Thromboembolic Complications of Elective Coil Embolization of Unruptured Aneurysms

Hwang, Gyojun,Jung, Chulkyu,Park, Sukh Que,Kang, Hyun Sung,Lee, Sang Hyung,Oh, Chang Wan,Chung, Young Seob,Han, Moon Hee,Kwon, O-Ki Oxford University Press 2010 Neurosurgery Vol.67 No.3

<B>Abstract</B><B>OBJECTIVE</B><P>We retrospectively evaluated whether antiplatelet preparation lowered the thromboembolic complication rate during the perioperative period.</P><B>METHODS</B><P>We reviewed 328 elective coil embolization procedures in which only microcatheters were used for coiling. No antiplatelet medication was prescribed before the procedure in 95 cases (29%, group 1), whereas antiplatelet therapy was used in 233 cases (71%, group 2; 61 [18.6%] with a single agent [aspirin or clopidogrel] and 172 [52.4%] with both agents). Antiplatelet agents were not given after coiling unless atherosclerosis, severe coil protrusion, or a thromboembolic complication occurred during the procedure. A thromboembolic complication was defined as a procedural thromboembolic event or transient ischemic attack or stroke occurring within 2 days of embolization.</P><B>RESULTS</B><P>Thromboembolic complications occurred in 11 cases (3.4%): 6 (6.3%) in group 1 and 5 (2.1%) in group 2 (P = .085). In 195 cases (59.5%) treated by the single microcatheter technique, the risk of thromboembolic complications was low and not affected by antiplatelet preparation (1.8% [no preparation] vs 2.2% [preparation]; P = 1.000). However, in 133 cases (40.5%) treated by the multiple microcatheter technique, antiplatelet preparation significantly reduced the thromboembolic complication risk by 85.2% (12.8% [no preparation] vs 2.1% [preparation]; odds ratio, 0.148; 95% confidence interval, 0.027-0.798; P = .023). The aneurysms treated by the multiple microcatheter technique had more complex configurations for coiling (P &lt; .001). The risk of hemorrhage was not increased by antiplatelet preparation (P = .171).</P><B>CONCLUSION</B><P>Antiplatelet preparation lowered the periprocedural thromboembolic complication rate in unruptured aneurysms treated by the multiple microcatheter technique and did not increase the risk of hemorrhage. Therefore, antiplatelet preparation can help to reduce complications in patients in whom technical difficulties are expected without the risk of hemorrhage.</P>

Endovascular Embolization of a Ruptured Distal Lenticulostriate Artery Aneurysm in Patients with Moyamoya Disease

Hwang, Kihwan,Hwang, Gyojun,Kwon, O-Ki The Korean Neurosurgical Society 2014 Journal of Korean neurosurgical society Vol.56 No.6

A ruptured distal lenticulostriate artery (LSA) aneurysm is detected occasionally in moyamoya disease (MMD) patients presented with intracerebral hemorrhage. If the aneurysm is detected in hemorrhage site on angiographic evaluation, its obliteration could be considered, because it rebleeds frequently, and is associated with poorer outcome and mortality in MMD related hemorrhage. In this case report, the authors present two MMD cases with ruptured distal LSA aneurysm treated by endovascular embolization.

Procedural predictors of delayed cerebral infarction after intra-arterial vasodilator infusion for vasospasm following aneurysmal subarachnoid hemorrhage

Hwang, Gyojun,Jung, Cheolkyu,Sheen, Seung Hun,Kim, Sung Hyun,Park, Sukh Que,Oh, Chang Wan,Kwon, O-Ki Springer-Verlag 2010 Acta neurochirurgica Vol.152 No.9

Superficial Temporal Artery to Middle Cerebral Artery Bypass in Acute Ischemic Stroke and Stroke in Progress

Hwang, Gyojun,Oh, Chang Wan,Bang, Jae Seung,Jung, Cheol Kyu,Kwon, O-Ki,Kim, Jeong Eun,Bae, Hee-Jun,Han, Moon-Koo Oxford University Press 2011 Neurosurgery Vol.68 No.3

