Psoriasis severity classification based on adaptive multi-scale features for multi-severity disease.

Psoriasis is a skin disease that causes lesions of various sizes across the body and can persist for years with cyclic deterioration and improvement. During treatment, and a multiple-severity disease, with irregular severity within the observation area may be found. The current psoriasis evaluation is based on the subjective evaluation criteria of the clinician using the psoriasis area and severity index (PASI). We proposed a novel psoriasis evaluation method that detects representative regions as evaluation criteria, and extracts severity features to improve the evaluation performance of various types of psoriasis, including multiple-severity diseases. We generated multiple-severity disease images using CutMix and proposed a hierarchical multi-scale deformable attention module (MS-DAM) that can adaptively detect representative regions of irregular and complex patterns in multiple-severity disease analyses. EfficientNet B1 with MS-DAM exhibited the best classification performance with an F1-score of 0.93. Compared with the performance of the six existing self-attention methods, the proposed MS-DAM showed more than 5% higher accuracy than that of multiscale channel attention module (MS-CAM). Using the gradient-weighted activation mapping method, we confirmed that the proposed method works at par with human visual perception. We performed a more objective, effective, and accurate analysis of psoriasis severity using the proposed method.

Robust skin microrelief depth estimation using a mobile stereo system.

BACKGROUND: The skin surface becomes wrinkled and rough due to various internal and external factors. A three-dimensional (3D) analysis of the skin is required to improve skin conditions. Stereophotogrammetry, a noninvasive 3D analysis method, is easy to install and use, but most stereo systems have a fixed baseline and scale. Previous stereo systems are not suitable for observing micro-range skin features. Therefore, we suggest the optimal conditions and methods for the 3D analysis of skin microrelief using a multi-conditioned stereo system. METHODS: We constructed a nonconvergence model using a mobile device and acquired stereo images under multiscale and multi-baseline conditions. We extracted 3D information of the skin through our process: preprocessing, skin feature extraction, feature matching, and actual depth mapping. We improved the accuracy of the 3D analysis of the skin by using disparity values instead of disparity maps. We compared and analyzed the performances of six local feature detector and descriptor algorithms. In addition, we suggested depth-mapping formulas to estimate the actual depth of the skin microrelief. RESULTS: We confirmed that stereo images with a working distance of 70-75 mm and a baseline of 4-8 mm are effective for the 3D analysis of skin microrelief. In addition, accelerated KAZE exhibited the best performance for features extraction and stereo matching. Finally, the extracted 3D information was converted to the actual depth, and the performance of the 3D analysis was verified. CONCLUSION: The proposed system and method that provide texture information are effective for 3D skin disease analysis and evaluation.

Automatic analysis system for abnormal red blood cells in peripheral blood smears.

The type and ratio of abnormal red blood cells (RBCs) in blood can be identified through peripheral blood smear test. Accurate classification is important because the accompanying diseases indicated by abnormal RBCs vary. In clinical practice, this task is time-consuming because the RBCs are manually classified. In addition, because the classification depends on the subjective criteria of pathologists, objective classification is difficult to achieve. In this paper, an automatic classification method that is solely based on images of RBCs captured under a microscope and processed using machine learning (ML) is proposed. The size and hemoglobin abnormalities of RBCs were classified by optimizing the criteria used in clinical practice. For morphologically abnormal RBCs classification, used seven geometric features information (major axis, minor axis, ratio of major and minor axis, perimeter, circularity, number of convex hulls, difference between area and convex area) and five types of multiple classifiers (Support Vector Machine, Decision Tree, K-Nearest Neighbor, Random Forest, and Adaboost models). Among was categorized using SVM, highly accurate results (99.9%) were obtained. The classification is performed simultaneously, and results are provided to the user through a graphical user interface (GUI).

