Objective: : The treatment paradigm for acute ischemic stroke has undergone several major changes in the past decade, contributing to improved patient prognosis in clinical practice. However, the extent to which these changes have affected patient prognosis in the real-world is yet to be clarified. This study aimed to evaluate the real-world impact of modern reperfusion therapy for acute ischemic stroke using data from the National Health Insurance Service in Korea. Methods: : This study included patients aged 18–80 years who were admitted via the emergency room with an I63 code between 2011 and 2020. The rates of intravenous thrombolysis use and endovascular treatment according to the year of admission were investigated. Furthermore, the rates of decompressive craniectomy and 3-month mortality were also analyzed. The 10-year observational period was divided into three periods based on the 2015 guideline change as follows : prior, 2011–2014; transitional, 2015–2016; and modern, 2017–2020. Results: : A total of 307117 patients (mean age, 65.7±10.9 years) were included, and most patients were male (59.7%). The rate of endovascular treatment gradually increased during the study period from 0.71% in the prior period to 1.32% in the transitional period and finally to 1.85% in the modern period. Meanwhile, the 3-month mortality rate gradually decreased from 4.78% in the prior period to 4.03% in the transitional period and to 3.71% in the modern period. Conclusion : In Korea, the mortality rate decreased as the rate of modern reperfusion therapy increased in patients with acute ischemic stroke. Overall, technical and scientific advances in reperfusion therapy have improved the outcome of patients with acute ischemic stroke in Korea.

Treatment of complex aneurysms usually entails not only direct clipping but also alternative treatment modality. We recently experienced a case of vertebral artery dissecting aneurysm and obtained good treatment outcomes. Our case suggests that the endovascular segmental occlusion with posterior inferior cerebellar artery (PICA) to PICA side anastomosis might be a good treatment option in patients with complex vertebral artery dissecting aneurysms. A 45-year-old woman has a left vertebral dissecting aneurysm with dizziness. Based on the aneurysmal morphology and the involvement of PICA, the patient underwent side to side anastomosis of the PICA. This was followed by the endovascular segmental coil occlusion. The aneurysmal sac was completely obliterated. At a 2-year follow-up, the patient achieved a good patency of both PICA. In conclusion our case suggests that the endovascular segmental occlusion of the parent artery followed by PICA to PICA bypass surgery through a midline suboccipital approach is a reasonable multimodal treatment option in patients with complex vertebral artery dissecting aneurysms.
Aneurysm ; Aneurysm, Dissecting* ; Arteries* ; Combined Modality Therapy ; Dizziness ; Female ; Follow-Up Studies ; Humans ; Middle Aged ; Parents ; Pica ; Vertebral Artery*

OBJECTIVE: Removal of the anterior clinoid process (ACP) is an essential process in the surgery of giant or complex aneurysms located near the proximal internal carotid artery or the distal basilar artery. An extradural clinoidectomy must be performed within the limits of the meningeal layers surrounding the ACP to prevent morbid complications. To identify the safest method of extradural exposure of the ACP, anatomical studies were done on cadaver heads. METHODS: Anatomical dissections for extradural exposure of the ACP were performed on both sides of seven cadavers. Before dividing the frontotemporal dural fold (FTDF), we measured its length from the superomedial apex attached to the periorbita to the posterolateral apex which connects to the anterosuperior end of the cavernous sinus. RESULTS: The average length of the FTDF on cadaver dissections was 7 mm on the right side and 7.14 mm on the left side. Cranial nerves were usually exposed when cutting FTDF more than 7 mm of the FTDF. CONCLUSION: The most delicate area in an extradural anterior clinoidectomy is the junction of the FTDF and the anterior triangular apex of the cavernous sinus. The FTDF must be cut from the anterior side of the triangle at the periorbital side rather than from the dural side. The length of the FTDF incision must not exceed 7 mm to avoid cranial nerve injury.
Aneurysm ; Basilar Artery ; Cadaver ; Carotid Artery, Internal ; Cavernous Sinus ; Caves ; Cranial Nerve Injuries ; Cranial Nerves

Moyamoya disease (MMD) is a rare progressive steno-occlusive cerebrovascular disorder. Currently, revascularization surgery is used as optimal treatment to overcome MMD. However, revascularization for MMD has reported several complications. Also, iatrogenic complications such as pseudoaneurysms formation or dural arteriovenous fistulas (dAVFs) formation—has been identified in rare cases after the surgical intervention for revascularizations.
We describe two cases. In first case, the patency of the anastomosis site was good and saccular type pseudoaneurysm formation was found at parietal branch of posterior middle meningeal artery (MMA) in transfemoral cerebral angiography (TFCA) performed on the twelfth day after surgery. We decided to treat pseudoaneurysm by endovascular embolization the next day, but the patient was shown unconsciousness and anisocoria during sleep at that day. Computed tomography showed massive subdural hemorrhage at the ipsilateral side, thus we performed decompressive craniectomy and hematoma evacuation.
In second case, the patency of the anastomosis site was good and dAVF formation at right MMA was found in TFCA performed on the sixth day after surgery. We performed endovascular obliteration of the arteriovenous fistula under local anesthesia.
Pseudoaneurysm formation or dAVF formation after revascularization surgery is an exceptional case. If patients have such complications, practioner should carefully screen the patients by implementing digital subtraction angiogram to identify anatomic features; as well as consider immediate treatment in any way, including embolization or other surgery

