Sildenafil citrate (Viagra(R); Pfeizer US Pharmaceutical Group, New York, NY, USA) is a potent vasodilating agent to treat male erectile dysfunction. Among its adverse effects, hemorrhagic stroke has not been widely reported yet. We present a case of a 33-year-old healthy man who ingested 50 mg sildenafil a half hour before onset of headache, nervousness and speech disturbance. Head computed tomogram of this stuporous man showed huge intracerebral hemorrhage and thick subarachnoid hemorrhage, but angiography failed to disclose any vascular anomalies. Subsequent surgical procedure was followed, and rehabilitation was provided thereafter. Sildenafil seems to act by redistributing arterial blood flow, and concurrent sympathetic hyperactivity, which lead to such hemorrhagic presentation. Extreme caution should be paid on even in a young adult male patient wven without known risk factors.
Adult ; Angiography ; Anxiety ; Cerebral Hemorrhage ; Citric Acid ; Eating ; Erectile Dysfunction ; Head ; Headache ; Hematoma ; Humans ; Male ; New York ; Piperazines ; Purines ; Risk Factors ; Stroke ; Stupor ; Subarachnoid Hemorrhage ; Sulfones ; Young Adult ; Sildenafil Citrate

OBJECTIVE: Subarachnoid hemorrhage (SAH) caused by rupture of an internal carotid artery (ICA) or vertebral artery (VA) dissecting aneuryesm is rare. Various treatment strategies have been used for ruptured intracranial dissections. The purpose of this study is to compare the clinical and angiographic characteristics and outcomes of endovascular treatment for ruptured dissecting aneurysms of the intracranial ICA and VA. METHODS: The authors retrospectively reviewed a series of patients with SAH caused by ruptured intracranial ICA and VA dissecting aneurysms from March 2009 to April 2014. The relevant demographic and angiographic data were collected, categorized and analyzed with respect to the outcome. RESULTS: Fifteen patients were identified (6 ICAs and 9 VAs). The percentage of patients showing unfavorable initial clinical condition and a history of hypertension was higher in the VA group. The initial aneurysm detection rate and the percentage of fusiform aneurysms were higher in the VA group. In the ICA group, all patients were treated with double stent-assisted coiling, and showed favorable outcomes. In the VA group, 2 patients were treated with double stent-assisted coiling and 7 with endovascular trapping. Two patients died and 1 patient developed severe disability. CONCLUSION: Clinically, grave initial clinical condition and hypertension were more frequent in the VA group. Angiographically, bleb-like aneurysms were more frequent in the ICA group and fusiform aneurysms were more frequent in the VA group. Endovascular treatment of these aneurysms is feasible and the result is acceptable in most instances.
Aneurysm ; Aneurysm, Dissecting* ; Carotid Artery, Internal* ; Humans ; Hypertension ; Retrospective Studies ; Rupture ; Subarachnoid Hemorrhage ; Vertebral Artery*

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

OBJECTIVE: Terson's syndrome, a complication of visual function, has occasionally been reported in patients with aneurysmal subarachnoid hemorrhage (SAH), however the factors responsible for Terson's syndrome in aneurysmal SAH patients have not yet been fully clarified. In this study, we report on potential risk factors for prediction and diagnosis of Terson's syndrome in the earlier stage of the disease course in patients with aneurysmal SAH. MATERIALS AND METHODS: The authors retrospectively analyzed the data of 322 consecutive patients who suffered from aneurysmal SAH in a single institution between Jan. 2007 and Dec. 2013. Medical records including demographics, neurologic examination, and radiologic images were collected to clarify the risk factors of Terson's syndrome. Patients with visual problem were consulted to the Department of Ophthalmology. RESULTS: Among 332 patients with aneurysmal SAH, 34 patients were diagnosed as Terson's syndrome. Four individual factors, including World Federation of Neurosurgical Societies (WFNS) grade at admission, aneurysm size, method of operation, and Glasgow outcome scale showed statistically significant association with occurrence of Terson's syndrome. Of these, WFNS grade at admission, aneurysm size, and method of operation showed strong association with Terson's syndrome in multivariate analysis. Terson's syndrome accompanied by papilledema due to increased intracranial pressure led to permanent visual complication. CONCLUSION: In patients with aneurysmal SAH, the patients' WFNS grade at admission, the size of the aneurysms, particularly the diameter of the aneurysm dome, and the method of operation might influence development of Terson's syndrome.
Aneurysm* ; Demography ; Diagnosis ; Glasgow Outcome Scale ; Humans ; Incidence* ; Intracranial Pressure ; Medical Records ; Multivariate Analysis ; Neurologic Examination ; Ophthalmology ; Papilledema ; Retrospective Studies* ; Risk Factors* ; Subarachnoid Hemorrhage* ; Vitreous Hemorrhage

