Endovascular surgery is rapidly advancing and is widely used for the management of various cerebrovascular diseases. Usually, chronic subdural hematomas are treated surgically; however, endovascular surgery is recently being attempted as a new treatment option based on the pathophysiology of this condition.Current Concepts: Chronic subdural hematomas have an outer membrane derived from the dura mater. Sinusoidal capillaries in the outer membrane are a source of bleeding, which leads to hematoma growth and postoperative recurrence. Theoretically, embolization of the middle meningeal artery using endovascular procedures can prevent bleeding from the outer membrane and promote spontaneous resolution of a hematoma. Clinical studies, including recent prospective trials, have demonstrated the superior efficacy and safety of middle meningeal artery embolization over conventional treatment.Discussion and Conclusion: More clinical trials on endovascular surgery for chronic subdural hematomas are forthcoming. We expect that the results of future studies will strengthen the findings of recent prospective trials and contribute to a major shift in the management of chronic subdural hematomas.

A ruptured distal lenticulostriate artery (LSA) aneurysm is detected occasionally in moyamoya disease (MMD) patients presented with intracerebral hemorrhage. If the aneurysm is detected in hemorrhage site on angiographic evaluation, its obliteration could be considered, because it rebleeds frequently, and is associated with poorer outcome and mortality in MMD related hemorrhage. In this case report, the authors present two MMD cases with ruptured distal LSA aneurysm treated by endovascular embolization.
Aneurysm* ; Arteries* ; Cerebral Hemorrhage ; Embolization, Therapeutic ; Hemorrhage ; Humans ; Mortality ; Moyamoya Disease*

Vertebrobasilar insufficiency can be caused by proximal vertebral artery (VA) occlusion. Performing endovascular recanalization for treating VA occlusion has high procedural risks, including vessel perforation. In contrast, surgical revascularization of the distal extracranial VA had been used for many decades to treat proximal VA occlusion or stenosis, and its safety and satisfactory long-term outcome are well established. We report here on a case of successful surgical revascularization by performing occipital artery to distal extracranial VA bypass for bilateral proximal VA occlusion and we discuss its potential role for the treatment of medical refractory recurrent ischemia in the vertebrobasilar territory
Arteries ; Constriction, Pathologic ; Glycosaminoglycans ; Ischemia ; Vertebral Artery ; Vertebrobasilar Insufficiency

OBJECTIVE: The authors evaluated the feasibility and targeting accuracy of CT fluoroscopy (CTF)-guided catheter placement and aspiration of intracerebral hematoma (ICH)s. MATERIALS AND METHODS: Nine patients (mean age, 63.3 +/- 15.3 years) were treated by CTF-guided hematoma aspiration under local anesthesia. The targeting errors in the lesion center, volume of the aspirated hematoma, accuracy of the final catheter position, procedure time, and clinical outcomes were evaluated. RESULTS: All catheters were successfully placed in the center of the hematoma. The mean volume of the aspirated hematoma was 20.6 +/- 8.8 mL (pre-treatment, 44.7 +/- 20.1 mL; post-treatment, 24.1 +/- 13.8 mL). The average procedure time was 25.1 minutes (range, 18-32 minutes). In one case with a scanty residual hematoma, the catheter was removed at the end of the procedure. In the remaining eight cases, the catheter was left in the residual hematoma for drainage and all catheter tips were accurately located in the final position. There were no procedure-related complications, including rebleeding and infection. CONCLUSION: CTF-guided ICH aspiration is a feasible, quick, and accurate procedure which could substitute for stereotactic methods. The accurate catheter position provided by real-time observation enables an effective aspiration and drainage of hematomas.
Anesthesia, Local ; Catheters ; Cerebral Hemorrhage ; Drainage ; Fluoroscopy ; Hematoma* ; Humans

Central retinal artery occlusion (CRAO) causes severe visual loss in affected eye and vision does not recover in more than 90% of the patients. It is believed that it occurs by occlusion of the central retinal artery with small emboli from atherosclerotic plaque of internal cerebral artery. Retina is a part of the brain, thus basically CRAO is corresponding to acute occlusion of intracerebral artery and retinal ischemia is to cerebral stroke. Therefore, intra-arterial thrombolysis (IAT) has been considered as a treatment method in CRAO. Recently, we treated 2 patients diagnosed as CRAO and could achieve complete recanalization on fundus fluorescein angiogram with IAT. Of them, one recovered visual acuity to 20/25. We report our 2 CRAO cases treated with IAT and discuss technical aspects for IAT and management of patient. To the best of our knowledge, this is the first Korean report of IAT for CRAO.

