 18, respectively), while PC400 registry had 59.2% in the ICA (N = 98). Mean age in PC400 registry was 63.5 ± 13.3 vs. Pipeline’s 60.0 ± 2.1 (p = 0.0135) and conventional coils’ 62.2 ± 1.9 (p = 0.3628). Mean aneurysm size (mm) was greater in PC400 registry than Pipeline (15.0 ± 6.7 vs. 13.5 ± 0.6, p = 0.0306) and similar to conventional coils (15.0 ± 6.7 vs. 14.9 ± 1.5, p = 0.8960). Total mean fluoroscopy time (min) was significantly lower for PC400 registry than both Pipeline (48.5 ± 32.8 vs. 56.1 ± 5.0, p = 0.0305) and conventional coils (48.5 ± 32.8 vs. 85.9 ± 11.9, p < 0.0001). The PC400 cohort had a 43.5% reduction in time compared with conventional coils.

Conclusion: Analysis of treatment of large and giant proximal aneurysms displayed significant reduction in fluoroscopy time in the PC400 cohort even with a greater aneurysm size. This demonstrates that coil embolization with the larger diameter PC 400 may have promise in requiring less radiation exposure.

324

Rescue Mechanical Thrombectomy Using a Retriever Stent for Thromboembolism During Coil Embolization of Ruptured Cerebral Aneurysms

HChun¹, JH Kim¹, JH Ahn¹, JK Oh¹*, JH Song¹ and IB Jang¹

¹Department of Neurosurgery, Hallym University Sacred Heart Hospital, Anyang, Korea

Purpose: In patients with subarachnoid hemorrhage, intraoperative thromboembolism during coil embolization of ruptured cerebral aneurysms is major concern, which is reported as 3% to 10%. Especially in the case of totally occlusive arterial thrombi, the role of intra-arterial fibrinolytic agent is limited. The authors report the experience and outcome of stent retriever in patient with totally occluded arterial thrombi during coil embolization.

Methods: Between January 2013 and December 2014, 91 patients with intracranial ruptured aneurysm were treated by using endovascular coil embolization. Among the 91 patients, arterial occlusion caused by thromboembolic event occurred in 7 patients (7.7%). In these patients, mechanical thrombectomy by using stent retriever (Solitaire AB stent, Covidien, Irvine, California) with or without adjuvant administration of intra-arterial fibrinolytic agent was performed. We respectively reviewed the angiographic and clinical outcomes of the rescue treatment with stent retreiver.

Results: Complete recanalization was achieved in 6 cases (85.7%) and partial recanalization in 1 case (14.3%). Whereas 5 patients were asymptomatic after thrombolysis by stent retriever, 1 patient suffered from postprocedural bleeding, and cerebral infarction occurred in the remaining 1 patient.

Conclusion: Mechanical thrombectomy with stent retriever may be considered as rescue treatment for the patients with totally occlusive arterial thrombi, as well as the patients who experienced failure from intra-arterial fibrinolytic agent. Attention should be paid for the prevention of fatal cerebral hemorrhage after procedure.

325

Effects of Smaller Finalising Coils (Less Than 2 Mm in Diameter) on Preventing Recurrence After Embolisation of Small Cerebral Aneurysm

YIChun¹, HG Roh² and DS Park¹

¹Department of Neurosurgery, Konkuk University, Seoul, Korea

²Department of Neuroradiology, Konkuk University, Seoul, Korea

Purpose: Smaller coils which are less than 2 mm in diameter has been used at the final stage of embolisation to achieve better aneurysm occlusion immediately. But good angiographic occlusion does not always guarantee the long-term stability of the aneurysms. We compared follow up results of aneurysms finalised with less than 2 mm coils to non-finalised aneurysms to evaluate the effects of these small coils on permanent occlusion of the small aneurysms.

Materials and Methods: Medical records and angiographic images of 92 aneurysms, located at anterior circulation, their occlusion procedures started with 3 mm to 6 mm frame coil, were analysed retrospectively. Mean age was 56.1 year and male to female ratio was 1:2.5. Forty-nine aneurysms were ruptured (53.3%). Aneurysm were divided into three groups, ‘Finalised’ which consists of 54 aneurysms treated with 2 mm or less diameter coils at the last stage of the procedure, ‘Not Finalised’ twenty aneurysms, only coiled with 3 mm to 6 mm diameter coils, and eighteen ‘Hydrosoft’ group treated with hydrogel coated coils regardless of finalising coil usage. The degree of the aneurysm occlusion were initially evaluated 6 months after the procedure and thereafter 1 year interval with magnetic resonance angiography. Seventy-two aneurysms (78.3%) were followed more than 6 months and the mean follow up interval was 26.6 months.

Results: In not finalised group, complete occlusion rate immediately after the procedure was 15% (3 of 20, mean packing density 22.3%). Among 17 aneurysms which have follow-up images, 16 aneurysms (94.1%) achieved satisfactory occlusion and only 1 aneurysm (5.9%) was retreated due to recurrence. Finalised aneurysms achieved 46.3% initial complete occlusion rate (25 of 54, mean packing density 21.9%) and 89.6% (43 of 48) satisfactory occlusion rate on follow-up. Four aneurysms (8.3%) were recurred in finalised group. Aneurysms treated with Hydrosoft coils achieved 5.6% (only 1 of 18, mean packing density 28.2%) immediate complete occlusion rate and 73.3% (11 of 15) on follow up. Three aneurysms (20%) were recurred in Hydrosoft group. Thromboembolic events were occurred 4 in finalised group, 3 in not finalised group and 1 in Hydrosoft group. There was no permanent neurological deficit nor death.

Conclusion: By finalising small aneurysms with less than 2 mm diameter coils, we could achieve higher immediate complete occlusion rate. But the long-term results did not match with initial degree of the occlusion. With not finalising technique, we achieved better satisfactory occlusion and less recurrence after coil embolisation of the small aneurysms.

326 Presentation withdrawn

A Modified Canine Side-Wall Aneurysm Model Designed for Testing of Intra-Luminal and Intra-Saccular Flow Diverters

DConsigny, D Niemann and C Strother

University Wisconin Medical School Madison, WI USA

Purpose: Our goal was to create a canine aneurysm model suitable for use in testing of intra-saccular and intra-luminal flow diverters.

Methods: All procedures were performed under an institutional approved protocol. Vein patch aneurysms were created as has been previously described in detail for construction of terminal aneurysms except the vein patch was offset to the side of the bifurcation formed by anastomosis of the proximal RCCA with the junction of the connected distal LCCA and RCCA.

Results: 24 aneurysms were created with the size ranging between 5 and 12 mm. in the greatest dimension. Over a period of 5.5 weeks between aneurysm creation and angiographic evaluation 2 partial thrombosis occurred. Angiography done at 30fps revealed a distinct flow jet entering the left side of the aneurysm pouch (the side closest to the proximal RCCA). Flow in these aneurysms was intermediate between the sluggish flow typical of sidewall aneurysms and the hyperdynamic flow seen in the bifurcation and terminal aneurysm models. The anatomy of this aneurysm closely resembles that of a side-wall type aneurysm occurring just distal to a major bifurcation.

Conclusion: The modified side-wall model has more robust flow than does that of the conventional model. It better mimics human aneurysms typically treated with flow diverters than does the conventional canine side wall aneurysm model. Additional modifications can be made with this model to simulate various asymmetric aneurysm configurations.

327

Patient-Specific Velocity and Flow Profiles of Intracranial Arteries

BMW Cornelissen^1,2,3, JJ Schneiders¹, MC Ruiz^1,2, ME Sprengers¹, P van Ooij¹, AJ Nederveen¹, HA Marquering^1,2, and CBLMMajoie¹

¹Department of Radiology, Academic Medical Center, University of Amsterdam, the Netherlands

²Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, the Netherlands

³MIRA Institute for Biomedical Engineering and Technical Medicine, University of Twente, Enschede, the Netherlands

Purpose: Computational Fluid Dynamics (CFD) is commonly used in studies to determine hemodynamic risk factors of intracranial aneurysm rupture. Most of these studies use generalized inflow profiles obtained from healthy volunteers as boundary conditions. However, there are large variations in arterial flow profiles between patients and between anatomical locations. The aim of this study was to generate location-specific velocity and flow parameters of aneurysmal parent arteries with the potential to use in CFD studies.

Methods: For 94 patients (62 male; mean age 55.2) with a total of 103 aneurysms (61 ruptured), we collected velocity information in aneurysmal parent arteries for a full cardiac cycle using 2D PC-MRI. Velocity profiles were collected for the middle cerebral artery (n = 30), anterior communicating artery (n = 26), internal carotid artery (n = 19), posterior communicating artery (11), basilar artery (n = 10), anterior cerebral artery (n = 6), and vertebral artery (n = 1). The maximum and mean velocity and the maximum and mean flow were determined and compared for each of the 15 artery combinations.

Results: Both the velocity and flow parameters showed significant differences between some of the different parent artery locations. For example, the median value of the maximum basilar artery velocities (74, range:38–87 cm/s) was significantly lower compared with the middle cerebral artery (97, range:50–150 cm/s). Both flow parameters showed significant differences in 10 of the 15 combinations. In 4 of the 15 and 6 of the 15 combinations, a significant difference was found for the mean and maximum velocity, respectively.

Conclusion: There are large variations in intracranial arterial flow profiles both per location as well as per patient. Our study underscores the need for using patient specific inflow profiles in CFD. When this information is not available, location specific inflow profiles can be used for more realistic CFD simulations.

328

The Influence of Vessel Straightening After Stent Placement on Hemodynamics in Sidewall Intracranial Aneurysms

BMWCornelissen^1,2,3, HA Marquering^2,3, CH Slump¹, R Berg van den² and CBLM Majoie²

¹MIRA Institute for Biomedical Engineering and Technical Medicine, University of Twente, Enschede, The Netherlands

²Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands

³Department of Biomedical Engineering & Physics, Academic Medical Center, Amsterdam, The Netherlands

Purpose: Neurovascular stent assisted coil embolization is frequently used for the treatment of wide necked aneurysms. These stents may have substantial effects on the vascular geometry and therefore also on intra-aneurysmal hemodynamics. This may promote thrombus formation in the aneurysm sac and reduce recurrence rates. In this study, we quantified straightening of the parent artery and the accompanying hemodynamic changes after stent placement.

Methods: From 6 patients with 6 sidewall aneurysms, 3D vascular models were created from 3DRA (n = 11) and MRA (n = 1) imaging data before and after treatment. The aneurysm morphology and parent vessel radii were assumed to be identical in the before and after treatment models. To quantify straightening of the parent vessel, the tortuosity (ratio between the artery length and the distance between both end points) was calculated. Computational fluid dynamics was used to simulate intra-aneurysmal hemodynamics. Flow patterns were characterized by two experienced neuroradiologists in consensus. Furthermore, the velocity magnitude, wall shear stress, and oscillatory shear index were calculated.

Results: For 2 cases, in which the stent was partially located in the extra-dural space, tortuosity and flow patterns remained unchanged. In the remaining 4 cases, tortuosity decreased with a mean of 56% and flow patterns changed in 3 cases.

Conclusion: Vessel straightening of the parent artery is likely to occur after stent placement in intra-dural arteries, resulting in alteration of flow patterns in some cases. However, hemodynamic changes vary and the changes in parent artery tortuosity are hard to predict. A larger population is needed to confirm these findings and to relate induced changes with recurrence rates.

329

The Relation Between Aneurysmal Inflow and Early Recurrence in Coiled Intracranial Aneurysms

JJ Schneiders¹, JW van den Berg¹, BMWCornelissen^1,2,3, R van den Berg¹, E VanBavel², HA Marquering^1,2 and CBLM Majoie¹

¹Department of Radiology, Academic Medical Center, University of Amsterdam, the Netherlands

²Department of Biomedical Engineering & Physics, Academic Medical Center, University of Amsterdam, the Netherlands

³MIRA Institute for Biomedical Engineering and Technical Medicine, University of Twente, Enschede, the Netherlands

Purpose: Coil embolization is an established technique for treatment of intracranial aneurysms. Recurrence occurs in 20% of coiled aneurysms due to coil compaction or enlargement of a remnant. Little is known about the relation of hemodynamics with early recurrence of coiled intracranial aneurysms.

Methods: 19 patients with 19 early aneurysm recurrences were identified in our database of 270 patients. Hemodynamics of untreated aneurysms were simulated using computational fluid dynamics to determine the location of the inflow jet. Overlap of the entire inflow jet and its core (highest 20 percentile inflow velocity) with the area of recurrence at the aneurysm neck was assessed.

Results: In 14 out of 19 cases (74%) the location of the core of the jet agreed with the area of recurrence. In 16 out 19 cases (84%), the area of the whole inflow jet overlapped with the area of recurrence.

Conclusion: In most aneurysms, there is a strong agreement between the pre-treatment aneurysmal inflow location and the position of early recurrence. However, this strong relation was not found in all recurrent aneurysms. This study suggests that hemodynamics may have an important role in aneurysm recurrence, but that more aspects should be taken into account to accurately predict location and prevalence of recurrence.

330

Endovascular Treatment of Persistant Hypoglossal Artery Aneurysm

Dolek¹, I Akmangit¹, E Daglioglu¹, D Belen¹, T Kaya¹, R Akdag¹ and A Arat²

¹Ankara Numune Education and Research Hospital, Ankara, Turkey

²Hacettepe University Faculty of Medicine, Ankara, Turkey

Purpose: Persistent hypoglossal artery is a rare vascular anomaly. The persistent hypoglossal artery (PHA) is the second most common carotid-vertebrobasilar artery anastomosis and its reported prevalence is 0.02%–0.10%. There were seldom reports regarding endovascular treatment of PHA aneurysm in the literature. The present case is the first PHA aneurysm treated with Surpass flow diverter.

Methods: 51- year-old men was admitted to emergency wards with loss of consciousness. CT revealed severe subarachnoid hemorrhage. There were no positive neurological sign on admission.

Angiograms showed communication between the right internal carotid and basilar arteries through an anomalous vessel penetrating the hypoglossal canal. Three-dimensional reconstructions showed an optimal visualization of the PHA aneurysm’s neck and measurement of the sac. Aneurysm size was calculated as 4.5×5 mm.

Results: The patient was successfully treated with primary coil embolization. Residual neck filling was noted on 10 months follow up angiograms and a Surpass flow diverter 3x20mm was deployed at the aneurysmatic segment. On 18 months follow-up angiograms the aneurysm was completely eliminated from the circulation.

Conclusion: PHA is a rare vascular anomaly that might be associated with other vascular disorders such as aneurysms and atherosclerotic diseases. In the present report, endovascular treatment with flow diverter treatment and opotimum result was achieved with good clinical outcome on 18 months of follow up. To our knowledge; this is the first reported case of PHA aneurysm reported to be treated with intracranial flow diverter.

331

True Posterior Communicating Artery Aneurysms: Report of 2 Seldom Cases Treated with Primary Coiling and Silk Flow Diverter

TKaya¹, I Akmangit¹, E Daglioglu¹, B Tunc¹, D Belen¹ and A Arat²

¹Ankara Numune Education and Research Hospital, Ankara, Turkey

²Hacettepe University Faculty of Medicine, Ankara, Turkey

Purpose: True posterior communicating artery (PCoM) aneurysms are rare in which the aneurysm arises only from the PCOM rather than the junction of the ICA or PCOM. Most of the previous reports featured microsurgical clipping rather than endovascular measures. True PCoM aneurysms might also be associated with ipsilateral ICA occlusion. PCOM must be followed posteriorly to visualise the aneurysm neck for microsurgical clipping though visualisation might be associated with periprocedural complications due to temporal lobe retraction particularly in cases presenting with rupture.

Methods: The present report featured 2 female cases 52 and 79 years old respectively. The former presented with rupture whereas severe headache was the symptom in the latter case. Patient presenting with SAH was featuring a trilobulated aneurysm close to P1 segment with a 5.5x4 mm in size and primary coiling was preferred for treatment. Second case was a 79-year-old female presenting with severe headache featuring an aneurysm with a size of 5x5.5 mm and Silk flow diverter covering the aneurysmal segment was preferred treatment modality.

Results: Follow up was reported to be 38 and 14 months respectively. There was no mortality or morbidity in any of the patients. Aneurysms were completely eliminated from the circulation in both patients. No periprocedural or late complication was encountered in any of the cases.

Conclusion: Primary endovascular treatment of true PCoM aneurysms is feasible and safe alternative to microsurgical clipping. Primary coiling or treatment with flow diverter stents are available options.

332

The endovascular treatment of the cerebral aneurysms with FRED – flow diverter – the experience on 21 patients

SDima and L Marginean

National Institute of Neurology and Cerebrovascular Diseases Bucharest Romania

Purpose: The analysis of the cerebral aneurysms treatment with FRED (flow diverter) in the period 20 august 2013 – 1 march 2015.

Methods: 21 patients with 24 aneurysms.

We covered with FRED 23 aneurysms– in 2 patients we covered 2 aneurysms with only 1 stent, and for 1 aneurysm we used coils.

The aneurysms

6 aneurysms were ruptured (1 cavernous segment aneurysm, 1 anterior coroidal artery origin aneurysm, 1 bazilar tip artery aneurysm, 1 MCA bifurcation aneurysm, 2 posterior communicating artery origin aneurysms) 18 aneurysms non-ruptured.

Localisation of the aneurysms

ICA cavernous segment – 7 aneurysms

ICA ophtalmic segment – 5 aneurysms

ICA posterior communicating artery origin – 2 aneurysms

MCA bifurcation – 1 aneurysm

Anterior communicating artery – 1 aneurysm

Bazilar tip bifurcation – 1 aneurysm

Results: 20 aneurysms – total occlusion – 1 year (87%)

2 aneurysms – got smaller – 1 year (9%)

1 aneurysm – unchanged – 1 year (4%)

19 patients – follow-up at 1 year (90.5%)

1 aneurysm ruptured 6 weeks after stent implantation (20 mm. diameter aneurysm – no coils inside)

3 cases – in stent moderate stenosis but without clinical symptoms at 8 weeks, solved at 1 year

2 FREDs needed balloon inflation for proper wall apposition (in very tortuous vessels)

1 stent occlusion (patient stopped the antiplatlets therapy after 4 weeks)

Conclusion: FRED is easy to use (very few technical complications).

FRED is efficient (high rate occlusion at 1 year).

333

Endovascular Treatment of Intracranial Infectious Aneurysms

AEsenkaya

Trakya University Medical Faculty

Purpose: Intracranial infectious aneurysms (IIA) are rare infectious neurovascular lesions, which account for %1–5 of all intracranial aneurysms. They are most often seen during bacterial endocarditis although they can be caused by fungal infections as well.

Methods: From 2000 to 2014, 13 patients (6 women, 7 men) with 15 mycotic aneurysms (13 were ruptured, 2 were unruptured) were treated by endovascular approach in our institution. The age of patients ranged from 5 to 68 year with a mean age of 41.6. Data of all patients were carefully and retrospectively reviewed including radiological studies and clinical records.

Results: All patients were treated immediately with endovascular approach after the confirmation and/or suspicion of IIA. In all but one occasions, aneurysms were located in distal cerebral circulation, while one aneurysm was located in cavernous part of the internal carotid artery which was due to the local invasion of cavernous sinus fungal infection. Detachable coil was used as an embolization material in 10 of 15 aneurysms, liquid embolic agent in 3 patients, and detachable balloon in one patient, while the last aneurysm was occluded spontaneously. Occlusion of parent vessel together with aneurysm was performed in 14 (including spontaneous occlusion) aneurysms, while intrasaccular coil embolization could be done in one patient. MRI and MRA follow-up was performed at least one occasion in all cases which revealed stable results. We did not encounter any extra morbidity after embolization, and we had no mortality in the follow-up.

Conclusion: Endovascular occlusion of parent vessel together with aneurysm appears to be the good management strategy in most cases in case of intracranial infectious aneurysm.

334

Mid-Term Experiences with the Pulserider

GGal

Odense University Hospital

Purpose: To report our experience with a recently developed adjunctive device for the endovascular treatment of bifurcational wide neck aneurysms.

Methods: Between May 2014 and May 2015, 12 wide-necked aneurysms, in 12 patients were treated with coils and the PulseRider® (Pulsar Vascular, San Jose, CA, USA), serving as a scaffold, placed at the aneurysm neck. Five aneurysms were located at the MCA bifurcation, five at the ACom, and two at the BA-tip. All aneurysms were considered “difficult to treat” lesions, two of them previously treated with coils, one with coils and WEB, and one surgically clipped. Five aneurysms were ruptured, one of them treated in the acute phase. All elective patients were premedicated with platelet inhibitors. The device was introduced through a 0.021″ microcatheter and deployed at the neck of the aneurysms. A 0.017″ microcatheter was navigated through the PulseRider® into the aneurysm, which was subsequently occluded with coils. Following completion of the coil packing, the device was electrically detached.

Results: In all cases the device could be navigated to and deployed at the target site. Crossing the device with a 2nd microcather for coil placement was possible in all cases, allowing for successful and complete aneurysm occlusion. No complications occurred during the procedures. All elective patients were discharged on the 2nd day after the treatment. Follow up examination with MRA in two patients showed permanent, total occlusion of the aneurysms. The rest await follow up angiograms.

Conclusion: The PulseRider® is a promising new device that can easily be deployed through a low profile (6 F) guiding catheter. It expands the neurointerventional armamentarium for “difficult to treat” cerebral aneurysms that would otherwise require double stenting or flow diverter. The lesser amount of intraluminal metal may allow for its future use in acutely ruptured cases.

335

Preliminary Experience with Pconus for the Treatment of Wide Neck Bifurcation Aneurysms in 10 Patients

EPampana¹, R Gandini¹, G Scevola², F Chegai¹ and A D’Onofrio¹

¹Department of Diagnostic Imaging, Interventional Radiology, Radiotherapy and Nuclear Medicine, IRCCS Policlinico Tor Vergata, Rome, Italy

²Interventional Radiology Department, Pertini Hospital, Rome, Italy

Purpose: The pCONus Bifurcation Aneurysm Implant is an intraluminal device intended to assist coiling in the treatment of complex and wide neck intracranial bifurcation aneurysms.

We report our preliminary experience with pCONus devices.

Methods: Ten patients with ten wide-neck aneurysms (3 recently ruptured) were treated with pCONus assisted coiling.

Seven aneuryms were located in the anterior circulation (3 aCom and 4 MCA) and three in the posterior circulation (basilar artery). pCONus device was preferred to other techniques due to its secure anchoring and optimal placement mainly related to its precise deployment and complete recoverability.

Primary end points were complete aneurysm occlusion and clinical safety considered as absence of death, of major or minor stroke.

Results: In 7 patients complete occlusion was achieved, in 3 a residual neck remnant was observed. Clinical safety was obteined in all patients as no ischaemic complications were observed.

Neurologic status remained unchanged at follow-up.

Angiographic controls at 6 months were obtained in 7 patients with no significant modifications of aneurysms filling.

No intimal hyperplasia was observed.

Conclusion: The use pCONus Bifurcation Aneurysm Implant system has confirmed to be safe and very effective, with a precise deployment control that allows the facilitates and extends the possibility of endovascular treatment of complex and wide neck intracranial bifurcation aneurysms.

336

Double Microcatheter Tehnique for Coiling of Wide-Neck Aneurysm

MI, HarsanAgus, A Onnie, S Ferry, S Gde Budi and JW Eka

Neuroscience Center, Siloam Hospital – Medical Faculty Pelita Harapan University

Tangerang – Indonesia

Purpose: To study effectiveness and problematic of using double microcatheter for coiling of a wideneck aneurysm.

Methods: Serial case report.

Result: With double microcatheter technique, coil can be stabilized in desired position. Advantage of this tehnique : it is simple and easy. While drawback of this tehnique is the stiffness of the coil that not yet detached sometime make difficult to get a tight filling.

Conclusion: Double microcatheter tehnique is feasible and helpfull for coiling of wide neck aneurysm.

337

Effect of Modeled Arterial Configuration on the CFD Predictions of Cerebral Aneurysm Hemodynamics

KM Saqr^1,3 and THassan^2,3

¹College of Engineering and Technology, Arab Academy for Science, Technology and Maritime Transport, Alexandria 1029, EGYPT

²Department of Neurosurgery, Alexandria School of Medicine, Alexandria University, Alexandria, EGYPT

³Research Center for Computational Neurovascular Biomechanics, Smouha University Hospital, Alexandria 21523, EGYPT

Purpose: Transient patient specific CFD simulations were conducted to investigate the effect of modeled arterial configuration on the predictions of cerebral aneurysm hemodynamics with an emphasis on wall shear stress and oscillatory shear index. The arterial configuration considered in a CFD model contributes significantly to the time required to perform the computations, especially in transient models.

Methods: The CFD model adopted two non-Newtonian blood viscosity model; namely power-law and Carreu models, in addition to Newtonian viscosity model.

Results: The findings suggest that the viscosity model affect the model sensitivity to the length of parent and child arteries considered in the model.

Conclusion: The reduction of modeled arterial configuration may reduce the required computational time segnificantly. however it may result in mispredictions of arterial hemodynamics. The use of non-Newtonian viscosity models increases the CFD model sensitivity to geometrical configurations. Therefore extensive patient specific simulations are required to define optimal arterial configuration for the CFD to become effective in cerebral aneurysm management.

338

A Case of Transbrachial Coil Embolization of Unruptured Basilar Tip Aneurysm

SKHwang

College of Medicine, Ewha Womans University, Seoul, Korea

Purpose: We describe a case of coil embolization of an unruptured basilar tip aneurysm via a transbrachial artery approach.

Methods: A 73-year-old female with a medical history of acute cerebral infarction, hypertension, and hyperlipidemia, presented with dysarthria and right sided limb weakness. Magnetic resonance angiography and digital subtraction angiography revealed an unruptured basilar tip aneurysm.

Results: She presented for a planned endovascular coil embolization. The initial attempt by transfemoral approach was complicated by persistent guide catheter instability and high risk of thromboembolism due to marked tortuosity of internal carotid artery and vertebral artery. The aneurysm was successfully treated by transbrachial coil embolization with a 5-French guide catheter. The patient recovered favorably without any further neurological deficit.

Conclusion: The transbrachial approach is a viable approach for endovascular aneurysm coil embolization in cases with an unstable guide catheter and high risk of thromboembolism due to tortuous vessels or abnormal anatomy when femoral access is complicated or contraindicated (Schönholz et al., 2004;. Wu et al., 2006; Zaidat et al., 2007).

339

Creating a Visualization Model of Filling Coil Insertion in Aneurysm

IMasashi, I Takashi, M Noriaki, O keisuke, S Kazunori, T Hayato, I Tasuku, N Masahiro and W Toshihiko

University of Nagoya, Nagoya, Aiti, Japan

Purpose: There are many kind of filling coil but detailed behavior is not clear, because of the coil of the past is placing in the aneurysm. The purpose of this study is observing some filling coils behavior in the aneurysm model.

Methods: We place the microcatheter in the center of the silicon aneurysm model (diameter 8 mm / neck 1.5 mm) and place three helical nylon coils (55 cm, VER 15%). Next we place seven kind of filling coils (Target 360 soft, CASHMERE, Galaxy Xtrasoft, Axium, COSMOS, ED COIL ExtraSoft, ED COIL ∞ ExtraSoft) and observe the behavior. We analyze size, position, form and reproducibility.

Results: Each coils have the characteristic behavior. In the same secondary coil roller, some coils have the different size. Target and Axium tend to become large size. ED COIL tend to become small size. ED COIL ∞ is placed different form in each practice. The primary coil roller is smaller, tend to place in the depths.

Conclusion: In this experiment, each coils have different behavior in the same conditions. This result may allow to choice suitable coil in various situation.

340

The Efficacy of Embolization Using Double Catheter Technique for Ruptured Very-Broad Aneurysms

TIzumi¹, N Matsubara¹, K Shintai¹, H Tajima¹, M Ito¹, T Imai¹, M Nishihori¹, S Miyachi² and T Wakabayashi¹

¹Nagoya University, Nagoya, Japan

²Osaka Medical University, Takatsuki, Japan

Purpose: We used double catheter technique (DCT) for very-broad-neck ruptured aneurysms for which balloon neck plasty technique is inappropriate. We analyzed our clinical result and discussed the adequacy of our strategy which was to avoid stent assisted technique in acute phase of subarachnoid hemorrhage.

Methods: Fifteen patients with 15 aneurysms underwent embolization with DCT between 2008 and 2013. The most frequent locations were IC-PC and BA tip. The mean size of aneurysms in maximum diameter was 10.8 (3–24) mm. The mean dome-neck ratio was 1.1 (0.65–1.4). We studied the occlusion grade, perioperative complication, mRS at 90 days and recurrence in follow-up.

Results: At initial treatment, 7 aneurysms resulted in complete occlusion or neck remnant. Although the remaining 8 aneurysms were recognized slow body filling, re-bleeding was not found. In 2 cases, asymptomatic infarction due to coiling was found. The ratio of mRS 0–2 was 88% and 29% among the patients with Hunt & Hess grade 2–3 and 4–5. Among 3 basilar aneurysms, recurrence was found and 2 aneurysms were retreated with stent-assisted coiling resulted in 1 further recanalization.

Conclusion: The embolization with DCT for ruptured very-broad-neck aneurysms was effective and safe. Although stent-assisted coiling for recurrent aneurysm in chronic stage was effective, the large thrombosed aneurysm need parent vessel occlusion or the application of flow-diverting stent.

341

Tactic and Pitfall of Residual or Recurrent Cerebral Aneurysm

SJJang¹ and DE Kim¹

¹University of Chosun, Gwang-ju, South Korea

Purpose: Among previously treated aneurysm, surgical clipping has 4% possibility of remant aneurysm and has 0.38–0.79% possibility of rebleeding from remnant aneurysm per year. Coiling has 60–90% possibility of total or near total occlusion rate, but has 2.9% possibility of rebleeding from remnant aneurysm. Several studies were done such as CARAT(cerebral aneurysm rerupture after treatment) study, ISAT study.

Materials and Methods: In total, 13 patients, with residual or recurrent aneurysm after treatment between January 1996 and June 2013 were included. We retrospectively evaluated the medical records, radiologic findings.

Result: Total 13 patient, male were 5 and female were 8. Ruptured aneurysms were 11 (clip 4, coil 7) and unruptured aneurysms were 2 (clip 1, coil 1). Residual or recurrent aneurysms after surgical clipping were 5 of 1868 (0.2%) and same after coiling were 8 of 222 (3.6%).

Location of recurrent aneurysm after clipping included the following; A-com (n = 2), P-com (n = 2), MCA (n = 1) and same of after coil included the following; A-com (n = 4), P-com (n = 2), ICA (n = 2).

Conclusion: Previouly treated aneurysms need to follow up imaging because of recurrence and rebleeding. A-com aneurysms and endovascular group have higher frequency of recurrence. Embolization could be safe, effective option with low morbidity and mortality, but it leaves a doubt of long term durability. Open microsurgery is the definitive treatment, but it is a heavy burden to neurosurgeons.

342

Clinical Implication of Fenestration in Patients with Anterior Communicating Artery Aneurysm Treated with Coil Embolization

P Jeon¹, KI Jo¹, JY Yeon¹, SC Hong¹, JS Kim¹, KH Kim¹, JW Baek¹ and JJ Park¹

¹Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Republic of Korea

Purpose: The purpose of this study was to evaluate morphologic factors associated with rupture in anterior communicating artery (AcomA) aneurysms and to investigate the clinical implication of AcomA fenestration as a risk factor for aneurysm rupture.

Methods: The clinical and radiologic findings of 255 patients with AcomA aneurysms treated with coil embolization between January 2005 and March 2014 were retrospectively reviewed. We performed univariate and multivariate analyses to evaluate the associations between morphologic variables and rupture status.

Results: The number of patients with AcomA fenestration was 17 out of 255 (6.6%). There were no statistically significant differences between the fenestration group and nonfenestration group in clinical and morphologic characteristics. Multivariate logistic regression tests showed that superior direction of aneurysm dome (OR 2.8, p = 0.018), presence of a daughter sac (OR 6.6, p < 0.001), high aspect ratio (OR 2.6, p = 0.019), size greater than 7 mm (OR 2.9, p = 0.021), and AcomA fenestration (OR 3.5, p = 0.043) were significantly associated with AcomA aneurysm rupture.

Conclusions: The results of this study demonstrated that a fenestrated AcomA is associated with risk of aneurysm rupture. Therefore, AcomA fenestration should be considered as an important morphologic risk factor for rupture, along with other known risk factors such as the direction of aneurysm dome, a daughter sac, high aspect ratio, and size.

343

Hemodynamic and Geometric Characteristics as Predictors for the Rupture of Cerebral Aneurysms: Case-Control Study in Two Groups of Patients with Ruptured and Stable Unruptured Lesions

CMJimenez¹, S Correa² and JR Cebral³

¹Neurosurgeon and MSc in Epidemiology, University of Antioquia and Eafit University, Medellin, Colombia, South America

²PhD in Biomedical Engineering, Eafit University, Medellin, Colombia, South America

³PhD in Physics, Center for Computational Fluid Dynamics, George Mason University Fairfax, VA, USA

Purpose: To identify hemodynamic and geometric characteristics that predict the rupture of cerebral aneurysms, comparing two groups of patients: ruptured (cases) versus unruptured stable lesions with at least one year of follow-up (control)

Methods: In this observational case-control study, two groups of patients with cerebral aneurysms were compared: 35 patients with a ruptured aneurysm and 35 patients wit an unruptured lesion; the control group had at least one year of follow-up after diagnosis in order to define the lesion as stable. In both groups the hemodynamic analysis of the lesions was performed by the method of computational fluid dynamics. At the same time, a total of fifteen geometric variables were analysed: max aneurysm size, max depth & width, aneurysm volume, aneurysm surface area, average neck diameter, undulation index, presence of blebs, height to width ratio, ellipticity index, non-sphericity index, aspect ratio, size ratio, volume to ostium ratio, bottleneck factor, aneurysm inflow-angle. To identify independent predictive variables for rupture, a multivariable logistic regression model was constructed, including the following information: demographic, genetic background, comorbidities (hypertension), smoking, and hemodynamic and geometric features.

Results: Two hemodynamic (mean wall shear stress and oscillatory shear index) and three geometric variables (max aneurysm size, aspect ratio and aneurysm inflow-angle) were identified as independent variables that predicted the rupture of cerebral aneurysms.

Conclusion: The study of hemodynamic and geometric features in unruptured cerebral aneurysms may yield valuable information to assess the risk of rupture, and thus to select patients for intervention or follow-up with more solid criteria.

344

Quantification of Velocity Changes in Patient-Specific 3D-Printed Replicas of Cerebral Aneurysms after Flow Diverter Placement by 3D Phase Contrast MR

CKarmonik^1,2, JR Anderson¹, O Diaz², YJ Zhang², RG Grossman³, R Klucznik² and GW Britz²

¹MRI Core, Houston Methodist Hospital Research Institute, Houston, Texas, USA

²Cerebrovascular Center, Houston Methodist Hospital, Houston, Texas, USA

³Department of Neurosurgery, Houston Methodist Hospital, Houston, Texas, USA

Purpose: To quantify intra-aneurysmal blood velocity changes after flow diverter (FD) placement in cerebral aneurysms by employing 3D-printed models and 3D phase contrast magnetic resonance imaging (3D pcMRI).

Methods: Based on retrospectively collected 3D digital subtraction angiographic (DSA) image data (Siemens AX), 3D models of five cerebral aneurysms were printed in polylactic acid (PLA, Makerbot Inc.). Models were attached to a continuous flow loop before and after covering the aneurysm ostium by a Pipeline FD device. Velocity components inside the aneurysm in three orthogonal directions were measured by 3D pcMRI (isotropic resolution: 1 mm, velocity encoding parameter: 100–120 cm/sec, Philips Ingenia 3.0 T). Blood velocities inside the aneurysm model with and without FD were calculated using full 3D velocity information obtained from the MRI image data.

Results: No MRI image artifacts were created by the Pipeline FD device. Blood velocities inside the aneurysm decreased for all cases (p < 0.03) and varied based on aneurysm and parent artery geometry from 13 to 50 % (mean: 23 %, range without FD: 28–52 cm/sec, range with FD: 16–43 cm/sec).

Conclusion: Patient-specific 3D-printed replicas of cerebral aneurysms were successfully used ex-vivo to quantify reduction in intra-aneurysmal blood velocities after FD placement. Decrease in velocities varied and depended on the geometry of the aneurysm and parent artery segment.

345

When the Working Angle at Cerebral Aneurysm Embolization Decided by 3D-RA is Beyond the Limits of C-Arm Range of Motion

M Katayama, S Inoue, R Sasao and S Suga

Department of Neurosurgery, Tokyo Dental College Ichikawa General Hospital

Purpose: Proper working angle results in excellent embolization at neuroendovasccular therapy of cerebral aneurysms. Analysis of 3D rotational angiography (3D-RA) makes it easy and proper to decide the working angle. However, sometimes the working angle decided by 3D-RA is beyond the limits of C-arm range of motion. We examined the difference between the limits of C-arm range of motion decided by workstation of 3D-RA theoretically and practically.

Methods: The limits of C-arm range of motion was plotted theoretically (decided by workstation) and practically from LAO 130°to RAO 130°and from cranial 90°to caudal 90°. DSA machine was AXIOM Artis dFA (Siemens), 3D-RA data was analyzed by LEONARD workstation with software syngo XWP version VA71C (old type) and syngo XWP version VB13F (new type).

Results: Region(1) within the limits of C-arm range of motion both theoretically and practically Region(2) within the limits of C-arm range of motion theoretically but beyond the limits practically. Region(3) within the limits of C-arm range of motion practically but beyond the limits theoretically. Region(4) Beyond the limits of C-arm range of motion both theoretically and practically. In cases of Region(1)(3), embolization is possible at the working angle decided by workstation. In cases of Region(2)(4), change of head position (chin up, chin down or head tilt) makes the working angle within the limits of C-arm range of motion practically. The new software makes the difference between the limits of C-arm range of motion theoretically and practically small.

Conclusion: When the working angle at cerebral aneurysm embolization decided by 3D-RA is beyond the limits of C-arm range of motion, change of the head position makes the working angle within the limits of C-arm range of motion practically.

346

Endovascular Coil Embolization of Intracranial Aneurysms with a Branch Arising from the Sac

KYasuhiro, T Tetsuya and F Shunichi

Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Kyoto, Japan

Background and Purpose: Because of a remarkable advance in technology and technique of endovascular coiling, a cerebral aneurysm with a branch incorporated into the sac can be safely treated. The purpose of this study is to review the feasibility, techniques, and clinical and angiographic outcomes of coiling aneurysms in this category.

Materials and Methods: Since 2012, we treated 17 patients with 18 cerebral aneurysms having a branch incorporated into the sac (8 unruputured, and 10 ruptured). In three of ruptured cases, retreatment was performed. Thus, we retrospectively reviewed and evaluated 21 procedures.

Results: Coiling was accomplished in 21 procedures without angiographical occlusion of the incorporated branch. Location of the aneurysms with the incorporated branch were the ICA-posterior communicating artery in 10 (55.6%), the middle cerebral artery in 3 (16.7%), the ICA-praclinoid artery in 1(5.6%), the anterior communicating artery in 1 (5.6%), the distal anterior cerebral artery in 1(5.6%) and the basilar artery in 1(5.6%). The aneurysms were treated using following tehchniques: single catheter (n = 10), stent-assisted coiling (n = 6), balloon-remodeling (n = 4), and double catheter (n = 1). Postembolization angiography revealed the folllowing: near-complete occlusion in 8 (38.1%), neck remnant in 10 (47.6%), and incomplete occlusion 3 (14.3%) aneurysms. Thromboembolisms were observed in 4 patients (19%) during or after the procedure. Procedure-related morbidity and mortality rates were 4.8% and 0%, respectively. Sixteen of the 17 patients had favorable outcome (modified Rankin Scale 0–2). Three recurrent aneurysms (16.6%) were observed during follow-up period exclusively in ruptured ICA-posterior communicating artery cases, and were treated endovascularly at 12–22 months.

Conclusions: By using the current techniques of endovascular treatment, cerebral aneurysms with a branch arising from the sac can be safely treated by coiling. However, risks and benefits should be carefully considered in the decision to treat aneurysm of this category especially for ICA-posterior communication artery aneurysms.

347

Functional Outcomes of Endovascular Coiling of Ruptured Cerebral Aneurysms

YKawabata¹, T Tsukahara¹, S Fukuda¹, T Aoki¹ and S Kawarazaki¹

¹Department of Neurosurgery, National Hospital Organization Kyoto Medical Center

Purpose: Since the publication of international subarachnoid aneurysm trial, endovascular coiling has been accepted as the first line treatment for ruptured cerebral aneurysms. We retrospectively reviewed and evaluated the functional outcomes of our experience.

Methods: Since 2011, 32 patients with saccular cerebral aneurysms presented with subarachnoid hemorrhage (SAH) were treated endovasuclarly. 8 patients were male and 24 patients were female. Median age was 65.5 years (range 36–88). 6 patients were classified as grade 5 according to Hunt and Hess grade. The modified Rankin Scale (mRS) was used to assess functional outcomes after treatment of at discharge.

Results: Procedure related morbidity was observed in a patient (3.1%). 25 patients (75.8%) had a good outcome. When we excluded a patient who had preictal mRS greater than 2 and 6 patients presented with grade 5 SAH, 24 of 25 patients (96%) had a good outcome. On the other hands, all the patients with grade 5 SAH were dependent or dead. Delayed cerebral ischemia was observed in 3 patients, and shunt-dependent hydrocephalus was observed in 2 patients.

Conclusion: Our data suggest that the prognosis after endorascular treatment of ruptured cerebral aneurysms has been improving. However, the prognosis of patients with grade 5 SAH remains poor.

348

Successful Endovascular Treatment of a Dissecting Aneurysm of Vertebral Artery Associated with Double Origin of the Posterior Inferior Cerebellar Artery: Case Report

YKawabata, T Tsukahara, S Fukuda, T Aoki and S Kawarazaki

National Hospital Organization Kyoto Medical Center, Kyoto, Kyoto, Japan

Background: Double origin of the PICA (DOPICA) were rarely reported in the literature, and reported incidence of DOPICA was 1.45% (Lesley, Rajab, and Case, 2007). In contrast, a high concurrence rate of DOPICA and vertebral artery dissecting aneurysm (VADA) has been reported (Kwon et al., 2007) (Koh et al., 2012).

Clinical presentation: A 61-year old woman presented with vomiting and diplopia with preceding headache. Magnetic Resonance Imaging (MRI) showed fresh infarction of left lateral medulla and a VADA of left vertebral artery (VA). The next day, she had transient loss of consciousness and worsening of headache, and MRI depicted subarachnoid hemorrhage.

Technique and intervention: Four-vessel digital subtraction angiography showed a posterior inferior cerebellar artery (PICA) arising both intracranially and extracranially from the left vertebral artery. Although the dissecting lesion involved V3 and V4 portion, it did not involve extracranially originating PICA. Internal trapping of V3 and V4 portion was chosen and performed safely, because the extracranial channel was expected to supply the PICA territory.

Conclusion: Early endovascular intervention should be considered in the treatment dissecting aneurysm of vertebral artery associated with double origin of the posterior inferior cerebellar artery for patients with relatively long lesions even in unruptured cases.

349

Endovascular Treatment for Superior Cerebellar Artery Aneurysms: Morphological Features, Technique, and Outcome

CHKim¹, YD Cho², SC Jung³, JH Ahn⁴, HS Kang⁵, JE Kim⁵, WS Cho⁵ and MH Han²

¹Department of Neurology, Myongji Hospital, Goyang, South Korea

²Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

³Department of Radiology, Asan Medical Center, Ulsan University College of Medicine Seoul, South Korea

⁴Department of Neurosurgery, Hallym Sacred Heart Hospital, Hallym University College of Medicine, Anyang, South Korea

⁵Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea

Purpose: Superior cerebellar artery (SCA) aneurysms have distinctive morphologic configurations and vascular origins. Herein, we have analyzed the angioarchitectural characteristics of SCA aneurysms and outcomes achieved through endovascular treatment.

Materials and Methods: Data accruing prospectively from January, 2002 to September, 2013 yielded 53 SCA aneurysms in 53 patients. Each lesion was classified as either basilar artery (BA), BA–SCA, or SCA type, according to the nature of incorporated vasculature. Clinical and morphologic outcomes were assessed, with emphasis on technical aspects of treatment.

Results: Angles formed by SCA and posterior cerebral artery were obtuse (124.8 ± 29.1°) on sides ipsilateral to aneurysms, differing significantly from contralateral counterparts (44.8 ± 22.0°) (p < 0.001). The most common type of aneurysm was BA-SCA (54.7 %), followed by SCA (28.3 %) and BA (17.0 %), and BA type aneurysms were the largest in size. Steam-shaped S-configured microcatheters (n = 19, 67.9 %) facilitated aneurysm selection for approach via contralateral vertebral artery (n = 28), whereas pre-shaped 45/90/J microcatheters (n = 21, 84.0 %) primarily were used for ipsilateral vertebral artery approach (n = 25). Single-microcatheter technique (52.8 %) was most often applied, followed by double-microcatheter (34.0 %), stent-assisted (9.4 %), and microcatheter-protection techniques (3.8 %). Aneurysmal occlusion was satisfactorily achieved in 45 lesions (82.1 %), with no procedure-related morbidity and mortality. In follow-up monitoring of 46 patients for a mean period of 25.8 ± 24.4 months, only a single instance of major recanalization (2.2 %) occurred.

Conclusion: Coil embolization of SCA aneurysms is a safe and effective treatment modality, enabling individualized procedural strategies to accommodate distinctive angio-anatomic configurations.

350

Transradial Approach for Intracranial Aneurysm Coil Embolization

H Kim, SR Kim, IS Park, MW Baik and YW Kim

Department of Neurosurgery, Bucheon St. Mary’s Hospital, The Catholic University of Korea

Purpose: To describe our experience with the transradial approach for coil embolization with or without stent assisted.

Materials and Methods: The clinical and imaging characteristics as well as periprocedural outcomes of patients treated for unruptured or ruptured intracranial aneurysm via the transradial approach were analyzed retrospectively. Between January 2008 and May 2013, ten patients with intracranial aneurysm (BA, n = 2, SCA, n = 2, PCA, n = 2, ICA, n = 2 and MCAB, n = 2) were treated via the transradial approach because of tortuous brachiocephalic and vertebral origin anatomy or bovine left common carotid artery.

Results: Simple coiling was two cases and other 8 cases (80%) are stent assisted coil embolization. Modified Raymond grade I results are 7 cases (70%), grade II are 3 cases. There were no procedure complications such as intracranial hemorrhage or ischemic stroke.

Conclusion: The transradial approach is an alternative method for coil embolization of intracranial aneurysms to the femoral approach for unfavorable access route.

351

Endovascular Treatment of Ruptured Anterior Inferior Cerebellar Artery Pseudoaneurysm Mimicking Non-Aneurysmal Subarachnoid Hemorrhage

JYKim, JW Oh, C Hu, K Whang, JS Pyen, YH Jung and JM Lee

Yonsei University Wonju College of Medicine, Wonju Severance Christian Hospital Department of Neurosurgery

Purpose: Subarachnoid hemorrhage (SAH) is usually caused by a ruptured intracranial aneurysm. However, in some patients, no source of hemorrhage might be detected despite repeated digital subtraction angiography (DSA). We report for the endovascular treatment is found in the case of anterior inferior cerebellar artery (AICA) pseudoaneurysm after repeated DAS.

Methods: A 74-year-old man presented with severe headache, drowsy mentality. Brain computed tomography revealed non-aneurysmal subarachnoid hemorrhage (SAH). DSA also revealed negative findings. After one week, DAS performed and found AICA pseudoaneurysm. Unfortunately, rebleeding was done after 2 hours to 2nd DSA.

Results: We tried endovascular treatment. Our plan was offending AICA occlusion by coil. Because we didn't select AICA, we only selected AICA proximal area. So, we deployed helical coil into AICA partially, then remained coil in basilar artery was stented by Enterprise stent. And we performed decompressive suboccipital craniectomy but the patient was expired.

Conclusion: In our case, we should be highly suspicious of patients with a nonaneurysmal SAH. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.

352

Telescopic Stenting as a Rescue Technique for Stent Displacement During the Endovascular Treatment of Intracranial Aneurysms – Case Series

EKisurin and S Kapatsevich

Republican Research and Clinical Centre of Neurology and Neurosurgery, Minsk, Belarus

Purpose: Flow diverters, self-expanding braided stents deployed across an aneurysm neck have wide applications. However giant, wide-necked and fusiform aneurysm represent a challenge to interventional neuroradiologists. We report our experience in telescopic stenting as a rescue technique for stent displacement during the endovascular treatment of intracranial aneurysms.

Methods: Between January 2013 and May 2015, 263 consecutive patients with intracranial aneurysms underwent endovascular treatment in our institution. 68 of 263 (26%) patients were treated with stents. After initially successful stent deployment in 4 patients we observed delayed (several minutes) stent dislodgement into the aneurysm. Location of aneurysm was as follows: ICA – 2, ACA – 1, basilar artery – 1.

Results: In 2 patients with dislodgement of the distal tip of the stent (ICA location both) we recatheterized the lumen of the displaced stent and the distal part of the parent artery and then successfully put second stent to reconstruct the artery. In case of giant basilar fusiform aneurysm it was proximal stent tip displacement, we deployed second stent from the first to the proximal segment of the parent artery. In case of giant partially thrombosed distal ACA aneurysm we observed delayed disjunction of initially telescopically deployed 2 stents, and third stent was used to reconstruct the artery.

Conclusion: Stent foreshortening may cause its dislodgement into the aneurysm. Maximize stent landing zone length may reduce the incidence of stent dislodgement. Telescopic stenting can be used successfully to reconstruct the artery.

353

Selection of Guiding System for Aneurysmal Coil Embolization

K Kitazawa¹ and Y Ito²

¹Department of Neurosurgery, Shinrakuen Hospital, Niigata, Japan

²Department of Neurosurgery, Brain Research Institute, Niigata University, Niigata, Japan

Purpose: Appropriate selection of guiding system is important to achieve successful coil embolization. We need to deliver guiding system to more distal part of the vessel and get strong support by guiding catheter, to obtain good handling with device. And we need the guiding catheter with large lumen to use several devices at once. We retrospectively investigated the selection of guiding catheter in patients who had previously undergone coil embolization.

Methods: Retrospective analysis was conducted for consecutive 95 patients who recieved coil embolization between May 2013 and May 2015 at our institutions. Type of guiding system, location of aneurysms and the technique for coil embolization were analyzed.

Results: 6Fr guiding catheters were selected in 20 patients (21%), 7Fr guiding catheters in 35 patients (37%) and 8Fr guiding catheters in 40 patients (42%). In all of 40 patients who underwent coil embolization with 8Fr guiding catheter, triple coaxial systems constructed with 6Fr intermediate catheter and 8Fr guiding catheter were selected. Most of the aneurysms located in MCA, Acom or ACA distal were treated with 8Fr triple coaxial system, aneurysms located in ICA with 7Fr guiding catheter and aneurysms located posterior circulation with 6Fr guiding catheter. Simple technique tended to be selected for coil embolization with 8Fr triple coaxial system. 85% of the cases with 8Fr triple coaxial systems were able to achieve beyond petrous ICA access. There was no complication related guiding catheter.

Conclusion: Simple technique with 8Fr triple coaxial system was used in most of the aneurysms located in distal part of the artery to achieve better microcatheter handling. Appropriate selection of guiding system might contributes to safe and successful coil embolization.

354

Follow-up Study of Intracranial Fusiform Aneurysms in the Vertebrobasilar Arteries

SKohyama, S Ishihara, F Yamane, N Uemiya, T Ostuka, K Mizogami and H Neki

International Medical Center, Saitama Medical University, Hidaka, Saitama, Japan

Purpose: Intracranial fusiform aneurysms in vertebrobasilar arteries (FAVBAs) are often detected incidentally by medical check-up with magnetic resonance imaging. FAVBAs are considered to be dissecting aneurysms in chronic stage which have not been diagnosed at onset. Although endovascular treatment is reported to be safe and effective for FAVBAs, their natural history is not well known. We report the follow-up data of FAVBAs and discuss their treatment strategy.

Methods: The clinical data of 83 patients (47 men, 36 women; mean age, 59 (35–82) years), who were incidentally diagnosed FAVBA (72 patients) or who had FAVBA derived from symptomatic unruptured vertebrobasilar dissection more than a year after onset (11 patients), were retrospectively analysed.

Results: Aneurysms were located in the basilar artery in 2 cases and in the vertebral artery in 75 cases. In other 6 cases, aneurysms extended from the vertebral artery to the basilar artery. With a mean follow-up of 41 months, enlargement of FAVBAs was occurred in 9 patients. Among them, three patients became symptomatic; rupture of aneurysm in 1, brainstem infarction in 1, brainstem symptom due to compression by aneurysm in 1. Significant risk factors for enlargement of FAVBAs were involvement of the basilar artery and the size of aneurysm.

Conclusion: Although Intracranial fusiform aneurysms in the vertebral artery have a good natural history, those involving the basilar artery tend to enlarge and become symptomatic. Observation is recommended for FAVBAs when they are stable.

355

3 Year Experience with Interventional Neuroradiology for Management of Cerebral Aneurysms at a Single Australian Centre Phase 1 of A Three Phase Study Investigating the Utility Of ROTEM Delta®, ROTEM Platelet® and Multiplate® Guided Management of Anti-Coagulation and Anti-Platelet Therapy in Adult Patients Undergoing Interventional Neuroradiological Procedures for Management of Cerebral Aneurysm

A McLaughlin¹, H Rice², L De Villiers², T Withers³, M Arnell¹, K Walters¹, S Czuchwicki^1,4, A Bulmer^1,4 and J Winearls¹

¹Intensive Care Unit, Gold Coast University Hospital and GCUH Critical Care Research Group

²Department of Interventional Radiology, Gold Coast University Hospital

³Department of Neurosurgery, Gold Coast University Hospital

⁴Heart Foundation Research Centre, School of Medicine, Griffith University

Purpose: Interventional Neuroradiological (NR) management of cerebral aneurysms carries the risk of thromboembolic and haemorrhagic complications, to which significant morbidity and mortality is attributed. As part of our three phase study investigating the utility of ROTEM Delta®, ROTEM Platelet® and Muliplate® guided management of anti-coagulation and anti-platelet therapy in adult patients undergoing Interventional NR procedures for management of cerebral aneurysm, we conducted a retrospective audit of experience at our centre.

Methods: The electronic medical records of all patients admitted to the Gold Coast University Hospital Intensive Care Unit following subarachnoid haemorrhage (SAH) or elective interventional NR or neurosurgical clipping of cerebral aneurysms between January 2011 and December 2014 were retrieved. Primary outcomes of interest were death, and thromboembolic and haemorrhagic events during hospital admission.