Diet-related behavioral modification for healthy eating and lifestyle is required to improve childhood obesity. The present study aimed to develop customized nutritional intervention protocol and education program to find barriers to adhere healthy diet and lifestyle for moderate to severe obese children and adolescents and their families. Theoretical framework approaches can be used to change behavior and achieve goals. Previous studies that described the relationship between behavioral modification and nutrition education theory were reviewed. The social cognitive theory and transtheoretical model were employed with behavioral changes to target a healthful diet and lifestyle. The nutrition care process (NCP) model was adopted to customize nutrition care for the participants. Customized nutritional intervention protocol was developed following as the four steps of the NCP. Firstly, nutrition status of the participants was assessed by the nutrition expert. Nutrition problems were described as “inadequate energy intake,” “overweight/obesity,” or “food and nutrition-related knowledge deficit.” All nutrition sessions were designed for nutrition intervention to give nutritional knowledge and a practical mission in real life for individual goal setting and self-control. Meal planning, portion control, healthy snack selection and cooking with fruits and vegetables were consisted of five components of the nutrition education session. During each session, the participants and their families were interviewed by a nutrition expert for monitoring and evaluating diet-related goal setting and achievement. A theoretical and evidence-based nutritional intervention was developed for the secondary to tertiary prevention of childhood obesity. This nutrition intervention protocol and program might be helpful for the further research on childhood obesity. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0002111
Adolescent ; Behavior Therapy ; Child ; Cooking ; Diet ; Eating ; Education ; Fruit ; Humans ; Information Services ; Life Style ; Meals ; Nutrition Assessment ; Nutritional Status ; Pediatric Obesity ; Self-Control ; Snacks ; Tertiary Prevention ; Vegetables

PURPOSE: We aimed to determine the prevalence of allergic rhinitis and nonallergic rhinitis, difference in symptoms between allergic rhinitis and nonallergic rhinitis, and the association between lung function and the degree of asthma control in children with asthma. METHODS: One hundred seventy patients who were followed-up for asthma treatment at the department of pediatrics of CHA Bundang Medical Center were enrolled in this study. We conducted the questionnaire regarding coexistence of rhinitis, childhood asthma control test (C-ACT), and the basic lung function test. The patients were classified as allergic rhinitis group and nonallergic rhinitis group according to the response to 11 common inhalation and food allergens, and assessed the degree of asthma control and the severity of rhinitis. RESULTS: One hundred thirty patients (73%) were found to have rhinitis. Of these, 79 patients (53%) had allergic rhinitis and 34 patients (20%) had nonallergic rhinitis. The allergic rhinitis group was older than the nonallergic rhinitis group or the nonrhinitis group (7.73+/-2.85 vs. 5.97+/-2.48 vs. 6.12+/-2.70, P<0.001). Nasal itching sense was more prevalent in the allergic-rhinitis group than in the nonallergic rhinitis group (3.23+/-1.90 vs. 2.44+/-1.56, P=0.036). There was an inverse correlation between the rhinitis and C-ACT (r= -0.329, P<0.05). Of note, nasal obstruction symptom was highly correlated with C-ACT (r=-0.334, P<0.001). CONCLUSION: Allergic rhinitis and nonallergic rhinitis were highly prevalent in the pediatric patients with asthma and both of them had a significantly adverse impact on asthma control by rhinitis-itself. Therefore, regardless of atopic status, clinicians should focus on relieving rhinitis symptoms.
Allergens ; Asthma ; Child ; Humans ; Inhalation ; Lung ; Nasal Obstruction ; Pediatrics ; Prevalence ; Pruritus ; Respiratory Function Tests ; Rhinitis ; Rhinitis, Allergic, Perennial ; Surveys and Questionnaires

The aim of this update of Korean clinical practice guidelines for stroke is to provide timely evidence-based recommendations on the antiplatelet therapy in secondary prevention of stroke. Evidence-based recommendations are included for the use of antiplatelet agents for noncardioembolic stroke. Changes in the guidelines necessitated by new evidence will be continuously reflected in the new guideline.
Aspirin ; Platelet Aggregation Inhibitors ; Secondary Prevention ; Stroke ; Ticlopidine

