Influence of dental implantation on bone mineral density distribution: a pilot study

PURPOSE@#Masticatory loading triggers active bone remodeling, altering alveolar bone mineral density (BMD). While dental implants are placed to bear masticatory loading, their influence on changing bone properties has not been fully investigated. Objective of this pilot study was to examine whether the dental implantation has an effect on BMD distribution of bone by comparing dentate, edentulous, and edentulous patients with implants. @*MATERIALS AND METHODS@#Cone beam computed tomography (CBCT) images of 19 partially edentulous patients (Dent), 19 edentulous patients (Edent), and 16 edentulous patients who received implants in the mandible (Edent+Im), were obtained. CBCT images were also obtained from 5 patients within Edent+Im group, before implant placement and after implant loading. Basal cortical bone region of the mandible was digitally isolated. A histogram of gray levels proportional to BMD was obtained to assess mean, histogram standard deviation (HSD), fifth percentile of low and high values (Low5 and High5) of the BMD distribution. Multivariate analysis of variance and paired t-test were used to compare the BMD parameters among the 3 dental status groups and between pre- and post-implantation, respectively. @*RESULTS@#Edentulous patients with implants had significantly greater HSD and High5 values compared to edentulous patients (P .097). Mean, HSD, and High5 values significantly increased after receiving implants (P < .022). @*CONCLUSION@#The current findings suggested that receiving dental implants promoted oral bone mineralization for edentulous patients. The longitudinal investigation could provide valuable information on understanding the effects of implantation on the behavior of oral bone quality.

Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. @*Materials and Methods@#From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017–2019). @*Results@#Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0–106.0), pre-COVID-19; 40.0 min (27.0–98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0–560.0), pre-COVID-19; 184.0 min (134.0–271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID-19, 46.7% in pre-COVID-19, p=0.039). @*Conclusion@#During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.

Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms

Objective@#: Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques. @*Methods@#: The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively. @*Results@#: There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0–2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance. @*Conclusion@#: In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.

Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era

Purpose@#The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. @*Materials and Methods@#From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017–2019). @*Results@#Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0–106.0), pre-COVID-19; 40.0 min (27.0–98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0–560.0), pre-COVID-19; 184.0 min (134.0–271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID-19, 46.7% in pre-COVID-19, p=0.039). @*Conclusion@#During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.

Comparative Analysis of Feasibility of the Retrograde Suction Decompression Technique for Microsurgical Treatment of Large and Giant Internal Carotid Artery Aneurysms

Objective@#: Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques. @*Methods@#: The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively. @*Results@#: There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0–2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance. @*Conclusion@#: In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.

Clinical Features and Outcomes of Intracranial Aneurysm Associated with Moyamoya Disease

Background@#and Purpose: Moyamoya disease (MMD) is a rare form of intracranial stenoocclusive disease that can be associated with intracranial aneurysms. We evaluated the clinical features and outcomes of MMD-associated aneurysms while focusing on their locations. @*Methods@#Between January 1998 and December 2018 there were 1,302 adult and pediatric patients diagnosed as MMD at a single institution. These patients included 38 with 44 MMD-associated aneurysms. The MMD-associated aneurysms were classified into two groups based on their locations: major-artery aneurysms and non-major-artery aneurysms. The clinical and radiological data for patients with MMD-associated aneurysms were reviewed retrospectively. @*Results@#The 44 MMD-associated aneurysms comprised 28 in major arteries and 16 in nonmajor arteries. All of the major-artery aneurysms were initially unruptured lesions, and follow-up angiography showed that 23 (82.1%) had an improved or stable status and 5 (17.9%) had a worse status. The non-major-artery aneurysms comprised 10 ruptured and 6 unruptured lesions, and follow-up angiography showed that 11 (68.8%) had improved or were stable and 5 (31.2%) had worsened. At the latest follow-up, there were four cases of unfavorable outcome: two initial hemorrhagic insults, one treatment-related morbidity, and one repeatedhemorrhage case. @*Conclusions@#MMD-associated aneurysms occurred in 3.3% of the MMD cohort in this study, of which 63.6% were major-artery aneurysms and 36.4% were non-major-artery aneurysms. The major-artery group included 17.9% that became angiographically worse, while 31.2% were growing or hemorrhaging in the non-major-artery group.

