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.

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.

Endogenous Agmatine Induced by Ischemic Preconditioning Regulates Ischemic Tolerance Following Cerebral Ischemia

Ischemic preconditioning (IP) is one of the most important endogenous mechanisms that protect the cells against ischemia-reperfusion (I/R) injury. However, the exact molecular mechanisms remain unclear. In this study, we showed that changes in the level of agmatine were correlated with ischemic tolerance. Changes in brain edema, infarct volume, level of agmatine, and expression of arginine decarboxylase (ADC) and nitric oxide synthases (NOS; inducible NOS [iNOS] and neural NOS [nNOS]) were analyzed during I/R injury with or without IP in the rat brain. After cerebral ischemia, brain edema and infarct volume were significantly reduced in the IP group. The level of agmatine was increased before and during ischemic injury and remained elevated in the early reperfusion phase in the IP group compared to the experimental control (EC) group. During IP, the level of plasma agmatine was increased in the early phase of IP, but that of liver agmatine was abruptly decreased. However, the level of agmatine was definitely increased in the ipsilateral and contralateral hemisphere of brain during the IP. IP also increased the expression of ADC—the enzyme responsible for the synthesis of endogenous agmatine—before, during, and after ischemic injury. In addition, ischemic injury increased endogenous ADC expression in the EC group. The expression of nNOS was reduced in the I/R injured brain in the IP group. These results suggest that endogenous increased agmatine may be a component of the ischemic tolerance response that is induced by IP. Agmatine may have a pivotal role in endogenous ischemic tolerance.

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.

Long-Term Clinical and Angiographic Outcomes of Wrap-Clipping Strategies for Unclippable Cerebral Aneurysms

PURPOSE: To evaluate the efficacy and stability of the wrap-clipping methods as a reconstructive strategy in the treatment of unclippable cerebral aneurysms. MATERIALS AND METHODS: Twenty four patients who had undergone wrap-clipping microsurgery were retrospectively reviewed. Type and morphology of the treated aneurysm, utilized technique for wrap-clip procedure, and clinical outcome with angiographic results at their last follow-up were evaluated. RESULTS: Of 24 patients, eleven patients had internal carotid artery (ICA) blister-like aneurysms, three had dissecting type aneurysms, and ten had fusiform aneurysms. The follow-up period for the late clinical and angiographic results ranged from 10 to 75 months (mean 35 months). Wrap-clipping was performed in eleven, wrap-holding clipping was in ten, and combination of wrap-clip and wrap-holding clip was in three cases. At the last angiographic follow-up study, twelve aneurysms (50%) were found to have completely healed, and nine aneurysms (38%) were at least stable. However, wrap-holding clip for the elongated blister type of ICA aneurysm was found failed, leading to fatal rebleeding in one case, and two cases of combination of wrap-clip-wrap-holding clip revealed delayed branch occlusion and marked regrowing, respectively. CONCLUSION: Wrap-clipping strategy could be an easy and safe alternative for unclippable aneurysms. The wrapped aneurysm mostly disappeared, or at least remained stationary, after a long-term period. However, surgeons should be aware of that the wrapped aneurysm might become worse. Therefore, follow-up surveillance for an extended period should be mandatory.

Effect of Premedication Method and Drug Resistance of Antiplatelet Agent on Periprocedural Thromboembolic Events During Coil Embolization of an Unruptured Intracranial Aneurysm