Results: One hundred and fifty-two patients underwent interventional NR procedures for cerebral aneurysms. This consisted of 92 (60.5%) elective cases and 60 (39.5%) emergency cases following SAH. The overall mortality rate was 5.9%, the rate of thromboembolic and haemorrhagic events was 11.2% and 7.2% respectively. For elective cases the mortality rate was 2.2%, the rate of thromboembolic and haemorrhagic events was 5.4% and 3.3% respectively. For emergency cases the mortality rate was 11.7%, thromboembolic and haemorrhagic event rates were 20% and 13.3% respectively. Intra-procedural complications occurred in 6.6% of the entire cohort; 4.3% of elective cases and 10% of emergency cases. Median length of follow-up was 448 days, with 91.6% of the entire cohort followed up. At follow up, 64.1% of patients had no neurological deficits, 29% had mild non-specific deficits and 6.9% had significant disability. Interventional NR represents the primary treatment modality for management of cerebral aneurysms at our centre. During the study period 9 patients underwent open neurosurgical clipping of cerebral aneurysms. These 9 patients were all elective and no patients with SAH underwent open neurosurgical intervention.

Conclusion: Management of cerebral aneurysms, particularly following rupture, is associated with significant risks of thromboembolic and haemorrhagic complications, which carry significant morbidity and mortality. The data from the cohort presented above forms the basis of the study design for subsequent phases. Phase 2 aims to identify patients at increased risk of complications using ROTEM Delta®, ROTEM Platelet® and Multiplate® devices.

356

Vascular and Hemodynamic Change in Endovascular Treatment for Ruptured Aneurysm with Coexistence of Severe Angiographic Vasospasm

CY Lee¹, HW Kim¹, CH Lee¹ and HR Kim¹

¹Department of Neurosurgery, Konyang University Hospital, Daejeon, Korea

Purpose: In severe vasospasm, various situations could be happened unlike non-spasmotic phase. We would like to report cases that experienced unforeseen circumstances in treatment for ruptured aneurysm with coexistence of severe vasospasm.

Methods: Three patients with subarachnoid haemorrhage (SAH) and severe vasospasm were treated with endovascular coiling.

Results: In two patients, non dominat ACA was not visualized and dominant ACA was severe narrowed. When the microcatheter was advanced near to aneurysm through parent ACA, blood flow arrest was occurred in total ACA territory. One of two patients, we quickly selected aneurysm, made frame using 2 coils and immediately, withdrew the microcatheter in proximal ACA.. After waiting for few minute, reselection and additional coiling was performed in several times. In this way, such as advance-withdrawal tip, aneurysm was obliterated and the blood flow was well maintained. In the other patient, Advance–withdrawal tip could not performed because proximal portion of A2 segment was curved, which made tension and jumping of microcatheter. Microcatheter was withdrawn to ICA and waited. Angiogram after few minutes, the ACA was more dilated and, when advanced in A2 segment, partial blood flow was observed in ACA territory. Aneurysm was obliterated and the blood flow was maintained. Vasospasm was slightly improved without angioplasty. In last patient, coiling was tried in A-com aneurysm. During coiling, contra-lateral ACA frequently was not visualized.

Conclusion: In final angiogram, the aneurysm seemed to be near totally obliterated. After two weeks, the vasospasm was improved but recanalization was occurred in previous coiled aneurysm. Although aneurysm seemed to be occluded completely on vasospasm period, early recanalization was happened between few days. In severe vasospasm period, the unfavorable influence on blood flow caused by intravascular device, effect of catheterlization to spasmotic vessel and the possibility of early recanalization should be considered.

357

Endovascular Treatment for Symptomatic Vertebral Artery Dissecting Aneurysms

DLim, S Ha and J Choi

Neurosurgery, Ansan Hospital, Korea University Medical Center, Ansan-si, Kyounggi-do, South Korea

Purpose: Vertebral artery dissecting aneurysms (VADA) are challenging disorders for neurosurgeons. Authors retrospectively evaluated our experience using endovascular techniques to treat these aneurysms.

Methods: Between July 2008 and December 2014, we treated 17 patients with dissecting aneurysms of the intracranial vertebral artery. Among them thirteen patients underwent endovascular treatment. Seven patients presented with subarachnoid hemorrhage from the ruptured aneurysm, another five presented with symptoms of abrupt severe headache and the other one with ischemia. The endovascular modalities were the following: 1) internal trapping (n = 7), 2) stent with coil (n = 2), 3) stent alone (n = 2), and 4) coil alone (n = 2).

Results: There were no procedural complications following endovascular treatment. Clinical outcomes were favorable in 11 patients (84.6%). Initial neurological status was the main factor for the clinical outcome. No re-hemorrhages were observed in these patients during follow-up.

Conclusion: Endovascular treatment, which includes several techniques, might be safe and effective strategy for patients with VADAs and can be the first choice for most patients. Risk can be managed by using appropriate endovascular techniques according to aneurysm location, configuration, and relationship with the posterior inferior cerebellar artery.

358

Protection Effect of Intentional Only Daughter Sac Coil Embolization of Complex Ruptured Cerebral Aneurysms(2 Years Long Term Follow Up)

JLim¹, J Lee¹, C Lee² and C Kang²

¹Neurosurgery department, Sun Hospital, Daejeon, Korea

²Neurosurgery department, Yuseong Sun Hospital, Daejeon Korea

Purpose: Protection effect of coil embolization of ruptured cerebral aneurysms has been well known against rebleeding, but whether only partial dome coiling of ruptured cerebral protects against rebleeding has been not as well known except only a few cases reports.

Methods: In the two cases, We had tried intentionally coiling in the only daughter sac of ruptured aneurysms. These two cases could be not done surgical clipping because of restrictively medical condition.

Results: In the all of cases, complete embolization of only daughter sac were done without procedural complications like aneurysmal rupture. We had performed regular fluoroscopy and magnetic resonance angiographic image follow-up during 2 years. First case, minimal coil compaction happened but an intra-aneurysmal blood inflow didn’t occur. Second case, any sort of change didn’t occur.

Conclusion: Proper use of a treatment strategy of intentional partial dome protection for complex aneurysms that are not favorable for clipping or primary complete coiling may prevent acute rebleeding and produce favorable clinical outcomes.

359

Therapeutic Strategies of Unruptured Intracranial Aneurysms Associated with Craniocervical Artery Stenosis

DLin, J Zhu, J Hu, H Jiang, Y Cai, W Zhao, J Shen and L Bian

Department of Neurosurgery, Ruijin hospital affiliated to Shanghai Jiaotong university school of medicine, No.197,RuiJjin Er Road,Shanghai, China, 200025

Purpose: To the therapeutic strategies of unruptured intracranial aneurysms associated with craniocervical artery stenosis.

Methods: The data of 72 patients diagnosed as UIAs associated with stenosis of carotid artery or vertebrobasilar artery by DSA examination were reviewed retrospectively. The parent arteries of UIAs were found stenosis with 37 patients. 35 patients had non-parent arteries stenosis including 5 patients with anterior communicating aneurysms. Aneurysm clipping and coiling, artery stenosis stenting, CEA, medical treatment and observation were chosen respectively count on the evaluation with each patient. All the patients underwent follow-up with DSA or MRA images.

Result: 11 of 37 UIAs patients with parent artery stenosis were performed procedures for UIAs or artery stenosis: 5 underwent simultaneous procedures for both aneurysm and stenosis, 4 only for aneurysm and 2 just for stenosis. Among 27 of 35 UIAs patients with non-parent artery stenosis: 11 underwent simultaneous procedures for both aneurysm and stenosis, 10 only for aneurysm and 6 just for stenosis. The other 34 patients received medical treatment or observation. The angiography during follow-up showed no in-stent restenosis and aneurysms recanalization.

Conclusion: The evaluation on each patient, including clinic information, images and hemodynamic factors, is important before invertvention. Positive procedures should be performed on high risk UIAs. Consecutive follow-up is essential for all patients.

360

Hemodynamic Analyses of Large Intracranial Aneurysms

L Aihua, W Jing, K Huibin and W Zhongxue

Department of Interventional Neuroradiology, Beijing Neurosurgical Institute, Beijing Tiantan Hospital Capital Medical University, Beijing, 100050, China

Purpose: To simulate the computational hemodynamics of large intrasranial aneurysms and analyze the hemodynamics of three types of large intracranial aneurysms.

Methods: A total of 64 patient-specific models of large intracranial aneurysms were constructed with the data of DSA (digital subtraction angiography). According to the location of outflow vessel, plane of main vortex and impact zone, large intracranial aneurysms were classified into type A (outflow vessel in the plane of main vortex), type B1(outflow vessel out of plane of main vortex, impact zone at the lateral wall of aneurysm) and type B2(outflow vessel out of plane of main vortex, impact zone at the dome of aneurysm). Blood flow was assumed to be laminar and incompressible and blood Newtonian fluid. The time-dependent pulsatile boundary condition was deployed at inlet. CFD ICEM and Fluent software packages were used to simulate the computational hemodynamics of large intracranial aneurysms.

Results: The distributions of hemodynamic variables during the cardiac cycle were analyzed for wall shear stress, velocity and streamlines. The velocity ratio (ratio of aneurysmal flow velocity to parent artery flow velocity) of type A, B1 and B2 was 0.186 ± 0.019, 0.706 ± 0.077 and 0.208 ± 0.041 respectively. The wall shear stress ratio (ratio of aneurysmal wall shear stress to parent artery wall shear stress) of types A, B1 and B2 was 0.081 ± 0.029, 1.019 ± 0.139 and 0.103 ± 0.031 respectively. The flow velocity and wall shear stress were the highest in type B 1 group followed by those in type B2 group and the lowest in type A group.

Conclusion: As reflected by the location of impact zone, the location of outflow vessel and inflow -angle can influence the level of blood flow in aneurysm sac.

361

Comparison of Packing Density of New Generation Coils to Last Generation Coils in Treating Cerebral Aneurysms

HMLiu¹, YH Hsu² and CW Lee¹

¹Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan

²Department of Neurosurgery, Cheng-Hsin General Hospital, Taipei, Taiwan

Purpose: To report the comparison of the packing density of new generation coils to last generation coils in treating cerebral aneurysms.

Methods: New generation coils (Target coils, Stryker, USA) were launched in our hospital since September 2013. Before that, we used mostly Matrix coils (Stryker, USA) for the treatment of cerebral aneurysms. Retrospectively, we selected 24 patients (27 aneurysms) using Target coils and 23 patients (23 aneurysms) using Matrix coils with age and sex matching in order to compare their effect in packing density. In both group, they consisted with 7 ruptured aneurysms, and 10 were treated with stent-assisted coiling.

Results: The aneurysm size in the Target group and Matrix group were 3.1–18.81 mm and 3.0–10.3 mm the volume were 7.71–309.46 mm³ (mean = 66.52) and 7.65–2967 mm³ (mean = 312.65), the packing density were 20.48–78.86% (mean = 40%) and 12.93–94.82% (mean = 21.0%) respectively. Complete obliteration of aneurysm (Raymond grade 1) in immediate post-procedural angiogram were shown in 21 aneurysms and 27 aneurysms. No complication noted in both groups. In the clinical and imaging follow-up (mean = 4.4 months and 15.1 months), recurrent aneurysms found in 4 and 7 (include 2 residual aneurysms) in Target and Matrix coil treated group respectively.

Conclusion: New generation coils have a trend of better packing density and might have the better obliteration rate as compare to the last generation coils.

362

Experience of Intracranial Aneurysms Treatment with LVIS and LVIS Jr.: Clinical and Angiographic Short Term Follow Up

J C Miranda^1,2, P Angelani^1,2 and M V Gonzalez Quaranta^1,2

¹FLENI, Buenos Aires, Argentina

²Sanatorio Sagrado Corazón, Buenos Aires, Argentina

Purpose: We present our experience with coils stent assisted with neurostents LVIS and LVIS Jr. of intracranial aneurysms, periprocedural results and short term follow up.

Methods: Descriptive and Retrospective analysis of reports of endovascular treatment of intracranial wide neck unruptured aneurysms withs coils assisted with neurostents LVIS and LVIS Jr. Type of device, reason of its implant, size of aneurysms, conformability, clinical and angiographic at short term FU.

Results: Twenty-seven patients (21 female) were registered. Small n = 23 (85%) and large n = 4 (15%) aneurysms. In 25 cases as a planned procedure and two cases devices were implanted as a rescue that include one through a Scepter balón during remodelling technique. Initial conformability was successful in 22 (81, 4%), in 4 cases conformability defect resolved with balloon (3 LVIS). One device removed due to unwanted safe position. One callosal haemorrage was registered related to microguire with transient morbidity and mRS 4 at 6 months (4%). 22 patients were controlled with DSA with 20 total occlusion (91%).

Conclusión

Endovascular reconstruction with LVIS and LVIS Jr with coils for small and large aneurysm in our experience represents a safe procedure and effective about rate of occlusion at short term FU with low procedural morbi-mortality.

363

Unruptured Aneurysms Treatment: Procedural Morbi-Mortality at Single Neurological Center (FLENI) in Buenos Aires

J C Miranda¹, P Angelani¹ and M V Gonzalez Quaranta¹

¹FLENI, Buenos Aires, Argentina

Purpose: Unruptured aneurysms are those dignosed incidentally, symptomatic related to mass effect, or those found in relationship to another one ruptured. We present the morbi-mortality results of endovascular treatment of unruptured aneurysms at a single neurological center in Buenos Aires.

Methods: Retrospective analysis of reports of endovascular treatment of unruptured aneurysms since august 2009 to April 2015: clinical presentation, size, techniques applied and morbi-mortality procedural results.

Results: 215 therapeutic procedures were analyzed for the treatment of 233 aneurysms. 207 (88.8%) were pure incidental, 23 related to mass effect symptoms and 3 were unruptured aneurysms in patientes with prior HSA of another one. About size: Small n = 178 (76.3%), large n = 47 (20.1%), giant n = 7 (3%) and one dissecting. Techniques include coils alone 53 (24.6%), coils stent assisted 66 (30.6%), coils balón assisted 35 (16.2%), endovascular flow diverters 59 (27.4%) and 2 endosaccular flow divertes. Procedures were performed in a biplane equipment, under general anesthesia in all cases and inmediate post operative care in a neurological ICU. Non mortality was registered. Overall procedural morbidity was 4.1 % and was divided in neurological (1.8%) : 3 bleeding, 1 ischemic and no-neurological : retroperitoneal haematoma n = 3, one femoral arterio –venous fistula and 1 femoral pseudoaneurysm (2.3%).

Conclusion: Endovascular treatment of unruptured aneurysms in our experience represents a safe procedure with experimented operators, high resolution equipment and specific neurological ICU, with low percent of complications most of them in patientes under double antiplatelet treatment.

364

Flow Diverters: A Curative Endovascular Treatment for Ruptured Intracranial Blood Blister Aneurysms

NMulimani

SRMC

Purpose: Data on durability and success rate of Pipeline Embolization Device (PED) as a new emerging endovascular device in treatment of Ruptured blood blister aneurysms is limited. We report our with ruptured blood outcomes of three patients angiographic and clinical treatment using endovascular reconstructive underwent blister aneurysms who pipeline flow diverters.

Methods: Five cases of blood blister aneurysms presented with SAH to Department of Neuroradiology, Sri Ramachandra Medical College and Research Institute, Chennai were treated with flow diverter stent device during year of 2013–2014. Data, including demographics, aneurysm location and features, clinical presentation, complications, results, and follow-up information, for up to 6 months is presented.

Results: Five patients (4 females and 1 male, aged between 40–60 yrs) who presented with SAH were diagnosed to have blood blister aneurysm involving basilar trunk (2), cavernous ICA (1), ACOM complex (1), Azygous ACA (1) were treated with Pipeline Embolization Device. The median time to treatment was 7–10 days from rupture in 4 patients and three months in 1 patient. All patients GCS at the time of admission was 15/15 and number of flow diverter devices used was one in each patient. Intra/post procedure period was uneventful without any evidence of stent stenosis/rerupture/ICH/death. The follow up period ranges from 3 to 6 months. Patients remained asymptomatic during the follow up period. The overall occlusion rate of blood blister aneurysm treated with flow diverter stent is 100% signifying flow diverter stent being the ideal choice of treatment for a ruptured blood blister aneurysm with patients condition taking in to consideration.

Conclusion: Flow diverting devices for the management of ruptured blood blister aneurysms offer a safer and more ideal solution with low morbidity-mortality, high angiographic complete occlusion rates. Since, treatment by surgical means predisposes high chance of morbidity and mortality. Long term efficacy of flow diverting device is yet to be established.

365

An Outcome After Saccular Packing for Ruptured Blood-Blister Like Aneurysm

MNishihori¹, T Izum¹, N Matsubara¹, H Tajima¹, K Shintai¹, T Imai¹, M Ito¹, K Nakabayashi², S Miyachi³ and T Wakabayashi¹

¹Department of Neurosurgery, Nagoya University Graduate School of Medicine, Nagoya, Japan

²Department of Neurosurgery, Osaka Medical College, Osaka, Japan

³Department of Neurosurgery, Yokkaichi Municipal Hospital, Yokkaichi, Japan

Purpose: Most of the blood blister-like aneurysms (BBAs) are found at the anterior wall of internal carotid artery (ICA), so this is considered as one of the dissecting aneurysms. Until now, we treated ruptured BBAs that were determined to be treatable with coil embolization. We researched the outcome of these BBA cases retrospectively.

Methods: We analyzed our prospectively maintained database to identify patients from January 2000 to April 2014 in Nagoya University and the related institutes.

During the period, 15 patients were treated for ruptured BBA with coil embolization. The mean age was 48 years, 2 patients were male. All of the aneurysms were located in the anterior wall of ICA. Only 1 aneurysm was excluded from the enrollment because it was too difficult to perform coil embolization and we changed the strategy to perform internal trapping of the parent artery.

Results: The Hunt and Kosnik Grade 2–3 was 8 cases (57%), Grade 4–5 was 6 cases (43%). We treated 2 cases (14%) at the acute phase, 6 cases (43%) at subacute and 6 cases at chronic phase respectively. Balloon-assisted technique was used in 7 cases as an adjunctive technique, simple technique in 5 cases, and stent-assisted technique in 2 cases. The intraoperative rupture was occured in only 1 case (7%) for complication associated with the procedure, no ischemic complication was observed. Rebleeding during the follow-up period was not observed. Meanwhile, the recurrence was observed in 6 cases (43%), all of which were re-treated. The interval from the initial treatment to re-treatment was average 63 days (28–148 days). These re-retreatments were observed in 2 cases, we performed internal trapping in one case of which. Complications associated with re-treatment and re-bleeding after embolizations in all cases was not observed. For clinical results, the 12 cases (86%) had good prognosis (GR), the 2 case (14%) had poor prognosis (MD + SD + D).

Conclusion: We think that coil embolization can be an option of treatment for the ruptured blood blister-like aneurysm that is considered to be treatable morphologically, though it requires a close post-operative follow-up to monitor the recurrence.

366

True Posterior Communicating Artery Aneuryms Compared with Junctional Posterior Communicating Artery Aneurysms: A Retrospective Study

S J Oh, Y J Lee and M C Kim

Pohang Stroke and Spine Hospital, Pohang, Kyoung-Buk, Republic of Korea

Purpose: Posterior communicating artery (PCoA) aneurysms occur at the junction with the internal carotid artery, PCoA, or the proximal PCoA itself. True PCoA aneurysms that originate from the PCoA itself are rare.^1–4 This study represents the comparison true PcoA aneurysms with aneurysms at the junction of the internal carotid artery and PCA.

Methods: Between January 2009 and December 2014, 133 consecutive patients with PCoA aneurysms underwent surgical clipping or endovascular coiling at our institution. Of these patients, 23 (17.3%) and 110 (82.7%) were true PCoA aneurysms and junctional PCoA aneurysms. The angiographical finding and clinical characteristics of both groups were evaluated.

Results: There were no significant differences of clinical characteristics in the two groups. True PcoA aneurysms were more frequent ruptured, but not statistically significant. (52.5% vs. 42.6%, p-value = 0.314) The maximal diameter of true PcoA aneurysms was smaller than junctional PCoA aneurysms. (4.05 ± 1.46 vs. 5.64 ± 1.76, p-value = 0.04) Moreover, among the patients suffered aneurysmal rupture, the maximal diameter of true PcoA aneurysm smaller than junctional PcoA aneurysms. (3.53 ± 1.83 vs. 5.75 ± 1.57, p-value = 0.02) The dome to neck ratio of true PcoA aneurysms was larger than junctional PcoA aneurysms, but not statistically significant. (1.68 ± 0.59 vs. 1.38 ± 0.67, p-value = 0.17) True PcoA aneurysms usually occurred in fetal type PCoA. (15/23, 65%) 3 true PcoA aneurysms were presented rapid growing. There was no difference of outcome of treatment in both groups.

Conclusion: These data suggest that true PCoA aneurysms are more prone to rupture of smaller size. We suggest the caution of closed follow up and treatment (surgical and interventional) in true PcoA aneurysms.

367

Aneurysmal Neck Plasty in Broad-Necked Aneurysms with a Unilateral Partial Stent Reconstruction: Half-Bridge Stenting Method

TOhshima¹

¹Kariya Toyota General Hospital, Department of Neurosurgery

Purpose: Here we describe a novel technique named “Half-bridge stenting method”, in which the aneurysmal neck was partially covered by a single stent before coiling with a microcatheter through the open side.

Technique: Two cases of broad-necked terminal-type aneurysm and one of broad-necked lateral wall-type aneurysm were treated. The stents were deployed from a unilateral branch or distal parent artery to the aneurysmal neck with a trumpet-like. All aneurysms were satisfactory embolized with coils.

Conclusions: This technique can be used to smoothly insert coils into the aneurysms without restriction of the microcatheter by the stents. Furthermore, additional stenting and coiling also can be performed in case of retreatment.

368

Preliminary Clinical Experience with Pipeline Embolization for Unruptured Large or Giant Intracranial Aneurysms in Japanese Patients

HOishi

Juntendo University

Purpose: The Pipeline embolization device is the first and only flow diversion device to be approved by the Japanese Ministry of Health, Labour and Welfare, the approval for which was received in April 2015. Prior to that, we performed clinical trials with the approval of our hospital’s ethics committee and written informed consent from all of the patients. The purpose of this study is to evaluate the safety and efficacy of pipeline embolization for large or giant unruptured intracranial aneurysms (UIAs) in Japanese patients.

Methods: A retrospective review of the medical records, outpatient charts, and operative records was performed.

Results: Six patients (4 female, 2 male) with a mean age of 61.8 years (range 48–72) underwent pipeline embolization for large or giant UIAs. Among those, 3 patients had symptoms due to the mass effect. The mean aneurysm size was 19.5 mm with the mean neck size of 9.4 mm. The locations of the aneurysms were the C4 segment of the internal carotid artery in 2 patients, C3 in 2, and C2 in 2. All the patients had an uneventful postoperative course with no clinical complications. The 6-month follow-up catheter angiogram showed complete aneurysm occlusion in all the patients except 1, in whom the angiogram showed persistent filling of a tiny aneurysm. All the patients reported significant relief of their symptoms.

Conclusions: The results of this preliminary clinical experience indicate that pipeline embolization is safe and effective for large or giant UIAs in Japanese patients.

369

Transradial Approach for Treatment a Brain Aneurysm

MSharafutdinov¹, B Zagidullin¹, I Sharipov¹, N Zagidullin², R Khafizov³ and T Khafizov³

¹Regional medical emergency center, Naberezhnye Chelny, Republic of Tatarstan, Russian Federation

²Bashkir State Medical University, Ufa, Republic of Bashkortostan, Russian Federation

³Republican Cardiology Center, Ufa, Republic of Bashkortostan, Russian Federation

Purpose: To estimate efficacy, safety, technical featuresof transradial approach before transfemoral in treatment of the brain aneurysm.

Methods: In 2013 and 2014 the 18 embolization of brain aneurysm of various localization by transradial approach was performed. To all patients Allen's hallmark before procedure was performed. Among the 18 patients, in 12 (58 + 8) the aneurismal dilating in basin of a medium cerebral artery, and in 6 – of anterior cerebral artery were revealed. To all the patients the CT – angiography of cerebral arteries, and MR – angiography was done. The indications for the embolization were the presence of hemorrhagic stroke in the anamnesis, presence of sacculated aneurysms of the significant dimensions in cerebral pots by CT-angiography or MR-angiography. The bunch included patients with sacculated aneurysms and presence of the narrow neck ≤2.5 mm. The central dimension of the aneurysm was 7.3×13.5 mm. To all patients the embolization was performed by 3D-spirals.

Results: In all 18 cases embolization it performed with good result. In one case it was the conversion the femoral approach, because of tortuosity of the brachiocephalic trunk. In the early postoperative period the relapses of the bleeding were not revealed. Mean duration of the hospitalization stay after transradial approach was 4.2 ± 0.9 days against 5.8 ± 1.1 days after transfemoral approach. According to CT-angiography in 1 and 3 months the loci of the hemorrhage was not revealed in basins of target pots. The neurologic status of patients was satisfactory.

Conclusion: Transradial approach showed the safety and efficacy in endovascular treatment of brain aneurysm and can be applied as the safer alternative to transfemoral approach.

370

Preliminary Experience with Surpass/Streamline Flow Diverter Stent for Unruptured Intracranial Aneurysms Treatment in 9 Patients

E Pampana¹, R Gandini¹, G Scevola², F Chegai¹ and A D’Onofrio¹

¹Department of Diagnostic Imaging, Interventional Radiology, Radiotherapy and Nuclear Medicine, IRCCS Policlinico Tor Vergata, Rome, Italy

²Interventional Radiology Department, Pertini Hospital, Rome, Italy

Purpose: The use of Flow Diverter stents have emerged for the endovascular treatment of difficult-to-treat or otherwise untreatable cerebral aneurysms. We report our preliminary experience with Surpass/Streamline devices.

Methods: Between February 2014 and March 2015 13 aneurysms were treated utilizing the Surpass/Stremaline stent in 9 patients (female/male, 8/1; age range, 46–67 years; mean age, 56 years).

Primary end points for clinical safety were the absence of death, of major or minor stroke, and absence of transient ischaemic attack.

Primary end point for treatment efficacy was complete occlusion at 3 and 6 months follow-up according to the O'Kelly Marotta grading scale (OKM).

Results: None of the patients died and in none of them ischaemic procedure-related complications were observed.

Immediate post-treatment angiography demonstrated reduced flow into all aneurysms.

In all but one patient complete aneurysm occlusion was observed at 3 months CT follow-up; in the other patient, with giant aneurysm treated with coiling also, DSA control was performed at 6 months has shown an angiographic filling grade of C1 accordinding to the OKM.

In all the patients collateral arteries were covered with FD and all were patent at the 3 and 6 months follow-up.

Conclusion: The use of Surpass/Streamline flow-diverter stent has confirmed to be safe and very effective, with a particularly precise deployment control. The ability of the Surpass Streamline to be recaptured after partial deployment and its increased navigability have raised the Surpass stent features.

371

The Interim Result of Pipeline Flow Divertor in a Single Centre

KYVPang¹, PKT Tse¹, CK Wong¹, KWW Leung² and KH Fung²

¹Department of Neurosurgery

²Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong

Purpose: Flow diverters are increasingly used in the endovascular treatment of intracranial aneurysms. Our aim was to determine obliteration, recurrences and complication rates following Pipeline embolization device (PED) placement for intracranial aneurysm treatment and their associated risk factors.

Methods: We retrospectively evaluated all patients with intracranial aneurysms treated with the PED between Oct 2008 and Nov 2014 in our institution. Neurologic complications included spontaneous rupture, intracranial hemorrhage, thromboembolism and 30-day mortality. Treatment outcome included aneurysm obliteration rates in 6 months, 1 year and 2 year respectively. Statistical analysis was performed by SPSS version 16 by Fisher Exact test with p value < 0.05 indicating statistical significance.

Results: 60 consecutive patients with pipeline embolization device performed were identified during the study period with mean age of 56.1 years (34–84) and a mean follow-up time of 31.6 +/− 21.2 months. 51.7% (31/60) were female, 48.3% (29/60) were male. 60% (36/60) were non-ruptured aneurysms while 40% (24/60) were ruptured cases. 81.7% (49/60), 6.7% (4/60), 11.7% (7/60) of cases were due to aneurysms, dissection and dissecting aneurysms respectively. 71.1% (43/60) were treated with pipeline alone while 28.3% (17/60) were treated with pipeline-assisted coiling. 78.3% (47/60) of aneurysms were located along anterior circulation while 21.7% (13/60) were along posterior circulation. The aneurysms treated had a mean size of 6.69 +/− 6.06 mm (2–31), with a mean aspect ratio of 1.40 +/− 0.84. 78.3% (47/60) were saccular aneurysms while the remaining ones were fusiform. 19.2% were giant aneurysms >/ = 10 mm. 6.7% (4/60) were complicated with thromboembolism during procedure and immediate recanalization was achieved with chemical treatment in 3 of them and both mechanical and chemical treatment in 1 of them. 1 patient suffered from intracranial hemorrhage due to clopidogrel overdose. 25% cases noted spasm during procedure and were treated with chemical angioplasty. 30-day mortality was 3.3% (2/60) and rebleeding rate was 1.6%. Obliteration rates in 6 months, 1 year and 2 year were 55%, 70% and 70% respectively. There was no aneurysm progression or recurrence after pipeline placement noted. Aneurysms along posterior circulation had statistically significant association with higher recurrence rate (p = 0.005) after PED placement.

Conclusion: PED placement is a reasonably safe and effective treatment for intracranial aneurysms especially those with unfavorable morphologic features, such as wide neck, large size, and fusiform morphology.

372

Treatment of Bleeding Dissecting Aneurysms – Cases Illustration

KYVPang¹, CK Wong¹, WKW Leung² and KH Fung²

¹Department of Neurosurgery

²Department of Radiology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong

Purpose: Acute dissecting aneurysms are prone to rebleed. Surgical reconstruction is difficult and sometimes ends up in disasters due to the poor anatomical integrity of artery wall. Proximal occlusion of parent artery after testing balloon occlusion and flow reversal has been tried before. The failure to occlude the diseased segment may lead to rerupture of the aneurysm. Embolizaton occlusion of the aneurysm together with the parent artery provides the definitive treatment to protect from rebleeding albeit the risk of distal territory ischemia. With the availability of flow divertor, this offers a chance to tackle the problem with a reconstructive strategy. There is some success in using flow divertor to treat vertebral basilar dissecting aneurysms and anterior circulation dissecting aneurysms as well. The use of antiplatelet has to take into consideration the rebleeding risk and stent-related thromboembolic risk.

Case 1

A 38-yr-old lady found collapse in bus, was taken to the Emergency Department, suffering from seizure. CT scan showed acute subarachnoid hemorrhage and intraventricular hemorrhage. CT Angiogram showed 5 mm aneurysmal dilatation of distal left VA, compatible with ruptured dissecting aneurysm. In view of dominance of left VA, pipeline flow divertor was placed in L VA the following day. She recovered well after the vasospasm was over. Control CTA showed patent L VA and AICA-PICA artery.

Case 2

A 60-yr-old lady was taken to Emergency Department after collapse. She regained semi-consciousness on arrival. CT scan showed acute subarachnoid hemorrhage. CT Angiogram showed some irregularity of supraclinoid right ICA. DSA revealed a mild focal dilatation of right ICA. Early CTA on D3 showed progression of the diseased segment. Pipeline flow divertor was placed across the focal dissection on D4. However, it was complicated by acute stent thrombosis which was recanalized by iv and ia abciximab. She suffered diffuse cerebral vasospasm. Control DSA showed further progression of the dissection and a second Pipeline flow divertor was placed inside the first one. Control CTA showed healed R ICA dissection.

373

Comparison of Enterprise with Neuroform Stent-Assisted Coil Embolization of Unruptured Wide Neck Aneurysms in Internal Carotid Artery: a Single Center Study

JJPark¹, K Jo², JY Yeon², SC Hong², JS Kim², KH Kim¹ and P Jeon¹

¹Department of Radiology, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Republic of Korea

²Department of Neurosurgery, Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Republic of Korea

Purpose: The Enterprise and Neuroform stents are the most well used two self-expandable stents in stent-assisted coil embolization (SACE). Comparative knowledge about technical feasibility, peri-and post procedural complications as well as follow-up data is limited in using these two different stents in treating distal internal cartodi artery (ICA) aneurysm under SACE. differed stent design would yield difference results. Comparisons of technical and complications of deploying two different stent designs in performing SACE of distal ICA aneurysm were done.

Methods: We enrolled 237 patients with 244 aneurysms: 82 cases with an open-cell stent (Neuroform) and 164 cases with a close-cell stent (Enterprise), starting from January 2005 and June 2014. A single stent was placed in ICA segment, including carotid siphon, unruptured aneurysm with clinical and image follow-up s were done within 30 days, one-year and above 1year after the embolization Stent-assited coil embolization using more than one stent, stent deployement only and patients with no record of at least 1 year of image and clinical data were excluded. Baseline characteristics, peri-and post procedural (one year and over one year) complications were compared.

Results: Baseline charecteristics of open cell (Neuroform) and close cell (Enterprise) groups showed no difference. Peri-procedural complication events were frequent in Enterprise group. (27% vs. 12%,p = 0.013). Asymptomatic diffusion positive lesions were much higher in close cell group. (24% vs. 11%,p = 0.017) Within the peri-procedural complication There were no significant difference in delayed infarction, in-stent stenosis, hemorrhagic complications and recanalization in either group in 1-year and over 1-year follow-up. However, the Enterprise stent group had a tendency of delayed infarction and in-stent stenosis after 1 year of deployment.

Conclusion: There were significantly lower peri-procedural event and complication recurrence after 1 year of procedure in Neuroform. One the basis of the finding, Neuroform stent could be preferred when considering stent-assisted coil embolization of aneurysm in internal carotid artery.

374

Relationship Between MR-DWI-Positive Lesions and Symptomatic Ischemic Complications After Coiling of Ruptured Intracranial Aneurysms

JH Park¹, H Kim² and GW Jo²

¹Dongtan Sacred Heart Hospital, Hallym University, Hwaseong, Gyeonggi-Do, Korea

²St. Mary’s Hospital, Catholic University, Bucheon, Gyeonggi-Do, Korea

Purpose: The aims of this study were to evaluate the risk factors for developing symptomatic ischemic complication (SIC, transient ischemic attack or stroke) and microembolism detected as Magnetic resonance diffusion-weighted imaging positive (DWI positive) lesions in coiling of ruptured intracranial aneurysms. Plus, relationship between each factor and modified Rankin Scale (mRS) after 3 month was studied.

Methods: From March 2010 and to March 2013, forty two subarachnoid hemorrhage patients with ruptured intracranial aneurysm underwent both coiling and postoperative Magnetic resonance diffusion-weighted imaging (MR-DWI). The incidence and risk factors for SIC and DWI positive were retrospectively analyzed. The relationships between 3-mRS and DWI positive or SIC were also analyzed.

Result: The incidence of DWI positive was 50%. There is no big difference from incidence of unruptured aneurysm (54.5%).

The incidence of SIC was 9.5% (4/42). Patients aged older than 65 years have a tendency for SIC (p = 0.011). Patients with SIC appeared unfavorable 3 month mRS (mRS 3 ∼ 6, p = 0.032).

Conclusion: Conclusion – When endovascular surgeon tries coil embolization to ruptured intracranial aneurysm, should try to reduce the occurrence of SIC, particularly in patients older than 65 years old.

375

Preliminary Computational Fluid Dynamics (CFD) Analysis with a New Test Version Research Platform: Comparison Between Recurred Aneurysms and Virtually Occluded Aneurysm Models

WPark¹, KJ Park¹, Y Song¹, HW Koo¹, DH Lee¹ and DC Suh¹

¹Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Purpose: Several patients have experienced the recurrence after coiling or clipping of aneurysms. Practical application of computational fluid dynamic (CFD) analysis was limited due to complexity in long processing time. Therefore, we attempted to identify hemodynamic factors related to the recurrence of treated intracranial aneurysm by using recently developed test version.

Methods: Six patients with recurred aneurysm were identified in our database for further CFD analysis. The patient-specific recurred aneurysm models were reconstructed from 3D digital subtraction angiographic images acquired during follow-up. The virtual models of occluded aneurysms were generated by manually removing the recurred aneurysm from the parent artery. CFD analysis was performed using an integrated CFD research platform (Siemens Healthcare GmbH) for pre-processing and simulation. For each aneurysm case, the CFD results from recurred and virtually occluded aneurysm model were visualized in Paraview 3.0 (Kitware, Sandia National Labs and CSimSoft) and compared in a side-by-side view. Two experienced observers independently reviewed and compared the hemodynamic features (WSS, pressure, velocity) of two datasets in each patient.

Results: We obtained complete set of data in 6 patients. It took 20 minutes in obtaining whole data sets for the successfully applicable cases. Slightly increased WSS and pressure and no significant change of velocity were identified near the neck of the recurred aneurysm. The Cohen’s kappa-values were 1.00, 0.71 and 0.33 for WSS, pressure and velocity.

Conclusion: The preliminary CFD analysis with a new test version indicated that slightly increased WSS and pressure could be observed near the neck of the recurred aneurysm in relatively short processing time. Application of such results warrants further study in a larger patient population.

376

Preoperative Three-Dimensional Angiographic Evaluation of Middle Cerebral Artery Trunk Aneurysms: Successful Demonstration of the Close Relationship between the Early Frontal Cortical Branches and Lateral Lenticulostriate Arteries

JC Park¹, JH Shim², WPark² and DH Lee²

¹Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

²Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Purpose: Understanding the anatomic relationship between the aneurysm, branching vessels, and the lenticulostriate arteries (LSAs) is important for the treatment planning of a patient with the middle cerebral artery (MCA) trunk aneurysm. We aimed to demonstrate the branching-vessel anatomy related to the MCA trunk aneurysm using three-dimensional (3D) angiography.

Methods: We retrospectively reviewed 3D angiographic findings of 64 cases of MCA trunk aneurysm using 3D workstation with various post-processing conditions. We classified the aneurysms into 4 groups (early frontal cortical branch (EFCB) aneurysm, early temporal cortical branch (ETCB) aneurysm, LSA aneurysm, non-branching aneurysm) and analyzed the relationship between the branching vessels and the LSAs.

Results: There were 30 EFCB aneurysms, 25 ETCB aneurysms, seven LSA aneurysms and two non-branching aneurysms. Twenty-six (86%) of the 30 EFCB aneurysms, in contrast to none of the 25 ETCB aneurysms, were associated with the LSAs, and shared common origins.

Conclusion: With 3D angiography, we were able to classify the MCA trunk aneurysms and identify clinically important anatomic relationship between the aneurysm and branching vessels including the LSAs. EFCB aneurysms showed a close relationship with the LSAs, in contrast to the ETCB aneurysms, pre-treatment identification of the origin of LSAs is important to obviate any perforator injury in EFCB aneurysms.

377

Tapered Flow Diverters: Initial Experience

APeker¹, I Akmangit^1,2, A Akgoz¹, E Daglioglu² and A Arat^1,2

¹Hacettepe University School of Medicine, Ankara, Turkey

²Ankara Numune Education and Research Hospital, Ankara, Turkey

Purpose: Tapered flow diverters (TFD, Silk, Balt, Montmorency, France) are manufactured for the treatment of intracranial aneurysms in which the there is a discrepancy between the diameters of the distal and proximal landing zones of the device on the parent artery. We present the initial findings with the use of TFDs.

Methods: Eleven patients with 12 unruptured aneurysms (4 supraclinoid, 5 paraophthalmic, 1 carotid bifurcation, 1 vertebral, 1 cavernous) were treated by TFD. Procedural findings, complications, clinical and imaging follow-up were assessed.

Results: Mean age was 46.2 years (range, 16–74; 8 women). Aneurysms size ranged from 4 to 30 mm with an average diameter of 15.5 mm. Nine aneurysms were wide-neck saccular, 3 were fusiform. Treatment was successful in all patients, deployment technique was similar to the non-tapered version and subjectively, it appeared to be easier in the paraophthalmic segment. Mortality and permanent morbidity rates at discharge were 0%. On clinical follow-up (10 patients, mean 11 months) there were no clinical events. Imaging follow-up was available in 9 patients, (mean 8.5 months). All patients with imaging follow up beyond 5 months had complete occlusion of the aneurysm (100%). Asymptomatic stent occlusion was noted in one patient and symptomatic parent artery stenosis was present in 1 case.

Conclusion: TFD was safe to use in this series. The occlusion rate was higher with respect to the previous reports using the non-tapered version. TFD may be preferred especially for aneurysms in the paraophthalmic region.

378

The Role of Closed Cell Stents in the Treatment of Blood Blister-Like Aneurysms : A Brazilian Single Center Experience

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Blood blister-like aneurysms (BBAs) are arterial lesions from non-branching sites, located mainly on the ophthalmic internal carotid artery (ICA), and with uncertain behavior. Our goal is to describe the experience of a single center of Brazil, especially with closed cell (not flow diverters) stents, in the management of these lesions.

Methods: We performed a retrospective analysis from medical records of 12 consecutive patients diagnosed with BBAs and undergoing treatment between December/09 and July/14 in our service. Four patients were treated with flow diverter stents (FDS), seven patients with some closed cell stent, and one with stent-assited coiling (after frustrated attempt to clipping). The main parameters analyzed were aneurysms site, time from bleeding to the treatment, rebleeding, and occlusion rate at 3 and 6 months.

Results: In our series, there was a predominance of female patients (75%) and the average age was 48.7 years. The main localization of the aneurysms was the supraclinoid internal carotid artery (83.3 %). The average time between bleeding and treatment was 11.3 days. We observed a low rebleeding rate, compared to the literature (16.7%). The occlusion rate at 3 months in the cases treated with closed cell stents was 85.7 %, the same observed in patients treated with FDS.

Conclusions: In our series the use of closed-cell stents proved to be safe and effective, with occlusion rates similar to those with FDS. In locations with a high density of perforating vessels (as basilar and middle cerebral arteries), closed cell stents appear as a safer alternative to the use of FDS.

379

Tips and Tricks Using the Surpass Flow Diverter (SFD): Giant Aneurysm with Complex Carotid Accesses

FEPetra

Spanish Hospital of Mendoza

Purpose: The new generation endo-luminal device SFD was developed as other flow diverter devices (FDD) to reconstruct parent artery and exclude cerebral aneurysm. Until present the median maximum diameter (MMD) of this vascular pathology treated by the SFD according to the literature is 7.2 mm. We present our prospective clinical and angiographic single-center experience in giant aneurysm with a MMD of 20.4 mm and complex access treated by the FDS, considering technical tips to succeed during procedures.

Materials: Twenty-six (26) patients with a range of complex giant ruptured and un-ruptured aneurysms and complex accesses were treated between May 2014 and May 2015 with the SFD. Clinical and angiographic follow-up were performed at 1 and 3 months. Data were prospectively collected mainly centered in the different materials, techniques and anatomical consideration to improve procedures safety considering this is the only over the wire FDS available in the market.

Results: Twenty-six PATIENTS (26) (mean age, 65 years; range, 32–84), harboring 7 ruptured and 19 unruptured aneurysms were treated at our center. All patients were treated with a single device. Successful delivery of the device was achieved in all patients. In this central population of giant aneurysm no major peri-procedural morbidity or mortality was observed. During follow-up, no patient experienced transient or permanent neurological deficit. Nine patients had neurological symptoms related to their aneurysm and 7 showed improvement of these symptoms during follow-up (mainly ocular nerve palsy). At 3-month follow-up, 25 of 26 aneurysms showed a complete occlusion. In all cases tri-axial system was used, characterized by a 7 Fr carotid sheath, an intermediary catheter (DAC) an a micro-catheter after replaced by a 14 or 16 inches 300 cm length guide-wire. In 11 cases intra-cerebral balloon was anchored in the medial cerebral artery to rectified guide-wire loops. In 9 cases it was necessary to advance the DAC into intracranial internal carotid artery to perform the delivery.

Conclusions: SFD stents showed high safety and efficacy profile as a new generation FDD in treatment of giant and complex intracranial aneurysms even with challenging carotid access.

380

Flow Diverter Devices in Ruptured Intracranial Aneurysms: A Single Center Experience

MPiano¹, L Valvassori¹, E Lozupone¹, G Pero¹, L Quilici¹ and E Boccardi¹

¹AO Ospedale Niguarda-Cà Granda, Milan, Italy

Purpose: In this single center series, we retrospectively evaluate the effectiveness, the safety and the midterm follow-up of ruptured aneurysms treated by implantation of flow diverter device.

Methods: We retrospectively reviewed 15 patients (11 F 4 M) with subarachnoid hemorrhage due to a ruptured intracranial aneurysm which were treated with flow diverter device. Of fifteen ruptured aneurysm, eight were blood blister-like aneurysm and the remaining seven were dissecting/fusiform. Average time between subarachnoid hemorrhage and the treatment was 3,7 days. Intra/peri-procedural morbidity and mortality was recorded.

Clinical follow-up and angiographic follow-up were carried between 6 and 12 month from the procedure.

Results: None of the ruptured aneurysm rebleed after the endovascular treatment.

Overall mortality was 13% (2/15); two patients died after few days because of complications of the SAH. Overall morbidity was 6%; one patient experienced an intraparenchymal bleeding during the positioning of an external ventricular drainage.

During the endovascular procedure, 3 adverse events without clinical sequelae occurred. Angiographic follow-up shows a complete occlusion of the aneurysm in 10 of 13 surviving patients; one patient shows a remnant of the aneurysm, one patient was retreated due to an enlargement of the aneurysm, one patient was lost at the mid-term follow-up.

Conclusion: Flow diverter device can be utilized as last choice in patient with ruptured aneurysm, like blood blister-like and dissecting type, in which conventional neurosurgical or endovascular treatments can be challenging.

381

Tasmanian Experience with Aneurysms

KPoulgrain¹, J Froelich¹, A Hunn¹, A Erasmus¹, A Dubey¹, J Peters-Willke¹ and N Thani¹

¹Royal Hobart Hospital, Hobart, Tasmania, Australia

Purpose: In the era where imaging is increasingly identifying smaller aneurysms due to its improving quality, the results of ISUIA are coming into question. In the face of the recommendation that small (<7 mm) aneurysms have a low rupture rate we analysed the Tasmanian population for size and location of intracranial aneurysms.

Methods: 4 years of retrospective data was collected for all aneurysms treated at the Royal Hobart Hospital, the only centre for neurosurgery in Tasmania (population around 500,000). During the period all cases, encompassing both ruptured and non-ruptured aneurysms treated both surgically and endovascularly were included. Data was collected on rupture, grade, aneurysm size and location and method of treatment.

Results: 175 cases were identified during the time period investigated. 103 (59%) cases were incidental/unruptured aneurysms. >90% of the ruptured aneurysms were in the anterior circulation. Two thirds of posterior circulation aneurysms were incidental findings. 65% of the ruptured anterior circulation aneurysms were less than 7 mm. The mean size of anterior ruptured aneurysms was 6.36 (±4.48) mm. The mean size of posterior ruptured aneurysms was 8.08 (±3.93) mm. In the unruptured categories, the mean for anterior and posterior aneurysms was 5.5 (±3.60) mm and 5.61 (±2.61) mm respectively. There was only 1 in each of the following categories: large ruptured, large unruptured, giant ruptured, giant unruptured aneurysms.

Conclusion: The remote geography of Tasmania allows a unique population analysis of intracranial aneurysms. While the natural history of unruptured aneurysms remains incomplete, it appears the paradigms of ISUIA need to be carefully considered.

382

Endovascular Treatment of Wide Neck Aneurysms of Cerebral Arteries Bifurcation: Does the New Single Layer Web Device Improve Its Own Feasibility?

MResta

SS Annunziata Hospital

Purpose: Endovascular treatment of wide neck brain aneurysms can be very challenging, particularly wide-neck bifurcation intracranial aneurysms. WEB is an intrasaccular flow disruption device, placed within the aneurysm pouch, creates blood flow stasis with subsequent thrombosis. The first double layer version of the WEB devices presented some troubles in its feasibility with a not negligible rate of recurrence. We report our experience with both versions, double and single layer, of the WEB device.

Methods: Since June 2012, 14 patients with 14 brain unruptured aneurysms, were treated at our institution using WEB devices. The former 2/14 aneurysms were treated using the double layer initial version of the WEB device. The latter 12/14 ones were treated with the new single-layer version. All treated aneurysms were unruptured. Seven out of 14 aneurysms were located at MCA bifurcation (6 small; 1 large recurrent aneurysm, already treated twice with coiling), 2/14 at Acomm bifurcation (1 small, 1 medium), 4/14 at intracranial carotid bifurcation (2 medium, 2 small), 1/10 basilar tip (small). Follow-up was performed by MRI at one month in 10/14 aneurysms, while just 3/10 have reached one year follow-up performed by both MRI and DSA.

Results: All treatments were performed without any procedural and post-procedural complication. Follow-up showed recurrence in 1/14 aneurysm. This case, successfully retreated with p-Conus device, will be discussed. It referred to the first case in our experience and, as previously mentioned, it was performed with a double layer WEB device.

Conclusions: According to our preliminary experience, despite some troubles during first treatment, WEB endosaccular device revealed safe and feasible. Feasibility improved using single layer device that looked softer and more reliable than the stiffer double layer one. To obtain optimal results, the importance of initial measurements has to be stressed.

383

Clinical Experience with Flow Diverting Stent (PIPELINE) at Centro Médico de Puerto Rico

C Olivera, C González-Villamán, C Feliciano-Vals, and RRodríguez-Mercado

University of Puerto Rico

Medical Sciences Campus

Endovascular Neurosurgery Program

San Juan, Puerto Rico

Purpose: The treatment of wide neck, fusiform and large aneurysms represents a challenge for the interventional Neurosurgeon whose goals are to successfully embolize the aneurysm while minimizing complications. The use of flow diverting stent (Pipeline) represents a useful tool in the treatment of these complex aneurysms, in an effective and safe way. Describe our clinical experience with the use of Pipeline stent (flow diverting stent) at the Department of Endovascular Neurosurgery, Medical Center of Puerto Rico.

Methods: Records of 16 patients treated with a flow diverting stent Pipeline between 2011 and 2015 were revised. Clinical results and complications were analyzed.

Results: Sixteen patients with complex aneurysms were treated with flow diverting Pipeline stent. Age range was 46–84 years (mean 66 yrs.). Size of aneurysm range from 1.5 to 3.6 cm. There was no history of ruptured aneurysm. Location of the aneurysm were the following: Carotid cavernous (6), Carotid ophthalmic (4), Posterior communicating (3), Supraclinoid fusiform (1). One patient had contralateral aneurysm already treated with coils. Complications were the following: proximal end of stent migration (1), air embolism (1) (both with no significant neurological sequelae), Hematoma formation at femoral area (2), ophthalmoplegia secondary to petrosistis (1). Total occlusion was recorded in 50% of patients at 3 months by magnetic resonance angiogram and 80% complete occlusion was documented by cerebral angiogram at 6 months. Two of the most recent patients treated within 3 months are in the process of follow up.

Conclusion: Our clinical experience in the treatment of complex cerebral aneurysms with flow diverting stent (Pipeline) has shown to be effective with a low morbidity and no significant permanent neurological complication. Patients with complex aneurysms which are not candidates for regular stent and coil embolization can benefit in a safe and effective way with treatment of flow diverting stent (Pipeline).

384

Flow Diverter Treatment for Recurrence After Stent Assisted Coil Embolization of Intracranial Aneurysms

NSakai, C Sakai, H Imamura, K Arimura, H Adachi, S Tani, T Funatsu, M Beppu, N Takebe and K Suzuki

Kobe City Medical Center General Hospital, Kobe, Japan

Purpose: To show efficacy and safety of Flow Diverter (FD) treatment for recurrence after stent assisted coil embolization of intracranial aneurysms (AN).

Methods: Since 2008, we introduced neck bridge stent assisted coil embolization (SACE) for wide neck intracranial ANs. We experienced about 2.5% recurrence of 450 SACE and mainly repeat endovascular treatment is effective. We introduced FD for 3 cases of recurrence after second treatment of recurrent intracranial ANs, treated with SACE.

Results: All s cases treated with Surpass Flowdiverting Stent. One is ruptured vertebral dissecting AN, Second is unruptured ICA AN, treated with SACE followed by SAH. Third is unruptured ICA AN, treated with SACE and has rapidly recurrence. All 3 cases were successfully treated with FD without any complication and additional recurrence.

Conclusion: FD treatment is one of choice for recurrence after SACE.

385

Technical Aspects and Clinical and Radiographical Results of Endovascular Coiling of Aneurysm with a Brunch Arising From the Sac

MSakamoto¹, H Takeuchi², M Kurosaki¹ and T Watanabe¹

¹Department of Neurosurgery, Tottori University, Yonago, Tottori, Japan

²Department of Neurosurgery, Nojima Hospital, Kurayoshi, Tottori, Japan

Purpose: Aneurysms with a brunch arising from the sac have been thought to be contraindication for endovascular embolization. In such cases, there is major risk of occluding the branch during the procedure, and consequently, incomplete aneurysm occlusion increase. The purpose of this study is to evaluate the techniques and long-term clinical and radiographic outcomes of coiling for aneurysms with branch arising from the sac.

Methods: Sixty patients with 60 aneurysms with a branch arising from the sac (28 ruptured, 32 unruptured) were retrospectively reviewed and evaluated. There were 49 women and 11 men (mean age, 65.1 years). Location of the aneurysms were the anterior cerebral artery in 2 (3.3%), the middle cerebral artery in 10 (16.7%), the anterior choroidal artery in 10 (16.7%), posterior communicating artery in 21 (35%), ophthalmic artery in 2 (3.3%), basilar artery-superior cerebellar artery in 9 (15%), vertebral artery-posterior inferior cerebellar artery in 6 (10%). Twenty-six procedures were performed by using a single catheter; 20, by double catheter; 9, by balloon remodeling; 2, by stent assisted; and 3, by balloon and double catheter techniques.

Results: Periprocedural complications occurred in 2 cases, including 2 thromboembolic events (incorporated branch occlusion and embolic infarction). Forty-eight of the 60 aneurysms were followed-up more than 6 months after embolization, of which 39 showed stable or improved occlusion; 5, minor reccurence; and 4, major reccurence. Major recurrence is found more often in large, IC-PC aneurysm.

Conclusion: The double catheter technique was very useful to preserve a branch arising from sac, and 3D complex shape coils, especially inner direction coils were effective for a framing coil. Coiling of aneurysms with a brunch arising from the sac could be performed safely with acceptable clinical and radiographic outcomes.

386

During Waffle Cone Technique in Management of Wide Neck Aneurysm, Stent Migration into Cerebral Aneurysm

LSang Bok and KJong Youn

Department of Neurosurgery, Uijongbu St. Mary’s Hospital, The Catholic University of Korea, College of Medicine

Purpose: Stent-assisted coil embolization (SACE) is a common method to manage intracranial wide-neck aneurysm. Using waffle cone technique, a stent must be successfully deployed into the parent artery to cross the aneurysm neck. Sometimes, we meet unexpected complications. We describe the complication case that during waffle cone technique in management of wide neck basilar tip aneurysm, stent migration into aneurysmal sac.

