Analysis of Factors Related to Growth and Growth Patterns of Unruptured Intracranial Aneurysms / 대한신경손상학회지

Objective@#The goal of the present study was to identify factors related to the growth and growth patterns of unruptured intracranial aneurysms (UIAs). @*Methods@#Between January 2011 and December 2018, a total of 275 patients were diagnosed with UIAs in our institution. Of them, 91 patients were evaluated using computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography. Aneurysm size, morphology, location, and its changes were investigated. Patient factors, including gender, history of stroke, smoking, hypertension, diabetes mellitus, and excessive alcohol consumption, were studied to identify factors associated with aneurysm growth. @*Results@#A total of 91 patients (121 aneurysms) with a mean follow-up duration of 37.2±23.9 months and a mean age of 64.0±11.4 years were included. The growth of unruptured aneurysms was identified in 23 patients (27 aneurysms, 22.3%). Regarding morphology, the diffuse growth pattern was the most common (12 aneurysms in 10 patients, 44.4%). Univariate analysis showed that patients with multiple aneurysms (p=0.010), history of stroke (p=0.021), and aneurysm location in the posterior circulation (p=0.029) were significantly associated with aneurysm growth. @*Conclusion@#The growth of an UIA is associated with the history of stroke, posterior location, and multiplicity. Considering the risk of unruptured aneurysm growth, patients with such risk factors should receive additional attention during follow-up.

Development of Delayed Acute Subdural Hematoma after Mild Traumatic Brain Injury: A Case Report / 대한신경손상학회지

We report a case involving the development of a delayed acute subdural hematoma (ASDH) after trauma, with the absence of any abnormal radiological and clinical findings at initial examination. A 54-year-old male visited the emergency department after a minor trauma. The patient only complained of mild headache after head injury. He presented no abnormal findings on neurological examination, and brain computed tomography (CT) did not show any intracranial lesion or skull fractures. However, he developed seizure with disorientation eight hours after trauma, and ASDH with midline shift was found during a follow-up CT. He recovered without neurological deficits after immediate primary care and admission to the neurosurgery department. On serial follow-up CT images, a gradually increasing mass effect of hematoma was detected, and removed by craniotomy. The patient recovered without neurologic deficits.

Comparison of Complications Following Cranioplasty Using a Sterilized Autologous Bone Flap or Polymethyl Methacrylate / 대한신경손상학회지

OBJECTIVE: The aims of current study are to compare complications following cranioplasty (CP) using either sterilized autologous bone or polymethyl methacrylate (PMMA), and to identify the risk factors for two of the most common complications: bone flap resorption (BFR) and surgical site infection (SSI). METHODS: Between January 2004 and December 2013, 127 patients underwent CP and were followed at least 12 months. Variables, including sex, age, initial diagnosis, time interval between decompressive craniectomy (DC) and CP, operation time, size of bone flap, and presence of ventriculo-peritoneal shunt, were analyzed to identify the risk factors for BFR and SSI. RESULTS: A total of 97 (76.4%) patients underwent CP using PMMA (Group I) and 30 (23.6%) underwent CP using autologous bone (Group II). SSI occurred in 8 (8.2%) patients in Group I, and in 2 (6.7%) in Group II; there was no statistically significant difference between the groups (p=1.00). No statistically significant risk factors for SSI were found in either group. In Group I, there was no reported case of BFR. In Group II patients, BFR developed in 18 (60.0%) patients at the time of CP (Type 1 BFR), and at 12-month follow up (Type 2 BFR) in 4 (13.3%) patients. No statistically significant risk factors for BFR were found in Group II. CONCLUSION: CP using sterilized autologous bone result in a significant rate of BFR. PMMA, however, is a safe alloplastic material for CP, as it has low complication rate.

