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Aortic dissection is one of the causes of acute ischemic stroke. Endovascular recanalization therapy (EVT) has emerged as an essential treatment for acute ischemic stroke due to large artery occlusion. However, it is rarely performed in the situation of hidden aortic dissection (AD). Two patients presented to the emergency room with focal neurologic deficits. The first patient was diagnosed with right internal carotid artery (ICA) occlusion. Angiography revealed that the ICA was occluded by the dissection flap. After a stent deployment in the proximal ICA, the antegrade flow was restored. The patient was diagnosed with AD on chest computed tomography (CT) after EVT. For the second patient, intraarterial thrombectomy was performed to treat left middle cerebral artery occlusion. AD was first detected on echocardiography, which was performed after EVT. Herein, we report successful endovascular recanalization therapy performed in two patients with acute ischemic stroke in the situation of undiagnosed aortic dissection. We also reviewed previous case reports and relevant literature.
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Objective@#: Chronic subdural hematoma (CSDH) is a common neurosurgical disease and generally treated with burr-hole surgery alone. Tranexamic acid (TXA) is an antifibrinolytic agent that potentially reduces recurrence rates and the residual hematoma volume. However, the role of postoperative TXA medication remains unclear to date. This study aimed to verify the effectiveness of adjunctive TXA in the view of early hematoma resolution. @*Methods@#: Between January 2018 and September 2021, patients with CSDH who underwent burr-hole trephination in a single tertiary institute were reviewed. The study population was divided into three groups, TXA, non-TXA, and antithrombotics (AT) groups, according to the medical history of cardio-cerebrovascular disease and TXA administration. The primary endpoint was CSDH recurrence, defined as re-appearance or re-accumulation of CSDH requiring neurosurgical interventions. The secondary outcome was CSDH resolution, defined as complete or near-complete resorption of the CSDH. The CSDH resolution time and serial changes of hematoma thickness were also investigated. @*Results@#: A total of 240 patients was included in the analysis consisting of 185 male and 55 female, with a median age of 74 years. During the median imaging follow-up period of 75 days, 222 patients were reached to the primary or secondary endpoint. TXA was administered as an adjunctive therapy in 41 patients (TXA group, 16.9%) while 114 patients were included in the non-TXA group (47.9%) and 85 were in the AT group. The recurrence rate was the lowest in the TXA group (2.4%), followed by non-TXA (7.0%) and AT (8.2%) groups. However, there was no statistical significance due to the small number of patients with recurrence. CSDH resolution was achieved in 206 patients, and the median estimated time to resolution was significantly faster in the TXA group (p<0.001). Adjunctive TXA administration was a significant positive factor for achieving CSDH resolution (p<0.001). The hematoma thickness was comparable among the three groups at the initial time and after surgery. However, CSDH thickness in the TXA group decreased abruptly in a month and showed a significant difference from that in the other groups (p<0.001). There was no TXA-related adverse event. @*Conclusion@#: The adjunctive use of TXA after CSDH surgery significantly facilitated the resorption of residual CSDH and resulted in the early CSDH resolution. Adjunctive TXA may be an effective treatment option to reduce recurrence by enhancing CSDH resolution in the selective patients.
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Symptomatic Rathke’s cleft cysts (RCCs) can be treated by surgical procedures, usually through an endonasal transsphenoidal corridor using either a microscope or an endoscope. We report a large suprasellar extended RCC causing obstructive hydrocephalus, which was efficiently managed by a novel surgical route named “reverse” trans-sellar approach using transventricular neuroendoscopy. A 48-yearold woman complained of persistent headache and a tendency to fall that had begun 6 months previously. The images obtained from MRI scan showed intra- and supra-sellar cystic masses occupying the third ventricle with obstruction of the foramina of Monro and the aqueduct of Sylvius. The cystic wall showed a slight enhancement, and the cystic contents showed iso-signal intensity on T1-and T2-weighted images. Instead of trans-nasal trans-sellar surgery, we decided to operate using a conventional transventricular endoscope. A thin cystic capsule, which blocked the foramina of Monro and the aqueduct of Sylvius, was fenestrated and removed and a third ventriculostomy was performed. The defect in the infundibulum between sellar and suprasellar cysts was widened and used as a corridor to drain cystic contents (reverse trans-sellar route). The final pathological finding revealed an RCC with focal metaplasia. We efficiently managed a large RCC by transventricular neuroendoscopic surgery with cyst fenestration and third ventriculostomy and simultaneously drained the sellar contents using a novel surgical route. Reverse trans-sellar neuroendoscopic surgery is a relevant treatment option for selective patients with large suprasellar extensions of RCCs.
