Transcranial Doppler study in acute spontaneous intracerebral hemorrhage: The role of pulsatility index

Objective@#Pulsatility index (PI) is a parameter calculated by transcranial Doppler sonography (TCD), which is commonly used for patients with subarachnoid hemorrhage or ischemic stroke. However, we performed a retrospective analysis of patients with acute spontaneous intracerebral hemorrhage (ICH) to assess the function of TCD, particularly the PI. @*Methods@#This study involved a total of 46 patients with acute ICH who received treatment at a single center between May 2013 and December 2014. Medical records of baseline characteristics, except for the modified Rankin scale, were obtained at initial evaluation in the emergency room, and TCD was used to calculate middle cerebral artery flow velocity (MFV) and PI at admission (baseline), 24 h, and 7 days. The PI and MFV values on the affected middle cerebral artery were compared with those on the contralateral side. Linear regression analysis was used for statistical analyses (SPSS 21.0, IBM Corp., Armonk, NY, USA). @*Results@#Statistical analysis indicated that sex, age, Glasgow coma scale, intraventricular hemorrhage, and hematoma size were not correlated with PI (p＞0.05); however, only PI was positively correlated with functional outcome at 6 months after treatment (R=0.846, p=0.002). @*Conclusions@#These results provide evidence that the parameter of PI is an independent determinant prognostic factor in acute spontaneous ICH. Further research is needed to investigate the influence of cerebral blood flow dynamics on a larger, more controlled, and more randomized basis.

Authors' Reply to Letter to the Editor: A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation (Korean J Neurotrauma 2018;14:159–163) / 대한신경손상학회지

No abstract available.

A Case of Posterior Inferior Cerebellar Artery Infarction after Cervical Chiropractic Manipulation / 대한신경손상학회지

We describe the case of a patient who had infarction of the posterior inferior cerebellar artery (PICA) after a chiropractic cervical manipulation. A 39-year-old man visited the emergency room with signs of cerebellar dysfunction, presenting with a 6-hour history of vertigo and imbalance. Two weeks ago, he was treated by a chiropractor for intermittent neck pain. At the time of admission, brain computed tomography, magnetic resonance imaging, and angiography revealed an acute infarction in the left PICA territory and occlusion of the extracranial vertebral artery (VA; V1/2 junction) as a result of the dissection of the VA. Angiography revealed complete occlusion of the left PICA and arterial dissection was shown in the extracranial portion of the VA. He was treated with antiplatelet therapy. Three weeks later, he was discharged without any sequelae. The possibility of VA dissection should be considered at least once in patients presenting with cerebellar dysfunctions with a recent history of chiropractic cervical manipulation.

The Rupture Risk of Aneurysm in the Anterior Communicating Artery: A Single Center Study

OBJECTIVE: The aim of this study was to evaluate the characteristics of ruptured aneurysms at anterior communicating artery (A com) with an analysis of clinical and morphological data, which could further our understanding of the risks of ruptured A com aneurysms. MATERIALS AND METHODS: An analysis of data with 86 ruptured and 44 unruptured A com aneurysms were analyzed using a digital subtraction angiography or 3-dimensional computed tomography angiography between January 2010 and December 2015 in a single center. RESULTS: Fifty-five percent of ruptured A com aneurysms were smaller than 4 mm in size. They had a smooth wall (44%), with a mean size ratio of 4.22 (range: 0.7-14.3) and mean height/width ratio of 1.48 (range: 0.5-2.9); 23 patients of A1 positive difference. Unruptured aneurysms were mostly 2-10 mm in size (94%) and had an irregular wall (43%), with a mean size ratio of 4.1 (range: 0.8-9.1) and mean height/width ratio of 1.2 (range: 0.1-2.6); 6 patients of A1 positive difference. In terms of the morphology of aneurysms, size of A com, maximum aneurysm size, neck width, aneurysm wall morphology, and size ratio were not different with statistical significance. However, dominance of A1 (p = 0.01) and height/width ratio (p = 0.03) were found to be a significant predictive factor for rupture of A com aneurysms. CONCLUSION: To better understand the rupture risk of A com aneurysms, a large, multicenter, collaborative, and prospective study should be performed in the future.

