Endovascular Treatment of Symptomatic Basilar Artery Stenosis / 신경중재치료의학

Purpose@#While symptomatic basilar artery (BA) stenosis is associated with a higher risk of recurrent stroke or death, there is no consensus on the management of these patients who are refractory to antiplatelet therapy. This study retrospectively assesses the outcomes of endovascular treatment (EVT) for symptomatic BA stenosis. @*Materials and Methods@#We conducted a retrospective review of patients with symptomatic BA stenosis who underwent EVT, including angioplasty or stenting, from 2006 to 2018. A total of 15 patients, who experienced transient ischemic attacks or strokes despite dual antiplatelet therapy, were included. EVT was performed under local anesthesia after pretreatment with antiplatelet medications. Angiographic follow-up was performed at 12 and 24 months post-EVT. Clinical outcomes were evaluated using the modified Rankin Scale (mRS). @*Results@#EVT was successfully completed in all patients. Peri/post-procedural complications occurred in 33% of cases, including in-stent thrombosis, intracranial hemorrhage, and pontine infarction. At long-term follow-up (mean 98.5±80.5 months), 73.3% of patients achieved a favorable functional outcome (mRS≤2) without disability or mortality. Patients with unfavorable outcomes had previous infarcts, with 2 experiencing new pontine infarctions after stenting. @*Conclusion@#This study suggests that EVT, including angioplasty and stenting, may offer promise as a treatment option for symptomatic BA stenosis refractory to medical therapy. However, the procedure carries a notable risk of complications, especially in patients with severe stenosis and previous infarcts. Careful patient selection, based on clinical and radiological criteria, is crucial.

Endovascular Reperfusion Therapy in Minor Stroke with Neurologic Deterioration beyond 24 Hours from Onset / 신경중재치료의학

Purpose@#Patients with minor stroke (National Institutes of Health Stroke Scale score ≤5) and large vessel occlusion (LVO) often experience neurological deterioration >24 hours after onset. However, the efficacy of endovascular reperfusion therapy in these patients remains unclear. The aim of this study was to determine the efficacy and safety of reperfusion therapy in patients with minor stroke and neurological deterioration >24 hours after onset. @*Materials and Methods@#Data were retrospectively reviewed from patients between January 2019 and April 2022 who met the following criteria: (1) minor stroke and small definitive ischemic lesions at initial visit, (2) onset to neurological deterioration >24 hours, (3) cortical signs, Alberta Stroke Program Early computed tomography (CT) Score >6 points, and large artery occlusion confirmed by CT angiography at neurological deterioration. Efficacy and safety outcomes were based on final thrombolysis in cerebral infarction (TICI), incidence of symptomatic intracranial hemorrhage (ICH), and mortality. Outcomes were assessed using the modified Rankin Scale (mRS) at 3 months. Good outcome was defined as a mRS of 0, 1, or 2. @*Results@#Data from 26 patients (38.4% female, mean age 75.8 years) were analyzed; 18 (69.2%) had a good outcome. A final TICI of 2b or 3 was observed in 24 (92.3%) patients. No other adverse events, including dissection, vasospasm or distal embolization, were observed during the procedures. Hemorrhagic events occurred in 8 patients after the procedure; however, there were no symptomatic ICHs. Good prognostic factors were younger age (P=0.062) and carotid stenting (P=0.025). @*Conclusion@#Endovascular reperfusion therapy performed in selected patients with minor stroke, LVO, and neurological deterioration >24 hours after stroke onset demonstrated favorable outcomes and safety.

Rescue Endovascular Treatment to Prevent Neurological Deterioration in Acute Symptomatic Bilateral Vertebral Artery Occlusion / 신경중재치료의학