Methods: A 40-year-old woman presented with severe headache, drowsy mentality. Brain computed tomography revealed all cisternal subarachnoid hemorrhage (SAH). DSA revealed giant basilar tip aneurysm. We determined to treat by waffle cone technique in endovascular treatment.

Results: During the waffle cone technique using Enterprise stent, there was stent migration into aneurysmal sac. But, fortunately we noticed early. Then, we deployed coils aneurysmal sac and in stent portion into sac. The procedure. That procedure has ended satisfactorily.

Conclusion: It is sometimes meet the complication of intra-procedural distal stent migration. In waffle cone technique, there is required special attention this is because the risk of rupture. If the rest of the treatment as soon recognized because it is not particularly difficult, always requires careful attention.

387

Experiences of Using HydroGel Coil in Small Aneurysms: Procedural Safety, Treatment Efficacy and Tips for Complete Occlusion

HSato

Tokyo Metropolitan Police Hospital

Purpose: In most endovascular therapy centers, ordinary pure platinum coils have been used for intra-cerebral aneurysmal endovascular therapy. To prevent a recurrence after the therapy, recently we use a HydroGel-frame coil called Hydro-Frame as the first coil of the embolization for intra-cerebral aneurysms of more than 5 mm size. In addition to that, after the improvement of detaching system called Advanced Detach System, we are able to use this Hydro-frame coil for aneurysms of less than 4 mm size. This presentation discusses some advantages and problems of this HydroGel Coil from our experiences.

Methods: I would like to present a few cases of neuroendovascular therapy with HydroGel Coil, and consider the effectiveness and diversity of them.

eg. 56 y/o female with un-ruptured IC-PC ANof 4 mm, 62 y/o female with Acom AN of 3.21 mm × 2.36 mm × 2.26 mm, and 74 y/o female with SAH case due to ruptured Acom aneurysm.

Conclusion: The HydroGel Coil with new detaching system is able to be smoothly delivered and detached immediately with good performance, therefore it will effectively provide easy-to-perform endovascular operations for various sizes of intra-cerebral aneurysms.

388

Comparison of Efficacy of Assisted Coiling Techniques in Endovascular Treatment of Cerebral Aneurysms of Anterior Circulation

KOrlov, P Seleznev, A Krivoshapkin, V Berestov, T Shayakhmetov, D Kislitsin and A Gorbatykh

Novosibirsk Research Inistitute of Circulation Pathology (NRICP), Novosibirsk, Russia

Methods: 687 patients underwent endovascular treatment for cerebral aneurysms in our department since 01.2011 to 12.2014. In 579 (84.4%) of them, the aneurysms were located in anterior circulation.

Results: Since 01.2011 to 12.2013 n = 409 patients were treated; n = 146 (36.7%) operated using assisting techniques; The first group n = 68 /146 (46.6%) – balloon assistance, the second group n = 66 /146 (45.2%) – stent assistance, the third group n = 12 /146 (8.2%) – both techniques simultaneously. Comparison of long-term outcomes in all groups revealed significant decrease of recanalization rates in second and third groups. According to that, stent-assisted and combined technique became the preferred treatment strategy in our department.

Since 01.2014 to 12.2014 n = 170 patients were operated. In n = 87 (49.5%) of them, assisting techniques were used: n = 24 /170 (33.3%) – balloon assistance, n = 42 (50.0%) – stent-assistance, n = 14 (16.7%) – combined technique. Analysis of short-term results demonstrates remarkable switch of the spectrum of performed procedures towards utilization of stent-assisted and combined techniques.

Conclusion: Both balloon- and stent-assistance are useful for treatment of wide-necked cerebral aneurysms. Balloon-assistance allows more dense packing of coils inside the aneurysm, while stent creates the frame for future endothelium growth over the ostium of the aneurysm, which significantly decrease the recanalization rates.from the report

389

Direct Puncture of Vertebral Artery Pseudoaneurysm for Parent Artery Occlusion in Patient with Neurofibromatosis Type 1

TSeruga¹ and M Jevsek¹

¹Department of Radiology, University Clinical Center Maribor, Slovenia, Europe

Purpose: Pseudoaneurysms of the cervical part of vertebral artery (VA) are uncommon lesions that may be induced by trauma, dissection, or rarely infection or even neurofibromatosis. Endovascular treatment is becoming a method of choice in such cases.

Case Report

A 47-year-old woman presented to the emergency room with acute onset of headache, vomiting and neck pain. The clinical history revealed a neurofibromatosis type 1 but with no previous problems affecting neck or extremities. On physical examination there was a pulsatile mass in the left posterior suboccipital region. Neurologic examination showed a mild weakness of the right upper extremity and intact cranial nerves.

Diagnostic imaging showed a large pseudo-aneurysm in V3 segment with surrounding hemathoma that compressed spinal cord. Since it was a ruptured aneurysm, we decided to do the parent artery occlusion. Atempt to catheterize the distal part of left VA failed, so just proximal part occlusion with coils was performed. Patient improved clinically, but after few days subociptal mass started to grow again due to retrograde filling of the aneurysm and string fistulous flow into cervical veins.

A decision was made to perform a direct percutaneous puncture of pseudoaneurysm and occlude parent artery. Under US guidance Seldinger needle has been placed into the aneurysm sack pointing to the distal ostium of aneurysm. Distal part of left VA was catheterised and occluded with GDC coils. Three month follow up arteriogram revealed occluded V 4 segment, thrombosed pseudoaneurysm and normal flow in to basilar artery. All symptoms improved and hematoma diminished.

Conclusion: Direct percutaneous puncture and embolization has been practiced in treatment of variety of head and neck diseases, including tumors and arteriovenous malformations. To our knowledge, however, a direct percutaneous puncture of aneurysm and subsequnt parent artery occlusion of vertebral artery has not been reported and published untill now.

390

Complete Spontaneous Thrombosis of an Unruptured Anterior Communicating Artery Aneurysm After Partial Clipping

W-B Seung and Y-S Park

Department of Neurosurgery, Gospel Hospital, Kosin University College of Medicine, Busan, Republic of Korea

Purpose: Complete spontaneous thrombosis of saccular aneurysms is a rare event that can be discovered incidentally.

Summary of Case

In this case report, the author described a woman who has an unruptured anterior communicating artery (AcoA) aneurysm incidentally in MR angiography. Cerebral angiography revealed a bilobulated saccular aneurysm at AcoA. She received operation with clip ligation but partial clipping was done. After 4 years, she visited to our hospital for follow-up. We performed conventional angiography and found complete obliteration of residual aneurysm suspected to spontaneous thrombosis. Aneurysm shape is very important feature which is narrow, long neck of the aneurysm. Also, systemic condition was affected such as hypotension, anti-fibrinolytic agent, and thrombogenic potential of non-ionic contrast media.

Conclusion: Recanalization of spontaneously thrombosed aneurysm due to combine clot organization and clot retraction can occur. Repeat follow-up imaging study is very important.

391

Transvenous Stenting of Sigmoid Venous Varix for Treatment of Pulsitile Tinnitus

RKShastri¹, N Chaudhary¹ and JJ Gemmete¹

¹University of Michigan, Ann Arbor, Michigan, USA

Purpose: To present a new application of stenting in the treatment of venous disease. To review a case of pulsitile tinnitus and discuss its treatment and outcome utilizing modern stenting technology.

Methods: We present a case of a patient treated by transvenous stenting for the treatment of a venous varix or diverticulum in the sigmoid sinus and desribe the technique as well as outcome of the case. To this date, intracranial angioplasty and stent deployment has been used in the treatment of dural arteriovneous fistulas and multiple reports have been described in the literature (Levrier et al 2006, Liebig et al 2005, Malek et al1999, Murphy et al 2000).

Results: We will review the technique of these treatments and discuss intracranial transvenous treatments of other venous pathologies within the neural axis.

Conclusion: We present the case of a patient with pulsitile tinnitus related to a dural venous varix successfully treated with transvenous stenting and will review other described applications of transvenous stenting in the literature.

392

Low Recanalization Rate in Pconus Assisted Coiling

CSicignano¹, G Buono¹, L Delehaye¹ and G Sirabella¹

¹Neuroradiology Department of the P.O. San Giovanni Bosco, Napoli, Italy

Purpose: Here we report our experience of follow-up for intracranial aneurysm treated by stent assisted coling, using the pCONus device.

Methods: From May 2013 to may 2015 we treated 10 patients (range of age 33–69 years) with intracranial aneurysms (1 at the basilar top, 3 at A1-A2 bifurcation, 6 at M1-M2 bifurcation) using the pCONus device and coils.

5 patients have 5 unruptured aneurysms; the other 5 patients had SAH (Sub-Arachnoid Haemorrhage) and they were treated from 15 hours to 15 days after the bleeding.

Antiplatelet therapy followed the procedure.

9 of 10 patients underwent follow-up, as usual in our department, doing Contrast Enhanced MR-angiography (CEMRA) at 6 months and Digital Subtraction Angiography (DSA) at 1 year.

Results: At the follow-up, in all cases, we observed the stent and the vessels patency and the exclusion of the aneurysms; only in 1 case we decided to leave a basal remnant to preserve a branch arising from the neck of the aneurysm, and the remnant did not increase till now.

Conclusion: Complex aneurysms often require complex assisted coiling technique with one or more balloons or stents, increasing the procedural risks; in selected case, with favourable geometry of the vessels, the pCONus stent alone improves the coiling creating something like a “barrier” to migration or protrusion of coils during the procedure, even if wide necked aneurysms; it makes possible a stable cast of coils.

This may be the answer to this very good outcome at follow-up for this short series of patients; the follow-up will go on, so these are just preliminary data.

393

Embolization of Intracranial Aneurysm Performed by Carotid Puncture and Hemostatic Closure of the Puncture Site in the Carotid Artery

MHHTeng¹ and HF Wong²

¹Department of Medical Imaging, Cheng Hsin General Hospital, Taipei, Taiwan

²Departments of Medical Imaging and Intervention, Chang Gang General Hospital, Linkou, Tao-Yuan, Taiwan

Purpose: We would like to report embolization of intracranial carotid aneurysm by puncture of the common carotid artery in the neck, and hemostasis in the puncture site after the procedure.

Summary of case:A patient post heart transplantation with residual aortic dissection in the thoracic descending aorta, abdominal aorta and left common iliac artery has a left supraclinoid internal carotid aneurysm. Femoral approach cannot be performed safely without damage to the aorta because of presence of residual dissection.

Embolization was performed under general anesthesia. We punctured the left common carotid artery in the lower neck in proper location and direction so that the catheter can enter the internal carotid artery without difficult. We placed a 5-French short sheath at the puncture site. A 5-French guiding catheter was placed in the high cervical internal carotid artery. After implanted an Enterprise stent, coiling was performed by a microcather selectively placed inside the aneurysm.

One of the difficulty is how to do hemostasis after removing the catheter and sheath in this patient who was under dual antiplatelet pre-medication and heparinization during the procedure. An Angio-seal vascular closure device was used for hemostasis. Before using it, we injected sterile saline in the soft tissue of neck to increase thickness of neck to ensure the entire collagen of the Angio-seal device was placed inside the soft tissue of neck without protruding outside of the skin. At the end of the procedure, hemostasis was achieved without problem using Angio-seal device and described technique.

Conclusion: Embolization of intracranial aneurysm can be performed by carotid puncture and hemostasis can be successfully achieved after the embolization.

394

A Case of Subarachnoid Hemorrhage from De Novo Anterior Communicating Aneurysm: Analysis by CFD Technology

NUemiya, F Yamane, S Ishihara, S Kohyama, T Otsuka, K Mizokami, H Neki and H Kurita

Saitama Medical University International Medical Center, Saitama, Japan

Purpose: Several reports described relationship between de novo aneurysms and hemodynamic change after mechanical injury on parent artery by clipping for the initial aneurysm. However CFD analysis of de novo aneurysm developed very close to initial ruptured aneurysm performed coil embolization is rare.

Methods: We report a 42-year-old male with subarachnoid hemorrhage caused by ruptured anterior communicating aneurysm that performed coil embolization by simple technique. Four years later, he developed second subarachnoid hemorrhage caused by ruptured de novo aneurysm located on another site of anterior communicating artery. We performed coil embolization for his ruptured second aneurysm, but it was re-ruptured again after three weeks later. Digital subtraction angiography demonstrated the aneurysm had coil compaction, so the aneurysm was clipped consecutively.

Results: We examined the features on vessel site of de novo aneurysm occurred and rupture point of the aneurysm using computational fluid dynamics (CFD) technology. CFD results compared before and after initial coil embolization suggested that de novo aneurysm’s orifice had high WSS vector variant degree consistently. And the results also showed that the flow pattern on a rupture point of de novo aneurysm on a cardiac cycle had changed characteristically.

Conclusion: Results of CFD analysis demonstrated that the site of having high WSS vector variant degree which reflects hemodynamic instability had tendency to develop a de novo aneurysm. CFD technology has possibility to detect de novo aneurysms, and in cases with obvious changes in the CFD factors after not only clipping but also coiling, long term follow up was strongly recommended.

395

Analysis of Perioperative Complication Risks Associated with Stent-Assisted Coil Embolization

TUeno¹, Y Naito¹, K Nishiyama¹, T Shinohara², S Takanashi³ and T Nakagomi⁴

¹International University of Health and Welfare, Minato-ku, Tokyo, Japan

²Shiraoka Central General Hospital, Shiraoka, Saitama, Japan

³Tokyo Metropolitan Geriatric Center, Itabashi-ku, Tokyo, Japan

⁴Teikyo University School of Medicine, Itabashi-ku, Tokyo, Japan

Purpose: This study was conducted to clarify risk factors of perioperative complications associated with stent-assisted coil embolization.

Methods: We retrospectively reviewed all cases of cerebral aneurysms treated with coiling at our neuro-endovascular team’s affiliated hospitals between October 2010 and November 2014. Totally 398 cases consisting of 241 unruptured (stent usage: 34.4%) and 157 ruptured cases (stent usage: 15.3%) were reviewed. Patient outcomes were assessed with the occurrence of procedure-related complications during 30 days following coiling, including transient ischemic and asymptomatic hemorrhagic events, and in-stent thrombosis if counter-measures needed. Multiple regression analysis was performed by using the following factors as independent variables; Sex, Age, Aneurysm location (middle cerebral artery or not), Hospitals (full time or part time), Rupture or not, Stent used or not.

Results: Perioperative complications were observed by 13.1% in cases with stent assistance, and 5.2% without stent assistance. Multiple regression analysis revealed that stent-assistance was significantly associated with perioperative complications (p = 0.0073). Morbi-mortality rates were 2.8% with stent assistance, and 0.7% without stent assistance. Multiple regression analysis showed that stent assistance and treatment at a part-time hospital likely increased the risk of morbi-mortality, but not statistically significant. When the analysis was limited to the patients who were treated at a full-time hospital, the morbi-mortality rates were 1.03% with stent assistance and 0.78% without stent assistance, showing no statistically significant difference.

Conclusion: Permanent complication rate associated with stent placement is not high, although it is obvious that stent placement increases potential risks of perioperative complications. Physicians should inform patients and their family members about potential risks of stent placement including risks related to anti-platelet therapy. Use of stent at part-time hospitals should be considered with caution. Considering unfavorable natural history of untreated ruptured aneurysms, perioperative risks of stent placement in cases with ruptured aneurysms seem acceptable when an experienced endovascular team conducts procedures.

396 Presentation withdrawn

Cavernous ICA Aneurysms: Unpredicted Results of Endovascular Treatment in Siriraj Hospital

PWithayasuk, DSongsaeng, TAurboonyawat, EChankaew and AChurojana

Siriraj hospital, Mahidol University, Bangkok, Thailand

Purpose: 2–9% of intracranial aneurysms is cavernous ICA (Internal carotid artery) aneurysm or CIA. Nowsday, natural history of cavernous sinus is still unpredictable. However, many institutions have reports about benign natural history of these type of aneurysms, or low risk of complication. The treatment may be not necessary. The purpose of this study is to evaluate final result of example cases of CIA.

Methods: Four cases of CIA, from total 636 aneurysms in 497 patients between 1997–2013 at Siriraj Hospital, Bangkok, Thailand were retrospectively reviewed. The results of each CIAs were described.

Results: 2/4 cases had spontaneous resolution of CIA but parent ICA was occluded in one of the case but another case the ICA was preserved during follow up. One case presented with incomplete right third cranial nerve palsy with findings of CIA in the first MRI but there is no evidence of aneurysm in cerebral angiogram. Annual MRI follow up shows progressive enlargement of the aneurysm with stable in symptom. The last case presented with left ptosis. We decided to use flow-divertor, however, the aneurysm still increase in size even there was evidence of complete thrombosis in the aneurysm.

Conclusion: Most of our CIA showed benign result without serious complication. But sometimes the result end up with enlargement of the lesion even treatment or not. The natural history of the CIA is still misery and large series of CIA should be done to make sure which is the best management for them.

397

Dynamic Morphological Change of Cavernous Internal Carotid Artery Aneurysmal Vasculopathy: is it Predictable?

P Withayasuk, T Aurboonyawat, D Songsaeng, S Chankaew and A Churojana

Interventional Neuroradiology, Siriraj Hospital, Mahidol univervity, Bangkok, Thailand

Purpose: Unruptured cavernous internal carotid artery aneurysm (CIA)was accounted for 2–9% of intracranial aneurysms. Its natural history is still unpredictable. The purpose of this study is to evaluate the outcome of CIA after the aneurysmal sac was obliterated.

Methods: From total 636 aneurysms in 497 patients between 1997–2013 at Siriraj Hospital, Bangkok, Thailand, there were 42 CIA with mean size about 13.75 mm. A retrospective review of 4 CIA who had aneurysmal sac obliteration was performed.

Result: Of 4 patients, there were two females, with means age at 66.5 year-old (ranging from 41 to 78) All presented with compressive effect to cranial nerve. Three of four had partially thrombosis on first imaging. Among 3 patients who had spontaneous obliteration of the aneurysmal sac, 1 had ICA occlusion, 1 had progressive enlargement of the thrombus even no residual aneurysmal sac. The other one patient who had flow diverter, had both recanalization of the aneurysmal sac and progressive enlarged thrombus. Symptoms resolved in two patients, whereas persistent symptoms in the others.

Conclusion: Obliteration of an aneurysmal lumen in CIA does not always mean cessation of the ongoing process, and the symptom may not resolved. Thus endoluminal reconstruction of a CIA is a decision-making challenge, particularly in patient with unruptured status.

398

Ruptured Intracranial Vertebral Artery Dissecting Aneurysms: an Evaluation of Prognostic Factors of Treatment Outcome

K Urasyanandana¹, P Withayasuk², D Songsaeng², T Aurboonyawat², E Chankaew² and A Churojana²

¹Phramongkutklao hospital, Phramongkutklao collage of medicine, Bangkok, Thailand

²Siriraj hospital, Mahidol University, Bangkok, Thailand

Purpose: Intracranial spontaneous vertebral artery (VA) dissecting aneurysms could present with haemorrhage or thromboembolic events. In patients who presented with haemorrhage carried a risk of recurrent bleeding about 70% and mortality rate about 8.3%. Even no standard recommendation for treatment of dissecting VA aneurysms, but simple endovascular procedure with parent vessel occlusion have shown results of good treatment outcome. Reconstructive techniques such as stent-assisted coiling embolization have been also effective, particularly, in the parent vessel that might not be sacrificed. The purpose of this paper is to analyse the prognostic factors of good treatment outcome in patients with ruptured intracranial VA dissecting aneurysms.

Methods: A total of 26 patients with VA dissecting aneurysms who were treated at Siriraj hospital, during 2008 to 2014 were retrospective reviewed. Parent VA sacrificed was the initial treatment option, if it was possible, for the ruptured aneurysms. Endovascular reconstructive treatment was indicated in ipsilateral dominant VA or PICA involvement. Favourable outcome was determined by using a modified Rankin score (mRS = 0–2). Statistical significance was taken as P-value < 0.05.

Results: There were 17 patients who had aneurysmal ruptured, 53% were female, with the mean age of 52.7 years. Parent VA sacrifice and VA reconstruction were each equal at 41% whereas conservative treatment at 18%. The good clinical outcome was found at 61.1%. The mortality rate was 17.6%. The favourable outcome were associated with initial Hunt and Hess grading (65%), mild GCS (65%) and the total occlusion of aneurysms after treatment (65%).

Conclusion: The good prognostic factors in patients with ruptured intracranial VA dissecting aneurysms were initial Hunt and Hess grading, mild GCS and total occlusion of aneurysms after treatment. We recommend endovascular parent vessel sacrifice to be the first option for treatment ruptured vertebral artery dissecting aneurysm.

399 Presentation withdrawn

Clinical Results of Endovascular Trapping for Consecutive 11 Patients with Ruptured Vertebral Artery Dissecting Aneurysms Involved Posterior Inferior Cerebellar Artery

TYamauchi, Y Koguchi, K Suzuki, M Aikawa, I Matsuura, Y Kijima, A Miyata and S Kobayashi

Chiba Emergency Medical Center, Chiba, Japan

Purpose: In endovascular trapping for ruptured vertebral artery dissecting aneurysm (rVADA) involved posterior inferior cerebellar artery (PICA), were either partial trapping or the sacrifice of PICA acceptable? We hereby report the clinical results of treatment that made use of the endovascular trapping with or without the sacrifice of PICA.

Methods: We totally experienced 61 cases of rVADA from 2000 to 2014. 11 cases of the PICA involved type were treated by endovascular trapping with coils with or without the sacrifice of PICA. All patients received full dose heparin against thromboembolic events during procedures only, and the effect was neutralize naturally.

Results: Patient’s background: mean age = 49.3, Male: female = 8:3, Hunt & Kosnik grade: 3 in 2, 5 in 3, 2 in 4, 1 in5. All procedure was carried out within 24 hours after onset, and divided into 4 in proximal parent artery occlusion, 3 in partial trapping, and 4 in complete trapping. No external decompression was necessary for the cerebellar infarction. In ischemic complication, distal embolic events and brainstem infarction broke out 2 and 3 cases, respectively. At 6 months after embolization, modified Rankin scale for their outcome was 8 cases in 0 to 2, 1 case in 3 and 2 cases in 6. No rebleeding event and angiographical recurrence happened in 9 cases of alive. The H&K grade of subrarachnoid hemorrhage on admission was poor (4 and 5) in 2 cases of dead.

Conclusion: The endovascular trapping could be acceptable treatment for rVADA involved PICA.

400

Endovascular Treatment for Failed Surgical Procedure of Blood Blister-Like Aneurysm: A Report of Two Cases

PSYen and CH Liao

China Medical University Hospital, Department of Neuroradiology, Taichung city, Taiwan

Purpose: Blood blister-like aneurysm (BBA) of the internal carotid artery (ICA) is a rare but clinically important cause of subarachnoid hemorrhage (SAH), which accounts for 0.5% of incidences of ruptured intracranial aneurysms. They arise from non-branching sites on the supraclinoid ICA and are suspected to originate from a dissection. The purpose of the report is to describe our experience of endovascular treatment of two cases of surgical failed blood blister-like aneurysm (BBA) of the internal carotid artery (ICA).

Methods: A 46-year-old and a 32-year-old male patient presented with subarachnoid hemorrhage (SAH). Cerebral angiography study revealed a BBA from supraclinoid ICA. Surgical clipping were then applied but aneurysm recurrence at the initial clipping site were detected in both cases.

Results: Endovascular treatment by coiling and stent-within-a-stent method was then applied. Follow-up angiography studies showed successful occlusion of the aneurysms without complication.

Conclusion: Endovascular treatment may be a salvageable option for BBA, especially when surgical treatment has failed.

401

Rebleeding From Cerebral Aneurysms During 3DCT Angiography

KYoshida¹, Y Harada¹, K Kudo¹ and T Mitsuhashi¹

¹Department of Neurosurgery, Tokyo Metropolitan Hiroo Hospital, Tokyo, Japan

Purpose: Computed tomographic angiography (CTA) is commonly used for the non-invasive detection of cerebrovascular lesions responsible for subarachnoid hemorrhage, but rebleeding may occur during this procedure (Hondny, 2003; Yasui, 1996). We investigated imaging findings and related factors in patients who experienced rebleeding during CTA in our hospital.

Materials and Methods: Participants comprised 112 patients who underwent CTA for ruptured cerebral aneurysm in our hospital between January 2009 and December 2012. CTA was performed using a 64-row detector system.

Results: Rebleeding occurred during CTA in 5 of 112 patients, representing a rebleeding rate of 4.5%. Mean time from initial onset of hemorrhage to CTA was shorter in patients with rebleeding (median, 95 minutes) than in patients without rebleeding (median, 228 minutes). Patients with rebleeding showed either: a) spiral or wave-shaped hemorrhage into the cistern in which the aneurysm was located; or b) tear-drop-shaped hemorrhage within the hematoma. Patients with rebleeding were all grade 5 according to the World Federation of Neurological Surgeons (WFNS) and underwent CTA within 3 h of onset.

Conclusion: CTA offers excellent performance for the diagnosis of cerebral aneurysm, but rebleeding rate was 4.5% in hyperacute stage in this study.

402

Efficiency and Prognosis of Intracranial Aneurysm Treated with Flow-Diverter Devices – Meta-Analysis and Systematic Review

W Yunyan *, Gengfan Ye and Meng Zhang

Department of Neurosurgery, Qilu Hospital,Shandong University, 107#, Wenhua Xi Road, Jinan 250012, China

*Corresponding to Yunyan Wang, MD, Department of Neurosurgery, Qilu Hospital,Shandong University, 107#, Wenhua Xi Road, Jinan 250012, China, Tel: 86-531-82166615, Fax: 86-531-82166615, Email: wangyunyan0618@126.com

Purpose: Flow-diverter devices (FDD) are increasingly used in the treatment of intracranial aneurysms. This study is to evaluate the safety and feasibility of FDD, through the literatures of single centers and multicenters which has been reported.

Methods: The literatures up to February 2015 were searched by using MEDLINE, Embase, Cochrane, CNKI, and Web of Science database. We adopted literatures according to the eligibility criteria and exclusion criteria. Then the baseline characteristics of patients and the aneurysms, aneurysm occlusion, incidence of security incidents and the corresponding number, mortality rate and the corresponding number, etc were collected. We conducted meta analysis using STATA 12.0 software and using chi-square test to evaluate whether there was statistical difference between complications and mortality with aneurysm types.

Result: A total of 48 studiesincluded2508 patients with 2826 aneurysms. The mean follow-up interval was 6.3 months. The aneurysm occlusion was 78.8% (95% CI: 74.8–82.8; I²= 82.7%). The total morbidity rate was 9.8%. The total mortality rate was 3.8%. The rate of spontaneous rupture was 2.0%. The rate of intraparenchymal hemorrhage was 2.5%. The rate of ischemic stroke was 5.5%. The morbidity rate and mortality rate of giant aneurysms were significantly higher than that of the small or large aneurysm (χ2 = 56.96, p < 0.05;χ2 = 14.88, p < 0.05). The morbidity rate of posterior aneurysms was significantly higher than that of anterior aneurysms (χ2 = 11.29, p < 0.05). The morbidity rate of ruptured aneurysms was significantly higher than that of unruptured aneurysms (χ2 = 10.36, p < 0.05). Publication bias of aneurysm occlusion was detected through Begg rank correlation method and the corrected result was less than 0.05.

Conclusion: Our meta-analysis suggests that treatment of intracranial aneurysms with FDD is feasible and effective with high occlusion rates and acceptable morbidity and mortality. But the morbidity and mortality of giant aneurysms were high. The morbidity of posterior circulation aneurysms and posterior aneurysms were significantly high.

403

A Method to Measure the Hydraulic Resistence of FD Stents

C Fülöp¹, GZávodszky¹, I Szikora² and G Paál¹

¹Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economy

²Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary

Purpose: The working mechanism of a FD (flow diverter) stent is to provide a hydraulic resistance between the parent artery and the aneurysm sac, thereby slowing the intraaneurysmal flow leading to intra-anerurysmal thrombosis. Different parameters, such as porosity and pore density have been used to characterize individual devices. While the impact of these geometrical features is debatable, the most relevant parameter of a FD is its hydraulic resistance. The purpose of the paper is to present a measurement rig and a method to determine the hydraulic resistance of various types of FD-s as a function of the flow rate. Its importance is double: it provides a measure to compare the performance of various products and it provides input data to simulate stents using a porous layer.

Methods: The measurement fluid is water. The device consists of two tanks. The upper one provides the hydrostatic pressure. The stent is placed under water in the lower one to avoid bubble formation on the stent surface. The stent is placed into a small tube whose side contains a hole. The inlet in the tube is symmetrical from both sides, the outlet is through the stent and the hole. The flow rate is measured by metering.

Results: The dependence of the hydraulic resistance is quadratic, indicating that two parameters are needed for its description. These parameters are obtained by curve fitting on measurement points. By inserting two stents into each other, there is a random factor how the struts are located relative to each other. Repeating the procedure many times, the average resistance will be roughly twice that of one stent. The effect of the second stent on slowing the intraaneurysmal flow is much less than that of the first one.

Conclusion: We provided a rig description and a method to determine the hydraulic resistence of FD stents.

404

Endovascular Treatment of Ruptured Internal Carotid Artery Aneurysms by SAC Technique

KZeleňák¹, J Zeleňáková¹, J DeRiggo¹, E Kantorová¹ and E Kurča¹

¹University Hospital, Martin, Slovakia

Purpose: To evaluate the safety and efficiency of stent-assisted coiling in treatment of ruptured internal carotid aneurysms.

Methods: 58 consecutive ruptured ICA aneurysms were treated by stent-assisted coiling between November 2003 and April 2011 with average size 7.86 mm. Average follow-up time was 4.9 years.

Results: Intraoperative rupture occurred in 2 aneurysms. 30-days mortality was 1.7%. Immediate complete occlusion and occlusion with residual neck was achieved in 87.9. mRS 0–2, 3 and 4–6 was achieved in 49, 4 and 5 cases respectively.

Conclusion: The stent-assisted coiling provides high rates of accurate occlusion in endovascular treatment of ruptured ICA aneurysms. Stent-assisted coiling of ruptured carotid aneurysms can be performed with acceptable complication rate.

405

Comparison of the Tubridge Flow Diverter and Conventional Stents in Large and Giant Aneurysms: Safety and Efficacy Based on a Propensity Score-Matched Analysis

YZhang¹, Y Zhou¹, P Yang¹, J Liu¹, Y Xu¹, B Hong¹, W Zhao¹, Q Chen² and QH Huang¹

¹Department of Neurosurgery, Changhai Hospital, Second Military Medical University, P.R. China

²Department of Health Statistics, Second Military Medical University, P.R. China

Purpose: The Tubridge flow diverter (FD) is a novel device aimed at reconstructing the parent artery and occluding an aneurysm. We performed a propensity score-matched analysis to compare the safety and efficacy between the Tubridge FD and conventional stents.

Methods: A database review was conducted to identify patients with large and giant unruptured aneurysms (≥10 mm) treated with the Tubridge FD or conventional stents. Demographic and aneurysmal data, complications, angiographic and clinic outcomes were collected. A propensity score, representing the probability of using the Tubridge FD, was generated for each aneurysm using the relevant patient’s and aneurysmal variables. Angiographic results, complications, and clinical outcomes were compared following propensity score adjustment.

Results: After matching of the propensity score, 45 aneurysms treated with the Tubridge FD and 45 treated with conventional stents were matched. The Tubridge cohort had a significantly (P = 0.0002) higher complete occlusion rate at the 6-month follow-up (68.6%) than the conventional stent cohort (24.3%). The Tubridge cohort more frequently achieved improvement (P < .0001) and had a much lower recurrence rate (P = 0.0001). The rate of peri-procedural complications was similar (P = 1), as was the proportion of patients who attained a favorable outcome (mRS ≤ 2) at discharge (P = 1) and at the 6-month follow-up (P = 1).

Conclusion: The Tubridge FD provided a remarkably higher complete occlusion rate than conventional stents, with comparable morbidity and clinical outcomes. Our findings provide reliable evidence to demonstrate that the Tubridge FD could be a preferred treatment option for large and giant unruptured aneurysms.

406

Endovascular Stenting for Blood Blister-Like Aneurysms: Report of 42 Cases

YBFang, PF Yang, QH Huang and JM Liu

Department of neurosurgery of Changhai hospital affiliated to the Second Military Medical University, Shanghai, China

Purpose: To evaluate the safety and efficacy of stent assisted coiling and determine the effect of the overlapping stents in the treatment of BBAs.

Methods: A retrospective review of the aneurysm database identified 42 patients carrying BBAs treated by stent assisted coiling in our institution from November, 2004 to August, 2014. The clinical characteristics, and angiographic results were reviewed.

Results: Endovascular stenting with/without coiling was applied in 42 BBAs, including single stent in 22, double stents in 9, and triple stents or more in 11 cases. Over the strut technique was applied in 8 cases (successful rate 50%), and jailing or semi-jailing technique (successful rate 100%) was used in 34 cases. The Jailing or semi-jailing technique provide higher successful rate than the over the strut technique (P = 0.001). The clinical follow-ups at 36.4 months (on average) was 0–2 in 32 cases (78.0%) and 3–6 in 9 cases (22.0%), with a mortality of 12.2%. Angiographic follow-ups in 38 BBAs revealed total occlusion in 22 cases (57.9%), improvement in 2 cases (5.3%), and recanalization in 14 cases (36.8).

Conclusions: It’s feasible to treat ICA BBAs with endovascular stent assisted coiling. Jailing or semi-jailing technique is helpful to increase the successful rate. Overlapping stents provide better angiographic and clinical results.

407

Endovascular Treatment for Saccular Aneurysms of the Early Cortical Branch of the Middle Cerebral Artery

CWang, Q Huang and J Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: Saccular aneurysms located at the early cortical branch of the middle cerebral artery (MCA) are uncommon, and endovascular treatment (EVT) for them is not well documented. We performed this study to evaluate the feasibility, safety, and efficacy of EVT for early cortical branch aneurysms of the middle cerebral artery.

Methods: From July 2011 to June 2014, 34 consecutive patients harbouring 35 early cortical branch aneurysms were treated at our institution via endovascular approach. The clinical and angiographic results were retrospectively evaluated.

Results: Treatments were successful in all cases, including coiling alone in 18 patients, balloon-assisted coiling in 2, and stent-assisted coiling in 15. Immediate angiograms showed total occlusion in 8 patients, neck remnant in 5 and partial occlusion in 22. Two (5.7%) procedure-related complications occurred, including early aneurysm rebleeding in one patient and acute stent thrombosis in the other one. Three (8.5%) patients suffered from postoperative complications including one early cortical branch obliteration, one late stent thrombosis and one delayed aneurysm rebleeding. Twenty-three of 23 patients underwent follow-up cerebral angiography at intervals ranging from 3 to 14 months (mean, 5.7 months). The result showed 17/23 (73.9 %) aneurysms were completely occluded, 2/23 (13 %) were stable or improved, and others were partially recanalized. The clinical follow-up (mean, 7.6 months) of all survived patients demonstrated no neurologic deteriorationor rebleeding.

Conclusion: Our preliminary experience demonstrates that EVT for the early cortical branch aneurysms is feasible and safe. However, more adequate follow-up is required to evaluate its long-term results.

408

Endovascular Treatment of Middle Cerebral Artery Aneurysm with the LVIS Junior Stent

FZhengzhe¹, L Qiang¹, Z Rui¹, Z Ping¹, C Lei¹, X Yi¹, H Bo¹, Z Wenyuan¹, L Jianmin¹ and H Qinghai¹

¹Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: Middle cerebral artery (MCA) aneurysms often occur in small parent vessels and are incorporated with the orifice of acute-angled efferent branch vessels. Endovascular treatment for these aneurysms remains technically challenging. This study aimed to assess the clinical safety and efficacy of the Low-profile Visualized Intraluminal Support Junior (LVIS Jr) stent for embolization of MCA aneurysms.

Methods: Eighteen intracranial aneurysms, including 13 unruptured and 5 ruptured aneurysms, were treated with LVIS Jr stent–assisted coil embolization. The clinical data and technical results are presented.

Results: A total of 18 stents were successfully delivered to the target aneurysms, and the technical success rate was 100%. There was complete occlusion in 8 (44.4%) of 18 cases, neck remnants in 7 (38.9%) cases, and partial occlusion in 3 (16.7%) cases. In-stent thrombosis occurred in 1 case, and the symptoms disappeared after transvenous tirofiban injection. The modified Rankin Scale score at discharge was 0 in 14 patients, 1 in 3 patients, and 2 in 1 patient.

Conclusions: The LVIS Jr stent provided excellent trackability and deliverability and is safe and effective for the treatment of wide-necked MCA aneurysms with tortuous and smaller parent vessels.

409

Endovascular Treatment of Ruptured Wide-Neck Anterior Communicating Artery Aneurysms-Treatment and Short- and Mid-Term Results in 164 Cases

YChen, KJ Zhao, YB Fang, QH Huang, Y Xu and JM Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: We aimed to assess the safety and efficacy of endovascular treatment for ruptured wide-neck anterior communicating artery aneurysms (AcomAAs) and determine predictors of treatment results.

Methods: A total of 164 patients (M:F = 69:95; median age, 55 years) with 164 ruptured wide-neck AcomAAs were treated by endovascular method between January 2011 and June 2013 at our institution. Treatment and predictors of complete embolization, perioperative adverse events, recanalization, and unfavourable outcome were analysed, respectively.

Results: A total of 69 aneurysms were treated by stent-assisted coiling, and the remaining 95 ones were managed by only coiling. Perioperative complications occurred in 21 (12.8%) patients, including 9 haemorrhagic and 12 ischemic complications. The available median durations of angiographic (n = 131) and clinical (n = 164) follow-ups were 11 months (range, 6–40months) and 18months (range, 1 days-40months), respectively. Aneurysms bleb formation and posterior dome orientation were independent predictors of perioperative haemorrhagic complications. A total of 10 cases occurred angiographic recanalization, which was affected by stent implantation (p = 0.0099) and the immediate angiographic results (p = 0.0003), and progressive thrombosis and in-stent occlusion were not detected on follow-up angiograms. 90.24% (148/164) patients had favourable outcomes (the modified Rankin Scale score [mRS], 0–2), and unfavourable Hunt-Hess scale (odds ratio [OR] = 75.826; 95% confidence interval [CI], 17.903–321.147; p < 0.0001) was the only independent predictor of unfavourable outcomes in the treated AcomAAs.

Conclusion: Without the increasement of stent-related perioperative complications, stent-assisted coiling for ruptured wide-neck AcomAAs was more efficient than single coiling in decreasing recurrence. Unfavourable Hunt-Hess scale was the only independent predictor of unfavourable outcomes in the treated AcomAAs.

410

Endovascular Treatment of Wide-Neck Anterior Communicating Artery Aneurysms Using the LVIS Junior Stent

FZhengzhe¹, Z Lei², L Qiang¹, Z Rui¹, X Yi¹, H Bo¹, Z Wenyuan¹, L Jianmin¹ and H Qinghai¹

¹Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

²Department of Neurology, Shandong Ji’ning First People’s Hospital, Ji’ning China

Purpose: We performed this retrospective study to assess the clinical safety and efficacy of the low-profile visualized intraluminal support junior (LVIS Jr.; MicroVention Inc., Aliso Viejo, CA, USA) stent placement in anterior communicating artery (ACA) aneurysms. ACA aneurysms are one of the most common intracranial aneurysms. Stent placement is particularly difficult due to the complexity of the vascular anatomy and the small vessels of the ACA complex.

Methods: From November 2013 and June 2014, LVIS Jr. stent-assisted coiling was performed in 11 patients with 12 wide-neck ACA aneurysms. Patient demographics, morphologic features of the aneurysm, clinical results and follow-up results were presented.

Results: Successful deployment of the LVIS Jr. stent in the targeted artery was achieved in all patients. Complete occlusion was achieved in seven patients, neck remnant in three, and partial occlusion in two. The angiographic follow-up of nine patients (mean 4.4 months) showed that all aneurysms remained stable or improved. There was no in-stent stenosis, recurrence or retreatment. The modified Rankin scale score at discharge was 0 in eight patients and one in three patients.

Conclusions: The LVIS Jr. stent provided excellent trackability and deliverability and is safe and effective for the treatment of wide-necked ACA aneurysms. Further follow-up is needed to assess the long-term efficacy of LVIS Jr. stent placement in ACA.

411

Predictors of Recurrence After Stent-assisted Coil Embolization of Paraclinoid Aneurysms

NLv, R Zhao, Y Fang, Q Li, Y Xu, B Hong, J Liu and Q Huang

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: Stent-assisted coil embolization has been increasingly used to treat paraclinoid aneurysms. The study was aimed to evaluate safety and efficacy of stent-assisted coil embolization for paraclinoid aneurysms and explore the factors influencing the long-term outcomes.

Methods: Under an institutional review board approved protocol, the clinical and angiographic data of 129 paraclinoid aneurysms in 120 patients (Male:Female = 36:84; median age, 52 years; range, 21–84) treated by stent-assisted coil embolization were reviewed retrospectively. Clinical status, aneurysmal morphology, treatment strategy and results were analyzed using Chi-square tests in the univariate analysis and further analyzed using backward stepwise logistic regression.

Results: The univariate analysis indicated significance between the groups regarding hypertension, ruptured aneurysms, size, wide neck and immediate treatment results (P < 0.05). Multivariate logistic regression analysis found that ruptured aneurysms (odds ratio [OR] = 5.893, 95% confidence interval [CI], 1.512–23.054; p = 0.011), larger size (OR = 2.339; 95%CI, 1.148–4.781; p = 0.020) and hypertension (OR = 6.143; 95%CI, 1.560–24.183; p = 0.009) might be predictors of recurrence.

Conclusion: Stent-assisted coil embolization of paraclinoid aneurysm has a risk of recurrence. Ruptured aneurysms, larger size and hypertension may be the risk factors for recurrence.

412

Risk Factors and Regression Models for Prediction of Posterior Communicating Artery Aneurysm Rupture

NLv, Y Yu, J Xu, C Wang, J Liu and Q Huang

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: Morphology and hemodynamics are believed to play an important role in rupture of intracranial aneurysms. We aimed to determine the independent risk factors of aneurysm rupture by focusing on only posterior communicating artery (PCoA) aneurysms and build regression models for rupture risk assessment of PCoA aneurysms.

Methods: In 129 PCoA aneurysms (85 ruptured, 44 unruptured), clinical, morphological and hemodynamic characteristics were compared between the ruptured and unruptured groups. Multivariate logistic regression analysis was performed to determine the independent predictors for the rupture status of PCoA aneurysms and build logistic regression models based on morphology, hemodynamics and both of them. Then morphological and hemodynamic features of another 28 consecutive aneurysms were measured and applied in the previous regression models. The model performances at predicting rupture statuses at different cut-off were measured and compared against anecdotal metrics (aneurysm size > 7 mm, aspect ratio > 1.6 and size ratio > 2.0).

Results: In univariate analysis, the size of aneurysm dome, aspect ratio (AR), size ratio (SR), dome-to-neck ratio (DN), inflow angle (IA), normalized wall shear stress (NWSS) and percentage of low WSS area (LSA) were significant parameters (P < 0.05). In multivariate logistic regression analysis, 3 different logistic regression models were built. Size and IA were demonstrated to be the independently significant factor in the morphology model, whereas NWSS was the only independently significant parameters in the hemodynamics model. IA and LSA were retained in the combined model. For the test cohort of 28 PCoA aneurysms, the combined model showed relatively higher sensitivity (0.79) and specificity (0.78) simultaneously at a cutoff score of 50% than the other 2 models and anecdotal metrics.

Conclusion: Hemodynamics and morphology were important in discriminating rupture status of PCoA aneurysms and the models could potentially assist in clinical decision-making for unruptured PCoA aneurysms.

413

Ruptured Intracranial Aneurysm Endovascular Treatment (RIAEVT) Risk Score: A Predictive Modelling Study for Individual Elderly Patients

GDuan, L Zhang, B Hong, Y Xu, W Zhao, J Liu and Q Huang

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: Endovascular treatment (EVT) entails a higher risk of complication in elderly patients with ruptured intracranial aneurysms (RIAs). Our aim was to develop and validate a complication risk score for individual elderly patients about to undergo EVT.

Methods: Retrospectively collected data, including clinical, lesion, and procedure-related characteristics of consecutive elderly patients with RIA who had undergone EVT within a period of 10 years, were used to develop a complication predictive score by performing a multivariable logistic regression analysis. The complications included intraprocedural rupture, ischemic stroke, recurrent subarachnoid hemorrhage (SAH), and distant intraparenchymal hemorrhage within 30 days after EVT. The score was validated internally with bootstrapping techniques.

Results: Five hundred and twenty elderly patients who underwent EVT were enrolled. At 30 days, the procedure-related complication rate was 13.08%. Six risk factors, namely hypertension, Hunt-Hess score, Fisher score, wide-necked aneurysm, a bleb on the aneurysm sac, and tiny aneurysm were independently associated with procedure-related complications. The RIAEVT score model was developed based on these six variables and predicted the risk of complications at a sensitivity of 63.22% and specificity of 84.79%.

Conclusions: Our study indicated that hypertension, high Hunt-Hess score, high Fisher score, wide-necked aneurysm, a bleb on the aneurysm sac, and tiny aneurysm were independent risk factors of EVT-related complications. In combination with these risk factors, the RIAEVT risk score can be a useful tool in the prediction of EVT-related complications but needs to be validated in prospective cohorts from various centers before it can be recommended for application.

414

Ruptured Intracranial Aneurysms in Elderly Patients: Risk Analysis of Endovascular Treatment Complications

GDuan, L Zhang, B Hong, Y Xu, W Zhao, J Liu and Q Huang

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: To retrospectively evaluate the periprocedure complications from endovascular treatment (EVT) for ruptured intracranial aneurysms (RIAs) in elderly patients and to explore preliminarily which factors are associated with complications.

Methods: Retrospectively collected data included clinical, lesions and procedural related characteristics of 520 consecutive RIAs elderly patients underwent EVT over a period of 10 years in a single center were used to evaluate the periprocedure complications and preliminarily risk factors with multivariable logistic regression analysis. The periprocedure complications including death, intraprocedural rupture, ischemic stroke, recurrent SAH and distant intraparenchymal hemorrhage after EVT. All patients included underwent independent neurological evaluation before and after the procedure and at 30 days.

Results: We reported 12 cases (2.31%) of intraprocedural rupture, 35 cases (6.73%) of ischemic stroke, 16 cases (3.08%) of recurrent SAH, and 5 cases (0.96%) of distant intraparenchymal hemorrhage. The overall complication rate at 30 days after EVT was 13.08%. Multivariable logistic regression analysis revealed that hypertension, high GCS score, high Hunt-Hess score, size ratio, aneurysm shape irregular and timing of coiling after rupture less than 72 hours were independent risk factors of periprocedure death. With a bleb on the aneurysm sac and large aneurysm size were independent risk factors of intraprocedural rupture. Ventricle hematocele, high Hunt-Hess score and with a bleb on the aneurysm sac were independent risk factors of recurrent SAH. Past cerebral infarction history, high Fisher scale score and tiny aneurysm size were independent risk factors of distant intraparenchymal hemorrhage. Hypertension, high Hunt-Hess score, high Fisher scale score, wide-necked aneurysm, aspect ratio and with a bleb on the aneurysm sac were independent risk factors of ischemic stroke after EVT.

Conclusion: Cerebrovascular complications from EVT for RIAs are diverse. The clinical grade including Hunt-Hess score, Fisher scale score and some important morphological characteristics are associated with thewe complications.

415

Stent Assisted Coiling for the Treatment of 211 Acutely Ruptured Wide-Necked Intracranial Aneurysms: A Single Center 11-Year Experience

PYang, K Zhao, Y Zhou, R Zhao, L Zhang, W Zhao, B Hong, Y Xu, Q Huang and J Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: To evaluate the safety, angiographic and clinical outcome of stent assisted coiling (SAC) for acutely ruptured wide-necked intracranial aneurysms treated in a single center over an 11 year period.

Methods: Under an IRB approved protocol, we retrospectively reviewed the angiographic and clinical data of 211 patients (52 male, 159 female; median, 56 years; range, 31–83 years) with acutely ruptured wide-necked intracranial aneurysms (neck >4 mm and/or dome to neck ratio ≤2) treated by SAC from September 2000 to December 2011. Baseline characteristics, procedure-related complications, angiographic follow-up results and clinical outcome were analyzed statistically. A Mann-Whitney U test was performed for non-normally distributed continuous variables. A Pearson’s chi-square or Fisher’s exact test was performed for categorical variables. Univariate analysis and Logistic regression analysis were performed to determine the association of procedure-related complications and clinical outcome with potential risk factors.

Results: Procedure-related complications occurred in 30 patients (14.2%). They were more common in AComA (26.7%, 12/45) and MCA-bifurcation (40%, 4/10) aneurysms than in aneurysms at other locations (9.0%, 14/156). Clinical outcome (median, 33 months) was good in 175 patients (82.9%) with a MRS of ≤2. Older age (p = 0.013, OR value = 1.054) and higher Hunt-Hess grade (p < 0.001, OR value = 15.876) were independent risk factors for unfavorable outcome. 152 of 190 (80%) survived patients underwent angiographic follow-up at least once (median, 12 months). The complete occlusion rate improved from immediate 45.5% to 75.7% at follow-up (115/152).

Conclusion: Angiographic and clinical outcomes in our series were comparable to those reported using coiling alone or balloon assisted coiling techniques. SAC for the treatment of acutely ruptured MCA-bifurcation and AcomA aneurysms was associated with a significantly higher incidence of complications than was the case for treatment of aneurysms at other locations.

416

Stent Assisted Coiling Versus Non Stent Assisted Coiling for Intracranial Aneurysms: A Systematic Review and Meta-Analysis

QHHuang and JM Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai 200433, P.R. China

Purpose: Endovascular embolization has become an effective and important way for treating intracranial aneurysms and parent artery reconstruction is becoming the consensus of interventional doctors. We systematically reviewed the literature which compares the treatment of stent assisted coiling and non stent assisted coiling, a meta-analysis was done to compare the safety and efficacy of these two kinds of schemes. This may help to provide basis for physicians to choose a better way to treat intracranial aneurysms and improve patients’ outcome.this may provide evidence for physicians when making clinical decisions to treat intracranial aneurysms and improve patients’ outcome.

Methods: According to the methods and guidelines for Meta analysis, searching PubMed, Embase, Medline and Cochrane Controlled Trials Register database, we reviewed all the documents about the comparison of stent assisted coiling and non stent assisted coiling. Extracting dates about complication rate, ischemic stroke rate, hemorrhagic stroke rate, immediate occlusion rate, cure rate at follow up, progressive occlusion rate and recurrence rate from the literature and then the meta-analysis was done.

Results: 15 papers including 1 RCT and 14 observational studies were selected. NO statistical differences were found in immediate occlusion rate (OR = 1.06; 95% CI, 0.75–1.50), complication rate (OR = 1.28; 95% CI, 0.98–1.66;), ischemic stroke rate (OR = 1.59; 95% CI, 0.94–2.69; P = 0.08) and hemorrhagic stroke rate (OR = 1.20; 95% CI,0.59–2.45). However, comparing with non stent assisted coiling, stent assisted coiling has an advantage in cure rate at follow up (OR = 1.95; 95% CI, 1.22–3.11), progressive occlusion rate (OR = 2.86; 95% CI, 1.85–3.90) and recurrence rate (OR = 0.42; 95% CI, 0.31–0.56).

Conclusion: In cure rate at follow up and recurrence rate, stent assisted coiling is superior to non stent assisted coiling. No statistical differences were found in the safety of the two methods.

417

Stepwise Stent Deployment Technique for Tandem Intracranial Aneurysms: A Review of 26 Cases

YBFang, ZL Zhang, PF Yang, WL Wen, QH Huang and JM Liu

Department of neurosurgery of Changhai hospital affiliated to the Second Military Medical University, Shanghai, China

Purpose: We performed this study to report our experience using a stepwise stent deployment technique for the treatment of tandem intracranial aneurysms.

Methods: Patients with intracranial tandem aneurysms that were treated with a stepwise stent deployment technique between May 2009 and December 2014 were retrospectively reviewed.

Results: Twenty-six patients with 52 tandem aneurysms were identified (11 men, 15 women), with a mean age of 55.3 years (range, 17–82 years). Subarachnoid haemorrhage was confirmed in 13 patients using computed tomography at onset. Complete occlusion was achieved in 23 of the aneurysms (44.2 %) after the procedure, neck remnant in 10 (19.2 %), and aneurysm remnant in 19 (36.5 %). The perioperative complications included in-stent thrombosis in one case and vasospasm in two cases, none of which left a permanent neurological deficit. The modified Rankin Scale (mRS) score at discharge was 0–2 in 25 cases and 3 in one case. The follow-up angiograms available for 19 patients showed complete occlusion in 38 aneurysms, improved in 4, and stable in 4. All of the patients had mRS scores of 0–1 during the clinical follow-up period.

Conclusions: The stepwise stent deployment technique is feasible and helpful in the treatment of intracranial tandem aneurysms.

418

Stromal Cell-Derived Factor 1± Dynamically Mediates Saccular Aneurysm Remodelling in Rabbits

ZFLi, R Zhao, QH Huang and JM Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University

Purpose: The factors which attract those stem or progenitor cells to injury site become the key point of facilitating aneurysm repair. Stromal-cell-derived factor 1α (SDF-1α) plays an essential role in angiogenesis and aneurysm wall inflammation. However, the dynamic expression profile and role of SDF-1α in aneurysm wall remodelling remains unknown. Here, we investigated the expression profile of SDF-1α during the remodelling process in induced saccular aneurysm in rabbits using porcine elastase.

Methods: Saccular aneurysms were induced in thirty New Zealand White rabbits. The aneurysm were harvested on day 1, 3, 7, 14 and 21. Blood sample were collected to investigate the serum SDF-1α level at different time points before model establishment and postoperatively on day 1, 3, 7, 14 and 21. The endothelial cells lying on the inner surface of aneurysm sac were observed with scanning electron microscopy on different time points. After the procedure, SDF-1α expression level was examined with immunohistochemistry, Western blot and real-time PCR. In vitro, expression of adhesion molecular on endothelial progenitor cells was examined after given SDF-1α stimulation. Migration assay were also investigated using endothelial progenitor cells after given SDF-1α with different concentration gradient.

Results: All aneurysm models were successfully established in New Zealand White rabbits. Aneurysms were harvested on day 1, 3, 7, 14 and 21. Aneurysm sacs were substantially filled with thrombosis 3 days after model induction and were subsequently remodeled, accompanied by progressive thrombosis degradation and intima re-endothelialization. Serum SDF-1α levels increased in a bimodal fashion during the 21 days post-operation. Immunohistochemistry, western blot and real-time PCR analyses showed that SDF-1α expression was increased in the local aneurysm wall and reached a maximum on day 14. Vascular endothelial (VE)-cadherin was up-regulated after stimulation with SDF-1α and endothelial progenitor cell migration was enhanced by SDF-1α.

