Postoperative Digital Subtraction Angiography Research Articles

Dolichoectatic Posterior Inferior Cerebellar Artery Aneurysm Treated With Excision and Posterior Inferior Cerebellar Artery Double Reimplantation Bypass: 2-Dimensional Operative Video.

Posterior inferior cerebellar artery (PICA) aneurysms account for 0.3% of all intracranial aneurysms, and they commonly present with a complex fusiform morphology that necessitates unique bypass strategies.1-5 An adolescent boy with a familial predisposition to aneurysmal subarachnoid hemorrhage was identified as harboring a fusiform aneurysm of the right distal PICA, characterized by 2 outflow branches. Our recommended treatment strategy involved a right far lateral craniotomy, followed by P1 PICA reanastomosis and P2 PICA reimplantation. Informed written consent was obtained. On exposure, the aneurysm was trapped, and the inflow and 2 outflow PICA branches were excised. Revascularization was established through a P1 PICA end-to-end reanastomosis using running continuous suturing techniques, followed by P2 PICA end-to-side reimplantation into a more distal portion of PICA. Subsequent indocyanine green videoangiography confirmed patency of the P2 PICA reimplantation; however, the initial P1 PICA reanastomosis was noted to be thrombosed. After several unsuccessful attempts to dissolve the thrombus, the decision was made to proceed with a P2 PICA side-to-side in situ reimplantation into the V4 segment of the vertebral artery. Indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of the PICA double reimplantation bypass. The patient tolerated the procedure well and was discharged home at his neurological baseline. This video showcases the microsurgical treatment of a complex dolichoectatic, distal PICA aneurysm using a double reimplantation technique, in addition to highlighting bypass decision-making processes for managing complex PICA aneurysms.

Posterior Interhemispheric-Transtentorial Approach for Resection of an Arteriovenous Malformation of the Superior Medullary Velum and Fourth Ventricle: 2-Dimensional Operative Video.

Brain arteriovenous malformations (AVMs) of the fourth ventricle represent a rare subtype associated with an aggressive natural course.1,2 In this case, a woman in her early 50s presented with dizziness. An AVM was diagnosed in the left superior cerebellar peduncle extending into the fourth ventricle. The AVM was supplied by superior cerebellar artery branches and classified as a Spetzler-Martin grade III and a Lawton-Young grade III, with a supplemented grade of 6.3,4 Being a single case report, institutional review board approval was not needed. Patient consent was obtained. The lesion was accessed through a torcular craniotomy and posterior interhemispheric-transtentorial approach, employing gravity to naturally retract the parietooccipital lobe.5-7 Dissection continued into the quadrigeminal and ambient cisterns, where the tentorium was incised parallelling the straight sinus to reach the superior vermis. Partial resection of the lingual and central lobules of the vermis facilitated access to the superior medullary velum. The superior cerebellar artery feeders were divided and followed to the superior cerebellar peduncle and through the superior medullary vellum. A vertical incision in the superior medullary velum facilitated entry into the fourth ventricle, where the AVM nidus was dissected circumferentially and resected en bloc. Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed complete obliteration of the AVM. After surgery, the patient experienced mild ataxia, but motor symptoms greatly improved during 3-month follow-up. This video illustrates resection of a complex fourth ventricular AVM through a posterior interhemispheric-transtentorial approach, highlighting pivotal considerations of patient positioning and approach selection to optimize treatment outcome for complex posterior fossa AVM resection.

Far Lateral Approach and Occipital Artery to Posterior Inferior Cerebellar Artery Bypass With Staged Flow Diversion for Treatment of De Novo Vertebrobasilar Junction Aneurysm: 2-Dimensional Operative Video

Intracranial aneurysms refractory to endovascular treatment often require complex cerebral revascularization strategies, including combined open-endovascular techniques. 1-3 An adolescent girl presented with headache, and a fusiform right V4 vertebral artery aneurysm was diagnosed. Initial treatment was attempted with coil embolization. Surveillance imaging at 3 years after embolization demonstrated a de novo vertebrobasilar junction (VBJ) aneurysm with involvement of the right anterior inferior cerebellar artery-posterior inferior cerebellar artery (PICA) origin. The VBJ aneurysm was initially observed. Enlargement was noted at 1 year, and secondary treatment was attempted with left V3 segment coil occlusion to induce flow reversal. Follow-up demonstrated progressive VBJ aneurysm enlargement, prompting attempted left occipital artery (OA)-PICA bypass at an outside facility, which was unsuccessful. The patient was referred to our institution. After her parents gave informed consent, she underwent right OA-PICA bypass on the contralateral side through far lateral craniotomy with inside-out harvest of the donor vessel. 4 After trapping and arteriotomy of the recipient PICA, an OA-PICA end-to-side anastomosis was performed using a running continuous technique. 5 Intraoperative indocyanine green videoangiography and postoperative digital subtraction angiography confirmed patency of the bypass. The patient tolerated the procedure well and remained neurologically intact. On postoperative day 3, a staged transcirculation flow diversion device was placed to facilitate progressive thrombosis of the aneurysm. 6,7 Follow-up angiography at 1 year demonstrated complete occlusion of the aneurysm. This video demonstrates successful multimodal management of a complex de novo VBJ aneurysm after a series of refractory endovascular treatments and unsuccessful cerebral revascularization techniques.

