Yong Cheol Lim

Background: Cardiac injury is a well-recognized extracranial complication in patients with acute brain injury, yet limited data exist on its occurrence and clinical implications in traumatic brain injury (TBI). This study aimed to evaluate the incidence, associated risk factors, and outcomes of cardiac wall motion abnormalities (WMA) detected by echocardiography in patients with TBI. Methods: A retrospective observational study was conducted at a regional trauma center in South Korea. Patients admitted with TBI between 2019 and 2023 who underwent transthoracic echocardiography (TTE) were included. Cardiac injury was defined as newly appeared WMA on TTE. Demographics, clinical characteristics, cardiovascular comorbidities, complications, and Glasgow Outcome Scale-Extended (GOSE) scores were analyzed. Comparative analyses between WMA and non-WMA groups were performed using chi-square and t-tests, and univariate/multivariable logistic regression analyses were conducted to identify predictors of post-traumatic WMA and unfavorable outcomes. Results: Among 1,942 TBI patients, 659 underwent TTE, and after excluding preexisting WMA, 641 were analyzed. Of these, 41 patients (6.4%) demonstrated post-traumatic WMA. Patients with WMA had a significantly higher prevalence of cardiovascular comorbidities (75.6% vs. 56.0%, OR = 2.436, p = 0.014) and pulmonary complications (31.7% vs. 18.7%, OR = 2.023, p = 0.041). Severe TBI and major trauma were not significantly associated with WMA. The WMA group had lower mean GOSE scores (3.78 ± 1.90 vs. 4.19 ± 1.86), and a higher proportion of patients with poor outcomes (GOSE 1–2: 31.7% vs. 20.7%). Pulmonary complication was significantly associated with poor outcomes (OR = 2.433, p < 0.001). Conclusion: Cardiac WMA is not uncommon in TBI patients and may be associated with preexisting cardiovascular disease, increased pulmonary complications, and poor neurological outcomes. Early screening for cardiac injury in high-risk TBI patients may enable tailored treatment strategies and improve clinical outcomes.

Objective: The optimal timing of bypass surgery for patients with moyamoya disease (MMD) or moyamoya syndrome (MMS) following an acute stroke episode remains unclear, mainly owing to the risk of postoperative complications. In this study, we aim to validate the safety and efficacy of early intervention using multiple burr hole (MBH) and erythropoietin (EPO) therapy, thereby refining the management strategy for patients with acute stroke episode of MMD or MMS.Methods: We retrospectively analyzed data from 70 patients with MMD or MMS who underwent MBH and EPO therapy. The cohort was divided based on the time interval between the latest neurological deterioration and surgery: early (p < 0.01). In addition, a notable reduction (≥50%) in basal moyamoya vessels was observed in 30/47 hemispheres (63.8%) from the early group vs. 12/44 (27.3%) hemispheres from the later group (OR = 4.71; 95% CI: 1.97–11.82; p < 0.001). During the average follow-up of 56.5 months, only six patients experienced infarction or hemorrhage.Conclusion: Our dataset suggests that MBH and EPO combination therapy is an effective, minimally invasive, and acceptable treatment, even in the early period of patients with MMD or MMS following an acute stroke episode.

Objective : The use of reconstructive treatment with a double-overlapping stents has proven to be effective and safe in the current treatment of intracranial vertebral artery dissecting aneurysms (VADAs). We employed a combination of overlapping stents, using low-profile visualized intraluminal support (LVIS) within the Enterprise stent. This combination was chosen to minimize the outward bulging of the inner LVIS by overlapping it with the Enterprise stent while maintaining flow diversion and stability. This study aimed to evaluate the clinical and angiographic outcomes following the use of double-overlapping stents with LVIS within the Enterprise stent for the treatment of VADAs.Methods : From March 2016 to January 2022, total 28 patients with unruptured VADAs were treated with the double-overlapping stent technique using LVIS within an Enterprise stent in our institute. The Enterprise stent was deployed first, followed by the LVIS stent. Patient clinical and angiographic characteristics, procedural complications, and follow-up outcomes were retrospectively reviewed.Results : All 28 patients (18 males and 10 females) were successfully treated with double-overlapping stent deployment. There were no procedural complications or new neurological deficits in any patient. Of the 28 patients, four VADAs had posterior inferior cerebellar artery involvement. Procedure-related parent artery occlusion did not occur during the angiographic follow-up conducted 6 to 12 months after the procedure. Out of 28 patients, 24 showed complete healing, three had focal residual stenosis or dilatation with residual sac and only one had a residual dissecting flap with aneurysm. All patients, including the four patients, did not require any additional procedures. The postoperative modified Rankin scale scores were 0–1 for all patients.Conclusion : A double-overlapping stent, with a flow-diversion effect, is a safe and effective treatment for patients with VADAs. In particular, when using the LVIS stent within an Enterprise stent, it minimizes the bulging of the inner LVIS stent while maintaining flow diversion and stability. Therefore, both can be effectively utilized as overlapping stents.

