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Aortic dissection is one of the causes of acute ischemic stroke. Endovascular recanalization therapy (EVT) has emerged as an essential treatment for acute ischemic stroke due to large artery occlusion. However, it is rarely performed in the situation of hidden aortic dissection (AD). Two patients presented to the emergency room with focal neurologic deficits. The first patient was diagnosed with right internal carotid artery (ICA) occlusion. Angiography revealed that the ICA was occluded by the dissection flap. After a stent deployment in the proximal ICA, the antegrade flow was restored. The patient was diagnosed with AD on chest computed tomography (CT) after EVT. For the second patient, intraarterial thrombectomy was performed to treat left middle cerebral artery occlusion. AD was first detected on echocardiography, which was performed after EVT. Herein, we report successful endovascular recanalization therapy performed in two patients with acute ischemic stroke in the situation of undiagnosed aortic dissection. We also reviewed previous case reports and relevant literature.
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Syncope is a common symptom in clinical practice. Rotational vertebral artery occlusion syndrome, also referred to as Bow Hunter’s syndrome (BHS), is a rare condition associated with syncope and is caused by mechanical occlusion or stenosis secondary to mechanical compression of the vertebral artery during head rotation. BHS is associated with a multifactorial etiology; however, in most cases, this condition is attributed to degenerative changes. A 53-year-old man visited our hospital for the evaluation of fainting and dizziness episodes that occurred when he turned his head. Evaluation as an outpatient in the Department of Neurology showed a positive result on the Frenzel goggle test. Transfemoral cerebral angiography performed at the Department of Neurosurgery revealed stenosis of the proximal right vertebral artery. Complete occlusion of the vertebral artery was observed, and the head was turned to the right. Decompression and fusion were performed, and the contributory lesion was completely removed. Postoperative imaging confirmed complete removal of the spur and sufficient vertebral artery decompression; the patient’s symptoms resolved postoperatively.
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Background@#Anterior choroidal artery (AchA) aneurysms are usually small in diameter because of the size of the involved artery and are often wide-necked. Coil embolization of AchA aneurysm is thus challenging because of serious risks, such as thromboembolic occlusion of artery and perforation of aneurysm dome. Therefore, aneurysmal neck clipping remains widely performed despite a recent increase in the use of coil embolization for aneurysm treatment. We report the treatment results of AchA aneurysms mostly (92.3%) treated with coil embolization at our institute. @*Methods@#The database and medical records of patients who underwent coil embolization for AchA aneurysms were retrospectively analyzed. The clinical and imaging results and procedure-related complications were investigated after coil embolization performed between January 2006 and March 2022 at our institute. @*Results@#In total, 96 AchA aneurysms comprising 65 unruptured and 31 ruptured aneurysms, including only 1 ruptured aneurysm (1.0%) re-embolized at postoperative day 192 because of coil compaction, were evaluated. After the initial coil embolization, complete occlusion was attained in 41, residual neck in 45, and residual aneurysm in 10 patients. Follow-up radiological studies after 6–174 months were performed for 80 aneurysms. Complete occlusion was noted in 57 patients, residual neck in 22, and residual aneurysm in 1. The dysarthria experienced by one (1.0%) patient was the only symptomatic procedure-related complication. After coil embolization, neither delayed new rupture nor re-rupture was observed. @*Conclusions@#The results of this study demonstrate that coil embolization is a safe and effective treatment option for patients with AchA aneurysms.
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Radiation-induced cavernous hemangiomas (RICHs) have been increasingly reported as a late complication after conventional radiotherapy. RICH after stereotactic radiosurgery (SRS) is extremely rare and the few cases have been reported to demonstrate their properties. A 72-year-old female patient presented with progressive neurologic deficits. She underwent tumor surgery for meningioma 13 years ago and two times of SRS for treating a residual tumor. Newly-developed mass was 4.3 cm-sized heterogeneously enhancing mass with severe cerebral edema. She underwent surgical resection and the histologic examinations revealed organized hematoma. Finally, it was diagnosed as a RICH following SRS based on radiological and histological findings and a history of multiple radiosurgeries. Clinical, radiological, and histological features of a RICH following SRS were discussed in this report.
