A fenestrated middle cerebral artery (MCA) is a rare congenital anomaly, and is related to interference in the normal embryonic development of the MCA. Fenestrated MCA has been regarded to have no clinical significance other than a rare event of hemorrhage from associated aneurysm. However, the fenestration within the arterial trunk can be an obstacle against thrombus migration and may be associated with a major cerebral infarction. Moreover, the presence of this anomaly can be hardly detected prior to thrombolytic procedures, and emergent treatments are proceeded without any information of anatomical configurations. Therefore, the recanalization procedures would carry a high risk of intraprocedural complications. We report a rare case of MCA territory infarction from occlusion of fenestrated M1 segment, and also introduce a safe method of mechanical thrombolysis using coil.
Aneurysm ; Cerebral Infarction ; Embryonic Development ; Female ; Hemorrhage ; Infarction ; Mechanical Thrombolysis ; Middle Cerebral Artery ; Pregnancy ; Thrombosis

Rapid reduction of a large acute subdural hematoma has been frequently reported. In my knowledge, however, it was rarely reported that rapid spontaneous reduction occurred in large volume of spontaneous intracerebral hematoma (sICH). We describe a patient with a rapid spontaneous decrease in the volume of a large hematoma. A 73-year-old man presented semi-comatose mentality. Initial brain computed tomography (CT) revealed the huge sICH. An emergency operation was planned, but was not performed due to the refusal of patient's family. Therefore, we decided to treat with conservative therapy. However, follow-up brain CT 16 hours after initial scan showed a remarkable reduction of previous sICH. The mechanism involving the spontaneous rapid decrease of the hematoma is presumed to occur through redistribution in brain atrophy, compression effect from the increased intracranial pressure and dilution through a wash out by the cerebrospinal fluid.
Aged ; Atrophy ; Brain ; Disulfiram ; Emergencies ; Follow-Up Studies ; Hematoma ; Hematoma, Subdural, Acute ; Humans ; Intracranial Pressure

The blood blister-like aneurysm (BBA) of the internal carotid artery (ICA) is a rare but clinically important cause of subarachnoid hemorrhage (SAH), which accounts for 0.5% of incidences of ruptured intracranial aneurysms. BBA is a thin-walled, broad-based aneurysm that lacks an identifiable neck and is one of the most difficult lesions to treat. In this paper, a case is presented of a 57-year-old woman with SAH. Her cerebral angiography demonstrated a small BBA on the dorsal wall of her right ICA. Endovascular treatment that consisted of a stent-within-a-stent was attempted, but the replacement of the second stent failed, and the aneurysm became bigger. Surgery was performed by clipping the BBA with a Sundt slim-line encircling graft clip. The patient completely recovered with no complications. This treatment may be a salvageable option for BBA, especially when endovascular treatment has failed.
Aneurysm ; Carotid Artery, Internal ; Cerebral Angiography ; Endovascular Procedures ; Female ; Humans ; Incidence ; Intracranial Aneurysm ; Middle Aged ; Neck ; Stents ; Subarachnoid Hemorrhage ; Transplants

Endovascular treatment has been increasingly performed for unruptured intracerebral aneurysms. However, thromboembolic complications, which develop mostly within 48 hours after the procedure, are the most common and major complications of endovascular treatment. We present a rare case of delayed symptomatic thromboembolism in an ischemic stroke patient who had undergone coil embolization for unruptured middle cerebral artery (MCA) aneurysm.
Aneurysm ; Humans ; Intracranial Aneurysm ; Middle Cerebral Artery ; Stroke ; Thromboembolism