Bilateral vertebral artery occlusive disease has been considered as a favorable condition with good collaterals. However, the prognosis of acute ischemic stroke secondary to symptomatic bilateral vertebral artery occlusion (BVAO) and endovascular treatment (EVT) has rarely been reported. We retrospectively selected patients with acute ischemic stroke admitted for symptomatic BVAO between January 2020 and February 2023. All patients with ischemic stroke were evaluated for ischemic lesion and arterial status using brain imaging and angiography. The prognosis of acute stroke with symptomatic BVAO was compared between EVT and conventional treatment. Outcomes were evaluated using modified Rankin Scale (mRS) score at 3 months follow-up. Within the study period, 17 of 2,655 acute ischemic stroke patients were diagnosed with ischemic stroke with symptomatic BVAO. The median age of these patients was 70 (interquartile range 44–89) years, and 13 (76%) were male. Seven patients received emergent EVT with stenting and 10 patients received conventional medical treatment only. Nine of 10 patients with conventional treatment had in-hospital stroke progression and developed new ischemic lesions in the pons and midbrain. Five patients with fetal and hypoplastic posterior communicating artery presented bilateral cerebral peduncular lesions. At 3 months follow-up, 6 patients (35%) had favorable outcomes (mRS 0–2), of which 5 were treated with vertebral artery stenting and 1 received conventional treatment. Ischemic stroke in patients with acute symptomatic BVAO is uncommon. However, stroke progression is common, and the prognosis of most patients is poor. Rescue management such as EVT might be considered for symptomatic BVAO.

Prevalence of Unruptured Intracranial Aneurysms: A Single Center Experience Using 3T Brain MR Angiography / 신경중재치료의학

Purpose@#The purpose of this study was to evaluate the prevalence and risk factors of unruptured intracranial aneurysms (UIAs), which can help establish guidelines of treatment for asymptomatic Korean adults using 3T magnetic resonance angiography (MRA). @*Materials and Methods@#Our Institutional Review Board approved this retrospective study, and informed consent was waived. All patients consisted of healthy individuals who underwent brain MRA using 3T magnetic resonance imaging between January 2011 and December 2012 as part of a routine health examination. Patient data and follow-up results were obtained from medical records. @*Results@#A total of 2,118 individuals (mean age=53.9±9.6 years, male:female=1,188:930) who had undergone brain MRA were enrolled in the study. UIAs were found in 80 patients with 105 UIAs (3.77%). Female predominance (55% in UIA vs. 43.47% in non-UIA, P=0.0416) and hypertension were more common in the UIA group (43.75% vs. 28.8%, P=0.004, respectively). The mean size of the aneurysms was 3.10±1.62 mm, and they were all saccular in shape and asymptomatic. The UIAs were most common in the internal carotid artery (59.1%), internal carotid-posterior communicating artery (15.2%), middle cerebral artery (9.5%), anterior communicating artery (8.6%), anterior cerebral artery (4.8%), and vertebral artery (2.9%). Twenty-eight of 80 patients (35%) had multiple aneurysms. The incidence of UIAs increased significantly with age (P=0.014). @*Conclusion@#In single center experience, we demonstrated the characteristics and prevalence of UIAs in asymptomatic adults, which may help establish guidelines or therapeutic standards for UIAs.

Prevalence of Unruptured Intracranial Aneurysms: A Single Center Experience Using 3T Brain MR Angiography / 신경중재치료의학

Purpose@#The purpose of this study was to evaluate the prevalence and risk factors of unruptured intracranial aneurysms (UIAs), which can help establish guidelines of treatment for asymptomatic Korean adults using 3T magnetic resonance angiography (MRA). @*Materials and Methods@#Our Institutional Review Board approved this retrospective study, and informed consent was waived. All patients consisted of healthy individuals who underwent brain MRA using 3T magnetic resonance imaging between January 2011 and December 2012 as part of a routine health examination. Patient data and follow-up results were obtained from medical records. @*Results@#A total of 2,118 individuals (mean age=53.9±9.6 years, male:female=1,188:930) who had undergone brain MRA were enrolled in the study. UIAs were found in 80 patients with 105 UIAs (3.77%). Female predominance (55% in UIA vs. 43.47% in non-UIA, P=0.0416) and hypertension were more common in the UIA group (43.75% vs. 28.8%, P=0.004, respectively). The mean size of the aneurysms was 3.10±1.62 mm, and they were all saccular in shape and asymptomatic. The UIAs were most common in the internal carotid artery (59.1%), internal carotid-posterior communicating artery (15.2%), middle cerebral artery (9.5%), anterior communicating artery (8.6%), anterior cerebral artery (4.8%), and vertebral artery (2.9%). Twenty-eight of 80 patients (35%) had multiple aneurysms. The incidence of UIAs increased significantly with age (P=0.014). @*Conclusion@#In single center experience, we demonstrated the characteristics and prevalence of UIAs in asymptomatic adults, which may help establish guidelines or therapeutic standards for UIAs.