A randomized, double-blind, Phase 1 study of IN-006, an inhaled antibody treatment for COVID-19

RationaleAlthough COVID-19 is predominantly a respiratory tract infection, current antibody treatments are administered by systemic dosing. We hypothesize that inhaled delivery of a muco-trapping monoclonal antibody would provide a more effective and convenient treatment for COVID-19. ObjectiveWe investigated the safety, tolerability, and pharmacokinetics of IN-006, a reformulation of regdanvimab, an approved intravenous treatment for COVID-19, for nebulized delivery by a handheld nebulizer. MethodsA Phase 1 study was conducted in healthy volunteers. Study staff and participants were blinded to treatment assignment, except for pharmacy staff preparing the study drug. The primary outcomes were safety and tolerability. Exploratory outcomes were pharmacokinetic measurements of IN-006 in nasal fluid and serum. ResultsTwenty-three participants were enrolled and randomized across two single dose and one multiple dose cohorts. There were no serious adverse events (SAEs). All enrolled participants completed the study without treatment interruption or discontinuation. All treatment-emergent adverse events were transient, non-dose dependent, and were graded mild to moderate in severity. Nebulization was well tolerated and completed in a mean of 6 minutes in the high dose group. Mean nasal fluid concentrations of IN-006 in the multiple dose cohort were 921 {micro}g/g of nasal fluid at 30 minutes after dosing and 5.8 {micro}g/g at 22 hours. Mean serum levels in the multiple dose cohort peaked at 0.55 {micro}g/mL at 3 days after the final dose. ConclusionsIN-006 was well-tolerated and achieved concentrations in the respiratory tract orders of magnitude above its inhibitory concentration. These data support further clinical development of IN-006. RegistrationAustralian New Zealand Clinical Trials Registry: ACTRN12621001235897

Stable nebulization and muco-trapping properties of Regdanvimab/IN-006 support its development as a potent, dose-saving inhaled therapy for COVID-19

The respiratory tract represents the key target for antiviral delivery in early interventions to prevent severe COVID-19. While neutralizing monoclonal antibodies (mAb) possess considerable efficacy, their current reliance on parenteral dosing necessitates very large doses and places a substantial burden on the healthcare system. In contrast, direct inhaled delivery of mAb therapeutics offers the convenience of self-dosing at home, as well as much more efficient mAb delivery to the respiratory tract. Here, building on our previous discovery of Fc-mucin interactions crosslinking viruses to mucins, we showed that regdanvimab, a potent neutralizing mAb already approved for COVID-19 in several countries around the world, can effectively trap SARS-CoV-2 virus-like-particles in fresh human airway mucus. IN-006, a reformulation of Regdanvimab, was stably nebulized across a wide range of concentrations, with no loss of activity and no formation of aggregates. Finally, nebulized delivery of IN-006 resulted in 100-fold greater mAb levels in the lungs of rats compared to serum, in marked contrast to intravenously dosed mAbs. These results not only support our current efforts to evaluate the safety and efficacy of IN-006 in clinical trials, but more broadly substantiate nebulized delivery of human antiviral mAbs as a new paradigm in treating SARS-CoV-2 and other respiratory pathologies.

Optimization of psoriasis assessment system based on patch images.

Psoriasis is a chronic inflammatory skin disease that occurs in various forms throughout the body and is associated with certain conditions such as heart disease, diabetes, and depression. The psoriasis area severity index (PASI) score, a tool used to evaluate the severity of psoriasis, is currently used in clinical trials and clinical research. The determination of severity is based on the subjective judgment of the clinician. Thus, the disease evaluation deviations are induced. Therefore, we propose optimal algorithms that can effectively segment the lesion area and classify the severity. In addition, a new dataset on psoriasis was built, including patch images of erythema and scaling. We performed psoriasis lesion segmentation and classified the disease severity. In addition, we evaluated the best-performing segmentation method and classifier and analyzed features that are highly related to the severity of psoriasis. In conclusion, we presented the optimal techniques for evaluating the severity of psoriasis. Our newly constructed dataset improved the generalization performance of psoriasis diagnosis and evaluation. It proposed an optimal system for specific evaluation indicators of the disease and a quantitative PASI scoring method. The proposed system can help to evaluate the severity of localized psoriasis more accurately.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling

Objective@#: Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. @*Methods@#: Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with singlemicrocatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. @*Results@#: Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). @*Conclusion@#: Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling

Objective@#: Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. @*Methods@#: Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with singlemicrocatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. @*Results@#: Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). @*Conclusion@#: Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

Adaptive Fine Distortion Correction Method for Stereo Images of Skin Acquired with a Mobile Phone.