OBJECTIVE: Many previous studies have shown that electrocardiographic (ECG) changes occur patients with subarachnoid hemorrhage (SAH). This study was designed to identify the frequency, influencing factors, and outcome of clinically significant cardiac arrhythmias after SAH. METHODS: We retrospectively analyzed clinical data of 122 patients including ECG finding, age, sex, the Hunt-Hess grade, the Fisher's grade, the history of hypertension, peak blood pressure and heart rate, location of aneurysm, Glasgow Outcome Scale (GOS) score, the days of admission to the intensive care unit, the presence of symptomatic vasospasm. RESULTS: Of 122 SAH patients, 50% (n = 61) had a verified clinically significant arrhythmia. There were no statistically significant independent factors associated with clinically significant arrhythmia in multivariate analysis. Although adjustments for the effects of age, Hunt-Hess grade, and the presence of symptomatic vasospasm on death were made, clinically significant arrhythmias were still independently predictive of death (no arrhythmia versus arrhythmia, 11.5% versus 27.9%, adjusted odds ratio [OR] 3.524, 95% confidence interval [CI] 1.229-10.100, p = 0.019) and poor outcome (GOS < or = 2, 13.1% versus 29.5%, adjusted OR 3.202, 95% CI 1.174-8.732, p= 0.023). CONCLUSION: Clinically significant arrhythmias after SAH are associated with a high mortality rate, and serious cardiac and neurological comorbidity. Patients with an abnormal ECG on admission should undergo close cardiac monitoring, and the presence of rhythm disturbances should prompt aggressive measures to treat myocardial infarction (MI), maintain a normal cardiac rhythm, and minimize the presence of autonomic stress.
Aneurysm ; Arrhythmias, Cardiac ; Blood Pressure ; Comorbidity ; Electrocardiography ; Glasgow Outcome Scale ; Heart Rate ; Humans ; Hypertension ; Intensive Care Units ; Multivariate Analysis ; Myocardial Infarction ; Odds Ratio ; Retrospective Studies ; Subarachnoid Hemorrhage

OBJECTIVE: The purpose of the study is to determine the effectiveness and safety of nicardipine infusion for controlling blood pressure in patients with subarachnoid hemorrhage (SAH). METHODS: We prospectively evaluated 52 patients with SAH and treated with nicardipine infusion for blood pressure control in a 29 months period. The mean blood pressure of pre-injection, bolus injection and continuous injection period were compared. This study evaluated the effectiveness of nicardipine for each Fisher grade, for different dose of continuous nicardipine infusion, and for the subgroups of systolic blood pressure. RESULTS: The blood pressure measurement showed that the mean systolic blood pressure / diastolic blood pressure (SBP/DBP) in continuous injection period (120.9/63.0 mmHg) was significantly lower than pre-injection period (145.6/80.3 mmHg) and bolus injection period (134.2/71.3 mmHg), and these were statistically significant (p < 0.001). In each subgroups of Fisher grade and different dose, SBP/DBP also decreased after the use of nicardipine. These were statistically significant (p < 0.05), but there was no significant difference in effectiveness between subgroups (p > 0.05). Furthermore, controlling blood pressure was more effective when injecting higher dose of nicardipine in higher SBP group rather than injecting lower dose in lower SBP group, and it also was statistically significant (p < 0.05). During the infusion, hypotension and cardiogenic problems were transiently combined in five cases. However, patients recovered without any complications. CONCLUSION: Nicardipine is an effective and safe agent for controlling acutely elevated blood pressure after SAH. A more systemic study with larger patients population will provide significant results and will bring solid evidence on effectiveness of nicardipine in SAH.
Aneurysm ; Blood Pressure ; Humans ; Hypertension ; Hypotension ; Nicardipine ; Prospective Studies ; Subarachnoid Hemorrhage

OBJECTIVE: To perform a comparative study between two groups of populations, titanium (T) group versus stainless steel (S) group, who were clipped with titanium and stainless steel materials, respectively, the incidence of regrowth from the original aneurysms, the clip slippage, and post-clipping seizure attack were analyzed. The patients were followed more than 5 years after microsurgical cerebral aneurysms clipping. METHODS: Data from 1986 through 2008 were extensively reviewed on a consecutive series of 3,770 patients who referred for ruptured/unruptured cerebral aneurysms. Forty-seven patients in the S group and 48 in the T group who met inclusion criteria, were selected for this study. RESULTS: The incidence of regrowth were noted that two out of total 47 patients (4.3%) in the S group, and none in the T group. The clip slippage was not observed in both groups. And there was no statistical difference (p = 0.242) in terms of regrowth between two groups. Seven out of 47 cases (14.9%) developed post-clipping seizure in the S group. On the other hand, two (4.2%) of 48 patients presented the symptom in the T group. Also, there was no significant difference (p = 0.091) between two groups. CONCLUSIONS: The metallic types of clip employed for the microsurgical cerebral aneurysm clipping does not have any significant clinical outcome differences in this study.
Aneurysm ; Hand ; Humans ; Incidence ; Intracranial Aneurysm ; Seizures ; Stainless Steel ; Titanium