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Syncope is a common symptom in clinical practice. Rotational vertebral artery occlusion syndrome, also referred to as Bow Hunter’s syndrome (BHS), is a rare condition associated with syncope and is caused by mechanical occlusion or stenosis secondary to mechanical compression of the vertebral artery during head rotation. BHS is associated with a multifactorial etiology; however, in most cases, this condition is attributed to degenerative changes. A 53-year-old man visited our hospital for the evaluation of fainting and dizziness episodes that occurred when he turned his head. Evaluation as an outpatient in the Department of Neurology showed a positive result on the Frenzel goggle test. Transfemoral cerebral angiography performed at the Department of Neurosurgery revealed stenosis of the proximal right vertebral artery. Complete occlusion of the vertebral artery was observed, and the head was turned to the right. Decompression and fusion were performed, and the contributory lesion was completely removed. Postoperative imaging confirmed complete removal of the spur and sufficient vertebral artery decompression; the patient’s symptoms resolved postoperatively.
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Background@#Anterior choroidal artery (AchA) aneurysms are usually small in diameter because of the size of the involved artery and are often wide-necked. Coil embolization of AchA aneurysm is thus challenging because of serious risks, such as thromboembolic occlusion of artery and perforation of aneurysm dome. Therefore, aneurysmal neck clipping remains widely performed despite a recent increase in the use of coil embolization for aneurysm treatment. We report the treatment results of AchA aneurysms mostly (92.3%) treated with coil embolization at our institute. @*Methods@#The database and medical records of patients who underwent coil embolization for AchA aneurysms were retrospectively analyzed. The clinical and imaging results and procedure-related complications were investigated after coil embolization performed between January 2006 and March 2022 at our institute. @*Results@#In total, 96 AchA aneurysms comprising 65 unruptured and 31 ruptured aneurysms, including only 1 ruptured aneurysm (1.0%) re-embolized at postoperative day 192 because of coil compaction, were evaluated. After the initial coil embolization, complete occlusion was attained in 41, residual neck in 45, and residual aneurysm in 10 patients. Follow-up radiological studies after 6–174 months were performed for 80 aneurysms. Complete occlusion was noted in 57 patients, residual neck in 22, and residual aneurysm in 1. The dysarthria experienced by one (1.0%) patient was the only symptomatic procedure-related complication. After coil embolization, neither delayed new rupture nor re-rupture was observed. @*Conclusions@#The results of this study demonstrate that coil embolization is a safe and effective treatment option for patients with AchA aneurysms.
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Radiation-induced cavernous hemangiomas (RICHs) have been increasingly reported as a late complication after conventional radiotherapy. RICH after stereotactic radiosurgery (SRS) is extremely rare and the few cases have been reported to demonstrate their properties. A 72-year-old female patient presented with progressive neurologic deficits. She underwent tumor surgery for meningioma 13 years ago and two times of SRS for treating a residual tumor. Newly-developed mass was 4.3 cm-sized heterogeneously enhancing mass with severe cerebral edema. She underwent surgical resection and the histologic examinations revealed organized hematoma. Finally, it was diagnosed as a RICH following SRS based on radiological and histological findings and a history of multiple radiosurgeries. Clinical, radiological, and histological features of a RICH following SRS were discussed in this report.
