OBJECTIVES: True spontaneous intracranial arteriovenous fistulas (AVFs) of posterior circulation are very rare. Clinical entity and natural history of these lesions are not well known. We describe our experience in treating these lesions by microsurgical and/or endovascular techniques. CLINICAL PRESENTATION: Two patients were presented with subarachnoid hemorrhage and one with progressive hearing deficit and tinnitus. Angiograms revealed the presence of intracranial AVFs in all three cases and feeding vessels from the basilar perforator, vertebral artery, and anterior inferior cerebellar artery (AICA), respectively. Venous ectatic changes were also combined in all cases. Surgery was performed via a transpetrosal approach in a case of an unruptured AVF, which was fed by a basilar perforator with venous aneurysmal dilatation in pons. However, afferent vessel to the fistula could not be identified in microsurgical field. Endovascular occlusion was performed successfully 2 months later. In a case of spontaneous vertebral AVF presented with subarachnoid hemorrhage, the fistula was occluded and entangled dilated veins were completely excised via a far lateral suboccipital approach. The last case of AICA origin also presented with subarachnoid hemorrhage died from rebleeding during the preparation of endovascular treatment on the same day of the first ictus. CONCLUSION: Spontaneous intracranial AVFs of posterior circulation showed aggressive behavior. We recommand surgical and/or endovascular treatment for these lesions.
Aneurysm ; Arteries ; Arteriovenous Fistula* ; Dilatation ; Endovascular Procedures ; Fistula ; Hearing ; Humans ; Natural History ; Pons ; Subarachnoid Hemorrhage ; Tinnitus ; Veins ; Vertebral Artery

Aneurysms at the distal branch of the middle cerebral artery may be mycotic or congenital in origin. A 34 year-old male patient was admitted with a seizure and a 7-day history of upper respiratory tract infection. The neurological examination showed no abnormality except for headache and mild dysarthria. There was no intracardiac lesion suggesting infective endocarditis. CT, MRI and cerebral angiograms revealed a partially thrombosed giant aneurysm at the distal branch of the middle cerebral artery. Pathologic examination revealed acute inflammatory cells and focal necrosis in the aneurysmal wall as well as recent thrombus. Here, we are reporting an unusual case with a giant distal middle cerebral artery aneurysm with intramural inflammation, suggesting a congenital giant aneurysm with secondary infectious inflammation.
Adult ; Aneurysm ; Aneurysm, Infected* ; Dysarthria ; Endocarditis ; Headache ; Humans ; Inflammation ; Intracranial Aneurysm ; Magnetic Resonance Imaging ; Male ; Middle Cerebral Artery* ; Necrosis ; Neurologic Examination ; Respiratory Tract Infections ; Seizures ; Thrombosis

Intracerebral hematoma (ICH) after reperfusion procedure in cerebral ischemia is a rare but serious complication. The authors present 4 cases with ICH after reperfusion procedures in cerebral ischemia. First case is ICH after superficial temporal artery-middle cerebral artery anastomosis in moyamoya patient, second case is ICH after graft bypass usuing saphenous vein in traumatic carotid artery injury patient, third case is ICH after intra-arterial urokinase therapy in acute internal carotid artery occlusion and forth case is ICH after temporary clipping to the middle cerebral artery in middle cerebral artery aneurysm surgery. Defective cerebrovascular autoregulation in ischemic brain regions may predispose patients to ICH after reperfusion procedure in cerebral ischemia. The authors suggest reperfusion procedure in ischemia must be executed prudently because of possibility of reperfusion injury including ICH.
Brain ; Brain Ischemia* ; Carotid Artery Injuries ; Carotid Artery, Internal ; Cerebral Arteries ; Hematoma* ; Homeostasis ; Humans ; Intracranial Aneurysm ; Ischemia ; Middle Cerebral Artery ; Reperfusion Injury ; Reperfusion* ; Saphenous Vein ; Transplants ; Urokinase-Type Plasminogen Activator

