Erol Akgul

Background/Objectives: Same-session hybrid treatment joins embolization to immediate microsurgical resection under one anesthetic, closing the interval of partial devascularization that follows staged embolization. Comparative data are scarce. We set out to compare angiographic, functional and safety outcomes after hybrid and after endovascular-only treatment and to judge how far any difference reflects case selection and calendar period rather than the strategies themselves. Methods: We reviewed 43 consecutive patients treated for cerebral arteriovenous malformation at one center between May 2012 and December 2024. Nineteen received same-session hybrid treatment and 24 embolization without same-session surgery. The primary endpoint was complete obliteration on six-month angiography. Differences are reported with 95% confidence intervals, and odds ratios were estimated using Firth penalized regression, since both principal comparisons showed complete separation. Results: Hybrid patients were younger (median 31.0 versus 42.5 years; p = 0.040), with similar sex distribution and Spetzler–Martin grade. Complete obliteration was reached in all 19 hybrid patients (100%) and in 14 of 24 endovascular-only patients (58.3%), representing a difference of 41.7 percentage points (95% CI 17.6–61.2). All four deaths occurred in the hybrid group (21.1% versus 0%; p = 0.031). Complications (15.8% versus 12.5%) and favorable outcome (mRS 0–2, 68.4% versus 75.0%) did not differ. The strategies also belonged to different periods. Eight of 19 hybrid but 21 of 24 endovascular patients were treated before 2019 (p = 0.003), as were three of the four deaths. Conclusions: The hybrid treatment obliterated every malformation but accounted for every death, with no difference in functional outcome. Because the groups served different clinical purposes in different eras, these observations are hypothesis-generating rather than grounds for changing practice.

Flow-diverting stents in the management of extracranial carotid artery aneurysms - Diagnostic and Interventional Radiology

Background: There is no consensus on the duration of dual antiaggregant therapy after carotid stenting. This study aimed to evaluate the early contribution of dual antiaggregant therapy for three or six months to stent restenosis. Objective: This study aimed to identify the correlation between stent restenosis and the duration of dual antiplatelet therapy (DAPT) in carotid artery stenting (CAS) subjects by retrospectively scanning a CAS procedure dataset. Methods: Patients who underwent a CAS procedure received dual DAPT (acetylsalicylic acid (ASA) + clopidogrel) were recruited for this study. The first group was the patients who received dual antiaggregants for three months, and the second group was the patients who received dual antiaggregants for six months. Patients' demographic characteristics, comorbidities, and radiological results were reviewed. Follow-up activities for the following six months were assessed for stent status, complications, and new ischemic lesions. Results: A total of 65 patients received ASA (acetylsalicylic acid) + clopidogrel for six months, while the remaining 118 patients were treated for three months. The restenosis rates were not significantly different between the two groups. The complication and adverse event frequencies were also similar. Conclusion: This study revealed that the efficacy of 3-month and 6-month DAPT is similar regarding the restenosis frequency, and there are no significant differences in complication frequency.

AIM: To evaluate the safety and efficacy of flow diverter stents (FDSs) for treating remnant or recurrent intracranial aneurysms that were treated surgically. MATERIAL and METHODS: The patients who were treated with FDSs due to remnant or recurrent intracranial aneurysms after microsurgery were included in the study. The patients' demographics, treatment histories, aneurysm features, complications associated with flow diversion, and neurological and angiographic follow-up findings were evaluated. RESULTS: Twenty patients (eight males) with 20 aneurysms were included in the study. Of 20 aneurysms, 18 (90%) were in the anterior, and two (10%) were in the posterior circulation. The initial treatment methods were clipping in 17 (85%) and wrapping in three (15%) aneurysms. The endovascular procedure was successful in all patients. In three patients (15%), periprocedural and postprocedural complications were encountered. No hemorrhagic complications were detected on cone-beam computed tomography. One patient with a basilary aneurysm died because of brain stem ischemia. The total morbimortality was 5%. The mean length of follow-up was 13.7 & PLUSMN; 7.3 months in 18 patients. The first angiographic follow-up (3-6 months) revealed the complete occlusion in 7 of 11 aneurysms (63.6%). By contrast, 16 aneurysms (94.1%) were occluded at the last angiographic follow-up, one aneurysm (5.9%) was still filling. CONCLUSION: An FDS seems effective, safe, and extremely attractive in treating remnant and recurrent intracranial aneurysms treated surgically.

