Cerebrovascular Events During Pregnancy and Puerperium Resulting from Preexisting Moyamoya Disease: Determining the Risk of Ischemic Events Based on Hemodynamic Status Assessment Using Brain Perfusion Single-Photon Emission Computed Tomography.

OBJECTIVE: The purposes of this study were to review the cerebrovascular events (CVE) during pregnancy and puerperium in adults with moyamoya disease (MMD) and to evaluate its risk factors. METHODS: We reviewed electronic medical records on 141 pregnancies in 71 women diagnosed with MMD and this study included only 27 pregnancies (23 patients) diagnosed with MMD before pregnancy. Basal and acetazolamide-stress brain perfusion single-photon emission computed tomography (SPECT) was conducted for 40 hemispheres in 21 pregnancies within 1 year of the gestational period, ranging from 22 months before delivery to 12 months after delivery for evaluation of the hemodynamic status of the patients to devise the MMD treatment strategy. RESULTS: Twelve pregnancies (44.4%) showed CVE during pregnancy or puerperium in the group diagnosed with MMD before pregnancy. All the 12 CVE were ischemic, without any hemorrhagic events. A decreased cerebral vascular reserve capacity (CVRC) on stress SPECT was observed in 25 (62.5%) of the 40 hemispheres, and 18 of these 25 hemispheres showed TIA. In contrast, only 2 of 15 hemispheres which revealed normal CVRC on stress SPECT showed TIA. Overall, a decreased CVRC on stress SPECT imaging was statistically associated with development of CVE (P < 0.001). Furthermore, the clinical type of MMD was also regarded as predictive factor for CVE in this study. Especially, ischemic type MMD revealed a statistical association with the development of CVE (P = 0.014, odds ratio = 16.50). CONCLUSIONS: Assessment of cerebral hemodynamic status with stress SPECT may predict CVE during pregnancy and puerperium.

Extent of Contrast Enhancement on Non-Enhanced Computed Tomography after Intra-Arterial Thrombectomy for Acute Infarction on Anterior Circulation: As a Predictive Value for Malignant Brain Edema.

OBJECTIVE: To determine whether the use of contrast enhancement (especially its extent) predicts malignant brain edema after intra-arterial thrombectomy (IAT) in patients with acute ischemic stroke. METHODS: We reviewed the records of patients with acute ischemic stroke who underwent IAT for occlusion of the internal carotid artery or the middle cerebral artery between January 2012 and March 2015. To estimate the extent of contrast enhancement (CE), we used the contrast enhancement area ratio (CEAR)-i.e., the ratio of the CE to the area of the hemisphere, as noted on immediate non-enhanced brain computed tomography (NECT) post-IAT. Patients were categorized into two groups based on the CEAR values being either greater than or less than 0.2. RESULTS: A total of 39 patients were included. Contrast enhancement was found in 26 patients (66.7%). In this subgroup, the CEAR was greater than 0.2 in 7 patients (18%) and less than 0.2 in the other 19 patients (48.7%). On univariate analysis, both CEAR ≥0.2 and the presence of subarachnoid hemorrhage were significantly associated with progression to malignant brain edema (p<0.001 and p=0.004), but on multivariate analysis, only CEAR ≥0.2 showed a statistically significant association (p=0.019). In the group with CEAR ≥0.2, the time to malignant brain edema was shorter (p=0.039) than in the group with CEAR <0.2. Clinical functional outcomes, based on the modified Rankin scale, were also significantly worse in patients with CEAR ≥0.2 (p=0.003). CONCLUSION: The extent of contrast enhancement as noted on NECT scans obtained immediately after IAT could be predictive of malignant brain edema and a poor clinical outcome.

Three Cases of Calcifying Pseudoneoplasm which Involve the Epidural Space of the Spine.

Calcifying psuedoneoplasm of the spine is a rare non-neoplastic lesion of unknown origin. Radiologic and histologic manifestations are very variable and clinical symptoms include isolated pain, myelopathy, and radiculopathy. Surgical resection is the preferred option of treatment. This report describes three cases of calcifying pseudoneoplasm in the spine. The first case is a 77-year-old female with pain in both legs. The second case is a 67-year-old woman who presented as right leg pain. The third case is a 78-year-old woman with isolated back pain. The involved sites of each of cases were T12, L2-3, and L1, respectively. Surgical resection of the involved masses relieved symptoms.

Standard vs Modified Antiplatelet Preparation for Preventing Thromboembolic Events in Patients With High On-Treatment Platelet Reactivity Undergoing Coil Embolization for an Unruptured Intracranial Aneurysm: A Randomized Clinical Trial.

