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*

OBJECTIVE: The aim of this study was to compare the efficacy of indirect and combined bypass surgery for treatment of adult moyamoya disease (MMD). The definition of combined bypass surgery is a combination of superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis and indirect anastomosis. Development of collateral circulation after surgery was investigated. METHODS: Forty three patients (58 hemispheres) with MMD were followed by cerebral angiography for at least six months after surgery, between May 2002 and July 2011. Indirect and combined revascularization surgeries were performed in 33 and 25 cases, respectively. Good outcome was defined as more than group B, in accordance with the method suggested by Matsushima. RESULTS: Development of collateral circulation was not affected by sex (p = 0.493), clinical features (p = 0.206), or Suzuki stage (p = 0.428). Based on postoperative cerebral angiography, the combined bypass surgery group showed a better angiographic outcome, than the encephaloduroarteriomyosynangiosis (EDAMS) group (p = 0.100, odds ratio [OR] 4.107, 95% confidence interval [CI] 0.700 - 24.096). The combined bypass group showed a better response than the encephaloduroarteriogaleosynangiosis (EDAGS) group (p = 0.088, OR 4.600, 95% CI 0.721 - 29.332). Similar responses were observed for EDAGS and EDAMS (p = 0.886, OR 1.120, 95% CI 0.239 - 5.251). The combined bypass group showed a better response than the indirect group (p = 0.064, OR 4.313, 95% CI 0.840 - 22.130). CONCLUSION: Results of this study demonstrate that combined bypass results in better revascularization on angiographic evaluation in adult MMD. Therefore, among surgical procedures, combined bypass is a choice that can be recommended.
Adult ; Cerebral Angiography ; Cerebral Arteries ; Cerebral Revascularization ; Collateral Circulation ; Humans ; Moyamoya Disease ; Odds Ratio

INTRODUCTION: Patients with negative initial digital subtraction angiography (DSA) are at significant risk for re-bleeding, which can lead to severe disability and death. The purpose of this study was to evaluate the necessity of repeat DSA in subgroups of patients with subarachnoid hemorrhage (SAH) with negative initial DSA. METHODS: A total of 904 spontaneous SAH patients were admitted to our department between May 2005 and May 2012. Twenty eight patients were selected for inclusion in this study because repeated DSA performed due to the etiology of the SAH could not be demonstrated on the initial DSA. According to the SAH pattern on initial computed tomography scans, patients were divided into perimesencephalic nonaneurysmal SAH (PN-SAH) and non PN-SAH (NPN-SAH) groups. Repeat DSA was performed in all patients, and two of these patients underwent a third DSA. RESULTS: Of the 904 patients, 28 patients (3.1%) had no vascular abnormality on initial DSA. Sixteen PN-SAH patients underwent a repeat DSA; however, no aneurysms were found. In contrast, 12 patients with NPN-SAH underwent repeat DSA, with detection of two cerebral aneurysms. Overall, the false-negative rate of the initial DSA was 7.1% (2/28 patients). No significant differences in false-negative results on initial DSA were observed between the PN-SAH and NPN-SAH groups. CONCLUSION: In the line with the results of the current study, we should be highly suspicious of patients with a nonaneurysmal SAH, especially those with a NPN-SAH pattern. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.
Aneurysm ; Angiography, Digital Subtraction ; Diagnostic Errors ; Humans ; Intracranial Aneurysm ; Subarachnoid Hemorrhage

OBJECTIVE: A self-expanding retrievable intracranial stent, such as Solitaire AB, is useful for mechanical thrombectomy, producing novel results in the treatment of acute ischemic stroke. On the other hand, difficult situations can arise after a thrombectomy when using as in first-line treatment. METHODS: This was a retrospective, single-center study of 23 patients with an acute ischemic stroke attributable to a large artery occlusion within the first eight hours from symptom onset. The occlusion sites were the T segment in five patients, proximal middle cerebral artery in six patients, distal middle cerebral artery in three patients, vertebral and/or basilar artery in five patients, proximal internal cerebral artery in one patient and tandem in three patients. All patients underwent a mechanical thrombectomy using the Solitaire(TM) stent system as the first-line treatment but required additional procedures due to the unsatisfactory results of a thrombectomy. RESULTS: Only six patients achieved complete recanalization by a thrombectomy using the Solitaire. Permanent stent deployment after the thrombectomy was performed in ten patients. Stent and balloon angioplasty was performed after a stent-based thrombectomy in six patients. Balloon angioplasty after thrombectomy was performed in one patient. CONCLUSION: Mechanical thrombectomy with the Solitaire(TM) stent as a first-line treatment can produce unfortunate results that will require additional procedures.
Angioplasty, Balloon ; Arteries ; Atherosclerosis ; Basilar Artery ; Cerebral Arteries ; Hand ; Humans ; Middle Cerebral Artery ; Retrospective Studies ; Stents ; Stroke ; Thrombectomy