No abstract available.
Absorption* ; Cerebral Angiography ; Embolism, Air

An 8-month old female presented with spontaneous subarachnoid hemorrhage and was treated successfully with endovascular coil embolization of the ruptured aneurysm. Transcranial Doppler ultrasound performed four days later demonstrated middle cerebral artery (MCA) velocities greater than 350 cm/sec on the right and greater than 200 cm/sec on the left, despite medical management. The patient demonstrated no focal neurological deficits, though examination was limited by our patient's sedation and intubation. Angiography revealed severe vasospasm of the supraclinoid internal carotid and MCA territories, bilaterally. The vasospasm was refractory to the administration of intra-arterial verapamil. Balloon angioplasty was attempted, but the device could not be advanced safely due to the small size of the patient's vessels and the stiffness of the device. A microcatheter (0.0165" diameter) was advanced over a J-shaped soft microwire (0.014" diameter) to perform mechanical angioplasty in the internal carotid artery and MCA vessels bilaterally. Dramatic improvement was seen angiographically and on transcranial Doppler, and no complications were seen.
Aneurysm ; Aneurysm, Ruptured ; Angiography ; Angioplasty ; Angioplasty, Balloon ; Carotid Artery, Internal ; Embolization, Therapeutic ; Female ; Humans ; Infant* ; Intubation ; Middle Cerebral Artery ; Subarachnoid Hemorrhage ; Ultrasonography ; Vasospasm, Intracranial* ; Verapamil

Preoperative evaluation of precise aneurysmal geometry is important for the treatment of intracranial aneurysms. We present two cases of unclippable side wall aneurysms due to their extremely low dome height, which appeared as saccular in the preoperative image because of a comparatively narrow atherosclerotic parent arterial lumen. In both cases, a calcified vessel wall was noted preoperatively. Lack of a definitive neck and abrupt discrepancy between the fragile aneurysmal wall and the atherosclerotic parent arterial wall was confirmed intraoperatively in both cases. This study describes an illustrative mechanism for the finding with emphasis on the importance of its preoperative diagnosis. Intracranial atherosclerosis associated with small side walled aneurysms may lead to overestimation of aneurysm height on preoperative imaging of the intravascular compartment.
Aneurysm* ; Angiography* ; Arteries* ; Atherosclerosis ; Diagnosis ; Humans ; Intracranial Aneurysm ; Intracranial Arteriosclerosis ; Neck ; Parents*

OBJECTIVE: The aim of this study was to evaluate the characteristics of ruptured aneurysms at anterior communicating artery (A com) with an analysis of clinical and morphological data, which could further our understanding of the risks of ruptured A com aneurysms. MATERIALS AND METHODS: An analysis of data with 86 ruptured and 44 unruptured A com aneurysms were analyzed using a digital subtraction angiography or 3-dimensional computed tomography angiography between January 2010 and December 2015 in a single center. RESULTS: Fifty-five percent of ruptured A com aneurysms were smaller than 4 mm in size. They had a smooth wall (44%), with a mean size ratio of 4.22 (range: 0.7-14.3) and mean height/width ratio of 1.48 (range: 0.5-2.9); 23 patients of A1 positive difference. Unruptured aneurysms were mostly 2-10 mm in size (94%) and had an irregular wall (43%), with a mean size ratio of 4.1 (range: 0.8-9.1) and mean height/width ratio of 1.2 (range: 0.1-2.6); 6 patients of A1 positive difference. In terms of the morphology of aneurysms, size of A com, maximum aneurysm size, neck width, aneurysm wall morphology, and size ratio were not different with statistical significance. However, dominance of A1 (p = 0.01) and height/width ratio (p = 0.03) were found to be a significant predictive factor for rupture of A com aneurysms. CONCLUSION: To better understand the rupture risk of A com aneurysms, a large, multicenter, collaborative, and prospective study should be performed in the future.
Aneurysm* ; Aneurysm, Ruptured ; Angiography ; Angiography, Digital Subtraction ; Anterior Cerebral Artery ; Arteries* ; Humans ; Intracranial Aneurysm ; Neck ; Prospective Studies ; Risk Factors ; Rupture*