OBJECTIVE: A retrospective review of premedication method and drug resistance of aspirin and clopidogrel in association with thromboembolic events during and after coil embolization of an unruptured intracranial aneurysm was conducted. METHODS: Our premedication policy for coil embolization of an unruptured intracranial aneurysm has changed from administration of the loading dose before the procedure (i.e. loading group) to repeated administration of the maintenance dose for several days (i.e. preparation group). The loading group (27 patients with 29 aneurysms) and the preparation group (30 patients with 35 aneurysms) were compared for identification of the effect of premedication method on periprocedural thromboembolic events. The results of drug response assays of the preparation group were analyzed with respect to periprocedural thromboembolic events. RESULTS: No statistically significant difference in incidence of thromboembolic events was observed between the loading group and the preparation group. Analysis of the results of the drug response assay showed high prevalence (56.7%, 73.3%) of clopidogrel resistance and relatively low prevalence (6.7%) of aspirin resistance. Patients who had thromboembolic events tended to have lower responsiveness to both aspirin and clopidogrel than patients without it. CONCLUSION: The method of antiplatelet premedication does not affect the rate of periprocedural thromboembolic events in coil embolization for treatment of an unruptured intracranial aneurysm. Nevertheless, considering the high prevalence of drug resistance, it is reasonable to premedicate antiplatelet agents in the preparation method for the drug response assay. Use of a higher dose of aspirin and clopidogrel or addition of an alternative drug (cilostazol or triflusal) can be applied against antiplatelet agent resistance. However, because the hemorrhagic risk associated with this supplementary use of antiplatelet agent has not been well-documented, the hemorrhagic risk and the preventive benefit must be weighed.

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.

Distinction between Intradural and Extradural Aneurysms Involving the Paraclinoid Internal Carotid Artery with T2-Weighted Three-Dimensional Fast Spin-Echo Magnetic Resonance Imaging

OBJECTIVE: The precise intra- vs. extradural localization of aneurysms involving the paraclinoid internal carotid artery is critical for the evaluation of patients being considered for aneurysm surgery. The purpose of this study was to investigate the clinical usefulness of T2-weighted three-dimensional (3-D) fast spin-echo (FSE) magnetic resonance (MR) imaging in the evaluation of unruptured paraclinoid aneurysms. METHODS: Twenty-eight patients with unruptured cerebral aneurysms in their paraclinoid regions were prospectively evaluated using a T2-weighted 3-D FSE MR imaging technique with oblique coronal sections. The MR images were assessed for the location of the cerebral aneurysm in relation to the dural ring and other surrounding anatomic compartments, and were also compared with the surgical or angiographic findings. RESULTS: All 28 aneurysms were identified by T2-weighted 3D FSE MR imaging, which showed the precise anatomic relationships in regards to the subarachnoid space and the surrounding anatomic structures. Consequently, 13 aneurysms were determined to be intradural and the other 15 were deemed extradural as they were confined to the cavernous sinus. Of the 13 aneurysms with intradural locations, three superior hypophyseal artery aneurysms were found to be situated intradurally upon operation. CONCLUSION: High-resolution T2-weighted 3-D FSE MR imaging is capable of confirming whether a cerebral aneurysm at the paraclinoid region is intradural or extradural, because of the MR imaging's high spatial resolution. The images may help in identifying patients with intradural aneurysms who require treatment, and they also can provide valuable information in the treatment plan for paraclinoid aneurysms.

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 of Pediatric Cerebral Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: The aim of this study was to define the clinical characteristics of pediatric cerebral aneurysms. METHODS: During the past 30 years, among a total of 3,330 patients treated for cerebral aneurysms, 12 patients were under the age of 18. The authors reviewed the database and imaging studies as sources for identification and analysis. RESULTS: Seven patients were male and 5 were female. The mean age was 12.9 years old (range: 3~18). Nine patients had ruptured lesions and the remaining 3 had unruptured lesions. Four patients presented with a subarachnoid hemorrhage, and the other 5 patients presented with an intracerebral hemorrhage (ICH). Five aneurysms were located at the posterior cerebral artery or vertebrobasilar artery, 4 at the middle cerebral artery, and 3 at the internal carotid artery, respectively. The giant aneurysm was observed in 2 (18%) patients. Eleven aneurysms were saccular, and 1 was serpentine in shape. No patient had multiple aneurysms. Rebleeding was observed in 3 cases (33%). No child suffered from clinical vasospasm. All but one patient showed a favorable outcome (good: 11, dead: 1). CONCLUSIONS: Pediatric cerebral aneurysms in this study showed a male predominance, a high incidence of presentation with ICH, a location on the distal circulation of the major arteries or on the posterior circulation, and a large or giant aneurysm, high rebleeding rate and a low incidence of vasospasm. The overall clinical outcome was excellent in 91.7% in this study. With the knowledge of these features, aneurysmal obliteration and active brain resuscitation can improve the clinical outcome and prognosis.