A Case of Dural Arteriovenous Fistula of Superior Sagittal Sinus after Tamoxifen Treatment for Breast Cancer

We are reporting an unusual case of dural arteriovenous fistula (AVF) of the superior sagittal sinus (SSS) after tamoxifen treatment for breast cancer. A 30-year-old female arrived at the emergency room with a sudden headache and left sided weakness and sensory loss. In her past medical history, she was diagnosed with breast cancer 1 year prior, and subsequently underwent a breast conserving mastectomy with whole breast radiation and adjuvant chemotherapy with tamoxifen. At the time of admission, computed tomography showed a small acute intracerebral hemorrhage at the right parietal cortex, and magnetic resonance imaging showed that a dural AVF at the SSS with a prominent and tortuous venous enhancement along the centrum semiovale was present. Cerebral angiography showed that the dural AVF at the mid-portion of the SSS with meningeal arterial feeding vessels entering the wall of the SSS, then draining through the dilated cortical veins. Our patient had no signs of active malignancy or any abnormalities in her coagulation profile, so it can be concluded that the tamoxifen was the likely cause of the SSS thrombosis and dural AVF. The dural AVF was treated by an endovascular coil embolization for the arterialized segment of the SSS. The patient dramatically recovered favorably from left side motor and sensory deficit. The best clinical approach is to screen potential patients of tamoxifen hormonal therapy and educate them on the sign and symptoms of life threatening thromboembolic events while taking tamoxifen.

Primary Angioplasty for Symptomatic Atherosclerotic Middle Cerebral Artery Stenosis

OBJECTIVE: The objective of this study is to evaluate the clinical and angiographic outcomes after primary balloon angioplasty in patients with symptomatic middle cerebral artery (MCA, M1 segment) stenosis refractory to medical therapy. MATERIALS AND METHODS: Eleven patients with intracranial stenosis were treated with primary balloon angioplasty. All patients had MCA stenosis with recurrent transient ischemic attack (TIA). The indication for balloon angioplasty was patients with significant MCA stenosis: 1) age older than 18 years with recurrent or progressive TIA or infarction despite optimal medical therapy, including anti-coagulation, dual anti-platelet, and anti-lipid medication; 2) previous ischemic events or asymptomatic severe stenosis (more than 50%) with poor collateral cerebral circulation, or diminished cerebral perfusion on single photon emission computed tomography before and after administration of the intravenous dosage of acetazolamide. RESULTS: The median age of patients was 53 years (range 44-79). The technical success rate was 100%. Mean pretreatment stenosis degree was 83.63 +/- 9.53% and 29.1 +/- 15.4% before and after angioplasty, respectively. Procedural-related complications occurred in four of 11 patients (36%), but none of the patients had permanent neurological deficit. All patients were available for an average follow-up period of 19.4 +/- 5.1 months. One patient had a stroke in the territory of angioplasty at two months after angioplasty. The stroke free survival rate at 30 days and 12 months was 100% and 91%, respectively. Restenosis over 50% was observed in three of 11 patients (27%); all were asymptomatic. CONCLUSION: Intracranial angioplasty for symptomatic MCA stenosis refractory to medical therapy can be a treatment option to reduce the risk of further TIA or stroke.

Frameless Stereotactic Aspiration for Spontaneous Intracerebral Hemorrhage and Subsequent Fibrinolysis Using Urokinase

OBJECTIVES: The optimal management of patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. The aim of this study was to evaluate technical results and clinical outcomes of frameless stereotactic aspiration and fibrinolysis using urokinase performed in a single center. MATERIALS AND METHODS: The subjects of this study were 62 consecutive patients with spontaneous ICH who were treated with frameless stereotactic aspiration and subsequent fibrinolysis using urokinase between February 2009 and June 2010 in our hospital. The surgical results, procedure-related complications, and clinical outcomes were evaluated. RESULTS: A total of 62 patients were enrolled in the study. The median age was 54 years (range, 32-86). The mean initial Glasgow coma scale score was 7.7 (range 5-11). The mean initial hemorrhage volume was 43 cm3 (range 30-70). Seven patients (11.2%) died of respiratory failure (four patients), postoperative edema (two patients), and heart disease (one patient). There were seven cases of procedure-related complications (11.2%), including malpositioning of catheters (two patients), pneumocephalus (one patient), and rebleeding (four patients, 6.4%). At the three-month follow-up, a good outcome (three-month Glasgow outcome scale > 3) was noted in 32 patients (51.6%). CONCLUSIONS: Frameless stereotactic aspiration and subsequent fibrinolytic thearpy using urokinase for spontaneous ICH is a simple and safe procedure with low mortality and rebleeding rate.