Clinical Analysis of Epidural Fluid Collection as a Complication after Cranioplasty

OBJECTIVE: The epidural fluid collection (EFC) as a complication of cranioplasty is not well-described in the literature. This study aimed to identify the predictive factors for the development of EFC as a complication of cranioplasty, and its outcomes. METHODS: From January 2004 to December 2012, 117 cranioplasty were performed in our institution. One-hundred-and-six of these patients were classified as either having EFC, or not having EFC. The two groups were compared to identify risk factors for EFC. Statistical significance was tested using the t-test and chi-square test, and a logistic regression analysis. RESULTS: Of the 117 patients undergoing cranioplasty, 59 (50.4%) suffered complications, and EFC occurred in 48 of the patients (41.0%). In the t-test and chi-test, risk factors for EFC were size of the skull defect (p=0.003) and postoperative air bubbles in the epidural space (p<0.001). In a logistic regression, the only statistically significant factor associated with development of EFC was the presence of postoperative air bubbles. The EFC disappeared or regressed over time in 30 of the 48 patients (62.5%), as shown by follow-up brain computed tomographic scan, but 17 patients (35.4%) required reoperation. CONCLUSION: EFC after cranioplasty is predicted by postoperative air bubbles in the epidural space. Most EFC can be treated conservatively. However, reoperation is necessary to resolve about a third of the cases. During cranioplasty, special attention is required when the skull defect is large, since EFC is then more likely.

The Neuroprotective Effects of Carnosine in Early Stage of Focal Ischemia Rodent Model

OBJECTIVE: This study was conducted to elucidate neuroprotective effect of carnosine in early stage of stroke. METHODS: Early stage of rodent stroke model and neuroblastoma chemical hypoxia model was established by middle cerebral artery occlusion and antimycin A. Neuroprotective effect of carnosine was investigated with 100, 250, and 500 mg of carnosine treatment. And antioxidant expression was analyzed by enzyme linked immunosorbent assay (ELISA) and western blot in brain and blood. RESULTS: Intraperitoneal injection of 500 mg carnosine induced significant decrease of infarct volume and expansion of penumbra (p<0.05). The expression of superoxide dismutase (SOD) showed significant increase than in saline group in blood and brain (p<0.05). In the analysis of chemical hypoxia, carnosine induced increase of neuronal cell viability and decrease of reactive oxygen species (ROS) production. CONCLUSION: Carnosine has neuroprotective property which was related to antioxidant capacity in early stage of stroke. And, the oxidative stress should be considered one of major factor in early ischemic stroke.

Lumbar Nerve Root Compression due to Leakage of Bone Cement after Vertebroplasty / 대한신경손상학회지

We experienced a 73-year-old male with lumbar nerve root compression due to leakage of bone cement after vertebroplasty. He was underwent vertebroplasty for acute osteoporotic L4 compression fracture at our hospital. After vertebroplasty, his back pain was improved but right leg pain was newly developed. Lumbar computed tomography scanning showed that bone cements were leaked along the L4 nerve root. The leaked cements around L4 nerve root were removed carefully via paraspinal muscle-splitting approach. After operation, severe right leg radiating pain was improved. We recommend proper entry point, high viscosity of polymethylmethacrylate and constant monitoring can reduce complication.

The Usefulness of Brain Magnetic Resonance Imaging with Mild Head Injury and the Negative Findings of Brain Computed Tomography

OBJECTIVE: To investigate the cases of intracranial abnormal brain MRI findings even in the negative brain CT scan after mild head injury. METHODS: During a 2-year period (January 2009-December 2010), we prospectively evaluated both brain CT and brain MRI of 180 patients with mild head injury. Patients were classified into two groups according to presence or absence of abnormal brain MRI finding even in the negative brain CT scan after mild head injury. Two neurosurgeons and one neuroradiologist validated the images from both brain CT scan and brain MRI double blindly. RESULTS: Intracranial injury with negative brain CT scan after mild head injury occurred in 18 patients (10.0%). Headache (51.7%) without neurologic signs was the most common symptom. Locations of intracranial lesions showing abnormal brain MRI were as follows; temporal base (n=8), frontal pole (n=5), falx cerebri (n=2), basal ganglia (n=1), tentorium (n=1), and sylvian fissure (n=1). Intracranial injury was common in patients with a loss of consciousness, symptom duration >2 weeks, or in cases of patients with linear skull fracture (p=0.00013), and also more frequent in multiple associated injury than simple one (35.7%>8.6%) (p=0.105). CONCLUSION: Our investigation showed that patients with mild head injury even in the negative brain CT scan had a few cases of intracranial injury. These findings indicate that even though the brain CT does not show abnormal findings, they should be thoroughly watched in further study including brain MRI in cases of multiple injuries and when their complaints are sustained.