OBJECTIVE: Terson's syndrome, a complication of visual function, has occasionally been reported in patients with aneurysmal subarachnoid hemorrhage (SAH), however the factors responsible for Terson's syndrome in aneurysmal SAH patients have not yet been fully clarified. In this study, we report on potential risk factors for prediction and diagnosis of Terson's syndrome in the earlier stage of the disease course in patients with aneurysmal SAH. MATERIALS AND METHODS: The authors retrospectively analyzed the data of 322 consecutive patients who suffered from aneurysmal SAH in a single institution between Jan. 2007 and Dec. 2013. Medical records including demographics, neurologic examination, and radiologic images were collected to clarify the risk factors of Terson's syndrome. Patients with visual problem were consulted to the Department of Ophthalmology. RESULTS: Among 332 patients with aneurysmal SAH, 34 patients were diagnosed as Terson's syndrome. Four individual factors, including World Federation of Neurosurgical Societies (WFNS) grade at admission, aneurysm size, method of operation, and Glasgow outcome scale showed statistically significant association with occurrence of Terson's syndrome. Of these, WFNS grade at admission, aneurysm size, and method of operation showed strong association with Terson's syndrome in multivariate analysis. Terson's syndrome accompanied by papilledema due to increased intracranial pressure led to permanent visual complication. CONCLUSION: In patients with aneurysmal SAH, the patients' WFNS grade at admission, the size of the aneurysms, particularly the diameter of the aneurysm dome, and the method of operation might influence development of Terson's syndrome.
Aneurysm* ; Demography ; Diagnosis ; Glasgow Outcome Scale ; Humans ; Incidence* ; Intracranial Pressure ; Medical Records ; Multivariate Analysis ; Neurologic Examination ; Ophthalmology ; Papilledema ; Retrospective Studies* ; Risk Factors* ; Subarachnoid Hemorrhage* ; Vitreous Hemorrhage

Objective: Stent retrieval thrombectomy has recently been the standard treatment for acute ischemic stroke with large artery occlusion. However, the development of catheters for suction thrombectomy has recently led to results comparable to that of stent retrieval thrombectomy (SRT). This study aimed to analyze the safety and efficacy of forced suction thrombectomy (FST) using the SOFIA Plus (MicroVention Terumo, Tustin, CA, USA) device. Methods: We included patients with acute ischemic stroke who underwent FST using the SOFIA Plus device at our institution. Medical records and angiographic data were reviewed, and the results of this study were compared with those of other FST studies. Results: A total of 35 patients were included in this study. The occlusion sites were the internal carotid artery terminal (4), M1 segment (20), and posterior circulation (11). Of the 35 patients, FST was performed in only 21 (60%) patients, and the remaining 14 (40%) patients underwent SRT and FST. In all cases, the recanalization rate was 100%, and the average time from groin puncture to recanalization was 21±4.94 min. In particular, the average time required to reach the SOFIA Plus lesions from the groin puncture was 10.44±5.06 min and about 67% of the FST patients were recanalized at the first attempt. Three-months modified Rankin Scale (mRS) score of ≤2 was observed in 52% of the patients. Conclusions Forced suction thrombectomy using the SOFIA Plus yielded a high recanalization rate within a shorter time. In particular, the recanalization rate was higher than that reported in previous studies using other types of suction devices.

