Objective: : Stent-assisted coil embolization (SAC) has been increasingly used to treat various types of intracranial aneurysms. Delayed thromboembolic complications are major concerns regarding this procedure, so dual antiplatelet therapy with aspirin and clopidogrel is needed. However, clinicians vary the duration of dual antiplatelet therapy after SAC, and no randomized study has been performed. This study aims to compare the safety and efficacy of long-term (12 months) dual antiplatelet therapy and shortterm dual antiplatelet therapy (6 months) after SAC for patients with unruptured intracranial aneurysms (UIAs). Methods: : This is a prospective, randomized and multicenter trial to investigate the optimal duration of dual antiplatelet therapy after SAC in patients with UIAs. Subjects will receive dual antiplatelet therapy for 6 months (short-term group) or 12 months (longterm group) after SAC. The primary endpoint is the assessment of thromboembolic complications between 1 and 18 months after SAC. We will enroll 528 subjects (264 subjects in each group) and perform 1 : 1 randomization. This study will involve 14 topperforming, high-volume Korean institutions specializing in coil embolization. Results: : The trial will begin enrollment in 2022, and clinical data will be available after enrollment and follow-up. Conclusion : This article describes that the aim of this prospective randomized multicenter trial is to compare the effect of short-term (6 months) and long-term (12 months) dual antiplatelet therapy on UIAs in patients undergoing SAC, and to find the optimal duration.

The efficacy of P2Y12 reaction unit (PRU) of VerifyNow still remains as a controversial issue in neurointervention. So we investigated the usefulness of PRU of VerifyNow to predict the peri-procedural thromboembolic events (TE) and hemorrhagic events (HE). And we evaluated the safety of modified dual antiplatelet therapy (DAPT) or triple antiplatelet therapy (TAPT) for clopidogrel hyporesponders. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Scopus on August 19 2018. Data was collected the 1) incidence of TE between clopidogrel responder and clopidogrel hypo-responder, 2) incidence of HE between clopidogrel hyper-responder and clopidogrel responder and hypo-responder, and 3) incidence of TE and HE between modified DAPT or TAPT and standard DAPT in clopidogrel hypo-responder. High cut-off value of PRU was defined as PRU >40% or <220. Fifteen studies were enrolled. Clopidogrel responder showed lower incidence of TE than hypo-responder (risk ratio [RR], 0.32; 95% confidence interval [CI], 0.17-0.61; p<0.001). With the high cut-off value of PRU, clopidogrel responder showed more lower incidence of TE than hypo-responder (RR, 0.11; 95% CI, 0.02-0.45; p=0.002). The incidence of periprocedural HE have higher on clopidogrel hyper-responder than clopidogrel responder and hypo-responder (RR, 4.26; 95% CI, 1.10-16.44; p=0.04; I2=66%). The incidence of periprocedural TE after changing regimen of DAPT for clopidogrel hypo-responder have a tendency to reduce, but there was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). The incidence of periprocedural HE after changing regimen of DAPT for clopidogrel hypo-responder was no significant difference between modified DAPT or TAPT group and standard DAPT group (p>0.05). PRU is a useful tool as a predictor of peri-procedural TE or HE on neurointervention. PRU has a threshold effect of cut-off value to predict the peri-procedural TE. Modified DAPT or TAPT to prevent TE in clopidogrel hypo-responders could not reduce the incidence of TE. We should investigate the further research about modification of regiment on neurointervention.

OBJECTIVE: In respect of the health and safety of the public, universal access to health care is an issue of the greatest importance. The geographic distribution of doctors is one of the important factors contributing to access to health care. The aim of this study is to assess the imbalances in the geographic distribution of neurosurgeons across Korea.METHODS: Population data was obtained from the National Statistical Office. We classified geographic groups into 7 metropolitan cities, 78 non-metropolitan cities, and 77 rural areas. The number of doctors and neurosurgeons per 100000 populations in each county unit was calculated using the total number of doctors and neurosurgeons at the country level from 2009 to 2015. The density levels of neurosurgeon and doctor were calculated and depicted in maps.RESULTS: Between 2009 and 2015, the number of neurosurgeons increased from 2002 to 2557, and the ratio of neurosurgeons per 100000 populations increased from 4.02 to 4.96. The number of neurosurgeons per 100000 populations was highest in metropolitan cities and lowest in rural areas from 2009 to 2015. A comparison of the geographic distribution of neurosurgeons in 2009 and 2015 showed an increase in the regional gap. The neurosurgeon density was affected by country unit characteristics (p=0.000).CONCLUSION: Distribution of neurosurgeons throughout Korea is uneven. Neurosurgeons are being increasingly concentrated in a limited number of metropolitan cities. This phenomenon will need to be accounted when planning for a supply of neurosurgeons, allocation of resources and manpower, and the provision of regional neurosurgical services.
Geographic Mapping ; Health Manpower ; Health Services Accessibility ; Hospital Distribution Systems ; Korea ; Neurosurgeons ; Neurosurgery ; Resource Allocation

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
Aneurysm ; Brain Ischemia ; Cerebrovascular Disorders ; Diagnosis ; Disease Management ; Hydrocephalus ; Intracranial Aneurysm ; Mortality ; Neurology ; Quality Control ; Rehabilitation ; Risk Factors ; Search Engine ; Subarachnoid Hemorrhage ; Surgeons

