Pancytopenia represents a unique challenge for primary care doctors and its etiological causes encompass various specialties, including hematology and rheumatology. Despite the existence of effective tests such as bone marrow biopsy and immunoassays to rule out the potential causes of pancytopenia, it is often difficult to pinpoint the exact diagnosis. In this case report, we have described such a ‘gray zone’ patient, who presented with pancytopenia, neutropenia, and splenomegaly, and was being treated for fungal pneumonia before being transferred to Severance Hospital (department of family medicine). As the patient had a 10-year history of multiple, long-term hospital admissions that were having a severely debilitating impact on the quality of life, we performed a partial splenic embolization as a potential cure for the symptoms. Although this induced acute blood count recovery, it failed to prevent eventual mortality from septic shock.

Pancytopenia represents a unique challenge for primary care doctors and its etiological causes encompass various specialties, including hematology and rheumatology. Despite the existence of effective tests such as bone marrow biopsy and immunoassays to rule out the potential causes of pancytopenia, it is often difficult to pinpoint the exact diagnosis. In this case report, we have described such a ‘gray zone’ patient, who presented with pancytopenia, neutropenia, and splenomegaly, and was being treated for fungal pneumonia before being transferred to Severance Hospital (department of family medicine). As the patient had a 10-year history of multiple, long-term hospital admissions that were having a severely debilitating impact on the quality of life, we performed a partial splenic embolization as a potential cure for the symptoms. Although this induced acute blood count recovery, it failed to prevent eventual mortality from septic shock.

Management of cavernous sinus dural arteriovenous fistula (CSDAVF) continues to present significant challenges, particularly when the inferior petrosal sinus is thrombosed, collapsed, or angiographically invisible. In this study, we introduce facilitated retrograde access via the facial vein, which is employed in the transvenous embolization of CSDAVF with isolated superior ophthalmic venous drainage. We also present illustrative cases and technical points.

Purpose: Coil embolization of paraclinoid aneurysms should be simple, safe, and effective considering the benign nature of the aneurysm. Here, we present a microcatheter stabilization technique using a partially inflated balloon for the treatment of paraclinoid aneurysms. Materials and Methods: This retrospective study included 58 patients who underwent balloon-assisted coiling (BAC) for unruptured paraclinoid aneurysms at a tertiary neuro-intervention center between January 2019 and March 2020. We applied a technique to stabilize the microcatheter’s position using the modified BAC technique in paraclinoid aneurysms showing various projections around the ophthalmic curve of the internal carotid artery. The basic concept of the technique is to place a partially inflated balloon just distal to the aneurysm neck and support the distal curve of the microcatheter using the proximal bottom of the balloon. Immediate radiological outcomes were analyzed, and clinical outcomes were evaluated with modified Rankin Scale (mRS) scores. Results: The BAC was successfully performed in 51 of 58 patients (88%). We treated the remaining seven patients by switching to stent-assisted coiling. We obtained a 37% mean packing density resulting in favorable occlusion in all 58 aneurysms (complete occlusion in 35 and residual neck in 23). There were no intraprocedural thromboembolic or hemorrhagic events except one that revealed an asymptomatic infarction after the procedure (1.7%). Magnetic resonance angiography follow-up was performed in 37 patients at an average of 11.8 months, in which 11 minor recurrences (29.7%) were found. There was no major recurrence nor retreatment. The mRS score was 0 in all patients during a mean follow-up of 17.7 months (range, 12–25 months). Conclusion The modified balloon-assisted coiling technique using a partially inflated balloon was safe and effective and could serve as an option for treating paraclinoid aneurysms.

Purpose: Spontaneous cervicocephalic dissection (SCAD) is an important cause of stroke and shows various lesion locations and clinical features. The purpose of this study was to analyze the location of SCAD and its clinical and radiologic patterns in Korean patients. Materials and Methods: Patients with SCAD who were evaluated between 2013 and 2018 at a tertiary center in Korea were reviewed. We classified and compared the morphological (aneurysm or steno-occlusion) and presenting (hemorrhage or infarction) patterns according to the lesion locations (anterior circulation [AC] vs. posterior circulation [PC]; intradural [ID] vs. extradural [ED]). Results: A total of 166 patients were included in this study. The SCAD most commonly occurred in the PC-ID location (65.1%), followed by AC-ID (13.3%), AC-ED (13.3%), and PC-ED (8.4%). Aneurysm and steno-occlusion patterns were observed in 66.9% and 57.8% of the cases, respectively. The aneurysm pattern was significantly more common in the PC-ID location (78.7%) than in other locations. As for the presenting pattern, cerebral infarction was the most common pattern (39.8%), and intracranial hemorrhage was observed only in the ID location (7.2%). Conclusion In Korean patients, PC-ID, especially ID vertebral artery, was the most common location of SCAD, and most cases were accompanied by an aneurysm. It also suggested that these location trends differ by population or ethnicity.