With the development of the mobile phone, we can acquire high-resolution images of the skin to observe its detailed features using a mobile camera. We acquire stereo images using a mobile camera to enable a three-dimensional (3D) analysis of the skin surface. However, geometric changes in the observed skin structure caused by the lens distortion of the mobile phone result in a low accuracy of the 3D information extracted through stereo matching. Therefore, our study proposes a Distortion Correction Matrix (DCM) to correct the fine distortion of close-up mobile images, pixel by pixel. We verified the correction performance by analyzing the results of correspondence point matching in the stereo image corrected using the DCM. We also confirmed the correction results of the image taken at the five different working distances and derived a linear regression model for the relationship between the angle of the image and the distortion ratio. The proposed DCM considers the distortion degree, which appears to be different in the left and right regions of the image. Finally, we performed a fine distortion correction, which is difficult to check with the naked eye. The results of this study can enable the accurate and precise 3D analysis of the skin surface using corrected mobile images.

Current Status of Neurosurgical and Neurointensive Care Units in Korea : A Brief Report on Nationwide Survey Results

Objective@#: The purpose of this study is identify the operation status of the neurosurgical care units (NCUs) in neurosurgical residency training hospitals nationwide and determine needed changes by comparing findings with those obtained from the Korean Neurosurgical Society (KNS) and Korean Society of Neurointensive Care Medicine (KNIC) survey of 2010.Method : This survey was conducted over 1 year in 86 neurosurgical residency training hospitals and two neurosurgery specialist hospitals and focused on the following areas : 1) the current status of the infrastructure and operating systems of NCUs in Korea, 2) barriers to installing neurointensivist team systems, 3) future roles of the KNS and KNIC, and 4) a handbook for physicians and practitioners in NCUs. We compared and analyzed the results of this survey with those from a KNIC survey of 2010. @*Results@#: Seventy seven hospitals (87.5%) participated in the survey. Nineteen hospitals (24.7%) employed a neurointensivist or faculty member; Thirty seven hospitals (48.1%) reported high demand for neurointensivists, and 62 hospitals (80.5%) stated that the mandatory deployment of a neurointensivist improved the quality of patient care. Forty four hospitals (57.1%) believed that hiring neurointensivist would increase hospital costs, and in response to a question on potential earnings declines. In terms of potential solutions to these problems, 70 respondents (90.9%) maintained that additional fees were necessary for neurointensivists’ work, and 64 (83.1%) answered that direct support was needed of the personnel expenses for neurointensivists. @*Conclusion@#: We hope the results of this survey will guide successful implementation of neurointensivist systems across Korea.

Focal Xanthogranulomatous Pyelonephritis Associated with Xanthogranulomatous Cholecystitis: A Case Report

Xanthogranulomatous inflammation is a rare inflammatory reaction, characterized by lipid-laden macrophages, known as xanthomas, in histopathologic examination. Aggressive xanthogranulomatous inflammation often manifests as local infiltration but does not affect distant organs unless combined with rare systemic diseases. We report a case of focal xanthogranulomatous pyelonephritis (XGP) associated with severe xanthogranulomatous cholecystitis. Focal XGP was suspected in radiologic examination that showed a cystic lesion with an infiltrative margin, which were surgically resected and confirmed in pathologic examination. To our knowledge, this is the first report of focal xanthogranulomatous pyelonephritis associated with xanthogranulomatous cholecystitis. Moreover, we found peripheral hypointensity around the cystic lesion in the T2-weighted image, probably reflecting hemorrhage and fibrosis of the xanthogranulomatous inflammation.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

OBJECTIVE: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).METHODS: A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.RESULTS: Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.CONCLUSION: Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

OBJECTIVE: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR). METHODS: A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation. RESULTS: Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications. CONCLUSION: Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Exercise-Induced Paraspinal Muscle Rhabdomyolysis with Seconary Compartment Syndrome: A Case Report

Lumbar paraspinal compartment syndrome is an uncommon cause of acute lower back pain. It can result from intense physical activity or as a complication of surgery or medication. Lumbar paraspinal compartment syndrome without external trauma is rarely reported in literature. We report a case of compartment syndrome that followed back muscle exercise and caused rhabdomyolysis. MRI findings include bilateral bulging of the paraspinal muscle, hyperintensity on T2-weighted image, and heterogeneous enhancement. Moreover, loss of intramuscular vasculature on a contrast-enhanced CT scan attributed to diagnose compartment syndrome in this case.

