Usefulness of Dexmedetomidine during Intracerebral Aneurysm Coiling

OBJECTIVE: General anesthesia is often preferred for endovascular coiling of intracranial aneurysm at most centers. But in the authors' hospital, it is performed under monitored anesthesia care (MAC) using dexmedetomidine. To determine the feasibility and safety of this approach, the authors reviewed our initial experience. METHODS: Retrospective data was analyzed from July 2012 to November 2012. We performed coil embolization in 28 cases using this method. Among them, for statistical significance, we analyzed 12 cases in which the procedure time exceeded an hour. Vital signs were analyzed every 10 minutes. Depth of sedation was measured according to the Ramsay sedation scale and frequency of the repeated roadmap image(s) caused by movement of the patient's head during the procedure. RESULTS: All procedures were completed without occurrence of procedure related complications. Under MAC using dexmedetomidine, vital signs of the patients were stable, no statistical significance regarding hemodynamic and respiratory parameters was observed between time points (p>0.05). Adequate sedation was achieved. Mean Ramsay sedation scale was 3.67+/-1.61 (2 to 6). Repeated roadmap image(s) due to patient's factor occurred in only one case. The mean dosage of drug for adequate sedation for the procedure was 0.65+/-0.12 mcg/kg/hr without loading doses. CONCLUSION: To the best of my knowledge, this is the first report published in English using the method of monitored anesthesia with dexmedetomidine for intracranial aneurysm coiling. Monitored anesthesia care using dexmedetomidine without loading dose for embolization of intracranial aneurysms appeared to be a safe and effective alternative to general anesthesia.

Endovascular Treatment of a Ruptured Posterior Inferior Cerebellar Artery Aneurysm during Pregnancy

Aneurysmal subarachnoid hemorrhage (SAH) during pregnancy is quite rare, however it has a high maternal mortality rate. A pregnant woman in the 16th gestational week was admitted to our hospital with a drowsy level of consciousness. A brain magnetic resonance (MR) image showed hemorrhage on the prepontine cistern, and both sylvian fissures, and MR angiography and cerebral digital subtraction angiography demonstrated an aneurysm at the left posterior inferior cerebellar artery (PICA). We performed endovascular coil embolization attempting to minimize radiation exposure. She was discharged with no neurologic deficit and delivered a healthy baby by cesarean section at the 38th week of gestation. This case study reported the shortest gestational period and this is the first report on an aneurysmal rupture arising from PICA which was treated using an endovascular method. Using an appropriate technique for reduced radiation exposure to the fetus and limited alterations in maternal-fetal physiology, endovascular coil embolization could guarantee good results in treatment of aneurysmal SAH in pregnant women.

Mortality and Real Cause of Death from the Nonlesional Intracerebral Hemorrhage

OBJECTIVE: The case fatality rate of nonlesional intracerebral hemorrhage (n-ICH) was high and not changed. Knowing the causes is important to their prevention; however, the reasons have not been studied. The aims of this study were to determine the cause of death, to improve the clinical outcomes. METHODS: We retrospectively analyzed consecutive cases of nonlesional intracerebral hemorrhage in a prospective stroke registry from January 2010 to December 2010. RESULTS: Among 174 patients (61.83+/-13.36, 28-90 years), 29 patients (16.7%) died during hospitalization. Most common cause of death was initial neurological damage (41.4%, 12/29). Seventeen patients who survived the initial damage may then develop various potentially fatal complications. Except for death due to the initial neurological sequelae, death associated with immobilization (such as pneumonia or thromboembolic complication) was the most common in eight cases (8/17, 47.1%). However, death due to early rebleeding was not common and occurred in only 2 cases (2/17, 11.8%). Age, initial Glasgow Coma Scale, and diabetes mellitus were statistically significant factors influencing mortality (p<0.05). CONCLUSION: Mortality of n-ICH is still high. Initial neurological damage is the most important factor; however, non-neurological medical complications are a large part of case fatality. Most cases of death of patients who survived from the first bleeding were due to complications of immobilization. These findings have implications for clinical practice and planning of clinical trials. In addition, future conduct of a randomized study will be necessary in order to evaluate the benefits of early mobilization for prevention of immobilization related complications.