Endovascular treatment strategy and clinical outcome of tentorial dural arteriovenous fistula.

To evaluate treatment strategies and clinical outcomes following endovascular embolization of tentorial dural arteriovenous fistulas. We retrospectively analyzed 19 patients with tentorial dural arteriovenous fistulas admitted to the Department of Neurosurgery at Jiangsu Provincial People's Hospital between October 2015 and May 2022, all treated with endovascular therapy. To collect and analyze patients' clinical presentation, imaging data, postoperative complications, and prognosis and to analyze the safety and clinical outcomes of endovascular treatment of tentorial dural arteriovenous fistulas. Imaging cure was achieved in 18 patients, with the arterial route chosen for embolization in 17 patients and the venous route in one patient; one patient received partial embolization. Staged embolization was performed in four patients. At postoperative follow-up of 9-83 months (37.8 ± 21.2), all 19 patients had recovered well (mRS score ≤ 2). Three patients experienced perioperative complications: intraoperative Onyx reflux into the middle cerebral artery in one patient; postoperative permanent limited left visual field loss and deafness in the left ear in one patient; and transient diplopia, vertigo, and decreased pain and temperature sensation of the left limb in one patient, with no abnormalities on post-procedure magnetic resonance examinations. A total of 17 patients completed a postoperative digital subtraction angiography review during follow-up, and one patient had a recurrence of an arteriovenous fistula. Endovascular treatment of tentorial dural arteriovenous fistulas is safe and effective. Reduction of the Borden or Cognard classification via eliminating cortical venous reflux through multi-staged embolization or combined open surgery is a reasonable goal of treatment where complete obliteration of the fistula is not achievable.

In situ interposition bypass for complex intracranial aneurysms: A single-center experience and efficacy analysis.

The purpose of this study was to investigate the application and efficacy analysis of in situ interposition bypass in complex intracranial aneurysms. This study retrospectively analyzed the clinical data of 21 patients with complex intracranial aneurysms treated with in situ interposition bypass grafting in the Department of Neurosurgery at Tianjin Huanhu Hospital from June 2015 to December 2022. The aneurysms were located in the middle cerebral artery in 16 cases, the anterior cerebral artery in 3 cases, the posterior cerebral artery in 1 case, and the posterior inferior cerebellar artery in 1 case. The interposition graft vessels were taken from the radial artery in 15 cases, the superficial temporal artery in 5 cases, and the occipital artery in 1 case. All patients underwent end-to-end anastomosis with in situ interposition bypass after aneurysm resection, including 13 cases of "I-shaped" type, 5 cases of "V-shaped" type, and 3 cases of "Y-shaped" type. Postoperative digital subtraction angiography (DSA) or computed tomography angiography (CTA) reviews were performed for all the patients, and modified Rankin Scale (mRS) score was used to assess patient prognosis. Three patients developed postoperative basal ganglia infarction and two of them recovered well. One case developed transient incomplete aphasia and one case developed mild hemiparesis, which recovered well after 3months. The remaining 16 patients did not develop new neurological deficits. Postoperative DSA or CTA showed that the anastomosis of the bypass graft and the graft vessels were patent, and all aneurysms were completely eliminated. Regular postoperative follow-up ranged from 3 to 89months, and no aneurysm recurred. The percentage of patients with mRS ≤ 2 at the final follow-up was 90.5%. Based on the experience of surgical treatment in our center, in situ interposition bypass technique is a safe and effective option for the treatment of some complex intracranial aneurysms.

Surgical evolution in spinal dural arteriovenous fistula treatment-a 7 years monocentric experience.