<B>Abstract</B><B>BACKGROUND:</B><P>Surgical reperfusion may be beneficial in patients with acute ischemic stroke who are ineligible for thrombolysis.</P><B>OBJECTIVE:</B><P>To evaluate the outcome of superficial temporal artery to middle cerebral artery (STA-MCA) bypass in acute stroke and stroke in progress.</P><B>METHODS:</B><P>The clinical and radiological data of 9 patients treated by STA-MCA bypass requiring urgent reperfusion but ineligible for intra-arterial thrombolysis (IAT) were reviewed. Pooled analysis was performed of published literature concerning STA-MCA bypass in acute stroke (21 cases in 2 articles).</P><B>RESULTS:</B><P>Of the 9 patients enrolled, symptom aggravation occurred during medical treatment in 4 patients and after IAT in 2. Three patients were ineligible for IAT despite being within 8 hours of symptom onset. Bypass significantly improved National Institutes of Health Stroke Scale scores (preoperatively, 12.4 ± 4.88; 3 days postoperatively, 8.6 ± 6.39, P = .046; discharge, 5.4 ± 5.15, P = .008; 3 mo postoperatively 3.7 ± 4.82, P = .008) without significant infarction growth by diffusion weighted imaging (preoperatively, 15.0 ± 8.87 mL; 7 days postoperatively, 15.2 ± 8.28 mL; P = .110). Abnormal perfusion regions (mean transit time &gt;145% of contralateral side value) were reduced in all cases (2.63 ± 0.93 mL). Good outcomes (modified Rankin scale ≤2) were achieved by 6 patients. Pooled analysis with our patients showed a significant neurological improvement (P &lt; .001) and a good outcome in 25 (83.3%) patients without hemorrhage or complication.</P><B>CONCLUSION:</B><P>STA-MCA bypass may be beneficial to patients with acute stroke or stroke in progress who are ineligible for IAT. Furthermore, it appears safe when the infarction is small. These findings indicate that STA-MCA bypass could be considered as a treatment option in selected patients with acute stroke or stroke in progress.</P>

CT Fluoroscopy-guided Aspiration of Intracerebral Hematomas: Technique and Outcomes

황기환,Gyojun Hwang,권오기,Jae Seung Bang,오창완 대한뇌혈관외과학회 2015 Journal of Cerebrovascular and Endovascular Neuros Vol.17 No.1

Objective:The authors evaluated the feasibility and targeting accuracy of CT fluoroscopy (CTF)-guided catheter placement and aspiration of intracerebral hematoma (ICH)s. Materials and Methods:Nine patients (mean age, 63.3 ± 15.3 years) were treated by CTF-guided hematoma aspiration under local anesthesia. The targeting errors in the lesion center, volume of the aspirated hematoma, accuracy of the final catheter position, procedure time, and clinical outcomes were evaluated. Results:All catheters were successfully placed in the center of the hematoma. The mean volume of the aspirated hematoma was 20.6 ± 8.8 mL (pre-treatment, 44.7 ± 20.1 mL; post-treatment, 24.1 ± 13.8 mL). The average procedure time was 25.1 minutes (range, 18-32 minutes). In one case with a scanty residual hematoma, the catheter was removed at the end of the procedure. In the remaining eight cases, the catheter was left in the residual hematoma for drainage and all catheter tips were accurately located in the final position. There were no procedure-related complications, including rebleeding and infection. Conclusion:CTF-guided ICH aspiration is a feasible, quick, and accurate procedure which could substitute for stereotactic methods. The accurate catheter position provided by real-time observation enables an effective aspiration and drainage of hematomas.