Symptomatic Sinus Pericranii with Adult Onset Headache: A Case Report with Pathologic Perspective

Sinus pericranii (SP) is a rare vascular anomaly of the scalp that consists of an abnormal pericranial venous channel connected to adjacent dural venous sinuses. Most SP are asymptomatic and are found in the pediatric age group. We aim to report a case of symptomatic SP in adult and describe the clinical, radiological, and pathohistological findings to help understand and differentiate this lesion from other scalp lesions. A 40-year-old man with a scalp mass was admitted to our hospital complaining of headache. The lesion enlarged when the patient was in a recumbent position or during Valsalva maneuver. The radiologic imaging suggested its diagnosis as an accessory type of SP with bone erosion. Surgical resection and cranioplasty were successfully performed, and the related headache also gradually subsided. At the 3-year follow-up, there was no recurrence on magnetic resonance imaging.

A Newly-Developed Flow Diverter (FloWise) for Internal Carotid Artery Aneurysm: Results of a Pilot Clinical Study

OBJECTIVE: We report the results of a pilot clinical study that evaluated the safety and efficacy of a newly-developed, retrievable flow diverter (FloWise; Taewoong Medical) for the treatment of internal carotid artery (ICA) aneurysm. MATERIALS AND METHODS: A total of 10 patients were enrolled. Inclusion criteria were 1) unruptured aneurysm with a dome size of ≥ 8 mm and a neck size of ≥ 4 mm at the ICA, or 2) two or more unruptured aneurysms of any size able to be spanned by a single FloWise at the ICA. Co-primary effectiveness end points were technical success of FloWise placement, and a 50% or greater decrease in aneurysm volume at the 6-month follow-up angiogram. The primary safety end point was the new development of neurological deficits persisting for more than 1-month post-treatment. RESULTS: Ten patients harboring 14 ICA aneurysms (median diameter, 9.4 mm; range, 2.3–31.0 mm) were enrolled between January 2016 and July 2017. FloWise placement was successful in all patients. There were no newly-developed neurological deficits during the 6-month clinical follow-up period. One patient did not receive follow-up imaging due to pregnancy. Nine patients with 12 aneurysms received a 6-month angiographic follow-up. Ten aneurysms (83.3%) showed decreases in volume greater than 50% (mean volume decrease, 82.8 ± 32.9%), of which 8 (66.7%, 95% confidence interval, 35.4–98.0%) showed complete occlusion. One patient was retreated due to mass symptom aggravation. CONCLUSIONS: In this pilot study, FloWise appeared to be safe and effective for ICA aneurysm treatment. A prospective multicenter study to validate the effectiveness and safety of FloWise would be worthwhile.

Clinical Analysis of Traumatic Cerebral Pseudoaneurysms / 대한신경손상학회지

OBJECTIVE: Traumatic pseudoaneurysms are rare but life-threatening lesions. We investigated the patients with these lesions to clarify their clinical characteristics and therapeutic strategies and we also reviewed the literatures on the treatment principles, possible options, and outcomes. METHODS: There were a total of 8 patients who were treated with traumatic intracranial pseudoaneurysms between April 1980 and January 2009. Medical charts and the imaging studies were reviewed for analysis. The outcome was measured with modified Rankin Scale (mRS) score at 6 months after treatment. RESULTS: All 8 patients were male and the mean age was 25 years old. Six of those were located at the cavernous segment of the internal carotid artery (ICA) and the other 2 was located at the M2 segment of middle cerebral artery. The causes of trauma were car accidents in 6, penetrating injury through the orbit in 1, and slip down injury in 1 patient. Massive epistaxis or hematemesis occurred in all patients with a pseudoaneurysm at the cavernous and ophthalmic segment of the ICA. All 6 patients of the cavernous and ophthalmic ICA group showed favorable outcome of mRS 0 to 1. The outcome of patients with middle cerebral artery pseudoaneurysm was mRS 2 to 3. CONCLUSION: Upon prompt diagnosis and proper treatment planning, it is possible to achieve favorable outcome in these patients. Lesions located at the cavernous segment of the ICA favored endovascular treatment while those at the middle cerebral artery favored surgical treatment.