Accounting for 70% of all spinal vascular malformations, spinal dural arteriovenous fistulas (SDAVF) are the most common type of malformation. Interruption of the fistulous arterialized vein point is the goal of surgical treatment. The aim of the study was to compare open surgery (laminectomy) versus minimal invasive surgery (MIS) in SDAVF treatment. Between March 2013 and March 2020, we retrospectively collected 21 consecutive adult patients with SDAVF. Since March 2017, MIS has been routinely used for surgical treatment. Pre- and post-operative clinical evaluations used Aminoff-Logue score (ALS). Complication rate was noted. Post-operative occlusion of the malformation was confirmed by digital subtraction angiography (DSA) in all patients. MIS was compared to open surgery in terms of efficacy and complications with statistical evaluation. Standard laminectomy was performed in 12 patients and MIS technique in 9 patients. No difference was noted on pre-operative parameters. ALS and MRI signs of myelopathy were improved in all cases except for 1 patient in each group. All SDAVFs were excluded based on post-operative DSA. Significant differences were noted between the 2 groups in terms of perioperative blood loss (p<0.001), post-operative pain visual analog scale values (p<0.001), and first time out of bed (p<0.001). Wrong level surgery occurred in one patient in each group; patients were re-operated using the same technique. No infection or cerebrospinal fluid (CSF) leak was noted. In our experience, MIS is a safe alternative to open laminectomy for SDAVF treatment. MIS contributes to patient comfort and minimizes blood loss without increasing complication rate.

Application of the Willis Covered Stent in the Treatment of Complex Vascular Diseases of the Internal Carotid Artery and Vertebral Artery: A Retrospective Single-Center Experience.

To retrospectively evaluate the efficacy and security of Willis covered stent (WCS) deployment for complex vascular diseases of the internal carotid (ICA) and vertebral (VA) arteries. Retrospective analysis was performed on complex vascular disease patients (n=36) treated with WCSs at our center between March 2017 and December 2022, with a 3-36-months follow-up surveillance and digital subtraction angiography (DSA) examination. The WCSs were successfully deployed in all the patients. The 36 included lesions were carotid-cavernous sinus fistulas (CCFs; n=10) (27.8%), complex saccular aneurysms (n=10) (27.8%), traumatic pseudoaneurysms (n=7) (19.4%), blood blister-like aneurysms (BBAs; n=5) (13.9%), and iatrogenic carotid or vertebral artery ruptures (n=4) (11.1%). The WCS was released at the communicating segment (n=2) (5.6%), the ophthalmic segment (n=3) (8.3%), the clinoid and cavernous segment (n=28) (77.8%), the petrous segment (n=2) (5.6%) of ICA and the V3 segment (n=1) (2.8%) of VA. Postoperative DSA showed complete lesion occlusion in 26 patients (72.2%) who were immediately treated with WCSs, and endoleaks occurred in 3 patients (8.3%) (endoleaks resolved postadjustment in 7 patients (19.4%)). In patients (n=3) (8.3%) treated with double stents at the break of the ICA, the endoleak remained in 1 CCF patient (2.8%) during the 3-month follow-up, and the residual shunt disappeared after the second stent system was placed 3 months later. No aneurysm, bleeding or infarct recurrence reported, and only 1 patient (2.8%) had mild asymptomatic in-stent stenosis. Deaths and procedural complications did not occur during follow-up. Treatment with a WCS for intracranial complex vascular diseases resulted in satisfactory clinical outcomes and appeared effective and safe. Controlled, multicenter, large sample sizes and longer follow-up periods studies are necessary.

Hemodynamic alterations of flow diverters on aneurysms at the fetal posterior communicating artery: A simulation study using CFD to compare the surpass streamline, pipeline flex, and tubridge devices

PurposeTraditional flow diverters (FDs) for treating aneurysms at the fetal posterior communicating artery are unsatisfactory. Surpass Streamline is a novel FD with different mesh characteristics; however, the outcomes for such aneurysms remain unclear. This study aimed to compare hemodynamic alterations induced by Surpass Streamline, Pipeline Flex, and Tubridge devices and explore possible strategies for aneurysms at the fetal posterior communicating artery. MethodsTwo simulated aneurysms (Case 1, Case 2) were constructed from digital subtraction angiography (DSA). The three FDs were virtually deployed, and hemodynamic analysis based on computational fluid dynamics was performed. Hemodynamic parameters, including the sac-averaged velocity magnitude (Velocity), high-flow volume (HFV), and wall shear stress (WSS), were compared between each FD and the untreated model (control). Surpass Streamline was performed in real life for two aneurysms and the clinical outcomes were collected for analysis. ResultsCompared to the control, the Surpass resulted in the most significant reduction in flow. In Case 1, the Velocity, HFV, and WSS were reduced by 51.6%, 78.1%, and 64.3%, respectively. In Case 2, the Velocity, HFV, and WSS were reduced by 48.0%, 81.1%, and 65.3%, respectively. Tubridge showed slightly larger changes in hemodynamic parameters than Pipeline. In addition, our analysis suggested that metal coverage was correlated with the WSS, Velocity, and HFV. The postoperative DSA showed that the aneurysm was nearly occluded in Case 1 and decreased in Case 2. ConclusionCompared to that with the Pipeline and Tubridge, the Surpass resulted in the greatest reduction in hemodynamic parameters and might be effective for aneurysms at the fetal posterior communicating artery. Virtual FD deployment and computational fluid dynamics analysis may be used to predict the treatment outcomes.