OBJECTIVE: The objective of this study was to determine the efficiency and safety of Y configuration stent-assisted coiling with double-closed stents for wide-necked intracranial aneurysms located at arterial bifurcations thorough analysis of a multicenter case series. MATERIALS AND METHODS: A retrospective chart review was done on 10 patients who underwent endovascular treatment of wide-necked intracranial aneurysms with Y-configuration stent-assisted coil embolization in three centers from August 2011 to March 2014. The degree of aneurysmal occlusion was assessed using the Raymond scale. Clinical outcomes were assessed before operation, at discharge, and at the last follow-up visit using the Glasgow outcome scale. RESULTS: The 10 patients included 6 females and 4 males with a mean age of 58.6 years. Indications for treatment included 6 unruptured intracranial aneurysms and 4 ruptured intracranial aneurysms. Five aneurysms were located at the basilar artery bifurcation, four aneurysms were located in an anterior communicating artery, and one aneurysm was in the pericallosal artery. The mean size of the 10 aneurysms was 9.7 mm. All aneurysms had a dome-to-neck ratio of < 1.5 (mean, 0.89). Immediate complications included one thromboembolic event out of the 10 cases. Immediate posttreatment angiograms showed complete occlusion in 1 aneurysm and residual necks in 9 aneurysms. Follow-up results showed 8 complete occlusions and 2 residual necks. No delayed complications were observed during the follow-up period (mean: 20 months). CONCLUSION: Y configuration using double-closed cell stents is feasible and safe in selected patients. This method is an acceptable option for managing complex wide-necked bifurcations.
Aneurysm* ; Arteries ; Basilar Artery ; Embolization, Therapeutic* ; Female ; Follow-Up Studies ; Glasgow Outcome Scale ; Humans ; Intracranial Aneurysm ; Male ; Methods ; Neck ; Retrospective Studies ; Stents

No abstract available.
Infarction* ; Middle Cerebral Artery*

The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.
Cerebral Hemorrhage* ; Consensus ; Humans ; Intracranial Pressure ; Korea ; Peer Review ; Quality Control ; Stroke ; Surgical Procedures, Minimally Invasive ; Writing

The need for standard endovascular neurosurgical (ENS) training programs and certification in Korea cannot be overlooked due to the increasing number of ENS specialists and the expanding ENS field. The Society of Korean Endovascular Neurosurgeons (SKEN) Certification Committee has prepared training programs and certification since 2010, and the first certificates were issued in 2013. A task force team (TFT) was organized in August 2010 to develop training programs and certification. TFT members researched programs and systems in other countries to develop a program that best suited Korea. After 2 years, a rough draft of the ENS training and certification regulations were prepared, and the standard training program title was decided. The SKEN Certification Committee made an official announcement about the certification program in March 2013. The final certification regulations comprised three major parts: certified endovascular neurosurgeons (EN), certified ENS institutions, and certified ENS training institutions. Applications have been evaluated and the results were announced in June 2013 as follows: 126 members received EN certification and 55 hospitals became ENS-certified institutions. The SKEN has established standard ENS training programs together with a certification system, and it is expected that they will advance the field of ENS to enhance public health and safety in Korea.
Advisory Committees ; Certification* ; Education ; Korea ; Public Health ; Social Control, Formal ; Specialization

Intracranial aneurysmal rupture causes subarachnoid hemorrhage which usually leads to fatality or severe disability. Treatment of unruptured intracranial aneurysms (UIAs) can substantially reduce the risk of rupture and prevent the grave consequences, but the risk of prophylactic treatment cannot be ignored. UIAs have diverse characteristics and management strategy needs to be tailored according to their location, size and clinical status. In the absence of level I evidence, the treatment guidance often relied on expert's opinions and experience. Knowledge of the natural course and management risks of individual aneurysms can help to guide treatment decision, but the natural history is still controversial and risks are not clearly defined. The Korean Society of Cerebrovascular Surgeons (KSCVS) decided to issue a Korean version of UIA management guideline as a framework for the treatment decision and as a basis for future studies, following 'Guideline Development Manual' of the Clinical Research Center for Stroke (CRCS). The organized committee systematically reviewed relevant literature and major guidelines published between January 2000 and July 2010 and took a developmental strategy of adaptation rather than de novo methods. On the basis of interpretation of the published evidences, recommendations were synthesized, and the level of evidence and the grade of recommendation were determined using the methods adapted from those of the US Agency for Healthcare Policy and Research and CRCS. The current guideline focuses on three domains of natural history, diagnosis and treatment of UIAs. The hierarchy of evidence and the recommendation grading indicate the current level by the literature and do not indicate the necessity or the prohibition of a certain clinical practice. Accordingly, this guideline cannot provide the answer for every clinical situation and should not take precedence over the clinical judgment of responsible physicians for individual patients. The final judgment regarding the care of a particular patient must be made by the physician and patient in light of circumstances specific to that patient. This is the first version of the UIA management guideline in Korea and new evidences will be timely and continuously updated in the future guidelines.
Aneurysm ; Calcium Hydroxide ; Delivery of Health Care ; Humans ; Intracranial Aneurysm ; Judgment ; Korea ; Light ; Natural History ; Risk Management ; Rupture ; Stroke ; Subarachnoid Hemorrhage ; Zinc Oxide

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