The Anatomy of the Superficial Temporal Artery in Adult Koreans Using 3-Dimensional Computed Tomographic Angiogram: Clinical Research

OBJECTIVE: The increased use of bypass surgery in the treatment of ischemic cerebrovascular diseases requires a better understanding of the superficial temporal artery (STA) anatomy. This study is to describe the gross anatomy of STA in adult Korean population with respect to cranial surgery and to provide basic anatomic data for bypass surgery. METHODS: The study evaluated retrospectively 35 patients who visited the neurosurgery department at a single institution. For each patient, both the left and right STA (70 vessels) were evaluated by a 3-dimensional computed tomographic angiogramfor diameter and anatomic relationships to external landmarks. RESULTS: Of 70 STAs, 69 had a bifurcation. Among these, 57 (82.6%) were above the superior margin of the zygomatic arch. The STA bifurcation was 53.2 +/- 5.9 mm posterior to the keyhole, 9.5 +/- 5.3 mm anterior to the posterior margin of condylar process of the mandible, and 21.7 +/- 15.8 mm superior to the superior margin of the zygomatic arch. The inner diameter of the STA was 1.8 +/- 0.5 mm at the superior margin of the zygomatic arch, and 1.4 +/- 0.4 mm and 1.4 +/- 0.5 mm for frontal and parietal branches, respectively. The 75.7% of frontal and 66.7% of parietal branches were suitable for microvascular anastomosis. CONCLUSION: This present study demonstrated the STA in Korean adults, which may benefit the clinician in dealing with the surgical procedures related to this STA.

The Anatomy of the Superficial Temporal Artery in Adult Koreans Using 3-Dimensional Computed Tomographic Angiogram: Clinical Research

OBJECTIVE: The increased use of bypass surgery in the treatment of ischemic cerebrovascular diseases requires a better understanding of the superficial temporal artery (STA) anatomy. This study is to describe the gross anatomy of STA in adult Korean population with respect to cranial surgery and to provide basic anatomic data for bypass surgery. METHODS: The study evaluated retrospectively 35 patients who visited the neurosurgery department at a single institution. For each patient, both the left and right STA (70 vessels) were evaluated by a 3-dimensional computed tomographic angiogramfor diameter and anatomic relationships to external landmarks. RESULTS: Of 70 STAs, 69 had a bifurcation. Among these, 57 (82.6%) were above the superior margin of the zygomatic arch. The STA bifurcation was 53.2 +/- 5.9 mm posterior to the keyhole, 9.5 +/- 5.3 mm anterior to the posterior margin of condylar process of the mandible, and 21.7 +/- 15.8 mm superior to the superior margin of the zygomatic arch. The inner diameter of the STA was 1.8 +/- 0.5 mm at the superior margin of the zygomatic arch, and 1.4 +/- 0.4 mm and 1.4 +/- 0.5 mm for frontal and parietal branches, respectively. The 75.7% of frontal and 66.7% of parietal branches were suitable for microvascular anastomosis. CONCLUSION: This present study demonstrated the STA in Korean adults, which may benefit the clinician in dealing with the surgical procedures related to this STA.

Fusiform Aneurysm on the Basilar Artery Trunk Treated with Intra-Aneurysmal Embolization with Parent Vessel Occlusion after Complete Preoperative Occlusion Test

Fusiform aneurysms on the basilar artery (BA) trunk are rare. The microsurgical management of these aneurysms is difficult because of their deep location, dense collection of vital cranial nerves, and perforating arteries to the brain stem. Endovascular treatment is relatively easier and safer compared with microsurgical treatment. Selective occlusion of the aneurysmal sac with preservation of the parent artery is the endovascular treatment of choice. But, some cases, particularly giant or fusiform aneurysms, are unsuitable for selective sac occlusion. Therefore, endovascular coiling of the aneurysm with parent vessel occlusion is an alternative treatment option. In this situation, it is important to determine whether a patient can tolerate parent vessel occlusion without developing neurological deficits. We report a rare case of fusiform aneurysms in the BA trunk. An 18-year-old female suffered a headache for 2 weeks. Computed tomography and magnetic resonance image revealed a fusiform aneurysm of the lower basilar artery trunk. Digital subtraction angiography revealed a 7.1x11.0 mm-sized fusiform aneurysm located between vertebrovasilar junction and the anterior inferior cerebellar arteries. We had good clinical result using endovascular coiling of unruptured fusiform aneurysm on the lower BA trunk with parent vessel occlusion after confirming the tolerance of the patient by balloon test occlusion with induced hypotension and accompanied by neurophysiologic monitoring, transcranial Doppler and single photon emission computed tomography. In this study, we discuss the importance of preoperative meticulous studies for avoidance of delayed neurological deficit in the patient with fusiform aneurysm on lower basilar trunk.