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Symptomatic Rathke’s cleft cysts (RCCs) can be treated by surgical procedures, usually through an endonasal transsphenoidal corridor using either a microscope or an endoscope. We report a large suprasellar extended RCC causing obstructive hydrocephalus, which was efficiently managed by a novel surgical route named “reverse” trans-sellar approach using transventricular neuroendoscopy. A 48-yearold woman complained of persistent headache and a tendency to fall that had begun 6 months previously. The images obtained from MRI scan showed intra- and supra-sellar cystic masses occupying the third ventricle with obstruction of the foramina of Monro and the aqueduct of Sylvius. The cystic wall showed a slight enhancement, and the cystic contents showed iso-signal intensity on T1-and T2-weighted images. Instead of trans-nasal trans-sellar surgery, we decided to operate using a conventional transventricular endoscope. A thin cystic capsule, which blocked the foramina of Monro and the aqueduct of Sylvius, was fenestrated and removed and a third ventriculostomy was performed. The defect in the infundibulum between sellar and suprasellar cysts was widened and used as a corridor to drain cystic contents (reverse trans-sellar route). The final pathological finding revealed an RCC with focal metaplasia. We efficiently managed a large RCC by transventricular neuroendoscopic surgery with cyst fenestration and third ventriculostomy and simultaneously drained the sellar contents using a novel surgical route. Reverse trans-sellar neuroendoscopic surgery is a relevant treatment option for selective patients with large suprasellar extensions of RCCs.
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The crossing Y-stent method is one of the indispensable techniques to achieve sufficient neck coverage during coil embolization of bifurcation aneurysms with a wide neck and/or branch incorporation. However, the inevitable hourglass-like expansion of the second stent at the crossing point can result in insufficient vessel wall apposition, reduced aneurysm neck coverage, delayed endothelialization, and subsequent higher risks of acute or delayed thrombosis. It also interferes with engagement of the microcatheter into the aneurysm after stent installation. We expected to be able to reduce these disadvantages by installing a noncrossing type Y-stent using the Solitaire AB stent, which is fully retrievable with a tapered proximal end. Here we report the techniques and two successful cases.
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Objective@#As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age. @*Methods@#We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital. @*Results@#Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%). @*Conclusions@#Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.
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Spinal extradural arachnoid cysts (SEACs) are rare and usually asymptomatic, and they usually do not require surgical treatment. If symptoms manifest, however, surgical treatment is required. A 25-year-old male patient complained of impotence upon admission. Magnetic resonance images (MRIs) of his lumbar spine showed a SEAC located longitudinally from the T11 to L3, which was accompanied by thecal sac compression. Verifying the location of the dural defect is crucial for minimizing surgical treatments. Cystography, myelography, and lumbar spine MRI were conducted to locate the leak in real-time; however, it was not found.Hence, the location of the cerebrospinal fluid leak was estimated based on cystography, computed tomography, myelography, and MRI findings. We suggest that the region with the earliest contrast-filling, as well as the middle and widest area of the cyst, may correspond to the location of the dural defect.
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Objective@#As the average life span in modern society continues to increase, much interest is focused on high-risk procedures in elderly patients, including major surgical operations. We investigated the results of endovascular coiling of unruptured intracranial aneurysms (UIA) in patients over 80 years of age. @*Methods@#We retrospectively analyzed 39 patients aged over 80 years who underwent coil embolization for UIA between April 2007 and April 2019 at our hospital. @*Results@#Complete occlusion on digital subtraction angiography (DSA) immediately after surgery was performed in 44 (84.6%) of 52 cases of cerebral aneurysms. Four patients (7.7%) had residual aneurysmal necks, and four (7.7%) had contrast flow in the aneurysmal sac. Follow-up magnetic resonance angiography (mean: 8.2 months) was performed in 37 aneurysms in 24 patients. There was evidence of blood flow in the neck in seven cases (18.9%) and aneurysm in two cases (5.4%). Follow-up DSA (mean: 20.5 months) was performed in 14 aneurysms in 11 patients, and 11 aneurysms (78.6%) had complete occlusion, 1 aneurysm (7.1%) had an aneurysmal neck, and 2 aneurysms (14.3%) had contrast filling into the aneurysmal sac. Coil embolization procedure-related complications occurred in 3 patients (7.7%). Cerebral infarction occurred in 1 (2.6%), arterial dissection in 1 (2.6%), and hypoesthesia in 1 (2.6%). @*Conclusions@#Active treatment of UIA in elderly patients over 80 years of age through endovascular coil embolization can be considered.
