A Single Flow Re-direction Endoluminal Device for the Treatment of Large and Giant Anterior Circulation Intracranial Aneurysms

Purpose@#The purpose of this study was to report the author’s experiences in treating large (10–25 mm) and giant (>25 mm) intracranial aneurysms (IAs) using a single Flow Re-direction Endoluminal Device (FRED) without assistant coiling, with a focus on procedure-related complications. @*Materials and Methods@#A total of 33 patients who were treated with FRED between January 2018 and July 2020 were retrospectively reviewed. The timing of procedure-related complications was chronologically categorized as acute (within 7 days), subacute (8 to 21 days), and delayed (after 21 days) periods. Follow-up angiography was performed at 2 to 27 months (mean 9.7 months), and clinical follow-up was performed at 1 to 31 months (mean 14.1 months) in all patients. @*Results@#Six (18.2%) patients experienced procedure-related complications, including 2 (6.1%) in acute period, 1 (3.0%) in subacute period, and 3 (9.1%) in delayed period. Thromboembolic complications occurred in 5 (15.2%) patients and hemorrhagic complications in 1 (3.0%). Permanent morbidity and mortality rates were 3.0% each. Non-internal carotid artery (ICA) location of IAs (odds ratio 6.532; 95% confidence interval, 1.335–17.816; p=0.034) was the only independent risk factor for procedure-related complications on multivariate logistic regression analysis. @*Conclusion@#The procedure-related complication rate was 18.2% in this study. Procedure-related complications might increase when treating large and giant IAs located on a non-ICA, especially on the middle cerebral artery. Therefore, it may be suggested that neurointerventionists and endovascular neurosurgeons should pay attention to the location of IAs when treating large and giant IAs with a single FRED.

Discrepancy between Angiography and Operative Findings of Small Side Wall Aneurysms in Atherosclerotic Parent Arteries

Preoperative evaluation of precise aneurysmal geometry is important for the treatment of intracranial aneurysms. We present two cases of unclippable side wall aneurysms due to their extremely low dome height, which appeared as saccular in the preoperative image because of a comparatively narrow atherosclerotic parent arterial lumen. In both cases, a calcified vessel wall was noted preoperatively. Lack of a definitive neck and abrupt discrepancy between the fragile aneurysmal wall and the atherosclerotic parent arterial wall was confirmed intraoperatively in both cases. This study describes an illustrative mechanism for the finding with emphasis on the importance of its preoperative diagnosis. Intracranial atherosclerosis associated with small side walled aneurysms may lead to overestimation of aneurysm height on preoperative imaging of the intravascular compartment.

Spinal Subdural Hematoma Associated with Intracranial Subdural Hematoma

The simultaneous occurrence of an intracranial and a spinal subdural hematoma (SDH) is rare. We describe a case of cranial SDH with a simultaneous spinal SDH. An 82-year-old woman visited the emergency room because of drowsiness and not being able to walk 6 weeks after falling down. A neurological examination showed a drowsy mentality. Brain computed tomography showed bilateral chronic SDH with an acute component. The patient underwent an emergency burr-hole trephination and hematoma removal. She exhibited good recovery after the operation. On the fourth postoperative day, she complained of low-back pain radiating to both lower limbs, and subjective weakness of the lower limbs. Spine magnetic resonance imaging revealed a thoracolumbosacral SDH. A follow-up spinal magnetic resonance imaging study that was performed 16 days later showed a significant decrease in the size of the spinal SDH. We discuss the pathogenesis of this simultaneous occurrence of spinal and cranial SDH.

Are Blood Blister-Like Aneurysms a Specific Type of Dissection? A Comparative Study of Blood Blister-Like Aneurysms and Ruptured Mizutani Type 4 Vertebral Artery Dissections