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The crossing Y-stent method is one of the indispensable techniques to achieve sufficient neck coverage during coil embolization of bifurcation aneurysms with a wide neck and/or branch incorporation. However, the inevitable hourglass-like expansion of the second stent at the crossing point can result in insufficient vessel wall apposition, reduced aneurysm neck coverage, delayed endothelialization, and subsequent higher risks of acute or delayed thrombosis. It also interferes with engagement of the microcatheter into the aneurysm after stent installation. We expected to be able to reduce these disadvantages by installing a noncrossing type Y-stent using the Solitaire AB stent, which is fully retrievable with a tapered proximal end. Here we report the techniques and two successful cases.
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Objective@#As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age. @*Methods@#We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital. @*Results@#Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%). @*Conclusions@#Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.
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Objective@#As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age. @*Methods@#We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital. @*Results@#Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%). @*Conclusions@#Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.
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Spinal extradural arachnoid cysts (SEACs) are rare and usually asymptomatic, and they usually do not require surgical treatment. If symptoms manifest, however, surgical treatment is required. A 25-year-old male patient complained of impotence upon admission. Magnetic resonance images (MRIs) of his lumbar spine showed a SEAC located longitudinally from the T11 to L3, which was accompanied by thecal sac compression. Verifying the location of the dural defect is crucial for minimizing surgical treatments. Cystography, myelography, and lumbar spine MRI were conducted to locate the leak in real-time; however, it was not found.Hence, the location of the cerebrospinal fluid leak was estimated based on cystography, computed tomography, myelography, and MRI findings. We suggest that the region with the earliest contrast-filling, as well as the middle and widest area of the cyst, may correspond to the location of the dural defect.
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This is a report of a 58-year-old female with Cushing syndrome who underwent posterior lumbar fusion and lost both her vision completely. She was diagnosed with posterior ischemic optic neuropathy. Cushingoid features such as buffalo hump and central obesity might have attributed in triggering posterior ischemic optic neuropathy. When laid prone for surgery, perioperative high abdominal pressure causes venous hypertension leading to increase amount of blood loss. To compensate, infusion of large quantities of intravenous fluids is necessary which leads to hemodilution which decreases ocular perfusion pressure. Hypercoagulability of Cushing syndrome is also potentially a risk factor of this condition which increases the incidence of venous thromboembolism. For there is no known effective treatment for posterior ischemic optic neuropathy, means to prevent this complication must be strategically reviewed. When performing long spine surgery on patient who has Cushing syndrome or cushingoid features, caution must be taken to avoid this devastating complication.
Subject(s)
Female , Humans , Middle Aged , Buffaloes , Cushing Syndrome , Hemodilution , Hypertension , Incidence , Intraocular Pressure , Obesity, Abdominal , Optic Neuropathy, Ischemic , Perfusion , Risk Factors , Spinal Fusion , Spine , Thrombophilia , Venous ThromboembolismABSTRACT
Thoracic outlet syndrome is a relatively well known disease. Other than trauma, this disease is mostly caused by anatomical structures that cause vascular or neural compression. The cause of thoracic outlet syndrome is diverse; however, there are only few reports of thoracic outlet syndrome caused by lipoma in the pectoralis minor space. We report a case of compression of the lower trunk of brachial plexus in which a large lipoma that developed in the pectoral minor space grew into the subclavicular space, along with a review of literature.
Subject(s)
Brachial Plexus , Lipoma , Nerve Compression Syndromes , Thoracic Outlet SyndromeABSTRACT
We describe the case of a patient with an acute subdural hematoma (SDH) that was removed using urokinase irrigation after burr hole trephination in a limited situation where craniotomy was not possible. A 90-year-old woman was admitted to our hospital with a stuporous mental status. Computed tomography (CT) scans revealed a chronic SDH, and a burr hole procedure was performed. The patient's postoperative progression was good until the third day after surgery when we found that the acute SDH had increased on CT scans. The patient's guardian refused further surgery, and thus we drained the blood from the hematoma by injecting urokinase through a drainage catheter. We used urokinase for two days, and removed the catheter after confirming via CT scans that the hematoma was almost alleviated. The patient recovered gradually; she was discharged with few neurological deficits.