Endovascular Treatment for Acute Ischemic Stroke Patients over 80 Years of Age

황기환,Gyojun Hwang,권오기,Chang Hyeun Kim,Seung Pil Ban,한문구,배희준,Beom Joon Kim,Jae Seung Bang,오창완,Boram Lee,Eun-A Jeong 대한뇌혈관외과학회 2015 Journal of Cerebrovascular and Endovascular Neuros Vol.17 No.3

Objective:We evaluated the effect of endovascular treatment (EVT) for acute ischemic stroke in patients over 80 years of age. Materials and Methods:The records of 156 acute stroke patients aged over 80 years who were considered as candidates for EVT were analyzed. Fifty-six patients (35.9%, EVT group) underwent EVT and 100 patients (64.1%, non-EVT group) did not. Outcomes, in terms of functional outcomes and rates of symptomatic hemorrhage, in-hospital morbidity and mortality, were compared between groups. Each comparison was adjusted for age, time from onset, initial National Institute of Health Stroke Scale, and pre-stroke modified Rankin Scale (mRS). Results:More patients in the EVT group achieved good outcomes (mRS score of 0-2) at 3 months (35.7% vs. 11.0%, adjusted odds ratio [OR] 4.779 [95% confidence interval 1.972-11.579], p = 0.001) and 12 months (35.7% vs. 14.0%, adjusted OR 3.705 [1.574-8.722], p = 0.003) after stroke. During admission, rates of hospital-acquired infection including pneumonia (12.5% vs. 29.0%, adjusted OR 0.262 [0.098-0.703], p = 0.008) and urinary tract infection (16.0% vs. 34.0%, adjusted OR 0.256 [0.099-0.657], p = 0.005) were significantly lower in the EVT group. More symptomatic hemorrhages (10.7% vs. 2.0%, adjusted OR 6.859 [1.139-41.317], p = 0.036) occurred in the EVT group, but no significant difference was observed in in-hospital mortality rate (12.5% vs. 8.0%, adjusted OR 1.380 [0.408-4.664], p = 0.604). Conclusion:EVT improved functional outcome and reduced the risk of hospital-acquired infections in acute stroke patients over 80 years of age without increasing the risk of in-hospital mortality, although symptomatic hemorrhage occurred more frequently after EVT.

Safety and Efficacy of Flow Diverter Therapy for Unruptured Intracranial Aneurysm Compared to Traditional Endovascular Strategy : A Multi-Center, Randomized, Open-Label Trial

Kim, Junhyung,Hwang, Gyojun,Kim, Bum-Tae,Park, Sukh Que,Oh, Jae Sang,Ban, Seung Pil,Kwon, O-Ki,Chung, Joonho,Committee of Multicenter Research, Korean Neuroendovascular Society, The Korean Neurosurgical Society 2022 Journal of Korean neurosurgical society Vol.65 No.6

Objective : Endovascular treatment of large, wide-necked intracranial aneurysms by coil embolization is often complicated by low rates of complete occlusion and high rates of recurrence. A flow diverter device has been shown to be safe and effective for the treatment of not only large and giant unruptured aneurysms, but small and medium aneurysms. However, in Korea, its use has only recently been approved for aneurysms <10 mm. This study aims to compare the safety and efficacy of flow diversion and coil embolization for the treatment of unruptured aneurysms ≥7 mm. Methods : The participants will include patients aged between 19 and 75 years to be treated for unruptured cerebral aneurysms ≥7 mm for the first time or for recurrent aneurysms after initial endovascular coil embolization. Participants assigned to a flow diversion cohort will be treated using any of the following devices : Pipeline Flex Embolization Device with Shield Technology (Medtronic, Minneapolis, MN, USA), Surpass Evolve (Stryker Neurovascular, Fremont, CA, USA), and FRED or FRED Jr. (MicroVention, Tustin, CA, USA). Participants assigned to a coil embolization cohort will undergo traditional endovascular coiling. The primary endpoint will be complete occlusion confirmed by cerebral angiography at 12 months after treatment. Secondary safety outcomes will evaluate periprocedural and post-procedural complications for up to 12 months. Results : The trial will begin enrollment in 2022, and clinical data will be available after enrollment and follow-up. Conclusion : This article describes the aim and design of a multi-center, randomized, open-label trial to compare the safety and efficacy of flow diversion versus traditional endovascular treatment for unruptured cerebral aneurysms ≥7 mm.