Quantitative analysis with multiphase contrast-enhanced computed tomography to evaluate residual tumor activity of hepatocellular carcinoma after DEB-TACE.

Most hepatocellular carcinomas (HCC) treated by transcatheter arterial chemoembolization with drug-eluting beads (DEB-TACE) are characterized by coagulation necrosis; therefore, it is often difficult to distinguish enhancement in the arterial phase that would lead to false negative evaluation. This study aimed to evaluate the specificity and sensitivity of the difference value of multiphase contrast-enhanced computed tomography (CECT) in predicting residual tumor activity in HCC lesions after DEB-TACE. This retrospective diagnostic study analyzed CECT images of 73 HCC lesions in 57 patients 20 to 40 days (average 28 days) after DEB-TACE treatment at our Hospital from January to December 2019. Postoperative pathology or digital subtraction angiography images were used as references. Residual tumor activity after the first intervention was determined based on the presence of tumor staining in digital subtraction angiography or the postoperative pathological discovery of HCC tumor cells. A significant difference was observed between the active and inactive residual groups in ∆ HU difference between CT values of arterial phase and non-contrast scans (AN, P = .000), difference between CT values of venous phase and non-contrast scans (VN, P = .000), difference between CT values of delay phase and non-contrast scans (DN, P = .000), (difference between CT values of venous and arterial phase scans, P = .001), and (difference between CT values of delay and arterial phase scans, P = .005). No statistically significant difference was observed between the delayed and venous phases (difference between CT values of delay and venous phase scans, P = .361). The area under the curve (AUC) of the ROC curve showed that the diagnostic efficacies in difference in CT value of AN (AUC = 0.976), VN (AUC = 0.927), and DN (AUC = 0.924) were higher, and their cutoff values were 4.86, 12.065, 20.19 HU with their sensitivities of 93.3%, 84.4%, 77.8% and specificities of 100%, 96.4%, and 100%, respectively. difference in CT value values of AN, VN, DN, difference between CT values of venous and arterial phase scans and difference between CT values of delay and arterial phase scans can sensitively detect residual tumor activity 20-40 days after DEB-TACE. Thus, more sensitive active residual foci were detected using all 3 enhanced phases rather than only the arterial phase. Quantitative analysis of multiphase CECT can detect residual tumor activity in an early and noninvasive manner, which can provide time for patients to receive early follow-up treatment.

Cost-Effectiveness of Forgoing Postoperative Catheter Angiography After Microsurgical Occlusion of Spinal Dorsal Intradural Arteriovenous Fistulas

Spinal dorsal intradural arteriovenous fistulas (DI-AVFs) represent 70% of all spinal vascular lesions. Diagnostic tools include pre- and postoperative digital subtraction angiography (DSA) and intraoperative indocyanine green videoangiography (ICG-VA). ICG-VA has a high predictive value in DI-AVF occlusion, but postoperative DSA remains a core component of postoperative protocols. The aim of this study was to evaluate the potential cost reduction of forgoing postoperative DSA after microsurgical occlusion of DI-AVFs. Cohort-based cost effectiveness study of all DI-AVFs within a prospective, single-center cerebrovascular registry from January 1, 2017, to December 31,2021. Complete data including intraoperative ICG-VA and costs were available for 11 patients. Mean (SD) age was 61.5 (14.8) years. All DI-AVFs were treated with microsurgical clip ligation of the draining vein. ICG-VA showed complete obliteration in all patients. Postoperative DSA was performed for 6 patients and confirmed complete obliteration. Mean (SD) cost contributions for DSA and ICG-VA were $11,418 ($4,861) and $12 ($2), respectively. Mean (SD) total costs were $63,543 ($15,742) and $53,369 ($27,609) for patients who did and did not undergo postoperative DSA, respectively. Comorbidity status was identified as the main driver of total cost (P= 0.01 after adjusting for postoperative DSA status). ICG-VA is a powerful diagnostic tool in demonstrating microsurgical cure of DI-AVFs, with a negative predictive value of 100%. Eliminating postoperative DSA in patients with confirmed DI-AVF obliteration on ICG-VA may yield substantial cost savings, in addition to sparing patients the risk and inconvenience of a potentially unnecessary invasive procedure.

