Kenichiro Suyama

Purpose Digital subtraction angiography (DSA) is the gold standard for follow-up evaluation of intracranial aneurysms treated with the Woven EndoBridge (WEB) device. This study aimed to assess the efficacy of high-resolution CT angiography (HR-CTA) as a less invasive alternative by comparing its diagnostic performance with that of DSA. Methods This single-center retrospective study analyzed the angiographic and clinical data of patients treated with the WEB device for cerebral aneurysms between January 2021 and December 2024. Patients who underwent HR-CTA within 2 weeks before or after follow-up DSA were included. Occlusion status was assessed using the Bicêtre Occlusion Scale Score (BOSS) and binary classification. The concordance rate between HR-CTA and DSA was evaluated. Results A total of 54 eligible examinations were identified. Using the BOSS, 46 examinations were concordant, resulting in an agreement rate of 85.2%. The Cohen’s κ coefficient was 0.81 (95% CI 0.69 to 0.93), indicating a very high level of agreement. All discordant cases resulted from HR-CTA overestimating occlusion status; however, HR-CTA accurately identified aneurysm remnants. Univariate analyses identified BOSS 0’ as the only significant factor contributing to discrepancies. In the binary evaluation, all 54 examinations were fully concordant (κ=1.00, 95% CI 1.00 to 1.00). Conclusions HR-CTA demonstrated a high concordance rate with DSA for evaluating occlusion status after WEB placement. Its reliable assessment of aneurysm remnants suggests HR-CTA could serve as a practical and less invasive alternative to DSA in follow-up evaluations.

It is impossible to predict underlying anomalies in acute large vessel occlusion and it could be a problem when performing mechanical thrombectomy (MT). We report a case of MT for occlusion of the fenestrated middle cerebral artery (MCA) M1 segment. A 49-year-old woman presented to our hospital with dysarthria and left hemiparesis. Acute ischemic stroke due to right occluded MCA was diagnosed. During performing emergent MT, a part of the M1 segment was revealed to be slit-shaped by digital subtraction angiography, suggesting a fenestrated MCA. The aspiration catheter could not be advanced through the narrow limb of the fenestration, and the distal thrombus was retrieved using a stent retriever, additionally. Postoperatively, the patient's symptoms improved without complications. When occlusion of the fenestrated MCA is suspected, it is necessary to consider converting the strategy from an aspiration catheter alone to the combined use of a stent retriever.

PURPOSE: Prasugrel is not approved for patients treated with flow diverters, which have a high metal coverage ratio. However, robust antiplatelet therapy with prasugrel may prevent thromboembolic complications. We administered prasugrel and aspirin to all patients treated with flow diverters and reported the safety of the antiplatelet therapy regimen. METHODS: This retrospective, single-center study evaluated the angiographic and clinical data of consecutive patients treated with flow diverters for cerebral unruptured aneurysms between June 2020 and May 2022. All patients received dual antiplatelet therapy, including prasugrel and aspirin. The administration of prasugrel ended 3 or 6 months after the procedure, whereas aspirin use continued for at least 12 months. Periprocedural complications (< 30 days post-procedure) and delayed complications (> 30 days post-procedure) were recorded. RESULTS: During the study period, 120 unruptured aneurysms were treated with flow diverters in 110 patients. All patients, except one, survived longer than 12 months after the procedure. The rate of thromboembolic complications was 6.4%, and more than half of the patients had transient symptoms; one (0.9%) had a major ischemic stroke. One patient (0.9%) each had an asymptomatic, small subarachnoid hemorrhage and significant hemorrhagic complications with melena. The rate of permanent neurological deficits was 1.8%, and the mortality rate was 0.9%. CONCLUSIONS: Dual antiplatelet therapy comprising routine use of prasugrel and aspirin for flow diverter-implanted patients possibly contributed to a low rate of thromboembolic complications and low risk of hemorrhagic complications.