OBJECTIVE: Preoperative extra-ventricular drainage in poor grade aneurysmal subarachnoid hemorrhage (SAH) patients has been known to improve patient's clinical grade. However, the risk of rebleeding due to increase of transmural pressure hinders its popular clinical use. The authors present new experience of preoperative extra-ventricular drainage in poor grade aneurysmal SAH. MATERIALS AND METHODS: From January 1996 to November 2001, 56 SAH patients underwent extra-ventricular drainage preoperatively. The mean age was 57.9 years (range 27 to 88). Hunt and Hess grade (HH grade) on the time of extra-ventricular drainage insertion were grade 3 in 4 patients, grade 4 in 35 patients and grade 5 in 17 patients. The overall clinical outcome of the patients who underwent extra-ventricular drainage and final clinical outcome according to the intervals between ventricular drainage and direct clipping/endovascular coiling were analysed retrospectively. RESULT: Twenty-six patients (46.4%) improved clinically (average HH grade was improved from 4.6 to 3.3), 25 patients (44.6%) have not been changed, 5 patients (9%) aggravated (4 to 5) after ventricular drainage. Seven of 30 unchanged or aggravated patients underwent CT scan which revealed rebleeding of the aneurysm. 32 patients (57.1%) were treated with surgery or endovascular coiling. Seventeen patients (30.4%) have lost their opportunity of ultimate treatment because they had poor clinical course after extra-ventricular drainage. Final clinical outcome was not statistically different between early therapeutic group who underwent operation within 24 hours after extra-ventricular drainage and delayed therapeutic group who underwent operation after 24 hours. (Fisher extract test, survival rate P=0.603, clinical outcome P=1.000). CONCLUSION: Preoperative extra-ventricular drainage had additional risk of rebleeding, however, it provides immediate improvement of patient's neurological status and final clinical outcomes.
Aneurysm* ; Drainage* ; Humans ; Retrospective Studies ; Subarachnoid Hemorrhage* ; Survival Rate ; Tomography, X-Ray Computed

OBJECTIVES: This study was designed to examine whether melatonin has a neuroprotective effect against hippocampal neuronal damage following transient global ischemia in a gerbil. Polyamine is known to play a role in the pathophysiology of ischemic neuronal damage, we evaluated the influences of melatonin on the polyamine level as well as histology. MATERIAL AND METHODS: Male Mongolian gerbils (60-80 g) were used in this study. Transient global ischemia was induced by occlusion of the bilateral common carotid arteries for 3 min with microclips. Melatonin was administered immediately after occlusion. The animals were decapitated 24 h after the occlusion for polyamine measurement by a high performance liquid chromatography (HPLC) and 4 days after the occlusion for histological evaluation (hematoxylin and eosin staining). A histological examination was performed by a blinded investigator. RESULTS: The hippocampal putrescine level increased compared to sham-operated animals and the increase of putrescine was attenuated by 20 mg/kg melatonin administration. Spermidine and spermine levels didn't show significant changes after ischemia. Hippocampal neuronal damage in the CA1 region was markedly observed in vehicle-treated animals compared to sham-operated animals. Melatonin administration (10 or 20 mg/kg) significantly inhibited hippocampal CA1 neuronal damage after ischemia compared to corresponding vehicle-treated animals (p<0.05 and p<0.01, respectively). CONCLUSION: Melatonin attenuates the putrescine level after transient global ischemia and may have putative neuroprotective effects against global ischemia induced neuronal damage.
Animals ; Brain* ; Carotid Artery, Common ; Chromatography, Liquid ; Eosine Yellowish-(YS) ; Gerbillinae* ; Hippocampus ; Humans ; Ischemia* ; Male ; Melatonin* ; Neurons* ; Neuroprotective Agents ; Putrescine ; Research Personnel ; Spermidine ; Spermine

This study was designed to elucidate the clinical course of patients with vertebro-basilar arterial dissection and to show the guidelines for options of the management. Between 1992 and 2001, 23 patients were diagnosed as having vertebro-basilar arterial dissection by clinical course, magnetic resonance imaging (MRI) and angiography. The male to female ratio was 20 to 3, showing male dominance. Their clinical data were analyzed retrospectively. Fourteen cases presented with subarachnoid hemorrhage (SAH) and the other 9 with ischemic symptoms. Among those with SAH, there were 6 mortalities. The causes of mortalities were rebleeding in five cases and initial poor Hunt-Hess grade in one case. In most cases, rebleeding happened within 14 days after initial bleeding and in five patients within 4 days. Five patients were managed by surgical treatment, twelve by endovascular treatment and the other 2 by conservative management. Recently, since 1999, initially endovascular techniques had been tried to patients immediately after diagnosis and the results were good. Previous cases underwent endovascular management only when surgical treatment failed or was inappropriate. These patients showed poor prognosis. Nine cases with ischemic symptoms showed benign clinical course with no mortality and only one symptomatic recurrence following endovascular treatment. Six patients were treated by antiplatelet and/or anticoagulation therapy, two by endovascular treatment and the other one by surgery. Four of these nine patients had history of severe exercise or trauma immediately before onset of symptoms and two others had similar history several months before. In conclusion, among patients diagnosed as vertebro-basilar arterial dissection, those with SAH should be managed aggressively by either surgical or endovascular techniques because these patients showed rapid deterioration with high incidence of rebleeding and mortality. Since those with ischemic symptoms demonstrated benign clinical course, the authors recommend initial conservative management such as antiplatelet and/or anticoagulation or endovascular treatment.
Angiography ; Diagnosis ; Endovascular Procedures ; Female ; Hemorrhage ; Humans ; Incidence ; Magnetic Resonance Imaging ; Male ; Mortality ; Prognosis ; Recurrence ; Retrospective Studies ; Subarachnoid Hemorrhage