Acute Cerebral Artery Occlusion by Direct Tumor Embolus

In acute stroke, emboli are mostly composed of thrombi from artery, cardiac chamber, valve and vein. Non-thrombotic emboli are sometimes difficult to identify the origin. According to the increased number of cancer patients, now 10% of stroke patients have a cancer. However, the potential mechanisms of stroke in patients with cancer are various. We presented a case of serious acute arterial occlusion with a tumor embolus, which was revealed by histopathologic analysis of retrieved emboli during mechanical thrombectomy.

Delayed Onset Acute Subdural Hematoma after Burr Hole Drainage in a Patient with Chronic Subdural Hematoma and Liver Cirrhosis / 대한신경손상학회지

Although acute intracranial bleeding after burr hole drainage for chronic subdural hematoma (SDH) is rare, it could still occur and is associated with a poor clinical outcome. Although rare, most of them occur immediately or within a few days after drainage, especially in patients who are on antiplatelet drugs or anticoagulants. We report an unusual case of delayed-onset acute SDH that developed 14 days after burr hole drainage of chronic SDH in a 54-year-old man with liver cirrhosis and thrombocytopenia. The possible pathophysiological mechanisms of this rare entity are discussed, and the relevant literature is reviewed.

Current Status of Interhospital Transfer in Acute Ischemic Stroke

BACKGROUND: Selecting the appropriate patients and reducing stroke onset to endovascular recanalization therapy (ERT) time are essential elements of a successful ERT. Since ERT is available only in large hospitals, proper patients transfer is important. The purpose of study is to examine the suitability of the transfer of acute stroke patients. METHODS: We retrospectively reviewed the medical records of patients who diagnosed as acute ischemic stroke from January to December in 2017. Patients were divided into two groups based on transfer (direct visit vs. transfer) and Alberta Stroke Program Early computed tomography (ASPECT) score (≥8 vs. <8) respectively. Each group was assessed by demographics, type and rate of reperfusion therapy, onset to reperfusion therapy time, stroke risk factors and neurological deficit severity. Interhospital distance and transfer time was calculated in transferred patients. RESULTS: Among the 455 patients, the 228 (50.2%) patients underwent interhospital transfer. The ratio of reperfusion therapy was not significant different between direct visit and transferred group (34.8% vs. 37.3%, p=0.397). The transferred patients tended to be older (p=0.003), female (p=0.001), more hypertension (p=0.019), less transient ischemic attack (p=0.001), longer onset to ERT time (178.55±85.92 vs. 131.48±82.89; p=0.001) lower ASPECT score (6.72±2.04 vs. 8.01±1.65; p<0.001) and higher National Institute of Health Stroke Scale (NIHSS) (p<0.001) and modified Rankin Scale (mRS) (p<0.001). High ASPECT score (≥8) patients were more direct visited (63.9%), shorter onset to ERT time (p=0.047), lower initial NIHSS and mRS (p<0.001), and greater in differences between mRS at admission and 3 months later (p=0.016). CONCLUSIONS: This study suggests emergency and interhospital transfer of acute stroke patients is inefficient, and systematization of transfer is necessary.

Adjacent Bilateral Stress Pedicle Fractures after Instrumented Lumbar Fusion: A Case Report / 대한신경손상학회지

Bilateral pedicle stress fractures are rare even in the elderly. Bilateral pedicle fractures are due to post-surgical complications at the level of fusion or stress related activities in most cases. The authors describe a unique case of adjacent L4 bilateral pedicle fractures, which developed 4 years after anterior lumbar interbody fusion with bone cement augmented screw fixation at the L5-S1 level. As far as the authors' knowledge, no similar case has been previously reported in the literature. The pathophysiological mechanism of this rare entity is discussed with review of relevant literature.

Reversible splenial lesion syndrome caused by rubella infection

Reversible splenial lesion syndrome can be caused by viral infection. Rubella generally occurs in childhood, and it is rarely accompanied by neurological complications in adulthood. A 35-year-old man visited our hospital due to conjunctival injection, mild fever, and headache 3 days after experiencing skin rash. Brain magnetic resonance imaging (MRI) revealed distinct lesions involving white matter in the splenium of the corpus callosum approximately 3 days following the onset of symptoms. Enzyme immunoassay performed on serum and CSF samples was positive for rubella virus IgM. A follow-up brain MRI was performed 24 days after the onset of symptoms, and reduced lesion size with decreased signals were observed on diffusion weighted image. This case showed that rubella infection can result in reversible splenial lesion accompanied by only mild neurological symptoms.