Localization and Treatment of Unruptured Paraclinoid Aneurysms: A Proton Density MRI-based Study

OBJECTIVE: The purpose of this study was to evaluate the usefulness of proton density magnetic resonance (PD MR) imaging for localization of paraclinoid internal carotid artery aneurysms. MATERIALS AND METHODS: From April 2014 to April 2015, 76 unruptured paraclinoid aneurysms in 66 patients were evaluated using PD MR and angiography (CT/MR angiography or digital subtraction angiography). The locations (extradural, transdural, intradural) in relation to the distal dural ring (DDR) and projection (superior, inferior/posterior, medial, lateral) of the aneurysms were assessed and compared. RESULTS: The most common location of paraclinoid aneurysms was extradural (n = 48, 63.2%), followed by intradural (n = 18, 23.7%), and transdural (n = 10, 13.2%). In the medial projection group (n = 49, 64.5%), 31 were extradural (63.3%), 5 were transdural (10.2%), and 13 were intradural (26.5%). In the inferior/posterior projection group (n = 19, 25.0%), there were 14 extradural (73.7%), 4 transdural (21.0%), and 1 intradural (5.3%). In the superior (n = 4, 5.3%)/lateral (n = 4, 5.3%) projection groups, there were 0/3 extradural (0/75.0%), 1/0 transdural (25.0/0%), and 3/1 intradural (75.0/25.0%). CONCLUSION: PD MR showed sufficient contrast difference to distinguish paraclinoid aneurysms from surrounding dural structures.

Localization and Treatment of Unruptured Paraclinoid Aneurysms: A Proton Density MRI-based Study

OBJECTIVE: The purpose of this study was to evaluate the usefulness of proton density magnetic resonance (PD MR) imaging for localization of paraclinoid internal carotid artery aneurysms. MATERIALS AND METHODS: From April 2014 to April 2015, 76 unruptured paraclinoid aneurysms in 66 patients were evaluated using PD MR and angiography (CT/MR angiography or digital subtraction angiography). The locations (extradural, transdural, intradural) in relation to the distal dural ring (DDR) and projection (superior, inferior/posterior, medial, lateral) of the aneurysms were assessed and compared. RESULTS: The most common location of paraclinoid aneurysms was extradural (n = 48, 63.2%), followed by intradural (n = 18, 23.7%), and transdural (n = 10, 13.2%). In the medial projection group (n = 49, 64.5%), 31 were extradural (63.3%), 5 were transdural (10.2%), and 13 were intradural (26.5%). In the inferior/posterior projection group (n = 19, 25.0%), there were 14 extradural (73.7%), 4 transdural (21.0%), and 1 intradural (5.3%). In the superior (n = 4, 5.3%)/lateral (n = 4, 5.3%) projection groups, there were 0/3 extradural (0/75.0%), 1/0 transdural (25.0/0%), and 3/1 intradural (75.0/25.0%). CONCLUSION: PD MR showed sufficient contrast difference to distinguish paraclinoid aneurysms from surrounding dural structures.

Pipeline Embolization Device for Giant Internal Carotid Artery Aneurysms: 9-Month Follow-Up Results of Two Cases

The pipeline(TM) embolization device (PED) is a braided, tubular, bimetallic endoluminal implant used for occlusion of intracranial aneurysms through flow disruption along the aneurysm neck. The authors report on two cases of giant internal carotid artery aneurysm treated with the PED. In the first case, an aneurysm measuring 26.4 mm was observed at the C3-C4 portion of the left internal carotid artery in a 64-year-old woman who underwent magnetic resonance imaging (MRI) for dizziness and diplopia. In the second case, MRI showed an aneurysm measuring 25 mm at the C4-C5 portion of the right internal carotid artery in a 39-year-old woman with right ptosis and diplopia. Each giant aneurysm was treated with deployment of a PED (3.75 mm diameter/20 mm length and 4.5 mm diameter/25 mm length, respectively). Nine months later, both cases showed complete radiological occlusion of the giant intracranial aneurysm and sac shrinkage. We suggest that use of the PED can be a therapeutic option for giant intracranial aneurysms.

