Middle meningeal artery embolization for chronic subdural hematoma in elderly patients at high risk of surgical treatment

Objective@#The purpose of this study was to evaluate the effectiveness of middle meningeal artery embolization (MMAE) in elderly high-risk patients with symptomatic chronic subdural hematoma (CSDH) in terms of reduction in hematoma volume and recurrence rate. @*Methods@#We retrospectively reviewed data prospectively collected from nine patients who underwent 13 MMAE for CSDH between June 2017 and May 2022. The volume of the subdural hematoma was measured using a computer-aided volumetric analysis program. Hematoma volume changes during the follow-up period were analyzed and clinical outcomes were evaluated. @*Results@#The mean follow-up period was 160 days (range, 46−311 days). All procedures were technically successful and there were no procedure-related complications. Of the 13 MMAE, 84% (11 out of 13 hemispheres) showed mean 88% of reduction on follow-up volumetric study with eight cases of complete resolution. There was one refractory case with MMAE which had been performed multiple burr-hole trephinations, for which treatment was completed by craniotomy and meticulous resection of multiple pseudomembranes. There was no recurrent case during the follow-up period, except for refractory case. @*Conclusions@#MMAE for CSDH in selected high-risk elderly patients and relapsed patients might be effective. Despite the small cohort, our findings showed a high rate of complete resolution with no complications. Further prospective randomized trials are warranted to evaluate its usefulness as a primary treatment option for CSDH.

Selective Temporary Stent-Assisted Coil Embolization for Intracranial Wide-Necked Small Aneurysms Using Solitaire AB Retrievable Stent

OBJECTIVE: Stent-assisted coil embolization of intracranial wide-necked aneurysm requires long-term postoperative antiplatelet therapy to prevent in-stent thrombosis. This study aimed to demonstrate results of temporary stent placement for coiling wide necked small intracranial aneurysms, which eliminated need for antiplatelet agents, and to discuss its feasibility and safety.METHODS: Data of 156 patients who underwent stent-assisted coil embolization between 2011 and 2014 were retrospectively analyzed. Thirteen cases of temporary stent-assisted coil embolization were included, and their clinical and radiological results were evaluated.RESULTS: The aneurysms treated were all unruptured except one case. All of them had wide neck with mean dome-to-neck ratio of 0.96 and were small-sized aneurysms with mean maximal diameter of 4.2 mm. There was no technical failure in retrieval of stent after completion of embolization of the target aneurysm. Immediate angiography revealed 11 complete and two partial embolization (one residual neck and one residual aneurysm). Two cases encountered thrombosis complication, and they were managed without neurological sequelae. The mean follow-up period was 43 months, angiographic follow-up revealed two cases with minor recurrence, and clinical outcome was good with modified Rankin scale score of 0.CONCLUSION: Temporary stent-assisted coil embolization of small wide-necked intracranial aneurysm using fully retrievable stent appears safe and effective. Further application and evaluation of this technique in more cases with larger size aneurysm is warranted.

Selective Temporary Stent-Assisted Coil Embolization for Intracranial Wide-Necked Small Aneurysms Using Solitaire AB Retrievable Stent

OBJECTIVE: Stent-assisted coil embolization of intracranial wide-necked aneurysm requires long-term postoperative antiplatelet therapy to prevent in-stent thrombosis. This study aimed to demonstrate results of temporary stent placement for coiling wide necked small intracranial aneurysms, which eliminated need for antiplatelet agents, and to discuss its feasibility and safety. METHODS: Data of 156 patients who underwent stent-assisted coil embolization between 2011 and 2014 were retrospectively analyzed. Thirteen cases of temporary stent-assisted coil embolization were included, and their clinical and radiological results were evaluated. RESULTS: The aneurysms treated were all unruptured except one case. All of them had wide neck with mean dome-to-neck ratio of 0.96 and were small-sized aneurysms with mean maximal diameter of 4.2 mm. There was no technical failure in retrieval of stent after completion of embolization of the target aneurysm. Immediate angiography revealed 11 complete and two partial embolization (one residual neck and one residual aneurysm). Two cases encountered thrombosis complication, and they were managed without neurological sequelae. The mean follow-up period was 43 months, angiographic follow-up revealed two cases with minor recurrence, and clinical outcome was good with modified Rankin scale score of 0. CONCLUSION: Temporary stent-assisted coil embolization of small wide-necked intracranial aneurysm using fully retrievable stent appears safe and effective. Further application and evaluation of this technique in more cases with larger size aneurysm is warranted.

How to Escape Stentriever Wedging in an Open-cell Carotid Stent during Mechanical Thrombectomy for Tandem Cervical Internal Carotid Artery and Middle Cerebral Artery Occlusion

We present 2 cases of complicated mechanical thrombectomy involving tandem cervical internal carotid artery and middle cerebral artery occlusion using the Solitaire FR stent and simultaneous carotid stent angioplasty. During the procedures, the Solitaire stents containing the thrombus were wedged into the open-cell carotid stents, which were already deployed for proximal flow restoration. We describe the methods used to avoid and overcome such complications.