Subject(s)
Aged, 80 and over , Female , Humans , Catheters , Craniotomy , Drainage , Hematoma , Hematoma, Subdural, Acute , Stupor , Tomography, X-Ray Computed , Trephining , Urokinase-Type Plasminogen ActivatorABSTRACT
Posttraumatic delayed vertebral collapse, known as Kummell’s disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.
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Humans , Diagnosis , Fractures, Compression , Kyphosis , Neurologic Manifestations , Osteonecrosis , Osteoporosis , Pain, Intractable , Risk FactorsABSTRACT
Posttraumatic delayed vertebral collapse, known as Kummell’s disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.
Subject(s)
Humans , Diagnosis , Fractures, Compression , Kyphosis , Neurologic Manifestations , Osteonecrosis , Osteoporosis , Pain, Intractable , Risk FactorsABSTRACT
BACKGROUND: Stroke is the number one cause of adulthood disability in Korea. Rehabilitation after stroke can minimize functional disability, enhance recovery toward independence, and optimize community reintegration. The inter-departmental stroke meeting (IDSM) is a potential method to improve rehabilitation outcomes in patients with stroke. We aimed to analyze the effect of IDSM on rehabilitation after acute ischemic stroke management. METHODS: Medical records of 753 patients with acute ischemic stroke admitted to the neurology department of our medical center between January and December 2014 were reviewed retrospectively. In May 2014, weekly IDSMs were initiated. All physicians responsible for the patient's care reviewed patient treatment, methods of secondary prevention, and future rehabilitation plans. RESULTS: The transfer rate significantly increased after initiation of IDSM (phase 2, 3) and the length of stay (LOS) before transfer to the rehabilitation department decreased significantly from 9.68 ± 8.50 days to 5.75 ± 2.12 days. There was a reduction in the total LOS from 52 ± 28.57 days to 35 ± 27.21 days after IDSMs were introduced. In non-transferred patients also, the total LOS reduced significantly. The transfer rate increased significantly and the LOS before transfer to the rehabilitation department decreased significantly after implementation of IDSM in a subgroup of patients with moderate to severe stroke. CONCLUSION: The introduction of IDSM was significantly correlated with improvements in transfer rates and reduction of LOS in hospital. This finding shows that IDSMs are an important intervention to improve therapeutic progress and outcomes for patients with stroke.
Subject(s)
Humans , Cerebrovascular Disorders , Korea , Length of Stay , Medical Records , Methods , Neurology , Rehabilitation , Retrospective Studies , Secondary Prevention , StrokeABSTRACT
OBJECTIVE: Among pediatric injury, brain injury is a leading cause of death and disability. To improve outcomes, many developed countries built neurotrauma databank (NTDB) system but there was not established nationwide coverage NTDB until 2009 and there have been few studies on pediatric traumatic head injury (THI) patients in Korea. Therefore, we analyzed epidemiology and outcome from the big data of pediatric THI. METHODS: We collected data on pediatric patients from 23 university hospitals including 9 regional trauma centers from 2010 to 2014 and analyzed their clinical factors (sex, age, initial Glasgow coma scale, cause and mechanism of head injury, presence of surgery). RESULTS: Among all the 2617 THI patients, total number of pediatric patients was 256. The average age of the subjects was 9.07 (standard deviation±6.3) years old. The male-to female ratio was 1.87 to 1 and male dominance increases with age. The most common cause for trauma were falls and traffic accidents. Age (p=0.007), surgery (p<0.001), mechanism of trauma (p=0.016), subdural hemorrhage (SDH) (p<0.001), diffuse axonal injury (DAI) (p<0.001) were statistically significant associated with severe brain injury. CONCLUSION: Falls were the most common cause of trauma, and age, surgery, mechanism of trauma, SDH, DAI increased with injury severity. There is a critical need for effective fall and traffic accidents prevention strategies for children, and we should give attention to these predicting factors for more effective care.