Conclusion: SDF-1α dynamically mediates aneurysm wall remodelling and may facilitate aneurysm maturation by up-regulating VE-cadherin expression and promoting the migration of endothelial progenitor cells to the site of injury. SDF-1α expression levels in peripheral blood and local aneurysm wall were associated with the status of aneurysm wall inflammation and intra-aneurysmal thrombus.

419

Treatment of Ruptured Vertebral Artery Dissecting Aneurysms Distal to the Posterior Inferior Cerebellar Artery: Stenting or Trapping?

YBFang, PF Yang, YN Wu, QH Huang, Y Xu and JM Liu

Department of neurosurgery of Changhai hospital affiliated to the Second Military Medical University, Shanghai, China

Purpose: The treatment of ruptured vertebral artery dissecting aneurysms (VADAs) continues to be controversial. Our aim was to evaluate the safety, efficacy, and long-term outcomes of internal trapping and stent-assisted coiling (SAC) for ruptured VADAs distal to the posterior inferior cerebellar artery (supra-PICA VADAs), which is the most common subset.

Methods: A retrospective review was conducted of 39 consecutive ruptured supra-PICA VADAs treated with internal trapping (n = 20) or with SAC (n = 19) at our institution. The clinical and angiographic data were retrospectively compared.

Results: The immediate total occlusion rate of the VADAs was 80% in the trapping group, which improved to 88.9% at the follow-ups (45 months on average). Unwanted occlusions of the posterior inferior cerebellar artery (PICA) were detected in 3 trapped cases. Incomplete obliteration of the VADA or unwanted occlusions of the PICA were detected primarily in the VADAs closest to the PICA. In the stenting group, the immediate total occlusion rate was 47.4%, which improved to 100% at the follow-ups (39 months on average). The immediate total occlusion rate of the VADAs was higher in the trapping group (p < 0.05), but the later total occlusion was slightly higher in the stenting group (p > 0.05).

Conclusions: Our preliminary results showed that internal trapping and stent-assisted coiling are both technically feasible for treating ruptured supra-PICA VADAs. Although not statistically significant, procedural related complications occurred more frequently in the trapping group. When the VADAs are close to the PICA, we suggest that the lesions should be treated using SAC.

420

Fenestration of Vertebro-Basilar Artery with a Complex Intracranial Aneurysm

Z Yajun, Y Hongkuan, C Rudong, H Yue and Y Jiasheng

Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China

Vertebro-basilar artery fenestration is an uncommon congenital variant, which has been associated with saccular aneurysm. There are rare reports of aneurysm in children who have vertebro-basilar artery fenestration. We present a case of an 8-year-old girl who suffered with a sudden headache. Computed tomography revealed subarachnoid hemorrhage and acute hydrocephalus. The following magnetic resonance imaging showed an abnormal signal in the vertebro-basilar artery, which we confirmed on digtal subtraction angiography to be a complex aneurysm. The girl recovered without any complications after the endovascular treatment with coils by double microcatheter technique. Based on the literature review, the etiology of the fenestration, aneurysm morphology and the treatment strategy are discussed. (CASE REPORT)

421

The Clinical Features and Endovascular Treatment of Moyamoya Disease with Intracranial Aneurysms

YHongkuan, ZYajun, C Rudong, H Yue, YJiasheng, C Jincao, C Jian and L Ting

Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China

Purpose: To explore the clinical manifestation, neuro-imaging characteristics and endovascular treatment for intracranial aneurysms associated with Moyamoya disease.

Methods: The clinical data of 7 cases with moyamoya associated with intracranial aneurysm confirmed by cerebral digital subtraction angiography (DSA), and treated with embolization were retrospectively analyzed, involved clinical manifestation, neuro-imaging characteristics and curative effect.

Results: 5 cases had aneurysms showed subarachnoid hemorrhage. 2 cases showed intracerebral hemorrhage and flooding into ventricular. 5 cases belonged to the major artery type and 2 peripheral artery type. All cases were treated by endovascular embolization. All of 7 patients achieved good curative effects and excellent clinical outcomes.

Conclusion: Moyamoya disease associated with intracranial aneurysm may result in different types of clinical manifestation and imaging characteristics, endovascular treatment is feasible for aneurysms associated with Moyamoya disease.

422

Ibuprofen Inhibits ASA: A Potentially Fatal Interaction

R Martinez¹, M Aguilar Perez¹, W Kurre¹, O Ganslandt², H Bäzner³ and H Henkes¹

¹Clinic for Neuroradiology

²Neurosurgical Clinic

³Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany

Purpose: Ibuprofen, a nonsteroidal anti-inflammatory drug, has been used to prevent inflammatory reactions and related aneurysm rupture due to excessive thrombus formation after flow diversion of large and giant aneurysms. Ibuprofen, however, interferes with the platelet function inhibition effect of acetylsalicyclic acid (ASA).

Methods: A 53-year-old patient presented with an incidental aneurysm of the proximal basilar artery (fundus 24 mm, neck 13 mm). On April 15th the patient underwent a ventricular shunt operation. On April 17th the patient was loaded with 500 mg ASA IV and 180 mg ticagrelor PO. During the procedure on the same day, 500 mg ASA IV and 15.8 mg eptifibatide IV were added. Five coils were inserted inside the aneurysm sac. An Enterprise2 stent (4/39) and two p64 flow diverters (4/24) were deployed in the basilar artery without difficulty. The postprocedural medication included 100 mg ASA, 2x 90 mg ticagrelor, 2x 3,000 U certoparin sodium, 3x 4 mg dexamethasone and 1x 400 mg ibuprofen daily.

Results: The patient was discharged home asymptomatic on April 20th after dual platelet inhibition was confirmed (Multiplate). On April 24th, the patient lost consciousness and was transferred to us. The family confirmed that all medications had been taken. Multiplate showed platelet inhibition from ticagrelor and no ASA effect. MRI and DSA confirmed acute in-stent thrombosis. Despite rapid and successful aspiration thrombectomy of the basilar artery the patient died due to brainstem infarction. Ibuprofen was detected in urine and blood.

Conclusion: Ibuprofen can significantly inhibit ASA. Patients who need dual platelet function inhibition (e.g., following intracranial stent or flow diverter treatment) must not receive ibuprofen. In case of doubt, response testing using Multiplate or VerifyNow is recommended.

423

Feasibility and Safety of Premedication with Tirofiban for Stent Assisted Coiling in Acute Ruptured Intracranial Aneurysms

MKang¹, S Kim¹ and J Choi¹

¹Busan-Ulsan Regional Cardiocerebrovascular Center, Dong-A University Hospital, Busan, South Korea

Purpose: To evaluate the feasibility and safety of intravenous tirofiban injection as a premedication instead of oral dual antiplatelet agent for stent assisted coiling in acute ruptured intracranial wide neck aneurysms.

Methods: 55 patients underwent stent assisted coiling of acute ruptured wide neck aneurysms with intravenous tirofiban injection as a premedication of antiplatelet agent. We analyzed retrospectively the rates of periprocedual intracerebral hemorrhage, thromboembolic event, tirofiban related morbidity and mortality, and systemic complication.

Results: Six patients (11%) showed increased size of intracerebral hemorrhage or subarachnoid hemorrhage in immediate follow up brain computed tomography after endovascular coiling. Among of them, 2 patients (3.6%) showed clinical worsening and the other 4 patients' clinical status did not change. Ten patients presented hydrocephalus and required a ventriculostomy after endovascular coiling. Even though intravenous tirofiban injection was not stopped during a ventriculostomy, there was no hemorrhagic complication. No immediate or delayed thromboembolic event occurred, and there was no systemic complication. Overall, the respective rates of tirofiban related morbidity and mortality were 3.6%.

Conclusion: Our findings suggest that stent assisted coiling with intravenous tirofiban injection as a premedication of antiplatelet agent is a viable option in the management of ruptured intracranial wide neck aneurysms.

424

Association Between Carotid Artery Stenosis and the Ratio of Serum Eicosapentaenoic / Arachidonic Acid

TOhashi¹, S Koyama², D Watanabe², T Hashimoto² and M Kono²

¹Tokyo Medical University Ibaraki Medical Center, Inashiki, Ibaraki, JAPAN

²Tokyo Medical University Hospital, Shinjuku, Tokyo, JAPAN

Purpose: This study aimed to investigate the association between carotid artery stenosis and the ratio of eicosapentaenoic / arachidonic acid (EPA/AA).

Methods: We retrospectively reviewed records of 68 patients who underwent carotid artery stenting between November 2005 and March 2015 in our hospital. Of 68 cases, symptomatic 37 cases (54.4%) and asymptomatic 31 cases were (45.6%) included. Cases were classified as L group ( < 0.55), M group (0.55–1.05) and H group (>1.05).

Results: The mean EPA/AA ratio was lower in symptomatic cases (0.50) than asymptomatic cases (0.66), and 65% were L group in symptomatic cases whereas 52% in asymptomatic. In addition, 67% of vulnerable plaque imaging was seen in L group. For perioperative results of carotid stenting, all 5 cases of DWI-positive and 1 case with neurological complication were in L group and never seen in H group. The mean EPA/AA of restenosis cases showed 0.48, and 2 of 3 cases were L group, and never seen in H group, too.

Conclusion: The EPA/AA ratio relates to histological features of atherosclerosis of carotid artery, and EPA medication may reduce complications of carotid stenting and may prevent restenosis.

425 Presentation withdrawn

Prevalence and Risk Factors for Increased Platelet Reactivity after Carotid Artery Stenting

TMasanori, E Yukiko, E Yusuke and I Toru

Department of Neurosurgery, Gifu University Graduate School of Medicine

Purpose: Increased platelet reactivity after carotid artery stenting (CAS) may cause thromboembolic complications. This study aimed to investigate the incidence of and determine the factors related to increased platelet reactivity after CAS.

Materials and Methods: Between October 2013 and December 2014, all patients admitted with a diagnosis of internal carotid artery stenosis and treated with CAS at the Department of Neurosurgery, Gifu University Hospital were investigated prospectively. Patients received preprocedural antiplatelet therapy comprising some combination of aspirin (100 mg/day), clopidogrel (75 mg/day), and/or cilostazol (200 mg/day) for a minimum of 7 days. Adenosine diphosphate (ADP)- and collagen-induced platelet aggregation were measured before and 4 days after CAS. Changes in platelet reactivity were evaluated as changes in the categorized platelet reactivity grade based on the effective-dose 50%. Clinical characteristics of patients with and without increased platelet reactivity were compared.

Results: Among 39 consecutive patients who underwent CAS, 19 (49%) exhibited increased platelet reactivity. In the univariate analysis, a significantly larger number of patients in the activated group presented with diabetes mellitus (DM) when compared with the non-activated group (14/19, 74% vs. 3/20, 15%; p < 0.001). The level of glycated hemoglobin (HbA1c) was also significantly higher in the activated group than in the non-activated group (6.6 ± 0.7 mg/dl vs. 5.9 ± 0.7 mg/dl; p = 0.011). Furthermore, high-intensity signal (HIS) was significantly more frequently observed on time-of-flight (TOF)- MR angiography (MRA) evaluations of patients in the activated group (10/19; 53%) relative to the non-activated group (1/20; 5%; p = 0.002). DM (odds ratio [OR], 17.1; 95% confidence isnterval [CI], 2.4–120.4; p = 0.004) and carotid artery plaques exhibiting HIS on TOF-MRA (OR, 24.5; 95% CI, 1.9–311.8; p = 0.014) were independently associated with increased platelet reactivity in a multivariate analysis.

Conclusion: Increased platelet reactivity occurred in nearly half of patients subjected to CAS, and was independently associated with DM and carotid artery plaques exhibiting HIS on TOF-MRA.

426

Preliminary Experience of Tirofiban Infusion in Coil Embolization of Ruptured Intracranial Aneurysms

CHYoon¹, YS Kim² and SK Baik¹

¹Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine

²Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine

Purpose: Thromboembolic complications are the most commonly reported complications during endovascular treatment of intracranial aneurysms with coils. There have been some reports on the use of intraarterial tirofiban in ruptured aneurysms. We represent our experience with intravenous tirofiban infusion in patients who have received coil embolization for intracranial aneurysms.

Methods: Between December 2008 and November 2014, we retrospectively reviewed 249 ruptured intracranial aneurysms that treated with coiling at our institutions. 28 patients harboring 31 ruptured intracranial aneurysms underwent intravenous tirofiban infusion during and after coil embolization procedure. Intraarterial tirofiban infusion through a microcatheter was also performed to resolve thrombus formation in 26 patients during the procedure.

Results: 26 aneurysms (83.9%) were located in the anterior circulation. The mean size of aneurysms was 6.0 mm. 26 aneurysms were saccular and 13 aneurysms treated with stent-assisted coiling. Antiplatelet premedication was administered in only three cases before procedure and thrombus formation during procedure was detected in 24 cases. Two intracranial hemorrhagic complication (increase in the amount of hematoma) occurred during a follow up period. In addition, two systemic hemorrhagic complication was also found.

Conclusion: Intravenous tirofiban as a monotherapy or in addition to intraarterial tirofiban seem to be safe during and after coil embolization in patients with ruptured intracranial aneurysms.

427

Endovascular Treatment of Spinal Sulcal Artery Pseudoaneurysm as a Rare Complication of Epidural Anesthesia

FCharvát, J Malík, V Beneš and V Charvátová

Military University Hospital Prague, Praha, Czech Republic

Purpose: Pseudoaneurysm of spinal arteries is a rare pathology, usually occurring as a complication of spinal intervention. Symptoms are mainly caused by edema of spinal cord due to congestion in draining veins. Topical neurological symptoms correlate with the location of lesion, typically dysesthesia and paresis to plegia and alternatively conus medullaris or cauda equina syndromes.

Methods: A 26-yo patient with familial adenomatous polyposis after subtotal colectomy in general and spinal anesthesia who developed lower limbs dysesthesias, progressive paraparesis and cauda equina syndrome has been referred to our department for further investigation. MRI of thoracic and lumbar spine showed spinal cord edema from Th11 to L1 with suspected spinal AV malformation. DSA clearly demonstrated pseudoaneurysm of sulcal artery of spine feeded by Adamkiewicz artery originating from left Th12 intercostal artery. First attempt to catheterize the lesion using Sl-10 microcatheter was unsuccessful due to sharp angle from anterior spinal artery to sulcal artery, therefore Magic 1.2 F microcatheter with Hybrid007D and Hybrid008D microguidewires were used to cross over the angle. Pseudoaneurysm was occluded with one Balt Flow Coil 2.5/20.

Results: Successful complete exclusion of pseudoaneurysm was achieved. Edema together with dysesthesias and paraparesis regressed, patient could walk unaided, with significant neurological restoration.

Conclusion: Pseudoaneurysm of spinal artery is a rare iatrogenic complication, to our best knowledge, we could not find any yet reported similar case of sulcal artery pseudoaneurysm. We suggest that embolization with Balt Flow Coils is a safe and efficient endovascular procedure in treatment of such vascular lesions.

428

Acute Cerebral Haemorrhage with Arteriovenous Malformation (AVM): Role of Angiographic – CT (Dynacta)

VGupta¹, G Goel¹, R Parthasarathy¹, SI Sirajee, A Mahajan¹, A Gupta², K Singh², V Singhal³ and AN Jha²

¹Department of Interventional Neuroradiology, Institute of Neurosciences, Medanta -the Medicity, Gurgaon, Haryana, India

²Department of Neurosurgery, Institute of Neurosciences, Medanta- the Medicity, Gurgaon, Haryana, India

³Department of Neuroanaesthesia and critical care, Institute of Neurosciences, Medanta- the Medicity, Gurgaon, Haryana, India

Purpose: In patients with hematoma associated with arteriovenous malformations (AVMs), it is critical to evaluate the angio-architecture of the malformation and determine the relationship of a peri or intra-nidal aneurysm to the hematoma.

Methods: Combined angiography/CT suite that uses flat-panel detector (FD) technology provides with higher-resolution angiography and CT-like images (Angiographic-CT). We retrospectively reviewed cases of cerebral hematoma due to ruptured AVM in whom Angiographic CT was done.

Results: Ten patients [median age: 43 years (12–75); male 6(60%)] were evaluated with the technique. The AVM nidus measured ≤3 cms in seven (70%, n = 10) and 4 cms in one patient. DSA images revealed possible peri/intranidal aneurysm in eight patients. Angiographic CT examination revealed projection of aneurysm sac into the hematoma cavity thereby confirming the presence of a ruptured intra/perinidal aneurysm in seven patients. Suspected intranidal aneurysm on DSA was identified as venous loop on AngioCT in one patient. In another case with feeding artery and venous aneurysm, it confirmed that the arterial aneurysm was the ruptured one by its relationship to the hematoma. In seven patients, the aneurysm and part of AVM were embolized in acute stage and was followed with radiosurgery or surgery for the residual AVM. Two patients were directly operated upon with excision of aneurysm, AVM and hematoma. One patient awaits treatment. During surgery the Angio-CT images were useful to localize the AVM in relationship to the hematoma. In one patient with very small AVM, the Angiographic-CT images were used for neuronavigation during surgery. AngioCT also helps planning the surgical approach.

Conclusion: Angiographic-CT with intra-arterial injection is a useful adjunct to cerebral angiography in evaluating patients with cerebral hematoma due to ruptured AVMs. It is more accurate than DSA to localize and confirm intra/perinidal aneurysms, delineating relationship of hematoma and AVM and for image guidance during surgery.

429

Onyx^tm Embolization of Cerebral AVM Using Scepter^tm Balloon Catheter

A Hyodo¹, N Shimizu¹, K Suzuki¹, Y Tanaka¹, M Nagaishi¹, Y Kawamura¹, K Tsuda¹, Y Inoue¹, Y Fujii¹, R Suzuki¹, Y Sugiura¹ and I Takano¹

¹Department of Neurosurgery, Dokkyo Medical University Koshigaya Hospital, Koshigaya, Saitama, Japan

Purpose: Onyx™ embolization of cerebral AVM is useful, especially for using “Plug and Push method”. However, during this method, sometimes the tip of the catheter is embedded into the plug, and it is difficult to retrieve the non-detachable catheter (such as Marathon™ catherer). Using Scepter™ balloon catheter (Scepter™) is very easy to push Onyx™ without any backflow and it is like “Plug and Push method”. And after the injection of Onyx™, Scepter™ is very easy to retrieve. We present our experiences of Onyx™ embolization of cerebral AVM using Scepter™ and show its usefulnesss.

Methods: We have experienced 4 cases (6 sessions) of Onyx™ embolization of cerebral AVM using Scepter™. They were 3 males and 1 female, and mean age was 48.8 years old. All AVM were located in cerebrum and 3 cases were ruptured. Spezter & Martin grade were III in 2 cases and IV in 2 cases. Under general anesthesia, through a 6 or 7 french sized guiding catheter, Scepter™ was navigated into appropriate feeding artery as near as possible to the nidus using 0.014 microguidewire. And after inflation of the balloon, Onyx™ was injected into the nidus as much as possible.

Results: Within 6 sessions, 2 feeders were embolized in 2 sessions, and 1 feeder was embolized in 4 sessions. Scepter™ was retrieved easily after embolization in all cases. After embolization, one case was complete occlusion, 2 cases were 90% occlusion, but one case was less than 50% occlusion. As a complication, one case occurred intracerebral hemorrhage a day after embolization. Modified Rankin Score 30days after treatment were 0 in 3 cases and 2 in 1 case.

Conclusion: Onyx™ embolization of cerebral AVM using Scepter™ is easy for “Plug and Push method”, and useful for the treatment of AVM.

430

Improved Cerebrovascular Reserve After Embolization of Ruptured Cerebral Proliferative Angiopathy

SJJang¹ and SW Ha¹

¹University of Chosun, Gwang-ju, South Korea

Purpose: Cerebral proliferative angiopathy is a rare and peculiar type of cerebral vascular malformation characterized by diffuse network with normal brain tissue intermingled, multiple nondominant arterial feeders, relatively small draining veins, angiographic capillary angioectasia and vascular proliferation. It should be separated from cerebral AVMs in angioarchitecture, nature history, clinical presentation.

Materials and Methods: In our case, we present a 61-year-old male stuporous patient who suffered headache with left side weakness and his brain radiographic images showed characteristics of ruptured cerebral proliferative angiopathy. We treated him through endovascular method.

Result: After treatment of embolization, brain SPECT showed improvement of cerebrovascular reserve on perilesional area. And previous stroke like symtom was disappeared.

Conclusion: There are many consideration points of endovascular treatment of cerebral proliferative angiopathy. And therapeutic strategy of neurointervention should be done carefully.

431

Pre-Existing, Incidental and Hemorrhagic Avms in Pregnancy and Postpartum: Gestational Age, Morbidity and Mortality, Management and Risk for Fetus

XMDLv, ZM Wu and YMD Li

Beijing Neurosurgerical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing

Email: liyouxiang@263.net

Correspondence to: Xianli Lv M.D., Beijing Neurosurgerical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing. Tiantan Xili, No. 6, Beijing, 100050

Objective: The aim of this study was to review maternal and fetal outcomes of pregnancies who present with AVMs according to the pathology and gestational age.

Methods: A literature review was performed and analyzed 65 cases of verified AVM during pregnancy previously reported in the literature in English.

Results: Sixty-five cases of pregnancy-associated AVM were identified. The patient age ranged from 16--45 years, mean 28 years. There were 16 cases (24.6%) with pre-existing AVMs and 2 (3.1%) were incidental. There were 54 cases (83.1%) of AVM ruptured during pregnancy and postpartum, 6 cases (11.1%) were in the first trimester, 24(44.4%) were in the 2nd, 22(40.7%) were in the 3rd trimester and 2(3.7%) was postpartum. Unfavorable clinical outcome (mRS ≥ 2) was identified in 20 cases (30.8%) and abortion occurred in 10 cases (15.4%). There were 3 maternal deaths, giving a case mortality rate of 4.6%. Fifty-three fetus was born via cesarean section in 42 cases and vaginal delivery in 10 cases, 48 were good health, 3 were temporally intubated, 1 was macrosomia and 1 was died. In univariate analysis, AVM hemorrhage presentation were significantly associated with a maternal poor outcome (modified Rankin Scale ≥2) (p = 0.030), however, not significantly associated with fetus risk (p = 0.864). Gestation age was not significantly associated with maternal poor outcome (p = 0.875) and fetus risk (p = 0.790).

Conclusion: AVM hemorrhage presentation was significantly associated with a maternal poor outcome, however, not significantly associated with fetus risk. Gestation age was not significantly associated with maternal poor outcome and fetus risk.

432

Endovascular Embolization of Brainstem Arteriovenous Malformation

JH Park¹, I Choi¹, HS Hwang¹ and IY Sin¹

¹Dongtan Sacred Heart Hospital, Hallym University, Hwaseong, Gyeonggi-Do, Korea

Purpose: Brainstem Arteriovenous malformation (BSAVM) is not common, and it represents about 2.5% of brain AVM. BSAVM is still challenging even with modern microsurgical, endovascular and radiosurgical techniques and tools because of high risk of deterioration due to hemorrhage and infarction. There are only a few cases of patients with BSAVM, and adequate treatment strategies are yet to be elucidated, especially about endovascular management of BSAVM. We report a case with endovascular embolization of BSAVM. The relevant literature is also discussed.

Methods: This 54-year-old male presented with a history of severe headache, nausea followed by deep drowsy consciousness and general weakness. Computed tomography (CT) scan showed a hyperdense lesion in the ventral pontine region. CT angiogram demonstrated abnormal vascular structure around superior cerebellar artery (SCA) and anterior inferior cerebellar artery (AICA) on the right side.

Results: Cerebral angiography showed arterial supply from right AICA and multiple small branches of the basilar artery. Venous drainage was to the sagittal sinus.

Conclusion: After Onyx embolization, residual small feeding arteries and venous drainage were seen on angiogram, but main component of the AVM was suggested to be eliminated.

433

Cerebral Proliferative Angiopathy, Rare and Recent Discovered Clinical Entity: Case Series of a Single Health Care Center in the Amazon, Brazil

EHAPaschoal^1,2, GS Jong-A-Liem³, FM Paschoal-Júnior⁴, JKSF Paschoal⁴, RL Piske⁵, ES Yamada², MJ Teixeira⁶, AKCR Santos² and E Bor-Seng-Shu⁶

¹Hospital Ophir Loyola (HOL), Belém, Pará, Brazil

²Universidade Federal do Pará (UFPA), Belém, Pará, Brazil

³Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil

⁴Centro de Ensino Superior do Pará (CESUPA), Belém, Pará, Brazil

⁵Centro de Neuro-Angiografia (CNA-HBPSP), São Paulo, São Paulo, Brazil

⁶Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP, São Paulo, São Paulo, Brazil

Purpose: Describe the retrospectively determined cases of Cerebral Proliferative Angiopathy (CPA) in a health care center.

Methods: Retrospective analysis of the hospital’s brain arteriovenous malformation databank of 570 cases since 2004. CPA was determined based on the definitions proposed recently (Lasjaunias et al., 2008). The patients’ clinical and hospital charts were reviewed. In addition, vascular specialists, whom classified the cases based on the architectural nature, consulted the cerebral angiogram and magnetic resonance imaging.

Results: Nine patients with CPA were identified, representing 1.57% of all vascular malformations in our center. We have identified a high prevalence of CPA in young adults (mean age 24), besides a male predominance (77.8%; n = 7). Seizures was the most common symptom (n = 6); only one case presented a hemorrhagic event and three cases showed stroke-like symptoms. None of the patients was managed through endovascular procedure. Only one patient was sent to the operating room for a ventriculoperitoneal shunt; due to the possibility of the hemorrhagic event to narrow the fourth ventricle. No patient died due to CPA and all procedures were uneventful with no complications due to procedure.

Conclusion: Neurosurgeons and interventional neurorradiologista need to understand the conservative medical management of this recent described cerebral vascular entity. Moreover, be reminded that, despite, the known “benign” evolution, CPA can present complications that require aggressive medical care. At last, we affirm that stroke-like events can be present as a main symptom, the light for treatment will not discovered until this time.

434

Developmental Venous Anomaly (Dva) could be Related to Cerebral Proliferative Angiopathy?

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Abnormal venous drainage patterns, such as developmental venous anomalies (DVAs), are frequently related to neighbouring vascular malformations. Although the clinical relevance of DVAs remains controversial, increasing attention has been focused on the possible importance of venous outflow disturbance and venous hypertension in DVAs for the appearance of other malformations, like cerebral proliferative angiopathy (CPA). Our purpose is describe a case where we observed a direct relationship between DVA and CPA.

Methods: We report a case of a 12 years old boy with long-standing complaints of right sided hypoesthesia and seizures, whose brain angiogram had findings compatible with a DVA draining a vascular malformation with cerebral proliferative angiopathy features.

Results: Our patient, since childhood, had complaints of right sided hypoesthesia and seizures. After neurologic evaluation (where a Magnetic Resonance showed a DVA in the left post-central cortex), he was referred to our service.

Conclusion: A cerebral angiography was performed and reveals a tangle of small vessels in the transition of arterial and capillary phase, without early venous drainage, but draining into a DVA located along the left post-central cortex. As well as some theories already described, we believe that our case is an example that some degree of compromise in venous drainage, due to DVA, leads to a process of angiogenesis and vascular malformations development.

435

Wyburn Mason Syndrome: A Report about an Incomplete Metameric Capillary Malformation

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Wyburn-Mason syndrome (WMS), also known as Bonnet-Dechaume-Blanc syndrome or retinoencephalofacial angiomatosis, is a rare condition. It is considered one of the nonhereditary congenital phakomatoses and is characterized by vascular malformations (arteriovenous and capillary mostly) that affect the retina, visual pathways, midbrain, and facial structures. It usually is unilateral and often is asymptomatic. Our aim is describe a case where the WMS presents incompletely.

Methods: We report a case of a 32 years old woman with long-standing complaints (from the childhood) of right visual commitment, whose brain angiogram had findings compatible with a capillary malformation affecting the optic pathway.

Results: Our patient, since childhood, had complaints of right visual disturbances, which gradually evolved into complete loss. After ophthalmologic evaluation (ophthalmoscopy examination reveals multiple dilated vascular channels over the right retina suggestive of retinal vascular malformation), it was referred to the holding of a cerebral angiography.

Conclusion: Cerebral angiography reveals a tangle of small vessels in the transition of arterial and capillary phase, without early venous drainage, following the path of the right optical way, starting in the retina, through nerve, chiasm and optic tract. Features were in keeping with Wyburn-Mason syndrome (WMS). Because it is only capillary, and because there is already complete loss of vision, the treatment of our patient was conservative.

436

Spontaneous Thrombosis of Brain Arteriovenous Malformation after Partial Endovascular Embolization

WTakong, S Pongpech, P Jiarakongmun, E Chanthanaphak, C Kobkitsuksakul, T Worakijthamrongchai and K Somboonnithiphon

Interventional Neuroradiology Unit, Department of Radiology,

Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Introduction: Spontaneous thrombosis of brain arteriovenous malformation (BAVM) rarely occurs. Frequency of spontaneous BAVM occlusion after partial endovascular embolization is not known and few case reports were published.

Objective: To demonstrate a case of spontaneous BAVM occlusion after partial endovascular embolization.

Case presentation: A 60-year-old male patient who had presented with generalize tonic clonic seizure (GTC) for 30 years. CT scan of brain was performed and showed right frontal brain AVM with partially thrombosed venous ectasia. Cerebral angiography was done which presented moderate-sized BAVM at right frontal lobe, Spetzler Martin was grade III. Two branches of transarterial embolization were done using mixtures of NBCA/Lipiodol. Control angiogram showed 30% flow reduction of BAVM. Five months after embolization, cerebral angiogram confirmed complete obliteration of the BAVM.

Conclusion: Most of spontaneous thrombosis of BAVMs after partial embolization are small size. However, this event can occur in moderate or large size of the BAVM likes our case.

437

Bilateral Segmental Agenesis of the ICA with Vascular Re-Routing Through a Trans-Sellar Intercavernous Anastomotic Artery, a Persistent Trigeminal Artery and a Hypertrophied Ascending Pharyngeal Artery

RKabra¹, C Franconi² and TJ Phillips¹

¹Neurological Intervention and Imaging Services of Western Australia (NIISwa), Perth, WA, Australia

²Department of Neurology, Royal Perth Hospital, Perth, WA, Australia

Purpose: To describe a case of bilateral congenital agenesis of the ICA with collateral support via a rare trans-sellar intercavernous anastomotic artery, the origin of which remains elusive in the literature. We discuss the embryogenesis of the ICA (Lasjaunias, 1980), the patterns of collateral support in ICA agenesis (Lie, 1968) and the theory behind the vascular re-routing which occurs when a particular segment of the ICA fail to form, as well as the clinical relevance of these anomalies.

Methods: A 39-year-old woman presented with a symptomatic small left parietal cortical infarct, which was later ascribed to an ASD diagnosed on echocardiography. MRI/MRA, cerebral DSA, and cone-beam CT with intra-arterial contrast demonstrated agenesis of the right ICA from its origin and continuation of the right CCA as a hypertrophied ascending pharyngeal artery, which penetrated through the tympanic canal entering the intrapetrous carotid canal and reconstituting the ICA via anastomoses with the caroticotympanic artery. The left ICA was also absent from its origin to the cavernous segment, with a trans-sellar anastomotic artery providing right to left flow between the cavernous ICAs, and a right paramedian artery connecting the upper basilar trunk (at the expected origin of a PTGA) directly to the intercavernous artery, a persistent right dorsal ophthalmic artery and small extradural aneurysms.

Conclusion: Agenesis of the ICA is a rare congenital anomaly, with an incidence of less than 0.01%. Approximately 100 cases are reported in the literature (a small proportion of which are bilateral) and the trans-sellar intercavernous anastomosis seen here is reported in less than one fifth of these cases (Given et al., 2001). Furthermore an inter-cavernous collateral artery and a contralateral persistent trigeminal artery have not previously been described in a single patient (Quint et al., 1989), which may lend weight to one of the two main theories on the origin of this unusual vessel.

438

Dosimetry of Patient and Personnel Radiation Exposure During Diagnostic and Interventional Endovascular DSA Procedures

OKrahula, DOlejár, FCharvát and J Vrána

Military University Hospital Prague, Praha, Czech Republic

Purpose: Interventional radiology is experiencing significant progress with success in treating various diseases. Increasing number of angiography procedures raises proportion of this subspecialty on population medical radiation dose. Interventional procedures place the greatest burden on the patient and the staff in the terms of radiation dose.

Methods: Presented work examined group of 141 patients, who underwent various endovascular procedures. We used three basic measures of radiation exposure: dose area product (DAP), surface dose and effective dose. The DAP was measured by DAP-meter during the procedure, other measures were calculated. We compared radiation burden of different procedures.

Results: The measured values show significant difference between diagnostic and therapeutic procedures. The diagnostic procedures do not pose significant radiation risk for patient. Conversely, the dose in the therapeutic procedures is not low, although it does not reach level for deterministic effects. In one case, interventional procedure on abdominal aorta reached surface dose of 1.5 Gy. In the case of brain aneurysm or AVM embolization the surface dose averaged 1 Gy. If the patient undergoes several such sessions, the dose can easily exceed the limit of 2 Gy. Nonetheless such case was not recorded in our department.

Conclusion: All angiography procedures have concomitant risk of exposing the patient and staff to ionizing radiation. In several published cases the surface dose reached the limit for deterministic effects. Understanding principles influencing radiation burden of patients and staff during interventional procedures can help reduce the doses and can prevent radiation emergencies.

439

Bilateral Infra-Optic Origin of Anterior Cerebral Arteries- A Rare Variant: Its Embryogenesis and Clinical Significance

RPadmanabhan¹, EA Cora¹, N Bradey¹, N Mukerji², KS Manjunath Prasad², FP Nath² and RD Strachan²

¹Department of Neuroradiology, James Cook University Hospital, Middlesbrough, UK

²Department of Neurosurgery, James Cook University Hospital, Middlesbrough, UK

Purpose: Phylogenetically, the anterior cerebral artery is amongst the oldest vessels of the telencephalon. Its early connection with choroidal vasculature and primary role as a rostral internal carotid artery trunk, leads to many important variations with considerable clinical significance (e.g. cerebral aneurysm and perforator AVM supply). Of importance is the fact that this anomaly is associated with intracranial aneurysms and approximately 44% of patients with this variation will have an anterior communicating artery aneurysm (Chakraborty S et al., 2006)

Although anatomical variations of the anterior cerebral artery are common, bilateral infra-optic course of the anterior cerebral artery is extremely rare with less than 5 cases described in literature. (Ji C et al., 2010)

Methods: We describe a case of bilateral infra-optic origin of the anterior cerebral arteries associated with a posterior communicating artery aneurysm that was admitted to our unit. We also present a hypothesis of the embryogenesis of this rare anatomical variant and its clinical significance.

Results: A 54 year old female patient was transferred to our institution with sudden onset severe occipital headache and collapse. The initial CT brain scan demonstrated subarachnoid haemorrhage.

Subsequent CT angiography showed an aneurysm of the left posterior communicating artery which was suspected to be the cause of the subarachnoid haemorrhage.

This study also demonstrated the anomalous origin of the right anterior cerebral artery.

Conclusion: Subsequent catheter angiography revealed bilateral infra-optic origins of the anterior cerebral arteries and a left posterior communicating artery aneurysm. The posterior communicating artery aneurysm was embolised and the patient made a good clinical recovery.

440

Anomalous Origin of the Posterior Inferior Cerebelar Artery (Pica) from the Cervical Cervical Internal Carotid Artery: A Kind of Carotid-Basilar Anastomosis?

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Anastomotic vessels between the carotid and vertebrobasilar systems exist during embryonic development. The one that persists most frequently in adults is the persistant trigeminal artery, occurring with an incidence about 0.5% in cerebral angiograms. Unlike those arteries that have a direct communication with the basilar artery, there are case reports in the literature of direct anastomosis between the intracranial internal carotid artery and the cerebellar arteries, without the interposition of the basilar artery. These arteries are considered persistent trigeminal artery variants. Our goal, therefore, is to describe a case where we observe a posterior inferior cerebellar artery (PICA) originating from the cervical internal carotid artery under an embryological analysis.

Methods: We report a case of a 36 years-old woman with chronic complaints of headache, with not well-defined characteristics, which underwent a vascular study that showed, as an incidental finding, the left PICA originated from the left cervical internal carotid artery.

Results: Because of a chronic condition of headache, our patient underwent a study of magnetic resonance imaging (MRI) with angio (MRA), whose only finding was a cerebellar arterial branch originated from the left cervical internal carotid artery (ICA). Therefore, for a better evaluation of anatomy, a cerebral angiography was requested.

Conclusion: This showed the left PICA originated from the ipsilateral cervical ICA, without other anatomical variants.

441

Anterior Cerebral Artery: An Anatomical Analysis of its Variations

F Navarro¹, M Acuña², N Florenzano², H Moya¹, F Villasante¹ and A Ceciliano¹

¹Hospital Alemán – Ciudad de Buenos Aires, Argentina / Hospital Universitario Austral – Pilar Buenos Aires, Argentina

²Instituto de Morfología J.J Naón – Unidad de Neurociencias – Facultad de Medicina, Universidad de Buenos Aires (UBA), Argentina

Purpose: Anterior cerebral artery (ACA) complex has indisputable functional, neurological and neurosurgical significance. The purpose of this study is to describe some of the features, variations of this artery and its angiographic correlation.

Methods: We retrospectively review 300 digital substraction angiography (Phillips Allura™ and Allura Clarity™) from patients without pathology. Then gross anatomy, patterns of origin, its course, branches and the variability of the ACA complex was studied with special emphasis in A-1 segments, A-2 and anterior communicating artery (AcoA).

Results: ACA arise from the carotid bifurcation, in its first portion it passes through the carotid cistern, it runs horizontal and anterior direction. It has a lower caliber 1–4 mm (2.6 mm) in its origin in regard to the Middle cerebral artery (MCA) in 70 % of the cases, equal 24 % and higher 6 % (especially in A-1 contralateral hypoplasia). The A-1 segments varied in length from 7.2 to 18.0 mm. A difference in diameter between the right and left A-1 was found in 62 % and hypoplasia in 10 %. The average diameter of the ACoA was 1.2 mm, one AcoA in 60 %, double en 30 %. ACA Acygos 3 %. The A-2 segment describes an anterior and superior shape curve, in relation with the corpus callosum.

Conclusion: The precise knowledge of the anatomic variation in this vascular complex is essential to a correct analysis, interpretation and therapeutic planning, both interventional neuro-radiology and neurosurgical.

442

Emergency Balloon Embolization for a Traumatic Carotid-Cavernous Fistula Presenting with Hemorrhagic Venous Infarction: A Case Report

EChanthanaphak, C Kobkitsuksakul, T Worakijthamrongchai, A Somboonnithiphol, W Takong, P Jiarakongmun and S Pongpech

Ramathibodi Hospital Medical School, Mahidol University, Bangkok, Thailand

Purpose: To demonstrate an emergency endovascular treatment for traumatic carotid-cavernous fistula with hemorrhagic complication using gold-valve balloon.

Methods: A 42-year-old male presented with progressive chemosis and proptosis of the right eye for 2 months. He had a history of motor cycle accident with severe head injury before his symptoms occurred about 2 weeks. He met the physician and underwent MRI / MRA of the brain demonstrated an arterialization of enlarged bilateral cavernous sinuses and bilateral superior ophthalmic veins, indicating traumatic carotid-cavernous fistula. Cortical venous reflux to the right cerebral and cerebellar hemispheres was seen without definite brain signal change. However, he was not given any treatment.

Results: Then approximately 3 weeks later, he developed generalized seizure and acute left hemiparesis. CT of the brain showed a large acute intraparenchymal hematoma at the right fronto-parieto-temporal lobe. He was referred to our hospital and then, emergency digital subtraction angiogram was done which confirmed a traumatic carotid-cavernous fistula in the right side with aggressive reflux to the right sphenoparietal sinus, right uncal vein and right superior petrosal sinus which connected to the right right cerebral and cerebellar cortical veins. Furthermore, other refluxes to bilateral superior ophthalmic veins and bilateral inferior petrosal veins were visualized.

In the meantime, transarterial embolization was done under local anesthesia using one gold-valve balloon with successful closure of the fistula. Total procedural time including diagnosic angiogram & treatment was less than 45 minutes.

Conclusion: Balloon embolization is an easy, rapid and effective emergency treatment for a traumatic carotid-cavernous fistula with hemorrhagic venous infarction.

443

Eagle Syndrome Presented with Neurological Symptoms

HGuliyev

Ege University School of Medicine Department of Radiology, 35100 Izmir/TURKEY

Purpose: Eagle syndrome caracterized by the long styloid process acompanied by the styloid ligament calcification. Most symptomatic cases have craniofacial and cervicofacial regions pain. Clinical findings related to the lower cranial nerves compression have also been reported. Another way of symptomatology is the carotid artery compression. Eagle syndrome with neurologic symptoms has been reported rarely.

Methods: Four cases, aged 22–68 years, admitted to hospital with different neurological symptoms were reviewed retrospectively.

Results: Case 1

32 –year-old male patients presented with headache and ataxia. Craniocervical angio CT and MRI revealed bilateral long styloid process, right transverse-sigmoid sinus thrombosis related to the right jugular vein compression by the styloid process. The patient managed with llong term anticoagulation.

Case 2

22-year-old man presented with papilledema and headache. Angio CT revealed hypoplasic right transverse sinüs and compressed left internal jugular vein between the C2 transvers process and calcified styloid ligament. The patient was prescribed antiodema medications.

Case 3

39 -year-old presented with recurrent aphasia and right hemiparesia. Angio CT revealed bilateral long styloid process and left cervical internal carotid artery loop caused by the abnormal left styloid process. And a result of compression of the left İCA developed ischemia in parietal region. The abnormal styloid process was resected surgically.

Case 4

69-year-old male patient presented with recurrent TIA related to the right cerebral hemisphere. Angio CT revealed abnormally long right styloid process compressing the right ICA acompanied by the fusiform aneurysmal dilatation of the artery. The patient was managed by the life long antiagregant treatment.

Conclusion: Eagle syndrome may be presented with neurological symptoms. It would be kept in mind in differential diagnosis in case of neurological symptoms without any objective etiological factors.

444

A Case Report: Critical Skull Base Infection after Contralateral Carotid Angioplasty with Stenting for Thrombotic Acute Stroke due to Ipsilateral Iatrogenic Traumatic Thrombotic Pseudo-Aneurysm of the Cervical Internal Carotid Artery

OInho¹, O Hyungsug¹ and L Sunjoo¹

¹Department of Neurosurgery, Veterans Health System Medical Center, Seoul, Korea

Purpose: The purpose of this case study is to demonstrate the clinical efficacy of contralateral carotid angioplasty with stenting (CAS) for acute stroke due to ipsilateral iatrogenic traumatic thrombotic aneurysm of the cervical internal carotid artery (ICA) to the patient who diagnosed skull base infection.

Methods: 78 year old male patient underwent left mastoidectomy for chronic otitis media at otorhinolaryngology department. 3 months after the operation, patient complained continuous left side headache and ear discharge, so check up the temporal computed tomogram (CT) and neck angio CT. The 15.2x11.1 mm sized thrombotic pseudo-aneurysm on petrous segment of the left ICA and severe stenosis of right carotid bulb was seen on CT scan. So transfer to neurosurgery department for treatment of developing acute stroke due to thrombogenesis by pseudo-aneurysm and contralateral ICA stenosis. Trans-femoral carotid angiography and contralateral angioplasty with stenting for developing acute stroke due to iatrogenic traumatic thrombotic pseudo-aneurysm was done. After stenting, left ICA was automatically occluded and right ICA supplied contralateral ICA territory.

Results: 2 months after contralateral CAS, although there are no neurologic change, patient complained continuous left eye ball pain and ear discharge. So after check up the orbit CT and Brian MRI (magnetic resonance image) enhance, he diagnosed severe skull base infection and uveitis. Although adequate antibiotics therapy, patient expired due to severe skull base infection with progressed systemic infection.

Conclusion: Although right ICA blood flow increased and supplied left ICA territory via anterior communicating artery, skull base infection and uveitis was aggravated due to interrupted blood supply of left distal ICA territory. Meticulous attention is required to the contralateral CAS with thrombotic pseudo-aneurysm occlusion of the ipsilateral ICA on severe skull base infection patient.

445

Spontaneous Angiographic Changes in Venous Drainage Patterns Related to Symptom Changes in Patients with Untreated Cavernous Sinus Dural Arteriovenous Fistula

BJin Wook¹, J Kyung-Il¹, Y Je Young¹, H Seung-Chyul¹, K Jong-Soo¹, J Pyeong¹, Keun Ha Kim¹ and P Jeong Jin¹

¹Samsung Medical Center, Sunkyunkwan University School of Medicine, Seoul, Republic of Korea

Purpose: We aimed to evaluate the relationship between symptom changes and angiographic changes in untreated cavernous sinus dural arteriovenous fistula (CSdAVF), with a focus on venous drainage patterns

Method: The clinical and radiologic features of 34 untreated CSdAVF patients were retrospectively reviewed. We classified venous drainage patterns as Type I (only antegrade drainage), Type II (combined antegrade drainage and venous reflux), Type III (venous reflux without antegrade drainage), and Type IV (stasis or occlusion of venous reflux). Symptom changes were categorized as improvement, aggravation of initial symptom, and pattern change.

Results: Twenty-one patients (61.7%) showed symptom changes during the follow-up period (median, 12; range, 3–151 months). In the symptom improvement group (n = 10), all patients with follow-up angiography (n = 4) exhibited spontaneous occlusion. In the symptom aggravation group (n = 4), new venous reflux developed in two (Type I to Type II) and spontaneous occlusion occurred in two (Type III to spontaneous occlusion). In the pattern change group (n = 7), two showed new venous reflux (Type I to Type II) and five showed stasis or occlusion of an engorged ophthalmic vein (Type II or III to Type IV). Angiographic regression was observed in all Type III and IV, while cortical venous reflux (CVR) developed in one Type I patient.

Conclusion: Symptom changes correlated with chronologic angiographic changes. Without treatment, most CSdAVFs behaved benignly with a low incidence of CVR. Therefore, close observation is possible in CSdAVFs with tolerable symptoms, no CRV, and no antegrade drainage despite aggravation or fluctuation in symptoms.

Christophe Cognard et al., 1995

Dae Chul Suh et al., 2005

Dong Joon Kim et al., 2010

Hiro Kiyosue et al., 2008

446

Signal Intensity Mimicking Dural Arteriovenous Fistula in Dural Sinuses on Time-Of-Flight Magnetic Resonance Angiography: Changes Caused by Head Elevation

SK Baik¹, JA Yeom¹, CH Yoon¹ and YS Kim²

¹Department of Radiology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea

²Department of Neurosurgery Research Institute of Convergence for Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea

Purpose: The presence of a flow-related signal in the normal dural sinus on time-of flight (TOF) magnetic resonance angiography (MRA) is common. The aim of this study was to identify changes in signal intensity in the dural sinus caused by changes in patient position.

Materials and Methods: We performed TOF MRA of the cerebral region in supine/head elevation in 64 patients who showed abnormal flow-related signals in the dural sinuses. Flow related signal intensity of the dural sinuses was analyzed.

Results: Flow-related signal was seen in 113 sites (64 patients), specifically in the sigmoid, inferior petrosal, and cavernous sinuses in 45 sites (70.3%; 23 bilateral, 19 left, 3 right), 43 sites (67.2%; 19 bilateral, 20 left, 4 right), and 25 sites (39.1%; 7 bilateral, 13 left, 5 right), respectively. Following head elevation, flow-related signal changes were observed in cavernous, inferior petrosal, and sigmoid sinuses in 105(105/113, 92.9%) sites: there was loss of signal (60/113, 53.1%), or decrease (13/113, 11.5%), mixed decrease (30/113, 26.5%), increase (2/113, 1.8%), or no change (8/113, 7.1%) of intensity.

Conclusions: Flow-related signal of dural sinuses on TOF MRA was affected by head elevation in 92.9% of the sites. Head elevation could be used to differentiate between pathologic and physiologic states.

447

Anterior Ethmoidal Durals Arteriovenous Fistulae (Davf): Radiologic Iconography and Treatment by Endovascular Approach through the Ophthalmic Artery

CPerazzini, E Pomero, A Flores, E Farah and A Biondi

CHRU Jean Minjoz

Purpose: To review the radiologic findings (at Computed Tomography, Magnetic Resonance and Angiography) of anterior ethmoidal dural arteriovenous fistulae (dAVF), a rare intracranial lesion associated with a high risk of intracranial hemorrhage, where a prompt diagnosis and treatment may improve prognosis.

To report the feasibility of endovascular treatment with Onyx, with an approach through the ophthalmic artery, for these high risk lesions that are usually treated by surgery.

Methods: Anterior ethmoidal dAVF are rare intracranial lesions associated with a reported hemorrhage rates ranged from 62 to 91%. We present the radiologic findings in our series of 4 patients with anterior ethmoidal dAVF in median and paramedian localization: three were unexpected findings, one patient presented with a frontal intraparenchymal haematoma.

Results: The prompt diagnosis was suspected at magnetic resonance and computed tomography imaging and confirmed by a cerebral angiography. A procedure of endovascular embolization was considered feasible.

In two cases the endovascular embolization with Onyx was successfully performed through the ophthalmic artery. One patient died for cardiac failure and one patient did not consent to the treatment.

A middle (6 months) and a long (1 year) term follow up was performed in treated patients and no residual fistula was observed.

Conclusion: A prompt diagnosis and a following endovascular treatment may improve prognosis of the anterior ethmoidal dAVF, a rare intracranial lesion associated with a high risk of intracranial hemorrhage.

448

Selective Percutaneous Coil + Squid Embolization of a Recurrent Caroticocavernous Fistula under DSA + Ultrasonograhic Guidance

IAkmangit¹, E Daglioglu¹, T Kaya¹, G Gunerhan¹, D Belen¹, D Dede¹ and A Arat²

¹Ankara Numune Education and Research Hospital, Ankara, Turkey

²Hacettepe University Faculty of Medicine, Ankara, Turkey

Purpose: Caroticocavernous fistulas are usually encountered after trauma. Detachable intracranial balloons as well as covered stents and coiling were the most common procedures reported in the literature. Transvenous or transarterial routes might be preferred depending on the availability of the access. However treatment poses a particular challenge when both arterial and venous access including ECA were unavailable.

Methods: A 60 year old patient was treated for caroticocavernous fistula due to previous head trauma. The patient was treated transarterially through bilateral ECA injections. Vascularization through left ICA supraclinoid segment through capillaries were not treated at this session. Follow up angiograms on 6 months of follow-up featured a dilated superior ophthalmic vein with marked dilatation at the cavernous sinus. Nevertheless transvenous access to the fistula was unavailable.

Results: Percutaneous selective puncture of the superior ophthalmic vein was performed with the needle of pediatric 4 F introducer sheath (Terumo Inc, Japan). Puncture was performed on venous routemap of SOV under lateral projection of DSA and Toshiba Applio ultrasonography was utilized for AP sonographic visualization of SOV. After introducing the needle through SOV, a preshaped Hybrid double angled microguidewire was introduced through the needle. The microguidewire was introduced to the cavernous sinus and an Excelsior SL10 microcatheter (Stryker Inc.) was introduced over it through the skin to the cavernous sinus. Coiling was performed from SL10 microcatheter and Squid was injected through the microcatheter after the detachment of the last coil.

Conclusion: Percutaneous embolization with the puncture of the superior ophthalmic vein was reported as seldom in the literature. Both ultrasonographic (AP projection) and angiographic routemapping (lateral projection) was reported at the same patient in a biplanar manner.

449

Endovascular Management of Middle Meningeal Arteriovenous Fistula

HEndo, T Ogino, K Takahira and H Nakamura

Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan

Purpose: Middle meningeal arteriovenous fistula is rare. The purpose of this study was to evaluate the clinical and radiological features and the treatment outcomes of middle meningeal arteriovenous fistulas.

Methods: Six patients (mean age 46.5 years; 3 men, 3 women) diagnosed with middle meningeal arteriovenous fistula between 1996 and 2013 in our institution were included. We reviewed their medical records, retrospectively.

Results: The clinical presentation was tinnitus without intracranial hematoma in four cases, and epidural hematoma and subarachnoid hemorrhage in two cases. There were the histories of head trauma in two cases. One case was post-craniotomy for ruptured aneurysm, and the remaining three cases were idiopathic. Tinnitus appeared just after head injury in trauma patients, and epidural hematoma was revealed three days after craniotomy. All patients were diagnosed with conventional angiography. The main feeder was middle meningeal artery in all cases, and the meningeal branches of ophthalmic artery also supplied in two cases. The main drainage route was pterygoid plexus in four cases, superior sagittal sinus in one case, and both in one case. The drainage into cavernous sinus was also showed in two cases. One patient’s symptom disappeared with spontaneous closure after diagnostic angiography, but it relapsed one week later. All patients were cured with endovascular shunt occlusion. No periprocedual complication was occurred. There were no recurrences during a mean follow-up period of 29.3 months.

Conclusion: Middle meningeal arteriovenous fistulas were induced not only by head trauma, but also by craniotomy and idiopathic. Endovascular treatment was less invasive and effective. It is also important to investigate the etiology and the mechanism of middle meningeal arteriovenous fistulas.

450

Imaging Anatomy and Variation of Inferior Petroclival Vein Evaluated by Contrast-Enhanced 3D-FFE MR Imaging at 3-Tesla

S Ide¹, S Tanoue², H Kiyosue², R Tanoue³, K Tomonari³ and H Mori²

¹Nagatomi Neurosurgical Hospital, Oita, Oita, Japan

²Oita University Faculty of Medicine, Yufu, Oita, Japan

³Oita Diagnostic Imaging Center, Beppu, Oita, Japan

Purpose: The inferior petroclival vein (IPCV) is a venous structure that originates from the postero-inferior part of the cavernous sinus (CS) and terminates at the anterior condylar confluence (ACC). In the case with cavernous or ACC dural arteriovenous fistula (DAVF), IPCV sometimes plays a role of access route and/or drainage vein. The information about the anatomy of IPCV can be useful for advancing catheters and placing coils in the endovascular treatment of DAVFs. In this study, the imaging anatomy and variations of IPCV are evaluated on high-resolution images at 3.0-Tesla MRI.

Methods: Thirty-two cases without any lesions affecting cavernous or ACC were examined by using fat-suppressed, contrast-enhanced, 3D fast-gradient-echo sequences. Two radiologists evaluated the anatomy of IPCV in the 64 sides (32 patients) on a workstation.

Results: IPCV were identified in all cases. IPCV originated from postero-inferior wall of CS in 49, medio-inferior wall in one, carotid canal venous plexus in 14 sides. IPCV terminated at ACC in 63 sides and the inferior petrosal sinus (IPS) in one side. IPCV was connected with ipsilateral upper part of IPS in 2, middle part in 36, and lower part in 8. Other connections, including basilar plexus, contralateral IPCV, and anterior condylar vein, were identified in 3, 2, and one respectively.