APOA5 Polymorphism Is Associated with Metabolic Syndrome in Korean Postmenopausal Women

BACKGROUND: Menopause is an independent risk factor in metabolic syndrome which induced an alteration of the lipid metabolism by hormonal changes. Apolipoprotein A5 gene (APOA5) was related to the regulation of triglyceride and high density lipoprotein cholesterol (HDL-C) level with biosynthesis and decomposition. This study was conducted to investigate the relationship between APOA5 polymorphism and metabolic syndrome in Korean postmenopausal women. METHODS: This study included 307 postmenopausal women with anthropometric and biochemical measurement in 2010-2011. The polymorphism of APOA5 was analyzed by polymerase chain reaction-restriction fragment length polymorphism method with MseI restriction enzyme. RESULTS: The metabolic syndrome prevalence with TT genotype was significantly lower than the frequency in those with TC/CC (27.09%, 38.46%, and 45.71% for TT, TC, and CC, respectively; P < 0.05). Multiple regression analysis of metabolic syndrome risk factors indicated that postmenopausal women with CC genotype had a higher risk with 3 times than that in TT genotype (P < 0.05). APOA5 C carriers showed an increased risk of triglyceride level (odd ratio, 2.93 and 1.85 for CC and TC+CC, respectively; P < 0.05). Interestingly, HDL-C was related to triglyceride directly in comparison to APOA5. CONCLUSION: The results of this study indicate that APOA5 has an influence on serum triglyceride and HDL-C, which contribute to metabolic syndrome in Korean postmenopausal women.

Chronic Subdural Hematoma Treated by Small or Large Craniotomy with Membranectomy as the Initial Treatment

OBJECTIVE: There are few studies comparing small and large craniotomies for the initial treatment of chronic subdural hematoma (CSDH) which had non-liquefied hematoma, multilayer intrahematomal loculations, or organization/calcification on computed tomography and magnetic resonance imaging. These procedures were compared to determine which would produce superior postoperative results. METHODS: Between 2001 and 2009, 317 consecutive patients were surgically treated for CSDH at our institution. Of these, 16 patients underwent a small craniotomy with partial membranectomy and 42 patients underwent a large craniotomy with extended membranectomy as the initial treatment. A retrospective review was performed to compare the postoperative outcomes of these two techniques, focusing on improvement of neurological status, complications, reoperation rate, and days of post-operative hospitalization. RESULTS: The mean ages were 69.4+/-12.1 and 55.6+/-9.3 years in the small and large craniotomy groups, respectively. The recurrence of hematomas requiring reoperation occurred in 50% and 10% of the small and large craniotomy patients, respectively (p<0.001). There were no significant differences in postoperative neurological status, complications, or days of hospital stay between these two groups. CONCLUSION: Among the cases of CSDH initially requiring craniotomy, the large craniotomy with extended membranectomy technique reduced the reoperation rate, compared to that of the small craniotomy with partial membranectomy technique.

Disseminated Cysticercosis

Disseminated cysticercosis is a rare form of cysticercosis in which the cysticerci spread out through the whole body. We report the first case of a 39-year-old Mongolian with disseminated cysticercosis. He visited our hospital with generalized tonic-clonic seizure. After extensive investigation from brain computed tomography (CT), spine magnetic resonance imaging (MRI), whole body MRI and pathologic biopsy, he was diagnosed as having cysticercosis involving the brain, subcutaneous tissue, and skeletal muscles through the whole body. We treated him with the albendazole in which case the followed MRI showed that numbers of cystic lesions were copiously decreased. We report an unsual case of disseminated cysticercosis treated with medical therapy.