Subject(s)
Child , Female , Humans , Male , Accidental Falls , Accidents, Traffic , Brain Injuries , Cause of Death , Craniocerebral Trauma , Developed Countries , Diffuse Axonal Injury , Epidemiology , Glasgow Coma Scale , Hematoma, Subdural , Hospitals, University , Korea , Mortality , Pediatrics , Republic of Korea , Trauma CentersABSTRACT
OBJECTIVE: To determine whether baseline cerebral atrophy can predict the rate of future chronic subdural hematoma (CSDH) after head trauma and compare indirect markers of brain atrophy with volumetric analysis of computed tomography (CT). METHODS: Single institution case-control study involving 1,476 patients who visited our hospital after head trauma from January 2009 to December 2014. Forty-one patients with delayed CSDH were identified and age, gender matched 41 patients were selected as control group. Both volumetric analyze on CT and Evans index, frontal horn index, bicaudate ratio, sylvian fissure ratio and cortical atrophy scale of 82 patients were estimated by different raters and relationship of those factors with CSDH was analyzed. RESULTS: Every indirect indices except cortical atrophy scale were not enough to give a good estimate of CSDH. Brain atrophy and cortical atrophy scale were predisposing factors of CSDH on multivariate analysis with statistical significance. CONCLUSION: Brain atrophy was a potential prognostic factor of CSDH after trauma. In practice, patients with a value of cortical atrophy scale over moderate grade needed more attention for CSDH.
Subject(s)
Animals , Humans , Atrophy , Brain , Case-Control Studies , Causality , Craniocerebral Trauma , Evaluation Studies as Topic , Hematoma, Subdural, Chronic , Horns , Multivariate AnalysisABSTRACT
With the recent advent of suction catheters, the use of manual aspiration thrombectomy (MAT) for patients with acute ischemic stroke with large vessel occlusion has increased. Although contrast leakage and subarachnoid hemorrhage have been reported during MAT procedures, pseudoaneurysm formation due to vessel injury by suction catheters has not been. We discuss the case of a 60-year-old woman who presented to our emergency room with dysarthria and left-sided weakness. She underwent suction thrombectomy 5 times for acute middle cerebral artery occlusion and significant contrast leakage occurred during the procedure. On follow-up angiogram on post-operative day 15, we noticed a pseudoaneurysm, which was treated with detachable coil embolization. Surgeons who perform suction thrombectomy should keep in mind the possibility of vessel injury that results in the formation of a pseudoaneurysm, especially at the branching site or tortuous segments.
Subject(s)
Female , Humans , Middle Aged , Aneurysm, False , Catheters , Dysarthria , Embolization, Therapeutic , Emergency Service, Hospital , Follow-Up Studies , Infarction, Middle Cerebral Artery , Stroke , Subarachnoid Hemorrhage , Suction , Surgeons , ThrombectomyABSTRACT
Nafamostat mesilate (NM), a synthetic serine protease inhibitor, has anticoagulant and anti-inflammatory properties. The intracellular mediator and external anti-inflammatory external signal in the vascular wall have been reported to protect endothelial cells, in part due to nitric oxide (NO) production. This study was designed to examine whether NM exhibit endothelium dependent vascular relaxation through Akt/endothelial nitric oxide synthase (eNOS) activation and generation of NO. NM enhanced Akt/eNOS phosphorylation and NO production in a dose- and time-dependent manner in human umbilical vein endothelial cells (HUVECs) and aorta tissues obtained from rats treated with various concentrations of NM. NM concomitantly decreased arginase activity, which could increase the available arginine substrate for NO production. Moreover, we investigated whether NM increased NO bioavailability and decreased aortic relaxation response to an eNOS inhibitor in the aorta. These results suggest that NM increases NO generation via the Akt/eNOS signaling pathway, leading to endothelium-dependent vascular relaxation. Therefore, the vasorelaxing action of NM may contribute to the regulation of cardiovascular function.