A Case of Cerebral Aneurysmal Subarachnoid Hemorrhage in Fabry's Disease

We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry's disease. A 42-year-old woman presented with aneurysmal SAH originated from a saccular aneurysm of the right posterior communicating artery. The patient was treated by an endovascular coil embolization of aneurysm. Postoperatively the patient recovered favorably without any neurological deficit. During her admission, the patient had a sign of proteinuria in urine analysis. The pathologic findings of kidney needle biopsy implied nephrosialidosis (mucolipidosis of lysosomal stroage disease), which is consistent with a Fabry's disease. It is uncommon that Fabry's disease is presented with aneurysmal SAH, especially in middle-aged patients, but could be a clinical concern. Further investigations are needed to reveal risk factors, vascular anatomy, and causative mechanisms of Fabry's disease with aneurysmal SAH.

A Case of Lateral Medullary Infarction after Endovascular Trapping of the Vertebral Artery Dissecting Aneurysm

We report an unusual case of lateral medullary infarction after successful embolization of the vertebral artery dissecting aneurysm (VADA). A 49-year-old man who had no noteworthy previous medical history was admitted to our hospital with a severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage, located in the basal cistern and posterior fossa. Cerebral angiography showed a VADA, that did not involve the origin of the posterior inferior cerebellar artery (PICA). We treated this aneurysm via endovascular trapping of the vertebral artery distal to the PICA. After operation, CT revealed post-hemorrhagic hydrocephalus, which we resolved with a permanent ventriculoperitoneal shunt procedure. Postoperatively, the patient experienced transient mild hoarsness and dysphagia. Magnetic resonance image (MRI) showed a small infarction in the right side of the medulla. The patient recovered well, though he still had some residual symptom of dysphagia at discharge. Such an event is uncommon but can be a major clinical concern. Further investigation to reveal risk factors and/or causative mechanisms for the medullary infarction after successful endovascular trapping of the VADA are sorely needed, to minimize such a complication.

Endovascular Treatment of Intracranial Aneurysms Using Polymer Polyglycolic-Lactic Acid Coated Coils / 이화의대지

OBJECTIVES: In treatment for intracranial aneurysms by coil embolization, recanalization remains the major limitation of coiling, particularly wide-necked or larger aneurysms. The aim of this study was to evaluate technical results and clinical outcome in a single center of consecutive patients with intracranial aneurysms treated with endovascular embolization using polyglycolic-lactic acid (PGLA) coated coils. METHODS: Between January 2005 and December 2010, 33 patients (male, 8 patients; female, 25 patients; mean age, 57 years) with saccular intracranial aneurysms were treated by means of an endovascular approach using PGLA coated coils. The endovascular procedures and technical outcomes were evaluated. The mean follow-up duration was 15.9 months (range, 6 to 72 months). RESULTS: Successful embolizations with satisfactory results were achieved in 91%. The degree of occlusion of the treated aneurysm was complete in 23 (69.6%), small neck remnant in 7 (21.2%), and residual filling in 3 (9%). Thirty patients (90.9%) showed no interval change of the residual neck. Three patients (9.1%) demonstrated the recanalization, and 2 of them were successfully recoiled. CONCLUSION: This preliminary study showed that PGLA coated coils may be safe option and preventable for recanalization in patients with intracranial aneurysms. Further study with more cases, longer follow-up data and well controlled design are required to confirm our results.