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Most cases of spinal subdural hematoma are very rare and result from iatrogenic causes, such as coagulopathy or a spinal puncture. Cases of non-traumatic spinal subdural hematoma accompanied by intracranial hemorrhage are even more rare. There are a few reports of spontaneous spinal subdural hematoma with concomitant intracranial subdural or subarachnoid hemorrhage, but not with intracerebral hemorrhage. Especially in our case, the evaluation and diagnosis were delayed because the spontaneous intracerebral hemorrhage accompanying the unilateral spinal subdural and subarachnoid hemorrhages caused hemiplegia. We report a case of spinal subdural and subarachnoid hemorrhage with concomitant intracerebral hemorrhage, for the first time, with a relevant literature review.
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Hemorragia Cerebral , Diagnóstico , Hematoma , Hematoma Subdural Espinal , Hemiplejía , Hemorragias Intracraneales , Punción Espinal , Hemorragia SubaracnoideaRESUMEN
BACKGROUND: Stroke is the number one cause of adulthood disability in Korea. Rehabilitation after stroke can minimize functional disability, enhance recovery toward independence, and optimize community reintegration. The inter-departmental stroke meeting (IDSM) is a potential method to improve rehabilitation outcomes in patients with stroke. We aimed to analyze the effect of IDSM on rehabilitation after acute ischemic stroke management. METHODS: Medical records of 753 patients with acute ischemic stroke admitted to the neurology department of our medical center between January and December 2014 were reviewed retrospectively. In May 2014, weekly IDSMs were initiated. All physicians responsible for the patient's care reviewed patient treatment, methods of secondary prevention, and future rehabilitation plans. RESULTS: The transfer rate significantly increased after initiation of IDSM (phase 2, 3) and the length of stay (LOS) before transfer to the rehabilitation department decreased significantly from 9.68 ± 8.50 days to 5.75 ± 2.12 days. There was a reduction in the total LOS from 52 ± 28.57 days to 35 ± 27.21 days after IDSMs were introduced. In non-transferred patients also, the total LOS reduced significantly. The transfer rate increased significantly and the LOS before transfer to the rehabilitation department decreased significantly after implementation of IDSM in a subgroup of patients with moderate to severe stroke. CONCLUSION: The introduction of IDSM was significantly correlated with improvements in transfer rates and reduction of LOS in hospital. This finding shows that IDSMs are an important intervention to improve therapeutic progress and outcomes for patients with stroke.
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Humanos , Trastornos Cerebrovasculares , Corea (Geográfico) , Tiempo de Internación , Registros Médicos , Métodos , Neurología , Rehabilitación , Estudios Retrospectivos , Prevención Secundaria , Accidente CerebrovascularRESUMEN
We describe the case of a patient with an acute subdural hematoma (SDH) that was removed using urokinase irrigation after burr hole trephination in a limited situation where craniotomy was not possible. A 90-year-old woman was admitted to our hospital with a stuporous mental status. Computed tomography (CT) scans revealed a chronic SDH, and a burr hole procedure was performed. The patient's postoperative progression was good until the third day after surgery when we found that the acute SDH had increased on CT scans. The patient's guardian refused further surgery, and thus we drained the blood from the hematoma by injecting urokinase through a drainage catheter. We used urokinase for two days, and removed the catheter after confirming via CT scans that the hematoma was almost alleviated. The patient recovered gradually; she was discharged with few neurological deficits.
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Anciano de 80 o más Años , Femenino , Humanos , Catéteres , Craneotomía , Drenaje , Hematoma , Hematoma Subdural Agudo , Estupor , Tomografía Computarizada por Rayos X , Trepanación , Activador de Plasminógeno de Tipo UroquinasaRESUMEN
Posttraumatic delayed vertebral collapse, known as Kummell’s disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.
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Humanos , Diagnóstico , Fracturas por Compresión , Cifosis , Manifestaciones Neurológicas , Osteonecrosis , Osteoporosis , Dolor Intratable , Factores de RiesgoRESUMEN
Posttraumatic delayed vertebral collapse, known as Kummell’s disease, is increasing in number of patients. This disease is already progressive kyphosis due to vertebral collapse at the time of diagnosis and it causes intractable pain or neurologic deficit due to intravertebral instability. Treatment is very difficult after progression of the disease, and the range of treatment, in hospital day, and cost of treatment are both increased. Clinical features, pathogenesis and radiologic findings of these disease groups were reviewed to determine risk factors for delayed vertebral collapse. The purpose of this article is to suggest appropriate treatment before vertebral collapse for patients with osteoporotic vertebral compression fracture who have risk factors for posttraumatic delayed vertebral collapse.