Long-Term Follow-up Results of Laparoscopic Pyeloplasty

PURPOSE: To assess the long-term follow-up results of laparoscopic pyeloplasty for ureteropelvic junction obstruction. MATERIALS AND METHODS: Sixty-five patients (mean age, 43.8 years) who underwent standard laparoscopic pyeloplasty by transperitoneal approaches were enrolled in this study. The chief complaint was flank pain (n=57 patients); the remaining cases were detected incidentally. Twenty-three patients had undergone previous abdominal surgeries, including open pyeloplasty and endopyelotomy. Mean stricture length was 1.06 cm. Grade 3/4 and 4/4 hydronephrosis was detected in 36 and 14 patients, respectively. An obstructive pattern was present on the renal scan in 53 patients (81.5%). RESULTS: Fifty-seven patients were treated with dismembered Anderson-Hynes pyeloplasty and eight patients with Fenger pyeloplasty. During the operation, crossing vessels were found in 27 patients (41.5%). Mean operating time was 159.42 minutes. Although there were no cases of open conversion, two patients with colon and spleen injuries were detected postoperatively. The mean starting time of postoperative ambulation and diet was 1.54 days and 1.86 days, respectively. Mean hospital stay was 8.09 days. Mean follow-up period was 36.5 months. Follow-up intravenous pyelography and renal scan showed improvements in 59 patients, and the radiologic success rate was 90.8%. Eight patients showed failure on radiologic or symptomatic evaluation, and the overall success rate was 87.7%. In the comparative analysis between the success and failure groups, drained amount was the only risk factor related to failure (554.41 mL. vs. 947.70 mL, p=0.024). CONCLUSIONS: Long-term follow-up results support laparoscopic pyeloplasty as the standard treatment for ureteropelvic junction obstruction. Drained amount is a risk factor for failure of the operation.

Effectiveness of Fiberoptic Endoscopic Evaluation of Swallowing (FEES) in Patients with Swallowing Disorders -A Systematic Review-

OBJECTIVE: The objective of this systematic review is to evaluate the safety and effectiveness of fiberoptic endoscopic evaluation of swallowing (FEES) for dysphagia patients. METHOD: We performed a systematic review of the literature. We searched Ovid-Medline(R), EMBASE(R) and Cochrane library(R) and Eight domestic databases including KoreaMed up to 19 April 2010. In addition, we added hand search. Searches were conducted without language restriction. We identified ten studies that met our eligibility criteria. Two reviewers independently extracted prespecified data from each study. Also reviewers assessed quality of each study. The qualities of these studies were assessed according to Scottish Intercollegiate Guidelines Network (SIGN) tool. RESULTS: Ten studies (nine diagnostic evaluation studies and one case series) were identified. The complication rate of FEES was 6% which was reported only one study as nose bleeding that did not need further treatment. The effectiveness of FEES was evaluated based on diagnostic accuracy, agreement rate with videofluoroscopy as a reference test. The sensitivities of FEES were 0.87~1.0 (penetration), 0.22~0.96 (aspiration), 0.68~0.91 (pharyngeal residue), and 0.75 (premature spillage) respectively. Specificities of FEES were 0.75~1.0 (penetration), 0.88~1.0 (aspiration), 0.86~1.0 (pharyngeal residue), and 0.56 (premature spillage) respectively. Agreement rate with VFFS were 85~100% (penetration), 82.3~100% (aspiration), 80~89.3% (pharyngeal residues), and 60.7% (premature spillage) respectively. There was no evidence of statistical heterogeneity. The body of evidence as a whole suggests a grade C for FEES. CONCLUSION: FEES is considered as a safe and effective test in patients with dyspahgia and grade C evidence based on existing studies.

Cases report of unicentric Castleman's disease: revisit of radiotherapy role

Castleman's disease or angiofollicular lymph node hyperplasia is a rare lymphoproliferative disorder. Complete surgical resection was recommended in unicentric Castleman's disease. Radiotherapy was considered alternative therapeutic option. However, there have been consistent favorable responses to radiotherapy. We also experienced two cases of uncentric Castleman's disease salvaged successfully with radiotherapy. This paper described these cases and reviewed the literature about Castleman's disease treated with radiotherapy. Reviewed cases showed that radiotherapy is a successful treatment option in unicentric Castleman's disease. Furthermore, our report confirms the radiotherapy role in uncentric Castleman's disease.

