OBJECTIVE: The purpose of this study is to compare the incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm in elderly patients following intracranial aneurysm rupture with those of younger patients. METHODS: We retrospectively reviewed the medical records of 189 patients who were treated with open surgery between May 1994 and December 2000. They were divided into two groups; elderly (> or =60 yrs) and younger (< or =59 yrs) group. Incidence of shunt-dependent chronic hydrocephalus and symptomatic vasospasm was analysed in each group during 6 months after surgery. RESULTS: Shunt-dependent chronic hydrocephalus has developed more frequently in the elderly group (27.8%) than in the younger group (7.3%). Incidence of symptomatic vasospasm was not significantly different between two groups, even though poor grade patients were more represented in the elderly group. CONCLUSION: Meticulous clinical long-term follow-up is needed to detect shunt-dependent chronic hydrocephalus as early as possble in the elderly patients with operated ruptured intracranial aneurysms and in that case, shunt operation should be undertaken.
Aged* ; Follow-Up Studies ; Humans ; Hydrocephalus* ; Incidence ; Intracranial Aneurysm* ; Medical Records ; Retrospective Studies ; Rupture

Percutaneous balloon angioplasty has been reported to be useful in the treatment of intracranial atherosclerotic arterial stenosis. However, arterial dissection with increased risk of acute closure and stroke has limited its widespread implementation. Stenting of the intracranial vasculature recently has been shown to be feasible in a variety of circumstance. However, stenting of middle cerebral artery has been limited because of difficulty with tracking stents across the carotid siphon. We report a case of successful percutaneous stenting of a symptomatic middle cerebral artery stenosis using a balloon-expandible flexible coronary stent.
Angioplasty ; Angioplasty, Balloon ; Constriction, Pathologic* ; Middle Cerebral Artery* ; Stents* ; Stroke

Microsurgical neck clipping has been believed to be the most reliable treatment for the intracranial aneurysm. However, recurrence or regrowth from so called "completely clipped aneurysm" with catastrophic outcome has been infrequently reported. We describe an unusual case of regrowth of posterior communicating artery aneurysm which was found 13 years after the first successful clipping at the same site. Surgeons should pay attention to the possibility of such a regrowth even though the initial clipping seemed to be perfect. Additional deliberate postoperative angiography might resolve this late consequence.
Aneurysm ; Angiography ; Intracranial Aneurysm* ; Neck ; Recurrence

OBJECT: It is reported that spontaneous subcortical intracerebral hemorrhage consists about 10 to 44% of spontaneous intracerebral hemorrhage. Recently, spontaneous subcortical intracerebral hemorrhage due to the complication of the systemic disease has been increasing, and the selection of management strategy according to the cause of hemorrhage closely affected the management outcome. This study was designed to analyze the cause of spontaneous subcortical intracerebral hemorrhage and the outcome in order to establish the appropriate management strategy. SUBJECT: One hundred and seventy-nine cases of spontaneous subcortical intracerebral hemorrhage managed at Yonsei University Hospital from January 1998 to December 2000 were included in this study. Patients who suffered from subcortical intracerebral hemorrhage due to the ruptured intracranial aneurysm were excluded. The patient's sex, age, mental state on admission, neurologic condition, past history, systemic disease related to hemorrhage, location of hemorrhage, the diagnosis of intracranial or systemic disease, treatment methods, and clinical outcome were analyzed. Consciousness on admission was evaluated and scored based on Glasgow Coma Eye Motor Scale (GCEMS), which was the sum of eye response score and motor response score of the Glasgow Coma Scale. Patients were categorized into 4 groups according to GCEMS: Group 1 (10 points), Group 2 (8, 9 points), Group 3 (5-7 points), and Group 4 (2-4 points). The clinical outcome of the patient was evaluated based on Glasgow outcome scale (GOS). Differences in diagnostic procedure were present depending on the condition of the patients, thus the final diagnostic procedure was used to diagnose the reason behind bleeding. When accurate diagnosis was difficult to perform, the reasons with the highest likelihood were chosen. RESULTS: The patients corresponding to each group were as follow: 79 (44.1%) in Group 1, 35 (19.6%) in Group 2, 27 (15.1%) in Group 3, and 38 (21.2%) in Group 4. Fifty-five patients (30.7%) were hypertensive intracerebral hemorrhage, 45 patients (25.1%) had anticoagulant therapy and thrombocytopenia due to the systemic disease and bleeding diathesis after anticancer drug therapy, 23 patients (12.8%) had brain tumor including the metastatic tumor, 19 patients (10.6%) had arteriovenous malformation, 18 patients (10.1%) had postinfarct hemorrhages, 5 patients (2.8%) had infective endocarditis, 2 patients (1.1%) had cerebral vasculitis. Conservative treatment was done in 115 patients (64.2%), open craniotomy in 31 patients (17.3%), and catheter insertion in 33 patients (18.4%). Group 1 mainly had conservative treatment (58 patients, 73.4%), Group 2 and 3 had 12 patients (37.1%) and 16 patients (59.3%) each underwent open craniotomy respectively. In Group 4, conservative treatment was done for 24 patients (63.2%), and open craniotomy was done for only one patients among 14 patients treated surgically. Overall clinical outcome was: 77 patients (43.0%) in GOS 5, 21 (11.7%) in GOS 4, 14 (7.8%) in GOS 3, 11 (6.1%) in GOS 2, and 56 patients (31.3%) died. Poor neurological state (low GCEMS) on admission was closely related to mortality (Group 1, 7.6%; Group 2, 22.8%; Group 3, 45.0%; Group 4, 78.9%). CONCLUSION: The major causes of spontaneous subcortical intracerebral hemorrhage were hypertension, metastatic brain tumor, vascular malformation, and the bleeding tendency due to the systemic disease, complication of the anticancer drug, anticoagulant, and thrombolytics therapy. Conservative treatment could be considered for the patients with GCEMS 10, removal of hematoma by open craniotomy or catheter insertion for the patients with GCEMS 5-9, and the catheter insertion or deferring the active treatment could be considered for the patients with GCEMS 2-4.
Arteriovenous Malformations ; Brain Neoplasms ; Catheters ; Cerebral Hemorrhage* ; Coma ; Consciousness ; Craniotomy ; Diagnosis ; Disease Susceptibility ; Drug Therapy ; Endocarditis ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Hematoma ; Hemorrhage ; Humans ; Hypertension ; Intracranial Aneurysm ; Intracranial Hemorrhage, Hypertensive ; Mortality ; Thrombocytopenia ; Vascular Malformations ; Vasculitis, Central Nervous System

