Geometric influence of anterior cerebral artery rotation on the formation of anterior communicating artery aneurysm

Objective@#Several particular morphological factors that contribute to the hemodynamics of the anterior communicating artery (ACoA) have been documented, but no study has investigated the role of the degree of anterior cerebral artery (ACA) rotation on the presence of ACoA aneurysms (ACoAAs). @*Methods@#A retrospective study of an institutional aneurysm database was performed; patients with ruptured or nonruptured ACoAAs were selected. Two sex- and age-matched control groups were identified: control Group A (nonaneurysms) and control Group B (middle cerebral artery aneurysms). Measurements of ACA rotation degree were obtained by using a three-dimensional imaging tool. @*Results@#From 2015 to 2020, 315 patients were identified: 105 in the ACoAA group, 105 in control Group A, and 105 in control Group B. The average age at the time of presentation was 64 years, and 52.4% were female. The ACA rotation degree of the ACoAA group was significantly higher than that of control Group A (p <0.01). The A1 ratio and the A1A2 ratio of the ACoAA group were greater than those of control Group A (p <0.01 and p <0.01, respectively). The ACA rotation degree correlated insignificantly with aneurysm size in ACoAA patients (p=0.78). The ACA rotation degree in the ACoAA group was also insignificantly different from that in control B (p=0.11). @*Conclusions@#The degree of ACA rotation was greater in the ACoAA group than in the nonaneurysm group, and it may serve as an imaging marker for ACoAA.

The Fate of Partially Thrombosed Intracranial Aneurysms Treated with Endovascular Intervention

Objective@#: The fate of partially thrombosed intracranial aneurysms (PTIAs) is not well known after endovascular treatment. The authors aimed to analyze the treatment outcomes of PTIAs. @*Methods@#: We retrospectively reviewed the medical records of 27 PTIAs treated with endovascular intervention between January 1999 and March 2018. Twenty-one aneurysms were treated with intraluminal embolization (ILE), and six were treated with parent artery occlusion (PAO) with or without bypass surgery. Radiological results, clinical outcomes and risk factors for major recurrence were assessed. @*Results@#: The initial clinical status was similar in both groups; however, the last status was better in the ILE group than in the PAO group (p=0.049). Neurological deterioration resulted from mass effect in one case and rupture in one after ILE, and mass effect in two and perforator infarction in one after PAO. Twenty cases (94.2%) in the ILE group initially achieved complete occlusion or residual neck status. However, 13 cases (61.9%) showed major recurrence, the major causes of which included coil migration or compaction. Seven cases (33.3%) ultimately achieved residual sac status after repeat treatment. In the PAO group, all initially showed complete occlusion or a residual neck, and just one case ultimately had a residual sac. Two cases showed major recurrence, the cause of which was incomplete PAO. Aneurysm wall calcification was the only significantly protective factor against major recurrence (odds ratio, 36.12; 95% confidence interval, 1.85 to 705.18; p=0.018). @*Conclusion@#: Complete PAO of PTIAs is the best option if treatment-related complications can be minimized. Simple fluoroscopy is a useful imaging modality because of the recurrence pattern.

The Fate of Partially Thrombosed Intracranial Aneurysms Treated with Endovascular Intervention

Objective@#: The fate of partially thrombosed intracranial aneurysms (PTIAs) is not well known after endovascular treatment. The authors aimed to analyze the treatment outcomes of PTIAs. @*Methods@#: We retrospectively reviewed the medical records of 27 PTIAs treated with endovascular intervention between January 1999 and March 2018. Twenty-one aneurysms were treated with intraluminal embolization (ILE), and six were treated with parent artery occlusion (PAO) with or without bypass surgery. Radiological results, clinical outcomes and risk factors for major recurrence were assessed. @*Results@#: The initial clinical status was similar in both groups; however, the last status was better in the ILE group than in the PAO group (p=0.049). Neurological deterioration resulted from mass effect in one case and rupture in one after ILE, and mass effect in two and perforator infarction in one after PAO. Twenty cases (94.2%) in the ILE group initially achieved complete occlusion or residual neck status. However, 13 cases (61.9%) showed major recurrence, the major causes of which included coil migration or compaction. Seven cases (33.3%) ultimately achieved residual sac status after repeat treatment. In the PAO group, all initially showed complete occlusion or a residual neck, and just one case ultimately had a residual sac. Two cases showed major recurrence, the cause of which was incomplete PAO. Aneurysm wall calcification was the only significantly protective factor against major recurrence (odds ratio, 36.12; 95% confidence interval, 1.85 to 705.18; p=0.018). @*Conclusion@#: Complete PAO of PTIAs is the best option if treatment-related complications can be minimized. Simple fluoroscopy is a useful imaging modality because of the recurrence pattern.