IMPORTANCE: Thromboembolism is the most common complication in coiling for an unruptured aneurysm and is frequent in patients with high on-treatment platelet reactivity (HTPR) who are prescribed a standard antiplatelet preparation for its prevention. OBJECTIVE: To evaluate the effect of a modified antiplatelet preparation compared with a standard preparation in patients with HTPR undergoing coiling. DESIGN, SETTING, AND PARTICIPANTS: A prospective randomized open-label active-control trial with blinded outcome assessment at the Seoul National University Bundang Hospital from May 27, 2013, to April 7, 2014. Patients with HTPR were randomly assigned (1 to 1) to the standard or modified preparation group. Patients without HTPR were assigned to the non-HTPR group. A total of 228 patients undergoing coiling for unruptured aneurysms were enrolled and allocated to the study, 126 in the HTPR group (63 to the standard preparation group and 63 to the modified preparation group) and 102 to the non-HTPR group. Intent-to-treat analysis was performed. INTERVENTIONS: The modified preparation (HTPR to aspirin, 300 mg of aspirin and 75 mg of clopidogrel bisulfate; and HTPR to clopidogrel, 200 mg of cilostazol added to the standard regimen) was performed before coiling in the modified preparation group. Standard preparation (100 mg of aspirin and 75 mg of clopidogrel) was maintained in the standard preparation and non-HTPR groups. MAIN OUTCOMES AND MEASURES: The primary outcome was a thromboembolic event defined as thromboembolism during coiling and a transient ischemic attack or ischemic stroke within 7 days after coiling. The principal secondary outcome was a bleeding complication according to Thrombolysis in Myocardial Infarction bleeding criteria within 30 days after coil embolization. RESULTS: The thromboembolic event rate was low in the modified preparation group (1 of 63 [1.6%]) compared with the standard preparation group (7 of 63 [11.1%]; adjusted risk difference, -11.7% [95% CI, -21.3% to -2.0%]; P = .02), which had a higher thromboembolic risk than the non-HTPR group (1 of 102 [1.0%]; adjusted risk difference, 8.6% [95% CI, 1.0% to 16.3%]; P = .03). All bleeding complications were of minimal grade according to Thrombolysis in Myocardial Infarction bleeding criteria. The bleeding rate was not different between the modified (6 of 63 [9.5%]) and standard (4 of 63 [6.3%]) preparation groups (adjusted risk difference, 5.6% [95% CI, -4.2% to 15.4%]; P = .26). CONCLUSIONS AND RELEVANCE: Modified antiplatelet preparation for patients with HTPR compared with standard antiplatelet preparation reduced the thromboembolic event rate in coiling for an unruptured aneurysm without increasing bleeding. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0000804.

The usefulness of the frontolateral approach as a minimally invasive corridor for clipping of anterior circulation aneurysm.

OBJECTIVE: Several studies have reported on the effectiveness of fronto-lateral craniotomy in reducing the operating time and post-operative complications. However, no study has practically evaluated this method from the cosmetic point of view. MATERIALS AND METHODS: We designed this study for comparison of the clinical differences and cosmetic outcomes between the frontolateral craniotomy and the conventional pterional craniotomy for clipping of unruptured intracranial aneurysms. We performed a retrospective analysis of the two groups based on their medical records and radiologic findings juxtaposed with their length of hospital stay, intensive care unit day and operation time, and the emergence of postoperative complication, mean size of aneurysm, and temporal depression. RESULTS: After careful comparison of the thickness of temporalis muscle between the craniotomy side and the contralateral side, the results clearly showed that the conventional pterional craniotomy group was asymmetric by a p value of 0.152 and the frontolateral craniotomy group was symmetric by a p value of 0.002. CONCLUSION: Frontolateral craniotomy could be a practical alternative for patients with an unruptured intracranial aneurysm in the anterior circulation including the posterior communicating artery, particularly those who are in a medically poor state or who highly demand minimal aesthetic mutilation.

Clinicoepidemiological features of asymptomatic moyamoya disease in adult patients.

OBJECTIVE: The aim of this study was to document the natural course of asymptomatic adult moyamoya disease (MMD) and the factors related to disease progression to aid in treatment decisions. MATERIALS AND METHODS: Among 459 adult MMD patients (aged ≥ 20 years), 42 patients were included in this retrospective cohort study. Clinical records of adult asymptomatic MMD patients (n = 42) and follow-up data from September 2013 were reviewed to determine the factors related to disease progression. RESULTS: The mean age of patients at the time of diagnosis was 41.2 years (range, 23-64 years), and the mean follow-up period was 37.3 months (range, 7.4-108.7 months). Of the 42 patients and 75 hemispheres, there were 12 patients (28.6%) and 13 hemispheres (17.3%) with disease progression. There were four hemispheres (5.3%) with symptomatic progression (three hemorrhage, one transient ischemic attack) and nine hemispheres (12.0%) with asymptomatic radiographic progression. There were no relationships with sex, diabetes, hypertension, thyroid disease, family history of MMD, or family history of stroke. However, reduced initial cerebrovascular reserve capacity was observed in seven hemispheres (9.3%) in patients with disease progression. A relationship was found between disease progression and initial cerebrovascular reserve capacity (p = 0.05). None of the patients underwent bypass surgery during the follow-up period. CONCLUSION: It appears that asymptomatic adult MMD is not a permanent stable disease. In particular, reduced cerebrovascular reserve capacity is an indication of MMD progression, so close regular observation is needed.

Pressure measurement in carpal tunnel syndrome : correlation with electrodiagnostic and ultrasonographic findings.

OBJECTIVE: This study was done to evaluate the correlation between carpal tunnel pressure (CTP), electrodiagnostic and ultrasonographic findings in patients with carpal tunnel syndrome (CTS). METHODS: CTP was measured during endoscopic carpal tunnel release (ECTR) for CTS using Spiegelberg ICP monitoring device with parenchymal type catheter. Neurophysiologic severity and nerve cross sectional area were evaluated using nerve conductive study and ultrasonography (USG) before ECTR in all patients. RESULTS: Tests were performed in a total of 48 wrists in 39 patients (9 cases bilateral). Maximum CTP was 56.7 +/- 19.3 mmHg (Mean +/- SD) and 7.4 +/- 3.3 mmHg before and after ECTR, respectively. No correlation was found between maximum CTP and either neurophysiologic severity or nerve cross sectional area, whereas we found a significant correlation between the latter two parameters. CONCLUSION: CTP was not correlated with neurophysiologic severity and nerve cross sectional area. Dynamic, rather than static, pressure in carpal tunnel might account for the basic pathophysiology of CTS better.