Antihypertensive Treatment of Acute Intracerebral Hemorrhage by Intravenous Nicardipine Hydrochloride: Prospective Multi-Center Study

The authors performed a multicenter prospective study to evaluate the feasibility and safety of intravenous nicardipine hydrochloride for acute hypertension in patients with intracerebral hemorrhage (ICH). This study included 88 patients (mean age: 58.3 yr, range 26-87 yr) with ICH and acute hypertension in 5 medical centers between August 2008 and November 2010, who were treated using intravenous nicardipine. Administration of nicardipine resulted in a decrease from mean systolic blood pressure (BP) (175.4 +/- 33.7 mmHg) and diastolic BP (100.8 +/- 22 mmHg) at admission to mean systolic BP (127.4 +/- 16.7 mmHg) and diastolic BP (67.2 +/- 12.9 mmHg) in 6 hr after infusion (P or = 2) was observed in 2 (2.2%) of 88 patients during the treatment. Aggressive nicardipine treatment of acute hypertension in patients with ICH can be safe and effective with a low rate of neurological deterioration and hematoma expansion.

Multiple Congenital Melanocytic Nevi in Association with Dandy-Walker Malformation / 대한피부과학회지

Congenital melanocytic nevi (CMN) are benign pigmented lesions found in about 1% of all newborns or shortly after birth. Giant melanocytic nevi, with multifocal involvement, show significantly greater risk of developing malignant melanomas and neurocutaneous melanosis (NCM), particularly in a posterior axial location. NCM is a rare congenital disease characterized by multiple (> or =3) small nevi, or at least one large congenital melanocytic nevus in combination with cerebral and/or leptomeningeal melanin deposits or melanoma. Dandy-Walker malformation (DWM) consists of a cystic dilatation of the fourth ventricle, hypoplasia or aplasia of the cerebellar vermis, and enlarged posterior fossa with or without hydrocephalus. The association of DWM and NCM has rarely been reported in the literature. A 3 month-old girl presented with increased head circumference and multiple various sized black plaques on her whole body. She underwent a ventriculoperitoneal shunt operation when she was 2 months-old. A skin biopsy was taken from the largest and darkest plaque of the trunk and showed hyperpigmentation of the basal layer of the epidermis. The dermis contained nevus cells in nests and sheets throughout the dermis, but no cellular atypia was noted. Magnetic resonance image (MRI) of the brain revealed severe hydrocephalus with hypoplasia of cerebellar vermis and agenesis of cerebellar tonsil which are consistent with Dandy-Walker malformation. We recommended a spinal MRI for check up the presence of leptomeningeal melanosis, but could not evaluate the result because of her being adapted. Herein, we present a rare case of multiple congenital melanocytic nevi in association with DWM in a neonate.

Long Term Improvement of Dysphagia in Lateral Medullary Infarction: A Case Report / 이화의대지

This report concerns a male patient suffered from refractory dysphagia after subarachnoid hemorrhage. A 49-year-old man admitted with severe headache followed by mental change. Imaging studies revealed that subarachnoid hemorrhage was located in basal cistern, and demonstrated ruptured vertebral dissecting aneurysm. After operation, the patient recovered well except severe dysphagia. Initial VFSS showed aspiration in fluid trial, penetration in semisolid bolus, and large amount of pharyngeal residue with poor relaxation of upper esophageal sphincter. For about 5 months, his symptom and several follow-up VFSS findings did not show marked improvement by various treatments. On magnetic resonance imaging for further evaluation of his brain lesion, an old infarction in right lateral side of medulla was found. He kept dysphagia rehabilitation more than one year, and his symptom improved to the level of oral feeding at last.

Dandy-Walker Malformation Associated with Neurocutaneous Melanosis

Neurocutaneous melanosis associated with Dandy-Walker malformation is a rare dysmorphogenesis that is associated with single or multiple giant pigmented cutaneous nevi and diffuse involvement of the central nervous system. In this article, we present a 2-month-old patient with neurocutaneous melanosis associated with Dandy-Walker malformation. In addition, we reviewed the literature and discussed the pathogenesis based on the preferred hypotheses.