Combined Double-Barrel Superficial Temporal Artery to M4 Bypass and Parent Artery Occlusion for the Treatment of Complex Intracranial Aneurysms in Internal Carotid Artery and Middle Cerebral Artery: A Retrospective Case Series.

Very little research has been conducted to assess the efficacy of combined double-barrel superficial temporal artery (STA) to M4 bypass and parent artery occlusion (PAO) in the treatment of complex intracranial aneurysms. To determine whether this operation could become a reasonable flow replacement therapy and have longer-term benefits. A series of double-barrel STA-M4 bypasses performed between 2016 and 2021 were reviewed. Preoperative digital subtraction angiography (DSA), computed tomography angiography (CTA), computed tomography perfusion (CTP), and balloon test occlusion were routinely performed for a thorough evaluation of individual benefits and risks. After bypass, the proximal end of the parent artery was permanently occluded with the coil. Augmentation and patency of STA were reassessed by postoperative DSA, CTA, and CTP. The blood flow volume of STA was measured by ultrasound at admission and a 3-month follow-up. This study included 12 consecutive patients (5 males, 7 females) who successfully underwent double-barrel STA-M4 bypass, including 8 complex aneurysms in the internal carotid artery (ICA) and 4 in the middle cerebral artery (MCA). Postoperative angiography and CTP suggested that all the STAs were patent, and there was a significant improvement in perfusion after the operation ( P < .05). Ultrasonic measurement at the 3-month follow-up showed that the blood flow provided by STA was 76.3 to 190.5 mL/min. Postoperative ischemia was found in 1 patient, but she recovered after treatment. Double-barrel STA to M4 bypass can provide adequate flow for the parent artery area, which may be a reasonable flow replacement therapy for some complex intracranial aneurysms in ICA and MCA.

Coexisting filum terminale arteriovenous fistula and filum terminale lipoma treated with single-stage surgery: illustrative case

Both filum terminale arteriovenous fistulas (FTAVFs) and filum terminale lipomas (FTLs) are rare. Because of this rarity, there is a paucity of data regarding concomitant FTAVF and FTL, and the optimal treatment remains to be defined. The authors describe a patient with coexisting FTAVF and FTL treated with single-stage surgery. A man in his 70s was referred to the authors' department because of a suspected spinal vascular malformation seen on magnetic resonance imaging that was performed to investigate lower limb weakness, intermittent claudication, and urinary incontinence. Previous imaging had shown a terminal lipoma with an internal flow void. Computed tomography angiography and digital subtraction angiography revealed an FTAVF, the feeder being a lateral sacral artery. The patient was treated surgically with curative intent. The FTL and tethered cord that had been identified by imaging were treated in the same procedure. Postoperative digital subtraction angiography showed absence of the abnormal vessels. The patient was discharged home on the 19th postoperative day. When considering treatment, it is important to determine whether symptoms are attributable mainly to FTL, tethered cord, or FTAVF. One-stage treatment is useful because it eliminates both the FTAVF and the factors that led to its development.

Microsurgical Treatment of Previously Coiled Giant Aneurysms: Experience with 6 Cases and Literature Review

Surgical treatment of insufficiently embolized (coiled) or recurrent giant aneurysms has not been well established in the literature. The aim of this study is to bring up the surgical difficulties of these rare aneurysms and to offer solutions. A database was queried for giant aneurysms that had been previously embolized and subsequently required surgical treatment. We only found 29 aneurysms in the literature and here, we report 6 more surgical cases with patient characteristics, radiological studies, applied surgical techniques, and outcomes which were reviewed retrospectively. Four females and 2 males, with a mean age of 45.6years took part in the study. The most common aneurysm location was the middle cerebral artery. While 5 aneurysms were successfully clipped, 1 was excised and the neck was closed with micro sutures. The coils were compulsorily removed in 3 patients. Postoperative digital subtraction angiography confirmed total occlusion of the aneurysms in all cases. Overall morbidity was 16.6%. There was no mortality. No recurrence was observed in the angiographic follow-up (mean 22.6months, range 7-47months). The literature review also determined that 97.1% of 35 previously coiled giant aneurysms (including ours) were occluded using various surgical techniques, with 82.8% good outcome. Surgical clipping is a safe and effective procedure for the treatment of insufficiently embolized or recurrent giant aneurysms after coiling. If possible, the coils should not be removed. However, if safe clipping is not possible due to the coils, the removal of the coils should not be avoided.