The Combined Effects of Ginkgo Biloba Extracts and Aspirin on Viability of SK-N-MC, Neuroblastoma Cell Line in Hypoxia and Reperfusion Condition

OBJECTIVE: The purpose of this study is to investigate the combined effects of ginkgo biloba extract, ginkgolide A and B and aspirin on SK-N-MC, human neuroblastoma cell viability and mRNA expression of growth associated protein43 (GAP43), Microtubule-associated protein 2 (MAP2), B-cell lymphoma2 (Bcl2) and protein53 (p53) gene in hypoxia and reperfusion condition. METHODS: SK-N-MC cells were cultured with Dulbecco's Modified Eagle's Medium (DMEM) media in 37degrees C, 5% CO2 incubator. The cells were cultured for 8 hours in non-glucose media and hypoxic condition and for 12 hours in normal media and O2 concentration. Cell survival rate was measured with Cell Counting Kit-8 (CCK-8) reagent assay. Reverse transcriptase polymerase chain reaction (RT-PCR) was used to estimate mRNA levels of GAP43, MAP2, Bcl2, and p53 genes. RESULTS: The ginkgolide A and B increased viable cell number decreased in hypoxic and reperfused condition. The co-treatment of ginkgolide B with aspirin also increased the number of viable cells, however, there was no additive effect. Although there was no increase of mRNA expression of GAP43, MAP2, and Bcl2 in SK-N-MC cells with individual treatment of ginkgolide A, B or aspirin in hypoxic and reperfused condition, the co-treatment of ginkgolide A or B with aspirin significantly increased GAP43 and Bcl2 mRNA levels. In MAP2, only the co-treatment of ginkgolide A and aspirin showed increasing effect. The mRNA expression of p53 had no change in all treating conditions. CONCLUSION: This study suggests that the combined treatments of Ginkgo biloba extracts and aspirin increase the regeneration of neuroblastoma cells injured by hypoxia and reperfusion.

Role of 'Spot Sign' on CT Angiography to Predict Hematoma Expansion in Spontaneous Intracerebral Hemorrhage

OBJECTIVE: Patients with spontaneous intracerebral hemorrhage (ICH) presenting within 24 hours of symptom onset are known to be increased risk of hematoma expansion which is closely correlated with morbidity and mortality. We investigated whether tiny enhancing foci ('Spot sign') on axial view of 3-dimensional computed tomography angiography (3D-CTA) source images can predict subsequent hematoma expansion in spontaneous ICH. METHODS: During a 2-year period (March 2007-March 2009), we prospectively evaluated 3D-CTA of 110 patients with spontaneous ICH. Based on source images of 3D-CTA, patients were classified according to presence or absence of 'Spot sign'; 'Spot sign' (+) group, 'Spot sign' (-) group. Radiological factors and clinical outcomes were compared between two groups. RESULTS: Hematoma expansion occurred in 16 patients (15%). Mean Glasgow Coma Scale (GCS) score of patients with hematoma expansion was significantly different compared to score of patients without hematoma expansion (5 vs. 9, p < 0.001). Nineteen patients (16%) of 110 ICH patients demonstrated 'spot sign' on 3D-CTA. Among the 'spot sign' (+) group, 53% of patients developed hematoma expansion. Conversely 7% of patients without 'spot sign' demonstrated the hematoma expansion (p < 0.001). Initial volume and location of hematoma were significantly not associated with hematoma expansion except shape of hematoma. CONCLUSION: Our study showed that patients with hematoma expansion of spontaneous ICH had significant clinical deterioration. And the fact that 'spot sign' (+) group have higher risk of hematoma expansion suggests the presence of 'spot sign' on source images of 3D-CTA can give a clue to predict hematoma expansion in spontaneous ICH.