De Novo Intracranial Aneurysms Detected on Imaging Follow-Up of Coiled Aneurysms in a Korean Population

OBJECTIVE: Coiled aneurysms are known to recanalize over time, making follow-up evaluations mandatory. Although de novo intracranial aneurysms (DNIAs) are occasionally detected during routine patient monitoring, such events have not been thoroughly investigated to date. Herein, we generated estimates of DNIA development during long-term observation of coiled cerebral aneurysms, focusing on incidence and the risk factors involved. MATERIALS AND METHODS: In total, 773 patients undergoing coil embolization of intracranial aneurysms between 2008 and 2010 were reviewed retrospectively. Their medical records and radiologic data accrued over the extended period (mean, 52.7 ± 29.7 months) were analyzed. For the detection of DNIA, follow-up magnetic resonance angiography and/or conventional angiography were used. The incidence of DNIAs and related risk factors were analyzed using Cox proportional hazards regression and Kaplan-Meier product-limit estimator. RESULTS: In 19 (2.5%) of the 773 patients with coiled aneurysms, DNIAs (0.56% per patient-year) developed during continued long-term monitoring (3395.3 patient-years). Of these, 9 DNIAs (47.4%) were detected within 60 months, with 10 (52.6%) emerging thereafter. The most common site involved was the posterior communicating artery (n = 6), followed by the middle cerebral artery (n = 5) and the basilar top (n = 4). Multivariate analysis indicated that younger age ( 60 years; p < 0.001) and in the absence of post-coiling aneurysm recurrence (p = 0.006). CONCLUSION: In most patients with coiled aneurysms, development of DNIAs during long-term monitoring is rare. However, younger patients (< 50 years) or patients with recurring aneurysms appear to be predisposed to DNIAs.

Symptomatic Retinal Artery Occlusion after Angioplasty and Stenting of the Carotid Artery: Incidence and Related Risk Factors

OBJECTIVE: Retinal artery occlusion (RAO) is rarely seen as a complication in patients undergoing carotid artery stenting (CAS); hence, its characteristics have not been documented in detail. This study aimed to investigate the incidence of this complication and the related risk factors, focusing on differences in ophthalmic artery (OA) supply (whether by the external or internal carotid artery [ECA or ICA]) prior to CAS procedures. MATERIALS AND METHODS: We retrospectively examined 342 patients who underwent CAS for severe and/or symptomatic carotid artery stenosis between January 2009 and December 2017. Cumulative medical records and radiologic data were assessed. RAO was confirmed by photography and fluorescent angiography of the fundus, which were performed by an ophthalmologist. In all patients, distal filter systems of various types were applied as cerebral protection devices (CPDs) during procedures. Univariate and multivariate analyses were conducted to identify the risk factors for RAO after CAS. RESULTS: Symptomatic RAO was observed in six patients (1.8%), of which five (6.8%) were ECA-dominant group members (n = 74). In a binary logistic regression analysis, OA supply by the ECA (odds ratio [OR], 9.705; 95% confidence interval [CI], 1.519–62.017; p = 0.016) and older age (OR, 1.159; 95% CI, 1.005–1.336; p = 0.041) were identified as significant risk factors in patients with RAO after CAS. ECA-supplied OA was also associated with the severity of ipsilateral ICA stenosis (p = 0.001) and ulcerative plaque (p = 0.021). CONCLUSION: In procedures performed using ICA distal filtering CPD systems, RAO as a complication of CAS (performed for severe stenosis) showed a relationship to ECA-supplied OA. For older patients, simultaneous use of ICA-ECA CPDs might help prevent such complications.

Endovascular Treatment of Bilateral Cavernous Sinus Dural Arteriovenous Fistula: Therapeutic Strategy and Follow-Up Outcomes