Symptomatic Epidural Fluid Collection Following Cranioplasty after Decompressive Craniectomy for Traumatic Brain Injury / 대한신경손상학회지

OBJECTIVE: Symptomatic epidural fluid collection (EFC) arising as a complication of cranioplasty is underestimated and poorly described. The purpose of this study was to investigate the risk factors for development of symptomatic EFC after cranioplasty following traumatic brain injury (TBI). METHODS: From January 2010 to December 2014, 82 cranioplasties following decompressive hemicraniectomy for TBI were performed by a single surgeon. Of these 82 patients, 17 were excluded from this study due to complications including postoperative hematoma, hydrocephalus, or infection. Sixty-five patients were divided into 2 groups based on whether they had developed symptomatic EFC: 13 patients required an evacuation operation due to symptomatic EFC after cranioplasty (Group I), and 52 obtained good outcome without development of symptomatic EFC (Group II). We compared the 2 groups to identify the risk factors for symptomatic EFC according to sex, age, initial diagnosis, timing of cranioplasty, cerebrospinal fluid (CSF) leakage during cranioplasty, size of bone flap, and bone material. RESULTS: A large bone flap and CSF leakage during cranioplasty were identified as the statistically significant risk factors (p<0.05) for development of symptomatic EFC. In Group I, 11 patients were treated successfully with 5 L catheter drainage, but 2 patients showed recurrent EFC, eventually necessitating bone flap removal. CONCLUSION: A larger skull defect and intraoperative CSF leakage are proposed to be the significant risk factors for development of symptomatic EFC. Careful attention to avoid CSF leakage during cranioplasty is needed to minimize the occurrence of EFC, especially in cases featuring a large cranial defect.

Spinal Cord Stimulation for Refractory Neuropathic Pain of Neuralgic Amyotrophy / 대한신경손상학회지

The aim of this paper was to report the effect of temporary and chronic spinal cord stimulation for refractory neuropathic pain in neuralgic amyotrophy (NA). A 35-year-old female presented with two-months history of a severe, relentless neuropathic pain of the left shoulder, forearm, palm, and fingers. The neuropathic pain was refractory to various medical treatments, including nonsteroidal anti-inflammatory drugs, opiates, epidural and stellate ganglion blocks, and typically unrelenting. The diagnosis of NA was made with the characteristic clinical history and magnetic resonance imaging. The patient underwent a temporary spinal cord stimulation to achieve an adequate pain relief because her pain was notoriously difficult to control and lasted longer than the average duration (about 4 weeks on average) of a painful phase of NA. Permanent stimulation was given with paddle lead. The neuropathic pain in her NA persisted and she continued using the spinal cord stimulation with 12 months after development of NA. The temporary spinal cord stimulation was effective in a patient with an extraordinary prolonged, acute painful phase of NA attack, and the subsequent chronic stimulation was also useful in achieving an adequate analgesia during the chronic phase of NA.

Chronological Changes of C-Reactive Protein Levels Following Uncomplicated, Two-Staged, Bilateral Deep Brain Stimulation

OBJECTIVE: The occurrence of acute cerebral infection following deep brain stimulation (DBS) is currently being reported with elevation of C-reactive protein (CRP) level. The aim of the present study was to establish normal range of the magnitude and time-course of CRP increases following routine DBS procedures in the absence of clinical and laboratory signs of infection. METHODS: A retrospective evaluation of serial changes of plasma CRP levels in 46 patients undergoing bilateral, two-staged DBS was performed. Because DBS was performed as a two-staged procedure involving; implantation of lead and internal pulse generator (IPG), CRP was measured preoperatively and postoperatively every 2 days until normalization of CRP (post-lead implantation day 2 and 4, post-IPG implantation day 2, 4, and 6). RESULTS: Compared with preoperative CRP levels (0.12+/-0.17 mg/dL, n=46), mean CRP levels were significantly elevated after lead insertion day 2 and 4 (1.68+/-1.83 mg/dL, n=46 and 0.76+/-0.38 mg/dL, n=16, respectively, p0.05). Mean CRP levels after IPG implantation were significantly higher in patients whose IPGs were implanted at post-lead day 3 than those at post-lead day 5-6 (3.99+/-2.80 mg/dL, n=30, and 2.31+/-1.56 mg/dL, n=16, respectively, p0.05). CONCLUSION: The mean postoperative CRP levels were highest on post-IPG insertion day 2 and decreased rapidly, returning to the normal range on post-IPG implantation day 6. The duration of post-lead implantation period influenced the magnitude of CRP elevation at post-IPG insertion day 2. Information about the normal response of CRP following DBS could help to avoid unnecessary diagnostic and therapeutic efforts.