Subarachnoid Hemorrhage with Negative Baseline Digital Subtraction Angiography: Is Repeat Digital Subtraction Angiography Necessary?

INTRODUCTION: Patients with negative initial digital subtraction angiography (DSA) are at significant risk for re-bleeding, which can lead to severe disability and death. The purpose of this study was to evaluate the necessity of repeat DSA in subgroups of patients with subarachnoid hemorrhage (SAH) with negative initial DSA. METHODS: A total of 904 spontaneous SAH patients were admitted to our department between May 2005 and May 2012. Twenty eight patients were selected for inclusion in this study because repeated DSA performed due to the etiology of the SAH could not be demonstrated on the initial DSA. According to the SAH pattern on initial computed tomography scans, patients were divided into perimesencephalic nonaneurysmal SAH (PN-SAH) and non PN-SAH (NPN-SAH) groups. Repeat DSA was performed in all patients, and two of these patients underwent a third DSA. RESULTS: Of the 904 patients, 28 patients (3.1%) had no vascular abnormality on initial DSA. Sixteen PN-SAH patients underwent a repeat DSA; however, no aneurysms were found. In contrast, 12 patients with NPN-SAH underwent repeat DSA, with detection of two cerebral aneurysms. Overall, the false-negative rate of the initial DSA was 7.1% (2/28 patients). No significant differences in false-negative results on initial DSA were observed between the PN-SAH and NPN-SAH groups. CONCLUSION: In the line with the results of the current study, we should be highly suspicious of patients with a nonaneurysmal SAH, especially those with a NPN-SAH pattern. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.

Chronic Subdural Hematoma after Spontaneous Intracranial Hypotension : A Case Treated with Epidural Blood Patch on C1-2

Spontaneous cerebrospinal fluid (CSF) leak is a recognized cause of spontaneous intracranial hypotension (SIH). Subdural hematoma (SDH) is a serious but rare complication of SIH. An autologous epidural blood patch at the CSF-leak site can effectively relieve SIH. We report a case of bilateral SDH with SIH caused by a CSF leak originating at the C1-2 level. A 55-year-old male complained of orthostatic headache without neurological signs. His symptoms did not respond to conservative treatments including bed rest, hydration and analgesics. Magnetic resonance imaging showed a subdural hematoma in the bilateral fronto-parietal region, and computed tomography (CT) myelography showed a CSF leak originating at the C1-2 level. The patient underwent successful treatment with a CT-guided epidural blood patch at the CSF-leak site after trephination for bilateral SDH.

The Fluid-Blood Level in a Spontaneous Intracerebral Hematoma / 대한뇌혈관외과학회지

A fluid-blood level is rarely seen on computed tomography (CT) studies of intracerebral hematomas (ICHs). The CT appearance of a fluid-blood level in an ICH has been associated with intratumoral bleeding, subdural hematomas, anti-coagulation and ruptured arteriovenous malformations. When fluid-blood levels are located around a hematoma with significant peri-hematoma edema, the fluid-blood level may merely indicate bleeding of recent origin. A fluid-blood could also represent a coagulopathy when the fluid-blood level is located in the center of a hematoma with less peri-hematoma edema. We report four cases of acute intracerebral hematomas in which fluid levels were noted on CT scans with a review of previous reports.

Pure Acute Subdural Hematoma without Subarachnoid Hemorrhage Secondary to Posterior Communicating Artery Aneurysm Rupture: A Case Report / 대한뇌혈관외과학회지

There are not many reports of a spontaneous acute subdural hematoma (ASDH) without the presence of a subarachnoid hemorrhage as a result of a ruptured aneurysm. A 66-year-old woman presented with acute subdural hematoma secondary to a ruptured intracranial aneurysm. She was admitted with an acute onset of bursting headache and nausea. There was no past history of head trauma. The CT scan demonstrated a left subdural hematoma with extension along the tentorium in the absence of subarachnoid or intraparenchymal hemorrhage. CT angiography revealed an aneurysm of the left posterior communicating aneurysm, which was directed posterolaterally. Uneventful clipping was performed without any neurological deficits. The possibility of aneurysmal subdural hemorrhage should be considered in all cases of ASDH that present with a sudden bursting headache without any history of trauma. Therefore, CT angiography can be an indispensable tool for detecting the aneurysm that has an unusual pattern of subdural hematoma.