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Humanos , Diagnóstico , Fracturas por Compresión , Cifosis , Manifestaciones Neurológicas , Osteonecrosis , Osteoporosis , Dolor Intratable , Factores de RiesgoRESUMEN
With the recent advent of suction catheters, the use of manual aspiration thrombectomy (MAT) for patients with acute ischemic stroke with large vessel occlusion has increased. Although contrast leakage and subarachnoid hemorrhage have been reported during MAT procedures, pseudoaneurysm formation due to vessel injury by suction catheters has not been. We discuss the case of a 60-year-old woman who presented to our emergency room with dysarthria and left-sided weakness. She underwent suction thrombectomy 5 times for acute middle cerebral artery occlusion and significant contrast leakage occurred during the procedure. On follow-up angiogram on post-operative day 15, we noticed a pseudoaneurysm, which was treated with detachable coil embolization. Surgeons who perform suction thrombectomy should keep in mind the possibility of vessel injury that results in the formation of a pseudoaneurysm, especially at the branching site or tortuous segments.
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Femenino , Humanos , Persona de Mediana Edad , Aneurisma Falso , Catéteres , Disartria , Embolización Terapéutica , Servicio de Urgencia en Hospital , Estudios de Seguimiento , Infarto de la Arteria Cerebral Media , Accidente Cerebrovascular , Hemorragia Subaracnoidea , Succión , Cirujanos , TrombectomíaRESUMEN
OBJECTIVE: To determine whether baseline cerebral atrophy can predict the rate of future chronic subdural hematoma (CSDH) after head trauma and compare indirect markers of brain atrophy with volumetric analysis of computed tomography (CT). METHODS: Single institution case-control study involving 1,476 patients who visited our hospital after head trauma from January 2009 to December 2014. Forty-one patients with delayed CSDH were identified and age, gender matched 41 patients were selected as control group. Both volumetric analyze on CT and Evans index, frontal horn index, bicaudate ratio, sylvian fissure ratio and cortical atrophy scale of 82 patients were estimated by different raters and relationship of those factors with CSDH was analyzed. RESULTS: Every indirect indices except cortical atrophy scale were not enough to give a good estimate of CSDH. Brain atrophy and cortical atrophy scale were predisposing factors of CSDH on multivariate analysis with statistical significance. CONCLUSION: Brain atrophy was a potential prognostic factor of CSDH after trauma. In practice, patients with a value of cortical atrophy scale over moderate grade needed more attention for CSDH.
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Animales , Humanos , Atrofia , Encéfalo , Estudios de Casos y Controles , Causalidad , Traumatismos Craneocerebrales , Estudios de Evaluación como Asunto , Hematoma Subdural Crónico , Cuernos , Análisis MultivarianteRESUMEN
BACKGROUND AND PURPOSE: Rapid recanalization might improve clinical outcomes after intraarterial thrombolysis (IAT) for acute ischemic stroke patients with collateral circulation. We determined whether rapid recanalization and collateral circulation affect clinical outcomes after IAT. METHODS: We retrospectively evaluated the clinical and radiological data of 134 consecutive patients who underwent IAT for intracranial artery occlusion. The interval from symptom onset to recanalization after IAT (onset-to-recanalization time) as an estimate of the probability of good clinical outcome (modified Rankin scale 0-2) was calculated in patients with collateral circulation in the ischemic hemisphere, which was rated poor (0/1 American Society of Interventional and Therapeutic Neuroradiology criteria) or good (2-4). Changes in National Institute of Health Stroke Scale (NHISS) score before and after IAT and modified Rankins scale scores 3 months after discharge were compared with respect to onset-to-recanalization time. RESULTS: In patients with good collateral circulation, the estimated onset-to-recanalization time for a 0.5 probability of a good clinical outcome was 347 minutes; with poor collateral circulation, it was 172 minutes for a 0.2 probability of good clinical outcome. Outcome analyses according to onset-to-recanalization time showed patients recanalized 6 hours of onset-to-recanalization time, and non-recanalization: 5.1, 6.9, 11.9, and 19.8, respectively) at discharge and higher percentages of good clinical outcome (69%, 66.7%, 21.9%, and 0%, respectively) 3 months after IAT. CONCLUSIONS: The time window to expect a high probability of a good clinical outcome after IAT is highly dependent on the collateral circulation.