Background/aim: This study aimed to evaluate the diameter and flow changes in the circle of Willis and side branches following the use of FDSs extending from the middle cerebral artery (MCA) to the internal carotid artery (ICA) for the treatment of aneurysms in the terminal segment of ICA, and the clinical results. Material and method: This study was conducted in a single center between January 2012 and April 2018 in patients with the anterior choroidal artery (AChoA), the posterior communicating artery (PComA), and the ICA terminal segment aneurysms treated with the FDSs. The changes in aneurysm size, arterial structures covered by the FDSs, and changes in the diameter and flow in arteries forming the circle of Willis were retrospectively analyzed. Results: Fourteen patients with a total of 25 aneurysms treated with FDSs extending from MCA to ICA were evaluated. The mean aneurysm fundus size was 5.14 mm (range 1.5-22 mm). Before treatment, the anterior communicating artery (AComA) was patent in all patients. Implanted FDSs covered the anterior cerebral artery (ACA) and AChoA in all patients (100%), nonhypoplasic PComA in two patients (14.28%), and the ophthalmic artery in nine (64.3%). The mean follow-up time was 36.78 ± 22.44 months. In followup, there was a decrease in the mean ipsilateral ACA A1 segment diameter from 1.99 ± 0.58 cm to 1.81 ± 0.31 cm (p = 0.01). The mean contralateral A1 segment diameter increased from 1.66 ± 0.48 cm to 1.93 ± 0.42 cm (p = 0.004). All aneurysms were totally occluded. Conclusion: If the AComA is patent, ipsilateral anterior circulation can be compensated through modifications in the contralateral ACA A1 segment in patients with ICA terminal segment aneurysms treated with FDSs extended from MCA to ICA and covering ACA. Although covering the anterior choroidal and lenticulostriate arteries by FDSs, ischemic complications may not occur frequently. Thus, this effective therapy can be applied more safely.

Background: We assessed the safety and efficacy of flow diverter stents (FDSs) in the treatment of recanalized or residual intracranial aneurysms treated endovascularly. Materials & Methods: Patients whose recanalized or residual aneurysms were treated with FDSs in five tertiary hospitals were reviewed retrospectively. The patients’ demographic data, aneurysm characteristics, types of previous treatment, and clinical complications, or serious adverse events associated with FDSs, as well as the results of neurological and angiographic follow-up assessments, were recorded. Results: Eighty-six patients (37 males) with 87 aneurysms were included in this study. Eighty (91.9%) aneurysms were in the anterior and seven (8.1%) in the posterior circulation. The initial treatment methods were the primary coiling or balloon remodeling technique in 69 (79.3%) and stent-assisted coiling in 18 (20.7%) aneurysms. The endovascular procedure was successful in all patients. Complications occurred in four patients, for a total complication rate of 4.6%. A technical complication developed in one patient (1.2%). An in-stent thrombosis treated with tirofiban was seen in two cases. Late in-stent stenosis exceeding 50% was treated with balloon angioplasty in one patient. The mean length of follow-up was 21.0 months. The first angiographic follow-up (3–6 months) revealed the complete occlusion of 74 aneurysms (85.1%). While 76 aneurysms (87.4%) were occluded at the last angiographic follow-up (mean: 26.0 months), 11 aneurysms (12.6%) were still filling. Morbimortality was zero. Conclusion: The drawback of endovascular treatment is aneurysmal remnants or recurrences, which is safely and durably amenable to flow diversion.

Amaç: Bu çalışmanın amacı supraaortik çoklu stenotik lezyonlarda yapılan, eş zamanlı endovasküler tedavinin başarısı ile komplikasyonlarını değerlendirmektir.Gereç ve Yöntem: 1 Ocak-2004 ile 31 Aralık 2009 tarihler arasında supraaortik damar yatağında çoklu darlık nedeni ile perkütan girişimsel işlem uygulanan hastaların kayıtları geriye dönük incelendi. Doppler ultrasonografi, manyetik rezonans inceleme, bilgisayarlı tomografi veya dijital subtraksiyon anjiyografi ile supraaortik damarlarda %50 nin üzerinde darlık saptanması koşuluyla perkütan endovasküler girişim uygulanması kararı alındı. Klinik olarak en az 2 tane ciddi darlığı olan ve aynı seansta çoklu girişimsel işlem kararı verilen hastalar çalışmaya dahil edildi.Bulgular: Çalışmaya 6’sı kadın (%17,4) toplam 34 hasta (ortalama yaş 60,4±12,5) dahil edildi. Otuzdört hastada toplam 74 lezyona girişim uygulandı. Girişimlerin tamamında stent kullanıldı. Mortalite veya ciddi morbidite görülmedi. İşlemin teknik olarak akut başarısı %100’dü. Ortalama 29,5±18,3 aylık takipte, 4 hastada (%11,7) restenoz geliştiği görüldü. Bu hastalardan 3’üne tekrar girişim uygulandı.Sonuç: Çalışmamızın sonuçlarına göre supraaortik dallarda tıkayıcı aterosklerotik damar hastalığı gelişmesi durumunda endovasküler girişim güvenle uygulanabilir. Bu tedavinin mortalitesive morbiditesi oldukça düşüktür. Takiplerinde restenoz gelişen hastalara tekrar girişim güvenle uygulanabilir. Aynı hasta grubunda çoklu lezyon var ise aynı seansta çoklu girişim güvenle uygulanabilen bir tedavi seçeneğidir.