The Effects of TWEAK, Fn14, and TGF-beta1 on Degeneration of Human Intervertebral Disc

OBJECTIVE: The purpose of this study is to explain the effect and reciprocal action among tumor necrosis factor (TNF) like weak inducer of apoptosis (TWEAK), fibroblast growth factor-inducible 14 (Fn14), and transforming growth factor-beta1 (TGF-beta1) on degeneration of human intervertebral disc (IVD). METHODS: Human intervertebral disc tissues and cells were cultured with Dulbecco's Modified Eagle's Medium/Nutrient F-12 Ham (DMEM/F-12) media in 37degrees C, 5% CO2 incubator. When IVD tissues were cultured with TWEAK, Fn14 that is an antagonistic receptor for TWEAK and TGF-beta1, the level of sulfated glycosaminoglycan (sGAG) was estimated by dimethyl methyleneblue (DMMB) assay and sex determining region Y (SRY)-box 9 (Sox9) and versican messenger ribonucleic acid (mRNA) levels were estimated by reverse transcriptase polymerase chain reaction (RT-PCR). RESULTS: When human IVD tissue was cultured for nine days, the sGAG content was elevated in proportion to culture duration. The sGAG was decreased significantly by TWEAK 100 ng/mL, however, Fn14 500 ng/mL did not change the sGAG production of IVD tissue. The Fn14 increased versican and Sox9 mRNA levels decreased with TWEAK in IVD tissue TGF-beta1 20 ng/mL elevated the sGAG concentration 40% more than control. The sGAG amount decreased with TWEAK was increased with Fn14 or TGF-beta1 but the result was insignificant statistically. TGF-beta1 increased the Sox9 mRNA expression to 180% compared to control group in IVD tissue. Sox9 and versican mRNA levels decreased by TWEAK were increased with TGF-beta1 in primary cultured IVD cells, however, Fn14 did not show increasing effect on Sox9 and versican. CONCLUSION: This study suggests that TWEAK would act a role in intervertebral disc degeneration through decreasing sGAG and the mRNA level of versican and Sox9.

Radiographic Parameters of Segmental Instability in Lumbar Spine Using Kinetic MRI

OBJECTIVE: To investigate the effectiveness of radiographic parameters on segmental instability in the lumbar spine using Kinetic magnetic resonance imaging (MRI). METHODS: Segmental motion, defined as excessive (more than 3 mm) translational motion from flexion to extension, was investigated in 309 subjects (927 segments) using Kinetic MRI. Radiographic parameters which can help indicate segmental instability include disc degeneration (DD), facet joint osteoarthritis (FJO), and ligament flavum hypertrophy (LFH). These three radiographic parameters were simultaneously evaluated, and the combinations corresponding to significant segmental instability at each level were determined. RESULTS: The overall incidence of segmental instability was 10.5% at L3-L4, 16.5% at L4-L5, and 7.3% at L5-S1. DD and LFH at L3-L4 and FJO and LFH at L4-L5 were individually associated with segmental instability (p<0.05). At L4-L5, the following combinations had a higher incidence of segmental instability (p<0.05) when compared to other segments : (1) Grade IV DD with grade 3 FJO, (2) Grade 2 or 3 FJO with the presence of LFH, and (3) Grade IV DD with the presence of LFH. At L5-S1, the group with Grade III disc and Grade 3 FJO had a higher incidence of segmental instability than the group with Grade I or II DD and Grade 1 FJO. CONCLUSION: This study showed that the presences of either Grade IV DD or grade 3 FJO with LFH at L4-L5 were good indicators for segmental instability. Therefore, using these parameters simultaneously in patients with segmental instability would be useful for determining candidacy for surgical treatment.