Cauda Equina Syndrome Associated with Dural Ectasia in Chronic Anlylosing Spondylitis

Cauda equina syndrome (CES) associated with dural ectasia is a rare neurologic complication in patients with longstanding ankylosing spondylitis (AS). We report a 68-year-old male with a 30-year history of AS who presented a typical symptom and signs of progressive CES, urinary incontinence and neuropathic pain of the lumbosacral radiculopathy. Computed tomography (CT) and magnetic resonance imaging (MRI) findings showed the unique appearances of dural ectasia, multiple dural diverticula, erosion of posterior element of the lumbar spine, tethering of the conus medullaris and adhesion of the lumbosacral nerve roots to the posterior aspect of the dural ectasia. Considering the progressive worsening of the clinical signs, detethering of the conus medullaris through resection of the filum terminale was performed through a limited laminectomy. However, the urinary incontinence did not improve and there was a partial relief of the neuropathic leg pain only. The possible pathogenetic mechanism of CES-AS and the dural ectasia in this patient with longstanding AS are discussed with a literature review.

Clinical Outcomes of Percutaneous Endoscopic Surgery for Lumbar Discal Cyst

OBJECTIVE: Discal cyst is rare and causes indistinguishable symptoms from lumbar disc herniation. The clinical manifestations and pathological features of discal cyst have not yet been completely known. Discal cyst has been treated with surgery or with direct intervention such as computed tomography (CT) guided aspiration and steroid injection. The purpose of this study is to evaluate the safety and efficacy of the percutaneous endoscopic surgery for lumbar discal cyst over at least 6 months follow-up. METHODS: All 8 cases of discal cyst with radiculopathy were treated by percutaneous endoscopic surgery by transforaminal approach. The involved levels include L5-S1 in 1 patient, L3-4 in 2, and L4-5 in 5. The preoperative magnetic resonance imaging and 3-dimensional CT with discogram images in all cases showed a connection between the cyst and the involved intervertebral disc. Over a 6-months period, self-reported measures were assessed using an outcome questionaire that incorporated total back-related medical resource utilization and improvement of leg pain [visual analogue scale (VAS) and Macnab's criteria]. RESULTS: All 8 patients underwent endoscopic excision of the cyst with additional partial discectomy. Seven patients obtained immediate relief of symptoms after removal of the cyst by endoscopic approach. There were no recurrent lesions during follow-up period. The mean preoperative VAS for leg pain was 8.25+/-0.5. At the last examination followed longer than 6 month, the mean VAS for leg pain was 2.25+/-2.21. According to MacNab' criteria, 4 patients (50%) had excellent results, 3 patients (37.5%) had good results; thus, satisfactory results were achieved in 7 patients (87.5%). However, one case had unsatisfactory result with persistent leg pain and another paresthesia. CONCLUSION: The radicular symptoms were remarkably improved in most patients immediately after percutaneous endoscopic cystectomy by transforaminal approach.