Cardiac Troponin I Elevation in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: Cardiac dysfunction after aneurysmal subarachnoid hemorrhage (SAH) is associated with elevation of serum cardiac troponin I (cTnI) levels. Elevation of cTnI predicts cardiopulmonary and neurological complications, and poor outcome. METHODS: We retrospectively reviewed the medical and radiologic records of 114 (male : 30, female : 84) patients who developed aneurysmal SAH between January 2006 and June 2007 and had no history of previous cardiac problems. We evaluated their electrocardiography and cTnI level, which had been measured at admission. A cTnI level above 0.5 microgram/L was defined as an indicator of cardiac injury following SAH. We examined various clinical factors for their association with cTnI elevation and analyzed data using chi-square test, t-test and logistic regression test with SPSS version 12.0. The results were considered significant at p < 0.05. RESULTS: The following parameters shows a correlation with cTnI elevation : higher Hunt-Hess (H-H) grade (p = 0.000), poor Glasgow Outcome Scale (GOS) score (p = 0.000), profound pulmonary complication (p = 0.043), higher heart rate during initial three days following SAH (p = 0.029), ruptured aneurysm on communicating segment of internal carotid artery (p = 0.025), incidence of vasospasm (p = 0.421), and duration of hyperdynamic therapy for vasospasm (p = 0.292). A significant determinants for outcome were cTnI elevation (p = 0.046) and H-H grade (p = 0.000) in a multivariate study. CONCLUSION: A cTnI is a good indicator for cardiopulmonary and neurologic complications and outcome following SAH. Consideration of variable clinical factors that related with cTnI elevation may be useful tactics for treatment of SAH and concomitant complications.

Analysis of Clip-induced Ischemic Complication of Anterior Choroidal Artery Aneurysms

OBJECTIVE: The surgical approach is typically similar to those used for other supraclinoid internal carotid artery (ICA) lesions. However, the surgical clipping of this aneurysm is complicated and as a result, can result in postoperative ischemic complications. We studied to clarify the clip-induced ischemic complication risk of AChA aneurysm and to get the benefits for helping decision making. METHODS: We retrospectively investigated 53 cases (4.0%) of AchA aneurysm treated surgically. We divided the AChA aneurysm to 3 subtype according to the origin of aneurysmal neck; A type originating from the AChA itself, J type from junction of AChA and ICA, and I type from the ICA itself. We evaluated brain CT about 1 week post-operative day to confirm the low density in AChA territory. RESULTS: Ruptured aneurysm was 26 cases and unruptured aneurysm 27 cases. The aneurysmal subtype of A, J, and I was 13, 17, and 23 cases. Of the 53 cases who performed surgical neck clipping, twelve (22.6%) had postoperative AChA distribution infarcts. Increased infarct after neck clipping had statistic significance in non-I subtype (p=0.005). CONCLUSION: It is easy to classify as "easy" surgery. But surgery for AChA aneurysms carries with it a significant risk of postoperative stroke. Don't always stick to clipping only, especially in non-I type of incidental small aneurysm, which has high risk of post-clip ischemic complications.

Atypical Cerebellar Medulloblastoma Originating from Tentorium: Case Report / 영남의대학술지

The extraaxial presentation of a medulloblastoma is rare. This article describes the case of a 12-year-old boy who presented with severe headache, nausea, and vomiting. The tumor developed in the left tentorium; it was misdiagnosed as a meningioma based on the radiology examination. We review the literature and discuss the atypical presentation of medulloblastoma.

Delayed Tension Pneumocephalus Caused by Ventriculoperitoneal Shunt

The authors describe a rare case of tension pneumocephalus, caused by ventriculoperitoneal(V-P) shunting for communicating hydrocephalus. The patient had a history of a right frontal skull fracture and pneumocephalus after a traffic accident five months prior to the present presentation of gait disturbance and memory impairment. A CT scan showed hydrocephalus and a V-P shunt was put in place. On the fourth day after surgery, the mental status of the patient gradually deteriorated due to a tension pneumocephalus; this was treated by repairing a fistula in the frontal sinus and a dural defect. The patient's mental status improved and symptoms were completely recovered. We report a case of tension pneumocephalus following V-P shunt for hydrocephalus in a patient who sustained a right frontal skull fracture.