Intracranial Metastases of Cervical Intramedullary Low-Grade Astrocytoma without Malignant Transformation in Adult

The first case of intracranial metastases of a cervical intramedullary low-grade astrocytoma without malignant transformation in adult is presented in this report. Seven years ago, a 45 year-old male patient underwent biopsy to confirm pathologic characteristics and received craniocervical radiation and chemotherapy for a grade II astrocytoma in the cervical spinal cord. Two years later, posterior fusion was necessary for progressive kyphosis in the cervical spine. He was well for approximately 7 years after the primary surgery. Two months ago, he presented with partial weakness and incoordination with gait difficulty. MRI Scan demonstrated multiple small lesions in the cerebellar vermis and left hemisphere. After suboccipital craniectomy and posterior cervical exposure, the small masses in the cerebellar vermis and hemispheres were excised to a large extent by guidance of an intraoperative navigation system. The tumor at the cervical and brain lesions was classified as an astrocytoma (WHO grade II). When a patient with low-grade astrocytoma in the spinal cord has new cranial symptoms after surgery, radiaton, and chemotherapy, the possibility of its metastasis should be suspected because it can spread to the intracranial cavity even without malignant transformation as shown in this case.

A Complicated Case of Endovascular Stent Assisted Coil Embolization of an Aneurysm / 대한뇌혈관외과학회지

Endovascular coiling is one of the recent methods for treating cerebral aneurysm and this method is considered to be an alternative method for treating aneurysms. Yet there are several disadvantages of endovascular coiling. As is well known, a wide-necked aneurysm is not completely treated with endovascular coiling. Infarction of the parent artery due to coil compaction, recanalization and embolization is a significant problem of endovascular coiling for a wide-necked aneurysm. Wide-necked aneurysms have been recently treated with stent assisted coil embolization. Stent-assisted coil embolization results in a higher rate of complication. In this case report, we present a case with complication after stent-assisted endovascular coiling. We concluded that precise, cautious procedures are needed when performing complicated stent assisted endovascular coiling to prevent thromboembolic complications.

Neurochemical Characterization of the TRPV1-Positive Nociceptive Primary Afferents Innervating Skeletal Muscles in the Rats

OBJECTIVE: Transient receptor potential vanilloid subfamily type 1 (TRPV1), a most specific marker of the nociceptive primary afferent, is expressed in peptidergic and non-pepetidergic primary afferents innervating skin and viscera. However, its expression in sensory fibers to skeletal muscle is not well known. In this study, we studied the neurochemical characteristics of TRPV1-positive primary afferents to skeletal muscles. METHODS: Sprague-Dawley rats were injected with total 20 microliter of 1% fast blue (FB) into the gastrocnemius and erector spinae muscle and animals were perfused 4 days after injection. FB-positive cells were traced in the L4-L5 (for gastrocnemius muscle) and L2-L4 (for erector spinae muscle) dorsal root ganglia. The neurochemical characteristics of the muscle afferents were studied with multiple immunofluorescence with TRPV1, calcitonin gene-related peptide (CGRP) and P2X(3). To identify spinal neurons responding to noxious stimulus to the skeletal muscle, 10% acetic acids were injected into the gastrocnemius and erector spinae muscles and expression of phospho extracellular signal-regulated kinase (pERK) in spinal cords were identified with immunohistochemical method. RESULTS: TRPV1 was expressed in about 49% of muscle afferents traced from gastrocnemius and 40% of erector spinae. Sixty-five to 60% of TRPV1-positive muscles afferents also expressed CGRP. In contrast, expression of P2X3 immnoreaction in TRPV1-positive muscle afferents were about 20%. TRPV1-positive primary afferents were contacted with spinal neurons expressing pERK after injection of acetic acid into the muscles. CONCLUSION: It is consequently suggested that nociception from skeletal muscles are mediated by TRPV1-positive primary afferents and majority of them are also peptidergic.

The Relation Between Sox9, TGF-beta1, and Proteoglycan in Human Intervertebral Disc Cells