Clinical Analysis of Patients with Ruptured Cerebral Aneurysms associated with Polycystic Kidney Disease / 대한뇌혈관외과학회지

OBJECTIVE: This study is to define the clinical characteristics and formulate the management strategies of the patients with ruptured cerebral aneurysms associated with polycystic kidney diseases (PKD). METHODS: During the past 30 years, among of 3,013 patients who were treated with intracranial aneurysms, 7 patients had ruptured cerebral aneurysms associated with PKD. The authors retrospectively reviewed the database and imaging studies of such patients as sources for identification and analysis. RESULTS: All 7 patients presented with subarachnoid hemorrhage (SAH). One patient showed Hunt and Hess grade I, 4 of grade II, and 2 of grade III. Six patients showed Fisher group II and 1 patient of group III. Four aneurysms were located at anterior cerebral artery, 2 at middle cerebral artery, and 1 at internal carotid artery. Five patients had small aneurysms and the remaining 2 had large (diameter > or = 10 mm) aneurysms. All aneurysms were in saccular shape. Two of the 7 patients (28.6%) had multiple aneurysms. One patient suffered delayed ischemic neurological deficit. All patients were treated by microsurgery and showed favorable outcome (good: 7). CONCLUSIONS: The patients harboring PKD had high probability of hypertension. So, intact aneurysms in those patients were exposed to higher rate of being ruptured. Surgery was necessary for ruptured lesions, as well as unruptured lesions which size was increased at follow up imaging study. Multimodality management approach with nephrologist and neuroradiologist are very necessary. The ultimate management outcome was satisfactory.

Spontaneous Dissecting Aneurysm of the Intracranial Vertebral Artery: Management Strategies

PURPOSE: Pathogenesis and treatment of spontaneous dissecting aneurysm of the intracranial vertebral artery (VA) remain controversial. This study was designed to provide management strategies and to improve management outcome in patients with these aneurysms. MATERIALA AND METHODS: Among a total of 1,990 patients treated for intracranial aneurysms from February 1992 to June 2005, 28 patients (1.4%) were treated either by surgery (8 patients) or neurointervention (20 patients) for spontaneous dissecting aneurysms of the intracranial VA. Twenty-two patients had ruptured aneurysms. We analyzed indications of surgery or neurointervention for each case, and assessed the management outcome at a 6-month follow-up. RESULTS: For selection of therapeutic options, patients were initially evaluated as possible candidates for neurointervention using the following criteria: 1) poor clinical grade; 2) advanced age; 3) medical illness; 4) unruptured aneurysm; 5) equal or larger opposite VA; 6) anticipated surgical difficulty due to a deep location of the VA-posterior inferior cerebellar artery (PICA) junction. Surgery was considered for patients with: 1) high-risk aneurysms (large or irregular shaped); 2) smaller opposite VA; 3) failed neurointervention; or 4) dissection involving the PICA. Management outcomes were favorable in 25 patients (89.3%). Causes of unfavorable outcome in the remaining 3 patients were the initial insult in 2 patients, and medical complications in one patient. CONCLUSION: Ruptured aneurysms must be treated to prevent rebleeding. For unruptured aneurysms, follow-up angiography would be necessary to detect growth of the aneurysm. Treatment modality should be selected according to the clinical characteristics of each patient and close collaboration between neurosurgeons and neurointerventionists is essential.