OBJECTIVES: To evaluate the diagnostic accuracy of three-dimensional digital subtraction angiography in the surgical or interventional treatment of intracranial aneurysms. MATERIAL AND METHODS: We reviewed the clinical records, radiological findings, and surgical results of seventy-two patients with eight-five aneurysms who had undergone 2-dimensional digital subtraction angiography (2-D DSA) and 3-D DSA as the diagnostic evaluation. 3-D images were compared with 2-D images and surgical or interventional results. The shape of the aneurysms, their necks, and their relationships to the parent vessels and other branches were evaluated. RESULTS: The existence of the aneurysms was diagnosed exclusively by 3-D DSA in 13 patients. The site (n=27) and the shape (n=15) of the aneurysms were evaluated more accurately with 3-D DSA than with 2-D DSA images. Depiction of aneurysmal necks and their relationships to the parent vessels was clearer with 3-D DSA images than with 2-D DSA images, especially in cases of the distal internal carotid artery aneurysms. CONCLUSION: With its advantages, such as unlimited projection, similarity to surgical view, and high resolution especially in the cavernous portion of ICA, the 3-D DSA provides more valuable information in the planning the surgical or interventional treatments of cerebral aneurysms.
Aneurysm ; Angiography, Digital Subtraction* ; Carotid Artery, Internal ; Diagnosis* ; Humans ; Imaging, Three-Dimensional ; Intracranial Aneurysm* ; Neck ; Parents

Intracranial aneurysms are the most common source of nontraumatic subarachnoid hemorrhage (SAH) in elderly patients. Despite the fact that more patients who present with SAH are middle-aged, the age-specific incidence for SAH increases with increasing age. The elderly patients with aneurysmal SAH have a trend toward poor outcome. Furthermore there are age-associated factors that increase perioperative and postoperative risks. In this paper, authors will review and discuss the reason why older patients have a poorer outcome and management for aneurysmal SAH in geriatric patients.
Aged ; Aneurysm* ; Humans ; Incidence ; Intracranial Aneurysm ; Subarachnoid Hemorrhage*

OBJECTIVE: The purpose of this study is to compare the incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm in elderly patients following intracranial aneurysm rupture with those of younger patients. METHODS: We retrospectively reviewed the medical records of 189 patients who were treated with open surgery between May 1994 and December 2000. They were divided into two groups; elderly (> or =60 yrs) and younger (< or =59 yrs) group. Incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm was analysed in each group during 6 months after surgery. RESULTS: Shunt-dependent chronic hydrocephalus has developed more frequently in the elderly group (27.8%) than in the younger group (7.3%). Incidence of symptomatic vasospasm was not significantly different between two groups, even though poor grade patients were more represented in the elderly group. CONCLUSION: Meticulous clinical long-term follow-up is needed to detect shunt-dependent chronic hydrocephalus as early as possble in the elderly patients with operated ruptured intracranial aneurysms and in that case, shunt operation should be undertaken.
Aged* ; Follow-Up Studies ; Humans ; Hydrocephalus* ; Incidence ; Intracranial Aneurysm* ; Medical Records ; Retrospective Studies ; Rupture

Percutaneous balloon angioplasty has been reported to be useful in the treatment of intracranial atherosclerotic arterial stenosis. However, arterial dissection with increased risk of acute closure and stroke has limited its widespread implementation. Stenting of the intracranial vasculature recently has been shown to be feasible in a variety of circumstance. However, stenting of middle cerebral artery has been limited because of difficulty with tracking stents across the carotid siphon. We report a case of successful percutaneous stenting of a symptomatic middle cerebral artery stenosis using a balloon-expandible flexible coronary stent.
Angioplasty ; Angioplasty, Balloon ; Constriction, Pathologic* ; Middle Cerebral Artery* ; Stents* ; Stroke