Evaluation of the Utility of Indocyanine Green Video Angiography in Cerebral Arteriovenous Malformation Surgery

To assess the utility of intraoperative indocyanine green video angiography (ICG-VA) during microsurgical resection of arteriovenous malformations (AVMs). Data of the 24 patients, who were surgically treated for AVM using intraoperative ICG-VA, were reviewed retrospectively. Postoperative digital subtraction angiography (DSA) was performed in all patients before they regained consciousness and became fully awake, and the results were compared with those obtained with intraoperative ICG-VA. A scheduled DSA was performed in all patients in the third, sixth, and twelfth postoperative months as well. Authors retrospectively analyzed the records of intraoperative ICG-VA application of all 24 patients. Though the exposures were limited and the image qualities were poor at higher magnification on the surgical microscope within deep surgical fields, the AVM niduses, feeding arteries, draining veins, and their relations to normal vasculature were observed precisely with ICG-VA in all the procedures. Furthermore, the visualization was not qualified enough to identify these pathological vascular structures accurately before evacuating and irrigating the layer of blood clots that obscure the view in patients who presented with hemorrhage. In a patient in our series, a residual nidus in the tail of the caudate nucleus was detected with immediate postoperative DSA which was not revealed by terminal assessment with final intraoperative ICG-VA. Intraoperative ICG-VA is particularly effective in the identification of the feeder, nidus, and drainer and in the assessment of the flow dynamics of the nidus in cerebral AVM surgery. It may be a quick and safe technique for intraoperative imaging of the angioarchitecture of superficial AVMs, but it may be less helpful for deep-seated lesions. Furthermore, this method alone may not be useful in the identification of residual disease or improvement of the clinical outcomes. DSA has remained the gold standard for confirming AVM obliteration. Despite the technical limitations associated with ICG-VA, a combination of intraoperative ICG-VA and immediate postoperative DSA may advance the safety and efficacy of AVM surgery.

Modified pedicled temporoparietal fascial flap combined revascularization in adult moyamoya angiopathy

Pedicled temporoparietal fascial flaps (TPFF), which are flexible, thin, and highly vascularized, have been tried for the moyamoya angiopathy (MMA) treatment. To reduce postoperative complications and improve prognosis, we performed surgical modification and followed up to observe the efficacy. From February 2018 and June 2022, the clinical data of 31 adult MMA patients who underwent the modified TPFF combined revascularization were collected. The clinical outcomes and complications of the patients were recorded until the cut-off date of follow-up. The primary endpoints were the magnetic resonance perfusion (MRP), modified Rankin Scale (mRS) scores, and Matsushima Grade; the secondary endpoints were the clinical symptom outcome and Postoperative complications. Descriptive statistics and rank sum test to assess the therapeutic effect of the modified TPFF combined revascularization for adult MMA treatment. The clinical symptoms of MMA were alleviated in 26 patients and disappeared in five. In all patients, MRP showed improvement in cerebral perfusion on the operated side, and no deterioration or new cerebral infarction occurred during follow-up. Postoperative digital subtraction angiography (DSA) showed that the anastomotic site was patent, and the MMA collateral was decreased in all patients. Only 1 case (3%) of Matsushima grade C showed poor collateral compensation. The admission mRS score (1.54±0.66) of the ischemic MMA was significantly reduced compared with ≥6 months postoperatively (0.54±0.72, P<0.01). The admission mRS score (0.57±0.53) of the hemorrhagic MMA was reduced compared with ≥6 months postoperatively (0, P<0.05). Postoperative complications included epileptic seizures in 2 cases, a cerebral hyper-perfusion syndrome in 2 cases, intracranial rebleeding in 2 cases, skin necrosis in 1 case, and skin maceration in 1 case. Modified TPFF combined revascularization might be a feasible and safe surgical technique for MMA, but it is still necessary to increase the sample size and extend the follow-up time to evaluate its efficacy. Ischemic MMA may have a more significant prognostic benefit than hemorrhagic MMA by this surgery.

CT perfusion-based delta-radiomics models to identify collateral vessel formation after revascularization in patients with moyamoya disease.