Conclusion: IPCV can communicate not only with IPS but various surrounding venous structures. The information about the anatomical variation can be essential for the transvenous approach in case with CS and ACC lesions.

451

A Case of Convexity Dural Arteriovenous Fistula Causing Intracerebral Hemorrhage

YIki, S Fukuda, Y Morofuji, N Horie, K Hayashi, T Izumo and T Matsuo

University of Nagasaki, Nagasaki, Japan

Dural arteriovenous fistulas (dAVFs) are abnormal arteriovenous connections within the dura mater and convexity dAVFs involving diploic venous systems have been rarely reported (Shim et al., 2011). We report a rare case of convexity dural arteriovenous fistula causing intracerebral hemorrhage. She presented with transient left leg paralysis. Magnetic resonance imaging of the brain didn’t demonstrate any signs of acute cerebral infarction or hemorrhage. On the fourth day after initial symptom, she became comatose and showed left hemiparesis. Computed tomography revealed intracerebral hemorrhage in the right parietal lobe. Digital subtraction angiography revealed a dAVF within the right temporoparietal bone along right middle meningeal artery grooves. The fistula was fed by frontal branch of right middle meningeal artery and dural branches of right internal maxillary artery and drained into diploic vein finally reaching superior sagittal sinus with cortical vein reflux. Emergency transarterial embolization was performed with NBCA and the shunt flow disappeared. The postoperative course was uneventful and her level of consciousness was gradually improved. Diploic vein is rarely confirmed in digital subtraction angiography, but is revealed under abnormal state, such as dAVFs or trauma (Inui et al., 2012). Since diploic veins have connections to intracranial dural sinuses and play a role for maintaining cerebral venous perfusion (Gonzalez et al., 2009), dAVFs involving diploic veins, might cause intracerebral hemorrhage. We report a rare case of convexity dAVFs associated with the diploic vein which was successfully treated with transarterial NBCA embolization. For curative treatment, the angiographic architecture must be analyzed carefully.

452

Onyx Embolization of Dural Arteriovenous Fistulas with Cortical Venous Drainage

TIzumi, N Matsubara, K Shintai, H Tajima, M Ito, T Imai, M Nishihori and T Wakabayashi

Nagoya University, Nagoya, Japan

Purpose: We assessed the efficacy of onyx embolization of dural arteriovenous fistulas (DAVF).

Methods: We performed onyx embolization for 5 patients with DAVF which was difficult to apply transvenous approach. The location of DAVF is transvers-sigmoid sinus among 4 patients and superior sagittal sinus among 1 patient. In all patients, onyx was injected trans-arterially.

Results: In all cases, affected sinus was filled with onyx and total occlusion was achieved. In 1 case, the fixed microcatheter by onyx was ruptured during the removal. But there were no neurological worsening after onyx injection.

Conclusion: Onyx embolization of dural arteriovenous fistulas with cortical venous drainage was safe and effective.

453

Contralateral Venous Approach with Sinus Angioplasty for Treatment of Transverse-Sigmoid Dural Arteriovenous Fistula with Cortical Reflux

JYJung¹, BG Shin¹, SW Joo¹ and HW Jeong²

¹Department of Neurosurgery, Cerebrovascular center, Dong-Eui Medical Center, Busan, Korea

²Department of Radiology Busan Paik Hospital, Inje University College of Medicine, Busan, Korea

Purpose: Endovascular treatment options for dural arteriovenous fistula (DAVF) involving the transverse-sigmoid sinus include transvenous and transarterial embolization. However, in certain conditions such as venous stenosis or venous occlusion, transvenous embolization can be difficult to achieve. We report two cases of DAVF treated by transvenous embolization with balloon angioplasty via contralateral venous approach.

Methods: Case 1: A 62-year-old male patient with a history of dural venous sinus thrombosis refractory to anticoagulant therapy presented with acute onset of aphasia and hemiparesis. Magnetic resonance imaging (MRI) revealed dilated cortical veins and cerebral edema. Angiography showed DAF with occlusion of ipsilateral transverse-sigmoid sinus and severe stenosis of contralateral transverse sinus.

Case 2: A 57-year-old female patient presented with generalized seizure and deteriorated mental status. MRI and angiography showed DAVF of the left transverse-sigmoid sinus and the proximal segment of the right transverse sinus occlusion with massive cortical reflux.

Results: Endovascular approaches were attempted via the contralateral venous route. Mechanical dilatation or recanalization of the contralateral transverse sinus was achieved by balloon angioplasty. Subsequently, the microcatheter was advanced into the fistulous point at left transverse-sigmoid region through right transverse sinus. Embolization of the fistula was then accomplished by filling with coils. Angiograms after endovascular treatment showed restoration of antegrade venous drainage as well as complete occlusion of the fistulous shunting. The patients were discharged with improving neurological symptoms and signs.

Conclusion: In selected patients with serious intracranial hypertension due to massive cortical reflux, the treatment options should be considered not only to obliterate the fistula but also to restore a normal cerebral venous drainage. Contralateral venous approach with sinus angioplasty can be a viable option for management of DAVF.

454

Predictive Factors for Response of Intracranial Dural Arteriovenous Fistulas to Transarterial Onyx Embolization

BKim², P Jeon¹, K Kim¹, H Byun¹ and KI Jo¹

¹Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea

²Department of Radiology, Anam Hospital, Korea University Medical center, Korea University College of Medicine, Seoul, Korea

Purpose: Endovascular embolization with Onyx has been increasingly used to treat intracranial dural arteriovenous fistulas (DAVFs). This study evaluated predictive factors for favorable treatment outcome in patients with intracranial non-cavernous dural arteriovenous fistulas undergoing transarterial Onyx embolization.

Methods: Between 2008 to 2014, 55 patients who underwent transarterial Onyx embolization for non-cavernous DAVFs were retrospectively reviewed. Fistulas were angiographically classified by traditional and revised classification systems. A revised classification system revealed that 30 patients had sinus fistulas and the remaining 25 patients had non-sinus fistulas. Demographic, clinical, and procedural data were analysed to determine a statistically significant predictive factors for favorable treatment outcomes.

Results: Sixty-eight Onyx embolizations were performed in 55 patients. Complete angiographic occlusion was achieved in 28 patients (50.9%) and small residual shunts in 14 patients (25.5%). These 42 patients showed durable or progressive occlusion on follow-up studies (mean; 19.0, range; 1 – 43 months) and the overall favorable treatment outcome was 76.4%. Thirteen patients (23.6%) showed incomplete occlusion after treatment and three of them showed recurrence on follow-up studies. Nine patients experienced procedure related complications and the overall complication rate was 13.2%. Statistically, non-sinus DAVFs was a significant predictive factor for favorable reponse to transarterial Onyx embolization (odds ratio, 5.02).

Conclusion: Transarterial Onyx embolization is a highly effective and safe treatment method for non-sinus DAVFs. Careful consideration of angiographic subtypes and combination of other adjunctive embolic materials may enhance treatment outcomes.

455

Onyx Embolization for Aggressive-type Isolated Dural Arteriovenous Fistula using the Double-lumen Balloon Catheter

JKim¹, BM Kim¹, DJ Kim¹, KY Park², JH Baek¹ and HJ Jeon¹

¹Department of Radiology

²Neurosurgrey, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea

Purpose: This study aimed to compare the results of transarterial Onyx embolization using a dual-lumen balloon catheter with those using non-balloon catheter for aggressive-type (Borden type, 2 or 3) isolated dural arteriovenous fistula (ai-DAVF).

Materials and Methods: A total of 29 patients (mean age, 52 years; M:F = 20:9) underwent transarterial Onyx embolization for ai-DAVF using a dual-lumen balloon or non-balloon catheters between November 2007 and November 2014. Since introduction of the dual lumen balloon catheter, it has been exclusively used for Onyx embolization of ai-DAVF. We compared balloon catheter group (n = 15) with historical non-balloon catheter group (n = 14) in treatment-related complication, angiographic outcome, total procedural and Onyx injection times, and the number of feeders embolized.

Results: The balloon group showed complete occlusion of ai-DAVF in 13 and near complete in 2 patients, while the non-balloon group showed complete occlusion in 5, near complete in 5, and incomplete in 4 patients. (p < 0.05) Treatment-related complications occurred in 2 patients; cranial nerve palsy in 1 patient (6.7%) of the balloon group and Onyx migration to middle cerebral artery in 1 patient (7.1%) of the non-balloon group, respectively. The median number of feeders needed to be embolized was 1 (range, 1 – 3) in the balloon and 2 (range, 1–4) in the non-balloon group, respectively. (p < 0.05) The mean total procedural time was 62 minutes ± 32 minutes in the balloon and 171 minutes ± 88 minutes in the non-balloon group. (p < 0.05) The mean Onyx injection time was 10 minutes ± 6 minutes in the balloon and 49 minutes ± 32 minutes in the non-balloon group. (p < 0.05)

Conclusion: The utilization of the dual-lumen balloon catheter for Onyx embolization of ai-DAVF seemed to significantly increase immediate complete occlusion rate and to significantly decrease both total procedural and Onyx injection times and the number of feeders needed to be embolized.

456 Presentation withdrawn

Traumatic Carotid Cavernous Fistula with a Connection between the Supraclinoid Internal Carotid Artery and Cavernous Sinus via a Pseudoaneurysm Presenting with Delayed Life-Threatening Epistaxis

JKKo¹, CH Choi¹ and TH Lee²

¹Department of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea

²Department of Diagnostic Radiology, Medical Research Institute, Pusan National University Hospital, Busan, Korea

Purpose: To the best of our knowledge, this is the first case of a traumatic carotid cavernous fistula (CCF) with a connection between the supraclinoid internal carotid artery (ICA) and cavernous sinus (CS) via a pseudoaneurysm, presenting with delayed life-threatening epistaxis.

Methods: A patient with a history of basal skull fracture due to blunt head trauma eight months previously was referred to our emergency room for massive epistaxis.

Results: Cerebral angiography demonstrated a high-flow CCF with a connection between the supraclinoid portion of left ICA and CS via a pseudoaneurysm, suggesting the life-threatening epistaxis had been caused by high-flow shunting, through the gap created by the basal skull fracture.

Conclusion: After complete obliteration of the pseudoaneurysm arising from the supraclinoid ICA by stent-assisted coil embolization, the CCF was no longer evident and epistaxis ceased.

457

Venous Congestion of the Brain Stem in CCF and Hypoglossal Canal DAVF Mimicking Arterial Infarction in MRI; the Abandoned Venous Anatomy

CKobkitsuksakul, E Chantanapak, P Jiarakongmun and S Pongpech

Division of Interventional Neuroradiology, Department of Radiology, Ramathibodi hospital, Bangkok, THAILAND

Purpose: The objectives of two case reports are emphasis of venous anatomy & related MRI abnormalities occurred in case of arteriovenous fistulae & venous drainages

Methods: Imaging of patients who diagnosed of carotid cavernous fistulae (CCF) & hypoglossal canal DAVF were analyzed including follow up imaging.

Results: A woman who diagnosis of left CCF underwent MRI. The MRI reviewed hypersignal T2W with restricted DWI at the right cerebral peduncle. She was free of neurological deficit, specifically, hemiparesis. Her angiogram revealed venous reflux via the left uncal vein toward the right peduncular vein. Another patient had two shunts, left cavernous and hypoglossal DAVFs. The MRI showed restricted DWI at left sided pons. The venous reflux around the brain stem was demonstrated in angiogram. These two patients had provisional diagnosis of arteriovenous shunt with brain stem arterial infarction. The shunts were successfully obliterated, endovascularly. Six months follow up MRI, the brains returned to normal state.

Conclusion: The knowledge of venous anatomy is crucial to explain the abnormality of arteriovenous shunt. The discordance of MRI abnormality and symptoms of the arteriovenous shunt patient should raise suspicion of venous congestion/ infarction rather than co-incidental abnormality e.g. acute arterial infarction.

458

Transvenous Injection of N-Butyl 2-Cyanoacrylate to Obliterate the Pathologic Cavernous Sinus as a Salvage Technique for Incompletely Obliterated Complex Cavernous Sinus Dural Arteriovenous Fistula after Transvenous Coil Embolization

JYLee, HJ Jeon, DY Yoon and BM Cho

Hallym University Gangdong Sacred Heart hospital, Hallym University, College of Medicine, Seoul, Korea

Purpose: We present a case of transvenous injection of n-butyl 2-cyanoacrylate (NBCA) to obliterate the pathologic cavernous sinus as a salvage technique for incompletely obliterated complex cavernous sinus dural arteriovenous fistula (CSdAVF) after transvenous coil embolization.

Methods: A 60-year-old female patient with exophthalmos, chemosis of the right eye and diplopia secondary to right third nerve palsy visited an ophthalmologic clinic. Diagnostic cerebral angiogram demonstrated a Barrow type D of complex CSdAVF, and it was completely obliterated by using coils, NBCA and Onyx via transvenous approach. Especially, after transvenous coil embolization of the pathologic cavernous sinus (CS), follow-up angiography revealed residual shunt could not be negligible. Hence, transvenous injection of NBCA was done to obliterate residual shunts recruited into CS.

Results: During injection of NBCA, it was continuously infiltrated into coiled pathologic CS as a one column to proximal segment of SOV, and refluxed into distal segment of multiple fine feeders. We achieved complete obliteration of the complex CSdAVF without periprocedural complications.

Conclusion: Ttransvenous injection of NBCA could be considered as a feasible option for obliteration of pathologic CS in a case of incompletely obliterated complex CSdAVF after transvenous coil embolization. Because it is a challenging technique with significant potential risks, however, transvenous injection of NBCA should be limited to specific cases.

459

Treatment of AVM/DAVF with Perimedullary Drainage

HMLiu¹, CW Lee¹, YH Lin¹ and YF Chen¹

¹Section of Neuroradiology, Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan

Purpose: Report the diagnosis and treatment of 4 patients of intracranial AVM/DAVF with perimedullary drainage.

Methods: In last 3 years, we experienced 4 patients diagnosed to have intracranial AVM (n = 1) or DAVF (n = 3) with perimedullary venous drainage. They aged 57 to 81 years old and 3 of them were female. Two patients presented mainly with tetraplegia, one with subacute loss of consciousness, and one with frequent dizziness. All of them have abnormal bright T2 signal and enhancement on MR examination. Perimedullary flow void were found on only 2 patients. CTA are major tool for treatment planning except for the AVM case. The lesion of AVM case located in the right parieto-occipital lobe with straight sinus occlusion. Two of the DAVF cases were at the posterior cavernous –tentorium junction, and one at the sigmoid sinus.

Results: The 4 patients were treatment by endovascular management. Coiling along were used in 2 patients, onyx alone in one patient, and mixed coil and onyx in the remaining one. Two of them have good recovery while the remaining 2 have moderate disability in long-term follow-up.

Conclusion: The vascular lesion with perimedullary drainage mainly presented myelopathy but the main lesion may be far away. They can be managed by endovascular treatment but the outcome is depending on the initial clinical status.

460

Clinical Aggressive Cavernous Sinus Dural Arteriovenous Fistula: Angio-Architecture Analysis and Embolization by Various Approaches

CBLuo^1,2, FC Chang^1,2 and Teng^2,3, CJ Lin^1,2, WY Guo^1,2

¹Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan

²Department of Radiology, National Yang-Ming University School of Medicine, Taipei, Taiwan

³Department of Medical Images, Cheng-Hsin General Hospital, Taipei, Taiwan

Purpose: Most cavernous sinus dural arteriovenous fistulas (CSDAVFs) presented with benign neuro-ophthalmic symptoms. CSDAVFs manifest with clinically aggressive neurologic symptoms deficits is rare. The purpose of this study is to analysis the angio-architectures of clinically aggressive CSDAVF and to report our experiences of embolization.

Materials and Methods: In the past 10 years, a total of 118 CSDAVFs had been managed by embolization. From these databases, eight patients (6.8%) were found to have clinically aggressive CSDAVF. There were 6 women and 2 men, age ranged from 58 to 79 years (mean: 69). We retrospectively analyzed the angio-architecture of clinically aggressive CSDAVF, and angiographic as well clinical outcomes of embolization.

Results: The causes of clinical aggressive of CSDAVF were constraint fistula drainage of CSDAVFs because of occlusion of inferior petrous sinus (IPS) with fistula flow reflux to veins of brainstem (n = 6) leading to non-hemorrhagic brainstem ischemia/ edema, while 2 fistula flow reflux to cortical vein leading to intracererbral hemorrhages. Transvenous embolization via occlusive IPS to fistula was achieved in 1, five underwent trans-orbital access, while trans-arterial embolization was performed in 2. Total fistula occlusion was achieved in all 7 patients. All patients had gradually total (n = 7) or partial (n = 1) resolution of their symptoms within 6 months. One patient had limb weakness because of inadvertent pial embolization. Mean clinical follow-up period was 16 months.

Conclusions: Clinically aggressive CSDAVFs always associated with occlusion of IPS with leptomeningeal reflux. Most present with brainstem ischemia, followed by hemorrhagic or non-hemorrhagic stroke in cerebrum. Embolization by various accesses is a feasible and safe method to manage these clinically aggressive CSDAVFs.

461

Dural Arteriovenous Fistula Spontaneous Closure and Resurgence: Possible Mecanisms and Literature Review

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Our goal is describe a case about spontaneous regression and resurgence of a Dural Arteriovenous Fistula (DAVF), analyzing the possible mechanisms based on a literature review.

Methods: We report a case of a 53 years old woman with long-standing complaints of right pulsatile tinnitus who was diagnosed with a DAVF of the right sigmoid sinus, which later showed spontaneous closure and subsequent recanalization through the same sinus.

Results: The patient underwent a cerebral angiography that revealed a DAVF in the wall of the right sigmoid sinus, fed by branches of the right middle meningeal, occipital and posterior auricular arteries. By decision of the patient, it was decided not to carry out any treatment. 8 years later, a new angiography was performed, and to our surprise, it was not observed the fistula, but only irregularities in the wall of the sigmoid sinus and reduction in its caliber, findings compatible with venous thrombosis. Months later, she presents, one more time, complaints of pulsatile tinnitus. This time, we observed the reappearance of the DAVF at the same topography, however, associated with isolation of the right sigmoid sinus, exclusively draining the fistula, and no more normal brain.

Conclusion: The relationship between DAVF and venous thrombosis is extremely close and cause – effect. The secondary hypertension due to venous thrombosis can open dural communications pre – existing, in the same way that the arterialization of the sinus can lead to endothelial injury and thrombosis. The evolution in the case that we have described would be an example of these hypotheses.

462

Selective Transvenous Embolization Combined with Balloon Sinoplasty for the Treatment of Intracranial Dural Arteriovenous Fistulas with Sinus Occlusion

YSagara¹, H Kiyosue¹, Y Hori², S Tanoue¹, M Okahara¹, T Kubo¹, S Ide² and H Mori¹

¹Oita University, Faculty of Medicine, Yufu, Oita, Japan

²Nagatomi Neurosurgical Hospital, Oita, Oita, Japan

Purpose: Transvenous sinus packing with coils has been widely accepted as a curative treatment method for the dural arteriovenous fistulas (DVAF) with sinus occlusion. Some technical reports including luminal angioplasty or stent placement have been described to reconstruct the antegrade venous drainage. In addition, recent anatomical considerations describing about parasinuses have enabled us to achieve selective embolization of shunted venous pouch. We report the technical results in 5 cases of DAVFs with sinus occlusion which were treated by selective transvenous embolization combined with balloon sinoplasty (STVEBS).

Methods: Five consecutive patients undergone STVEBS between March 2009 and March 2015 in our institution were retrospectively reviewed. There were five male, aged 68 to 83 years old. Three patients had a DAVF at transverse sinus with ipsilateral sigmoid sinus or jugular vein occlusion. One patient had concurrent DAVF at right sigmoid sinus and left transverse sinus with left trans-sigmoid sinus occlusion and previous history of right jugular vein ligation. The other one had an isolated DAVF at superior sagittal sinus.

Results: In three of the five cases, the fistula was completely obliterated by selective embolization and antegrade sinus flow was successfully reconstructed by sinoplasty. The other 2 patients showed recanalization of DAVFs at the occluded sinus with reopening of the sinus after balloon angioplasty. They were subsequently treated by sinus packing. In all 5 patients, angiography showed complete obliteration of the DVAF. No complication occurred and clinical symptoms had improved. No recurrence was observed in all patients during 3 to 75 months follow-up periods, and reconstructed sinus was patent in all 3 patients who was undergone STVEBS successfully at the last follow-up.

Conclusion: STVEBS can obliterate the DAVFs with reestablish antegrade sinus flow, and would be an effective and safe treatment method for the cases of DAVFs with sinus occlusion.

463

Reversible Cognitive Impairment with Bilateral Thalamic Lesions Resulting from Dural Arteriovenous Fistula

KSomboonnithiphol, S Pongpech, P Jiarakongmun, E Chantanaphak, C Kobkitsuksakul and T Worakijthamrongchai

Interventional Neuroradiology Unit, Department of Radiology, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand

Introduction: Intracranial dural arteriovenous fistula (DAVF) is a rare cause of bilateral thalamic lesions and cognitive impairment.

Objective: To demonstrate an interesting case of DAVF at occipital dura with associated reversible thalamic dementia.

Case presentation: A 51-year-old man presented with a one-month history of lethargy and memory impairment. The cranial computer tomography (CT) and magnetic resonance images (MRI) showed bilateral thalamic lesions with associated enhancement. Initially cerebral venous thrombosis was considered and the patient received anticoagulants, which did not improve the symptoms. Repeated brain MRI and MRA suspected a tentorial DAVF. Cerebral angiography demonstrated DAVF in the right occipital dura which supplied by right middle meningeal artery (MMA) and dural branches from right vertebral artery. The DAVF was retrogradely drained into the cortical veins of right occipital lobe, the vein of Galen, internal cerebral veins and basal veins of Rosenthal, bilaterally. Endovascular embolization via transarterial approach was done. After embolization, his clinical symptoms were gradual improved and turn to baseline. Normalization of the imaging findings was also observed.

Conclusion: We report this case to emphasize an importance of accurate diagnosis and proper management of DAVF with thalamic dementia. Cognitive impairment caused by venous hypertension in bilateral thalami associated with DAVF is very rare and difficult to diagnosis however it may be reversible after timely treatment.

464

Concomitant Origin of the Anterior Spinal Artery from the Feeder of the Spinal Dural Arteriovenous Fistula (SDAVF)

DaeChul Suh, Yudhi Adrianto, Won Hyoung Park, Hae Won Koo and Ji Eun Park

▪▪

Purpose: Concomitant origin of the anterior spinal artery (ASA) or the posterior spinal artery (PSA) from the feeder of SDAVF is rare but sometimes occurs. We report management of the SDAVF in such cases.

Methods: We reviewed 63 patients with SDAVF in our database since 1993. Angiographic findings of the segmental artery including lesion level were reviewed. Feeder origin was evaluated whether ASA or PSA was concomitantly originated. Treatment modality (surgery vs. embolization) and outcome was evaluated. Technical outcome was evaluated as complete, partial or no obliteration. Clinical outcome during follow-up period was evaluated as aggravated, stationary or improved.

Results: Nine patients had the concomitant origin of the ASA or PSA with the feeder. There were 2 cervical, 5 thoracic, 2 lumbar levels. Concomitant origin the feeder was identified with ASA (n = 7) and PSA (n = 2). Embolization was performed in 4 and op in 5 patients. Embolization resulted in complete obliteration of the lesion in 3 and partial obliteration in 1 with improvement of symptom. Final patient outcome was assess as having improved state in 3 embolization and 4 surgery and stationary in 1 embolization and 1 surgery during 2–148 months.

Conclusion: Embolization may not be impossible and can be tried in selected cases even though operation is recommended in patients with SDAVF when there is concomitant origin of the feeder with ASA or PSA. We will discuss the technical point and risk in embolization.

465

Analysis of Intracranial Dural Arteriovenous Fistulas in Northern Thailand: A Preliminary Study

K Unsrisong, S Kongpromsuk and K Oranratanachai

Department of Radiology, Chiang Mai University, Thailand

Purpose: To analyse natural history, angioarchitecture, management and treatment outcomes of intracranial dural arteriovenous fistula in our institute.

Materials: A retrospectively reviewed 61 patients with intracranial dural arteriovenous fistulas (DAVF) presented at our institute between June 2010 and October 2014. The clinical presentations, presumable causes, imaging findings and treatment outcome were reviewed.

Results: The mean age of the study population was 50.4 years with a female predominant. The majority of cases (77%) presented with benign symptoms. DAVF at the sigmoid sinus and anterior cranial fossa were found to present with malignant clinical presentation (P < 0.05). A benign clinical manifestation was found with statistical significant (P < 0.001) in the location of the cavernous sinus. Cortical venous reflux (CVR) was found in all cases presented with aggressive manifestation (P < 0.001) and no CVR was present when there was no venous outflow restriction (P < 0.001). Conservative management and symptomatic treatment in patients with tolerable benign symptoms and absence of CVR showed an improved clinical outcome in about 82%. All of the patients underwent embolization had improved clinical outcome.

Conclusion: DAVF commonly occurs in middle to late adulthood with a variable clinical manifestations mostly associated to the shunt location. Shunt location, CVR and venous outflow restriction were shown to be related with aggressive manifestation. Endovascular embolization was the mainstay therapeutic method with high rate of good outcomes. In the absence of CVR and tolerable benign symptoms, conservative management with symptomatic treatment could be done.

466

Embolization of Galenic DAVF with Onyx

Q Zhang, Q Li, L Li, YB Fang, ZL Zhang, Y Xu and JM Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: Galenic DAVF is rare one accounting for about 23% in Tentorial DAVF. Microsurgery are main treatment method, but it hard to find operate approach due to deep dissection position, complex supplying artery, and expanded draining vein. We treated Galenic DAVF with onyx embolization through artery.

Methods: During a 10-years period, 8 Galenic DAVF underwent onyx embolization through artery, which takes 18% in tentorial DAVF.

Results: 8 patients take 10 times embolization, 6 get cured immediately, 2 patients who’s fistulas partial embolized, 1 get cured after treat again 1 month later, the other one, bleeding again in 8 months, also get cured with treating again. 8 patients average followed for 2.6 years; 8 patients improved obviously, and there is no deterioration in 3 month follow up.

Conclusion: It’s safe and feasible to embolize dural arteriovenous fistulas with onyx treatment through artery. Estimation of preoperative DSA imaging, artery approach, and venous protection are key issue for succeed embolization. Enhanced DynaCT clearly shows that Galen veins separate with expanded jugular obviously.

573

ONYX results in higher chances of complete embolization of Intracranial Dural arteriovenous fistulae versus nBCA and coils

JShankar and D Choo

Department of Diagnostic Imaging, Division of Neuroradiology, QE II Hospital; Halifax, Canada

Purpose: Background and Purpose: Intracranial Dural arteriovenous fistulae (DAVFs) with cortical venous drainage have a significant morbidity and mortality. Complete closure of these lesions is necessary to reduce these risks. This study retrospectively compares the outcomes of all the local endovascular embolization of DAVFs from 1998 to 2015. We propose that Onyx embolization resulted in fewer complications, similar procedure time and a higher chance of complete obliteration with no need for post-embolization surgery for the DAVF than other embolization methods.

Methods: 117 patients with endovascular embolization for intracranial vascular malformations from 1998 to 2015 were retrospectively reviewed. Patients with arteriovenous malformations or carotid cavernous fistulas were excluded. 27 patients had DAVFs which were treated with embolization during this time period. Inclusion criteria was patients that had DAVFs which were treated with embolization and had imaging on our archiving system. 23 patients met this criteria. Onyx cases were defined with intention to treat principle- any time Onyx was used, it was defined as Onyx case. 11 cases were treated with Onyx embolization, 9 cases were treated with nBCA (N-Butyl Cyanoacrylate) and 3 cases were treated with coils. Successful closure rates, complications and procedure time were compared between the various embolization treatment types.

Results: Post embolization surgery was required for only 2 out of 11 patients treated with ONYX, 7 out of 9 patients treated with nBCA and 1 out of 3 patients treated with coils. The chances of not requiring post embolization surgery with Onyx (81.8%) was significantly higher (p=0.008) than nBCA (22.22%). Although the complication rate with onyx (9.1%) was lower compared with that of nBCA (22.22%), it failed to reach statistical significance because of small sample size. Procedural time was not significantly different between Onyx (mean of 267 mins) and nBCA (mean 288 mins) (p=0.59). The odds ratio of a DAVF being treated with only ONYX and then requiring no follow up surgery was 15.75.

Conclusion: Over a 17 year period, our institution finds Onyx superior in completely obliterating DAVFs to nBCA. It was also found to be as safe and as fast as nBCA, as DAVF embolization with nBCA needed multiple catheterizations and multiple injections.

467

Increasing Role of Professional Neurovascular Communities on Facebook for Fast and Effective Second Opinion

MoiseyAronov

Burnazian FMBC Research Center

By now Facebook counts more than 1.5Bn users worldwide. Professional groups are becoming more and more actual for the last three years. The “Vascular Neurosurgery” is a closed professional group, counting more than 4000 vascular neurosurgeons and interventional neuroradiologists worldwide, among them leading specialists of the US, EU, Japan, China, Russia, India etc. Some patients requires second opinion for the best tactics. Tens of my own cases were published inside this closed group, and each time I received fast and very effective reply, often accompanied by references to the evidence based data. In all published for discussion cases good outcome, or best of possible, achieved. Here I present challenging cases of intracranial aneurysms, strokes, AVMs, SAH and vasospasm, published in Vascular Neurosurgery group and examples of discussion, accompanied by results of the treatment and follow up. Online real time discussion of the challenging cases in professional communities may be very helpful and fast. This type of professional communication can get a highly rated second opinion without borders and delays.

Aronov M1

468

Radial Access for Complex Aortic Arch Anatomy in Endovascular Treatment of Intracranial Aneurysms

SComelli¹, CComelli¹, L Di Maggio² and D Savio²

¹Interventional Neuroradiology, S. Giovanni Bosco Hospital, Nord Emergencies ASL TO²

²Interventional Radiology, S. Giovanni Bosco Hospital, Nord Emergencies ASL TO²

Purpose: As we work in a high flow Neuroradiological and Cardiological Interventional center, in selective challenging caes of complex aortic arch and supraortic branches anatomy, we have started using radial access as a valid and useful alternative for intracranial neuroendovascular treatment.

Methods: In 2014, we have adopted this strategy for 3 patients with uruptured basilar side wall and apex aneurysms, after uneffctive attempts from traditional femoral access. In all cases we have been using triaxial access to deploy a flow diverter stent and, as intermediate catheter, 5 Max Ace, Penumbra. In one case, a giant basilar apex aneurism, we also coiled the sac with jailing technique. In all cases 6 months DSA and MRI follow up demonstrated complete occlusion of the aneurysms.

Results: We didn't experienced any periprocedural complication, all radial and vertebral arteries are patent. All aneurysms are apparently cured.

Conclusion: In our experience radial access itself hasn't shown any addictional challenges, but instead has allowed us to reach safely and quickly the target lesion obteining an optimal endovascular result and outcome.

469

Safety and Efficacy of Staged Endovascular Treatment of Neonatal Vein of Galen Aneurysmal Malformations: A Case Series

AR Honarmand^1,2, K Ryan², TD Alden³, SA Ansari^1,2,3, MC Hurley^1,2,3 and AShaibani^1,2,3

¹Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA

²Department of Medical Imaging, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois, USA

³Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA

Purpose: Controversies surround the safety and efficacy of early endovascular management of Vein of Galen aneurysmal malformations (VGAMs) in the neonatal subgroup of paediatric population. Herein, we present our experience in the management of a series of neonatal VGAMs and the resultant outcome.

Methods: A retrospective review of prospectively maintained paediatric neurology and neurological surgery database was performed to identify cases with prenatal or neonatal VGAM diagnosis. Demographic data, clinical presentation, cross-sectional imaging including digital subtraction angiography (DSA) studies for obtaining angioarchitecture and hemodynamic characteristics of the lesions, treatment process, follow-up imaging, and clinical course were reviewed.

Results: Four neonatal cases of VGAMs (2 F/2 M) were identified. Review of the MR and DSA images revealed large type IV VGAMs causing high-flow arteriovenous shunts resulting in venous hypertension and impaired intracranial circulation in all cases. VGAM-induced clinical complications following delivery included: moderate to severe pulmonary hypertension, respiratory distress, and cardiac failure in all cases. In 3 cases that underwent endovascular embolization, 2 cases were diagnosed prenatally while VGAM was detected in one case during the diagnostic investigation for severe cardiac failure and intestinal ischemia. Multisession endovascular embolization was performed using ethylene vinyl alcohol copolymer and detachable coils starting in the first week of life without any procedural complication. Endovascular management resulted in significant improvement in intracranial circulation in follow-up DSA studies. Clinical complications were resolved dramatically and all 3 cases achieved appropriate growth and met all developmental millstones. One conservatively managed VGAM case was diagnosed prenatally; however, MR investigation in the first day post-delivery demonstrated extensive cortical ischemia which led to respiratory failure and death on the fifth day of life.

Conclusion: Prenatal diagnosis and early endovascular embolization of high-grade VGAMs in neonates plays a pivotal role in achieving favourable long-term outcome in this subgroup of paediatric patients.

470 Presentation withdrawn

Flow Diversion Device in the Treatment of Complex and Difficult Intracranial Aneurysms – Case Presentation

HTKoay

National Neuroscience Institute, Singapore

Purpose: The treatment of intracranial aneurysms has evolved from surgical clip ligation to endovascular therapy. The endovascular treatment has progressed from bare coiling to stent-assisted and balloon-assisted coiling. Nonetheless, the downside of coil embolization is its inability to completely and permanently occlude complex aneurysms. With the advent of flow diverter device, these complex aneurysms can be potentially treated. In this poster, we demonstrate different types of complex aneurysms, which can be potentially treated by using the flow diversion devices. In addition, encountered and potential complications are discussed.

Methods: The armamentarium for endovascular treatment of intracranial aneurysms includes bare coiling, balloon-assisted coiling, stent-assisted coiling, parent artery occlusion, intra-aneurysmal cage and flow diverter. These are briefly discussed with diagrammatic illustrations. The concept of flow diversion is elucidated. Flow diverters induce disruption of flow near the aneurysm neck, and induce thrombosis into the aneurysmal sac while preserving physiological flow in the parent vessel and adjacent branches. Besides, asymmetrical growth of neointimal layer on the inner surface of flow diverter reflects local differences in wall shear stress. Flow diversion devices have been used extensively in the treatment of may types of complex aneurysms with good outcome. Twelves cases of different types of complex aneurysms, which were treated with flow diverters in our institution, were demonstrated.

Results: These treated complex aneurysms include giant fusiform basilar aneurysms, giant thrombosed aneurysms, blister like aneurysms, intracranial dissections, difficult ruptured berry aneurysms, bifurcation aneurysms, recurrent/remnant aneurysms, wide neck lateral aneurysms. Encountered and potential complications are illustrated, such as in-stent/in-device thrombosis, intraprocedural vessel rupture/perforation, perianeurysmal edema, distant infarction, delayed hemorrhage, side branch occlusion, and perforator occlusion.

Conclusion: Treatment of complex aneurysms is challenging, because of high rate of recurrence and regrowth. This problem has been largely solved with the advent of flow diversion device.

471

Endovascular Treatment of Vertebra-Vertebral Arteriovenous Fitula with Hydrogel Coils: Two Case Reports

YKuramoto, H Bando, K Mikami, T Kuroyama, N Shinoda, M Matsumoto, O Hirai and Y Ueno

Shinko Memorial Hospital Department of Neurosurgery

Purpose: High flow spontaneous Vertebro-vertebral arterioveinous fistula (VVAVF) is rare disease. In Japan, it is approved only coils as embolic material.for VVAVFs.VVAVFs had sometimes high flow shunt so it is difficult for complete obilataration. We treated 2 case of VVAVF.with bare platinum coils and hydrogel coils. One case, we occluded vertebral artery (VA),another case, we occluded fistula and vein without VA.

Methods: Case 1, 45 y.o. male, VVAVF caused by rt.V3 segment aneurysm rupture. He also have celic artery aneurysms and left renal aneurysms,We think he is Segmental arterial mediolysis. Lt.VA diameter is similar to rt.VA. We occluded Aneurysm and rt.VA with large volume coils and hydrogelcoils via transarteral approach.

Results: Case 2,62 y.o male,VVAVF in rt.V3 segment.we nagivated micro catheter veinous site via fistula and balloon catheter to arteries site. We got complete occlusion veinous outlet and fistula by coils, preserved rt.VA by balloon catheter. We got complete obliteration with hydrogel coils.

Conclusion: VVAVF was treated by detachable balloon,NBCA, ONYX and coils in past repoprt. Coils alone treatment sometimes did not get complete obliteration. Combination of bare coils and hydrogel coils could be considered well tolerated treatment.

472

Use of a New Covered Stent for Emergency Bleeding Cases in INR

FTurjman¹, R Riva¹, B Gory¹, PE Labeyrie¹, T Leemor and E Jouhaneau²

¹INR Unit Neurosurgey Hôpital Neurologique et Neurochirugical Pierre Wertheimer, Lyon, France

²ITGI Medical, Or Akiva, Israel

Purpose: Complications of invasive neurological procedures require a bail-out device in case of emergency situations. We describe a complex case involving a life-threatening bleeding treated by a neurological pericardium-covered stent graft (AneugraftNx, ITGI Medical Ltd., Or Akiva, Israel) for immediate reconstruction of the blood vessel.

Methods: A 59 year old male underwent transsphenoidal surgery for to pituitary prolactinoma. A major bleeding episode occurred due to surgical damage of the internal carotid artery (ICA). A 8 F Guiding Sheath (Destination, Terumo) was placed in the left ICA. Angiogram showed a 1 mm pseudo-aneurysm at the siphon segment. Since a tolerance test failed to demonstrate collateral blood supply, we decided to use a covered stent. A 5 F intermediate catheter (DAQ, Stryker Neurovascular) was coaxially placed at the petrous segment of the ICA and a 4 x 18 mm pericardium covered stent (AneugraftNx, ITGI Medical) was deployed to exclude the lesion and stop the bleeding.

Results: The procedure was uneventful, with no signs of rebleeding. The next day MR follow up demonstrated patency of the left ICA; the patient did not experience new bleeding.

Conclusions: Neurological Covered stents may be an efficient and effective treatment in emergency procedures and demonstrates high deliverability with successful deployment to target lesion.

473

Cavernous Hemangioma Manifesting to Subarachnoid Hemorrhage – Case Report

OJiwoong, K Jongyeon, W Kum, H Sunki, P Jinsu, C Sungmin, K Sohyun, H Chul, J Yeongha and L Jongmin

Department of Neurosurgery, Wonju College of Medicine, Yonsei University, Wonju, Republic of Korea

Purpose: A 56-year-old male presenting with sudden headache was admitted to our hospital. Through the imaging studies of computed tomography (CT) angiography, all cisternal subarachnoid hemorrhage (SAH) without definite aneurysmal sac was noted. Transfemoral cerebral angiography (TFCA) failed to identify the source of the SAH. Initially we suspected a perimesencephalic SAH.

Methods: Conservative management with a follow-up angiography after 1 week was planned. However 3 days after the admission, the patient's neurologic status was acutely worsened to a semicomatose state. We performed MR brain with diffusion,TFCA and 4 times of brain CT. The follow-up imaging studies revealed neither aneurysmal sac nor anything to cause mental change. The only gross radiological change was the pattern of SAH from all cisternal SAH to localized SAH with newly formed intracerebral hemorrhage (ICH). The ICH was also focused the left peri- basal sylvian area.

Results: The MRI could not distinguish a simple ICH from the cavernous hemangioma. We planned an explorative craniectomy. We dissected from the distal middle cerebral artery (MCA) to posterior communicating artery (p-com A) to find out a bleeding focus. And we found out a ruptured large carenous hemangioma surrounding p-com A and distal internal carotid artery. We attempted a gross total mass removal, but encountered massive bleeding on deep and basal area during the internal decompression and manipulation of cavernous hemangioma. We clipped the ruptured point of cavernous hemangioma. After the bleeding was controlled, the operation was ended with bone flap removal and duroplasty. One week after the surgery, the patient wake up to the drowsy state. One month from the decompression, he subsequently received a ventriculo-peritoneal shunt to solve hydrocephalus. However, he died of a sudden developed mmulti-organ dysfunction 4 days after operationThe body must be divided into four sections (except for case reports).

Conclusion: Our case is very rare case of cavernous hemangioma manifesting to SAH. CT and TFCA can not revealed cavernous hemangioma. We performed several CT and TFCA, but finally we misdiagnosed the cavernous hemangioma as a non-aneurysmal SAH. Although the possibility of SAH in ruptured cavernous hemangomia is extremly low, but we should keep in mind that of cavernous hemangioma also could resulted to SAH.

474

Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Focus on Arterial Continuity Preservation

YS Park¹, and SKPark¹

¹Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea

Purpose: Rupture of spontaneous dissecting aneurysm of middle cerebral artery (MCA) is rare and the etiology remain obscure although the risk of rebleeding is greater than saccular aneurysm. Until now, most of reports about a treatment of dissecting rupture of anterior circulation are about surgical trapping or wrapping. Here, we report a case of MCA dissecting rupture treated with endovascular procedure.

Case report: 22-year-old female presented sudden stuporous mental change following severe headache and left side hemiparesis. CT showed a diffusion subarachnoid hemorrhage (SAH) and diffusion MR showed diffusion restriction at right putamen and internal capsule. There was no definite vascular abnormal finding except mild irregularity of right MCA (M1) on initial digital subtraction angiography (DSA). However, dissecting aneurysm was reported on 6-hour follow up DSA. We performed stent assisted coil embolization was done and double stent was applied for the effect of flow diversion. There was small remnant area of dissecting aneurysm, it was disappeared at 60-day and 12 –month follow up DSA.

Conclusion: We report a successful treatment about SAH due to rupture of spontaneous MCA dissection with endovascular technique. Flow diversion using stent assisted coil embolization is a good therapeutic option preserving arterial contituity.

475

Treatment of a Direct Carotid Cavernous Fistula with a Flow Diverter Stent and Coils: A Case Report

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Direct carotid-cavernous fistulas (CCF) are high-flow shunts between the internal carotid artery (in its intracavernous portion) and the cavernous sinus adjacent, whose clinical manifestations are due to congestion of ophthalmic veins. These lesions are highly related to trauma but can be spontaneous, especially in the presence of intracavernous aneurysms. Our goal is to describe a case of spontaneous CCF secondary to rupture of an intracavernous aneurysm and treated with coils, glue and a flow diverter stent (FDS).

Methods: We report a case of a 52 years old woman with acute complaints of diploplia and right ocular symptoms, whose brain angiogram had findings compatible with a direct CCF secondary to rupture of a left intracavernous aneurysm.

Results: Our patient came to our emergency department with reports of sudden onset of binocular diploplia, and right chemosis and proptosis. The patient denied any history of trauma. Physical examination showed a ophthalmoparesis on the right. Raised the suspicion of a CCF, was held local auscultation that revealed a mild murmur. Confirmed the engorgement of the right ophthalmic vein, the patient was referred for performing a cerebral angiography, which showed a ruptured intracavernous aneurysm in the left internal carotid artery, measuring 24 x 13 x 8 mm and associated with a high flow CCF with drainage to the contralateral cavernous sinus by the intercavernous sinus.

Conclusion: Because the aneurysm association, we chose to occlude the fistula (we used coils and glue) and after, deploy a FDS aimed at reconstruction of the vessel, with good clinical and angiographic results.

476

Treatment of Spontaneous Slow Flow Direct Carotid-Oftalmic Fistulas with a High Mesh Flow Diverter Stent. Report of 3 Cases

FEPetra

Spanish Hospital of Mendoza

Purpose: To describe the successful treatment of spontaneous direct high flow carotid-cavernous sinus fistulas (dCOFs) with the Surpass high mesh flow Diverter.

Materials: 10 (ten) patients with slow flow dCOFs were identified and treated endovasculary in our center between January 2012 and May 2015. Three (3) of them due to the slow flow behavior, considering the potential risk of navigating the carotid tear (under 1 mm) and the high clinical presentation mode were decided to be treated by a high mesh high mesh flow diverter device (Surpass). In all cases retino-fluoresceinography before and after was practice. All data including clinical improvement, time to heal and potential complications were recorded.

Results: All patients treated by this reconstructive technique had immediate angiographic and clinical successful outcome. The flow diverter was deployed with no complications in all cases and once heparin revertion and angiographic control, no residual fistula was observed. Clinical improvement (mainly oftalmoplegia) was observed in the first 24 hours. Average of 9 (nine) days were necessary to get total clinical recovery. On follow-up, all patients presented total clinical symptom resolution.

Conclusions: In slow flow dCOFs with high potential risks due to angiographic finding high mesh flow diverter deployment is an useful tool for the trans-arterial treatment.

477

Endovascular Options for Rapidly Recurrent Fusiform Aneurysm

KPoulgrain¹, J Froelich¹ and A Dubey¹

¹Royal Hobart Hospital, Hobart, Tasmania, Australia

Recurrence of intracranial aneurysms following microsurgical clipping is rare (1–2%). Most cases involve prolonged periods between clipping and recurrence. However recurrence does complicate treatment options. Repeat microsurgical approaches can be difficult due to adhesions and fibrosis, and readjustment of clips can cause significant blood vessel injury in the process. The armoury of endovascular options for primary treatment of intracranial aneurysms can also be applied to this problem.

We present the case of a ruptured left A1 aneurysm that was microsurgically clipped and had recurrence within 1 month. The recurrence was associated with re-rupture. After consideration of all treatment options there ensued a successful and complete endovascular coiling. In addition a literature review outlines other available endovascular options and the rates and time periods of intracranial aneurysm recurrences.

478

Significant Radiation Dose Reduction in Cerebral Angiography Using a New Imaging Acquisition and Processing Platform — A Phantom Study

CCooper¹, P Stewart¹, H Yu¹, X Jiang², K Taylor², W Chong^1,3, S Stuckey^1,3 and RV Chandra^1,3

¹Department of Imaging Monash Health, Melbourne, Victoria, Australia

²Philips Healthcare, Australia

³Faculty of Medicine, Nursing and Health Sciences, Monash University

Purpose: The new Philips Allura Clarity upgrade allows X-ray reduction during image acquisition by automatic motion compensation, temporal and spatial noise reduction and image enhancement. Our aim was to quantify the radiation dose reduction achieved after installation of the Philips Allura Clarity platform compared to the Philips Allura Xper platform.

Methods: Polymethylmethacrylate (PMMA) phantoms of 4 different thickness (15, 18, 20 and 23 cm) were used to simulate patient head attenuation. A direct dosimeter was used to measure Air Kerma rates (AKR) during fluoroscopy and cerebral digital subtraction angiography (DSA) on the Philips Allura Xper platform, and then again after the Philips Allura Clarity upgrade. The measurements conformed to the International Electrotechnical Commission (IEC) standards i.e. no table top, X-ray beam focus to PMMA entrance distance of 62.5 cm, source to image distance of 105 cm and dosimeter placement at the PMMA entrance.

Results: The pre and post Philips Allura Clarity upgrade fluoroscopy AKRs for 15, 18, 20 and 23 cm phantoms were 0.09 to 0.08, 0.15 to 0.12, 0.20 to 0.19, 0.32 to 0.23 mGy/s respectively. Mean dose reduction was 17% (range 9–30%). In DSA the pre and post upgrade AKRs for 15, 18, 20 and 23 cm phantoms were 3.08 to 0.23, 6.04 to 0.58, 9.57 to 0.89, 14.68 to 1.74 mGy/frame respectively. Mean dose reduction was 90% (range 88–92%).

Conclusion: This study confirms significant radiation dose reduction, particularly during DSA, after installation of the Philips AlluraClarity imaging platform.

479

Comparison of Radiation Dose in Diagnostic and Interventional Neuro-Angiography Before and After Installation of an Image Noise and Dose Reduction System – Philips Allura Clarity

WChong¹, J Yu¹, P Stewart¹, C Cooper¹, M Holt¹, R Chandra¹ and A Do¹

¹Monash Medical Centre, Melbourne, Victoria, Australia

Purpose: To compare patients’ dose of diagnostic and interventional neuro-angiography in matched cases before and after installation of a dose reduction system.

Methods: Radiation doses of 131 diagnostic and 75 interventional neuro-angiography cases before installation of Philips Clarity were compared with the same number of cases after installation matched to the number of 3D Digital Subtraction Angiography (DSA) acquisitions and the number of Xper CTs performed for each case. The dose was mainly dependent on the number of 2D DSA frames and screening time. Radiation dose was measured in centi-Gray per cm² and time in minutes.

Results: In the diagnostic cohort, there was the same 68% reduction in the average dose per patient and the average dose per 2D DSA frame, despite a 32% increase in screening time after Clarity. In the intervention cohort, the reduction was 54% and 65% respectively, with a 1% increase in screening time after upgrade. Image quality was at least equal, if not better after Clarity.

Before Clarity, the median dose for diagnostic cases was 14,045.1 with the range of 2,302.2 to 42,607.7 and after Clarity, the median dose was 4,356.4 with the range of 1,005.0 to 31,875.1. In the intervention cohort, before Clarity, the median dose was 24,598.0 with a range of 4,158.5 to 108,037.4. After upgrade the median dose was 10,007.3 with a range of 2,833.8 to 53,729.2.

Conclusion: The Philips Allura Clarity can reduce average patient dose by 68% in diagnostic and

54% in interventional cases with at least equal image quality.

480

High Resolutional MR Imaging for the Diagnosis of Intracranial Arterial Dissection

KFukasaku¹, M Negoro², I Nara², K Ngayama², Y Shiokawa², B Jones² and Jon²

¹Image Processing Team, RIKEN, Wako-shi, JAPAN

²Centre of Neurointervention, Department of Neurosurgery, Ichinomiya Nishi Hospital, Ichinomiya, Japan

³Department of Neurosurgery, Himon'ya Hospital, Tokyo, Japan

⁴Department of Neurosurgery, Kyorin University, Tokyo, Japan

Purpose: Intracranial arterial dissection has risk of rupture and ischemia simultaneously. Early diagnosis is required and prompt treatment is also required, if needed. Although it is not a rare disease especially vertebro-basilar territory, neurological diagnosis is difficult. We performed high resolutional MR (magnetic resonance) imaging for intracranial dissection to successfully visualize dissection.

Methods: In cases who were suspicious dissection, VISTA (Volume Isotropic TSE Acquisition) BB (Black Blood) scan was added. The MR equipment was Achieva 1.5T HP Nova Dual (Philips Medical Systems, Best, The Netherlands). FOV (Field of view) was 180 mm x 180 mm x 36 mm. Reconstructed voxel size was 0.8 x 0.8 x 0.8 mm. REST (regional saturation technique) slab was added at the proximal side of FOV. Acquired images were observed by MPR (multi-planner reformation) viewer. In early cases, the results were confirmed with catheter angiography.

Results: In some of the cases, dilatation of the artery, wall thickening, mural thrombi or intimal flaps were visualized. In initial a few cases, intimal flaps were visualized with VISTA BB and confirmed by DSA. In some cases, high signal intensity mural thrombus disappeared in long term follow (tow or more years). On the other hand, prolonged T1 high signal lesion also were observed, which might be plaque formation. T1 weighted images were better to show vessel wall. T2 WI were more effective to detect dilatation. It took 4 minutes 45 seconds for T1 acquisition and 3 min 52 sec for T2.

Conclusion: High resolutional MR imaging for the vessel wall is beneficial for the diagnosis of intracranial arterial dissections.

481

Visualization of Flow in Embolized Aneurysms by Superimposed MR

KFukasaku¹, M Negoro², I Nara², K Ngayama², Y Shiokawa², B Jones² and Jon²

¹Image Processing Team, RIKEN, Wako-shi, JAPAN

²Centre of Neurointervention, Department of Neurosurgery, Ichinomiya Nishi Hospital, Ichinomiya, Japan

³Department of Neurosurgery, Himon'ya Hospital, Tokyo, Japan

⁴Department of Neurosurgery, Kyorin University, Tokyo, Japan

Purpose: For coil embolization of brain aneurysms, follow up imaging is important. In cases of recurrence or neck remnant, the location of residual blood flow MR (magnetic resonance) angiography is an effective, however, it is not always effective to visualize the coil mass or the shape of aneurysm. Superimposing MR angiography to high resolutional T2 WI (weighted image), we tried to show the location of residual flow in embolized aneurysms.

Methods: In cases after coil embolization for aneurysms, high resolutional MRA and 3D (three dimensional) T2 WI were added for routine MR sturdy. The MR equipment was Achieva 1.5T HP Nova Dual (Philips Medical Systems, Best, The Netherlands). High resolutional TOF (Time-of-flight) MRA was taken at the resolution of 0.25 x 0.25 x 0.25 mm. 3D T2 WI was taken by VISTA (Volume Isotropic TSE Acquisition) BB (Black Blood) scan. VTSTA was acquired at 0.8 x 0.8 x 0.8 mm then reconstructed to 0.25 x 0.25 x 0.8. Both of TOF MRA and VISTA data were transfered to Osirix (an image processing application for Mac OS X dedicated to DICOM images). Then, VISTA BB T2 WI and TOF MRA were superimposed.

Results: Residual flow in the aneurysm could be well visualized. Concave deformity of coil, flow at the neck or at the spaces among coils were detected. Well packed aneurysm were difficult to detect on MRA, on the other hand, such lesion could be easily to detect on VISTA scan.

Conclusion: Superimpose high resolutional T2 WI upon MRA was effective to show hte location of flow in embolized aneurysms.

482

Patient Radiation Dose Reduction in Diagnostic and Interventional Procedures for Intracranial Aneurysms by Low Dose Angiography Protocol

BSKim, JH Song, YS Shin and YK Ihn

The Catholic University of Korea, Korea

Purpose: To describe effect of low dose angiography protocol on reduction of patient radiation dose in diagnostic and interventional procedures for intracranial aneurysms.

Methods: Retrospective analysis of radiation dose area product (DAP) in Gy-cm2 and air kerma (AK) in Gy for 1046 diagnostic and 317 therapeutic procedures for intracranial aneurysms in 1137 patients (799 females, 338 males; median age, 56 years; range, 13–88 years) between January 2012 and June 2014 was performed. Since April 2013, low dose angiographic protocol was applied (from 3.6 μGy/f to 1.8 μGy/f). DAP and AK were statistically compared in groups before (group 1) and after (group 2) application of low dose protocol.

Results: For diagnostic procedure, mean DAP and AK were 140.8 ± 48.1 Gy-cm2 and 1.02 ± 0.42 Gy in group 1 and 82.0 ± 30.0 Gy-cm2 and 0.6 ± 0.3 in group 2 (41.8% and 40% reduction for DAP and AK respectively). For therapeutic procedure, mean DAP and AK were 246.0 ± 148.3 Gy-cm2 and 3.67 ± 2.66 Gy in Group 1 and 169.8 ± 111.6 Gy-cm2 and 3.31 ± 3.21 Gy in group 2 (39.7% and 10% reduction for DAP and AK respectively).