OBJECTIVE: Surgical resection of thalamic and brainstem cerebral cavernous malformations (CCMs) is associated with significant operative morbidity, but it may be outweighed, in some cases, by the neurological damage from recurrent hemorrhage in these eloquent areas. The goals of this retrospective cohort study are to describe the technical nuances of surgical approaches and determine the postoperative outcomes for CCMs of the thalamus and brainstem. MATERIALS AND METHODS: We reviewed an institutional database of patients harboring thalamic or brainstem CCMs, who underwent surgical resection from 2010 to 2014. The baseline and follow-up neuroimaging and clinical findings of each patient and the operative details of each case were evaluated. RESULTS: A total of eight patients, including two with thalamic and six with brainstem CCMs, were included in the study cohort. All patients had progressive neurological deterioration from recurrent CCM hemorrhage, and the median modified Rankin Scale (mRS) at presentation was 3. The median CCM maximum diameter and volume were 1.7 cm and 1.8 cm³, respectively. The thalamic CCMs were resected using the anterior transcallosal transchoroidal and supracerebellar infratentorial approaches each in one case (13%). The brainstem CCMs were resected using the retrosigmoid and suboccipital trans-cerebellomedullary fissure approaches each in three cases (38%). After a median follow-up of 11.5 months, all patients were neurologically stable or improved, with a median mRS of 2. The rate of functional independence (mRS 0-2) was 63%. CONCLUSION: Microneurosurgical techniques and approaches can be safely and effectively employed for the management of thalamic and brainstem CCMs in appropriately selected patients.
Brain Stem* ; Cohort Studies ; Follow-Up Studies ; Hemangioma, Cavernous, Central Nervous System* ; Hemorrhage ; Humans ; Intracranial Hemorrhages ; Microsurgery ; Neuroimaging ; Retrospective Studies ; Thalamus* ; Vascular Malformations

OBJECTIVE: Angioplasty and Stenting of intracranial atherosclerotic lesions have a higher complication rate and a large proportion of this is attributable to side branch arterial occlusion from forceful displacement of the atheroma into the ostia or snowplowing effect. This can result in severe disabilities when it result in small infarcts involving eloquent areas in the posterior circulation or the motor tracts. MATERIALS AND METHODS: We present a series of 6 cases utilizing a new dual catheter technique for maintaining the patency of at-risk vessels during angioplasty and stenting. There are several methods previously described to help reduce the incidence of stroke but because they do not have a physical presence in the ostia to protect it, they are unable to guarantee the patency of the vessel. RESULTS: All 6 patients underwent angioplasty and stenting with the technique. The patients were assessed for complications with post-procedure magnetic resonance imaging and no complications were found. CONCLUSION: In this preliminary series, the dual catheter technique appears to safe and effective in preventing occlusion of the adjacent branch arteries. This technique may facilitate the use of the Wingspan stent in the treatment of intracranial atherosclerotic stenotic segments by reducing the risk of peri-procedural stroke.
Angioplasty* ; Arteries ; Catheters* ; Humans ; Incidence ; Magnetic Resonance Imaging ; Plaque, Atherosclerotic ; Stents* ; Stroke

OBJECTIVE: Ruptured middle cerebral artery (MCA) aneurysm with intrasylvian hematoma usually accompanied by progressive cerebral swelling with poorer outcomes. The authors present characteristics and importance of intrasylvian hematoma removal in the aneurysm surgery. MATERIALS AND METHODS: From 2012 February to 2014 March, 24 aneurysm surgeries for ruptured MCA aneurysms with intrasylvian hematoma were performed in the authors' clinic. The patients were classified according to three groups. Group A included patients who underwent decompressive craniectomy within a few days after aneurysm surgery due to progressive cerebral swelling, group B included patients for whom decompression was not necessary, and group C included patients who showed severe cerebral swelling on admission and decompressive craniectomy and aneurysm surgery in one stage. RESULTS: The mean hematoma volume on admission was 28.56 mL, 24.96 mL, and 66.78 mL for groups A, B and C, respectively. Removal of a larger amount of hematoma was observed on postoperative computerized tomography scan in groups B and C (63.2% and 59.0%) compared with group A (33.4%). Although no statistical difference was found between group A and group B (p = 0.115), it tends to show the lesser amount of hematoma removed, the more likely cerebral swelling will progress. CONCLUSION: The lesser amount of hematoma in ruptured MCA aneurysm with intrasylvian hematoma tends to show benign clinical course than larger amounts. But, even if the hematoma is not easily removed in the operation, we suggest the other procedures such as continuous external catheter drainage of hematoma to avoid unnecessary coagulation or brain retraction.
Aneurysm ; Brain ; Catheters ; Decompression ; Decompressive Craniectomy ; Drainage ; Hematoma* ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery*

Intracranial dissections commonly present as ischemic stroke and as hemorrhagic stroke. In general, while either ischemic stroke or hemorrhagic stroke may develop, the simultaneous onset of both may also occasionally occur. In this report, we present a case of simultaneous development of ischemic stroke and hemorrhagic stroke due to an intracranial artery dissection.
Aneurysm, Dissecting ; Arteries* ; Carotid Artery, Internal ; Stroke*

Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.
Aneurysm ; Arteries ; Embolization, Therapeutic* ; Emergencies ; Follow-Up Studies ; Humans ; Infarction, Middle Cerebral Artery* ; Jeollabuk-do ; Middle Aged ; Middle Cerebral Artery ; Neck ; Neurosurgical Procedures ; Parents ; Specialization ; Thromboembolism ; Thrombosis

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.
Angioplasty* ; Arteries ; Compensation and Redress ; Constriction, Pathologic* ; Embolism ; Follow-Up Studies* ; Hemodynamics ; Humans ; Ischemia ; Risk Factors ; Stroke ; Vertebral Artery*