Objective: : Transvenous embolization (TVE) via an occluded inferior petrosal sinus (IPS) in a cavernous sinus dural arteriovenous fistula (CSDAVF) is challenging, often requiring navigation of a microcatheter through resistive obstacles between the occluded IPS and shunted pouch (SP), although the reopening technique was successfully performed. We report five cases of successful access to the cavernous sinus (CS) or SP using the rigid-tipped microguidewire such as chronic total occlusion (CTO) wire aiming to share our initial experience with this wire. Methods: : In this retrospective study, four patients with CSDAVF underwent five procedures using the CTO wire puncture during transfemoral transvenous coil embolization. Puncture success, shunt occlusion, and complications including any hemorrhage and cranial nerve palsy were evaluated. Results: : Despite successful access through the occluded IPS, further entry into the target area using neurointerventional devices was impossible due to a short-segment stricture before the CS (three cases) and a membranous barrier within the CS (two cases). However, puncturing these structures using the rigid-tipped microguidewire was successful in all cases. We could advance the microcatheter over the rigid-tipped microguidewire for the navigation to the SP and achieved complete occlusion of the SP without complications. Conclusion : The use of the rigid-tipped microguidewire in the TVE via the occluded IPS of the CSDAVF would be feasible and safe.

Thromboembolism is one of the major complications of stent assisted coiling in treatment of cerebral aneurysm. Clopidogrel resistance is so common and prasugrel is more effective in its rapid and potent effect. We investigated changes in the value of P2Y12 resistance unit (PRU) when prasugrel was administered to patients with clopidogrel resistance. One hundred mg of aspirin and 75 mg of clopidogrel were administered for 5 days before the procedure, and PRU were examined. The resistance to clopidogrel was defined as the inhibition of PRU was less than 20%. PRU was re-examined after loading 20 mg of prasugrel. We treated 98 consecutive patients between January 2018 and July 2018, and 24 patients (24.5%) had resistance to clopidogrel. Nineteen patients were female. The mean PRU value at admission was 238.5±36.9 and the percentage inhibition value was 4.8±6.3%. After the use of prasugrel, the mean PRU and percentage inhibition values were measured as 124.9±49.9 and 48.0±19.24, respectively. All patients except one patient had a PRU inhibition value as a responder. There was no hemorrhage or thromboembolic complication during mean 1.5 months follow-up after embolization procedure. In conclusion, in patients resistant to clopidogrel, the low dose prasugrel seems to be effective in keeping the percentage inhibition value of PRU within the normal range in treatment of cerebral aneurysm. Further study will be needed to determine the optimal dose of prasugrel to enhance prevention effect of thromboembolism and to reduce hemorrhagic complications during stent assisted coiling.
Aspirin ; Drug Resistance ; Female ; Follow-Up Studies ; Hemorrhage ; Humans ; Intracranial Aneurysm* ; Platelet Aggregation Inhibitors ; Prasugrel Hydrochloride* ; Reference Values ; Stents ; Thromboembolism

PURPOSE: Hemodynamic factors are considered to play an important role in initiation and progression of the recurrence after endosaccular coiling of the intracranial aneurysms. We made paired virtual models of completely coiled aneurysms which were subsequently recanalized and compared to identify hemodynamic characteristics related to the recurred aneurysmal sac. MATERIALS AND METHODS: We created paired virtual models of computational fluid dynamics (CFD) in five aneurysms which were initially regarded as having achieved complete occlusion and then recurred during follow-up. Paired virtual models consisted of the CFD model of 3D rotational angiography obtained in the recurred aneurysm and the control model of the initial, parent artery after artificial removal of the coiled and recanalized aneurysm. Using the CFD analysis of the virtual model, we analyzed the hemodynamic characteristics on the neck of each aneurysm before and after its recurrence. RESULTS: High wall shear stress (WSS) was identified at the cross-sectionally identified aneurysm neck at which recurrence developed in all cases. A small vortex formation with relatively low velocity in front of the neck was also identified in four cases. The aneurysm recurrence locations corresponded to the location of high WSS and/or small vortex formation. CONCLUSION: Recanalized aneurysms revealed increased WSS and small vortex formation at the cross-sectional neck of the aneurysm. This observation may partially explain the hemodynamic causes of future recanalization after coil embolization.
Aneurysm* ; Angiography ; Arteries ; Embolization, Therapeutic ; Follow-Up Studies ; Hemodynamics* ; Humans ; Hydrodynamics* ; Intracranial Aneurysm ; Neck ; Parents ; Recurrence

No abstract available.
Follow-Up Studies ; Humans ; Intracranial Aneurysm ; Prasugrel Hydrochloride

Purpose: With the rapid expansion of the field of interventional neuroradiology (INR) and the diverse background of aspiring neuro-interventionists, there is an ever increasing need to establish consensus criteria for training and accreditation in INR. Materials and Methods: We performed a survey to explore the current state of criteria for training and accreditation in INR. The questionnaire consisting of 11 questions was emailed to the members of World Federation of Interventional and Therapeutic Neuroradiology (WFITN) worldwide. It was focused on the training charter, training program, qualifying examination, and education after training program as perceived by practitioners in each country. Results: A total of 52 WFITN members in 19 countries responded to the questionnaire. There was a huge variation internationally and nationally due to the unique situation and challenges in each country and institution. Criteria for training and accreditation in INR were well established in some countries of Europe, North America, and Asia but not specified in other countries. Conclusion It is critical to establish consensus criteria for training and accreditation in INR in order to ensure safe practice and continued expansion and development of INR as a specialty.