PURPOSE: To evaluate the effectiveness of pelvic arterial embolization (PAE) for intractable postpartum hemorrhage (PPH) after hysterectomy. MATERIALS AND METHODS: From March 2011 to December 2017, 14 patients who received PAE for PPH that persisted after total abdominal hysterectomy were included (mean age, 33.6 years; range, 26–37 years). The delivery type, cause of PPH, and angiographic findings were investigated. The technical and clinical success rates and clinical outcomes were evaluated. RESULTS: Of 14 patients, 8 patients (57%) had positive angiographic findings for bleeding; contrast extravasation (n = 6), and pseudoaneurysm (n = 2). Remnant uterine artery (UA) was the most common bleeding focus (n = 4), followed by vaginal artery (n = 2), left lateral sacral artery (n = 1), and left internal pudendal artery (n = 1). Technical and clinical success rates were 100% and 93% (13/14), respectively. In 1 patient, bleeding was not controlled after initial selective embolization and the entire anterior divisions of both internal iliac arteries were embolized with gelfoam. CONCLUSION PAE for persistent PPH after hysterectomy is a safe and effective treatment. Remnant UA was the most common bleeding site and all patients recovered without any significant sequelae after embolization.

OBJECTIVE: Interhemispheric subdural hematoma (IHSDH) is uncommon, because of their unusual location. However, it is a distinct lesion with its unique characteristics. We investigated clinical features and outcomes of consecutive 42 patients with IHSDH, retrospectively. METHODS: From 2006 to 2015, we treated 105 patients with IHSDH. All patients were diagnosed by computed tomography (CT) or magnetic resonance imaging. We selected 42 patients with thick (3 mm or more) IHSDH. We retrospectively reviewed the clinical and radiological findings, management and outcomes. RESULTS: The male to female ratio was 2:1. Two thirds of the patients were over 60 years old. Slip or fall was the most common cause of trauma. The level of consciousness on admission was Glasgow Coma Scale (GCS) 13 to 15 in 25 patients. The most common symptom was headache. All IHSDH was hyperdense in CT at the time of diagnosis. IHSDH frequently accompanied convexity subdural hematoma. The outcome was favorable in 27 patients, however, six patients were expired. Twenty-two patients were managed conservatively. Surgery was performed in ten patients to remove the concurrent lesion. The outcome was poor in spontaneous one, patients with low GCS, and patients with conservative treatment. CONCLUSION: IHSDH is rare especially the isolated one. The outcome was dependent to the severity of injury. Surgery may be helpful to remove the concurrent mass lesion, however, conservative treatment is generally preferred.
Consciousness ; Craniocerebral Trauma ; Diagnosis ; Female ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Headache ; Hematoma, Subdural* ; Humans ; Magnetic Resonance Imaging ; Male ; Retrospective Studies ; Symptom Assessment

Intracranial dural arteriovenous fistulas (DAVFs) are abnormal arteriovenous connections that lie within the dura. Intraosseous DAVFs involving diploic venous system are extremely rare. A 46-year-old woman presented with headache and right pulsatile tinnitus for three weeks. The tinnitus started after yelling. Digital subtraction angiography revealed DAVF within the basal portion of right parietal bone along the middle meningeal artery (MMA) groove. The fistula was fed by frontal branch of right MMA and drained into right transverse sigmoid sinus junction through dilated middle meningeal vein. The intraosseous DAVF involving diploic vein was successfully obliterated with Onyx embolization via transarterial route.
Angiography, Digital Subtraction ; Central Nervous System Vascular Malformations* ; Colon, Sigmoid ; Female ; Fistula ; Headache ; Humans ; Meningeal Arteries ; Middle Aged ; Parietal Bone ; Tinnitus ; Veins*