We report a rare case of an idiopathic pseudoaneurysm causing intraventricular hemorrhage (IVH). A 28-year-old man presented with sudden onset of severe headache. He underwent external ventricular drainage for an isolated IVH in the right lateral ventricle. Digital subtraction angiography (DSA) revealed that the aneurysm (7.5x4.5 mm) arose from the distal part of the medial lenticulostriate artery. Following removal of the external ventricular drainage catheter, the aneurysm decreased in size (4.0x2.3 mm). However, follow-up DSA revealed a slightly enlarged aneurysm (4.2x3.2 mm) with morphologic change. The aneurysm was clipped via the interhemispheric transcallosal approach, but postoperative DSA revealed a residual aneurysm sac beside the clips. Given the risk of rebleeding, a second operation was planned for complete resection of the aneurysm. After revised craniotomy and careful dissection of the caudate nucleus, the aneurysm sac was completely resected. Histopathological examination revealed that the aneurysm was a pseudoaneurysm. The patient recovered without any neurological sequel and was discharged. To the best of our knowledge, this is the first reported case of an idiopathic lenticulostriate artery pseudoaneurysm protruding into the right lateral ventricle and causing an IVH that was successfully treated with microsurgical resection.
Adult ; Aneurysm ; Aneurysm, False ; Angiography, Digital Subtraction ; Arteries ; Catheters ; Caudate Nucleus ; Craniotomy ; Drainage ; Follow-Up Studies ; Headache ; Hemorrhage ; Humans ; Lateral Ventricles

OBJECTIVE: We conducted a retrospective cohort study to elucidate the natural course of unruptured intracranial aneurysms (UIAs) at a single institution. METHODS: Data from patients diagnosed with UIA from March 2000 to May 2008 at our hospital were subjected to a retrospective analysis. The cumulative and annual aneurysm rupture rates were calculated. Additionally, risk factors associated with aneurysmal rupture were identified. RESULTS: A total of 1339 aneurysms in 1006 patients met the inclusion criteria. During the follow-up period, 685 aneurysms were treated before rupture via either an open surgical or endovascular procedure. Six hundred fifty-four UIAs were identified and not repaired during the follow-up period. The mean UIA size was 4.5+/-3.2 mm, and 86.5% of the total UIAs had a largest dimension <7 mm. Among these UIAs, 18 ruptured at a median of 1.6 years (range : 27 days to 9.8 years) after day 0. The annual rupture risk during a 9-year follow-up was 1.00%. A multivariate Cox proportional hazards analysis revealed that the aneurysm size and a history of subarachnoid hemorrhage (SAH) were statistically significant risk factors for rupture. For an aneurysms smaller than 7 mm in the absence of a history of SAH, the annual rupture risk was 0.79%. CONCLUSION: In our study, the annual rupture risk for UIAs smaller than 7 mm in the absence of a history of SAH was higher than that of Western populations but similar to that of the Japanese population.
Aneurysm ; Asian Continental Ancestry Group ; Cohort Studies ; Endovascular Procedures ; Follow-Up Studies ; Humans ; Intracranial Aneurysm* ; Natural History* ; Retrospective Studies* ; Risk Factors ; Rupture ; Subarachnoid Hemorrhage