Therapeutic Strategies of Middle Cerebral Artery M1 Trunk Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: This study was designed to define the clinical characteristics and to establish the therapeutic strategies for treating aneurysms located at the M1 trunk of the middle cerebral artery (MCA). METHODS: During the past 30 years from September 1976 to December 2006, 47 (6.2% of the 755 treated MCA aneurysms) consecutive patients with M1 aneurysms were treated at our institute. We retrospectively reviewed the database and imaging studies of these 47 patients for analysis. Nine patients (19.1%) were male and 38 (80.9%) patients were female. The mean age was 51.7 years (range: 381 years). Thirty-three (70.2%) patients had ruptured lesions: 3 patients were Hunt and Hess Grade I, 16 patients were Grade II, 7 patients-were Grade III, 4 patients were Grade IV and 3 patients were Grade V. Intracerebral hemorrhage was identified in 9 patients on the initial computed tomograph images. Fourteen patients had unruptured lesions. The diameters of the aneurysms were 25 mm in 2 patients. The mean diameter of the aneurysms was 5.1mm (range: 2.029.0mm). Eleven patients (23.4%) had multiple aneurysms. The repair methods for the aneurysms were microsurgery in 42 (89.4%) patients (clipping: 36, wrapping: 6, aneurysm resection and suture: 1) and coiling in 5 patients. The mean posttreatment follow up period was 45.5 months. The clinical outcome was assessed using the Glasgow Outcome Scale. The therapeutic results of lesion repair, the long-term clinical outcome and the causes of an unfavorable outcome were also analyzed. RESULTS: The overall outcome was favorable in 39 (82.9%) patients (excellent: 32, good: 7) and unfavorable in 8 (17.1%) (fair: 6, poor: 1, dead: 1) patients. The major causes of an unfavorable outcome were the initial insults. Seven patients suffered from a delayed ischemic deficit, and 3 of them were left with a permanent deficit. Surgery-related complications occurred in 8 patients (cerebral infarction: 6, intracerebral hemorrhage: 2) and 3 were left with a permanent deficit. The angiographic results of coiling were complete packing in 3 (60%), a neck remnant in 1 (20%) and incomplete packing for 1 (20%). There was no coiling-related complication. CONCLUSION: In our series, M1 aneurysms had characteristics of a female predominance, the patients more often presented with intracerebral hemorrhage, and a high risk of postoperative ischemic complication. Due to the small size, wide neck and location at the branching site, M1 aneurysms can be treated with surgery rather than coiling, but surgeons should be careful for injury of the branching vessels like the lateral lenticulostriate artery and they must be prepared for various inevitable situations that occur during surgery.

A Clinical Analysis of Twelve Cases of Ruptured Cerebral De Novo Aneurysms

Formation of cerebral de novo aneurysms (CDNA) is rare, and the pathogenesis remains obscure. In this study, we investigated the factors that contribute to the formation of CDNA and suggest guidelines for following patients treated for cerebral aneurysms. We retrospectively reviewed 2,887 patients treated for intracranial aneurysm at our institute from January of 1976 to December of 2005. Of those patients, 12 were readmitted due to recurrent rupture of CDNA, which was demonstrated by cerebral angiography. We assessed clinical characteristics, such as gender, size and site of rupture, past history, and the time to CDNA rupture. Of the 12 patients, 11 were female and 1 was male, with a mean age at rupture of the first aneurysm of 44.7 years (range: 30-69 years). The mean time between the first episode of subarachnoid hemorrhage (SAH) and the second was 8.9 years (range: 1.0-16.7 years). The most common site of ruptured CDNA was the internal carotid artery (5 patients, 41.7%), followed by basilar artery bifurcation (3 patients, 25.0%). In the remaining 4 patients, rupture occurred in the anterior communicating, middle cerebral, anterior cerebral (A1), or posterior cerebral (P1) arteries. In 5 cases (41.7%), the CDNA occurred contralateral to the initial aneurysm. Eleven patients (91.7%) had a past history of arterial hypertension. There was no history of habitual smoking or alcohol abuse in any of the patients. Eight patients underwent clipping for CDNA and three patients were treated with coiling. One patient who had multiple aneurysms was treated with clipping following intra-aneurysmal coiling. Assessment according to the Glasgow Outcome Scale (GOS) of the patients after the treatment was good in 10 cases (83.3%) and fair in 2 cases (16.7%). Although formation of CDNA after successful treatment of initial aneurysm is rare, several factors may contribute to recurrence. In our study, female patients with a history of arterial hypertension were at higher risk for ruptured CDNA. We recommend follow-up imaging studies every five years after treatment of the initial aneurysm, especially in women and those with a history of arterial hypertension.

Cerebral Aneursyms Associated with the Behcet's Disease / 대한뇌혈관외과학회지

We report two cases of ruptured cerebral aneurysms associated with Behcet's disease. One was from right superior cerebellar artery and treated by intra-aneurysmal coil embolization. The other was from the bifurcation of right middle cerebral artery and treated by clipping. Both patients showed good result.