The Role of Lumbar Drainage to Prevent Shunt-Dependent Hydrocephalus after Coil Embolization for Aneurysmal Subarachnoid Hemorrhage in Good-Grade Patients

OBJECTIVE: To evaluate the role of lumbar drainage in the prevention of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by coil embolization in good-grade patients. METHODS: One-hundred-thirty consecutive patients with aneurysmal subarachnoid hemorrhage in good-grade patients (Hunt & Hess grades I-III), who were treated by coil embolization between August 2004 and April 2010 were retrospectively evaluated. Poor-grade patients (Hunt & Hess grades IV and V), a history of head trauma preceding the development of headache, negative angiograms, primary subarachnoid hemorrhage (SAH), and loss to follow-up were excluded from the study. We assessed the effects on lumbar drainage on the risk of shunt-dependent hydrocephalus related to coil embolization in patients with ruptured intracranial aneurysms. RESULTS: One-hundred-twenty-six patients (96.9%) did not develop shunt-dependent hydrocephalus. The 2 patients (1.5%) who developed acute hydrocephalus treated with temporary external ventricular drainage did not require permanent shunt diversion. Overall, 4 patients (3.1%) required permanent shunt diversion; acute hydrocephalus developed in 2 patients (50%). There was no morbidity or mortality amongst the patients who underwent a permanent shunt procedure. CONCLUSION: Coil embolization of ruptured intracranial aneurysms may be associated with a lower risk for developing shunt-dependent hydrocephalus, possibly by active management of lumbar drainage, which may reflect less damage for cisternal anatomy than surgical clipping. Coil embolization might have an effect the long-term outcome and decision-making for ruptured intracranial aneurysms.

Non-Traumatic Primary Intraventricular Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: Non-traumatic primary intraventricular hemorrhage (PIVH) in adults has rarely been reported. This study aimed to identify clinical features, risk factors, and neurological outcomes of PIVH in adults. METHODS: We retrospectively reviewed the clinical data, complementary examinations, outcomes, and computed tomography (CT) scans for non-traumatic PIVH occurring between 2002 and 2008 at our institutions. We defined PIVH as "a hematoma caused by non-traumatic factors, either confined completely within the ventricular system or arising within 15 mm of the ventricular wall." Result: Among the 19 PIVH patients treated in our institutions, the mean age was 55.5 years (range 19-81), and the male to female ratio was 0.72. Symptom onset was abrupt in 18 patients and progressive in 1. The most frequent complaint was headache (47%) followed by nausea and vomiting (38%). Seven patients (38%) had mental status impairment, ranging from stupor to semicoma. The causes of PIVH were unknown, although arteriography showed a suspicious vascular malformation in 1 patient. Seven (37%) patients died or entered a vegetative state. All survivors became functionally independent. No patients received ventriculoperitoneal shunts. Two of the surviving patients had limb weakness. Overall, 7 patients (37%) had GOS scores 1 to 2 and 12 (63%) had GOS scores 3 to 5. CONCLUSION: Although present technology allows clinicians to reach a diagnosis in many PIVH patients, the condition's etiology remains unknown, and its clinical manifestations vary, due to the rarity of these cases. Overall results and prognoses seem relatively better than in secondary intraventricular hemorrhage. However, evaluating and clarifying the nature of PIVH requires experience with more cases.

Types of Thromboembolic Complications in Coil Embolization for Intracerebral Aneurysms and Management

OBJECTIVE: We describe our clinical experiences and outcomes in patients who had thromboembolic complications occurring during endovascular treatment of intracerebral aneurysms with a review of the literature. The types of thromboembolic complications were divided and the treatment modalities for each type were described. METHODS: Between August 2004 and March 2009 we performed endovascular embolization with Guglielmi detachable coils for 173 patients with 189 cerebral aneurysms, including ruptured and unruptured aneurysms at our hospital. Sixty-eight patients were males and 105 patients were females. The age of patients ranged from 22-82 years (average, 58.8 years). We retrospectively evaluated this group with regard to complication rates and outcomes. The types of thromboembolic complications were classified into the following three categories: mechanical obstruction, distal embolic stroke, and stent-induced complications, which corresponded to types I, II, and III, respectively. A comparison of the clinical results was made for each type of complication. RESULTS: Only eight patients had a thromboembolic complication during or after a procedure (4.6%). Of the eight patients, two had a mechanical obstruction as the causative factor; the other three patients had distal embolic stroke as the causative factor. The remaining three patients had stent-induced complications. In cases of mechanical obstruction, recanalization occurred due to the use of intra-arterial thrombolytic agents in one of two patients. Nevertheless, a poor prognosis was seen. In the cases of stent-induced complications, in one of three patients in whom a thrombus developed following stent insertion, a middle cerebral artery territory infarct developed with a poor prognosis despite the use of wiring and an intra-arterial thrombolytic agent. In the cases of distal embolic stroke, all three patients achieved good results following the use of antiplatelet agents. CONCLUSION: Treatment for thromboemboic complications due to mechanical obstruction and stent-induced complications include antiplatelet and intra-arterial thrombolytic agents; however, this cannot guarantee a sufficient extent of effectiveness. Therefore, active treatments, such as balloon angioplasty, stent insertion, and clot extraction, are helpful.