Although many patients with infective endocarditis (IE) complain of joint, muscle, and back pain, infections at these sights are rare. The incidence of spinal abscess in cervical spine complicating endocarditis is very rare. Although the surgical management is the mainstay of treatment, conservative treatment can get success in selected patients. We report a patient with cervical epidural abscess due to Streptococcus viridans endocarditis. Both epidural abscess and IE were managed conservatively with intravenous antibiotics for 8 weeks, with recovery. It is important to remind spinal epidural abscess can occur in those patients with bacterial endocarditis.
Abscess ; Anti-Bacterial Agents ; Back Pain ; Endocarditis ; Endocarditis, Bacterial* ; Epidural Abscess* ; Humans ; Incidence ; Joints ; Spine ; Spondylitis ; Viridans Streptococci*

OBJECTIVE: Treatment of intracranial dural arteriovenous fistulas (dAVFs) remains a challenge. However, after introduction of Onyx, transarterial approach is the preferred treatment option in many centers. We report our experience of dAVFs embolization with special emphasis on transarterial approach. METHODS: Seventeen embolization procedures were performed in 13 patients with dAVFs between Jan 2009 and Oct 2014. Clinical symptoms, location and type of fistulas, embolization methods, complications, radiological and clinical outcomes were evaluated using charts and PACS images. RESULTS: All 13 patients had symptomatic lesions. The locations of fistulas were transverse-sigmoid sinus in 6, middle fossa dura in 4, cavernous sinus in 2, and superior sagittal sinus in 1 patient. Cognard types were as follows : I in 4, IIa in 2, IIa+IIb in 5, and IV in 2. Embolization procedures were performed > or =2 times in 3 patients. Nine patients were treated with transarterial Onyx embolization alone. One of these required direct surgical puncture of middle meningeal artery. Complete obliteration of fistulas was achieved in 11/13 (85%) patients. There were no complications except for 1 case of Onyx migration in cavernous dAVF. Modified Rankin scale score at post-operative 3 months were 0 in 11, and 3 in 2 patients. CONCLUSION: Transarterial Onyx embolization can be a first line therapeutic option in patients with dAVFs. However, transvenous approach should be tried first in cavernous sinus dAVF because of the risk of intracranial migration of liquid embolic materials. Furthermore, combined surgical endovascular approach can be considered as a useful option in inaccessible route.
Cavernous Sinus ; Central Nervous System Vascular Malformations* ; Fistula ; Humans ; Meningeal Arteries ; Punctures ; Superior Sagittal Sinus

We report a case of cervical epidural abscess occurring four years after instrumentation. This 70-year-old female patient visited due to sudden right hemiparesis for a week. She had undergone a sublaminar wiring with a rod from the atlas to C4 for unstable C2 and C3 body fracture, about four years ago. On admission, she had neither fever nor febrile episodes. Computed tomography of the cervical spine suggested a protruded wire into the right side of the spinal canal at C3 level. On the operation, there was an epidural abscess by Staphylococcus aureus around the atlas and the axis. After removal of the instrumentation and the lesion, the hemiparesis was resolved. Although it is rare and difficult to diagnose, delayed symptoms in patients who underwent instrumentation arouses suspicion of spinal epidural abscess.
Aged ; Axis, Cervical Vertebra ; Epidural Abscess* ; Female ; Fever ; Humans ; Paresis ; Postoperative Complications ; Spinal Canal ; Spine ; Staphylococcus aureus

Stent assisted coiling (SAC) is a useful technique for the treatment of wide necked complex aneurysm. As the frequency of SAC increases, stent-related complications such as thromboembolism, aneurysm rupture, and vessel rupture have been reported. However, to the best of our knowledge, carotid-cavernous fistula (CCF) after SAC has never been reported. The authors experienced a case of direct CCF after a SAC procedure for treatment of a complex posterior communicating artery (PCoA) aneurysm regrowth, which was treated by clip ligation 12 years before. The patient was managed conservatively and angiograms performed three months after the procedure showed the complete obliteration of the left PcoA aneurysm and the spontaneous disappearance of CCF. Navigation of Solitaire stent lumen with microcatheter can cause unexpected arterial injury, especially when the proximal tip is placed in the curved portion. It seems to be desirable to place the proximal tip of Solitaire stent in the straight portion whenever possible to reduce the risk of inadvertent arterial injury which might be caused by future navigation of stent lumen.
Aneurysm ; Arteries ; Embolization, Therapeutic* ; Fistula* ; Humans ; Iatrogenic Disease ; Intracranial Aneurysm* ; Ligation ; Neck ; Rupture ; Stents* ; Thromboembolism