Surgical Results of Unruptured Intracranial Aneurysms

OBJECTIVE: To document surgical mortality and morbidity for the treatment of unruptured intracranial aneurysms, and to identify optimal treatment modalities, the authors reviewed and analyzed the surgical results. METHODS: The authors reviewed 49 cases of unruptured intracranial aneurysm without a previous history of subarachnoid hemorrhage from March 1984 through December 2003. Unruptured intracranial aneurysms were categorized as asymptomatic and symptomatic, and operative results were assessed using the Karnofsky scale at 3 months postoperatively. Outcomes were defined as 'excellent' for a Karnofsky scale score of 100, 'good' for a score of 80~90, 'fair' for 50~70, 'poor' for 10~40, or as 'death'. Excellent and good results were defined as a 'favorable' outcome and others as 'unfavorable' outcome. RESULTS: Of the 49 study subjects, 45 had a favorable outcome and 4 an unfavorable outcome. Surgical mortality was 6.1% and surgical morbidity was 2.0% for all subjects. And the symptomatic group had more complications. CONCLUSION: There were no significant relationships between aneurysmal size, location, and preoperative symptoms with surgical results. And we believe that the reasons for morbidity and mortality are attributable to strokes, thus more attention should be paid to peri- and post-operative patients care with a focus on strokes prevention in the symptomatic group.

Postpartum Cerebral Angiopathy-Presenting with Both Hemorrhagic and Ischemic Stroke

Postpartum cerebral angiopathy(PPCA) is a benign and, reVersible cerebrovascular disease in the postpartum period. The authors report here a 29-year-old woman who had severe headache, very poor consciousness and visual disturbances as the symptoms of PPCA. The clinical and radiological evaluation and treatment of this patient are disscussed.

The Time Evolution of Cerebral Apoptosis in the Permanent Middle Cerebral Artery Occlusion Model in Rats

OBJECTIVE: The purpose of this study is to determine the time evolution and distribution of cerebral apoptosis using the middle cerebral artery occlusion model in rats. METHODS: A total of twenty four male rats - with 2, 3, 4, 6, 8, 12, 24 and 48 hours of middle cerebral artery occlusion respectively - were studied. The terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick-end labeling(TUNEL) method was used for the observation of the apoptotic cells. The apoptotic ratio was calculated and the distribution of apoptosis was inspected in the pyriform cortex, basal ganglia and middle cerebral artery territory cortex. The rats were divided into three groups(Group I: 2~4 hours of occlusion, Group II: 6~12 hours of occlusion, Group III: 24~48 hours of occlusion). RESULTS: In this study, the proportion of apoptosis increased with the duration of middle cerebral artery occlusion and reached a maximum after about 12 hours of middle cerebral artery occlusion. The mean values of the apoptotic ratio were 30.7+/-11.3% in group I, 60.8+/-2.6% in group II and 48.7+/-0.7% in group III. The distribution of apoptosis differed in the pyriform cortex, basal ganglia and middle cerebral artery territory cortex according to the duration of time of the middle cerebral artery occlusion. CONCLUSION: In the middle cerebral artery occlusion model of the rats, apoptosis is found to increase according to the occlusion time, reaching a peak after 6 hours, and the distribution of apoptosis changed from the pyriform cortex to the basal ganglia and middle cerebral artery territory cortex.

External Ventricular Drainage System with Long Subcutaneous Tunnel

OBJECTIVE: The goal of this study is to introduce a new method of external ventricular drainage system to reduce the complications of infections by making a long subcutaneous tunnel. METHODS: Between January 2002 and March 2003, 59 cases of ventriculostomy including 44 cases of short subcutaneous tunnel and 15 cases of long subcutaneous tunnel were performed and analysed. Subarachnoid hemorrhage and intraventricular hemorrhage were major indications for ventriculostomy. RESULTS: No infection was noted in the group of 15 patients with long subcutaneous tunnel. Whereas, 6 cases(13.6%) of infection was diagnosed in the group of 44 patients with short subcutaneous tunnel. The ventriculostomy was kept maximally for 11(mean 7.4)days without infection in the patients with long subcutaneous tunnel. CONCLUSION: To reduce the infection as a complication of ventriculostomy, we devise a new drainage system that involves the long subcutaneous tunnel.

Unruptured Aneurysms / 대한뇌혈관외과학회지

No abstract available.

Fibromuscular Dysplasia with Cerebral Infarction in a Child: Case Report

An 11-year-old child presented with left hemiparesis and a seizure caused by fibromuscular dysplasia of the right internal carotid artery with cerebral infarction is presented. On conventional angiography, the authors found the classical `beaded' lesions. These pathognomic changes were most important to diagnosis. On brain single-photon emission computed tomography, we found the impaired vascular reserve of right basal ganglia, frontal and temporal area. We tried an antiplatelet agent and an encephaloduroarterio-synangiosis on the right hemisphere.