Objective : Gamma Knife radiosurgery (GKRS) is an effective and noninvasive treatment for high-risk arteriovenous malformations (AVMs). Since differences in GKRS outcomes by nidus type are unknown, this study evaluated GKRS feasibility and safety in patients with brain AVMs.Methods : This single-center retrospective study included patients with AVM who underwent GKRS between 2008 and 2021. Patients were divided into compact- and diffuse-type groups according to nidus characteristics. We excluded patients who performed GKRS and did not follow-up evaluation with magnetic resonance imaging or digital subtraction angiography within 36 months from the study. We used univariate and multivariate analyses to characterize associations of nidus type with obliteration rate and GKRS-related complications.Results : We enrolled 154 patients (mean age, 32.14±17.17 years; mean post-GKRS follow-up, 52.10±33.67 months) of whom 131 (85.1%) had compact- and 23 (14.9%) diffuse-type nidus AVMs. Of all AVMs, 89 (57.8%) were unruptured, and 65 (42.2%) had ruptured. The mean Spetzler-Martin AVM grades were 2.03±0.95 and 3.39±1.23 for the compact- and diffuse-type groups, respectively (p<0.001). During the follow-up period, AVM-related hemorrhages occurred in four individuals (2.6%), three of whom had compact nidi. Substantial radiation-induced changes and cyst formation were observed in 21 (13.6%) and one patient (0.6%), respectively. The AVM complete obliteration rate was 46.1% across both groups. Post-GKRS complication and complete obliteration rates were not significantly different between nidus types. For diffuse-type nidus AVMs, larger AVM size and volume (p<0.001), lower radiation dose (p<0.001), eloquent area location (p=0.015), and higher Spetzler-Martin grade (p<0.001) were observed.Conclusion : GKRS is a safe and feasible treatment for brain AVMs characterized by both diffuse- and compact-type nidi.

Objective : Delayed cerebral ischemia (DCI) is a major cause of disability in patients who survive aneurysmal subarachnoid hemorrhage (aSAH). Systemic inflammatory markers, such as peripheral leukocyte count and systemic immune-inflammatory index (SII) score, have been considered predictors of DCI in previous studies. This study aims to investigate which systemic biomarkers are significant predictors of DCI.Methods : We conducted a retrospective, observational, single-center study of 170 patients with SAH admitted between May 2018 and March 2022. We analyzed the patients’ clinical and laboratory parameters within 1 hour and 3–4 and 5–7 days after admission. The DCI and non-DCI groups were compared. Variables showing statistical significance in the univariate logistic analysis (p<0.05) were entered into a multivariate regression model.Results : Hunt-Hess grade “4–5” at admission, modified Fisher scale grade “3–4” at admission, hydrocephalus, intraventricular hemorrhage, and infection showed statistical significance (p<0.05) on a univariate logistic regression. Lymphocyte and monocyte count at admission, SII scores and C-reactive protein levels on days 3–4, and leukocyte and neutrophil counts on days 5–7 exhibited statistical significance on the univariate logistic regression. Multivariate logistic regression analysis revealed that monocyte count at admission (odds ratio [OR], 1.64; 95% confidence interval [CI], 1.04–2.65; p=0.036) and SII score at days 3–4 (OR, 1.55; 95% CI, 1.02–2.47; p=0.049) were independent predictors of DCI.Conclusion : Monocyte count at admission and SII score 3–4 days after rupture are independent predictors of clinical deterioration caused by DCI after aSAH. Peripheral monocytosis may be the primer for the innate immune reaction, and the SII score at days 3–4 can promptly represent the propagated systemic immune reaction toward DCI.

Purpose Neurogenic pulmonary edema (NPE) combined with Takotsubo cardiomyopathy (TCM) is a rare condition associated with aneurysmal subarachnoid hemorrhage (aSAH). Although several mechanisms have been proposed, the pathophysiology and management strategies are not yet fully established. We aimed to determine the radiological and clinical outcomes of patients with NPE and with TCM after aSAH to propose management strategies. Methods We analyzed the data of 564 patients with aSAH recorded at a single medical center from February 2015 to July 2022. This study retrospectively investigated the incidence and demographics of SAH combined with both NPE and TCM and the clinical outcomes of the patients. Correlating factors, independently associated with NPE-TCM, were also investigated. Results During the 7 years, 11 (2.0%) of 564 patients had NPE complicated with TCM after aSAH. Seven of 11 (63.6%) patients had poor-grade SAH (Hunt–Hess Grade 4 to 5). Three of 11 patients had a posterior circulation in the NPE-TCM group. The most prevalent treatment option was endovascular coil embolization, except for one case of clip. Long-term outcomes were favorable in 6 of 11 patients, and there was one case of mortality. Age, troponin I level, and alveolar-arterial oxygen gradient were correlating factors of NPE-TCM. Conclusion Although NPE-TCM represents a rare complication associated with aSAH, achieving active resolution of underlying neurological causes through early and appropriate treatment may contribute to a favorable prognosis. Considering the limited incidence of SAH complicated with NPE-TCM, a multi-center study may be needed.