The waffle-cone technique is a modified stent application technique, which involves protrusion of the distal portion of a stent into an aneurysm fundus to provide neck support for subsequent coiling. The authors report two cases of wide necked basilar bifurcation aneurysms, which were not amenable to stent assisted coiling, that were treated using the waffle-cone technique with a Solitaire AB stent. A 58-year-old woman presented with severe headache. Brain CT showed subarachnoid hemorrhage and angiography demonstrated a ruptured giant basilar bifurcation aneurysm with broad neck, which was treated with a Solitaire AB stent and coils using the waffle-cone technique. The second case involved an 81-year-old man, who presented with dizziness caused by brain stem infarction. Angiography also demonstrated a large basilar bifurcation unruptured aneurysm with broad neck. Solitaire AB stent deployment using the waffle-cone technique, followed by coiling resulted in near complete obliteration of aneurysm. The waffle-cone technique with a Solitaire AB stent can be a useful alternative to conventional stent application when it is difficult to catheterize bilateral posterior cerebral arteries in patients with a wide-necked basilar bifurcation aneurysm.
Aged, 80 and over ; Aneurysm ; Angiography ; Brain ; Brain Stem Infarctions ; Catheters ; Dizziness ; Female ; Headache ; Humans ; Middle Aged ; Neck ; Posterior Cerebral Artery ; Stents ; Subarachnoid Hemorrhage

The waffle-cone technique is a modified stent application technique, which involves protrusion of the distal portion of a stent into an aneurysm fundus to provide neck support for subsequent coiling. The authors report two cases of wide necked basilar bifurcation aneurysms, which were not amenable to stent assisted coiling, that were treated using the waffle-cone technique with a Solitaire AB stent. A 58-year-old woman presented with severe headache. Brain CT showed subarachnoid hemorrhage and angiography demonstrated a ruptured giant basilar bifurcation aneurysm with broad neck, which was treated with a Solitaire AB stent and coils using the waffle-cone technique. The second case involved an 81-year-old man, who presented with dizziness caused by brain stem infarction. Angiography also demonstrated a large basilar bifurcation unruptured aneurysm with broad neck. Solitaire AB stent deployment using the waffle-cone technique, followed by coiling resulted in near complete obliteration of aneurysm. The waffle-cone technique with a Solitaire AB stent can be a useful alternative to conventional stent application when it is difficult to catheterize bilateral posterior cerebral arteries in patients with a wide-necked basilar bifurcation aneurysm.
Aged, 80 and over ; Aneurysm ; Angiography ; Brain ; Brain Stem Infarctions ; Catheters ; Dizziness ; Female ; Headache ; Humans ; Middle Aged ; Neck ; Posterior Cerebral Artery ; Stents ; Subarachnoid Hemorrhage

Fractures in ankylosing spondylitis (AS) are often difficult to identify and treat. If combined with osteoporosis, the spine becomes weaker and vulnerable to minor trauma. An 83-year-old woman with a history of chronic AS and severe osteoporosis developed paraparesis and voiding difficulty for 4 days prior. She had been placed in the lateral decubitus position in a bedridden state in a convalescent hospital due to the progressive paraparesis. The laboratory findings showed CO₂ retention in the arterial blood gas analysis. After the patient was transferred to the computed tomography (CT) room, a CT was taken in the supine position. Approximately half an hour later, the resident in our neurosurgical department checked on her, and the neurological examination showed a complete paraplegic state. She was treated conservatively and finally expired 20 days later.
Aged, 80 and over ; Blood Gas Analysis ; Female ; Hospitals, Convalescent ; Humans ; Neurologic Examination ; Osteoporosis ; Paraparesis ; Spinal Fractures* ; Spine ; Spondylitis, Ankylosing* ; Supine Position