Conclusion: Application of low dose angiography protocol significantly decreases DAP and AK in both diagnostic and therapeutic procedures in patients with intracranial aneurysm.

483

Cone-Beam CT Angiography in Visualizing Stent and Coils for Aneurysm Treatment

KMurao¹, J Morioka¹ and H Miwa¹

¹Shiroyama Hospital, Habikkino Ciity, Osaka, Japan

Purpose: Developments in high-resolution cone-beam computational tomographic (CBCT) angiography have enabled visualization of both the neurovascular stents and host arteries in great detail. However, in the management of broad-based and fusiform intracranial large aneurysms, accurate stent assessment at the level of the coils was limited due to beam hardening artifacts.

Methods: A 64-year-old woman presenting with subarachnoid hemorrhage was confirmed to harbor a ruptured basilar artery large fusiform aneurysm by conventional angiography. Using a single calibrated flat-panel biplanar DSA system (Artis Q BA Twin; Siemens, Erlangen, Germany), the aneurysm was treated with a self-expanding intracranial Enterprise stent (Cordis, Miami Lakes, Florida) and subsequent aneurysm embolization with platinum microcoils.

Results: Enterprise stent and platinum coils were reconstructed as follows.

1. CBCT angiography was performed after stenting (“image A”: including bone + vessel + stent)

2. CBCT angiography was performed after coiling (“image B”: including bone + vessel + coil)

3. The “image A” and “image B” were superimposed based on the skull using a dedicated workstation (Leonardo; Siemens).

Conclusion: Based on the above process, the fusion image was created using visualized stent images before and after coiling. Thin section maximum intensity projections were used to obtain “in-stent” views and cross-sectional views of the stent lumen. For postprocessing, the images were viewed in volume-rendered technique (VRT), as multiplanar reconstructions or MIPs.

484

A Prospective Parallel Study Correlating Computational Flow Parameters with Aneurysm Occlusion after Flow Diverter Treatment

ACTsang¹, AYS Tang², WC Chung², GKK Leung¹ and KW Chow²

¹Division of Neurosurgery, Department of Surgery, The University of Hong Kong, Hong Kong

²Department of Mechanical Engineering, The University of Hong Kong, Hong Kong

Purpose: Flow diverters are gaining popularity in the treatment of unruptured cerebral aneurysms. The underlying hemodynamic factors that determine treatment outcome are not well understood. We investigated the hemodynamic effect of flow diverter in a prospective cohort using computational fluid dynamics and report the parameters that may predict to flow diverter outcome.

Methods: All patients who underwent elective flow diverter surgery for intracranial aneurysm from September 2012 to December 2014 were prospectively recruited. The preoperative angiogram was converted to computational geometric three-dimensional aneurysm model and a virtual flow diverter deployed to analyze the hemodynamics change by an engineering team blinded to the clinical outcome, using a verified computational simulation technique (Tsang et al., 2015). The patients were followed up clinically and radiologically after flow diverter treatment, and successful treatment was defined as complete occlusion of aneurysm at 6 months. The hemodynamics profiles of those aneurysms that were successfully treated were compared with failure cases to identify outcome-predicting flow parameters.

Results: 13 patients with anterior circulation aneurysms treated with flow diverters were recruited. 10 were treatment success with complete aneurysm occlusion at 6 months, 3 were treatment failures. All aneurysms demonstrated increase in turnover time after flow diverter, but treatment success group showed significantly greater increase in turnover time after stenting compared with treatment failures (383% vs 225%, p = 0.042), reflecting the higher degree of stasis within the aneurysm. The degree of energy loss was reduced in the treatment success group, but increased in treatment failures (-2.2% vs +2.3%, p = 0.024). The patient’s age, aneurysm volume, change in velocity and flow rate, and wall shear stress did not differentiate flow diverter success from failures.

Conclusion: Computational fluid dynamics in aneurysms treated with flow diverters correlated with clinical outcome. The change in turnover time and energy loss profile after stenting appears to predict flow diverter treatment success.

485

Usefulness of Arterial Spin Labelling with MRI during Carotid-Artery Stenting

RYoshimura¹, M Kawabata¹, Y Nakanishi¹, M Ishii¹, Y Nakamura¹ and K Nakai¹

¹Department of Neurosurgery, Minami-Wakayama Medical Center, Tanabe-shi, Wakayama, Japan

Purpose: Arterial spin labelling (ASL) is a useful modality of cerebral-perfusion analysis, but no reports are available that ASL can be a modality during carotid-artery stenting (CAS). We report the ASL analysis during CAS, comparing with SPECT.

Methods: In 2014, 52 consecutive cases performed CAS were registered. Some of the patients were excluded because of the incomplete study with any reasons. All of the registered cases were performed with ASL and IMP-SPECT. Age, sex, Powers’ stage, and the periprocedural changes of the cerebral perfusion status were analysed. On SPECT, periprocedural regional CBF (rCBF) ratio, which was compared with contralateral side, was calculated. On ASL, ASL perfusion was performed as continuous ASL with 3D FSE in 3 T MRI.

Results: 20 cases were registered. The average was 75,9 years old (60–90), 18 cases were in male, and 2 were in female.

All cases were uneventful during CAS. Powers’ stage were 14 in stage 0, 5 in stage I, and 1 in stage II. No cases were involved in hyperperfusion syndrome.

The rCBF changes during CAS were +1.8% increase in stage 0, +2.6% in stage I, and +5.8% in stage II. The changes of ASL were +0.7% in stage 0, +1.7% in stage I, and +3.8% in stage II.

It is very important revealing th cerebral perfusion status during CAS because the detection of the high-risk of hyperperfusion syndrome. However, it cannot be done because of the side effect of contrast medium or acetazolamide. ASL needs no tracers, but the metal artefact was the problem during CAS. 3D FSE enables minimizing the metal effect, which leads to the similar perfusion results compared with SPECT.

Conclusion: In our small study, ASL perfusion can be a good candidate analysing the cerebral perfusion status during CAS, in spite of its metal artefacts.

486

Angioplasty of Basilar and Intracranial Vertebral Arteries in 45 Consecutive Patients with Atherosclerotic Stenosis

TAbud^1,2, C Baccin¹ and R Piske¹

¹Hospital Albert Einstein, São Paulo, São Paulo, Brazil

²Federal University of São Paulo – UNIFESP, São Paulo, São Paulo, Brazil

Purpose: Symptomatic intracranial atheromatous disease is a severe condition, especially when located in the intracranial vertebral or basilar arteries. Although the negative results of recent trials, angioplasty is still performed in cases of recurrent symptoms. We performed a retrospective study of the last 15 years analyzing the outcomes of angioplasty in the treatment of this pathology.

Methods: Between January 2000 and April 2015, the Departments of Interventional Neuroradiology of Beneficência Portuguesa Hospital and Albert Einstein Hospital, São Paulo-Brazil performed 92 endovascular procedures for the treatment of intracranial arterial atherosclerosis stenosis in 90 patients. Forty-five of these procedures were to treat vertebrobasilar stenotic atheromatous disease. All patients were treated by stenting angioplasty using balloon-expandable stent. The mean age of the patients was 67 years (range, 44 – 84), 10 women and 35 men.

Results: Most patients were male (35), 25 had stenosis of the basilar artery. We have obtained satisfactory angiographic results in 95% of the patients. Complications were observed in 25% (12) of the patients, 5 presented ischemia related to perforator branches related at the site of angioplasty, 4 of them had thrombosis of the stent and 3 had hemorrhagic complications. In our series, we had 3 (5%) deaths, 2 of them related with bleeding and one with massive thrombosis.

Conclusion: The vertebrobasilar atherosclerotic stenosis is a serious condition and percutaneous angioplasty is an option for cases with recurrent symptoms, even with aggressive medical treatment, but with a high rate of morbidity and mortality.

487

Endovascular Treatment of Pseudotumor Cerebri with Concurrent Venous Sinus Stenting and Intracranial Pressure Monitoring: A Technical Note

DDing¹, RM Starke¹, CR Durst², RW Crowley^1,2 and KC Liu^1,2

¹University of Virginia, Department of Neurosurgery, Charlottesville, Virginia, United States of America

²University of Virginia, Department of Radiology and Medical Imaging, Charlottesville, Virginia, United States of America

Purpose: Increasing evidence supports dural venous sinus stenosis as the pathoetiology of pseudotumor cerebri (PTC) in a subset of affected patients.

Methods: We present our technique for the evaluation and endovascular treatment of PTC with associated stenosis of a dural venous sinus.

Results: A 27 year-old female with medically refractory PTC presented with two months of worsening headaches and vision. An intracranial pressure (ICP) monitor was placed three days prior to the stenting procedure, which demonstrated persistently elevated ICPs in the 30 to 40 cmH20 range. Diagnostic cerebral angiography confirmed flow-limiting stenoses of the bilateral transverse sinuses (TS). We elected to treat the patient with venous sinus stenting (VSS) of the dominant left TS. The right common femoral vein was cannulated with a triaxial system, consisting of 12 F, 10 F, and 7 F Flexor Raabe guiding sheaths, in order create an adequate microcatheter support construct. Venous pressure measurements were taken through a Renegade High Flow microcatheter. The mean venous pressure was 33 mmHg in the proximal transverse sinus and 13 mmHg in the sigmoid sinus, yielding a pressure gradient of 20 mmHg. A Protégé 10x40 mm stent was deployed across the stenosis in the left transverse sinus. Following stent deployment, the pressure gradient was reduced from 20 to 3 mm Hg. The ICP remained 36 cmH20 after stenting, but decreased to 12 cmH20 on the night following the procedure. The patient had an uneventful postoperative course. At six week follow-up, the patient had no headaches and improved visual fields on ophthalmologic examination.

Conclusion: Patients with medically refractory PTC and a physiologically significant pressure gradient across a dural venous sinus stenosis can be effectively treated with VSS. We demonstrate that VSS not only treats the clinical symptoms of PTC, but also provides immediate relief of intracranial hypertension.

488

Rapid Resolution of Bilateral Abducens Nerve Palsies in a Patient with Pseudotumor Cerebri after Treatment with Venous Sinus Stenting

DDing¹, RM Starke¹, RW Crowley^1,2 and KC Liu^1,2

¹University of Virginia, Department of Neurosurgery, Charlottesville, Virginia, United States of America

²University of Virginia, Department of Radiology and Medical Imaging, Charlottesville, Virginia, United States of America

Purpose: Pseudotumor cerebri (PTC) clinically manifests with symptoms of intracranial hypertension, including unilateral or bilateral abducens nerve palsy (ANP). Venous sinus stenting (VSS) has emerged as an effective treatment for PTC patients with stenosis of a major dural venous sinus and a concomitant physiologically significant pressure gradient. Although many of the common symptoms of PTC have been reported to resolve after VSS, the course of ANP recovery is unknown.

Methods: We report a case of a PTC patient with bilateral abducens nerve palsies which rapidly resolved after VSS.

Results: A 24 year-old female presented with left transverse sinus (TS) stenosis and a congenitally diminutive right TS was diagnosed with PTC. Ophthalmologic examination showed bilateral ANPs. We elected to treat the patient with VSS with concurrent ICP monitoring. After VSS, the pressure gradient across the left TS decreased from 28 mmHg to 3 mmHg, and the ICP decreased from 37 cmH20 to 14 cmH20. Additionally, the patient’s bilateral ANPs completely resolved eight hours after VSS.

Conclusion: VSS not only confers immediate relief from intracranial hypertension, but can also rapidly resolve bilateral ANPs in some cases. However, the pathophysiological basis of ANP in relation to ICP remains incompletely understood, and thus warrants further analysis.

489

Venous Sinus Stenting for the Management of Idiopathic Intracranial Hypertension: A Systematic Review

RM Starke¹, T Wang¹, DDing¹, CR Durst², RW Crowley^1,2, N Chalouhi³, DM Hasan⁴, AS Dumont⁵, P Jabbour³ and KC Liu^1,2

¹University of Virginia, Department of Neurosurgery, Charlottesville, Virginia, United States of America

²University of Virginia, Department of Radiology and Medical Imaging, Charlottesville, Virginia, United States of America

³Thomas Jefferson University, Department of Neurological Surgery, Philadelphia, Pennsylvania, United States of America

⁴University of Iowa, Department of Neurosurgery, Iowa City, Iowa, United States of America

⁵Tulane University, Department of Neurosurgery, New Orleans, Louisiana, United States of America

Purpose: Idiopathic intracranial hypertension (IIH) may result in a chronic debilitating disease and blindness in select cases if left untreated. Common treatment options are often associated with periprocedural complications and inadequate disease control. Dural venous sinus stenosis with a physiologic venous pressure gradient has been identified as a potential etiology in a number of IIH patients. Intracranial venous sinus stenting (VSS) has emerged as a potential treatment alternative, but the overall outcomes remain unclear.

Materials and Methods: A systematic review was carried out to identify studies employing VSS for IIH. Studies were reviewed for patient complications, neurological outcomes, and radiographic results.

Results: From 2002 to 2014, 17 studies comprising 185 patients who underwent 221 VSS procedures were reported. Patients had a mean age, BMI, and opening pressure on lumbar puncture of 34.6 years, 33.4 kg/m2, and 35.7 cmH20, respectively. One hundred sixty-one (87.0%) were women. The mean pre-stent pressure gradient was 20.1 mmHg, with a mean post-stent gradient of 4.4 mmHg. Complications occurred in 10 patients (5.4%), but were major in only 3 (1.6%). At a mean clinical follow-up of 22 months, clinical improvement was noted in 130 of 166 patients with headaches (78.3%), 52 of 56 patients with tinnitus (92.9%), 84 of 89 patients with papilledema (94.4%), and 64 of 74 patients with visual symptoms (86.5). At a mean radiographic follow-up of 15.2 months, in-stent stenosis was noted in six patients (3.4%), but only one required retreatment. Stent-adjacent stenosis was more common, occurring in 19 patients (11.4%) and necessitating treatment in 10 patients (6.0%).

Conclusion: In IIH patients with venous sinus stenosis and a physiologic pressure gradient, VSS appears to be a safe and effective therapeutic option. Further studies are necessary to determine the long-term outcomes of VSS and the optimal management of medically refractory IIH.

490

Mechanical Recanalization for Symptomatic Subacute and Chronic Middle Cerebral Artery Occlusion

D Guo, SF Shui, J Ma and XW Han

Department of Interventional Radiology, the First Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, China

Purpose: Try to treat symptomatic patients with subacute and chronic in middle cerebral artery occlusion by mechanical recanalization and to assess its feasibility and short-term effects.

Methods: 8 patients have undergone surgery. Preoperative computed tomographic angiograms (CTAs) were used to verify the middle cerebral artery occlusion. Relief of syndromes and improvement of blood circulation were evaluated after surgery. Intraoperative complications, vascular patency and follow-up review of its efficacy were recorded.

Results: 8 cerebral arteries occlusion in 7 patients were successfully recanalized. On postoperative day 1, 5 patients’ symptoms were relieved and 2 patients' symptoms were exacerbated, of which one was significantly improved after 3 days, the other one’s symptoms were recovered to preoperative levels in 2 weeks. No patients died after surgery. No stroke or transient ischemic attack occurred. The average follow-up of was 4.5 months, no worsening of condition, recurrence or death occurred.

Conclusion: For patients with subacute or chronic middle cerebral artery (M1) occlusion, mechanical recanalization was technically feasible under the premise of strict case screening. Mechanical recanalization is able to improve ischemic symptoms and promote dysfunction restoration. But its long-term effect remains to be evaluated by further large samples, long-term follow-up studies.

491

Subacute Stent Thrombosis in Basilar Artery Stenting: Case Report

TSGong

Department of Neurosurgery, Presbyterian Medical Center,Jeonju,Korea, Korea

Objective: Symtomatic basilar artery stenosis is a highly morbidity disease process. Treatment options are limited. Percutaneous angioplasty is associated with a significant complication rate. We report a case of subacute stent thrombosis in basilar artery stenting.

Clinical Presentation: A 63-year-old man admission our hospital due to vertebrobasilar stroke. Magnetic resonance angiography revealed severe proximal basilar artery stenosis. We successfully treated with a coronary stent and perioperative antiplatelet medications without incident. Poststenting angiography demonstrated a normal-caliber artery with patent perforators. After 7 days from stenting, the patient presented with mental deterioration. CT-angiogram showed occlusion of basilar artery. We treated intraarterial thrombolysis with urokinase and coronary balloon. Post procedual angiography revealed recanalization of occluded basilar artery.

Conclusion: Basilar artery stenting can lead to subacute thrombosis, even in patients who are treated standarized antiplatelet therapy. Such complications have been described for patients after coronary artery stenting, but to our knowledge, no one has reported on a comparable number of cases of intraarterial stenting procedures. In research about subacute stent thrombosis in the intracranial circulation would be a thorough analysis of platelet function in search of nonresponders to antiplatelet therapy before stenting. This might help to find the patients who are at risk for stent thrombosis and to prevent this life threatening complication.

492

Endovascular Treatment for Intracranial Stenosis

LJHaas

Regional University Of Blumenau, Hospital Santa Isabel

Purpose: Cerebral atherosclerosis is responsible for about 30% of cases of ischemic stroke. These ischemic events are mostly resulting from cerebral embolism due to change in the atherosclerotic plaque biology.

Methods: Retrospective analysis of 1.358 consecutive patients with atherosclerotic stenosis in the service of Neurosurgery, undergoing angioplasty with stent, 87 patients with intracranial stenosis were selected from November 2005 to May 2015, observing the variables: age, sex, presenting symptoms, degree and location of the stenosis, events and associated complications.

Results: Male (55.4%), mean age 62.4 years (18–78). 80% of patients were symptomatic at diagnosis, and 57.5% of those had ischemic stroke, transient ischemic 26.8% and 15.7% persistent dizziness. The vessels of the posterior circulation are responsible for stenosis in 49 cases (56.3%) and 38 (43.6%) in the posterior circulation. In the posterior circulation dominance in basilar artery (22 cases), vertebrobasilar (20 cases), posterior cerebral (7 cases). In the anterior circulation dominance of the middle cerebral artery (14 cases), petrous segment of the internal carotid artery (13 cases), supraclinoid segment (10 cases), anterior cerebral (1 case). Eighty percent of patients with critical stenosis (>90%). The mortality rate was 9%, artery rupture in 1 case, stent occlusion in 1 case.

Conclusion: The endovascular treatment for intracranial stenosis is constituting a safe and effective treatment for ischemic stroke, with low morbidity and mortality rate.

493

Intracranial Endovascular Stent Implantation of Middle Cerebral Artery Stenoses

D Hwang, I Kim¹ and C Hurh¹

Dongtan Sacred Heart Hospital,Hallym University,

¹Myongji St. Mary’s Hospital,Seoul,Korea

Purpose: Intracranial stent-assisted angioplasty is an emerging treatment modality for intracranial atherosclerotic stenosis. There are many reports that stent-assisted angioplasty is useful and safe. However, stent placement in MCA still remains as a challenge due to the risk of vascular dissection, elastic recoil, vasospasm stenosis.

The purpose of this study is to evaluate the initial success rate of the stent-assisted angioplasty for reducing the risk of second attack stroke in MCA stenosis.

Methods: 39 lesions of 35 patients were included in this study from March 2004 to September 2015. All patients had symptoms of acute cerebral infarction with stenoses in MCA (more than 50%). The locations of the stent implantation were all in M1 segment in MCA.

Results: The stent implantation was successful in 34 patients (87.1%). We had one case of microselection failure due to the tortuosity of the target vessel. There was one case (2.56%) of MCA rupture during the procedure and the patient expired after 1 week. There was no periprocedural thromboembolism in our study.

Conclusion: In our study, initial success rate of MCA stenoses stent implantation was 87.1%. Stent implantation in MCA stenosis is technically feasible and has relatively low rate of periprocedural complication. Long-term follow up study is necessary.

494

Prevalence of Venous Sinus Stenosis in Pseudotumor Cereberi (PTC) Using Digital Subtraction Angiography (DSA)

MH Ibrahim¹, SHA Zeid² and AA Elbar²

¹Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt

²Neurosurgery Department, Ain Shams University, Cairo, Egypt

Objectives: To Study the prevalence of intracranial venous stenosis in Pseudotumor cereberi patients.

Patients and methods: Thirty patients diagnosed as PTC according to Dandy criteria. All underwent general and neurological assessment. Radiological assessment included CT scan brain +/− MRI brain without contrast, MRV. All underwent digital subtraction cerebral Angiography (DSA) (venous phase) to confirm the validity of filing gaps seen at the level of MRV.

Results: MRV brain showed that 24 patients (80%) showed filling gaps. Digital subtraction cerebral angiography (venous phase) showed 9 patients (30%) had stenosis in their dural sinuses. MRV showed to be a good screening tool since it had 100% sensitivity and negative predictive value. However, since it has a moderate specificity (62%) with a positive predictive value (PPV) of only 35%, then lesions detected should be confirmed with digital subtraction cerebral angiography (venous phase) particularly those involving the transverse and sigmoid sinus.

Conclusion: Venous sinus stenosis is the etiology of PTC in 30% of cases using digital subtraction angiography (venous phase)

Keywords: Pseudotumor cereberi, venous sinus stenosis, headache, MRV, Digital subtraction angiography (venous phase).

495

Evaluation of Stenosis at Transverse Sinus by Intravascular Ultrasound

YKashimura

Neurosurgery Department of Showa University Fujigaoka Hospital

Background and Purpose: Intravascular ultrasound (IVUS) and its virtual histology are commonly used in carotid artery stenting to evaluate stenosis and histology of plaque. We report two cases of transverse sinus stenoses, in which the stenoses were evaluated by IVUS and its virtual histology.

Case description: First case was a 27-year-old male presenting with visual impairment. Intracranial pressure was elevated owing to the stenosis at the transverse sinus. We performed IVUS and deployed a stent at the stenosis, and his symptom was improved. Second case was a 51-year-old male presenting with tinnitus. An angiogram revealed an arteriovenous fistula with stenosis at the left transverse sinus. We performed the feeder embolization. After feeder embolization, the pressure gradient across the stenosis was improved. In both cases, IVUS was performed without any difficulties and complications. IVUS visualized the cross section of severe narrowing of the sinus. Virtual histology suggested fibro-fatty changes at the stenosis in both cases.

Conclusion: We could evaluate and visualize the sinus stenosis by IVUS. In both cases, virtual histology showed fibro-fatty changes at the senosis. To the best of our knowledge, this is the first report to demonstrate feasibility of virtual histology for sinus stenosis by IVUS.

496

Successful Intracranial Vertebral Artery Stenting for at Least 6-Month-Old Chronic Long Complete Occlusion with a Reverse Flow Technique

T Mori¹, T Iwata¹, Y Tanno¹, S Kasakura¹ and K Yoshioka¹

¹Shonan Kamakura General Hospital Stroke Center, Kamakura, Kanagawa, Japan

Purpose: A 74-year-old man experienced cerebral infarcts (CI) three times over 6 months. First, he experienced left cerebellar infarct, second, right posterior lobe infarct, and third, right cerebellar infarct. Cerebral angiography demonstrated left intracranial vertebral artery (VA) complete occlusion longer than 6 cm and right extracranial VA complete occlusion as fist CI occurred, and these findings had not changed over 6 months. The patient had received antiplatelet of aspirin, clopidogrel or cilostazol and several atherosclerotic risk factors had been treated. However, CIs recurred two times in the posterior cerebral circulation. We attempted to open at least 6-month-old left intracranial VA long occlusion.

Antegrade flow of the extracranial left VA was blocked with the balloon-guide catheter (7Fr Optimo) and reverse flow from the basilar artery (BA) to the left VA was produced during procedures. Under left VA proximal flow blockade and reverse flow, we performed intracranial balloon angioplasty and stenting of the left intracranial VA occlusion.

Materials and Methods: The long complete occlusion of the left intracranial VA was successfully opened with the Shiden (2.0x20mm) and Coyote (2.5x30mm) balloons and subsequent Wingspan stents deployment. Reverse flow was documented just after complete recanalization. No complications occurred and no stroke has occurred again.

Results: The intracranial reverse flow technique coupled with proximal flow blockade was very useful for safe recanalization of chronic long intracranial complete occlusion.

497

Intracranial Angioplasty and Stenting for Cerebral Atherosclerotic Stenosis: Long-Term Follow-Up from a Single Center in the Amazon

EHAPaschoal^1,2, GS Jong-A-Liem³, FFDL Teixeira², FM Paschoal-Júnior⁴, JKSF Paschoal⁴, RL Piske⁵, MJ Teixeira⁶ and E Bor-Seng-Shu⁶

¹Hospital Ophir Loyola (HOL), Belém, Pará, Brazil

²Universidade Federal do Pará (UFPA), Belém, Pará, Brazil

³Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil

⁴Centro de Ensino Superior do Pará (CESUPA), Belém, Pará, Brazil

⁵Centro de Neuro-Angiografia (CNA-HBPSP), São Paulo, São Paulo, Brazil

⁶Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP, São Paulo, São Paulo, Brazil

Purpose: Report the long-term outcome of 52 severe intracranial atherosclerotic stenosis (ICAS) treated at this health care center since 2006.

Methods: A retrospective chart analysis of 52 patients with intracranial atherosclerotic stenosis submitted for an endovascular procedure, out of which, four presented with two different lesions treated with angioplasty and stenting. All the lesions in this study presented with stenosis rates higher than 70% and approximately one third of these were higher than 95%.

Results: All cases were managed endovascularly. A male predominance (94.2%) was noticed and a peak incidence at the age of 72 (44–81). All patients were symptomatic, except for one. Ischemic and vertebrobasilar insufficiency were the most common clinical presentations. 75% of the patients underwent angioplasty with stenting. The remaining were submitted for an angioplasty without a stent, due to individual anatomic variability. The stent placement succeeded in all patients. Two cases needed re-operation, because they were at first handled with simple angioplasty and posteriorly, in a month, with stenting. Complications were rare (0.76%): hemorrhagic stroke (n = 2), stent thrombosis (n = 1) and deceased post-procedure (n = 1). In general, they presented a clinical good outcome through an 18-months follow-up; in this period, one patient died due to severe clinical systemic disease.

Conclusion: Severe intracranial atherosclerotic stenosis carries a high and proved risk of stroke of 8 to 22% per year if under conservative therapy (Kim et al., 2014). Emergent intracranial angioplasty with or without stenting is safe and feasible and yields a high rate of revascularization and favorable outcome in patients with hyper-acute stroke and underlying ICAS. Despite the low rates of complications, the indication of this procedure to treat ICAS needs to be prudent. Our case series emphasizes, that this elective procedure possess an existing, notwithstanding minimal risk, for a future stroke episode. This may affect in the full re-establishment and life quality of the patients.

498

Symptomatic Intracranial Atherosclerotic Stenosis: Is There Still Place for Endovascular Approach? A Systematic Review

EHAPaschoal¹, FFDL Teixeira², GS Jong-A-Liem³, FM Paschoal-Júnior⁴, JKSF Paschoal⁴, ES Yamada², AKCR Santos², MJ Teixeira⁵, E Bor-Seng-Shu⁵ and RL Piske⁶

¹Hospital Ophir Loyola (HOL), Belém, Pará, Brazil

²Universidade Federal do Pará (UFPA), Belém, Pará, Brazil

³Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil

⁴Centro de Ensino Superior do Pará (CESUPA), Belém, Pará, Brazil

⁵Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP, São Paulo, São Paulo, Brazil

⁶Centro de Neuro-Angiografia (CNA-HBPSP), São Paulo, São Paulo, Brazil

Purpose: Evaluate the morbidity and mortality in patients with symptomatic intracranial arterial stenosis undergoing aggressive medical therapy versus endovascular treatment.

Methods: This systematic review ranged clinical trials published from 2000 until 2015 that purposed to analyze the management of symptomatic intracranial arterial stenosis: primarily to compare the aggressive medical therapy versus endovascular treatment. The search was done in EMBASE, MEDLINE, LILACS and COCHRANE. Search terms included “intracranial stenosis”, “symptomatic intracranial stenosis”, “intracranial stenosis therapy”, “intracranial stenosis treatment”, “intracranial atherosclerotic disease”, and “angioplasty and stent intracranial stenosis”. Studies were selected according to Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines (Moher et al., 2009) and required to provide a comprehensive description of primary treatment with outcomes. Our search was restricted to clinical trials and studies in the English language.

Results: Primary results listed 12 studies; three (Chimowitz et al., 2011, Mohammadian et al., 2012, Zaidat et al., 2015)of these were included in the systematic review for mentioning clearly the specifications of the intervention group and the control group in a same study. Clinical trials carried out to date suggest that aggressive medical therapy has a lower incidence of death and stroke compared to endovascular treatment, however this showed good results when properly indicated.

Conclusion: Currently there are not enough studies in the literature to establish the superiority of a therapeutic modality over another, suggesting the need for more studies comparing those treatment modalities.

499

The Evaluation of In-Stent Restenosis after Intracranial Stenting: Qualitative and Quantitative Approach by Using a Cranial Phantom with 320-Row MDCT Angiography

SSuh¹, A Park¹, B Kim², NJ Lee² and HY Seol¹

¹Korea University, College of Medicine, Guro Hospital, Seoul, Korea

²Korea University, College of Medicine, Anam Hospital, Seoul, Korea

Purpose: MDCT angiography (MDCTA) has been conveniently used to evaluate in-stent restenosis (ISR) after stenting. However, recent reports suggested unsatisfactory results of qualitative analysis for intracranial ISR using MDCTA, because of poor image resolution, especially less than 3 mm-sized stent, and stent’s marker artifact (SMA). We want to propose the optimal scan parameters and quantitative analysis for an effective approach to ISR after intracranial stenting (ICS).

Methods: We scanned a cranial anthromorphic phantom, in which inserted a 3 mm-Wingspan stent with a 50% stenotic segment at the MCA, with various voltages (80 ∼ 135 kVp) and tube currents (50 ∼ 600 mAs) by 320-row MDCT (Aquilion One; Toshiba, Japan). We applied available reconstruction algorithms such as FBP and Adaptive Iterative Dose Reduction (AIDR-3D: strong [STR], standard [STD] options). Degree of ISR or SMA was assessed using a 3-point qualitative grading scale. MIP with 5 mm-thickness and MPR along the stent longitudinal axis were obtained for quantitative analysis. Quantitative evaluation of ISR was done by HU measurements of intrastent stenotic (lower HU) & non-stenotic segments (higher HU), followed by calculation of contrast-to-noise ratio (CNR).

Results: The poor intraobserver agreement for qualitative visual grading for ISR analysis (weighted ĸ = 0.47) was again verified. The SMA was decreased more than 100kVp/200mAs. In quantitative analysis for ISR, a 100 kVp/600 mAs/STD showed highest CNR. However, 100 kVp/450mAs/STD (effective dose: 3.2mSv) was optimal condition in terms of stability of CT machine, lowering radiation, and homogeneity of HU. The cut-off HU ratio for the suggestion of ISR was 0.7091 (95 % CI, 0.7104 to 0.706: p = 0.047).

Conclusion: The optimal parameter for quantitative evaluation for ISR of ICS with less than 3 mm-sized stent by using 320-raw MDCTA was 100 kVp/450 mAs/STD. Our alternative quantitative analysis of MDCTA may be helpful tool for practical screening for intracranial ISR.

500

Self-Expanding Stent for the Treatment of Symptomatic Atherosclerotic Basilar Artery: Complications Analysis

L Zhang, ZG Yang, YW Zhang, B Hong, QH Huang, Y Xu, WY Zhao and JM Liu

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai 200433, China

Purpose: We evaluate the safety of endovascular revascularization for intracranial symptomatic atherosclerotic stenosis with self-expanding stent in basilar artery.

Methods: We retrospectively analyzed the data of 51 patients since November,2007 to January, 2013 who accepted treatment with gateway balloon angioplasty and self-expanding stents implantation, including 37 wingspan stents, 8 enterprise stents, 5 solitaire stents and 1 neuroform stent. We evaluate the effect of clinical manifestations, imaging features and incidence of periprocedure complications.

Results: The technical success rate was 100%. The mean degree of stenosis decreased from (73.1 ± 11.5)% to (25.0 ± 15.3)% following treatment.4 patients (7.8%) had ischemic complications including slurred speech and limb weakness. The magnatic resonance imaging prompted infractions of pons, and these maybe the result of perforator infractions. Two of them improved and symptoms disappeared with active periprocedure treatment, and the others remained functional impairments to some extent. The incidence of perferator infarction at upper segment and middle-lower segment of basilar artery was 22.2% and 4.8%. Because of the deficient number of cases, there was no statistically significant difference (χ2 = 3.115, P < 0.05).

Conclusion: Intracranial angioplasty and self-expanding stenting can be performed for the treatment of basilar artery stenosis with a relative safety. But perforator infraction was of major concern, especially for stenosis at the upper segment.

501

Solitaire Stents for the Treatment of Complex Symptomatic Intracranial Stenosis after Antithrombotic Failure: Safety and Efficacy Evaluation

GDuan, Z Feng, L Zhang, P Zhang, L Chen, B Hong, Y Xu, W Zhao, J Liu and Q Huang

Department of Neurosurgery, Changhai Hospital, Second Military Medical University, Shanghai, China

Purpose: To evaluate the feasibility, safety and efficacy of Solitaire stent placement after balloon angioplasty for treatment of complex symptomatic intracranial atherosclerotic stenosis (ICAS).

Methods: We retrospectively reviewed the clinical data from 44 patients who underwent Solitaire stent placement for complex symptomatic ICAS at our department between November 2010 and March 2014, with focus on the clinical factors, lesion characteristics, treatment results and periprocedural complications. We also summarized the early outcomes and imaging findings during the follow-up period.

Results: Overall, the technical success rate was 100% (44/44). The post-stenting residual stenosis ranged from 0% to 40% (mean, 15.00 ± 12.94%). The overall 30-day rate of procedure-related complications was 9.09% (4/44). The incidence of recurrent ischemic events related to the territory artery was 4.55% during mean 25.5 months clinical follow-up. Five patients (11.36%) developed ISR during mean 9.3 months angiographic follow-up.

Conclusion: This is the first case series study of ICAS treated by Solitaire stent placement. Deployment of a Solitaire stent with balloon angioplasty in the treatment of complex severe intracranial stenosis appears safe and effective, with a high technical success rate, relatively low periprocedural complication rate and favorable outcome during follow-up.

502

Jugular Vein Occlusion with Rare Associated Diseases: How Implicates Endovascular Management Strategies; Two Case Reports

EChankaew, T Aurboonyawat, D Songsaeng, P Withayasuk and A Churojana

Siriraj Hospital, Mahidol University, Bangkok, Thailand

Purpose: Jugular vein occlusion is an uncommon condition associated with neurovascular disease and may affect clinical presentation and treatment.

Methods: The authors present how jugular vein occlusion implicates treatment strategies in two patients. The patient in Case 1 was a 31 year-old lady who presented with neck mass, bilateral exophthalmos, and pulsatile tinnitus.

Results: Angiography demonstrated AVM at right supraclavicular area with right jugular vein occlusion causing retrograde intracranial venous reflux and exophthalmos. The patient’s symptoms completely relieved after combined endovascular and surgical treatment. Embolization was scheduled later for treatment of minimal residual AVM in the next stage.

Conclusion: The patient in Case 2 was 47 year-old lady who presented with chronic progressive headache and behavioral change for 6 months. Angiography demonstrated aggressive type dural AVF at left transverse sigmoid sinus with left jugular vein occlusion. Balloon assisted Onyx embolization under direct left jugular vein approach was performed and completely cure the AVF. The authors describe different treatment techniques for this condition.

503

Endovascular Combined Approach for Subtotal Carotid Artery Stenosis with Acute Embolic infarction

CSCho

Dankook University Hospital

Carotid artery stenosis is an important cause of stroke. Carotid artery stenting (CAS) has emerged as an alternative to carotid endarterectomy. Several new devices were subsequently introduced as different options for cerebral embolic protection. Current data support the use of embolic protection devices for CAS. Proximal balloon occlusion is an alternative to filter protection, which, by occluding the external and common carotid artery (CCA), induces reversed flow in the target vessel before the lesion is crossed and stented. Despite the advantages of a low crossing profile and the ability to aspirated debris of all size, there are many drawbacks in using balloon occlusion of the distal ICA an embolic protection strategy. Internal carotid artery (ICA) occlusion is not tolerated by a minority of patients because of an inadequate Circle of Willis. Also, the balloon may damage and/or dissect the carotid wall. It may inadvertently and gradually deflate during the procedure, with resulting incomplete ICA protection. Finally, angiographic runs cannot be performed while the balloon is inflated, which limits the interventionist’s ability to confirm proper stent positioning before deployment. Filter devices also have potential disadvantages. They have larger crossing profiles than deflated balloons, which may complicate navigation across very severely stenotic, unstable, and tortuous lesions. A new combined technique that was developed to overcome this obstacle involves direct access to the CCA through an MERCI® balloon guiding catheter; the CCA is occlude with a balloon guide catheter, usually 8 or 9Fr, and the FilterWire EZ filter (Boston Scientific, Natick, MA) pass the stenotic lesion under flow arrested condition. We describe a case series of combined approach technique for a subtotal carotid artery occlusion.

504

Contrast -Enhanced Angiographic Cone -Beam Computed Tomography without Quantitative Contrast Dilution

KIJo, P Jeon and KH Kim²

¹Samsung Medical Center, Sungkyunkwan University, Seoul, Korea

Purpose: Contrast-enhanced cone-beam computed tomography (CBCT) has been introduced and accepted as a useful technique to evaluate delicate vascular anatomy and neurovascular stents. Current protocol for CBCT requires quantitative dilution of contrast medium to obtain adequate quality images. Here we introduce simple methods to obtain contrast-enhanced CBCT without quantitative contrast dilution.

Methods: A simple experiment was performed to estimate the change in flow rate in the internal carotid artery during the procedure. Transcranial doppler (TCD) was used to evaluate the velocity change before and after catheterization and fluid infusion. In addition, 0.3 cc/sec (n = 3) and 0.2 cc/sec (n = 7) contrast infusions were injected and followed by saline flushes using a 300 mmHg pressure bag to evaluate neurovascular stent and host arteries.

Results: Flow velocities changed -15% ± 6.8% and + 17% ± 5.5% from baseline during catheterization and guiding catheter flushing with a 300 mmHg pressure bag, respectively. Evaluation of the stents and vascular structure was feasible using this technique in all patients. Quality assessment showed that the 0.2 cc/sec contrast infusion protocol was better for evaluating the stent and host artery.

Conclusion: Contrast-enhanced CBCT can be performed without quantitative contrast dilution. Adequate contrast dilution can be achieved with a small saline flush and normal blood flow. The body must be divided into four sections (except for case reports).

505

Easy Advancement of Large-Profile Microcatheter (Excelsior XT27™) by Parallel Use of Two Microguidewires for Neuroform Stent Delivery

Y Adrianto³, KHYang¹, HW Goo¹, W Park¹, JC Park² and DH Lee¹

¹Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

²Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

³Department of Neurology, Airlangga University Medical Faculty, Surabaya, Indonesia

Purpose: Due to its relatively large profile of the microcatheter for a stent delivery, navigating the microcatheter could be challenging in some situation. We could overcome the difficulty by parallel use of two microguidewires through the stent-delivery microcatheter.

Methods: For the last 5 months, 16 patients with wide-necked bifurcation aneurysms (8 basilar tip, 4 Acom origin, 3 MCA, and 1 SCA origin) were treated with Neuroform stent-assisted coiling. A 300-cm 0.014-in microguidewire (Transend) was placed into the target branch by exchange technique followed by a 0.027-in microcatheter (Excelsior XT27) insertion. When there was any resistance, we inserted another microguidewire (Traxcess 14) along with the already placed microguidewire in parallel fashion to facilitate the microcatheter advancement. We analyzed the incidence and pattern of microguidewire delivery difficulty and success rate of the ‘parallel-wire technique’.

Results: Navigation difficulty occurred in 31.3% (5/16). All of them were due to the bump-like transition of the aneurysm neck and parent artery branch interfering passage of the microcatheter tip. We could advance the microcatheter successfully by applying parallel-wire technique in all the 5 cases. Neuroform stents were placed through the microcatheters in 4 and the microcatheter was used as a neck-protection device in 1. There was no procedure-related problem.

Conclusion: Simply by using another microguidewire together with pre-existing microguidewire in parallel fashion, the Neuroform stent-delivery microcatheter could easily be navigated into the target location in case of any advancement difficulty.

506

Relay Balloon Technique for Recanalization of Acute Symptomatic Proximal ICA Occlusion

DGLee^1,2, JH Shim¹ and DH Lee¹

¹Dept. of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea

²Dept. of Neurology, Sejong General Hospital, Bucheon, Gyeonggi-do, South Korea

Purpose: Endovascular recanalization of acute symptomatic occlusion of the internal carotid artery (ICA) due to underlying atherosclerotic stenosis could be technically challenging especially when there is no enough landing zone for a balloon-guiding catheter (BGC) at the bulb portion. The purpose of this study is to present the ‘relay-balloon technique’ devised for complete flow arrest until the end of the recanalization, and analyze its safety and effectiveness.

Methods: Endovascular recanalization with the ‘relay-balloon technique’ was attempted in ten consecutive patients with acute symptomatic proximal ICA occlusions from February 2013 to February 2015. The distal CCA was occluded with a BGC during balloon dilatation with an angioplasty catheter (APC) for the underlying proximal ICA stenosis. And then the inflated APC was repositioned a little upward assuring flow arrest so that the BGC could be repositioned into the bulb portion for further ICA flow arrest and aspiration of the he occluded ICA after removing the deflated APC. After full recanalization of the ICA and any combined distal embolic lesion, proximal ICA was stented while the BGC was removed. We analyzed technical success rate and early clinical and angiographic outcomes.

Results: Successful revascularization was achieved in all patients (thrombolysis in cerebral infarction [TICI] 2a/b and 3). Procedure-related complications occurred in one patient (Hemorrhagic tansformation) who recovered successfully. The mean NIHSS score at discharge was 3.55 (range 0–18). The mean modified Rankin Scale score at 3 months was 1 ± 1.67 (range 0–6).

Conclusion: Relay balloon technique can be safely and effectively applied for the endovascular revascularization of acute symptomatic proximal ICA occlusion.

507

Clinical Observation of Anticoagulation and Endovascular Mechanical Thrombectomy with Solitaire AB Stents in the Treatment of Cerebral Venous Sinus Thrombosis

JMa¹, SF Shui¹, XW Han¹, D Guo¹, TF Li¹ and L Yan¹

¹The First Affiliated Hospital Of Zhengzhou University

Purpose: To present the clinical outcomes of National Institutes of Health Stroke Scale (NIHSS) and visual analog scale (VAS) response after patients treated for cerebral venous sinus thrombosis with endovascular mechanical thrombectomy compared to patients treated with anticoagulation (control).

Materials and Methods: 42 patients were diagnosed as cerebral venous sinus thrombosis by clinical MRI, and MRV examination. They were divided into anticoagulation therapy group (group A, n = 22) and mechanical thrombectomy group (group B, n = 20). Heparin 100 mg/24h was infused intravenously during the first 3 days, and after that warfarin was administered orally for half a year in patients of group A; Mechanical thrombectomy with stents were performed and anticoagulant therapy was continued for 6 months in patients of group B. The present symptom (headache) of the patients was scored by VAS at the different time points before and 3 days, 3, 6 and 12 months after the treatment. The neurological function of the patients at the different time points before and after the treatment were evaluated by NIHSS.

Results: The VAS scores was 6.4 ± 1.7 three days after the treatment in group A, and it was 3.2 ± 1.2 in group B; the VAS score was 4.2 ± 1.1 three months after the treatment in group A, and it was 2.0 ± 1.3 in group B. There were significant differences between the two groups (P < 0.05). The NIHSS scores were 14.8 ± 2.1, 10.2 ± 1.3, 9.7 ± 1.8, and 7.1 ± 1.2 respectively at3 day, 3, 6, and 12 months after the treatment in group A, and they were 9.0 ± 0.6, 7.1 ± 1.4, 5.9 ± 2.1, and 5.3 ± 2.2 in group B. There were significant differences between the two groups at the same time point (P < 0.05).

Conclusion: There was a significantly better improving and neurological function in patients treat with endovascular mechanical thrombectomy compared to controls.

508

Mechanical Thrombectomy with Solitaire AB Stents in Combination with Thrombolysis for Treatment of Intracranial Venous Sinus Thrombosis

JMa¹, SF Shui¹, XW Han¹, D Guo¹, TF Li¹ and L Yan¹

¹The first affiliated hospital of Zhengzhou University

Purpose: To retrospectively determine the safety and effectiveness of mechanical thrombectomy for intracranial dural sinus thrombosis with Solitaire AB stents.

Materials and Methods: This is a retrospective analysis of consecutives 12 patients with intracranial dural sinus thrombosis who treated with mechanical thrombectomy by using Solitaire AB stents between January 2013 and October 2014. The patients were followed up for 3 to 12 months after the procedure.

Results: Fourteen Solitaire AB stents were used. The procedure was completed in all patients without complications. At the same time, 2 patients performed catheter-directed thrombolysis with urokinase 300 000 to 700 000 U. The postoperative symptoms in all the 12 patients were improved significantly. Glasgow coma scale scores at admission: 1 case was 3, 1 was 12, and 10 were 15. Glasgow coma scale scores at discharge: 11 cases were 5, and 1 was 4. Statistically significant difference between Glasgow coma scale scores admission and discharge was indentified (P < 0.05). The patients were followed up for 3 to 12 months, 1 were followed up by telephone, 1 were followed up at the outpatient department, 6 were followed up with MRV, 4 were followed up with DSA, and none had recurrence.

Conclusion: Using Solitaire AB stents for intracranial venous sinus mechanical thrombectomy may significantly improve the clinical symptoms of patients. Single-center experience has shown that no obvious complications occurred.

509

Easy Advancement of Large-Profile Microcatheter (Excelsior XT27™) by Parallel Use of Two Microguidewires for Neuroform Stent Delivery

Y Adrianto¹, KH Yang², WPark², HW Goo², JC Park³ and DH Lee²

¹Department of Neurology, Soetomo General Hospital/Airlangga Unniversity Hospital, Airlangga University Medical Faculty, Surabaya, Indonesia

²Department of Radiology, Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

³Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Purpose: Due to its relatively large profile of the microcatheter for a stent delivery, navigating the microcatheter could be challenging, especially in wide-necked bifurcation aneurysms such as basilar tip lesion. We could overcome the difficulty by parallel use of two microguidewires through the stent-delivery microcatheter.

Methods: Between December 2014 to April 2015, 16 patients with a wide-necked bifurcation aneurysms (8 basilar tip, 4 anterior communicating artery origin, 3 middle cerebral artery, and 1 superior cerebellar artery origin) underwent stent-assisted coiling. A 300-cm 0.014-in microguidewire (Transend) was placed into the target branch by exchange technique. A 0.027-in microcatheter (Excelsior XT27) was advanced over the guidewire. When there was any resistance in the advancement, we inserted another microguidewire (Traxcess 14) along with the already placed microguidewire in parallel fashion. Then the microcatheter was navigated further into the branch over the two guidewires. We analyzed the incidence and pattern of microguidewire delivery difficulty and success rate of the ‘parallel-wire technique’.

Results: Among the 16 cases, we faced with navigation difficulty in 5 (31.3%). All of them were due to the bump-like transition of the aneurysm neck and parent artery branch interfering passage of the relatively large external diameter of the microcatheter tip compared to with microguidewire. In those 5 cases, we could advance the microcatheter successfully by applying parallel-wire technique in all cases. Neuroform stents were placed through the microcatheters in 4 and the microcatheter was used as a neck-protection device in 1. There was no procedure-related problem.

Conclusion: Simply by using another microguidewire together with pre-exising microguidewire in parallel fashion, the Neuroform stent-delivery microcatheter can be easily navigated into the target location in case of any advancement difficulty.

574

LVIS Jr ‘shelf’ technique – an alternative to Y stent

JShankar

Dalhousie University

Purpose: Y stent has been used for wide neck bifurcation intracranial aneurysms particularly when both branch arteries are incorporated into the aneurysm dome or neck. With the advent of braided stent like LVIS Jr, these stent can potentially be used with the pull and push technique to create a ‘shelf’ at the neck of the aneurysm that can obviate the need for Y stents. The purpose of our study is to describe this ‘shelf’ technique with LVIS Jr stents in wide neck intracranial aneurysms.

Methods: We retrospectively reviewed our prospectively maintained interventional neuroradiology database for use of LVIS Jr stents. We assessed the aneurysms for their size, neck diameter and location. We used the ‘shelf’ technique in all but one of these patients. We assessed the immediate post-coiling results of these aneurysms. We assessed the perioperative mortality and morbidity and short term follow up of these patients.

Results: We have total of 7 patients (5 Female and 2 Male; mean age- 55 yrs) with 1 ruptured, 2 previously ruptured and 4 un-ruptured aneurysms located at anterior communicating (2), Basilar tip (3), paraophthalmic (1) and internal carotid termination (1). The average diameter of the aneurysm was 7.5 mm (range-3-12mm). All of these aneurysms were wide neck aneurysm with average diameter of the neck was 5.4 mm (range 3-8 mm) and average dome to neck ratio was 1.4 (range-1-1.8). One patient had an in-stent thrombosis which dissolved with use of Reopro. One patient needed another stent to jail a stretched coil. None of these resulted in any clinical morbidity or mortality.

Conclusion: Our small study shows that LVIS Jr ‘shelf’ technique is safe and can obviate the need of Y stent in wide neck intracranial aneurysms.

510

Patient Dosimetric Evaluation in Angiography Practice: Application in Interventional Neuroradiology

ECiceri¹, V Caldiera¹, G Faragò¹, A Torresin², L Fumagalli², F Ghielmetti² and I Zucca²

¹Interventional Neuroradiology Fondazione Neurological Institution C. Besta, Milan Italy

²Medical Physics Fondazione Neurological Institution C. Besta, Milan Italy

Purpose: To evaluate the risk of a deterministic skin injury from Interventional Radiology (IR) procedures, the Peak Skin Dose (PSD) and the skin dose mapping should be estimate. Dose metrics commonly available such as cumulative air kerma at the interventional reference point (K_a,irp) are usually employed. However, as the PSD may be substantially different from K_a,irp, it is necessary to estimate the PSD and skin dose mapping more accurately.

Methods: A custom made MatLab software has been developed. The code output is the PSD and a visual display of the surface dose mapped onto a spherical or cylindrical phantom modeling the head or the trunk of the patient respectively. The setting of the dimension of the geometrical phantom depends on the anatomical size of the patient measured from images stored during IR procedures. The code works by translating the K_a,irp (corrected by back-scatter factor) to the location of the patient’s skin, represented by a surface of the geometrical model and using dosimetric and geometric parameters (primary and secondary angles of the two tubes, longitudinal displacement of the bed) for each radiation event stored in the radiation dose structured report. To validate the code, arrays of thermoluminescent dosimeters (TLD) were placed on the surface of phantom and on the skin of 9 patients undergoing to neuroendovascular treatments.

Results: The percent difference between the PSD calculated and measured by TLD is within 40%. The skin dose mapped on the surface of the geometrical model is in agreement with the dose distribution measured by TLD, used as true standard.

Conclusion: The algorithm we implemented can be advantageously applied for radiation exposure evaluation in Interventional Neuroradiology, helping the Neuroradiologist in monitoring the x-ray dose, and consequently adjusting its practice in order to better accomplished the ALARA recommendations during procedures.

511

Intra-Aneurysmal Neck Plasty by “Super-Masamune”, Super Complaint Double Lumen Balloon Microcatheter

MEzura¹, T Kuramae² and H Uenohara¹

¹Department of Neurosurgery, NHO Sendai Medical Center, Sendai, Japan

²Department of Neurosurgery, NHO Tochigi Medical Center, Utsunomiya, Japan

Purpose: Balloon Neck plasty is very useful technique especially for wide neck aneurysm. It is usually required additional balloon microcatheter located in the parent artery. We developed new method of neck plasty which is performed by a balloon microcatheter located inside aneurysm.

Methods: Super-Masamune is super compliant double lumen balloon microcatheter. It can be inflated inside aneurysm. Because of double lumen, it allow coil insertion inflating its balloon. Using the Super-Masamune, we treated 5 cases by this method.

Results: Three cases are MCA aneurysm and 2 cases are AcomA aneurysm. One of the deriving branch is originated from aneurysmal dome in all the cases. Super-Masamune was introduced in the aneurysm and the balloon was inflated in the aneurysm where the branch is deriving. In 4 cases, coils were inserted via guidewire lumen of the Super-Masamune. Another microcatheter was introduced for coil insertion in one case. The aneurysmal dome was packed in all the cases preserving deriving artery.

Conclusion: Super-Masamune makes intra-aneurysmal neck plasty possible.

512

A Novel End-To-Side Anastomosis, Dual-Stent Endovascular Technique to Treat a Ruptured Wide-Necked Basilar Tip Aneurysm and Review of the Literature

JBZhang¹, LZ Li² and YX Li¹

¹Department of Interventional Neuroradiology, Beijing Neurosurgical Institute and Beijing Tiantan Hospital, Capital Medical University, Beijing, China

²Department of Neurosurgery, Coal Mining Group General Hospital, Hebi, Henan, China

Purpose: Basilar tip aneurysms are a group of bifurcation aneurysms. Although stent-assisted coiling is extensively used to treat wide-necked aneurysms to prevent coil migration to parent vessels, it remains technologically challenging in treating wide-necked basilar tip aneurysms. We design a novel end-to-side anastomosis, dual-stent coiling technique to treat wide-necked basilar tip aneurysms, with a review of the literature concerning the reported techniques in the treatment of this type of aneurysms.

Methods: In our design, two stents are aligned in the way of an end-to-side anasmotosis. The first stent is placed from the basilar trunk to one posterior cerebral artery (PCA). The proximal end of the second stent is placed abut to the side of the first stent, without overlapping interaction with the first stent. Afterwards, embolization is accomplished with coil release into the sac of the aneurysms.

Results: A 40-year-old female with a ruptured wide-necked basilar bifurcation aneurysm was treated in emergency, by an end-to-side anastomosis, dual-Solitaire stent-assisted coiling system, resulting in a complete and persistent embolization.

Conclusion: This technique safely protected the patency of the parent artery without any neurological compromise in a simple procedure. It may represent a significant advance in the management of basilar tip and other bifurcation aneurysms.

513

Aneurysm on the Middle Cerebral Artery in a Premature Neonate

W Calderon¹, L Moscote², H Alvis³, D Hayes⁴, J Meadows⁵, O Díaz⁶ and N Escobar⁷

¹National Autonomous University of Mexico, Mexico city, Mexico

²Universidad de Cartagena, Cartagena de Indias, Colombia

³Universidad de Cartagena, Cartagena de Indias, Colombia

⁴Department of Pediatrics and Internal Medicine, The Ohio State University, Nationwide Children’s Hospital, Columbus, Ohio

⁵Division of Neonatology, University of Tennessee Medical Center, Knoxville, Tennessee

⁶The Methodist Hospital Neurological Institute, Houston, TX, USA

⁷Department of Neuroradiology, Hospital Ángeles Mocel, Mexico City, Mexico

Purpose: Present a middle cerebral artery aneurism in a premature neonate.