Outcome of Aneurysmal Subarachnoid Hemorrhage Patients with Hunt-Hess Grade III / 대한뇌혈관외과학회지

OBJECT: We designed this study to bring the outcome and the outcome predictors of Hunt-Hess grade III patients to light, and to be aid in determining treatment protocol of such a intermediate group. METHODS: All patients with non-traumatic subarachnoid hemorrhage who visited our hospital between January 1998 and December 2004, were reviewed. We selected 72 Hunt-Hess grade III aneurysmal subarachnoid hemorrhage patients for detailed review. 54 operations and 10 endovacular procedures were performed. The outcome of the patients were evaluated with Glasgow Outcome Scale (GOS). Through univariate and multivariate analysis, several clinical and operative factors were evaluated to determine the significance for the outcome. RESULT: Overall 58 patients were in good outcome group (GOS 4 or 5). overall 6-month mortality was 5.6%. Age, presence of intracerabral hemorrhage(ICH) on the initial computed tomography (CT) scan, and vasospasm were independently important in determining outcome. CONCLUSION: In the Hunt-Hess grade III aneurysmal SAH patient, age, presence of ICH on intial CT scan vasospasm have independent statistical significance to the outcome. More aggressive treatment of vasospasm can improve the outcome.

Urokinase Thrombolysis for Nonaneurysmal Spontaneous Intraventricular Hemorrhage

OBJECTIVE: The authors report our experience of urokinase thrombolysis in treating patients harboring nonaneurysmal spontanesous intraventricular hemorrhage(IVH) and evaluated complications, safety and feasibility of this procedure retrospectively. METHODS: Fifty-three patients with nonaneurysmal IVH>15mL without underlying structural etiology or coagulopathy were recruited. The patients with Glasgow Coma Scale(GCS) or =3) and bad (GOS<3) prognosis group, and performed comparative analysis between two groups. RESULTS: Mean age was 60.2 years. The baseline hematoma size ranged 16 to 72mL. IVH volume reduction was done by an average of 74.2%. As complications, there were 3cases of rebleeding and 2cases of ventriculitis. No intracranial adverse effects were observed during thrombolytic theraphy. At 6months after the procedure, 29patients had achieved a good recovery, 15remained vegetative. 9patients died in hospital. The main good prognostic factors were young age, small IVH volume, and high GCS. CONCLUSION: The results of this study suggest that this relatively easy and safe method of treatment will improve the prognosis. However, further clinical studies also must assess optimal thrombolytic dosage, frequency, and timing of urokinase instillation for safety and effectiveness and must include controlled comparisons of mortality, disability outcome, quality of life, time until convalescence, and cost of care in treated and untreated patients.

Feasibility & Limitations of Endovascular Coil Embolization of Anterior Communicating Artery Aneurysms

OBJECTIVE: The purpose of this study is to analyze aneurysm morphology and define limitations and feasibility in endovascular Gugliemi detachable coil(GDC) embolization for anterior communicating artery (ACoA) aneurysms. METHODS: From January 2000 through October 2003, 123patients were treated with endovascular coil embolization for ACoA aneurysms. There were 75women and 48men, with a mean age of 63years. All ruptured aneurysms were treated within 15days of rupture. Aneurysm morphology was classified according to neck size and projection of aneurysm dome as follows - A: neck of aneurysm or =4mm) aneurysms are highly related to recanalization of aneurysms. CONCLUSION: Endovascular coil embolization of ACoA aneurysms shows good outcome in our study. Nevertheless, there is a limitation in the endovascular approach to ACoA, even though advanced modern techniques evolve rapidly. Compensatory surgical approach with the endovascular approach is required for successful treatment of ACoA aneurysms.