Objective: : To confirm the usefulness of the extradural anterior clinoidectomy during the clipping of a lower riding posterior communicating artery (PCoA) aneurysm through cadaver dissection. Methods: : Anatomic measurements of 12 adult cadaveric heads (24 sides total) were performed to compare the microsurgical exposure of the PCoA and internal carotid artery (ICA) before and after clinoidectomy. A standard pterional craniotomy and transsylvian approach were performed in all cadavers. The distance from the ICA bifurcation to the origin of PCoA (D1), pre-anterior clinoidectomy distance from the ICA bifurcation to tentorium (D2), post-anterior clinoidectomy distance from the ICA bifurcation to tentorium (D3), pre-anterior clinoidectomy distance from the tentorium to the origin of PCoA (D4) and post-anterior clinoidectomy distance from the tentorium to the origin of PCoA (D5) and the distance of the ICA obtained after anterior clinoidectomy (D6) were measured. We measured the precise thickness of the blade for the Yasargil clip with a digital precision ruler to confirm the usefulness of the extradural anterior clinoidectomy. Results: : Twenty-four sites were dissected from 12 cadavers. The age of the cadavers was 79.83±6.25 years. The number of males was the same as the females. The space from the proximal origin of the PCoA to the preclinoid-tentorium (D4) was 1.45±1.08 mm (max, 4.01; min, 0.56). After the clinoidectomy, the space from the proximal origin of the PCoA to the postclinoid-tentorium (D5) was 3.612±1.15 mm (max, 6.14; min, 1.83). The length (D6) of the exposed proximal ICA after the extradural clinoididectomy was 2.17±1.04 mm on the lateral side and 2.16±0.89 mm on the medial side. The thickness of the Yasargil clip blade used during the clipping surgery was 1.35 mm measured with a digital precision ruler. Conclusion : The proximal length obtained by performing an external anterior clinoidectomy is about 2 mm, sufficient for proximal control during PCoA aneurysm surgery, considering the thickness of the aneurysm clips. In a subarachnoid hemorrhage, performing an extradural anterior clinoidectomy could prevent a devastating situation during PCoA aneurysm clipping.

Meningioma is one of the most common types of benign primary brain tumors in older adults, and multiple meningiomas are reported in fewer than 1% to 10% of cases. However, there is no definitive treatment guideline for patients with multiple meningiomas. An 80-year-old man presented with abruptly impaired cognition and was found to have two distinct meningiomas located in the temporal and frontal lobes. A single frontotemporal craniotomy was performed to remove both tumors. Pathological analysis revealed different subtypes and World Health Organization grades for each mass. The patient showed symptomatic improvement, experienced no postoperative complications, and exhibited no signs of recurrence during a 1-year follow-up period with evaluations at 3-month intervals. Despite the absence of a standard treatment for multiple meningiomas, surgical resection in a single procedure is feasible in selected patients.

Objective: Decompression with instrumented fusion is a common approach for treating spinal metastatic disease. However, in many cases, poor bone quality and compromised general condition increase the likelihood of mechanical failure and other complications. This study investigated complications, including those related to surgery, following decompression and fusion in patients with spinal metastatic disease. Methods: A study at a single tertiary medical center focusing on surgical details and perioperative complications was performed on 35 patients who underwent spinal surgery due to metastatic spinal disease based on a review of a prospective database. Data on patients' underlying conditions and the status of the primary tumors were collected, and various complications that occurred within the first month after surgery were analyzed. Results: During the study, 35 patients (mean age, 66.5 years; 26 men) were enrolled. The most frequent primary cancers were lung (34%) and prostate cancer (17%), followed by liver and breast cancer and others. The overall complication rate was 37% (14% surgery-related complications, 23% general complications). In all cases, surgery was performed due to lower extremity weakness, and 59% of patients showed improvements in motor function after surgery. Furthermore, 23% of patients regained the ability to walk. Conclusion Surgery for spinal metastasis is frequently performed as an emergency due to the severity of symptoms such as lower extremity weakness. Despite a high risk of acute complications, the procedure has significant benefits, including improvement in weakness and recovery of walking ability. Therefore, proactive treatment using appropriate surgical techniques is recommended.

Meningioma is one of the most common types of benign primary brain tumors in older adults, and multiple meningiomas are reported in fewer than 1% to 10% of cases. However, there is no definitive treatment guideline for patients with multiple meningiomas. An 80-year-old man presented with abruptly impaired cognition and was found to have two distinct meningiomas located in the temporal and frontal lobes. A single frontotemporal craniotomy was performed to remove both tumors. Pathological analysis revealed different subtypes and World Health Organization grades for each mass. The patient showed symptomatic improvement, experienced no postoperative complications, and exhibited no signs of recurrence during a 1-year follow-up period with evaluations at 3-month intervals. Despite the absence of a standard treatment for multiple meningiomas, surgical resection in a single procedure is feasible in selected patients.