OBJECTIVE: Blood blister-like aneurysms (BBAs) resemble arterial dissections. The purpose of this study was to investigate the relationship between these two disease entities and highlight commonalities and distinct features. METHODS: Among 871 consecutive patients with aneurysmal subarachnoid hemorrhage, 11 BBAs of internal carotid artery and seven vertebral artery dissections (VADs) with a short segmental eccentric dilatation (Mizutani type 4), which is morphologically similar to a BBA, were selected. The following clinical factors were studied in each group : age, gender, risk factors, Hunt and Hess grade (HHG), Fisher grade (FG), vasospasms, hydrocephalus, perioperative rebleeding rate, and treatment outcome. RESULTS: The mean age was 47.9 years in the BBAs group and 46.4 years in the type 4 VADs group. All the BBA patients were female, whereas there was a slight male predominance in the type 4 VAD group (male : female ratio of 4 : 3). In the BBA and type 4 VAD groups that underwent less aggressive treatment to save the parent artery, 29% (n=2/7) and 66.6% (n=2/3), respectively, eventually required retreatment. Perioperative rebleeding occurred in 72.7% (n=8) and 28.6% (n=2) of patients in the BBA and type 4 VAD groups, respectively. There was no statistical difference in the other clinical factors in both groups, except for the male dominancy in the type 4 VAD group (p=0.011). CONCLUSION: BBAs and ruptured type 4 VADs have a similar morphological appearance but there is a distinct clinical feature in gender and perioperative rebleeding rates. Complete isolation of an aneurysm from the parent artery might be the most important discipline for the treatment of these diseases.

Quantitative Analysis of Factors Affecting Cobalt Alloy Clip Artifacts in Computed Tomography

OBJECTIVE: Clip artifacts limit the visualization of intracranial structures in CT scans from patients after aneurysmal clipping with cobalt alloy clips. This study is to analyze the parameters influencing the degree of clip artifacts. METHODS: Postoperative CT scans of 60 patients with straight cobalt alloy-clipped aneurysms were analyzed for the maximal diameter of white artifacts and the angle and number of streak artifacts in axial images, and the maximal diameter of artifacts in three-dimensional (3-D) volume-rendered images. The correlation coefficient (CC) was determined between each clip artifact type and the clip blade length and clip orientation to the CT scan (angle a, lateral clip inclination in axial images; angle b, clip gradient to scan plane in lateral scout images). RESULTS: Angle b correlated negatively with white artifacts (r=-0.589, p<0.001) and positively with the angle (r=0.636, p<0.001) and number (r=0.505, p<0.001) of streak artifacts. Artifacts in 3-D images correlated with clip blade length (r=0.454, p=0.004). Multiple linear regression analysis revealed that angle b was the major parameter influencing white artifacts and the angle and number of streak artifacts in axial images (p<0.001), whereas clip blade length was a major factor in 3-D images (p=0.034). CONCLUSION: Use of a clip orientation perpendicular to the scan gantry angle decreased the amount of white artifacts and allowed better visualization of the clip site.

Traumatic Aneurysm of the Callosomarginal Artery-Cortical Artery Junction from Penetrating Injury by Scissors

Traumatic intracranial aneurysms (TICAs) are rare and are associated with high rates of morbidity and mortality. TICAs usually result from head injuries caused by traffic accidents, industrial accidents, or gunshots. We report a traumatic aneurysm of the callosomarginal artery-cortical artery junction arising from a penetrating injury by scissors. A 51-year-old woman was admitted to our hospital after suffering a penetrating injury caused by scissors. Computed tomography (CT) and CT-angiography demonstrated a right orbital roof fracture, subarachnoid hemorrhage, frontal lobe hemorrhage, intraventricular hemorrhage, and a traumatic aneurysm of the right callosomarginal artery-cortical artery junction. We trapped the traumatic aneurysm and repositioned a galeal flap. Postoperative CT showed a small infarction in the left frontal lobe. Follow-up angiography two months later showed no residual aneurysm. We suggest that an aggressive surgical intervention be performed whenever TICA is diagnosed.

Silent Microembolism on Diffusion-Weighted MRI after Coil Embolization of Cerebral Aneurysms / 신경중재치료의학