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Humanos , Arterias , Circulación Colateral , Estudios Retrospectivos , Accidente CerebrovascularRESUMEN
OBJECTIVE: Spinal epidural abscess (SEA) can be fatal if untreated, so early diagnosis and treatment are essential. We conducted a retrospective study to define its clinical features and evaluate the risk factors of motor weakness. METHODS: We retrospectively analyzed the medical records and images of patients with SEA who had been hospitalized in our institute from January 2005 to June 2012. Pyogenic SEA patients were categorized as patients without motor weakness (Group A) and with motor weakness (Group B). Abscess volume was measured using the Gamma-Plan program. Intervertebral foramen height and posterior disc height were measured to evaluate degree of spinal stenosis. RESULTS: Of 48 patients with pyogenic SEA, 33 (68%) were treated surgically, and 15 (32%) were treated with antibiotics. Eleven patients had weakness and abscess volume was unrelated to motor weakness. Old age, 'spare room' (abscess volume subtracted from spinal volume) and intervertebral foramen height and posterior disc height were statistically significant. Among the 48 patients, 43 (85%) had good outcome and erythrocyte sedimentation rate (ESR) was the only meaningful prognostic factor (p=0.014). The cut-off value of ESR was 112mm/h with 80% sensitivity and 79% specificity and had borderline significance (p=0.062). CONCLUSION: SEA needs emergent diagnosis and treatment. Motor weakness is the most important factor in treatment decision. By careful image reading, early surgical treatment can be an option for selected patients with severe spinal stenosis for prevent motor weakness. Inflammatory markers, especially ESR, are valuable to identify worsening of SEA.
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Humanos , Absceso , Antibacterianos , Sedimentación Sanguínea , Causalidad , Diagnóstico , Diagnóstico Precoz , Absceso Epidural , Registros Médicos , Estudios Retrospectivos , Factores de Riesgo , Sensibilidad y Especificidad , Estenosis EspinalRESUMEN
OBJECTIVE: Brain atrophy and subdural hygroma were well known factors that enlarge the subdural space, which induced formation of chronic subdural hematoma (CSDH). Thus, we identified the subdural volume that could be used to predict the rate of future CSDH after head trauma using a computed tomography (CT) volumetric analysis. METHODS: A single institution case-control study was conducted involving 1,186 patients who visited our hospital after head trauma from January 1, 2010 to December 31, 2014. Fifty-one patients with delayed CSDH were identified, and 50 patients with age and sex matched for control. Intracranial volume (ICV), the brain parenchyme, and the subdural space were segmented using CT image-based software. To adjust for variations in head size, volume ratios were assessed as a percentage of ICV [brain volume index (BVI), subdural volume index (SVI)]. The maximum depth of the subdural space on both sides was used to estimate the SVI. RESULTS: Before adjusting for cranium size, brain volume tended to be smaller, and subdural space volume was significantly larger in the CSDH group (p=0.138, p=0.021, respectively). The BVI and SVI were significantly different (p=0.003, p=0.001, respectively). SVI [area under the curve (AUC), 77.3%; p=0.008] was a more reliable technique for predicting CSDH than BVI (AUC, 68.1%; p=0.001). Bilateral subdural depth (sum of subdural depth on both sides) increased linearly with SVI (p<0.0001). CONCLUSION: Subdural space volume was significantly larger in CSDH groups. SVI was a more reliable technique for predicting CSDH. Bilateral subdural depth was useful to measure SVI.
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Humanos , Atrofia , Encéfalo , Estudios de Casos y Controles , Tomografía Computarizada de Haz Cónico , Traumatismos Craneocerebrales , Cabeza , Hematoma Subdural Crónico , Cráneo , Efusión Subdural , Espacio Subdural , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVE: Chronic subdural hematoma (CSDH) is relatively common in neurosurgical field. However not all patients develop CSDH after minor head trauma. In this study, we evaluate the risk factors of post-traumatic CSDH. METHODS: Two-hundred and seventy-seven patients were enrolled and analyzed in this study from January 2012 to December 2013. Of those, 20 participants had minor head trauma developed CSDH afterward. We also included 257 patients with minor head trauma who did not develop CSDH during the same follow-up period as the control group. We investigated the risk factors related to the development of CSDH after minor head trauma. RESULTS: Old age (p=0.014), preexisting diabetes mellitus (p=0.010), hypertension (p=0.026), history of cerebral infarction (p=0.035), antiplatelet agents (p=0.000), acute subdural hematoma in the convexity (p=0.000), encephalomalacia (p=0.029), and long distance between skull and brain parenchyma (p=0.000) were significantly correlated with the development of CSDH after trauma. Multivariate analysis revealed that only the maximum distance between the skull and the cerebral parenchyma was the independent risk factor for the occurrence of CSDH (hazard ratio 2.55, p=0.000). CONCLUSION: We should consider the possibility of developing CSDH in the post-traumatic patients with the identified risk factors.