OBJECTIVE: The aim of this study is to elucidate the effects of transforming growth factor-beta (TGF-beta)1 and L-ascorbic acid on proteoglycan synthesis, and the relationship between Sox9, proteoglycan, and TGF-beta1 in intervertebral disc cells. METHODS: Human intervertebral disc tissue was sequentially digested to 0.2% pronase and 0.025% collagenase in DMEM/F-12 media and extracted cells were cultured in 37degrees C, 5% CO2 incubator. When intervertebral disc cells were cultured with TGF-beta1 or L-ascorbic acid, the production level of sulfated glycosaminoglycan (sGAG) was estimated by dimethyl methyleneblue (DMMB) assay. The changes of Sox9 mRNA and protein levels via TGF-beta1 were detected by RT-PCR and Western blot analysis in each. RESULTS: The amount of sGAG was increased with the lapse of time during incubation, and sGAG content of pellet cultured cells was much larger than monolayer culture. When primary cultured intervertebral disc cells in monolayer and pellet cultures were treated by TGF-beta1 20 ng, sGAG content of experimental group was increased significantly compared to control group in both cultures. L-Ascorbic acid of serial concentrations (50-300 ug/ml) increased sGAG content of mono layer cultured intervertebral disc cells significantly in statistics. The co-treatment of TGF-beta1 and L-ascorbic acid increased more sGAG production than respective treatment. After treating with TGF-beta1, Sox9 mRNA and protein expression rates were significantly increased in disc cells compared with the control group. CONCLUSION: This study suggests that TGF-beta1 would increase sulfated glycosaminoglycan (sGAG) and other proteoglycans such as versican by elevating Sox9 mRNA and protein expressions in order.

The Usefulness of 3D-CT Angiography as a Screening Tool for Vascular Abnormalities in Spontaneous ICH Patients

OBJECTIVE: We investigated the incidence of the vascular abnormalities associated with spontaneous intracerebral hemorrhage (ICH) using three-dimensional computed tomographic angiography (3D-CTA). METHODS: We prospectively assessed consecutive 76 patients with spontaneous intracerebral hemorrhage (ICH) who underwent 3D-CTA between June 2003 and May 2005. The patients with a recent history of trauma or mainly subarachnoid hemorrhage were excluded. We investigated relationship between vascular abnormality and ICH location. The findings of 3D-CTA were classified as one of three patterns with ICH; type A (without evidence of vascular abnormality), type B (with no vascular abnormality as the source of hemorrhage, but with incidental vascular abnormality), and type C (presence of a vascular abnormality as the source of hemorrhage). RESULTS: Sites of ICH were lobar 26, basal ganglia 23, thalamus 17, posterior fossa 6 and dominant intraventricular hemorrhage (IVH) 4. Among 76 patients, sixteen (21.1%) vascular abnormalities were noted excluding 13 cases of stenoocclusive disease. Sixteen cases included 6 cases of cerebral aneurysms (7.9%), 5 moyamoya diseases (6.6%), 4 arteriovenous malformations (5.3%) and 1 dural sinus thrombosis (1.3%). Lobar ICH (30.8%) had a higher vascular abnormalities than other types, and younger age (<40) group had a higher incidence of vascular abnormalities than old age group. The patterns of 3D-CTA include sixty cases (79.0%) of type A, 6 cases (7.8%) of type B and 10 cases (13.2%) of type C. The vascular abnormalities were found in 8 (13.5%) of 59 hypertensive patients and 8 (47.0%) of 17 non-hypertensive patients (p=0.006). CONCLUSION: 3D-CT angiography is considered a useful screening tool for ICH patients with suspected cerebrovascular abnormalities and should be considered in such clinical settings, especially in lobar type and in non-hypertensive younger patients.

A Case of Probable Moyamoya Disease (Unilateal Moyamoya Disease) Coexisting Arteriovenous Malformation

The authors report a unique case of unilateral Moyamoya disease with a rare combination of arteriovenous malformation (AVM) who presented with intracerebral hemorrhage (ICH). A 50-year-old man suffered from sudden onset of mental deterioration and right hemiparesis. Brain computed tomography (CT) showed intracerebral hemorrhage on left thalamus. Brain CT angiography and cerebral digital subtraction angiography (DSA) revealed AVM combined with unilateral moyamoya disease involving left middle cerebral artery (MCA) and choroid plexus in left lateral ventricle. Intraventricular hemorrhage and hydrocephalus were managed conservatively. A rare case of unilateral Moyamoya disease accompanied by a cerebral arteriovenous malformation is described and discussed with review of pertinent literature.