PurposeTo build CT perfusion (CTP)-based delta-radiomics models to identify collateral vessel formation after revascularization in patients with moyamoya disease (MMD).MethodsFifty-three MMD patients who underwent CTP and digital subtraction angiography (DSA) examination were retrospectively enrolled. Patients were divided into good and poor groups based on postoperative DSA. CTP parameters, such as mean transit time (MTT), time to drain (TTD), time to maximal plasma concentration (Tmax), and flow extraction product (FE), were obtained. CTP efficacy in evaluating surgical treatment were compared between the good and poor groups. The changes in the relative CTP parameters (ΔrMTT, ΔrTTD, ΔrTmax, and ΔrFE) were calculated to evaluate the differences between pre- and postoperative CTP values. CTP parameters were selected to build delta-radiomics models for identifying collateral vessel formation. The identification performance of machine learning classifiers was assessed using area under the receiver operating characteristic curve (AUC).ResultsOf the 53 patients, 36 (67.9%) and 17 (32.1%) were divided into the good and poor groups, respectively. The postoperative changes of ΔrMTT, ΔrTTD, ΔrTmax, and ΔrFE in the good group were significantly better than the poor group (p < 0.05). Among all CTP parameters in the perfusion improvement evaluation, the ΔrTTD had the largest AUC (0.873). Eleven features were selected from the TTD parameter to build the delta-radiomics model. The classifiers of the support vector machine and k-nearest neighbors showed good diagnostic performance with AUC values of 0.933 and 0.867, respectively.ConclusionThe TTD-based delta-radiomics model has the potential to identify collateral vessel formation after the operation.

Transverse Tibial Bone Transport Enhances Distraction Osteogenesis and Vascularization in the Treatment of Diabetic Foot.

ObjectiveTo investigate the effect of transverse tibial bone transport on the treatment of Wagner Stage 4 diabetic foot.MethodsFrom January 2017 to October 2019, a total of 19 patients with Wagner Stage 4 diabetic foot ulcers were recruited. All patients were treated with transverse tibial bone transport. A detailed follow‐up was carried out at 1 week, 1 month, 3 months, 6 months, and 1 year after surgery. The wound healing rate and the limb salvage rate at 1 year after the surgery were evaluated. Preoperative and 3‐month postoperative digital subtraction angiography (DSA) were obtained. The level of vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), epidermal growth factor (EGF) and platelet‐derived growth factor (PDGF) before surgery and on 1st, 4th, 11th, 18th, 28th, and 35th days after surgery were measured. Operation time, intraoperative blood loss, postoperative complications, visual analog scale (VAS) pain score, skin temperature, Semmes‐weinstein monofilament (SWM), and ankle brachial index (ABI) were also assessed.ResultsThe wound healing rate and the limb salvage rate were both 94.74% in the patients at 1 year after the surgery. DSA showed the thickening of the calf and foot arteries, clear visualization, and a rich vascular network. The levels of VEGF, bFGF, and PDGF on the 11th, 18th, 28th, and 35th days after surgery were significantly higher than those before surgery (p < 0.05). The EGF level on the 18th, 28th, and 35th days after surgery was significantly higher than that before surgery (p < 0.05). Superficial wound complications occurred in one patient during the hospitalization. There was no movement area infection, skin flap necrosis, tibial fracture, loosening of the external fixator, or rupture in study.ConclusionTransverse tibial bone transport can improve the blood circulation of the affected limbs, promote the healing of diabetic foot wounds, and reduce the amputation rate of the affected limbs. Transverse tibial bone transport can promote the healing of Wagner Stage 4 diabetic foot.

Comparison of Intraoperative Indocyanine Green Videoangiography vs Postoperative Catheter Angiography to Confirm Microsurgical Occlusion of Spinal Dorsal Intradural Arteriovenous Fistulas.

Dorsal intradural arteriovenous fistulas (DI-AVFs) represent 80% of spinal AVFs. Microsurgical clip occlusion is a durable treatment that uses preoperative and postoperative digital subtraction angiography (DSA) as standard practice. Intraoperative indocyanine green videoangiography (ICG-VA) is a valuable intraoperative adjunct in these cases. Intraoperative ICG-VA findings have not been compared with postoperative DSA findings. To assess the diagnostic value of intraoperative ICG-VA vs postoperative DSA for spinal DI-AVFs. A multi-institutional database of vascular malformations was queried for all surgically managed cases of DI-AVF. Patients with both intraoperative ICG-VA and postoperative DSA were included. Demographic and radiologic data, intraoperative findings, and surgical outcomes data were retrospectively analyzed. Forty-five patients with DI-AVF were identified (male sex, 32; mean age, 61.9 [range, 26-85] years). All DI-AVFs were treated with interruption of the fistula with clip occlusion of the draining vein. Intraoperative ICG-VA showed complete obliteration in all patients. Postoperative DSA was performed for 40 patients and confirmed complete obliteration in all patients. The negative predictive value of ICG-VA confirming complete occlusion of the DI-AVFs was 100%. Eighteen patients (47%) experienced clinical improvement, and 16 (42%) experienced no change in condition. ICG-VA is useful for intraoperative identification of DI-AVFs and confirmation of complete microsurgical occlusion. Correlation between intraoperative ICG-VA and postoperative DSA findings demonstrates the diagnostic power of ICG-VA. This finding suggests that postoperative DSA is unnecessary when intraoperative ICG-VA confirms complete occlusion of the DI-AVF, which will spare patients the procedural risk and cost of this invasive procedure.