PURPOSE: The purpose of this study was to investigate the frequency and risk factors of procedure-related thromboembolism on diffusion-weighted imaging (DWI) associated with aneurysmal coil embolization. MATERIALS AND METHODS: We prospectively evaluated 39 consecutive patients with a cerebral aneurysm with DWI after coil embolization. All hyperintense lesions on DWI with a drop of apparent diffusion coefficient values were classified into acute thromboembolic infarction (larger than 5 mm in maximal diameters, and located in the vascular territory of the parent artery) and silent microembolism (single or multiple tiny dot-like lesion, less than 5 mm, usually 1-2 mm in size). Possible risk factors for thromboembolic events included vascular risk factors, aneurysmal factors, and procedure-related factors. RESULTS: Hyperintense lesions on DWI were seen in 17 (43.6%) patients and symptomatic DWI positive lesions were four (10.3%). Acute thromboembolic infarction was observed in seven (17.9%) patients and silent microembolism in 14 (35.9%) patients. Numbers of silent microembolism ranged from 1 to 15 (mean: 2.86, standard deviation: 3.74). Silent microembolisms were located at ipsilateral (n=3, 21.4%), contralateral (n=5, 35.7%), bilateral (n=4, 28.6%), and not related (n=2, 14.3%) to the procedure site. There were no statistical significant risk factors in acute thromboembolic infarction. However, incidence of silent microembolisms was significantly correlated with left side approach (odds ratio, 4.44, 95% confidence interval, 1.08-18.36; P=0.03). CONCLUSION: Left side approach may have increased the likelihood of asymptomatic multiple scattered microemboli after aneurysmal coiling procedures. Particular care must be taken in the handling of guiding catheters, especially when proving left side great vessels.

Atypical Metronidazole-Induced Encephalopathy in Anaerobic Brain Abscess

Metronidazole-induced encephalopathy is a very rare complication of the long standing use of metronidazole. The encephalopathy is bilateral and symmetric in nature. We report on the magnetic resonance imaging (MRI) and clinical course of metronidazole-induced encephalopathy in a 60-year-old female with a persistent anaerobic brain abscess after draining of the abscess. After 3 months of metronidazole administration, the patient complained of dysarthria, tingling sense of all extremities, and left hemiparesis. MRI revealed symmetric hyperintensity lesions in medulla, pons, dentate nuclei of cerebellum, and splenium of corpus callosum, all of which represent typical findings of metronidazole-induced encephalopathy. In addition, asymmetric lesions in midbrain, thalamus, putamen and cerebral subcortical white matter were noted. The patient recovered after discontinuation of metronidazole and the remaining abscess was successfully treated with meropenem and levofloxacine.

Quantitative Analysis of Developmental Process of Cranial Suture in Korean Infants

OBJECTIVE: The purpose of this study was to elucidate the anatomical development of physiologic suture closure processes in infants using three dimensional reconstructed computed tomography (CT). METHODS: A consecutive series of 243 infants under 12 months of age who underwent three dimensional CT were included in this study. Four major cranial sutures (sagittal, coronal, lambdoidal and metopic suture) were classified into four suture closure grades (grade 0=no closure along the whole length, grade 1=partial or intermittent closure, grade 2=complete closure with visible suture line, grade 3=complete fusion (ossification) without visible suture line), and measured for its closure degree (suture closure rates; defined as percentage of the length of closed suture line divided by the total length of suture line). RESULTS: Suture closure grade under 12 months of age comprised of grade 0 (n=195, 80.2%), grade 1 (n=24, 9.9%) and grade 2 (n=24, 9.9%) in sagittal sutures, whereas in metopic sutures they were grade 0 (n=61, 25.1%), grade 1 (n=167, 68.7%), grade 2 (n=6, 24%) and grade 3 (n=9, 3.7%). Mean suture closure rates under 12 months of age was 58.8% in metopic sutures, followed by coronal (right : 43.8%, left : 41.1%), lambdoidal (right : 27.2%, left : 25.6%) and sagittal sutures (15.6%), respectively. CONCLUSION: These quantitative descriptions of cranial suture closure may help understand the process involved in the cranial development of Korean infants.