An age-dependent alteration of the respiratory exchange ratio in the db/db mouse / 한국실험동물학회지

The leptin receptor-deficient db/db mouse is a rodent model of type 2 diabetes and obesity. Diabetes in db/db mice shows an age-dependent progression, with early insulin resistance followed by an insulin secretory defect resulting in profound hyperglycemia. However, there is insufficient data on agedependent changes of energy metabolism in db/db mice. We demonstrated an age-dependent decrease in the respiratory exchange ratio (RER), calculated by a ratio of VO2/VCO2, in db/db mice. The RER determined by indirect calorimetry, was 1.03 in db/db mice under 6 weeks of age, which were similar to those in heterozygote (db/+) and wild-type (+/+) mice. However, RER decreased from approximately 0.9 to 0.8 by 10 weeks of age and subsequently returned to approximately 0.9 at 22 weeks of age. The changes in RER were concurrent with the alterations in body weight and blood glucose level. However, other metabolic indicators such as glucose tolerance, changes in body fat mass, and urinary glucose levels, did not change with age. The results suggested that the energy source utilized in db/db mice changed with the age-related progression of diabetes.

Successful Obliteration of Unclippable Large and Giant Middle Cerebral Artery Aneurysms Following Extracranial-Intracranial Bypass and Distal Clip Application

Large to giant middle cerebral artery aneurysm is a challenging disease, especially when incorporating important perforating arteries. Surgical risk increases by perforator infarction and anatomical complexity. In this clinical setting, extensive consideration of surgical options is needed. The two cases described here were unruptured and had rather stable wall. Because of their large and giant size, hardness and incorporated arteries, it was not affordable to isolate them by means of clipping or trapping. The procedure as the alternative to conventional treatment modalities, extracranial-intracranial bypass followed by clipping of only the efferent artery successfully treated the aneurysms.

A case of cardiac arrest following bupivacaine injection for shoulder arthroscopy : A case report

Intra-articular administration of local anesthetics such as bupivacaine can produce short-term postoperative analgesia in patients who are undergoing shoulder arthroscopy. Yet bupivacaine can result in cardiovascular toxicity that can lead to cardiac arrest. We experienced a case of 63-year-old male patient with severe cardiac toxicity that led to ventricular fibrillation 15 minutes after injecting 0.5% bupivacaine into the patient's shoulder joint for shoulder arthroscopy.

Uterine bleeding in a postmenopausal women following epidural triamcinolone acetonide injection: A case report / 대한마취과학회지

Epidural steroid therapy for herpes zoster associated pain is known to be effective with rare complications. However, certain amount of epidurally-injected steroid may be absorbed and affect endocrinological system. Specially, triamcinolone acetonide has high affinity for progesterone receptors and may influence mensturation. We report a case of a postmenopausal women treated with 40 mg of epidural triamcinolone acetonide twice with a two week interval and followed a large amount of uterine bleeding.

Embolization through the Ophthalmic Artery with Onyx in Bilateral Ethmoidal Dural Arteriovenous Fistula: A Case Report / 대한뇌혈관외과학회지

Endovascular treatment of ethmoidal dural arteriovenous fistula (DAVF) has not been widely performed because of the technical difficulty of the procedure and the potential risk of central retinal artery occlusion. We report the case of a patient who underwent Onyx embolization through the ophthalmic artery in bilateral ethmoidal DAVF; to our best knowledge this is the first report.

Spontaneous Bilateral Basal Ganglia Hemorrhage: Case Report / 대한뇌혈관외과학회지

A 39-year old man presented with comatose mentality. Brain computerized tomography revealed bilateral basal ganglia hemorrhage. The amount of hematoma was 35 cc each. He had no hypertension history through out regular health examination. Emergenct hematoma evacuation was performed. Histopathologic study disclosed no evidence of amyloid angiopathy or infection. He died 4 days after the operation due to myocardiac infarction. This report describe a rare case of simultaneous bilateral cerebral hemorrhages without history of hypertension.

Is Extravasation of Radiographic Contrast a Predictor of Hematoma Enlargement in Spontaneous Supratentorial Intracerebral Hemorrhage? / 대한뇌혈관외과학회지

BACKGROUND AND PURPOSE: The enlargement of a hematoma occurs commonly in patients with spontaneous intracerebral hemorrhage (ICH) after hospitalization and can worsen the clinical outcome. We conducted this study to determine whether extravasation of a radiographic contrast agent is a predictor of hematoma enlargement occurring after admission in patients with spontaneous ICH. METHODS: We reviewed the clinical records and computerized tomography (CT) scan findings of 384 patients with spontaneous ICH admitted within 24 hours of ictus from 2002 to 2005. Only 71 patients with primary ICH in the basal ganglia or thalamus were included in the study. The first CT scan was preformed within 24 hours of onset and the second CT scan was preformed within 72 hours of onset. We compared patients with and without hematoma enlargement according to the radiological findings, clinical characteristics and laboratory data. RESULTS: Seventeen patients (23.9%) showed hematoma enlargement after admission. Extravasation of the radiographic contrast agent on a CT scan was seen in 23 patients (32.4%). The presence of contrast extravasation on a CT scan closely correlated with evidence of hematoma enlargement, as seen on a follow-up CT scan (p = 0.000). Other variables did not reach statistical significance for the independent association with hematoma enlargement. CONCLUSIONS: Due to a high risk for hematoma enlargement, patients with spontaneous ICH in the basal ganglia and thalamus, especially those with evidence of contrast extravasation on a CT scan, should be closely observed. Short term followup radiological studies are needed for the verification of hematoma enlargement.