Summary of case: Male newborn, product of controlled 33 week pregnancy, birth weight 1870 g; with respiratory failure, requiring immediate resuscitation and Neonatal Intensive Care Unit transfer. Head circumference: 31 cm without changes in the neck. The anterior fontanelle is normal size and normotensive, normal-set ears, moist oral mucosa, hard palate without clefts. Irregular breathing with tachypnea and intercostal retractions; presence of crackles and mobilization of secretions on auscultation. Heart sounds were rhythmic without audible murmurs. The abdomen was soft, not distended, peristalsis present. External genitalia normal for age.

On neurological assesment patient was hypoactive, reactive to tactile stimulation, without paroxysmal movements. Limbs were mobile, symmetrical; distal and central pulses present, capillary refill of 2 seconds; skin with mild peripheral pallor. Routine sonography of the brain was normal for age. At birth, he was treated with antibiotics and ventilatory support under the impression of sepsis. On the 18th day after birth, bulging of the anterior fontanel was appreciated. Sonography of the brain showed hydrocephalus. Cranial MR imaging of the brain revealed supratentorial hydrocephalus and an apparent left frontal-parietal cerebral arteriovenous malformation. MR angiography showed a large saccular aneurysm on the left middle cerebral artery. Subsequently, the patient had neurological deterioration and died.

Conclusion: Although neonatal intracranial aneurysms are rare, their presence should be suspected with the presentation of increasing hydrocephalus and neurological decline.

With prompt diagnosis, satisfactory clinical outcome can be achieved with modern diagnostic tools and neurointerventional.

514

Adjuvant Coil Assisted Glue Embolization of High Flow Vein of Galen Aneurysmal Shunt Lesions in Pediatric Patients

DJKim¹, BM Kim¹, KY Park², JW Kim¹, S Kim¹, MK Park¹ and DI Kim¹

¹Department of Radiology and ²Neurosurgery, Yonsei University College of Medicine, Seoul, Korea

Purpose: Vein of Galen aneurysmal malformation/dilatation (VGAM/VGAD) patients are often difficult to treat due to the high flow fistulous angioarchitecture. The purpose of this study is to assess the feasibility of adjuvant coils in addition to transarterial glue embolization for treatment of these patients.

Materials and Methods: Six pediatric patients (VGAM (n = 4) /VGAD (n = 2), age range; 11weeks-5 yrs 2mos) with high flow fistulous angioarchitecture were treated with adjuvant coils for flow control in addition to distal feeder glue embolization. The angiographic / clinical outcome and complications were assessed.

Results: Adjuvant coils were deployed in the distal feeding artery (n = 2), vein of Galen + distal feeding artery/ initial venous pouch (n = 3), and initial venous pouch (n = 1). Coils were deployed in the vein of Galen for flow reduction and/ or as a scaffold for coil deployment in the distal feeding artery/initial venous pouch. Transarterial glue embolization in the distal feeding artery was successfully performed in all cases without distal migration. Complete occlusion was achieved for mural type cases (n = 3) with occlusion of high flow fistulae. Residual shunt remained in choroidal type and VGAD cases (n = 3) from nidal type feeders. Focal rebleed occurred after occlusion of the initial venous pouch in a VGAD case. Residual lesions were treated by additional glue embolization and/or gamma knife therapy. On follow up (2.3–95.4 mo, mean 58.2 mo), improvement of hydrocephalus was seen despite of coils in the dilated vein of Galen. One patient showed moderate mental retardation. Other patients showed normal development.

Conclusion: Adjuvant coils for flow control with glue embolization may be an effective treatment method for VGAM/VGAD patients with high flow fistulous feeders. Occlusion of flow in the draining veins with residual feeders should be avoided due to concerns of hemorrhage.

515

Neuro-Intervention within the First 14 Days of Life for the Neonates with Brain Arteriovenous Fistulas

MKomiyama¹, A Terada¹ and T Ishiguro¹

¹Osaka City General Hospital, Osaka Japan

Purpose: To report the feasibility and outcome of neuro-intervention for the neonates with brain arteriovenous fistulas (AVFs) in the first 14 days of life.

Methods: Fifteen neonates (12 boys and 3 girls) who underwent the initial neuro-intervention within the first 14 days of life were included. Deliveries were at the gestational periods between 31 weeks 0 day and 41 weeks 6 days (mean 37 weeks 1 day). Modes of delivery were 2 spontaneous deliveries and 13 caesarian sections. Birth-weight ranged from 1.538 to 3.778 g (mean 2.525 g). There was no neonate with birth-weight between 2.200 and 2.700 g. Indication of treatment was no serious brain damage on antenatal/postnatal CT/MR imaging (except for 1 neonate) and severe congestive heart failure. The clinical symptoms, diagnoses, treatments (neuro-interventions, especially access routes), and outcomes were reviewed retrospectively.

Results: All neonates presented with severe cardiac failure due to volume overload attributable to brain AVFs. Their diagnoses included 6 vein of Galen aneurysmal malformations (all choroidal types), 6 dural sinus malformations with AVFs (all medial types), 2 pial AVFs, and 1 epidural AVF. Neonates with birth-weight less than 2.200 g could not be treated by transfemoral arterial routes, but were treated by transumbilical routes or direct carotid access. Those with birth-weight more than 2.700 g could be treated through transfemoral arterial routes. In 13 neonates, transarterial embolization was performed, and in the remaining 2 neonates, both transarterial and transvenous embolization were performed. Initial treatments were performed on day 0 (3 neonates), on day 1 (4), within 7 days (13), with a mean of 3.7 days. Their overall outcomes were 6 good recovery, 1 moderate disability, 1 severe disability, 1 vegetative state (due to hemorrhage), and 5 deaths (due to hemorrhage in 4).

Conclusion: Neuro-intervention for the neonates with birth-weight less than 2.200 g requires transumbilical and/or direct carotid access routes. Those with birth-weight more than 2.700 g allow transfemoral arterial routes. Although their treatments are not straightforward, not all neonates have dismal outcomes in the circumstance of multi-disciplinary settings.

516

Fetal Torcular Dural Sinus Malformations: Imaging Features, Natural History, Prognosis, and Treatment

DBOrbach¹, A Storey¹ and E Yang²

¹Cerebrovascular Surgery & Interventions Center and Neurointerventional Radiology, Boston Children’s Hospital, Boston, MA, USA

²Division of Neuroradiology, Boston Children’s Hospital, Boston, MA, USA

Purpose: Dural sinus malformations (DSMs) are rare vascular malformations encountered in fetuses and infants. Due to the rarity of the disorder, the majority of cases are described in small case series making generalizable statements about this entity extremely difficult. Furthermore, different subspecialty literature (i.e. pathology, neuroangiography, and obstetrical ultrasound) have placed different emphases on aspects of malformations which appear superficially the same, raising questions about whether there is one DSM type or multiple.

Methods: We focus on the most common DSM, the torcular DSM (tDSM). The imaging features, and natural history, the outcome of 12 previously unpublished tDSMs are presented and compared to the entire extant literature series (93 cases).

Results: Common prognostic factors across tDSMs were identified, including a trend toward better outcome for lesions with absence of detectable arterialization, shrinking overall size, absence of ventriculomegaly, and absence of parenchymal destruction. Equally important, we present evidence that the favorable finding of decreasing tDSM size is generally an irreversible event and may still occur despite initial enlargement. The presence or development of tDSM thrombus is shown to be a relatively benign finding.

Conclusion: Although a unifying explanation encompassing all the heterogeneous literature describing tDSMs may prove elusive, we identified clearly essential prognostic features that should be reported in future cases to foster understanding of these vascular malformations.

517

Atypical Presentation of a Dural Arteriovenous Fistula in Newborn: A Case Report

EPereira Dos Santos Neto^1,3, JG Mendes Pereira Caldas¹, M Eli Frudit^1,2, V Eduardo Campos Oliveira¹ and L Lobão Salim Coelho¹

¹Department of Neuroradiology, Hospital das Clínicas, University of São Paulo – FMUSP, São Paulo, Brazil

²Department of Neurosurgery, Hospital São Paulo, University Federal of São Paulo – UNIFESP, São Paulo, Brazil

³NEURI – Brain Vascular Center, Hôpital Beaujon, University of Paris – Diderot VII, Paris, France

Purpose: Congenital dural arteriovenous fistulae (DAVF) are rare, much rarer than the already uncommon vein of Galen malformation. They are attributed to abnormal development of the cranial dural venous sinuses and because of the high flow usually have a poor prognosis, with a high incidence of heart failure. Our aim is describe a case of DAVF in newborn, whose clinical presentation was atypical.

Methods: We report a case of a newborn with intrauterine diagnosis of a DAVF and atypical clinical status at birth.

Results: Our patient had from the sixth month of pregnancy diagnosis of a dural arteriovenous malformation associated with a deformity throughout the superior sagittal sinus. He had at birth, performed via cesarean, Apgar score appropriate, to the surprise of the attending pediatric team. It conducted an echocardiogram that showed only a slight ectasia of the descending aorta without cardiac function (ejection rate) commitment signals. After discussion among multidisciplinary teams, because of the potential risk of progression to heart failure, we opted for early treatment. Angiography confirmed the intrauterine hypothesis, showing a malformation of all the superior sagittal sinus, associated with a high flow fistula, nourished mainly by the middle meningeal and superficial temporal arteries.

Conclusion: The treatment was then conducted through microcatheterization both middle meningea arteries, with injection of glue to 50 %, by Valsalva maneuver, with a satisfactory angiographic result to the end of the procedure.

518

New Material Compositions for an Increased Visibility of Flow Diverter Stents

T Hoffmann¹, ABoese², S Serowy¹, G Cattaneo³, W Mailänder³, M Skalej¹ and O Beuing¹

¹Department of Neuroradiology, Otto-von-Guericke University Magdeburg, Magdeburg, Germany

²Department of Medical Engineering, Otto-von-Guericke University Magdeburg, Magdeburg, Germany

³Acandis GmbH & Co KG, Pforzheim, Germany

Purpose: Braided nitinol flow diverter stents (FD) show poor radiopacity. Therefore, it is difficult to correctly assess the wall apposition or the exact position of the implant in-vivo in many cases. Changes of the construction address this problem. To evaluate the impact of the composition on visibility and artefacts, five FDs differing in the number and type of wires (singe wire and drawn filled tube, DFT) as well as the nitinol:platinum-ratio (NPR) were investigated using X-ray imaging.

Methods: The following FD stents were imaged with fluoroscopy, radiography and volume CT in a head phantom: FD1: 40 nitinol + 2 platinum wires; FD2: 24 nitinol + 24 DFT wires, NPR 70:30; FD3: 48 DFT wires, NPR 70:30, FD4: 24 nitinol + 24 DFT wires, NPR 90:10; FD5: 48 DFT wires, NPR 90:10). Experienced neuroradiologists evaluated the data sets with regard to contrast differences between FDs and the surrounding material and wall apposition. For verification, the results of the phantom study were compared with a radiopacity test for implants based on DIN 13273-7. Radiopacity was described in aluminium thickness for corpus and marker structures.

Results: DFT wires containing platinum increase radiopacity. Measured contrast differences between implants and surrounding material in the head phantom correlated with the results of the experimental radiopacity test. Wall apposition could be judged with all implants, except FD No. 3, which contained the highest amount of platinum. A 20% increase of platinum in NPR (FD4-2, FD5-3) is equivalent to an increase of 0.41 mm and 0.54 mm aluminium, respectively. Doubling the number of DFT wires (FD2-3, FD4-5) corresponds to an increase of aluminium thickness of 0.67 mm and 0.54 mm.

Conclusion: Vascular implants produced with the DFT technique homogenously increase the visibility. All DFT implants show an improved visibility compared to the investigated conventional nitinol FD in radiography. High amounts of platinum restrict the assessment of the implants wall apposition.

519

Imaging Anatomy and Variation of Inferior Sagittal Sinus Evaluated by Contrast-Enhanced CT Imaging and Cerebral Angiography

SIde¹, H Kiyosue², Y Hori¹, H Nagatomi¹, S Tanoue² and H Mori²

¹Nagatomi Neurosurgical Hospital, Oita, Oita, Japan

²Oita University Faculty of Medicine, Yufu, Oita, Japan

Purpose: The inferior sagittal sinus (ISS) is a small dural sinus situated in the free edge of the falx cerebri. The developed ISS receives tributaries from the corpus callosum, and the medial cerebral hemispheres, and it terminates into the straight sinus. However, development of the ISS is varied widely among individuals, and variations of the ISS have not been well-investigated. In this study, we evaluate the imaging anatomy and variations of ISS on CT angiography and cerebral digital subtraction angiography (DSA).

Methods: CT angiography and DSA in 30 patients with normal cerebral venous return were reviewed by two radiologists with special interest in the tributes of the ISS. Presence and terminations of ISS, complementarity with the superior sagittal sinus (SSS) and the posterior pericallosal vein (PPCV) were evaluated.

Results: ISS was identified in 26 cases (87%), which originated from genu of the corpus callosum in 18, from body of the corpus callosum in 8. ISS terminated into the straight sinus in 25 and the superior sagittal sinus (SSS) in one patient. The tributes of the ISS were drained the blood from the corpus callosum at the genue in 13, at the body in 18, from the cingulate gyrus at the anterior third part in 7, the middle third in 13, and the posterior third in 13 patients. The PPCV were identified in 24 patients (Bil: 18, Rt: 3, Lt: 3). In the patients with the hypoplastic ISS, the PPCV was markedly developed in one patient. In one patients, with absence of anterior part of the SSS, the developed ISS drains blood from a large area of the medial surface of the cerebrum.

Conclusion: ISS can be identified in the most cases with normal cerebral venous circulation, and it plays important roles in cerebral venous drainage together with SSS and the PPCV.

520

Histopathology of Healing Response Following Treatment with Flow Diverter in the Canine Side-Wall Aneurysm Model

JYLee¹, YD Cho², HS Kang² and MH Han²

¹Hallym University Gangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea

²Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea

Purpose: To characterize the histopathologic progression of wide-necked, side wall aneurysm following treatment with a flow diverter in a canine aneurysm model.

Methods: With institutional animal care and use committee approval, 21 side wall aneurysms were created in common carotid artery of 8 dogs and treated with two different flow diverters. Angiographic follow-ups were done immediately after placement of the device, after 4 weeks and 12 weeks. At last follow-up, the aneurysm and the device-implanted parent artery were harvested. The aneurysm occlusion rate was assessed by using a 5-point scale. The harvested aneurysm–parent artery complex was fixed with 5% formalin, embedded in methyl-methacrylated, and stained with hematoxilin-eosin stain.

Results: Overall final occlusion rate were noted as grade 0 in 2, grade 1 in 1, Grade 2 in 6, grade 3 in 5, and grade 4 in 7 of 21 aneurysms, respectively. Contrast stagnation in aneurysmal sac after procedure was not associated with 4-week angiographic outcome (p for trend = 0.029). Histopathologic findings of grade 4 occlusion aneurysms showed that multiple-staged thrombus formation in the aneurysmal sac, and neointimal thickening at the mid-segment of aneurysm at 4 weeks after the procedure, and markedly shrunken aneurysmal sac filled with collagenized attenuated connective tissues with collagenized neointima at 12 weeks. In a case of grade 0 occlusion at 12 weeks, 10-mm sized, wide-necked aneurysm became a small neck aneurysm with contrast stagnation at the venous phase of follow-up angiography. Histopathology of the aneurysm showed thick neointimal formation without any stage of thrombus formation in aneurysmal sac.

Conclusion: After the flow diverter insertion, intra-aneurysmal thrombus formation was progressed gradually according to the degree of flow modification. Neointimal formation seems to be processed independently of intra-aneurysmal thrombus formation, and it might be interrupted by inflow into aneurysmal sac.

521

Genetic Screening of Ruptured Intracranial Aneurysm: Meta-Analysis of the Relationship Between Endothelial Nitric Oxide Synthase (Enos) and Aneurysmatic Subarachnoid Hemorrhage

EHAPaschoal^1,2, VN Yamaki³, GS Jong-A-Liem³, FM Paschoal-Júnior⁴, JKSF Paschoal⁴, RL Piske⁸, ES Yamada², MJ Teixeira⁶, AKCR Santos² and E Bor-Seng-Shu⁶

¹Hospital Ophir Loyola (HOL), Belém, Pará, Brazil

²Universidade Federal do Pará (UFPA), Belém, Pará, Brazil

³Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil

⁴Centro de Ensino Superior do Pará (CESUPA), Belém, Pará, Brazil

⁵Centro de Neuro-Angiografia (CNA-HBPSP), São Paulo, São Paulo, Brazil

⁶Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP, São Paulo, São Paulo, Brazil

Purpose: Test the association between IA formation and eNOS gene polymorphism.

Methods: A systematic review was executed in Medline, Lilacs, Cochrane and EMBASE to identify all published case-control studies evaluating genetic polymorphisms of eNOS in intracranial aneurysms (IA) and subarachnoid hemorrhage (SAH) in humans since January 2000. The Medical Subject Headings and text words used for the search were “intracranial aneurysm,” “saccular aneurysm,” or “subarachnoid hemorrhage” in combination with “genetics,” “endothelial nitric oxide synthase,” “gene,” “single nucleotide polymorphism,” “oxide nitric synthase,” “polymorphisms,” or “genetic linkage.”

Results: The primary search resulted in 139 papers, out of which 22 met the initial inclusion criteria. After full text analysis, nine studies met the inclusion and exclusion criteria. Four studies (Akagawa et al., 2005, Krischek et al., 2006, Chimowitz et al., 2011, Song et al., 2006) evaluated the T786C polymorphism and its association with aSAH. Studies assessing the dominant T786C model found a significant association with IA (OR: 1.22, 95% CI: 1.04 – 1.44 p = 0.01), so did the studies of the recessive T786C model (OR: 0.37 95% CI: 0.30 – 0.45 p < 0.0001), but with opposite effect.

Conclusion: Our findings support the presence of the T786C SNP as a predictor for the development of intracranial aneurysm in the cerebral vascular system. However, this comprehensive meta-analysis could not come to any conclusion about an effect of an eNOS gene SNP in cerebral vasospasm. Therefore, more studies are necessary in order to elucidate the pathways of the eNOS in cerebrovascular diseases and in defining how different allelic combinations of the eNOS gene SNP could favor this pathological process.

522

Improved Image Quality by a Homogenization Algorithm for Flat Panel Detector CT Data

SSerowy¹, B Schreiber², C Köhler², M Rothmayer³, P Dorn², T Elsässer², O Beuing¹ and M Skalej¹

¹Otto-von-Guericke University, Magdeburg, Germany

²Siemens Healthcare GmbH, Forchheim, Germany

³Ilmenau University of Technology, Ilmenau, Germany

Purpose: Low frequent homogeneity artifacts in reconstructed 3D volume datasets can be a severe problem for a physician to reliably detect low contrast details like a bleeding, a tumor or a stroke area. These homogeneity artifacts can be cupping artifacts resulting e.g. from scatter, capping artifacts resulting e.g. from overexposure or an increase in density values towards the posterior part of the skull due to increased beam hardening of the thicker part of the calotte.

Methods: Entire head 3D volume datasets from 26 patients with intracranial hemorrhage were acquired by a flat panel detector CT (Artis Q, Siemens Healthcare GmbH, Germany) and processed retrospectively by a homogenization algorithm (prototype software, Siemens Healthcare GmbH, not for diagnostic use and not commercially available in all countries) based on a heuristic homogenization function with generic parameters to remove low-frequent artifacts. A thick-layered (4 mm) axial reconstruction was carried out for the homogenized as well as the non-homogenized 3D volume datasets. The evaluation of these data in terms of image quality and evaluability of soft tissue structures and bleedings was performed by experienced neuroradiologists.

Results: The algorithm produces images that contain less cupping artifacts and make a more homogeneous image impression. The gray values of the same structures, such as the gray matter, are more constant in the homogenized datasets over larger spatial regions. Epi- and subdural hemorrhages are easier to detect in the homogenized datasets. The assessment of the posterior fossa remains problematic.

Conclusion: The homogenization algorithm seems to be capable to suppress homogeneity artifacts in already reconstructed 3D volume datasets and can potentially improve low contrast detectability. This might result, in a more reliable detection of low contrast details like bleedings, tumors or stroke areas.

523

Treatment Results of Angio-Seal and Exoseal after Neuroendovascular Therapy

THayato¹, O Tomotaka², I Takashi¹, M Noriaki¹, S Kazunori¹, I Masashi¹, I Tsukasa¹, N Masahiro¹ and W Toshihiko¹

¹Department of Neurosurgery Nagoya university, Graduate School of Medicine, Nagoya, Aichi, Japan

²Department of Neurosurgery Kariya Toyota General Hospital, Kariya, Aichi, Japan

Purpose: Angio-Seal and Exoseal are useful to obtain hemostasis on a short period of time than manual compression. However, there are various complications. We aimed to evaluate the effective and safe of the Angio-Seal and Exoseal.

Methods: In a retrospective multi-center study, a total of 487 patients who underwent neuroendovascular treatment were performed. In each case, procedures with retrograde common femoral artery access and closure with Angio-Seal or Exoseal were included. The efficacy endpoint was a technically successful application of Angio-Seal or Exoseal and successful hemostasis. All complications at the access site were registered as a safety endpoint.

Results: The efficacy endpoint was observed in 300 of 312 procedures (96.2%) assigned to receive a Angio-Seal and 172 of 175 procedures (98.3%) assigned to Exoseal. There were no significant differences between Angio-Seal (5.8%) and Exoseal (6.9%) regarding safety endpoint. In both Angio-Seal and Exoseal, activated clotting time (ACT) was significantly higher in the complication group than in the no complication group.

Conclusion: These results indicate that Angio-Seal and Exoseal was effective and safe. However, high ACT requires special attention.

524

Can MRA Detect Cerebral Hyperperfusion after CAS?

Y Kentaro¹, K Yasuhiko¹, K Jouji¹, N Jiro¹ and T Hiroaki¹

¹Murakami Memorial Hospital, University of Asahi, Gifu, Japan

Purpose: Cerebral blood flow study is necessary for diagnosis of cerebral hyperperfusion. But it is actually unsuitable to repeat SPECT or PET. The purpose of this study is to verify if MRA can detect cerebral hyperperfusion after CAS.

Methods: This study included the patients have been accomplished SPECT within 24 hours and MRA within 48 hours after CAS from 2008 in our hospital. This study included patients who recognized cerebral hyperperfuision by SPECT more than 101 percent compared with contralateral MCA territory. Patients who had severe stenosis or occlusion in contralateral IC or M1 were excluded.

Results: Ten cases have been detected cerebral hyperperfusion by SPECT within 24 hours after CAS and the contralateral sites of them were normal. In 4 cases, ipsilateral MCA dilated or became high signal intensity by MRA. Especially, this sign was shown in all cases that had hyperperfusion more than 115 percent compared with contralateral sites.

Conclusion: Cerebral hyperperfusion can be conveniently detected with MRA if it is severe.

525 Presentation withdrawn

Should Informed Radiation Consent Exist for Neurovascular Interventional Radiology Procedures? The Patient Perspective

RZener¹, PB Johnson¹, A Mujoomdar^1,2 and S Pandey^1,3

¹Western University, London, Ontario, Canada

²London Health Sciences Centre, Victoria Hospital, London, Ontario, Canada

³London Health Sciences Centre, University Hospital, London, Ontario, Canada

Body

Purpose: Radiation exposure is inherent in neurovascular interventional radiology (IR). A potential exposure of 1 mSv has been suggested as a cutoff for provision of risk information, as it corresponds to a 1 in 10000 increased cancer risk (Semelka et al., 2012). Informed consent requires disclosure of rare yet potentially significant risks, yet patient and non-radiologist physician knowledge of these risks is lacking (Ricketts et al., 2013). Neurovascular IR patient perception and knowledge of these risks remains unknown. The purpose of this study is to explore neurovascular IR patient perception of cancer-related radiation risk exposure and whether radiation consent is warranted.

Materials and Methods: A multiple-choice survey was administered to 42 adult patients undergoing a non-emergent neurovascular IR procedure at a tertiary care centre. 67% of patients had previously undergone a neurovascular IR procedure. Statistical analysis of with Fisher Exact test was performed based on patient past neurovascular IR history (p < 0.05).

Results: Almost all subjects (90%) wanted to be informed if the radiation-related increased cancer risk was 1 in 100. Most (82%) wanted to be informed if the risk was moderate, 1 in 1000, or low, 1 in 10000 (70%). Only half of the patients were aware that they were exposed to radiation during their procedure, irrespective of previous neurovascular IR history. The majority (74%) believed that the ordering physician should be responsible for informing patients about radiation exposure. Most (85%) believed radiation consent should include radiation-related cancer risks, and that both verbal and written radiation consent should be obtained (74%). No significant difference was present based on past neurovascular IR history (p > 0.05).

Conclusion: Neurovascular IR patient awareness of radiation exposure is suboptimal. Based on this survey, most patients want to discuss cancer-related radiation risks with the ordering physician in order to make informed decisions. This is potentially concerning as non-radiologist ordering physicians may not be as knowledgeable on radiation-related cancer risks. Neurointerventional radiologists should consider obtaining informed consent for procedures with anticipated doses of 1 mSv or greater.

526

Giant Anterior Sacral Meningocoele Confirmed by CT-Guided Paraspinal Percutaneous Contrast Injection

K Bhatia¹, D Boshell¹, R Paschkewitz¹ and I Woodgate²

¹Department of Medical Imaging, St Vincent's Hospital, Darlinghurst, NSW, AUSTRALIA

²Department of Orthopaedic Surgery, St Vincent's Hospital, Darlinghurst, NSW, AUSTRALIA

Purpose: A 34 year old male presented to his general practitioner with progressive abdominal distension over several years, with increasing mild abdominal discomfort over the previous 3 months. He had also noted mild progression in the severity of weakness in his left lower limb, which had long-standing weakness and reduced function since early childhood (never investigated). Examination demonstrated disproportionate distension of the abdomen, and a pyramidal pattern of moderate weakness in the left lower limb with hyperreflexia.

Methods: Imaging findings CT imaging of the abdomen and pelvis demonstrated a giant extra-peritoneal cystic structure measuring 11.2 x 20.6 cm axial, 26.1 cm craniocaudal length. This structure was inseparable from an enlarged left S1-2 anterior sacral foramen. No contrast enhancement was seen. MRI demonstrated CSF-intensity within the structure, and likely communication with the thecal sac at the level of S1-2. MRI brain also demonstrated right cerebral open-lip schizencephaly. Demonstration of the communication was requested by the managing orthopaedic surgeon to help differentiate giant anterior sacral meningocoele from a giant Tarlov cyst.

Results: With the patient in prone position, a 20 gauge spinal needle was placed in the cystic structure within the left side of the pelvis under CT-guidance using a left paraspinal, trans-gluteal approach. Fluid was aspirated for cytological assessment. 20 ml of Isovue 200 contrast was instilled into the cyst.

The patient was turned supine, and CT imaging was performed through the sacrum and pelvis with both early (2 minutes delay) and delayed (40 minute delay) acquisitions. On delayed imaging, contrast was seen with the lumbar thecal sac, confirming communication.

Conclusion: Diagnosis of giant anterior sacral meningocoele was confirmed using a percutaneous paraspinal approach for contrast injection into the pelvic component of the meningoccoele.

527

Endovascular Treatment of a Spinal Epidural Arteriovenous Fistula with an Enlarging Venous Varix

DDing¹, RM Starke¹, D Manka², RW Crowley^1,3 and KC Liu^1,3

¹University of Virginia, Department of Neurosurgery, Charlottesville, Virginia, United States of America

²HemoShear, Charlottesville, Virginia, United States of America

³University of Virginia, Department of Radiology and Medical Imaging, Charlottesville, Virginia, United States of America

Purpose: Spinal arteriovenous fistulas (AVF) completed isolated to the epidural compartment are exceptionally rare. As such, the optimal management of these lesions is poorly defined.

Methods: We a report a case of a purely epidural AVF of the thoracic spine associated with spinal cord compression which was successfully treated with endovascular occlusion.

Results: A 40 year-old male presented with right-sided back pain and right anterior thigh numbness after a sports-related back injury six months previously. Spinal magnetic resonance imaging and computed tomography angiography showed an enhancing, extradural mass lesion at T12, with characteristics suggestive of a vascular lesion. Spinal angiography showed an epidural AVF, supplied by a muscular branch of the right T12 subcostal and draining into the paravertebral lumbar veins, as well as a 20 mm saclike area of contrast filling, compatible with a dilated draining venous varix or pseudoaneurysm. There was no evidence of intradural venous drainage. We elected to proceed with endovascular treatment of the lesion. At the time of intervention five days later, the contrast-filling lesion had enlarged to a maximal diameter of 26 mm. The microcatheter would not advance into the saclike area of contrast filling, suggesting that this was a dilated varix rather than a pseudoaneurysm. The right T12 subcostal artery was occluded with coils, distal to the origin of the posterior spinal artery but proximal to the point of fistulization. Follow-up spinal angiography one month after embolization showed no residual AVF. Follow-up thoracic spine MRI performed three months after embolization showed complete resolution of the enlarging venous varix and spinal cord compression. At three months clinical follow-up, the patient was completely asymptomatic.

Conclusion: An endovascular approach can be successfully employed for the treatment of appropriately selected spinal epidural AVFs, even in the setting of spinal cord compression.

528

Multidetector CT Angiography in Diagnosing Type I and Type IV Spinal Vascular Malformation : Technical Note

YIhn¹, W Jung¹ and BS Kim²

¹Department of Radiology, St. Vincent’s Hospital, The Catholic University of Korea, Suwon, Korea

²Department of Radiology, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea

Conventional angiography has been used as a primary imaging technique for the localization of the shunt of spinal dural arteriovenous fistula (SDAVFs) and perimedullary spinal cord simple arterivenous fistula (SCAVFs). The search for a SDAVF with conventional angiography is often tedious and requires selective injections into multiple bilateral thoracic intercostal, lumbar, and sacral arteries. Multidetector CT (MDCT) angiography is an imaging technique that can provide high resolution and high-constrast images. We present our experience in diagnosing type I and type IV spinal vascular malformation in 2 cases with similar spinal MR imagning abnormalities. Sixty-four row spinal CTA images led to diagnosis of a type I (spinal dural arteriovenous fistula) and type IV (perimedullary spinal cord arteriovenous fistula fed by a single arterial feeder) spinal vascular malformation, both confirmed by conventional angiography. MDCT angiography can localize the feeding vessel and the fistula, thus greatly reduce the amount of time required for conventional angiography.

529

CT Myelogram to Find the Leak and Patch in Spontaneous Intracranial Hypotension

SNair¹, A Coulthard¹ and N Waters¹

¹Royal Brisbane and Women’s Hospital, Herston, Queensland

Purpose: Computed Tomography (CT) guided epidural blood patching has been reported for the treatment of spontaneous intracranial hypotension and cerebrospinal fluid (CSF) leak. This exhibit is a case study of CT myelogram for the identification of the leak site and CT guided epidural blood patching for the treatment in a 39 year old gentleman who presented with postural headache.

Methods: Imaging findings, treatment details and clinical outcomes were reviewed for a patient referred for the management of spontaneous intracranial hypotension. Pre-treatment Magnetic Resonance Imaging (MRI) of brain and spine were performed which indicated spinal manifestation of intracranial hypotension and CSF leak.

Results: Fluoroscopic CT myelogram was performed to detect the CSF leak site. CT myelogram favoured the contrast leak to be located at T12/L1 level. Targeted epidural blood patching was performed at this location guided by CT imaging. Clinical evaluation indicated symptomatic relief following the treatment.

Conclusion: This case study suggested that CT guided epidural blood patching targeting observed leak sites can be effective for the treatment of spontaneous intracranial hypotension and CSF leak. Controlled studies are necessary to study the efficacy of this method in comparison with other methods.

530

The Utility and Technical Consideration of Spinal Angiography: Importance of Cooperation with Spine Surgeons

DSShin, BT Kim, SB Im and JH Jung

Department of Neurosurgery, Soonchunhyang University Bucheon Hospital

Purpose: Although endovascular approach is a useful option for treatment of spinal diseases, endovascular neurosurgeons haven’t had many opportunities to use this approach in spinal lesions. We investigated our institutional experience with spinal endovascular procedures before surgical operation.

Methods: From Mar. 2013 to Sep. 2014, seventeen patients underwent twenty-fourspinal endovascular procedures before surgical operation. Nine patients were males and mean age was 56.7(from 28 to 84). There were fourteencases of catheter angiography and ten cases of embolization. We investigated location, diagnosis, and described case presentation.

Results: Out of total twenty-four cases, there were four cases with cervical, eighteencases with thoracic, and two cases with lumbar spine lesion. Six cases werespinal cord tumor and ten cases were spinal arteriovenous fistula (AVF). Eight cases were spinal metastasis, which originated from lung, prostate, breast, gastric, hepatic and renal cancer. Polyvinyl alcohol (PVA) particle was used for all embolization in metastatic spinal tumors. Coil and N-butyl cyanoacrylate (NBCA) were used for embolization of spinal AVF. No patients had procedure-induced complications. However, in patients with spinal AVF, the paraesthesia (chief compliant) did not improve after embolization.

Conclusion: When we treat spinal lesions, cooperative approach with endovascular and surgical specialists working closely together is paramount to achieve the best possible results.

531

Comparison between Stenting Treatment and Medical Treatment for Vertebral Artery Origin Stenosis and Analysis of Risk Factors for In-Stent Stenosis

YCai

Department of Neurology, Chinese Beijing 306th Hospital, Chaoyang District Anxiang Beili 9, Beijing, China, 100101

Purpose: To confirm the efficacy and safety of treatment of vertebral artery origin stenosis stenting and to compare the difference of clinical effects between stenting treatment and medical therapy for the vertebral artery origin stenosis and to investigate the related risk factors of vertebral artery in-stent restenosis after stent implantation, which can be used to provide the basis for vertebral artery in-stent restenosis after stent implantation.

Methods: The clinical data of 82 patients with moderate or severe vertebral artery origin stenosis (stenosis rate > 50%) from January 2011 to January 2013 were retrospectively analyzed, including 40 cases treated with stenting plus medication and 42 cases treated with medication alone. One year later, the degree of vascular stenosis, restenosis rate, probability of cerebral infarction and the incidence of ischemic cerebrovascular diseases of the patients were recorded again. In addition, each patient also underwent the National Institutes of Health Stroke Scale. The measurement data were shown as Mean ± SD. As One-sample kolmogorov-smirnov Test showed that the measurement data was not in line with normal distribution, We used Rank sum test. Qualitative data was analyzed by chi-square test, if the sample is small (n < 40) or theoretical frequency is too small (T < 1), using Fisher 's exact test. We defined it as statistic significant when p < 0.05. Finally, analyze the clinical data of 39 patients who successfully underwent vertebral artery origin stent implantation and reviewed digital subtraction angiography one year later. The patients were divided into in-stent restenosis group (n = 11) and non in-stent restenosis group (n = 28), Univariate analysis and logistic regression analysis were used to study the relationship between in-stent restenosis and risk factors influencing vertebral artery origin stenosis after stent implantation.

Results: 44 stents were implanted in 40 patients, of which a patient had residual stenosis of 60% because of hard plaques. The operation success rate reached to 97.5% without any serious perioperation complications. The vascular stenosis degree in the stenting plus medication group decreased significantly (73.4 ± 12.9)% vs. (13.6 ± 10.6)%, P < 0.05). However, there were 11 stent restenosis (27.5%) in the stenting plus medication group, including 2 cases (5%) with stent fracture one year later. In the medication group, in 4 of 42 artery origin occlusion occurred (9.5%), but only 2 patients appeared the corresponding clinical symptoms. After the treatment, the NIHSS scores in both groups showed no statistically significant difference (P = 0.093), but the ischemic events in the stenting plus medication group was significantly lower than that in the medication group (17.5% vs. 38.1%, P = 0.038). Single factor analysis showed diabetes, smoking, and high ratio of residual stenosis were the effective factors of in-stent restenosis. Multivariate stepwise logistic regression analysis indicated that diabetes and high ratio of postoperative residual stenosis were the risk factors of in-stent restenosis. Among them, residual stenosis rate was positively correlated with stent restenosis.

Conclusion: Stenting treatment for vertebral artery origin stenosis is safe and effective, which can significantly improve the vertebral origin stenosis. As for preventing the occurrence of the posterior circulation ischemic events, stenting treatment plus medication may be better than medical treatment, but the incidence of vertebral artery in-stent restenosis after stent implantation was high. diabetes and high ratio of postoperative residual stenosis may be independent risk factor for in-stent restenosis, the other related factors still remain to be further studied.

532

Mechanical Thrombectomy with the Trevo device in Acute Vertebrobasilar Occlusion

CSCho¹ and CM Lee²

¹Department of Neurosurgery, Dankook University Hospital, College of Medicine, Cheon-an, Korea

²Department of Neurology, Dankook University Hospital, College of Medicine, Cheon-an, Korea

Purpose: The purpose of this study is to investigate the efficacy and safety of mechanical thrombectomy in acute vertebrobasilar artery occlusion (VBAO) using the Trevo Stentriever™ device

Methods: Six patients diagnosed with VBAO underwent digital subtraction angiography with the intention to perform mechanical thrombectomy with stent-retrievers between September 2014 and March 2015.

Results: thrombectomy with the Trevo device was performed in 6 patients. Stentriever™ was used as the sole device (100%). The device could be deployed and retrieved in all manuevers (100%). Twelve clot retrieval manuevers were performed (mean 2 ± 1, range 1–3). No device-related complications occurred. Mean duration of the endovascular intervention was 58 min. Complete or near complete recanalization (thrombolysis in cerebral infarction (TICI) ≥ 2b) was achieved in 6 patients. All patient survived and showed a good clinical outcome at discharge, defined as modified Rankin Scale (mRS) 0–2 or National Institute of Health Stroke Scale (NIHSS) improvement ≥10 points.

Conclusion: Mechanical thrombectomy in patients with acute VBAO using the Treve Stentriever™

Is feasible and seems to be similarly effective and safe as in the anterior circulation compared to reported data in the literature.

533

Diagnosis and Endovascular Management of Carotid Webs: Case Report

AH Elmokadem^1,2, AShaibani¹, SA Ansari¹ and MC Hurley¹

¹Department of Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA

²Department of Radiology, Mansoura University, Mansoura, Egypt

Purpose: A carotid web can be defined as an endoluminal shelf like projection at the internal carotid artery. Diagnosis of the carotid web as underlying cause of recurrent ischemic stroke is infrequent and can be overlooked. Surgery used to be the standard management for secondary stroke prevention in this condition.

Methods: Two patients were admitted to our institute in the last two years with recurrent ischemic strokes in the same territory that were investigated by computed tomographic angiograms (CTA) which revealed internal carotid artery (ICA) web.

Results: The diagnosis was confirmed by digital subtraction angiogram (DSA) and both of them underwent endovascular stenting as an alternative for surgery for purpose of secondary stroke prevention.

Conclusion: Carotid web is a rare cause of ischemic stroke recurrence in young and middle age adults which can be identified by CTA and managed successfully managed by endovascular stenting.

534

Compare the Clinical Outcomes of the IV-Tpa Only and IV-Tpa Plus Additional IA-Tx

YHwang¹ and DS Yoo¹

¹Uijeongbu St. Mary's Hospital, Uijeongbu-si, Gyeonggi-do, Republic Of Korea

Purpose: Intravenous tissue plasminogen activator administration (IV-tPA) for acute ischemic stroke patient, is the only standard treatment but its recanalization rate and therapeutic effectiveness on a large artery intracranial occluded disease (LAICOD) patients are questionable. The object of this study was to find out the difference between LAICOD patients and other acute stoke patients on thrombolytic therapy and proper management in LAICOD patients

Methods: 315 patients who treated IV-tPA therapy were analysis, recurrent stoke patients were excluded. Brain CT-angiography was an initial imaging study and just finished IV-tPA, acute stroke MRI, which included diffusion, perfusion and MRA image, was undertook. In 72 patients who was not recanalized after IV-tPA, additional intraarterial thromboysis (IA-Tx) was tried.

Results: 238 patients were defined as LAICOD, among them 166 patients underwent IV-tPA treatment only and 72 patients underwent IV-tPA and IA-Tx. Over all recanalization rate after IV-tPA was 27.3% (86/238 patients) and these recanalized patients showed 61.4% favorable neurologic outcome (mRS: 0 ∼ 2). But recanalization rate of whom defined as LAICOD patients was 12.8%. 72 patients who underwent additional IA-Tx, recanalization rate was 81.5% but favorable neurologic outcome (mRS 0 ∼ 2) after IA-Tx was non-significant compare with the IV-tPA treatment only patients (p = 0.114). But neurologic improvement (NIHSS at admission minus NIHSS at 3 month after treatment) was significantly better in IA-Tx group (p = 0.020).

Conclusion: From this study, large proportion of ischemic stroke was caused by large-vessel occlusion and these patients' recanalization rate after IV-tPA was very low. Authors would like to propose that initial image study should be include CT-angiography, and IA-Tx might be consider if the patients defined LAICOD and nonrecanalized after IV-tPA therapy.

535

Delayed Reocclusion of Recanalized Intracranial Arteries after Mechanical Thrombectomy in Acute Stroke Patients

KSJang, DK Jang, SK Park, YM Han, BH Moon and YS Park

Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea

Purpose: Occlusions of major intracranial vessels are presented with acute infarcts, which can lead to serious morbidity and mortality. Mechanical thrombectomy is an effective revascularization therapy for acute intracranial large vessel occlusion. Results of mechanical thrombectomy are varied according to the studies. Complications including dissection, hemorrhage, reocclusion are also varied. We reviewed the patients of reoccluded intracranial arteries which had initially recanalized by mechanical thrombectomy.

Methods: We reviewed 180 patients who have undergone Mechanical thrombectomy with Solitaire FR stent from March 2011 to January 2015. We achieved revasculisation (TICI 2,3) in 163 (91%) among 180 patients. But, we experienced delayed reocclusion of recanalized arteries after mechanical thrombectomy in 3 of 163 patients.

Results: Three patients were found with reocclusion of initially recanalized intracranial arteries with mechanical thrombectomy. Two of whom had occlusion of MCA, and one had occlusion of petrous ICA. We suspect the reasons of reocclusion were the dissection of occluded vessels in one patient and the thrombosis of remained thrombus (TICI2a,2b) in 2 patients. Initial NIHSS (National Institute of Health Stroke Scale) score were 21, 5 and 15, respectively and NIHSS score at discharge were 17, 4 and 15, respectively. For all 3 patients, TICI grade were 2b, 2b and 2a after the first mechanical thrombectomy. Follow-up Angiogram showed complete reocclusion with TICI grade 0. And Final TICI grade were 2a, 2b and 2b, respectively. All three patients had concomitant PTA with balloon catheter.

Conclusions: We reviewed these patients and found that delayed reocclusion of recanalized vessels were noted within 24 hours after first mechanical thrombectomy. The factors contributed to thsese results are assumed as TICI grade before and after the first mechanical thrombectomy. But, further evaluation of factors such as NIHSS score, underlying disease, laboratory findings and follow-up angiogram are needed. Also, procedural complications as vasospasm, dissection and hemorrhage should be investigated.

536

Emergency Intracranial Stenting after Recanalization Failure with Retrievable Stent in Acute Cerebral Artery Occlusion

KSJang, DK Jang, SK Park, YM Han, BH Moon and YS Park

Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea

Purpose: We present salvage intracranial stenting after recanalization failure with retrievable stent in acute cerebral artery occlusion patients.

Methods: Fourteen consecutive patients who have recanalization failure with clot retrievable stent in acute cerebral artery occlusion were underwent salvage intracranial stenting for prevention of reocclusion with deployment of same retrievable stent.

Results: At baseline, mean age was 71.9 years and mean initial NIHSS score was 15.5. A recanalization to TICI 2 or 3 was achieved in 7 patients (50%) after salvage stenting and 4 of this 7 patients had a good outcome (mRS ≤ 2). But, another seven patients had recanalization failure, 3 of this 7 patients expired due to aggravation of cerebral infarction.

Conclusion: The initial result of salvage stenting for recanalization failure patients makes it an attractive strategy for selected patients. But, large studies are needed to validate for this trial.

537

The Comparison of Characteristics between Solitaire Stent and Trevo Stent in Mechanical Thrombectomy

HWJeong¹, JH Seo², ST Kim³, WB Seung⁴ and EG Kim²

¹Department of Diagnostic Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea

²Department of Neurology, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea

³Department of Neurosurgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea

⁴Department of Neurosurgery, Gospel Hospital, Kosin University College of Medicine, Busan, Korea

Purpose: Recent reports have showed that mechanical thrombectomy (MT) has been demonstrated to improve functional outcome in patients with acute ischemic stroke (AIS). Their main device for MT was Solitaire stent. Trevo stent is a novel embolectomy device specifically designed to remove the thrombus in AIS. These two retrievable stent are known as effective devices for successful recanalization

We report our experiences to compare the safety and effectiveness of two retrievable stent systems during MT.

Methods: From January 2014 through April 2015, all seventy patients underwent MT for AIS with anterior circulation stroke. Among them, fifty two patients underwent MT using Trevo or Solitaire stent.

Patients were treated either with Trevo stent or Solitaire Stent according to the neurointerventionist preference. Recanalization was classified by TICI grade. Efficacy and safety during MT was analyzed first recanalization TICI grade after puncture, clot retrieve rate, final racanalization grade, pass number of stent,

necessity of rescue method, hemorrhagic complication and thromboembolic complication.

Results: Twenty nine were treated with Solitaire stent and 23 patients with the Trevo stent. Overall good recanalization (TICI 2b and 3) was achieved in 18 patients (62%) in the solitaire group and in 20 (87%) of the Trevo group (P = 0.043). First recanalization TICI grade after puncture, pass number of stent, necessity of rescue method were not significant between two groups. However, clot retrieve rate was 100% in Trevo group and 79% In solitaire group (P = 0.023). Rate of symptomatic ICH was 14.2% for Trevo versus 11.5% for Solitaire. Rate of thromboembolism was 14.2% and 19.2% for Trevo and Solitaire.

Conclusion: Our study showed superiority of Trevo stent to achieve successful recanalization and to retrieve the clot from the vessel. Higher recanalization rates of Trevo stent may be caused by higher clot retrieve rate.

538

Cerebral Angiographic Features of Patients with Central Retinal Artery Occlusion

SJung¹, C Jung¹, JH Kim¹, BS Choi¹, SJ Ahn², SJ Woo² and MK Han³

¹Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea

²Department of Ophthalmology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea

³Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea

Purpose: Retinal artery occlusion (RAO) could be a candidate for intra-arterial thrombolysis. However, angiographic feature of RAO were not well known and not previously reported. (Chawluk, Kushner et al., 1988, Leisser, Kaufmann et al., 2014) We reviewed cerebral angiography of the RAO patients to determine the angiographic features that could be confronted during procedure and try to investigate relation between angiographic feature and recanalization outcome after intra-arterial thrombolysis.

Methods: We analyzed digital subtraction angiography (DSA) of 82 consecutive patients diagnosed with acute non-arteritic RAO who underwent intra-arterial thrombolysis from January 2003 through February 2015. The angiographic features were reviewed and summarized in all patients.

Results: Fifty-eight of 82 (70.7%) patients had ophthalmic flow from the ICA. Among them, 24 (41.4%) patients had ophthalmic artery stenosis. Fifteen of the 82 patients (18.3%) had ophthalmic flow from the ECA due to ophthalmic artery occlusion and/or ipsilesional ICA occlusion. Of the 82 patients, 38 (46.3%) patients had atherosclerotic lesions in common carotid artery (CCA) and/or ICA. The most common (m/c) site of atherosclerotic lesion was cavernous ICA (n = 24, 29.3%), and 2nd m/c site was carotid bulb (n = 22, 26.8%). The maximal degree of stenosis in the ICA were mild in 27 patients (32.9%), moderate in 7 patients (8.5%) and severe in 3 patients (3.7%). Of the 38 patients with atherosclerotic lesion in CCA and/or ICA, 15 (39.5%) patients had an irregular and/or ulcerated plaque. There was no statistical difference of recanalization after IAT between ophthalmic flow from ICA and ECA. In addition, there was also no difference according to the stenotic degree of ophthalmic artery.

Conclusion: Angiographic features in patients presenting with RAO were diverse, while their procedural outcomes were similar. The atherosclerotic lesion in the ipsilesional ICA and/or OA were prevalent in patients with acute CRAO.

539

Intra-arterial Therapy for Acute Basilar Artery Occlusion; the Past and Present Status in Real Practice

SJung¹, C Jung¹, JH Kim¹, BS Choi¹, BJ Kim², MK Han² and HJ Bae²

¹Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea

²Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, South Korea

Purpose: Recently published reports showed that mechanical thrombectomy leads to better procedural and clinical outcomes in patients with acute large arterial occlusion of anterior circulation. (Berkhemer, Fransen et al., 2015, Campbell, Mitchell et al., 2015, Goyal, Demchuk et al., 2015) However, it is uncertain those beneficial effects in patients with acute basilar artery occlusion (BAO). (Lutsep, Rymer et al., 2008) The aim of this study was to evaluate the procedural and clinical outcomes in patients with acute BAO treated with intra-arterial therapy using the different methods.

Methods: After retrospectively reviewed our registry of consecutive pati (Lindsberg and Mattle 2006)ents with acute ischemic stroke who underwent ERT from September 2003 to January 2015, patients with acute BAO admitted to our hospital within 12 hours from stroke onset or last normal time were enrolled. And then they were categorized as thrombolytic-based ERT group (TLG) and thrombectomy-based ERT group (TEG) according to the primary technical option. We compared the procedural and clinical outcomes between the groups.

Results: Fifty-four patients were found to have acute BAO and 26 patients were assigned to TLG and 28 patients to TEG. The time from groin puncture to reperfusion was shorter in the TEG than those in the TLG, but it was not statistically significant. (p = 0.07). And the rate of complete recanalization (mTICI ≥ 2b) was significantly higher in the TEG than those in the TLG (TEG vs. TLG, 85.7% vs. 46.2%; p < 0.01). However, the functional outcome of mRS ≤ 2 and mortality at 3 months were not significantly different between the two groups.

Conclusion: Although thrombectomy based ERT in patients with acute BAO seems to be superior to thrombolytic based ERT in terms of the improvement of the rate of complete reperfusion, we failed to show its beneficial effect on the clinical outcome of these patients.

540

Central Retinal Artery Occlusion as a Warning Sign of Carotid Lesions

DW Kim, and SDKang

Department of Neurosurgery, Wonkwang University School of Medicine and Hospital, Iksan, Korea

Purpose: Central retinal artery occlusion (CRAO) is a rare disease with poor visual prognosis. We evaluated clinical effectiveness of local intra-arterial (IA) fibrinolysis and the rate of accompanying carotid lesion as a cause of CRAO.

Methods: A total 34 patients with CRAO were enrolled in this retrospective study between 2009 and 2014. Thirty patients underwent local IA fibrinolysis, 4 were excluded due to time window and inaccessible carotid lesion. The patients were divided into two groups: Group 1 (treated within 24 hrs.), Group 2 (treated after 24 hrs.). Fibrinolysis was performed with Urokinase with/without nimodipine. We evaluated carotid lesion by CTA or DSA, visual acuity (VA) before and after treatment, and VA improvement evaluated by ophthalmologist.

Results: In group 1 (18 patients), 3 patients (16.7%) had full recovery, 5 (27.8%) had partial recovery and 6 (55.8) were not recovered. All patients of group 2 were not recovered. There was 1 (3.3%) periprocedural complication. Among 34 patients, 11 patients (32.3) had carotid lesion which was same side of ophthalmologic symptom.

Conclusions: Although, the efficacy of intra-arterial thrombolysis for the treatment of CRAO needs to be further evaluated in a controlled trial, we suggest that ophthalmic artery thrombolysis may improve visual acuity of patients who are treated within 24 hours after the onset of symptoms. Because CRAOs are related to carotid lesion more than we are expected, the patients are referred to a highly specialized center with immediate access to the experienced interventionist.

541

Rapid Learning Curve and Fast Recanalization Time of Stent Retriever Compared to Suction Catheter for Acute Ischemic Stroke

MKoyanagi, M Oda, R Enatsu, Y Ioroi, T Kobayashi, O Narumi and M Saiki

Himeji Medical Center, National Hospital Organization, Himeji, Hyogo, Japan

Purpose: In acute ischemic stroke, good outcome depends on time and high successful recanalization rate. In this study, we compared our initial experience of mechanical thrombectomy using the stent retriever (Solitaire or Trevo) and the suction reperfusion catheter (Penumbra) in patients with acute ischemic stroke in our hospital.

Methods: We retrospectively reviewed the 30 patients who were performed mechanical thrombectomy in our hospital from November 2012 to April 2015. Because stent system was introduced in our hospital in July 2014, we could only access to Penumbra system before that time. Both anterior and posterior circulation stroke patients were included in this study. We compared parameters between patients treated with each device.

Results: 30 patients were treated with mechanical thrombectomy (10 were with Penumbra and 20 were with stent retriever). To evaluate time interval trends, patients were divided into three chronologically sequential groups of equal number. The first group included 10 Penumbras, the second group 10 first stent retrievers and the third group 10 second stent retrievers. Although successful recanalization rates (Thrombolysis in Cerebral Infarction (TICI) score ≥2b: 40.0% vs. 80.0% vs. 80.0 %, p = 0.122) were not significantly different between the three groups, puncture to recanalization time or final DSA time was significantly shorter compared to Penumbra and 2 stent retriever groups (140.5 min vs. 70.3 min vs. 61.1 min, p < 0.001) which was the significantly different in first group (Penumbra) and third group (second stent).

Conclusion: Although the two thrombectomy systems were associated with no significant difference in successful recanalization rates, stent system allows more rapid recanalization time than Penumbra system. There is a learning curve involved in the efficient use of stent system in acute ischemic stroke therapy.

542

The Usefulness of an Early Retrieval Stent Pull-Back Technique with Balloon Guide Catheter for Acute Ischemic Stroke

BHLee and YJ Hwang

Inje University of School of Medicine, Goyang, Korea

Purpose: The aim of this study was to evaluate the efficacy of early stent retrieval technique with balloon guide catheter in patients with acute ischemic stroke.

Methods: The study group comprised 21 consecutive acute ischemic stroke patients who were treated by intra-arterial thrombectomy using retrieval stent device as a first-line endovascular procedure. The stent was deployed to cover the thrombus and then left in place for 2–3 minutes. The modified Thrombolysis in Cerebral Infarction score was used for grading degrees of vessel recanalization. Immediate angiographic results were evaluated. Successful recanalization was defined as a TICI score of 2b or 3.

Results: Successful recanalization was achieved in 20 of the 21 (95.2 %). The mean number of passes for maximal recanalization was 2.19. No patient showed thrombus migration to a different territory. There was one procedure-related complication.