Thromboxane A2 Synthetase Inhibitor Plus Low Dose Aspirin : Can It Be a Salvage Treatment in Acute Stroke Beyond Thrombolytic Time Window

OBJECTIVE: There is no proven regimen to reduce the severity of stroke in patients with acute cerebral infarction presenting beyond the thrombolytic time window. Ozagrel sodium, a selective thromboxane A2 synthetase inhibitor, has been known to suppress the development of infarction. The antiplatelet effect is improved when aspirin is used together with a thromboxane synthetase inhibitor. METHODS: Patients with non-cardiogenic acute ischemic stroke who were not eligible for thrombolysis were randomly assigned to two groups; one group received ozagrel sodium plus 100 mg of aspirin (group 1, n=43) and the other 100 mg of aspirin alone (group 2, n=43). Demographic data, cardiovascular risk factors, initial stroke severity [National Institute of Health Stroke Scale (NIHSS) and motor strength scale] and stroke subtypes were analyzed in each group. Clinical outcomes were analyzed by NIHSS and motor strength scale at 14 days after the onset of stroke. RESULTS: There were no significant differences in the mean age, gender proportion, the prevalence of cardiovascular risk factors, stroke subtypes, and baseline neurological severity between the two groups. However, the clinical outcome for group 1 was much better at 14 days after the onset of stroke compared to group 2 (NIHSS score, p=0.007, Motor strength scale score, p<0.001). There was one case of hemorrhagic transformation in group 1, but there was no statistically significant difference in bleeding tendency between two groups. CONCLUSION: In this preliminary study, thromboxane A2 synthetase inhibitor plus a low dose of aspirin seems to be safe and has a favorable outcome compared to aspirin alone in patients with acute ischemic stroke who presented beyond the thrombolytic time window.

Postoperative Contralateral Supra- and Infratentorial Acute Epidural Hematoma after Decompressive Surgery for an Acute Subdural Hematoma: A Case Report

A postoperative contralateral supra- and infratentorial epidural hematoma after decompressive surgery is an extremely rare event. We describe a 38-year-old male with a contralateral supra- and infratentorial acute epidural hematoma just after decompressive surgery for an acute subdural hematoma. A contralateral skull fracture involving a lambdoidal suture and an intraoperative brain protrusion may be warning signs. The mechanisms, along with relevant literature, are discussed.

Clinical Characteristics and Outcome Predictor of Hypertensive Intracerebral Hemorrhage in the Very Elderly / 대한뇌혈관외과학회지

OBJECTIVE: We investigated clinical characteristics and independent outcome predictors of hypertensive intracerebral hemorrhage(ICH) in the very elderly patients. METHODS: From January 2001 to December 2005, we analyzed retrospectively 28 very elderly patients(> or = 80 years) with hypertensive ICH admitted to our neurosurgical department. As a control group, 200 younger patients( or = 80 years than in the control group(35.7% vs. 19.0%, respectively, p = 0.005). By multivariate analysis, in ICH patients > or = 80 years, only coma(Glasgow coma scale score < or = 8) was independently associated with 30-day mortality(odds rati[OR]25.5, 95% confidence interva[CI]2.36 - 275.74, p < 0.001). CONCLUSION: Our result suggests that the very elderly patients with hypertensive ICH may present some different clinical characteristics from those in their younger counterparts.

Vertebral Metastasis from Squamous Cell Carcinoma of the Anal Canal

Distant metastasis of squamous cell carcinoma from the anal canal is an uncommon event. However, hematogenous spread to the vertebrae may occur in the course of this disease. The route of metastasis from the anal canal seems to be Batson's vertebral venous system. A 52-year-old female patient presented with lower back and right leg pain of one-week history. She has undergone radiotherapy and chemotherapy for squamous cell carcinoma of the anal canal and then was followed by surgical resection. Three months later, magnetic resonance images of the lumbar spine disclosed a well-enhanced mass of L5 vertebral body compressing the thecal sac. Surgical decompression and biopsy were performed. Histopathological study confirmed carcinoma of the squamous cell origin. We report a rare case of vertebral metastasis from squamous cell carcinoma of the anal canal with a pertinent review of literature.

Analysis of Treatment Results of Vertebral Artery Dissecting Aneurysms Presented with Various Clinical Manifestations