Clinical Outcomes of Percutaneous Endoscopic Surgery for Lumbar Discal Cyst

OBJECTIVE: Discal cyst is rare and causes indistinguishable symptoms from lumbar disc herniation. The clinical manifestations and pathological features of discal cyst have not yet been completely known. Discal cyst has been treated with surgery or with direct intervention such as computed tomography (CT) guided aspiration and steroid injection. The purpose of this study is to evaluate the safety and efficacy of the percutaneous endoscopic surgery for lumbar discal cyst over at least 6 months follow-up. METHODS: All 8 cases of discal cyst with radiculopathy were treated by percutaneous endoscopic surgery by transforaminal approach. The involved levels include L5-S1 in 1 patient, L3-4 in 2, and L4-5 in 5. The preoperative magnetic resonance imaging and 3-dimensional CT with discogram images in all cases showed a connection between the cyst and the involved intervertebral disc. Over a 6-months period, self-reported measures were assessed using an outcome questionaire that incorporated total back-related medical resource utilization and improvement of leg pain [visual analogue scale (VAS) and Macnab's criteria]. RESULTS: All 8 patients underwent endoscopic excision of the cyst with additional partial discectomy. Seven patients obtained immediate relief of symptoms after removal of the cyst by endoscopic approach. There were no recurrent lesions during follow-up period. The mean preoperative VAS for leg pain was 8.25+/-0.5. At the last examination followed longer than 6 month, the mean VAS for leg pain was 2.25+/-2.21. According to MacNab' criteria, 4 patients (50%) had excellent results, 3 patients (37.5%) had good results; thus, satisfactory results were achieved in 7 patients (87.5%). However, one case had unsatisfactory result with persistent leg pain and another paresthesia. CONCLUSION: The radicular symptoms were remarkably improved in most patients immediately after percutaneous endoscopic cystectomy by transforaminal approach.

Clinical Analysis of Giant Intracranial Aneurysms with Endovascular Embolization

OBJECTIVE: The purpose of this study was to perform a clinical analysis of nine patients with giant aneurysms managed with endovascular embolization. METHODS: From March 2000 to September 2009, nine cases of giant intracranial aneurysms were treated (five unruptured and four ruptured). The nine patients included two males and seven females who were 47 to 72 years old (mean, 59.2 years old). The types of giant intracranial aneurysms were eight internal carotid artery aneurysms and one vertebral artery aneurysm. Treatment for each aneurysm was chosen based on anatomic relationships, aneurysmal factors, and the patients' clinical state. Three patients underwent endovascular coiling with stent and six initially underwent endovascular coiling alone. Medical records, operation records, postoperative angiographies, and follow-up angiographies were reviewed retrospectively. RESULTS: Eight out of nine patients showed good clinical outcomes. (six were excellent and two were good) after a mean follow-up period of 27.9 months. Six (67%) of the nine patients had a near-complete occlusions on the post-operative angiogram (mean, 13.5 months after the procedure). Occlusion rates of 90% or higher were obtained for eight (89%) of all the patients. One patient died due to multiple organ failure. Stents were ultimately required at some point for managing four aneurysms. Two patients needed additional procedures because of aneurysm regrowth. CONCLUSION: Endovascular treatment could be an alternative option for managing giant aneurysms adjuvant to surgical intervention.

Unilateral Lumbosacral Facet Interlocking without Facet Fracture

Acute traumatic spondylolisthesis at L5-S1 level is a rare condition, almost exclusively the result of major trauma, frequently associated with transverse process fractures and severe neurologic deficits. Recently, open reduction and internal fixation with posterior stabilization has been the method of treatment most frequently reported. We report a rare case of traumatic L5-S1 pondylolisthesis with a unilateral facet locking with a review of literatures.

ERRATUM: Unilateral Lumbosacral Facet Interlocking without Facet Fracture

In the March 2009 edition of the Journal of Korean Neurosurgical Society, we published an article entitled "Unilateral Lumbosacral Facet Interlocking without Facet Fracture" (Volume 45, pages 182-184). Fig. 1B on page 183 was supposed to be printed in color, but it was printed in black by mistake. We apologize to the authors and readers of JKNS for any inconvenience.

A case of fascioliasis diagnosed by endoscopic nasobiliary drainage fluid examination / 대한내과학회지

Fascioliasis is a zoonotic parasitic disease caused by Fasciola hepatica, the sheep liver fluke. Humans are accidental hosts in the life cycle of this parasite. Radiographic studies such as computerized tomography (CT) and ultrasonography are used widely for diagnosis. The abnormalities seen most commonly on a CT scan of the abdomen are multiple, small (less than 10 mm), indiscrete, hypodense lesions and microabscesses with tunnel-like branches, with frequent subcapsular locations of the lesions. A rare case of fascioliasis presenting with multi-septated hepatic cystic lesion like biliary cyst adenoma is reported. We experienced a 28-year-old woman who had epigastric pain for 5 months with severe eosinophilia and multi-septated 3.6 cm-sized hepatic cysts. We finally diagnosed the condition by identifying eggs of Fasciola hepatica from endoscopic nasobiliary drainage (ENBD) fluid.