Correlation between Serum Uric Acid and Bone Mineral Content in Healthy Women

BACKGROUND: Osteoporosis is a systemic skeletal disease characterized by reduced bone mineral density and skeletal microstructural abnormalities. We investigated the correlation between serum uric acid (SUA) levels and bone mineral content (BMC) values as a surrogate marker of bone health. Additionally, we assessed whether the correlation, if any, was evident even after classifying the study population into two groups based on a diagnosis of obesity in these individuals.METHODS: This study included 936 women who visited the healthcare centers that participated in this study. Fasting blood samples were obtained from all women to measure SUA, BMC of the lumbar spine was measured using dual-energy X-ray absorptiometry. We evaluated the correlation between SUA and BMC in obese and non-obese groups.RESULTS: SUA concentration and BMC were positively correlated (β=0.257, P=0.001); however, this correlation was significant only in the obese group (β=0.203, P=0.001).CONCLUSION: SUA concentration and BMC are positively correlated in women diagnosed obesity.

Endovascular Coiling for a Wide-neck Bifurcated Aneurysm with Anterograde Horizontal Stenting via Microcatheter Looping: A Technical Case Report

Technical advances with devices such as catheters, balloons, and stents have widened the indications for endovascular coiling for unfavorable aneurysms. The authors report two cases of coil embolization for a wide-neck bifurcated aneurysm with anterograde horizontal stenting via microcatheter looping. Two women, aged 56 and 38 years, respectively, had an undertall- and overwide-neck aneurysm with bifurcated branches at the basilar bifurcation and middle cerebral bifurcation, respectively. The delivery microcatheter was steamed so that it could be looped deliberately to the opposite vessel. The enterprise stent was first anchored to the vessel of the posterior cerebral artery on one side. The remaining portion was spanned into a looped microcatheter to the opposite branch while pushing the stent. The Neuroform Atlas stent was passed directly through the looped segment of the microcatheter at the M2 branch and spanned horizontally by unsheathing. Under horizontal stenting, complete coil embolization was achieved without immediate or delayed complications in both cases. This novel technique presents a viable option for stent-assisted coiling within an optimal anatomy.

Kümmell's Disease Treated with Percutaneous Vertebroplasty: Minimum 1 Year Follow-Up / 대한신경손상학회지

OBJECTIVE: To evaluate the radiographic and clinical outcomes of percutaneous vertebroplasty (PVP) in patients with Kümmell's disease. METHODS: A retrospective review was conducted for 19 vertebrae in 18 patients, between January 2012 and June 2016. A visual analogue scale (VAS) score was used to determine each patient's subjective level of pain (0=no pain to 10=severe pain) preoperative, immediately postoperative and at the last follow-up (at least 12 months after PVP). Radiographic parameters such as regional and global kyphotic angle, lumbar lordosis (LL), thoracolumbar junction (TLJ) angle, vertebral height, cement leakage, refracture, and adjacent level fracture were evaluated by the clinician preoperative, immediate postoperative and at the last follow-up. RESULTS: The mean VAS score significantly decreased after PVP and the decrease was maintained through to the final follow-up (p<0.05). However, the regional and global kyphotic angle, LL, and TLJ angle were not improved. Cement leakage was observed in 5 cases (26.3%): however, there were no cases of cement leakage into the spinal canal. No neurological deterioration was observed, even among patients with cement leakage. Adjacent level fractures were detected in 3 cases (15.8%). CONCLUSION: PVP can be considered as an effective treatment option for pain relief and maintenance of sagittal balance in patients with Kümmell's disease.