OBJECTIVE: The dissecting aneurysms of vertebral artery with various clinical manifestations have been increasingly reported with recent advent of diagnostic tools such as 3-Dimension computed tomography angiogram, magnetic resonance image and conventional angiogram. The authors analyzed the various treatment modalities according to their clinical presentations of vertebral artery dissecting aneurysms. METHODS: At the author's institution between March 2001 and February 2004, 28 patients were managed under diagnose of vertebral artery dissection. The medical record and neuroimaging studies of patients were reviewed retrospectively. RESULTS: Seven patients were presented with subarchnoid hemorrhage and 2 patients with mass effect. The other 12 patients were presented with ischemic stroke and 7 patients with headache or neck pain. 19 patients were treated with endovascular coils or stent. The other 8 patients were treated conservatively. and one patient was treated with operation. We had no endovascular treatment-related complications. Sixteen patients who underwent endovascular treatment survived with good recovery. but one patient died and 2 patients were in poor neurological status. Among patients with mass effect, one patient was treated with operation. and the other one patient with endovascular coils. We obtained optimal treatment results with improvement of myelopathy in both patients. CONCLUSION: The choice of the treatment of vertebral artery dissecting aneurysm of patients, clinical characteristics, and relation with posterior inferior cererebellar artery. The endovascular treatment using stent with/without coiling could be the treatment of choice if preservation of the vertebral artery is necessory.

Syringomyelia as a Sequelae of the 4th Ventricular Dilatation from Traumatic Hydrocephalus and Cerebellar Atrophy

A 32-year-old man with stuporous mental state was transferred to our hospital emergency room after a car accident. The brain computed tomography(CT) showed 4th ventricular hemorrhage. He woke up 2 weeks after admission and then discharged. However, he returned to the hospital 10 months after discharge because of both shoulder pain and weakness of both arms. His brain CT showed marked dilatation of the 4th ventricle. His MRI showed whole spinal syringomyelia without Chiari malformation. The patient then underwent ventriculo-peritoneal shunt. His symptoms dramatically improved on the immediate postoperative day, and the syringomyelia also disappeared after operation. The authors report a very rare case of syringomyelia that was developed as a sequelae, especially of the 4th ventricular dilatation without intracranial pressure elevation after traumatic hydrocephalus and cerebellar atrophy, favoring Gardner's hypothesis.

Clinical Analysis of Aneurysmal Subarachnoid Hemorrhage Patients with Vasospasm on Admission

OBJECTIVE: The purpose of this preliminary study is to evaluate the influence of the treatment time(early surgery versus delay surgery) on outcome in a series of 14 patients with the aneurysmal subarachnoid hemorrhage presenting clinical and angiographic vasospasm on admission. METHODS: The authors have reviewed retrospectively the clinical characteristics of 14 patients presenting vasospasm at admission among 430 patients admitted from January 1998 to December 2001. The patients were divided into two groups based on their preoperative time: in 7 days (early treated group): over 7 days from the hemorrhage(delayed treated group). RESULTS: There were no clinical differences between the two groups in age and sex distribution, preoperative Hunt-Hess scale and Fisher grade except anterior communicating artery aneurysm predominance in delayed treated group. The early treated group had a better outcome than the delayed treated group by Glasgow Outcome Scale(p<0.05): 6 good recovery in early treated group(100%, n=6) versus 3 good recovery, 3 moderate Disability, 1 severe disability and 1 death in delayed treated group(n=8). The latter group had high complication rates such as a hemiparesis, meningitis and hydrocephalus(n=6, 78%) CONCLUSION: The early treated group has a good outcome in spite of vasospasm period by early medical treatment for vasospasm. The authors suggest that active early treatment regardless of vasospasm would be one of the treatment choice which contribute to improve the clinical result for subarachnoid hemorrhage presenting vasospasm.

A Case of Parkinsonism Associated with Secondary Hydrocephalus following Aneurysmal Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

A case of parkinsonism caused by hydrocephalus after aneurysmal subarachnoid hemorrhage is reported. A 42-year-old man was admitted with typical symptoms of hydrocephalus, including deteriorated mental status, poor oral intake, gait disturbance and urinary incontinence. He had a past history of aneurysmal subarachnoid hemorrhage clipped one month before. Computed tomographic (CT) scan of the brain revealed dilatation of ventricles with periventricular low densities. He underwent a shunt operation and the symptoms of hydrocephalus were dramatically improved. However, new symptoms just like cogwheel rigidity, masked face, dysarthria and sialorrhea were developed. Levodopa was administrated and the patient showed marked improvement in above symptoms and discharged with independent daily activities. We report this rare clinical presentation and successful management with dopaminergic agent in parkinsonism induced by hydrocephalus after aneurysmal subarachnoid hemorrhage.