OBJECTIVE: Bilateral cavernous sinus dural arteriovenous fistula (CSdAVF) is very rare, even in Asian countries. The research intended to present clinical and radiologic outcomes of treating such fistulas through endovascular embolization. MATERIALS AND METHODS: Data was obtained from 220 consecutive patients, with CSdAVF, who were treated from January 2004 to December 2015. Bilateral CSdAVF was identified in 17 patients (7.7%). The clinical and radiologic outcomes of the fistulas were assessed with an emphasis on the technical aspects of treatment. RESULTS: At the time of treatment, 7 and 10 patients presented with bilateral and unilateral symptoms, respectively. In the former cases, 4 patients had progressed from unilateral to bilateral symptoms. Bilateral fistulas were treated with a single-stage transvenous embolization (TVE) in 15 patients, via bilateral inferior petrosal sinuses (IPS) (n = 9) and unilateral IPS (n = 6). In the other 2 patients with one-sided dominance of shunting, only dominant fistula was treated. Two untreated lesions were found on follow-up to have spontaneously resolved after treatment of the dominant contralateral fistula. Of the 34 CSdAVF lesions, complete occlusion was achieved in 32 lesions after TVE. Seven patients (41.2%) developed worsening of cranial nerve palsy after TVE. During the follow-up period, 4 patients obtained complete recovery, whereas the other 3 remained with deficits. CONCLUSION: With adjustments of endovascular procedures to accommodate distinct anatomical configurations, endovascular treatment for bilateral CSdAVF can achieve excellent angiographic occlusion results. However, aggravation of symptoms after TVE may occur frequently in bilateral CSdAVF. In the patients with one-sided dominance of shunt, treatment of only dominant fistula might be an alternative option.

Intracranial Mirror Aneurysms: Anatomic Characteristics and Treatment Options

OBJECTIVE: Mirror aneurysms are generally considered as a subset of multiple aneurysms, defined as aneurysms occurring bilaterally and symmetrically on the same-named vessels. Although not infrequent, the characteristics of mirror aneurysms are not well studied. This investigation was conducted to elucidate the anatomic features of such lesions and examine treatment options. MATERIALS AND METHODS: A retrospective review was conducted, aimed at 172 patients treated for 344 mirror aneurysms between January 2007 and December 2015. Aneurysms of similar nature but in asymmetric locations on the same-named vessels were excluded. All available records were examined and lesion characteristics, as well as treatment outcomes were assessed. RESULTS: In study subjects (n = 172), mirror aneurysms most often involved middle cerebral artery bifurcation (n = 83), followed by a paraclinoid internal carotid artery (n = 50) and posterior communicating artery (n = 21). Most of the lesions (95.3%) measured ≤ 10 mm, and in 126 patients (74.6%), the size ratios were > 50%. Of the 344 aneurysms studied, coil embolization was undertaken in 217, surgical clipping in 62, and observation alone (no treatment) in 65. Coil embolization and surgical clipping were done bilaterally in 83 and 12 patients, respectively. In 12 patients, combined coiling and clipping were implemented on each side. Single-stage coil embolization of both the aneurysms was performed in 73 patients, with excellent post-procedural (85.6%) and follow-up (86.8%) occlusive results. There was no procedure-related morbidity or mortality. CONCLUSION: By adopting different treatment strategies to different configurations and vascular sources, mirror aneurysms can be safely and effectively treated. If feasible, single-stage coil embolization should be considered as a reasonable treatment option for mirror aneurysms.

Microguidewire Looping to Traverse Stented Parent Arteries of Intracranial Aneurysms

OBJECTIVE: Stents are widely used in coil embolization of intracranial aneurysms, but on occasion, a microcatheter must traverse a stented segment of artery (so-called trans-cell technique) to select an aneurysm, or double stenting may necessary. In such situations, microguidewire passage and microcatheter delivery through a tortuous stented parent artery may pose a technical challenge. Described herein is a microguidewire looping technique to facilitate endovascular navigation in these circumstances. METHODS: To apply this technique, the microguidewire tip is looped before entering the stented parent artery and then advanced distally past the stented segment, with the loop intact. Rounding of the tip prevents interference from stent struts during passage. A microcatheter is subsequently passed into the stented artery for positioning near the neck of aneurysm, with microguidewire assistance. The aneurysm is then selected, steering the microcatheter tip (via inner microguidewire) into the dome. RESULTS: This technique proved successful during coil embolization of nine saccular intracranial aneurysms (internal carotid artery [ICA], 6; middle cerebral artery, 2; basilar tip, 1), performing eight trans-cell deliveries and one additional stenting. Selective endovascular embolization was enabled in all patients, resulting in excellent clinical and radiologic outcomes, with no morbidity or mortality directly attributable to microguidewire looping. CONCLUSION: Microguidewire looping is a reasonable alternative if passage through a stented artery is not feasible by traditional means, especially at paraclinoid ICA sites.