Objective: Aneurysms in systemic arteries are rare, and little is known about their relationship with aortic aneurysms. In this study, we aimed to evaluate the prevalence of aortic aneurysms and dissections (AAD) in patients with other systemic vessel aneurysms and dissections (OVAD) and identify their potential risk factors.Methods: This cross-sectional study used a nationwide representative cohort sample from the Korea National Health Insurance Service-National Sample Cohort database. We defined OVAD as systemic vessel aneurysms and dissections excluding intracranial and aortic dissections and aneurysms. With a total of 690 OVAD patients and 2,760 non-OVAD matched controls, we investigated the prevalence of AAD in patients with OVAD and potential risk factors for their concurrence using the χ² test and logistic regression.Results: The prevalence of AAD in patients with OVAD was 10.6% (73/690) and 0.3% (9/2,760) in patients with non-OVAD. The adjusted odds ratio (OR) for having concurrent AAD with OVAD was 37.56 (95% CI: 18.29–77.12, p < 0.001) after stratification by sex, age, income, region of residence and after adjustment for hypertension, diabetes mellitus, dyslipidemia, and extent of disability. The adjusted ORs of AAD were significantly higher in females [adjusted OR = 47.63 (95% CI: 10.72–211.55)], and individuals aged ≥60 years [adjusted OR = 28.18 (95% CI: 13.42–59.17)], as well as those without hypertension [adjusted OR = 95.44 (95% CI: 18.21–500.23)], diabetes mellitus [adjusted OR = 46.39 (95% CI: 18.85–114.17)], without dyslipidemia [adjusted OR = 60.99 (95% CI: 20.83–178.56), p < 0.001 for all]. The prevalence of AAD significantly differed by according to specific sites of OVAD in carotid artery, upper extremity artery, iliac artery, lower extremity artery, and splanchnic artery (p < 0.001 for all).Conclusions: The prevalence of AAD in patients with OVAD was 37.56 times higher than that in the matched population. We may approach aneurysms as systemic diseases and further investigations of pathophysiology would help to clarify the relationships between AAD and OVAD.

Objective : Stent-assisted coil embolization (SAC) has been increasingly used to treat various types of intracranial aneurysms. Delayed thromboembolic complications are major concerns regarding this procedure, so dual antiplatelet therapy with aspirin and clopidogrel is needed. However, clinicians vary the duration of dual antiplatelet therapy after SAC, and no randomized study has been performed. This study aims to compare the safety and efficacy of long-term (12 months) dual antiplatelet therapy and shortterm dual antiplatelet therapy (6 months) after SAC for patients with unruptured intracranial aneurysms (UIAs).Methods : This is a prospective, randomized and multicenter trial to investigate the optimal duration of dual antiplatelet therapy after SAC in patients with UIAs. Subjects will receive dual antiplatelet therapy for 6 months (short-term group) or 12 months (longterm group) after SAC. The primary endpoint is the assessment of thromboembolic complications between 1 and 18 months after SAC. We will enroll 528 subjects (264 subjects in each group) and perform 1 : 1 randomization. This study will involve 14 topperforming, high-volume Korean institutions specializing in coil embolization.Results : The trial will begin enrollment in 2022, and clinical data will be available after enrollment and follow-up.Conclusion : This article describes that the aim of this prospective randomized multicenter trial is to compare the effect of short-term (6 months) and long-term (12 months) dual antiplatelet therapy on UIAs in patients undergoing SAC, and to find the optimal duration.

Background: In patients with acute symptomatic stroke, reinforcement of transdural angiogenesis using multiple burr hole (MBH) procedures after EPO (erythropoietin) treatment has rarely been addressed. We aimed to investigate the efficacy and safety of cranial MBH procedures under local anesthesia for augmenting transdural revascularization after EPO treatment in patients with stroke with perfusion impairments. Methods: This prospective, randomized, blinded-end point trial recruited patients with acute ischemic stroke with a perfusion impairment of grade ≥2 within 14 days of symptom onset, steno-occlusive mechanisms on imaging examinations, and absence of transdural collaterals on transfemoral cerebral angiography. Patients were randomly assigned to receive MBH + EPO or MBH alone. The primary and secondary outcomes were revascularization success (trans-hemispheric and trans-burr hole) at 6 months and adverse events, respectively. Results: We evaluated 42 of the 44 targeted patients, with 2 patients lost to follow-up. The combined and MBH-only (n=21 each) groups showed no differences in demographic characteristics and baseline perfusion parameters. Significantly, more cases of trans-hemispheric (19/21 [90.5%] versus 12/21 [57.1%]) and trans-burr hole (42/58 [72.4%] versus 30/58 [51.7%]) revascularization and significant improvements in perfusion parameters were observed in the combined group relative to the MBH-only group. No differences in treatment-related complications were observed between groups. Even after adjustment for potential covariates, EPO usage was an independent factor of successful hemispheric revascularization in this study (odds ratio, 6.41 [95% CI, 1.08–38.02]). Conclusions: The combination of MBH and EPO is safe and feasible for reinforcing transdural revascularization in acute steno-occlusive patients with perfusion impairments. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02603406.

Kim YN, et al. Korean J Radiol. 2022 Feb;23(2):246-255. https://doi.org/10.3348/kjr.2021.0332