Intraarterial Tirofiban Thrombolysis for Thromboembolisms During Coil Embolization for Ruptured Intracranial Aneurysms

전진수,신승훈,Gyojun Hwang,강석형,Dong Hwa Heo,조용준 대한뇌혈관외과학회 2012 Journal of Cerebrovascular and Endovascular Neuros Vol.14 No.1

Objective: Thromboembolus can occur during endovascular coil embolization. The aim of our study was to show our experience of intraarterial (IA) tirofiban infusion for thromboembolism during coil embolization for ruptured intracranial aneurysms. Methods: This retrospective analysis was conducted in 64 patients with ruptured aneurysms who had emergent endovascular coil embolization from May 2007 to April 2011 at a single institute. Thromboembolic events were found in ten patients (15.6%). Anticoagulation treatment with intravenous heparin was started after the first coil deployment in ruptured aneurysmal sac. When a thrombus or embolus was found during the procedure, we tried to resolve them without delay with an initial dosage of 0.3 mg of tirofiban up to 1.2 mg. Results: Three patients of four with total occlusion had recanalizations of thrombolysis in myocardial infarction (TIMI) grade III and five of six with partial occlusion had TIMI grade III recanalizations. Eight patients showed good recovery, with modified Rankin Scale (mRS) score of 0 and one showed poor outcome (mRS 3 and 6). There was no hemorrhagic or hematologic complication. Conclusion: IA tirofiban can be feasible when thromboembolic clots are found during coil embolization in order to get prompt recanalization, even in patients with subarachnoid hemorrhage.

Impact of Time Interval between Index Event and Stenting on Periprocedural Risk in Patients with Symptomatic Carotid Stenosis

Wonsuck Han,Gyojun Hwang,Sung Han Oh,Jong Joo Lee,Mi Kyung Kim,Bong Sub Chung,Jong Kook Rhim,Seung Hun Sheen,Taehyung Kim 대한신경외과학회 2020 Journal of Korean neurosurgical society Vol.63 No.5

Objective : The purpose of this study was to evaluate the impact of time interval between index event and stenting on the periprocedural risk of stenting for symptomatic carotid stenosis and to determine the optimal timing of stenting. Methods : This retrospective study included 491 (322 symptomatic [65.6%] and 169 asymptomatic [34.4%]) patients undergoing carotid stenting. The symptomatic patients were categorized into Day 0–3, 4–7, 8–10, 11–14, 15–21, and >21 groups according to the time interval between index event and stenting. Periprocedural (≤30 days) risk for clinical (any neurological deterioration) and radiological (new infarction on postprocedural diffusion-weighted imaging) events of stenting in each time interval versus asymptomatic stenosis was calculated with logistic regression analysis adjusted for confounders, and provided as odds ratio (OR) and 95% confidence interval (CI). Results : Overall clinical event rate (4.3%) of stenting for symptomatic carotid stenosis was higher than that for asymptomatic stenosis (1.2%; OR, 3.979 [95% CI, 1.093–14.489]; p=0.036). Stenting in Day 0–3 (13.2%; OR, 10.997 [95% CI, 2.333–51.826]; p=0.002) and Day 4–7 (8.3%; OR, 6.775 [95% CI, 1.382–33.227]; p=0.018) was associated with high risk for clinical events. However, the clinical event rates in stenting after 7 days from index event (Day 8–10, 1.8%; Day 11–14, 2.5%; Day 15–21, 0%; Day >21, 2.9%) were not different from that in stenting for asymptomatic stenosis. Overall radiological event rate (55.6%) in symptomatic stenosis was also higher than that in asymptomatic stenosis (35.5%; OR, 2.274 [95% CI, 1.553–3.352]; p<0.001). The high risk for radiological events was maintained in all time intervals (Day 0–3 : 55.3%; OR, 2.224 [95% CI, 1.103–4.627]; p=0.026; Day 4–7 : 58.3%; OR, 2.543 [95% CI, 1.329–4.949]; p=0.005; Day 8–10 : 53.6%; OR, 2.096 [95% CI, 1.138–3.889]; p=0.018; Day 11–14 : 57.5%; OR, 2.458 [95% CI, 1.225–5.021]; p=0.012; Day 15–21 : 55.6%; OR, 2.271 [95% CI, 1.099–4.764]; p=0.028; Day >21 : 54.8%; OR, 2.203 [95% CI, 1.342–3.641]; p=0.002). Conclusion : This study showed that as stenting was delayed, the periprocedural risk for clinical events decreased. The clinical event risk was high only in stenting within 7 days and comparable with that for asymptomatic stenosis in stenting after 7 days from index event, although the radiological event risk was not affected by stenting timing. Therefore, our results suggest that delayed stenting after 7 days from symptom onset is a safe strategy for symptomatic stenosis.