Effect of Long Working Hours on Self-reported Hypertension among Middle-aged and Older Wage Workers

OBJECTIVES: Many studies have reported an association between overwork and hypertension. However, research on the health effects of long working hours has yielded inconclusive results. The objective of this study was to identify an association between overtime work and hypertension in wage workers 45 years and over of age using prospective data. METHODS: Wage workers in Korea aged 45 years and over were selected for inclusion in this study from among 10,254 subjects from the Korean Longitudinal Study of Ageing. Workers with baseline hypertension and those with other major diseases were excluded. In the end, a total of 1,079 subjects were included. A Cox proportional hazards model was used to calculate hazard ratios and adjust for baseline characteristics such as sex, age, education, income, occupation, form of employment, body mass index, alcohol habit, smoking habit, regular exercise, and number of working days per week. Additional models were used to calculate hazard ratios after gender stratification. RESULTS: Among the 1,079 subjects, 85 workers were diagnosed with hypertension during 3974.2 person-months. The average number of working hours per week for all subjects was 47.68. The proportion of overtime workers was 61.0% (cutoff, 40 h per week). Compared with those working 40 h and less per week, the hazard ratio of subjects in the final model, which adjusted for all selected variables, working 41-50 h per week was 2.20 (95% confidence interval [CI], 1.19-4.06), that of subjects working 51-60 h per week was 2.40 (95% CI, 1.07-5.39), and that of subjects working 61 h and over per week was 2.87 (95% CI, 1.33-6.20). In gender stratification models, the hazard ratio of the females tended to be higher than that of the males. CONCLUSION: As the number of working hours per week increased, the hazard ratio for diagnosis of hypertension significantly increased. This result suggests a positive association between overtime work and the risk of hypertension.

Association between Physical Workload and Work-related Back Pain: A Nationwide Study / 대한산업의학회지

OBJECTIVES: To date, no population-based epidemiological studies have estimated the association between physical workload (standing or walking, carrying heavy loads, carrying people, repetitive hand or arm movements, wearing protective equipment) and work-related back pain in Korea. The purpose of this study was to evaluate the relationship between physical workload and work-related back pain using a nationwide survey. METHODS: We analyzed data obtained from working men and women age 15 to 64 (n=10,043) who participated in the 2006 national working condition survey of random sample workers in Korea. Using both simple and multiple logistic regression analysis, the association between physical workload and work-related back pain was evaluated. RESULTS: Carrying heavy loads, repetitive hand or arm movements, and wearing protective equipment were associated with an increased risk of work-related back pain. CONCLUSIONS: This study identifies that an increased risk of work-related back pain related to the nature and intensity of the physical workload of the general working population in Korea. We also found a strong association between repetitive hand or arm movements and back pain.

User's Satisfaction on the Electronic Medical Record System in Seoul National University Bundang Hospital / 대한의료정보학회지

OBJECTIVE: Seoul National University Bundang Hospital is the first full digital hospital with electronic medical record(EMR) system in Korea. We evaluated the user's satisfaction on the EMR system at 15 months from its beginning. METHODS: A total of 105 doctors and 503 nurses participated in this study. The questionnaire was composed of four domains: user satisfaction between paper records and EMR, User perceived improvement of work efficiency with EMR, user interface satisfaction and advantage/ disadvantage of EMR. A Likert-type 5-point scale was used for the degree of satisfaction, with 5 indicating 'very satisfied'. RESULTS: Doctors were more satisfied with EMR system than paper records, especially on editing (3.33 vs. 2.73, p0.05). Nurses were more satisfied with EMR system than paper records, e.g., editing (3.51 vs. 2.74, p<0.05), retrieval (4.07 vs. 2.51, p<0.05) and input (3.82 vs. 2.90, p<0.05). Also, doctors and nurses showed satisfaction for most of user interfaces. CONCLUSION: Users seem to be satisfied with the EMR system. EMR system should have a flexible system to improve the input system, the structured forms, and the standardized terminology according to the need of users.

A Study on Model for Decreasing an Outpatient Waiting Time / 대한의료정보학회지

This study is tried to suggest the new model to shorten the patient's waiting time from counting department to receiving drugs from pharmacy after doctor's diagnosis. The method of this study is designed to simulate from counting time to finishing time of dispensing drugs for internal medicine outpatients. The results are as follows : First, the increasing the numbers of server at pharmacy and counting department in present model don't effect on shortening outpatient's waiting time. Second, in the case of application of OCS, the outpatient's waiting time for receiving dispensed drugs from pharmacy is rather delayed because of no waiting time for counting. Third, in the case of application OCS and ATC simultaneously, the outpatient's waiting time for receiving dispensed drugs is shortened, and in this case, the increasing the numbers of server at pharmacy effect more greatly on the changes of patient's waiting time for receiving dispensed drugs from pharmacy. From the results of this study, it is noted that the best optimal for shortening outpatient's waiting time in general hospital is to introduce the OCS and ATC simultaneously in the process between the counting department and pharmacy, and increasing the numbers of server at pharmacy.