OBJECTIVE: The objectives of the present study were to investigate the annual detection rate of patients with Moyamoya disease (MMD) and to describe the prevalence and epidemiological features of the Moyamoya patients in Korea. MATERIALS AND METHODS: The authors analyzed the epidemiological data of Korean patients taken from the National Health Insurance Corporation in Korea among Moyamoya patients who were treated from 2004 until 2008. RESULTS: Based on 2004 data, 2,539 MMD patients were treated in Korea and the prevalence rate was 5.2 per 100,000 people. There were 2,987 in 2005, 3,429 in 2006, 4,051 in 2007, and 4,517 cases in 2008, and the prevalence rates per 100.000 people were 6.3, 7.0, 8.6, and 9.1, for those respective years. This represents an annual increase of 15% of new cases during this period. In 2008, 466 people were newly diagnosed with MMD, representing an incidence rate of 1 per 100,000 persons. The gender ratio was 1,547 men (34%) and 2,970 women (66%). Women had a higher incidence rate than men (1.94 times). There were two age peaks: teenagers and those in their forties. CONCLUSION: The present study shows that the number of Moyamoya patients in Korea is increasing. This increase could partly be explained by a recent increase in newly diagnosed cases, suggesting that a more careful consideration of the disease and better diagnostic techniques should be promoted among clinicians.
Adolescent ; Female ; Humans ; Incidence ; Korea ; Male ; Moyamoya Disease ; National Health Programs ; Prevalence

OBJECTIVE: Malignant middle cerebral artery (MCA) infarction occurs in 10% of all ischemic strokes and these severe strokes are associated with high mortality rates. Recent clinical trials demonstrated that early decompressive craniectomy reduce mortality rates and improves functional outcomes in healthy young patients (less than 61 years of age) with a malignant infarction. The purpose of this study was to assess the efficacy of decompressive craniectomy in elderly patients (older than 70 years of age) with a malignant MCA infarction. METHODS: Between February 2008 and October 2011, 131 patients were diagnosed with malignant MCA infarctions. We divided these patients into two groups: patients who underwent decompressive craniectomy (n = 58) and those who underwent conservative care (n = 73). A cut-off point of 70 years of age was set, and the study population was segregated into those who fell above or below this point. Mortality rates and functional outcome scores were assessed, and a modified Rankin Scale (mRS) score of > 3 was considered to represent a poor outcome. RESULTS: Mortality rates were significantly lower at 29.3% (one-month mortality rate) and 48.3% (six-month mortality rate) in the craniectomy group as compared to 58.9% and 71.2%, respectively, in the conservative care group (p < 0.001, p = 0.007). Age (> or =70 years vs. < 70 years) did not statistically differ between groups for the six-month mortality rate (p = 0.137). However, the pre-operative National Institutes of Health Stroke Scale (NIHSS) score did contribute to the six-month mortality rate (p = 0.047). CONCLUSION: Decompressive craniectomy is effective for patients with a malignant MCA infarction regardless of their age. Therefore, factors other than age should be considered and the treatment should be individualized in elderly patients with malignant infarctions.
Aged ; Cerebral Infarction ; Decompressive Craniectomy ; Humans ; Infarction ; Infarction, Middle Cerebral Artery ; Middle Cerebral Artery ; National Institutes of Health (U.S.) ; Stroke

Migration of coils during endovascular procedures is a rare, but well-known complication. We are reporting two cases of successfully retrieving migrated coil using detachable intracranial stent. In both of our cases there was distal migration of coil during the intracranial aneurysm coiling procedure. The Solitaire® AB stent (Covidien, Irvine, CA, USA) was used to retrieve those coils. The stent was passed distal to the migrated coil using standard technique. It was then partially deployed and gradually withdrawn along with the entangled coil. Coil retrieval using the fully retrievable intracranial stent is a very simple, safe and easily available alternative for retrieval of distally migrated coil.
Embolization, Therapeutic* ; Endovascular Procedures ; Intracranial Aneurysm* ; Stents*