Clinical Aspects of Cerebral Venous Thrombosis: Experiences in Two Institutions

OBJECTIVE: Cerebral venous thrombosis (CVT) is a rare condition for which few clinical reviews have been conducted in Korea. Our aim was to investigate, risk factors, clinical presentations/courses, and outcomes of 22 patients treated for CVT at two centers. MATERIALS AND METHODS: A retrospective analysis was conducted, selecting 22 patients diagnosed with and treated for CVT at two patient care centers over a 10-year period (January 1, 2004 to August 31, 2015). Patient data, pathogenetic concerns (laboratory findings), risk factors, locations, symptoms, treatments, and clinical outcomes were reviewed. RESULTS: Mean patient age at diagnosis was 54.41 ± 16.19. Patients most often presented with headache (40%), followed by seizure (27%) and altered mental status (18%). Focal motor deficits (5%), visual symptoms (5%), and dysarthria (5%) were less common. Important predisposing factors in CVT included prothrombotic conditions (35%), infections (14%), hyperthyroidism (18%), trauma (14%), and malignancy (4%). By location, 9 patients (40%) experienced thrombosis of superior sagittal sinus predominantly, with involvement of transverse sinus in 20 (90%), sigmoid sinus in 12 (40%), and the deep venous system in 5 (23%). Treatment generally consisted of anticoagulants (63%) or antiplatelet (23%) drugs, but surgical decompression was considered if warranted (14%). Medical therapy in CVT yields good functional outcomes. CONCLUSION: Mean age of patients with CVT in our study exceeded that reported in Europe or in America and had difference in risk factors. Functional outcomes are good with use of antithrombotic medication, whether or not hemorrhagic infarction is evident.

Angiographic Results of Wide-Necked Intracranial Aneurysms Treated with Coil Embolization : A Single Center Experience

OBJECTIVE: Endovascular treatment of wide-necked intracranial aneurysms is a challenge and the durability and the safety of these treated aneurysms remain unknown. The aim of this study was to evaluate the clinical and long-term angiographic results of wide-necked intracranial aneurysms treated with coil embolization. METHODS: Between January 2002 and December 2012, 53 wide-necked aneurysms treated with coil embolization were selected. Forty were female, and 13 were male. Twenty eight (52.8%) were ruptured aneurysms, and 25 (47.2%) were unruptured aneurysms. The patents' medical and radiological records were reviewed retrospectively. RESULTS: Of the 53 aneurysms, coiling alone was employed in 45 (84.9%) and stent-assisted coiling was done in 8 (15.1%). The initial angiographic results revealed Raymond class 1 (complete occlusion) in 30 (56.6%) cases, Raymond class 2 (residual neck) in 18 (34.0%) cases, and Raymond class 3 (residual sac) in 5 (9.4%) cases. The mean angiographic follow-up period was 37.9 months (12-120 months). At the last angiographies, Raymond class 1 was seen in 26 (49.1%) cases, Raymond class 2 in 16 (30.2%), and Raymond class 3 in 11 (20.8%). Angiographic recurrence occurred in 22 (41.5%) patients, with minor recurrence in 7 (13.2%) cases and major recurrence in 15 (28.3%). Retreatment was performed in 8 cases (15.1%). A suboptimal result on the initial angiography was a significant predictor of recurrence in this study (p=0.03). CONCLUSION: The predictor of recurrence in wide-necked aneurysms is a suboptimal result on the initial angiography. Long-term angiographic follow-up is recommended in wide-necked aneurysms.

Intraoperative Endovascular Embolization of Middle Meningeal Artery and a Pseudoaneurysm by Using N-Butyl 2-Cyanoacrylate for Hemostasis during Operation of Acute Epidural Hemorrhage / 대한신경손상학회지

A 21-year-old female presented with acute epidural hemorrhage (EDH) on the left temporal region associated with skull fracture after traffic accident. She was neurologically deteriorated at four-hour after an admission, and follow-up computed tomography revealed increased amount of EDH. Under the general anesthesia, emergency craniotomy was performed. During the surgery, massive bleeding from the base of middle cranial fossa was observed. However, we could not identify an origin of bleeding and foramen spinosum due to brain swelling and obscured surgical field. Consequently, her systolic blood pressure was dropped to 60 mm Hg with >110 beat/min of heart rate. Therefore, we decided to perform an intraoperative angiography after gauze packing into the middle cranial fossa. Intraoperative angiography showed a large pseudoaneurysm with massive contrast leakage of the middle meningeal artery (MMA). Intraoperative endovascular embolization of the pseudoaneurysm and MMA by using n-butyl-2-cyanoacrylate was done. After that, her vital sign became stable, and we could complete the operation after the achievement of adequate hemostasis. Intraoperative angiography and endovascular embolization of MMA was effective in achieving adequate hemostasis in case with brisk bleeding from the middle cranial fossa could not be controlled in an open surgical field.