Impact of Time Interval between Index Event and Stenting on Periprocedural Risk in Patients with Symptomatic Carotid Stenosis

Han, Wonsuck,Hwang, Gyojun,Oh, Sung Han,Lee, Jong Joo,Kim, Mi Kyung,Chung, Bong Sub,Rhim, Jong Kook,Sheen, Seung Hun,Kim, Taehyung The Korean Neurosurgical Society 2020 Journal of Korean neurosurgical society Vol.63 No.5

Objective : The purpose of this study was to evaluate the impact of time interval between index event and stenting on the periprocedural risk of stenting for symptomatic carotid stenosis and to determine the optimal timing of stenting. Methods : This retrospective study included 491 (322 symptomatic [65.6%] and 169 asymptomatic [34.4%]) patients undergoing carotid stenting. The symptomatic patients were categorized into Day 0-3, 4-7, 8-10, 11-14, 15-21, and >21 groups according to the time interval between index event and stenting. Periprocedural (≤30 days) risk for clinical (any neurological deterioration) and radiological (new infarction on postprocedural diffusion-weighted imaging) events of stenting in each time interval versus asymptomatic stenosis was calculated with logistic regression analysis adjusted for confounders, and provided as odds ratio (OR) and 95% confidence interval (CI). Results : Overall clinical event rate (4.3%) of stenting for symptomatic carotid stenosis was higher than that for asymptomatic stenosis (1.2%; OR, 3.979 [95% CI, 1.093-14.489]; p=0.036). Stenting in Day 0-3 (13.2%; OR, 10.997 [95% CI, 2.333-51.826]; p=0.002) and Day 4-7 (8.3%; OR, 6.775 [95% CI, 1.382-33.227]; p=0.018) was associated with high risk for clinical events. However, the clinical event rates in stenting after 7 days from index event (Day 8-10, 1.8%; Day 11-14, 2.5%; Day 15-21, 0%; Day >21, 2.9%) were not different from that in stenting for asymptomatic stenosis. Overall radiological event rate (55.6%) in symptomatic stenosis was also higher than that in asymptomatic stenosis (35.5%; OR, 2.274 [95% CI, 1.553-3.352]; p<0.001). The high risk for radiological events was maintained in all time intervals (Day 0-3 : 55.3%; OR, 2.224 [95% CI, 1.103-4.627]; p=0.026; Day 4-7 : 58.3%; OR, 2.543 [95% CI, 1.329-4.949]; p=0.005; Day 8-10 : 53.6%; OR, 2.096 [95% CI, 1.138-3.889]; p=0.018; Day 11-14 : 57.5%; OR, 2.458 [95% CI, 1.225-5.021]; p=0.012; Day 15-21 : 55.6%; OR, 2.271 [95% CI, 1.099-4.764]; p=0.028; Day >21 : 54.8%; OR, 2.203 [95% CI, 1.342-3.641]; p=0.002). Conclusion : This study showed that as stenting was delayed, the periprocedural risk for clinical events decreased. The clinical event risk was high only in stenting within 7 days and comparable with that for asymptomatic stenosis in stenting after 7 days from index event, although the radiological event risk was not affected by stenting timing. Therefore, our results suggest that delayed stenting after 7 days from symptom onset is a safe strategy for symptomatic stenosis.