Hyperhomocysteinemia Is a Predictor for Poor Postoperative Angiogenesis in Adult Patients With Moyamoya Disease.

Background and PurposesThe risk factors of poor postoperative angiogenesis in moyamoya disease (MMD) patients remain unknown. We aimed to investigate the association between hyperhomocysteinemia (HHcy) and postoperative angiogenesis of adult patients with MMD.MethodsA total of 138 adult patients with MMD were prospectively recruited from July 1 to December 31, 2019. After excluding 10 patients accepting conservative therapy and 77 individuals without postoperative digital subtraction angiography (DSA), all 51 MMD patients were enrolled, and 28 patients received bilateral operations separately. Patients were grouped according to postoperative angiogenesis and HHcy presentation, respectively. Clinical data and laboratory examinations were compared. Potential risk factors were evaluated by univariate and multivariate logistic regression analysis. Nomogram was further performed. The biological functions of homocysteine (Hcy) were explored in vitro.ResultsComparing to the normal, patients with poor postoperative angiogenesis were higher in serum Hcy (p = 0.004), HHcy ratio (p = 0.011), creatinine (Cr) (p < 0.001), uric acid (UA) (p = 0.036), Triglyceride (p = 0.001), high-density lipoprotein cholesterol (HDL-C) (p = 0.001), low-density lipoprotein cholesterol (LDL-C) (p = 0.009), ApoA (p = 0.022), apolipoprotein B (ApoB) (p = 0.013). Furthermore, HHcy was more common in men (p = 0.003) than women. Logistic analysis results showed that Hcy (OR = 0.817, 95% CI = 0.707–0.944, p = 0.006) was an independent risk factor. HHcy and Cr were significantly associated with poor postoperative angiogenesis in MMD patients. Further, Hcy could inhibit the proliferation, migration, and tube formation of human brain microvascular endothelial cells (HBMECs), which can be reversed by vascular endothelial growth factor (VEGF).ConclusionThe HHcy was significantly correlated with poor postoperative angiogenesis in adult patients with MMD. Hcy significantly inhibits HBMECs proliferation, migration, and tube formation. Furthermore, VEGF could reverse the inhibition effect induced by Hcy. Lowering the level of Hcy may be beneficial for postoperative MMD patients. Focusing on the pathophysiology and mechanism of HHcy might help to guide postoperative clinical management.

Presurgical selection of the ideal aneurysm clip by the use of a three-dimensional planning system

Aneurysm occlusion rate after clipping is higher than after endovascular treatment. However, a certain percentage of incompletely clipped aneurysms remains. Presurgical selection of the proper aneurysm clips could potentially reduce the rate of incomplete clippings caused by inadequate clip geometry. The aim of the present study was to assess whether preoperative 3D image-based simulation allows for preoperative selection of a proper aneurysm clip for complete occlusion in individual cases. Patients harboring ruptured or unruptured cerebral aneurysms prior to surgical clipping were analyzed. CT angiography images were transferred to a 3D surgical-planning station (Dextroscope®) with imported models of 58 aneurysm clips. Intracranial vessels and aneurysms were segmented and the virtual aneurysm clips were placed at the aneurysm neck. Operating surgeons had information about the selected aneurysm clip, and patients underwent clipping. Intraoperative clip selection was documented and aneurysm occlusion rate was assessed by postoperative digital subtraction angiography. Nineteen patients were available for final analysis. In all patients, the most proximal clip at the aneurysm neck was the preselected clip. All aneurysms except one were fully occluded, as assessed by catheter angiography. One aneurysm had a small neck remnant that did not require secondary surgery and was occluded 15 months after surgery. 3D image-based preselection of a proper aneurysm clip can be translated to the operating room and avoids intraoperative clip selection. The associated occlusion rate of aneurysms is high.