Clinical Analysis of Microsurgery for Brainstem Cavernous Malformations: Surgical Indications, Optimal Approaches, and Clinical Outcomes / 대한뇌혈관외과학회지

OBJECTIVE: This study aimed to analyze patients who underwent microsurgery for brainstem cavernous malformations (BCMs) and to investigate the effectiveness and the limitations of surgical resection of BCMs. METHODS: We retrospectively analyzed the clinical data of patients who underwent surgical resections for BCMs between 1989 and 2010. We investigated the age distribution, preoperative hemorrhagic rates, initial clinical presentations, locations of the lesions, and preoperative and postoperative Karnofsky Performance Scale (KPS) scores. We also analyzed surgical indications, the timing of surgery, and surgical approaches. RESULTS: All 15 patients underwent microsurgery for BCMs; 13 underwent total resection of their lesions, but 2 underwent incomplete resections and consequently experienced postoperative recurrent hemorrhage. We observed 11 patients through a complete follow-up, for a mean of 53.1 months (range 1-131 months) after diagnosis (nine patients > 24 months follow-up). During the follow-up periods, 3 patients were lost to follow-up, and one patient expired, due to aspiration pneumonia, 31 months postoperatively. The mean preoperative KPS score was 50, and the mean postoperative KPS score was 67. During the complete follow-up period, 3 patients recovered completely (KPS scores of 90-100) and 7 patients (63.6%) showed improvement in KPS scores. CONCLUSIONS: Surgeons should consider microsurgery for BCMs the treatment of choice for patients who suffer from progressive neurological decline. Successful resection of BCMs depends on an optimal surgical approach, appropriate timing of surgery, and well-informed surgical techniques. The aim of surgery must be total resection of the lesions without any deteriorative neurological morbidity.

Remote Cerebellar Hemorrhage After Surgery for an Unruptured Aneurysm / 대한뇌혈관외과학회지

We report here on 2 cases of remote cerebellar hemorrhage (RCH) that developed after surgery for supratentorial unruptured aneurysm. In both cases, cerebral angiography was performed to diagnose the aneurysms and then screening was conducted for determining if there were any previous bleeding tendencies and comorbidities. After surgery, computed tomography (CT) was immediately performed to check for postoperative hemorrhage or infarction, and the images showed cerebellar hemorrhage that was relatively far away from the surgical site. We present the similarities of the 2 patients' preoperative angiography and CT and their perioperative blood pressure, and we discuss these findings to illuminate the pathophysiology of RCH.

Clinical Analysis of Distal Posterior Inferior Cerebellar Artery Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: This study was designed to determine the clinical characteristics of patients with aneurysms that are located at the distal posterior inferior cerebellar artery (dPICA). PATIENTS & METHODS: From September 1976 to June 2007, 54 consecutive patients with PICA aneurysms were treated at our institute. Among them, 19 patients had PICA aneurysms distal to the junction of the vertebral artery-PICA. We retrospectively reviewed the database and imaging studies as sources of information for analysis. RESULTS: Five patients were male and 14 patients were female. The mean age was 44.6 years old (range: 23-70). Sixteen patients had ruptured lesions: 1 patient was Hunt and Hess Grade I, 4 were Grade II, 5 were Grade III, 4 were Grade IV and 2 were Grade V. Intraventricular hemorrhage or intracerebral hemorrhage was identified in 5 patients on the initial computed tomography (CT). Three patients had unruptured lesions. The locations of aneurysm were the lateral medullary segment in 10 patients, the tonsillomedullary segment in 1 patient, the telovelotonsillar segment in 5 patients and the cortical segment in 3 patients. Most aneurysms (17) were the saccular shape. Seventeen aneurysms were small and 2 were large or giant. The mean diameter of aneurysm was 6.5 mm (range: 2.0-28.0) and the mean diameter of the ruptured aneurysm was 4.8 mm (range: 2.0-12.0). Two patients had mirror aneurysms. Post-hemorrhagic hydrocephalus was identified in 10 patients on the initial CT and shunt surgery was performed on 3 patients. The obliteration methods of the aneurysms were microsurgery in 15 patients (midline suboccipital approach: 9, lateral suboccipital approach: 6) and endovascular surgery in 4 patients (therapeutic distal PICA occlusion: 3, intra-aneurysmal coiling: 1). Early surgery was performed on 2 patients, intermediate surgery (days between rupture: 4-10) was performed on 4 patients and delayed surgery was performed on 10 patients. The mean post-treatment follow up period was 49.5 months (range: 7-156). The clinical outcome was assessed using the modified Glasgow Outcome Scale. All the patients showed favorable outcomes. Five patients suffered from treatmentrelated complications (a CSF collection requiring wound revision for dura repair: 2, shunt surgery: 1 and transient hemiparesis due to impairment of the blood flow distal to the aneurysm: 2). CONCLUSIONS: In our series, distal PICA aneurysms had the characteristics of a female predominance, they more often presented with intraventricular hemorrhage and the rupture was of a relatively small size. Both microsurgery and endovascular surgery can be troublesome due to the small size, wide neck and tortuosity of the proximal parent artery and the location of aneurysms at a branching site. The surgeons should be careful for preserving vessel patency and insuring watertight dura repair.