OBJECTIVE: MR perfusion and single photon emission computerized tomography (SPECT) are well known imaging studies to evaluate hemodynamic change between prior to and following superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis in moyamoya disease. But their side effects and invasiveness make discomfort to patients. We evaluated the ivy sign on MR fluid attenuated inversion recovery (FLAIR) images in adult patients with moyamoya disease and compared it with result of SPECT and MR perfusion images. METHODS: We enrolled twelve patients (thirteen cases) who were diagnosed with moyamoya disease and underwent STA-MCA anastomosis at our medical institution during a period ranging from September of 2010 to December of 2012. The presence of the ivy sign on MR FLAIR images was classified as Negative (0), Minimal (1), and Positive (2). Regions were classified into four territories: the anterior cerebral artery (ACA), the anterior MCA, the posterior MCA and the posterior cerebral artery. RESULTS: Ivy signs on preoperative and postoperative MR FLAIR were improved (8 and 4 in the ACA regions, 13 and 4 in the anterior MCA regions and 19 and 9 in the posterior MCA regions). Like this result, the cerebrovascular reserve (CVR) on SPECT was significantly increased in the sum of CVR in same regions after STA-MCA anastomosis. CONCLUSION: After STA-MCA anastomosis, ivy signs were decreased in the cerebral hemisphere. As compared with conventional diagnostic modalities such as SPECT and MR perfusion images, the ivy sign on MR FLAIR is considered as a useful indicator in detecting brain hemodynamic changes between preoperatively and postoperatively in adult moyamoya patients.
Adult* ; Anterior Cerebral Artery ; Brain* ; Cerebral Arteries* ; Cerebrum ; Hemodynamics* ; Humans ; Moyamoya Disease* ; Perfusion ; Temporal Arteries ; Tomography, Emission-Computed, Single-Photon

OBJECTIVE: This study proposes more objective methods for deciding the appropriate direction of the sylvian fissure dissection during surgical clipping in middle cerebral artery (MCA) bifurcation aneurysms. METHODS: We reviewed data of 36 consecutive patients with MCA bifurcation aneurysms. We measured 2 indices preoperatively on 3-dimensional computed tomography angiography (3D-CTA). Analysis of the calculated data allowed us to select the appropriate direction of sylvian fissure dissection for ease of proximal control of M1. Statistically, Mann-Whitney test was used. RESULTS: We classified subjects into 2 groups based on the technical level of M1 exposure during surgical clipping. When it was difficult to expose M1, subjects were assigned to Group I, and Group II were subjects in whom M1 exposure was easy. The mean difference between the distances extending from the limbus sphenoidale (LS) line to the internal carotid artery bifurcation and extending from the LS line to the MCA bifurcation was 1.00 +/- 0.42 mm in group I and 4.39 +/- 2.14 mm in group II. The mean M1 angle was 9.36 +/- 3.73degrees in the group I and 34.05 +/- 16.71degrees in the group II (M1 slope gap p < 0.05, M1 angle p < 0.05). CONCLUSION: We have found an objective method for preoperatively verifying ease of exposure of M1 artery during surgical clipping. Therefore, we suggest use of the preoperative M1 slope gap and M1 angle as indicators in 3D-CTA selecting the direction of sylvian fissure dissection for easy proximal control of M1.
Aneurysm ; Angiography ; Arteries ; Carotid Artery, Internal ; Humans ; Intracranial Aneurysm ; Middle Cerebral Artery ; Surgical Instruments

OBJECTIVE: This study proposes more objective methods for deciding the appropriate direction of the sylvian fissure dissection during surgical clipping in middle cerebral artery (MCA) bifurcation aneurysms. METHODS: We reviewed data of 36 consecutive patients with MCA bifurcation aneurysms. We measured 2 indices preoperatively on 3-dimensional computed tomography angiography (3D-CTA). Analysis of the calculated data allowed us to select the appropriate direction of sylvian fissure dissection for ease of proximal control of M1. Statistically, Mann-Whitney test was used. RESULTS: We classified subjects into 2 groups based on the technical level of M1 exposure during surgical clipping. When it was difficult to expose M1, subjects were assigned to Group I, and Group II were subjects in whom M1 exposure was easy. The mean difference between the distances extending from the limbus sphenoidale (LS) line to the internal carotid artery bifurcation and extending from the LS line to the MCA bifurcation was 1.00 +/- 0.42 mm in group I and 4.39 +/- 2.14 mm in group II. The mean M1 angle was 9.36 +/- 3.73degrees in the group I and 34.05 +/- 16.71degrees in the group II (M1 slope gap p < 0.05, M1 angle p < 0.05). CONCLUSION: We have found an objective method for preoperatively verifying ease of exposure of M1 artery during surgical clipping. Therefore, we suggest use of the preoperative M1 slope gap and M1 angle as indicators in 3D-CTA selecting the direction of sylvian fissure dissection for easy proximal control of M1.
Aneurysm ; Angiography ; Arteries ; Carotid Artery, Internal ; Humans ; Intracranial Aneurysm ; Middle Cerebral Artery ; Surgical Instruments