Recanalization Rate and its Associated Factors after Intravenous Tissue Plasminogen Activator Thrombolysis for Acute Major Cerebral Arterial Occlusion / 대한뇌혈관외과학회지

PURPOSE: To investigate the recanalization rate after intravenous administration of recombinant tissue plasminogen activator (IV-tPA) for acute major arterial occlusion of the anterior cerebral circulation and to investigate the relationship between atrial fibrillation and recanalization. METHODS: From April 2005 to April 2006, 16 patients with acute major arterial occlusion of the anterior cerebral circulation were treated with IV-tPA. Recanalization was classified as good (as compared with an unoccluded contralateral vessel; thrombolysis in myocardial infarction (TIMI) classification grade II and III) and poor (TIMI grade 0 and I). The clinical and radiological parameters associated with recanalization were analyzed. The clinical outcomes were evaluated by use of the National Institute of Health Stroke Scale (NIHSS) at 3 months after treatment. RESULTS: Of all of the 16 patients, 11 patients (68.8%) showed good recanalization. Among these 11 patients, nine patients survived (81.8%). However, only one patient survived (20%, p = 0.036) of the other five patients who showed poor recanalization. The pretreatment NIHSS score and atrial fibrillation were significantly correlated with the recanalization rate. Atrial fibrillation was found in 8 of 16 patients (50.0%) as the cause of the cerebral embolic infarction. Among the patients with atrial fibrillation only three patients showed good recanalization (37.5%); patients without atrial fibrillation showed good recanalization (100%, p = 0.026). CONCLUSIONS: I.-tPA appears to be effective and safe as a recanalization method for acute major cerebral arterial occlusion in patients that do not have atrial fibrillation. Good recanalization was associated with a good clinical result. Atrial fibrillation is a significant associated factor of poor recanalization and high mortality.

Histopathological changes of testes and eyes by neutron irradiation with boron compounds in mice

This study was performed to investigate the biological effects of boron neutron capture therapy (BNCT) on the testes and eyes in mice using HANARO Nuclear Reactor, Korea Atomic Energy Research Institute. BNCT relies on the high capacity of (10)B in capturing thermal neutrons. Sodium borocaptate (BSH, 75 ppm, iv) and boronophenylalanine (BPA, 750 ppm, ip) have been used as the boron delivery agents. Mice were irradiated with neutron (flux: 1.036739E +09, Fluence 9.600200E+12) by lying flat pose for 30 (10 Gy) or 100 min (33 Gy) with or without boron carrier treatment. In 45 days of irradiation, histopathological changes of the testes and eyes were examined. Thirty-three Gy neutron irradiation for 100 min induced testicular atrophy in which some of seminiferous tubules showed complete depletion of spermatogenic germ cells. Lens epithelial cells and lens fiber were swollen and showed granular changes in an exposure time dependent manner. However, boron carrier treatment had no significant effect on the lesions. These results suggest that the examination of histopathological changes of lens and testis can be used as "biological dosimeters" for gauging radiation responses and the HANARO Nuclear Reactor has sufficient capacities for the BNCT.

Postoperative Results of Kyphoplasty for Osteoporotic Vertebral Compression Fractures

OBJECTIVE: We analyze pain relief, deformity correction and complication rate after percutaneous kyphoplasty for osteoporotic vertebral compression fractures. METHODS: The authors retrospectively reviewed medical records and radiological findings of 32 patients who underwent percutaneous kyphoplasty for osteoporotic vertebral compression fractures. RESULTS: The patients had significant pain improvement with the procedure. The visual analogue scale score reduced from 8.6 to 3.4 significantly after the procedure. The midline vertebral body height significantly increased postoperatively, but mean kyphotic angle did not. There was no serious complication except one case of epidural cement leakage without neurological impairment. CONCLUSION: Balloon kyphoplasty safely can reduce severe back pain and returned geriatric patients to higher activity levels. The midline vertebral height is restored significantly. However kyphotic deformity correction is not significant as contrary to what we expected from the present study before it was carried out.

Rebleeding of Intramedullary Cavernous Angioma during Pregnancy

The authors report a rare case of aggravated myelopathy due to rebleeding of intramedullary cavernous angioma during pregnancy. A 29-year-old woman with a intramedullary cavernous angioma of the lower thoracic spinal cord was initially managed with a conservative treatment. She suffered the progressive paraparesis 16 months later during the 3rd trimester of her pregnancy. The follow-up magnetic resonance imaging revealed rebleeding of the previous cavernous angioma. The entire lesion was resected with a standard microsurgical technique after delivery, and her neurological symptoms subsequently resolved.