There have been a few studies reporting the epidemiology of moyamoya disease in Korea. Previous studies revealed relatively high prevalence and incidence of moyamoya disease in Korea and Japan. This study was designed to provide the latest epidemiologic information of moyamoya disease in Korea. We analyzed a database comprising of 50 million people covered in Korea by the National Health Insurance Service to calculate the prevalence. The incidence was estimated by eliminating the duplicated records of previous 3 years. We summarized the prevalence and incidence according to age, sex, and local distribution. In addition, the chronological changes were demonstrated with direct standardization using the 2010 population structure information. The standardized prevalence was 6.5 per 100000 persons in 2005, which was increased to 18.1 in 2013. In the same period, standardized incidence was increased from 2.7 to 4.3 per 100000 persons. The prevalence for men was 4.9 and 8.3 for women in 2005. In 2013, the prevalence had increased for men and women to 13.8 and 25.3, respectively. The incidence for men and women was 2.2 and 3.2, respectively, in 2005. It had increased to 3.5 and 5.7, respectively. The mean age of patients was 33.5 in 2005 and increased to 42.5 in 2013. The peak prevalent age group had shifted slightly to the older age groups, with chronologically consistent female predominance. The prevalence was highest in Jeollabuk province and lowest in Ulsan city.
Epidemiology* ; Female ; Humans ; Incidence ; Japan ; Korea ; Male ; Moyamoya Disease* ; National Health Programs* ; Prevalence ; Ulsan

OBJECTIVE: The authors evaluated the accuracies and ease of use of several commonly used microanastomosis training models (synthetic tube, chicken wing, and living rat model). METHODS: A survey was conducted among neurosurgeons and neurosurgery residents at a workshop held in 2009 at the authors' institute. Questions addressed model accuracy (similarity to real vessels and actual procedures) and practicality (availability of materials and ease of application in daily practice). Answers to each question were rated using a 5-point scale. Participants were also asked what types of training methods they would chose to improve their skills and to introduce the topic to other neurosurgeons or neurosurgery residents. RESULTS: Of the 24 participants, 20 (83.3%) responded to the survey. The living rat model was favored for model accuracy (p < 0.001; synthetic tube -0.95 +/- 0.686, chicken wing, 0.15 +/- 0.587, and rat, 1.75 +/- 0.444) and the chicken wing model for practicality (p < 0.001; synthetic tube -1.55 +/- 0.605, chicken wing, 1.80 +/- 0.523, and rat, 1.30 +/- 0.923). All (100%) chose the living rat model for improving their skills, and for introducing the subject to other neurosurgeons or neurosurgery residents, the chicken wing and living rat models were selected by 18 (90%) and 20 (100%), respectively. CONCLUSION: Of 3 methods examined, the chicken wing model was found to be the most practical, but the living rat model was found to represent reality the best. We recommend the chicken wing model to train surgeons who have mastered basic techniques, and the living rat model for experienced surgeons to maintain skill levels.
Animals ; Cerebral Revascularization ; Chickens ; Microsurgery ; Neurosurgery ; Rats ; Wings, Animal

OBJECTIVE: To assess the results of superficial temporal artery-middle cerebral artery anastomosis (SMA) in atherosclerotic disease (ASD) and in adult moyamoya disease (MMD) by comparing the complications that arise. METHODS: We retrospectively reviewed patients with ASD or adult MMD treated by means of SMA, between December 2004 and December 2006, at our neurovascular center. During this period, we performed 115 SMAs on 108 patients: 61 on ASD patients (61 SMAs; the ASD group) and 47 on adult MMD patients (54 SMAs; the MMD group). RESULTS: We found a higher incidence of permanent neurological deficits (PNDs) and a lower incidence of transient neurological deficits (TNDs) in the MMD group than in the ASD group (p-value=0.047). Patients with a preoperative stroke (cerebral infarction/hemorrhage) history were more likely to develop postoperative PND than were the patients with a preoperative history of transient ischemic attack (TIA), in both the ASD (p-values=0.012 and 0.033, respectively) and MMD groups (p-values=0.000 and 0.015, respectively), regardless of overall patients (n=108) and single SMA group (n=62). Delayed seizure (seizure occurring > 1 month after SMA) occurred only in 8 MMD patients (8/47, 17.0%; p-value=0.003) out of all 108 patients and in 2 patients (2/10, 20%, p-value=0.014) out of the single SMA group. CONCLUSION: Regardless of whether the diagnosis is ASD or MMD, patients with TIA preoperatively seem more prone to develop postoperative TND, and patients with a stroke history seem more prone to develop PND in both ASD and MMD groups. However, MMD patients appear more likely to experience a delayed seizure attack after SMA than ASD patients are.
Adult ; Cerebral Arteries ; Humans ; Incidence ; Ischemic Attack, Transient ; Moyamoya Disease ; Retrospective Studies ; Seizures ; Stroke