Therapeutic results of intracrainal dural arteriovenous fistula / 대한뇌혈관외과학회지

OBJECTIVES: This report was designed to study the prognostic factors that affect the therapeutic results of dural arteriovenous fistula (DAVF). METHODS: We retrospectively reviewed 97 patients who were treated for DAVF at our institute from January, 2000 to August, 2008. The DAVFs were usually located in four sites (cavernous sinus, transverse-sigmoid sinus, superior sagittal sinus and others). The diagnosis and the results of treatment were obtained by performing cerebral angiography. RESULTS: The most common location of DAVF was the cavernous sinus (59.4%) and the next most common location was the transverse-sigmoid sinus (30.2%). Borden classification type II (72.2%) was most common and the next most common was type I (18.6%). Cortical venous reflux was abundant in the transverse-sigmoid sinus DAVFs and superior sagittal sinus DAVFs. Complete obliteration was achieved in 52 cases (55.3%) of all the 94 treated cases and incomplete obliteration was achieved in 42 cases (44.7%). Complete obliteration of the DAVF was achieved for 66.7% of the cavernous sinus lesions and in 41.4% of the transverse-sigmoid sinus lesions. Repeated treatments due to partial obliteration or recanalization were done in 18 cases. CONCLUSION: Transverse-sigmoid sinus lesion and cortical venous reflux in a DAVF are closely related to the aggressive clinical features. Active treatment should be considered to treat these lesions. (ED note: some of this abstract was not clear and you need to check the revised abstract.)

Clinical Characteristics and Surgical Treatment of Patients with Distal Middle Cerebral Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Middle cerebral artery (MCA) aneurysm is a common source of aneurysmal subarachnoid hemorrhage, but distal MCA aneurysms are rare. This present study was conducted to evaluate the clinical characteristics of the distal MCA aneurysms and the optimal treatment for a good outcome. METHODS: Among 3323 patients underwent aneurysmal surgery from 1975 to 2007, 21 patients with distal MCA aneurysm was identified. The clinical, radiological and operative records of 21 patients with distal MCA aneurysms who underwent surgical management were reviewed retrospectively. The clinical outcomes were evaluated according to the Glasgow Outcome Scale. RESULTS: The clinical analyses of 21 patients with distal MCA aneurysms has following characteristics. (1) Mean aneurysm size of 5.3mm (range 2~8mm). (2) All lesions were considered to be saccular except one case. (3) The location being M2 in one patient, M2-3 junction in 12, M3 in 3, and M4 in 5 patients. (4) In 7 of 21 patients, initial CT scan revealed intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). (5) All patients underwent surgical treatment for aneurysm; the procedures were clipping in 17 patients, trapping in 2 patients, trapping and end-to-end anastomosis in 1 patient, and direct vessel suture in 1 patient. (6) All patients without ICH had a good recovery. However, the patient with ICH had a different prognosis. Of the 7 patients with ICH, 4 patients had a good recovery and 2 patients had a moderate disability. 1 patient died due to severe brain swelling. CONCLUSION: The patients with distal MCA aneurysm were relatively young, and there was no female predominance. The aneurysms have high rates of cardiac problems such as infective endocarditis or mitral valve prolapse, attributing to be developed infectious aneurysm. Ruptured distal MCA aneurysms are rare and can cause life-threatening ICH with SAH. However, the appropriate surgical treatments can obtain a favorable outcome.