Conclusion: The early retrieval stent pull-back technique with balloon guide catheter provides a high potential for recanalization in patients with acute ischemic stroke.

543

Detection of Vulnerable Plaque Related to the Timing of Carotid Intervention: Agreement between MR Vessel Wall Imaging and Carotid US

SM Lim and NY Shin

Dept. of Radiology, Ewha Womans University Mokdong Hospital, Seoul, Korea

Purpose: The purpose of this study was to evaluate the agreement of findings of plaque between carotid US and MR vessel wall imaging especially MPRAGE in the plaque characterization related to the timing of carotid intervention.

Materials and Methods: 21 patients (3 female, 18 male: mean age, 68 years) 33 sites carotid lesions with carotid stenosis more than 50% degree were examined from January 2014 to March 2015. We retrospectively analyzed the signal intensity and echogenicity of the plaque using MR vessel wall images including MPRAGE, T2WI, fat suppressed T1WI., and carotid US. Short term follow up DWI were evaluated for embolic infarction after carotid intervention in 7 patients. Statistical analysis was performed to calculate concordance of vulnerable or stable plaque between the two techniques employed.

Results: McNemar test showed low agreement of findings of vulnerable plaque between MR vessel wall imaging and carotid US (p > 0.05). Follow up DWI showed low probability of embolic infarction after carotid intervention with either technique.

Conclusions: We observed a poor agreement between carotid US and MR vessel wall imaging in the evaluation of vulnerable plaque. And the findings of vulnerable plaque in either technique cannot predict the embolic infarction after carotid intervention.

544

CAS Based on Plaque Imaging

NYukimi, OKoichiro, TEiji and KAkino

Toyota Kosei Hospital,Toyota city,Japan

Purpose: Carotid plaque constituents such as hemorrhage, lipid core, fibrosis, and calcification are important factors in predicting the clinical outcome of carotid artery stenting (CAS). Magnetic resonance imaging (MRI) can noninvasively assess changes in carotid plaque composition by avaluating the Sp/Sm ratio calculated with the signal intensity of carotid plaque (Sp)compared to that of sternocleidomastoid muscle (Sm) using the black-blood technique.

Purpose – We assessed the clinical result of CAS compared before with MRI plaque imaging to after with that

Methods: Number of subjects 137 cases (grou A : before using MRI plaque imaging 87cases, group B : using MRI plaque imaging 50cases). In group B, 5case excluded because of the plaque volume, we treated with CEA. We assessed baseline characters (age, gender, symptoms, heart disease, lesion position, lesion side, lesion length, diameter by bifurcation, ulceration and calcification)

And choosed tequnipue and devices are assessed such as protection devices and stents.

Results: At two intervals, Group B was thought to have good results, but recognized the dominant difference only in a part.

Conclusion: We think that it is very significant to investigate a property, quantity of the plaque thoroughly by MRI before treatment. think that Wecan expect the improvement of further results in what I combine with device choice in accord with a lesion in performing CAS safely.

545

Carotid Stent Vessel Wall Scaffolding May Not Depend on Calculated Free-Cell Area

KNamba and A Higaki

Jichi Medical University, Shimotsuke, Tochigi, Japan

Purpose: Free-cell area is defined as a ratio between quantities of stent material in comparison to the amount of vessel tissue, and is considered the best index of the scaffolding ability of the stent. A lower value indicates better scaffolding ability that prevents plaque protrusion or extrusion. The closed-cell design has a lower free-cell area compared to the open-cell stent. We evaluated the scaffolding of stents in a silicone carotid artery stenosis model simulating the in vivo placement of the device.

Methods: Comparable stents (Precise, Protégé, and Wall) were deployed in a 60% carotid artery stenosis silicone model. The scaffolding of the stents at the stenosis and the shoulder of the stenosis were visually inspected. Then, covering ratio of the stent material to the vessel wall was calculated using a digital picture image processed through a Photoshop software.

Results: The calculated free-cell area of the Precise, Protégé, and Wall stents was 5.89 mm², 10.71 mm², and 1.08 mm² respectively. Visually, covering of the stenotic portion was dense in the Precise and Protégé stents, and the Wall stent showed dense covering at the shoulder of the stenosis. Covering ratio at the stenotic area for the Precise, Protégé, and Wall stents were 45%, 49%, and 30% respectively, and 17%, 18%, and 22% respectively at the shoulder of the stenosis.

Conclusion: Scaffolding of the vessel wall may not depend on the calculated value of the free-cell area. In particular, open-cell stents may show better covering at the stenotic area where the most scaffolding is required. Further study is required to determine the scaffolding ability of stents to add material to the decision making in the optimal stent selection.

546

Arterial Spin Labeling Perfusion MRI for Acute Territorial Infarct, Compared with Dynamic Susceptibility Contrast-Enhanced Perfusion MRI

DWPark¹ and S Lee¹

¹College of Medicine, Hanyang University, Seoul, Korea, Republic of

Purpose: Arterial spin labeling (ASL) is a technique of non-invasive perfusion MR imaging, using endogenous labeled arterial blood water. This study aims to evaluate the clinical usefulness of ASL perfusion MR image for evaluating hemodynamic change in patients with acute territorial infarct, compared with dynamic susceptibility contrast-enhanced (DSC) perfusion MR image.

Methods: 86 patients were enrolled, who confirmed as acute territorial infarct on diffusion weighted image. All patients also underwent the brain MRI including ASL and DSC perfusion images, for evaluating acute infarct.

Acute infarct territory on ASL perfusion images were assessed and categorized as four subtypes, I (-/-), II (+/−), III (+/+), and IV (−/+) according to the visualization of hyperintense vessel signal/parenchymal perfusion defect. DSC perfusion images were evaluated for the perfusion defect as matched and mismatched areas. The correlation between ASL subtypes and abnormal DSC perfusion was statistically evaluated.

Results: ASL subtype IV and matched perfusion defect on DSC perfusion images showed an excellent correlation. ASL subtype II/III and mismatched perfusion defect on DSC perfusion images showed a good correlation. Interrater agreement was very good.

Conclusion: ASL perfusion MR image can provide a reliable estimate of the severity of perfusion defect, corresponding to the DSC perfusion MR image.

547

Hyperintense Vessel Signal on Arterial Spin Labeling MR Image in Acute Ischemic Stroke

DPark¹

¹Hanyang University, Seoul, Korea, Republic of

Purpose: Susceptibility vessel sign by the susceptibility effect of intravascular clot on susceptibility weighted image (SWI) depends on the clot composition, which is significantly more common in RBC dominant and mixed clots than fibrin-dominant clots. Meanwhile, the hyperintense vessel signal on arterial spin labeling (ASL) depends on the delayed arterial transit time of magnetically labeled blood water (Jahng et al., 2014, Tada et al., 2014, Yoo et al., 2015). The purpose of this study is to evaluate the hyperintense vessel signal on ASL in acute ischemic stroke, comparing with susceptibility vessel sign on SWI.

Methods: All images of patients who performed MRI for suspected acute ischemic stroke were analyzed with the respect to followings: hyperintense vessel signal on ASL, susceptibility vessel sign on SWI, arterial occlusion on time-of-flight MR angiography, and diffusion restricted area on diffusion weighted image. Hyperintense vessel signal on ASL was statistically compared in groups with and without arterial occlusion, and groups with territorial-pattern and small cortical pattern infarcts. And, hyperintense vessel signal on ASL was compared with the susceptibility vessel sign on SWI at arterial occlusion.

Results: Hyperintense vessel signal on ASL was significantly more identifed in groups with arterial occlusion and territorial-pattern diffusion restricted area than in groups without arterial occlusion and cortical-pattern small diffusion restricted area (79% [22/28] versus 31% [16/51], 64% [30/47] versus 38% [21/55], respectively; P < 0.05). Hyperintense vessel signal on ASL had a significantly higher sensitivity for the detection of occlusion than the susceptibility vessel sign (79% [22 of 28] versus 57% [16 of 28], P < 0.05).

Conclusion: Hyperintense vessel signal on ASL could identify arterial occlusion and acute territorial-pattern infarct in patients with acute ischemic stroke, which may be associated with stagnant flow at occlusion sites.

548

Predictors for Good Functional Outcome after Mechanical Thrombectomy in Acute Cerebral Artery Occlusion

SKPark¹, YS Park¹ and BH Moon¹

¹Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea

Purpose: To investigate good prognostic factors for an acute occlusion of a major cerebral artery using mechanical thrombectomy.

Methods: A single center retrospective analysis of 37 consecutive patients with acute occlusion of a major cerebral artery treated by mechanical thrombectomy with stent retrievers was conducted. Collaterals were assessed by the Thrombolysis in Myocardial Infarction (TIMI), and recanalization was assessed by the Thrombolysis in Cerebral Infarction (TICI) score. Outcome was assessed by National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 90 days.

Results: Most patients (27/37) demonstrated good recanalization (TICI 2b or 3) after thrombectomy. At the 90-day follow up, 19 patients had good (mRS, 0–2), 14 had moderate (mRS, 3–4) and four had poor outcomes (mRS, 5–6). Early recanalization, high TIMI, and low baseline NIHSS were closely related to 90-day mRS, whereas high TICI was related to both mRS and the decrease in the NIHSS.

Conclusion: NIHSS decreased markedly when recanalization was successful. A good mRS was related to low initial NIHSS and good collateral and early and successful recanalization.

549

Critical Use of Balloon Angioplasty after Recanalization Failure with Retrievable Stent in Acute Cerebral Artery Occlusion

YSPark¹, SK Park¹ and BH Moon¹

¹Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon, South Korea

Purpose: To examine mechanical recanalization with a retrievable self-expanding stent and balloon in acute intracranial artery occlusions.

Materials and Methods: Twenty-eight consecutive patients with acute intracranial artery occlusions were treated with a Solitaire retrievable stent. Balloon angioplasty was added if successful recanalization was not achieved after stent retrieval. The angiographic outcome was assessed by Thrombolysis in Cerebral Infarction (TICI) and the clinical outcomes were assessed by the National Institutes of Health Stroke Scale (NIHSS) and the modified Rankin Scale (mRS).

Results: At baseline, mean age was 69.4 years and mean initial NIHSS score was 12.5. A recanalization to TICI 2 or 3 was achieved in 24 patients (85%) after stent retrieval. Successful recanalization was achieved after additional balloon angioplasty in 4 patients. At 90-day follow-up, 24 patients (85%) had a NIHSS improvement of ≥4 and 17 patients (60%) had a good outcome (mRS ≤ 2). Although there was sICH, there was one death associated with the procedure.

Conclusion: Mechanical thromboembolectomy with a retrievable stent followed by additional balloon angioplasty is a safe and effective first-line therapy for acute intracranial artery occlusions especially in case of unsuccessful recanalization after stent thrombectomy.

550

Acute Stroke Due to Complete ICA Occlusion in a Young Patient with Fibromuscular Dysplasia

SPark¹, HY Choi², HS Shin³, CW Ryu¹, JS Koh³ and EJ Kim⁴

¹Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul, South Korea

²Department of Neurology, Kyung Hee University Hospital at Gangdong, Seoul, South Korea

³Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea

⁴Department of Radiology, Kyung Hee University Hospital, Seoul, South Korea

Purpose: Fibromuscular dysplasia (FMD) of the extracranial ICA (internal carotid artery) is an infrequent benign condition. Disastrous acute stroke can happen to a previously health young patient with FMD. Surgical management of the lesion is possible in selected cases. We report a case of an acute ischemic stroke by fibromuscular dysplasia with successful endovascular management.

Methods: A 29-year-old man was admitted due to right side weakness, aphasia with NIHSS 19. He had repeated TIA (transient ischemic attack) previously. No abnormal vascular lesions were identified on MRI which was taken one year ago. Initial CTA work-up showed occlusion of left ICA with cross-filling of left middle cerebral artery via anterior communicating artery. Administration of t-PA(plasminogen activator) did not improve his symptom. Left CCA angiography showed occlusion of left carotid bulb with irregular appearance. Retrograde filling of petrous ICA was noted. Microcatheter angiogram showed patent petrous ICA. ICA dissection was treated with direct stenting with rapid luminal gain and flow to the left cerebral hemisphere. Right ICA angiography showed lobulating contour of carotid bulb. Considering young age and bizzare shape bilateral ICAs, biopsy of temporal artery was done resulting in fibromuscular dyplasia with interal lamina defect on H&E.

Results: The patient was discharged with dual antiplatelet regimen with mRS 1 and NIHSS 0. 3 month follow-up angiography showed patent carotid bulb but another right distal cervical ICA. The patient shows no symptoms on 1 year follow-up.

Conclusion: FMD can cause acute ischemic in a previously health young patient in a form of ICA dissection and endovascular approach is feasible. Follow-up imaging is mandatory because another lesion can be identified.

551

Intimal Dissetion Caused by Mechanical Thrombectomy with Stentreiver Proven by MR Imaging

SPark¹, HS Shin³, CW Ryu¹, JS Koh³ and EJ Kim⁴

¹Department of Radiology, Kyung Hee University Hospital at Gangdong, Seoul, South Korea

²Department of Neurosurgery, Kyung Hee University Hospital at Gangdong, Seoul, South Korea

³Department of Radiology, Kyung Hee University Hospital, Seoul, South Korea

Purpose: Stentrievers are FDA-approved devices for acute ischemic stroke with promising clinical results. However, intimal vascular damage might be noticed. We report a case of intimal dissection of MCA due to mechanical thrombectomy in a patieht with acute ischemic stroke.

Methods: A 59-year-old patient presented with global aphasia. On admission, tPA(plasminogen activator) was administered resulting marked improvement of symptom from NIHSS 13 to 2. Imaging evaluation with CT and MRI was performed. Left ICA flow was decreased although left MCA was patent on CTA. MRI showed small acute lesions in the left internal border zone and left temporal subcortical white matter. PWI showed marked delay of left cerebral hemisphere. Due to marked improvement, intra-arterial treatment was waived. The patient’s symptom, however, recurred after 6 hours later with NIHSS 16. Emergency angiography showed occlusion of left ICA from carotid bulb with minimal reconstitution of left supraclinoid ICA and MCA flow. ICA occlusion was crossed with a microwire and microcatheter under balloon-tipped guide catheter. MCA occlusion was recanalized with Solitaire FR (Covidien, Irvine, CA, USA) and carotid bulb occlusion was treated with balloon angioplasty and stenting. High density at left sylvian fissure was identified on CT the following day.

Results: The lesion location was corresponded to the distal stentriever deploy zone. Retrospective angiographic analysis showed slender caliber of the M2 branch, corresponding to the high density lesion on CT. We regarded this as an intimal damage rather than localized SAH as patient’s symptom has improved. Serial follow-up CT showed gradual decrease of the lesion.12 days after the procedure, GRE showed prominent blooming low signal intensity along left M1 branch, although CT showed nearly disappeared high density. Follow up DSA showed improvement of the calibre of M2 with patent ICA and MCA flow. Patient was dischared with mRS 1 and NIHSS 1.

Conclusion: Although stentriever is highly effective in acute ischemic stroke, its deployment can cause intimal damage which interventionist should be cautious of.

552

The Role of Micro-RNA in Ischemic Stroke: A Systematic Review

GS Jong-A-Liem¹, VN Yamaki¹, FM Paschoal-Júnior², JKSF Paschoal², RL Piske³, E Bor-Seng-Shu⁴, MJ Teixeira⁴, AKCR Santos⁵, ES Yamada⁵ and EHAPaschoal^5,6

¹Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil

²Centro de Ensino Superior do Pará (CESUPA), Belém, Pará, Brazil

³Centro de Neuro-Angiografia (CNA-HBPSP), São Paulo, São Paulo, Brazil

⁴Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP, São Paulo, São Paulo, Brazil

⁵Universidade Federal do Pará (UFPA), Belém, Pará, Brazil

⁶Hospital Ophir Loyola (HOL), Belém, Pará, Brazil

Purpose: Describe and analyze the existing findings of micro-RNA (miRNAs) in ischemic stroke.

Methods: Execute a systematic review based on the MOOSE Guidelines (Stroup et al., 2000) in MedLine, Embase and Lilacs with the keywords: “miRNA”, “micro-RNA”, “stroke” and “cerebral ischemia”. Additionally, we hand searched the reference lists of selected and pertinent articles for any missing potential studies. Our search was restricted to co-hort studies realized in humans with a stroke and non-stroke control group.

Results: Primary results listed 88 articles, out of which fifteen met the inclusion and exclusion criteria; and eight were included in the systematic review after a full text analysis. The included studies reported 46 significantly altered miRNAs in ischemic stroke patients: 27 up-regulated and 19 down-regulated. A meta-analysis with the specificity and sensitivity data confirmed that these miRNAs are associated to stroke. Hsa-miR-30a, hsa-let7b, hsa-miR-126, hsa-miR221, hsa-miR-21 and hsa-miR210 present a sensitivity for ischemic stroke. A functional analysis of the 47 miRNAs correlates these with vascular, inflammatory and atherosclerotic processes. In addition, hsa-miR-210 has proven to define prognosis based on its level of expression. Despite its down-regulation in stroke, studies (Zeng et al., 2013, Zeng et al., 2011) affirm that the less down-regulated, the better the prognosis. Taken this in consideration we identify a dependent variable pre-defining the clinical course of stroke.

Conclusion: In ischemic stroke patients, 46 miRNAs are significantly altered. Some of these are highly sensitive for stroke, which favors its use as a screening tool. The functional miRNA analysis found that these are involved in various vascular, inflammatory and atherosclerotic processes that are known to cause stroke. There is also evidence that miRNA levels interfere in the clinical presentation, as noticed with hsa-miR-210. Current literature affirms the association and interference of miRNAs in stroke. However, more studies need to be done, to test if these miRNAs are necessary and/or sufficient to develop stroke.

553

Evaluating the Results of Thrombectomy Using Solitaire Stent in Acute Ischemic Stroke Patients

QANguyen¹, DL Vu¹ and MT Pham¹

¹Hanoi Medical University, Bach Mai hospital, Hanoi, Viet Nam

Purpose: Evaluating the results of the thrombectomy using Solitaire stent in acute ischemic stroke patients during 2.5 years (30 months) in Bach Mai hospital.

Methods: Single-center, prospective, non-control study on all acute ischemic patients due to big arterial occlusion and be able to treated with Solitaire stent at Bach Mai hospital. Site: 29 patients, follow-up: at 24th hours, 7–10 days discharge, 30 days, 90 days.

Results: There are 14 males and 15 females with mean age 56.6 ± 11.9. Mean interventional time in DSA (digital subtraction angiography) room was 62.4 ± 34.5 mins. Ratio of good revascularization was 86.7%. After 3 months, regarding to the clinical recovery, there are 21 patients with good result (72.4%) while 5 patients slow (17.3%), and 2 mortalities (10.3%).

Conclusion: Using stent solitaire in thrombectomy for the acute ischemic stroke patients is a new and potential treatment including revascularization and clinical recovery results.

554

Endovascular Intervention Plus Iv T-Pa for Acute Stroke Management

Initial Experience in Puerto Rico Medical Center

CGonzález-Villamán, C Olivera, C Feliciano-Vals and RRodríguez-Mercado

University of Puerto Rico

Medical Sciences Campus

Endovascular Neurosurgery Program

San Juan, Puerto Rico

Introduction: Intravenous thrombolysis used since 1990's has been supported by different studies resulting in the use of endovascular approach as a second line of treatment. In February of 2015 new clinical trials involving endovascular approach (MR. Clean, EXTEND-IA, ESCAPE) has shown impressive favorable results with combined intravenous plus endovascular management (IV-EV) of acute ischemic stroke, with results ranging from 50 to 70% of good functional outcomes and an index of cerebral reperfusion reaching above 80%.

Objetive: Analize the efficacy and safety of endovascular treatment plus intravenous thrombolysis in patients with acute ischemic stroke.

Materials and Methods: Prospective observational study included 10 patients with acute stroke receiving endovascular treatment and 9 patients receiving IV-EV. Epidemiological data included: localization of arterial occlusion, time of onset of stroke to treatment, National Institutes of Health Stroke Scale (at admission and upon hospital discharge), complications and functional evolution based on the modified Rankin Scale during hospital stay and by telephone interview.

Results: Among patients, 6 were men, mean age 57 y/o (range 21–79) with a mean hospital stay of 6 days at Stroke unit (range 1–21). Localization in all patients was in anterior circulation. Endovascular treatments included stent retriever (4 patients), aspiration (3), aspiration plus stent retriever (1), intra-arterial thrombolysis (1) and wire manipulation (1). Complete recanalization (TICI 3) was achieved in 5 patients, and partially complete (TICI 2a-2b) in 4. Five patients had a good recovery (mRS <2). 2 patients presented ICH bleeding after reperfusion and 2 patients died.

Conclusions: Endovascular treatment in the management of acute stroke provides a high degree of recanalization with a good functional outcome and few complications. We consider the need for systematic studies to compare the different modalities of mechanical thrombectomy.

555

Does Association with I.V. Thrombolysis Improve Mechanical Thrombectomy in Acute Ischemic Stroke?

ASaletti

Azienda Ospedaliero Universitaria Ferrara

Purpose: To assess if the association between i.v. thrombolysis and mechanical thrombectomy (MT) improves time to recanalization (TTR), rate of recanalization and outcome compared to pure MT.

Methods: We analyzed 907 stroke patients treated at 28 different centers in Italy. Patients with documented intracranial artery occlusion were treated with MT alone (n = 557) due to clinically or time related contraindication for i.v. thrombolysis or with a combination of MT and i.v. thrombolysis (MT+ i.v.; n = 350) as rescue therapy. In 689 cases were used stentriever and thromboaspiration for the others. Arterial recanalization was rated according to the TICI score. Outcome was determined with 3 months mRS (good outcome as mRS = 0–2). The onset CT to recanalization time, number of stentriever passes, thrombotic fragmentation and symptomatic intracranial haemorrhage (SICH) at 24 hours were recorded.

Results: There were no differences regarding sex, median NIHSS at onset and TTR between the two groups. Site of occlusion was carotid T-siphon (n = 140), M1 (n = 354), M2 (n = 107), vertebro-basilar artery (n = 156) and other sites, including tandem occlusion (n = 147). The two groups did not differ for TICI 2b-3, and SICH at 24 hours. However MT+ i.v. patients showed a less frequent thrombus fragmentation (p = 0.025), a more frequent good outcome (p = 0.032) and a lower mortality (p = 0.002) compared to pure MT patients. Moreover we found that in MT+ i.v. patients CT to recanalization time was longer while the number of stentriever passes were fewer than pure MT (p < 0.001). After adjusting for age, NIHSS, and site of occlusion, the lower number of device passes was independently associated to good outcome, while the association of MT and i.v. treatment did not.

Conclusion: Our data suggest that the association with i.v. thrombolysis reduces the number of device passes during thrombectomy, thus improving the efficacy of MT.

556

Early Reocclusion after Successful IV Thrombolysis

SHSheen and JH Choi

¹DMC Bundang Jesaeng Hospital

Purpose: The most recognized stroke syndromes occur in the middle cerebral artery (MCA) region. In addition to extracranial embolic sources, intracranial atherosclerotic stenosis is considered to be the leading cause of ischemic stroke. Endovascular stroke therapy is used for patients with ischemic stroke after failed intravenous thrombolysis or in patients not eligible for thrombolytics. With increasing experience, acute reocclusion after IV Thrombolysis has been described and Early reocclusion has worsens clinical outcomes. We present a case of Rt. Middle cerebral artery (MCA) infarction with early reocclusion after successful IV Thrombolysis successfully treated By Mechnical thrmobectomy and Rt. MCA M1 Stenting.

Methods: A 76-year-old man who had Lt. side motor weakness, dysarthria visited our clinic. Neurological examinations revealed Lt side motor GI and checked NIHSS 18. Magnetic resonance imaging revealed Rt. MCA M1 Segment severe stenosis. Neurology had a diagnosis MCA infarction and apply t-PA Treatment. After treatment, Lt side motor GIV+, and checked NIHSS 2 had recovered. But The next day he had Lt side weakness (GI) and checked NIHSS 18. Computer tomography-Perfusion imaging reveal Rt. MCA M1 reocclusion, we perfomed Mechnical thrmobectomy and Rt.MCA M1 stenting. The patients had recovered Lt side motor GV.

Results: The post-stenting course were uncomplicated, and neurologic deficits were resolved post-stentin and the patients had checked NIHSS 1.

Conclusion: The aim of intravenous thrombolysis or endovascular therapies is recanalization of occluded cerebral arteries. Early reocclusion can occur because of the appearance of early platelet aggregates after thrombolysis or when an underlying atheromatous lesion is present. Reocclusion has been linked to poor clinical outcomes.

We concluded that even though Early reocclusion after IV Thrombolysis can appropriate and Immediate recanalization should be consider to do the best.

557

Treatment Results and Risk Factors of CAS at the Institution of CAS First-Line Treatment for Internal Carotid Artery Stenosis

SKazunori¹, I Takashi¹, T Hayato¹, O Keisuke¹, A Takumi¹, M Noriaki¹, M Shigeru² and W Toshihiko¹

¹Department of Neurosurgery, Nagoya University, Aichi, Japan

²Department of Neurosurgery, Osaka Medical College, Osaka, Japan

Purpose: The existence of particular risks of carotid artery stenting (CAS) has become pointed out, while CAS is a well-established treatment for patients with internal carotid artery (ICA) stenosis. We therefore aimed to evaluate risk factors of CAS at our institution which takes CAS as first-line treatment for ICA stenosis.

Methods: We retrospectively reviewed 125 consecutive adult patients who underwent CAS at our institution between 2010 and 2013. Preoperative dual antiplatelet therapy (DAPT) and perioperative anticoagulation therapy were admitted in all cases. We evaluated association with suspected risk factors in CAS, such as plaque characteristics based on MRI and CT, type of aortic-arch and past history, and findings in postoperative MRI diffusion weighted image (DWI) and symptomatic stroke. We defined ipsilateral high intensity area over 5 mm in maximum diameter in DWI as positive remark.

Results: The mean age was 71 years and 83% were male. Postoperative MRI DWI demonstrated positive remarks in 35 patients (28%). In regard to each evaluation point, frequency of appearance of positive remarks were relatively less in calcification in entire circumference (11%) and patients on dialysis (20%), whereas the frequency were high in intraluminal thrombus (43%), type of aortic-arch, 2 or 3 or bovine (42%), high intensity lesion in MRI time of flight (33%). In univariate analysis, there were significant differences in type of aortic-arch (p = 0.007) and age (p = 0.02). Symptomatic stroke associated with procedure occurred in 3 patients (2.4%), and had significant association with age (>70) alone in univariate analysis.

Conclusions: Selection of proper devices and admittance of antithrombotic therapy resulted in good outcome for even the patients who have risk factors of CAS. Postoperative ischemic lesions are relatively high frequency in elderly people, aortic-arch to reduce the accessibility and intraluminal thrombus, which suggest to need more careful manipulation and rethink of treatment methods.

558

Intracranial Hemorrhagic Complication after Acute Thrombectomy: The Effect of Tortuosity of the Target Vessels

MShirakawa¹, S Yoshimura¹, K Uchida¹, S Shindo¹ and H Kageyama¹

¹Hyogo college of Medicine, Nishinomiya, Hyogo, Japan

Purpose: Intracranial hemorrhagic complications after acute thrombectomy are not rare. The purpose of this study was to elucidate the effect of tortuosity of the target vessel on the hemorrhagic complication.

Methods: A total of 71 consecutive patients who underwent mechanical thrombectomy for acute large vessel occlusion between Sep. in 2013 and May in 2014 were included. The patients were classified into two groups; hemorrhagic group and non-hemorrhagic group, based on the findings on head CT performed 12 to 24 hours after the procedure. Vessel tortuosity was assessed by measuring the distance between the highest and lowest points of M1 in the middle cerebral artery (MCA).

Results: Among 71 patients, 27 (38%) were classified into hemorrhagic group and 44 (62%) were in non-hemorrhagic group. The distance of highest and lowest points in M1 was significantly larger in hemorrhagic group compared to non-hemorrhagic group (8.8 vs 7.0, p = 0.01). Hemorrhagic group had higher baseline NIHSS (21.0 vs 16.5, p = 0.01), but there was no significant difference in procedure time, or time to reperfusion. The percentage of the favorable outcome (modified Rankin Scale 0–2) on discharge was less in hemorrhagic group compared to non-hemorrhagic group (38 % vs 51%, p = 0.02).

Conclusion: The results obtained in the present study indicated that the incidence of intracranial hemorrhagic after thrombectomy was significantly correlated with tortuosity of the target vessel.

559

Are Endovascular Procedures Better? A Meta Analysis

SSingh¹ and C Go²

¹National Institute of Neurological and Allied sciences, Kathmandu, Nepal

²Jose Reyes Memorial Medical Center, Manila, Philippines

Purpose: The purpose of this meta analysis is to compare the functional outcome (90 day mRS) among patients with acute ischemic stroke treated with either intravenous thrombolysis (iv tPA) or endovascular therapy

Methods: Through data-base search we identified randomized controlled trials from articles published between January2012-June 2013. We analysed the treatment effect of intravenous thrombolysis (iv tPA) and endovascular therapy for acute ischemic stroke. The treatment effect was interpreted as 90 day modified Rankin’s Score(mRS)

Results: Three randomized controlled trials with 1109 patients reported treatment effects of intravenous thrombolysis and endovascular procedures for acute ischemic stroke. Good outcome mRS ≤ 1 was achieved in 32.58 % (n = 145) in the intravenous arm versus 29.81 %(n = 198) in endovascular arm. Odds ratio 0.90 CI[0.69 to 1.17]. The P value 0.45.

Conclusion: The results trend to be marginally in favour of intravenous thrombolysis. We suggest more randomized controlled trials comparing two arms.

560

Relationship between Neurological Severity and CBF Grade of MR Perfusion in Acute Stroke Patients with the Carotid Artery Occlusion

YTakahashi, T Mori, K Yoshioka, T Iwata, Y Tanno and S Kasakura

Shonan Kamakura General Hospital Stroke Center, Kamakura City, Kanagawa, Japan

Purpose: It has recently been recognized that perfusion study is required to identify candidates suitable to endovascular therapy (ET) in hyperacute stroke. However, it remains unclear how strongly perfusion findings are related to neurological severity (NS) and MR-DW images (DWI).

The aim of our study was to assess whether or not CBF grade based on MR perfusion (MRp) is related to NS or DWI and then to find CBF grade suitable to ET.

Methods: Included in our retrospective analysis were acute ischemic stroke patients 1) who were admitted to our stroke center within 24 hours of the onset between Jan 2004 and May 2015, 2) who presented NIHSS as NS of 0 or more, 3) who underwent MRA, displaying complete occlusion of the affected carotid artery. We evaluated patients’ baseline features, NIHSS, DWI-ASPECTS (ACT) at arrival and CBF grade, which was calculated by using bilateral time-intensity curves (TICs) of MR perfusion. TICs were generated on region of interests set at symmetrical positions of the bilateral MCA territories. According to the time to peak (TP) and the peak signal (PS) comparing the affected side (a) with the contralateral side (c), we regarded the affected-sided PSa divided by TPa as possible CBFa and the contralateral-sided PSc divided by TPc as possible CBFc. CBF grade 1 was defined as CBFa divided by CBFc (CBF%) less than 0.2, grade 2 as CBF% of 0.2 or more and CBF% less than 0.7 and grade 3 as CBF% of 0.7 or more.

Results: During the study period, 176 patients matched our criteria for analysis. An average age was 77 years old, median NIHSS was 18, and median ACT was 6. There were 30 patients with CBF grade1, 81 with grade2 and 65 with grade3. Median NIHSS in grade1, 2, and 3 patients was 23, 19, and 7 (p < 0.0001), respectively, and there was a statistical significant difference between any grade groups (p < 0.016). Median ACT in grade1, 2, and 3 was 1, 5, and 8 (p < 0.0001), respectively, and there was a statistical significant difference between any grade groups (p < 0.016).

Among 32 patients with NIHSS of 7 or less and as ACT of 8 or more, there were 0 in grade1, 4 in grade2 and 28 in grade3. Among 10 patients with NIHSS of 23 or more and ACT of 1 ore less, there were 9 in grade1, 1 in grade2 and 0 in grade3. Among 40 patients with NIHSS of 8 or more and ACT of 8 or more, there was 0 in grade1, 22 in grade2 and 18 in grade3.

Conclusion: CBF grade defined by MRp had strong relation to NIHSS and ACT. Patients of grade1 had higher NIHSS score and lower ACT score and patients of grade3 had lower NIHSS score and higher ACT score. Patients with lower NIHSS score but higher ACT score were probable candidates for ET and many among them belonged to CBF grade2.

561

Initial Clinical Experience of Novel Cloud Based Telestroke System

HTakao^1,2, T Ishibashi¹, YC Yeh^1,2, T Sakano^1,2, H Arita^1,2, T Oobatake^1,2 and Y Murayama¹

¹Department of Neurosurgery Jikei University School of Medicine, TOKYO, JAPAN

²Department of Innovation for Medical Information Technology Jikei University School of Medicine, TOKYO, JAPAN

Purpose: Fast and precise diagnostic and therapeutic decision making is a key factor in emergencies such as cerebral stroke and that highly depends on the skills and experience levels of the physicians involved. However, these levels may vary, depending where and when the patient gets treated. Telestroke has been used to cover up this deficiency, by connecting two physicians remotely for information sharing between them, resulting in better medical decisions in such emergencies, wherever the patient is. ‘JOIN’ was developed to bring such communication among physicians to the next level, by taking advantage of today’s most common communication format: SNS in smartphones.

Methods: ‘JOIN’ is a closed environment SNS with an objective to share and discuss patient information and images between hospital systems and paramedical staff members in and out of the hospital and is designed to maximize the communication in emergencies. ‘JOIN’ allows treating physician and experts to have a real time discussion in the chat room, as well as share information such as clinical data, CT, MR, Angiographic and intraoperative images in same environment, making ‘JOIN’ an unique and ultimate hub for the professionals to understand ‘what’s going on’ with the patient on fly.

Results: A pilot run of ‘JOIN’ in our hospital showed adequate performance and proper information flow, resulting in proper diagnosis and management of all stroke patients. ‘JOIN’ was introduced to our institution in August 2014, for communication with our affiliated hospitals. Since then, over 200 cases have been efficiently assisted.

Conclusions: ‘JOIN’ is an efficient tool to standardize the time demanding treatment of conditions such as stroke. We expect that adoption of this app on smartphones will allow us to help and save the lives of more patients with cerebral stroke.

562

Clinical Significance of Bilateral Paramedian Thalamic Infarction on Baseline DWI in Patients Receiving Stent-Retriever Thrombectomy for Acute Basilar Artery Occlusion

WYoon, SK Kim, TW Heo and BH Baek

Department of Radiology, Chonnam National University Hospital, Gwangju, South Korea

Purpose: We sought to investigate the diagnostic and prognostic significance of bilateral paramedian thalamic infarction on baseline diffusion-weighted imaging (DWI) in patients with acute basilar artery occlusion who were treated with stent-retriever thrombectomy.

Methods: The data from 50 consecutive patients with acute basilar artery occlusion who underwent DWI before stent-retriever thrombectomy were retrospectively analyzed. The presence or absence of bilateral paramedian thalamic infarction was correlated to various patient characteristics (age, sex, risk factors, posterior circulation DWI-ASPECTS, underlying intracranial atherosclerotic stenosis, baseline NIHSS score, and successful revascularization [defined as modified TICI 2b or 3]) and clinical outcomes. A good outcome was defined as a mRS score of 0–2 at 3 months.

Results: Bilateral paramedian thalamic infarction was observed in 9 patients (18%). Patients with bilateral paramedian thalamic infarction had higher mean baseline NIHSS scores (15.3 versus 11.2, P = 0.040), a higher rate of futile revascularization (defined as poor outcome despite successful revascularization) (77.8% versus 38.5%; OR 6.067, 95% CI 1.114–33.046, P = 0.024), and a lower rate of good outcome (22.2% versus 60.9%; OR 0.183, 95% CI 0.034–0.993, P = 0.049) than those without it. Underlying intracranial stenosis was less frequently found in patients with bilateral paramedian thalamic infarction than those without it (0% versus 36.6%, P = 0.043).

Conclusion: Our study suggests that bilateral paramedian thalamic infarction on pre-treatment DWI is a poor prognostic marker in patients receiving stent-retriever thrombectomy for treatment of acute basilar artery occlusion. In addition, this finding can be used in negatively predicting underlying intracranial stenosis in patients with acute basilar artery occlusion.

563

Impact of Pretreatment DWI-ASPECTS on Functional Outcome after Stent-Retriever Thrombectomy for Acute Anterior Circulation Stroke

WYoon, SK Kim, TW Heo and BH Baek

Department of Radiology, Chonnam National University Hospital, Gwangju, South Korea

Purpose: It is unclear whether pretreatment diffusion-weighted imaging (DWI) predicts outcomes after stent-retriever thrombectomy in patients with acute ischemic stroke. This study aimed to investigate the impact of Acute Stroke Prognosis Early CT score (ASPECTS) applied to DWI images (DWI-ASPECTS) on functional outcome in acute stroke patients receiving stent-retriever thrombectomy.

Methods: We retrospectively analyzed the clinical and imaging data from 177 consecutive patients with acute anterior circulation stroke who were treated with stent-retriever thrombectomy within 6 hours of symptom onset. Pretreatment DWI-ASPECTS scores were assessed by two readers. DWI-ASPECTS scores were categorized into 0–3 (n = 6), 4–7 (n = 89), or 8–10 (n = 82) for analysis of prognostic impact on outcome. Good outcome was defined as an mRS score of 0–2 at 3-month.

Results: Overall, successful revascularization (defined as modified TICI grades 2b or 3) occurred in 83.1% (147/177), symptomatic hemorrhage in 3.4% (6/177), and good outcome in 45.8% (81/177) of patients. Mortality was 9% (16/177) at 3 months. No patient with DWI-ASPECTS scores 0–3 showed a good outcome. Good outcome was achieved in 43.8% (39/89) of patients with DWI-ASPECTS 4–7 and 51.2% (42/82) of those with high DWI-ASPECTS 8–10; this difference was not statistically significant (P = 0.360). There were also no significant differences in the rates of successful revascularization, symptomatic hemorrhage, and mortality between patients with DWI-ASPECTS 4–7 and those with DWI-ASPECTS 8–10.

Conclusion: Outcomes after stent-retriever thrombectomy in acute anterior circulation stroke were not different between patients with intermediate DWI-ASPECTS scores and those with high scores. Our study suggests that acute stroke patients with intermediate DWI-ASPECTS scores can benefit from stent-retriever thrombectomy.

564

Predictors for the Requirement of Rescuing Therapy after Stent Retriever Based Thrombectomy

WWen¹, Y Zhang², Q Huang¹, B Hong¹ and J Liu¹

¹Department of neurosurgery, Changhai hospital, Shanghai, China

²Department of neurology, Changhai hospital, Shanghai, China

Purpose: Thrombectomy with stent retriever is one of the most promising techniques currently available for its remarkable efficacy in vessel recanalization and tissue reperfusion. Instant re-occlusion or lesions refractory to thrombectomy are more frequently reported among populations with higher rate of intracranial stenosis (ICAS), despite that the correlation between ICAS and refractory lesion has not been proven. Rescuing therapy including intra-arterial administration of GPIIb/IIIa inhibitor, angioplasty or stenting are often applied in these cases. The object of this study is to analyze and evaluate the factors (especially ICAS related risk factors) in predicting the requirement of rescuing therapy after stent retriever based thrombectomy.

Methods: Patients’ eligibility: consecutive cases received mechanical reperfusion therapy in our database from September 1st 2013 to January 31st 2015. Patients were divided into rescuing therapy group and non-rescuing therapy group. Baseline information like number of risk factors for ICAS, the existence of high risk cardiac embolus factors, initial National Institute of Health Stroke Scale (NIHSS), hyperdense large artery sign, richness of collaterals and clot burden score and outcome (extend of reperfusion) were compared between groups. Univariate logistic regression analysis was adopted for odds ratio evaluation.

Results: 53 cases with 16 in rescuing therapy group and 37 in non-rescuing therapy group were enrolled. Baseline NIHSS, number of ICAS risk factors, hyperdense large artery sign and cardiac embolus factors differs between groups with statistical significance. Lack of hyperdense large artery sign and more ICAS risk factors were taken into logistic regression model.

Conclusion: Patients requiring rescuing therapy are lower in baseline NIHSS score, have more ICAS risk factors and lower odds of hyperdense large artery sign in baseline cranial CT.

565

Pre Operative Direct Percutaneous Embolisation of Carotid Paragangliomas Solely with Glue: A Case Series

Shridhar Khajindar and PC Gupta

Dept of Interventional Radiology and Dept of Vascular Surgery, Deenanath Mangeshkar Hospital, Pune, CARE Group of Hospitals Hyderabad, India

Purpose: To report our initial clinical experience and the efficacy of preoperative direct percutaneous embolization of carotid body tumor solely with n-butyl cyanoacrylate (NBCA).

Material and Methods: All (Five) the patients presented with mild discomfort in the neck with swelling. CT and MRI scans (plain and contrast) revealed a large well defined lobulated soft tissue lesion at the bifurcation of CCA with uniform contrast enhancement with or without causing mass effects in the form of compression of oro and nasopharynx. MRA showed classical splaying of carotid bifurcation and its branches. Also they were recently diagnosed with Hypertension and on anti HTN medication. With this diagnosis of carotid body tumor, surgical excision was planned. All the patients were referred to Interventional Radiology dept. for pre-operative embolization. Procedure was done under general anaesthesia. Embolisation was performed with Glue in different concentrations.

Result: It was a significantly less morbid surgery. Surgical separation of tumor from the carotid vessels & the adjacent soft tissues and the surgical excision of tumor were relatively easy. The overall blood loss during procedure was very minimal.

Conclusion: These cases are being presented to re-emphasize the role of pre operative embolisation of Carotid Body Tumor resulting in clean bloodless surgery and better patient outcome.

Corresponding Author: Dr. Shridhar R. Khajindar, Consultant Interventional Radiologist, Deenanath Mangeshkar Hospital, Pune, Maharashtra, India. E-mail: drshridhar2000@gmail.com

566

Infiltrated Embolization for Meningiomas with the Penetration of Very-Diluted Glue

HOnishi¹, S Miyachi¹, R Hiramatsu¹, K Murao² and T Kuroiwa¹

¹Osaka Medical College, Osaka, Japan

²Shiroyama Hospital, Osaka, Japan

Purpose: Meningiomas are often embolized before their surgical resection to reduce blood loss during surgery. We have used low concentration n-butyl cyanoacrylate(NBCA) since 2011. We report the efficacy and technical aspect of infiltrated preoperative embolization for meningiomas with the penetration of very-diluted glue.

Methods: In this method 13% NBCA-lipiodol mixture is extremely slow injected from the middle meningeal artery like a plug and push injection of Onyx after the tortuous side feeders are proximally embolized. The glue is infiltrated into small tumor arteries like a snow crystal and extends to the inaccessible feeders from pial artery or deep meningeal arteries. If the careful embolization not to reflux too much and migrate the glue into the normal arteries is achieved, this method is very useful to get the extremely effective devascularization on surgical extirpation, and also may applicable to the surgically untreatable meningiomas as a semi-radical treatment option.

Results: Since 2011, 32 cases preoperatively diagnosed with meningioma were embolized with this technique. Intratumoral embolization was possible in 30 cases (94%), and more than 50% reduction of contrast area in T1 Gd was achieved in 18 cases (56%).

Conclusion: Preoperative embolization of meningioma with the penetration of very- diluted glue was useful. We assessed the extent of intratumoral embolization and its effect on tumor removal.

567

Meningioma Embolization with SQUID Using the Pressure Cooker Technique

ZSzatmary

Linkoping University Hospital, Neurosurgery Department

Meningioma embolization is mainly performed by selective injection of microparticules and to a lesser extent by the injection of cyanoacrylate glue or Onyx, an ethyl vinyl alcohol copolymer (EVAC). The Pressure Cooker Technique (PCT) has recently been introduced as a technique to maximize the efficiency of Onyx embolization of cerebral arteriovenous malformations. It consists in the creation of an anti-reflux plug by trapping the detachable part of a DMSO-compatible microcatheter with coils and glue in order to obtain wedge-flow conditions and allows more comprehensive, forceful and controlled Onyx embolization.

This is, to our knowledge, the first report of the use of the PCT for the embolization of a meningio- ma with SQUID.

568

Development and Validation of an Intravascular Chemotherapy Filter Device to Enable High Dose Intra-Arterial Doxorubicin Therapy: In Vitro Proof of Concept in Whole Blood

SHetts¹, CH Sze¹, C Yee², K Raman², M Vander Schaaf², A Chin³, J Yang¹, M Saeed¹, M Wilson¹ and A Patel¹

¹University of California, San Francisco, California, USA

²Penumbra Inc, Alameda, California, USA

³ChemoFilter Inc, Hillsborough, California, USA

Purpose: A temporary intravenous chemotherapy filter (CF) device with ionic resin material was developed to remove doxorubicin (Dox) from the blood via an ionic mechanism. Filtration based targeted drug delivery could be important in expanding intra-arterial therapy to head and neck cancer by enabling high-dose therapy while limiting systemic toxicity. Previous studies demonstrated high-capacity rapid Dox binding of the resin in phosphate buffered saline (PBS), swine serum, and human serum in vitro. In this study, we aim to determine Dox binding rate and capacity of the CF prototype in porcine and human whole blood in vitro.

Methods: Research grade swine and human whole blood was collected and mixed with heparin to form a heparinized solution at 20 IU/ml. Dox was introduced and equilibrated into whole blood (37°C) at a concentration of 0.05 mg/ml. Ionic resin was then introduced at 2.5 ml of resin per liter of solution and mixed. Samples were collected periodically over 60 or 90 minutes, centrifuged at 1.300xg, and decanted. Dox concentrations were measured via HPLC-fluorescence spectrophotometry, and compared to controls without resin. Swine and human whole blood results were compared to respective serum results from previous studies, where similar methods were used.

Results: In porcine whole blood, the resin removed 29.4%, 50.7%, and 78.4% of available Dox at 10, 30, and 60 minutes respectively, compared to 52.3%, 78.8%, and 84.9% in porcine serum. In human whole blood, the resin removed 15.5%, 27.0%, and 52.0% of available Dox at the same time points, compared to 28.1%, 56.3%, and 76.1% in human serum.

Conclusion: Rapid and high-capacity capture of Dox by ionic resin in swine and human whole blood solutions were successfully demonstrated. The high rate of Dox binding by a small volume of resin paves way for a pre-clinical swine study testing in vivo Dox binding by a CF prototype containing over ten times more resin.

569

Superselective Intra-Arterial Chemotherapy Delivery is a Safe and Effective Technique in Advance Retinoblastoma. Five Years Experience in Argentina

A Ceciliano^1,2,3, J Botello^1,2,3, A Aguado^1,2,3, F Navarro^1,2,3, H Moya^1,2,3, P Schaiquevich⁴, A Fandiño⁴, G Chantada⁴ and FVillasante^1,2,3

¹Hospital Universitario Austral; Buenos Aires Pilar, Argentina

²Hospital Alemán; Ciudad Autónoma de Buenos Aires, Argentina

³Clínica y Maternidad Suizo Argentina; Ciudad Autónoma de Buenos Aires, Argentina

⁴Hospital Nacional de pediatría Juan. P. Garrahan; Ciudad Autónoma de Buenos Aires, Argentina

Purpose: To evaluate the safety and effective technique in superselective intra-arterial chemotherapy (SIAC) for advanced intraocular retinoblastoma.

Methods: Between May 2010 to May 2015, a total of 157 eyes of 111 patients with unilateral (n:42) and bilateral (n:69) advance intraocular retinoblastoma were treated. Mean age was 24 months (range 6–81, 53% women). We used direct OA micro-catheterization, in case inadequate choroidal crescent blush, alternative routes including the orbital branch of the MMA or the TSA were performed. The chemotherapies used were melphalan, topotecan, and/or carboplatin. Pulsatile Infusion technique was performed during 30 minutes. The main outcome measures were: procedural success and ocular and systemic complications.

Results: There were 411 chemotherapy injections. Delivering the drug in the choroidal ophthalmic blush was successful in 98.3% of procedures. Treatment routes included: 366 sessions of direct OA, 44 in MMA and only 1 TSA. Mean number of infusions was 3.7 per patient (range 1–14). Transient ocular complications were: 10 eyes with periocular edema, 5 eritema of the frontal skin and 3 third cranial nerve ipsilateral neuritis. Reversible extraocular occurrences were: 7 bronchospasm, 6 significant neutropenia, 4 loss of femoral pulse reversed by aspirin and 2 allergic reaction to iodinated contrast. Permanent complication: 11 avascular retinopathy, 10 intra-vitreous retinopathy. All children are alive.

Conclusion: SIAC delivery in the choroidal crescent is safe and effective technique for trained hands, with low rate of complication.

570

Solitaire Stent-assisted Chemical Angioplasty for Resistant Vasospasm in SAH Patients – Initial Experience

JKSung¹, HJ Kwon¹, HH Jung¹ and HS Koh¹

¹Chungnam National University Hospital, Daejeon, Republic of Korea

Purpose: To report our initial experience with Solitaire-assisted chemical angioplasty for medically refractory vasospasm in patients with subarachnoid hemorrhage (SAH).

Methods: We evaluated the retrospective series of patients with SAH and symptomatic vasospasm refractory to chemical only angioplasty, who were treated with Solitaire-assisted chemical angioplasty. Instead of balloon angioplasty, we deployed Solitaire stent temporarily at the spastic vessel segment for 2 minutes and retrieved completely before or after low dose vasodilator infusion. Immediate and follow-up angiographic results, procedure-related complications, and clinical outcomes were assessed.

Results: From April 2011 to May 2015, 12 patients with medically refractory vasospasm underwent Solitaire-assisted chemical angioplasty. There were 8 women (67%); patients were 40 to 85 years of age. A total of 27 vessels were angioplastied (20 proximal and 7 distal). Two cases of procedure-related thrombosis and one case of vessel injury occurred. Additional treatment was needed for 7 patients and vasodilator was infused before the temporary deployment of Solitaire in all of them. Good clinical outcomes or no vasospasm-related neurological aggravation was observed in10 (83%) patients.

Conclusion: Solitaire stent-assisted chemical angioplasty for SAH-induced vasospasm can be considered as another option for medically resistant cases.

571

Analysis of the Endothelial Nitric Oxide Synthase (Enos) Gene Single Nucleotide Polymorphisms in Post-Aneurysmal Subarachnoid Hemorrhage: Amazon Indigenous Population

EHAPaschoal^1,2, GS Jong-A-Liem³, VN Yamaki³, FM Paschoal-Júnior⁴, JKSF Paschoal⁴, RL Piske⁸, ES Yamada², MJ Teixeira⁶, AKCR Santos² and E Bor-Seng-Shu⁶

¹Hospital Ophir Loyola (HOL), Belém, Pará, Brazil

²Universidade Federal do Pará (UFPA), Belém, Pará, Brazil

³Universidade do Estado do Pará (UEPA), Belém, Pará, Brazil

⁴Centro de Ensino Superior do Pará (CESUPA), Belém, Pará, Brazil

⁵Centro de Neuro-Angiografia (CNA-HBPSP), São Paulo, São Paulo, Brazil

⁶Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP, São Paulo, São Paulo, Brazil

Purpose: Find the specific alterations in the eNOS and associate these findings to the occurrence and severity of cerebral vasospasm post-aneurysmal subarachnoid hemorrhage. In addition, we crossed the information with other ethnicities to test the ethnic influence on genotype expression.

Methods: We conducted a prospective cohort study of patients that suffered an aneurysmal subarachnoid hemorrhage followed by vasospasm or not. Vasospasm was determined by angiogram or transcranial ultrasonography Doppler findings. A sample of peripheral blood (5 ml) was collected to genotype the promoter SNP (T-786 C). As follow, we analyzed the data using t student analysis and multivariable logistic regression to test the association of eNOS polymorphisms in patients with vasospasm and of indigenous ethnicity.

Results: Patients with vasospasm were 3.7 times more likely to have a T allele (95 CI 1.3–9.6, p = 0.014, TT OR 12.7). Patients with T allele of eNOS gene and of South American indigenous ethnicity were more likely to present a more severe episode of cerebral vasospasm. Studies have demonstrated a link between single nucleotide polymorphisms (SNP) in the endothelial nitric oxide synthase (eNOS) gene with high incidence and aggressiveness with cerebral vasospasm (Wu et al., 2010, Li et al., 2009, Starke et al., 2008).

Conclusion: We believe that the presence of this genotype may allow the identification of individuals with more susceptibility and vulnerability for high-risk cerebral vasospasm post aneurysmal subarachnoid hemorrhage. These genetic testing are easy and fast to analyze and serve as a functional blood biomarker. Its result can alert the medical team to early detect and aggressively manage these patients to prevent this condition.

572

Endovascular Treatment for Ruptured Intracranial Aneurysms Associated with Cerebral Vasospasm

JZhu, D Lin, J Hu and J Shen

Neurosurgery department, Ruijin hospital affiliated to Shanghai Jiaotong university school of medicine, Shanghai, China, 200025

Purpose: To discuss the therapy for ruptured intracranial aneurysms with cerebral vasospasm.

Method: The data of 51 patients diagnosed as ruptured intracranial aneurysms with cerebral vasospasm (CVS) by DSA examination were reviewed retrospectively. According to Hunt and Hess grade, grade I 7cases, grade II 14 cases, grade III 19 cases, grade IV 7 cases and grade V 4 cases were among the patients. No one were found multiple aneurysms. The responsible aneurysms are respectively with 20 anterior communicating aneurysms, 15 posterior communicating aneurysms, 6 paraclinoid internal carotid artery aneurysms, 10 middle cerebral artery aneurysms. CVS were found on proximal part of aneurysms in 23 cases, on distal part in 9 cases and on both parts in 20 cases. All the patients were received coiling embolization following super selected within aneurysm sac. Successively the spasm arteries on the aneurysm side or the contralateral side were separately performed the artery perfusion, balloon or stent angioplasty.

Result: 51 aneurysms were successfully embolized with coils. To improve the CVS, all the patients were performed artery perfusion on the spasm sides. Moreover, 5 patients accepted balloon angioplasty, 2 patients accepted balloon and stent angioplasty on the condition that the CVS could not be relieved after artery perfusion. After endovascular interventions, the CVS were obviously relieved on the CAG images. There were no aneurysms re-rupture, artery occlusion, artery rupture and dissection in all the procedures. During follow-up, no aneurysms ruptured again, 40 patients got GOS 4 ∼ 5, 7 patients got GOS 3 ∼ 4, 4 patients were dead.

Conclusion: Relief of CVS improve the prognosis of patient with Hunt & Hess grade III. The procedures, such as artery perfusion, balloon and stent angioplasty, should be performed on the CVS in ruptured aneurysm patients. These positive endovascular treatments were safe after ruptured aneurysm embolization.