OBJECTIVE: The purpose of this study is to investigate changes of vasoreactivity after STA-MCA anastomosis in patients who develop hemodynamic cerebral ischemia associated with ICA or MCA occlusion. METHODS: Twenty-five patients with hemodyamic infarction due to symptomatic ICA or MCA occlusion were treated with extracranial-intracranial bypass surgery (EIAB). Of these, we enrolled 17 patients who underwent follow-up SPECT and follow-up angiogram. To test vasomotor reactivity, we measured relative regional cerebral blood flow (rrCBF) with SPECT both at rest and after diamox infusion. rrCBF were calculated using the following equation: (lesional radioactivity/contralateral radioactivity) x100. We performed EIAB in patients with impaired vasomotor reactivity. To evaluate changes in vasomotor reactivity after surgery, follow-up brain SPECT was performed 1-6 months after surgery and compared rrCBF before and after surgery. RESULTS: Base line radioactivity ratios did not change after surgery. These ratios after diamox challenge were 59.8+/-4.2%, however, 1-6 months after surgery, ratios increased to 77.7+/-.6% (p<0.05, Paired T-test). Preoperative degree of angiographic collateral circulation did not influence the restoration of vasoreactivity. All but two patients showed good collateral circulation through the bypass. There were no cerebral accidents in any these patients at 6 months to 2 years follow-up. CONCLUSION: These results demonstrate the restoration of vasomotor reactivity distal to the occluded ICA or MCA after EIAB, and also show that measurement of rrCBF using SPECT are useful indicators of the clinical and hemodynamic improvement.
Acetazolamide ; Brain ; Brain Ischemia ; Collateral Circulation ; Follow-Up Studies ; Hemodynamics ; Humans ; Infarction ; Radioactivity ; Tomography, Emission-Computed, Single-Photon

OBJECTIVE: This study was to define clinical characteristics and formulate the management strategies of the patients with posterior cerebral artery (PCA) aneurysms. PATIENTS AND METHOD: The authors reviewed the database and imaging studies as sources for identification and analysis. During the past 14 years, 16 consecutive patients with PCA aneurysms were treated either by surgery or neurointervention. RESULTS: Ten patients had ruptured PCA aneurysms: 4 patients were Hunt and Hess Grade I, 1 Grade II, 4 Grade III, and 1 Grade IV. Six patients had unruptured PCA aneurysms: one patient was Grade 1, and the other patient was Grade IV due to ruptured multiple aneurysms. Seven aneurysms were small, 9 (56.2%) were large or giant. Thirteen aneurysms were saccular, 2 were fusiform, and 1 was serpentine. Seven of the 16 patients (43.7%) had multiple aneurysms. Pterional (8) or subtemporal (5) approach was done in 13 patients. The obliteration methods of the aneurysms were neck clipping in 10 patients, and trapping in 3 patients. Endovascular treatment was performed in 3 patients. Five patients showed transient oculomotor nerve palsy and contralateral hemiparesis after the surgery. Persisting oculomotor nerve palsy occurred in one patient. All patients showed favorable outcome (food recovery 14, moderate disability 2). CONCLUSIONS: As a result, PCA aneurysms were characterized by high frequency of non - saccular shape, large or giant size with mass effect, and multiple aneurysms. Surgical treatment was necessary for large or giant aneurysm of the distal PCA to decompress midbrain. Wrapping and clipping technique were useful for treatment of fusiform aneurysms. Although ultimate management outcome of the patients with PCA aneurysms were better than the patients with aneurysms of the other location, intra-aneurysmal treatment with Guglielmi detachable coil would be useful for the proximal PCA aneurysms to avoid surgical injury of the P1 perforator or the oculomotor nerve.
Aneurysm ; Humans ; Intracranial Aneurysm* ; Intraoperative Complications ; Mesencephalon ; Neck ; Oculomotor Nerve ; Oculomotor Nerve Diseases ; Paresis ; Passive Cutaneous Anaphylaxis ; Posterior Cerebral Artery*

OBJECTIVES: The aim of this investigation is to provide the strategy of management and to improve the outcomes of elderly patients older than 80 years with the ruptured intracranial aneurysm. METHODS: 18 patients over 80 years old with aneurysmal subarachnoid hemorrhage who are admitted to our institute between Jan. 1996 and Nov. 2001 were included. Mean age was 81.6 years and female was predominant (89%). Hunt and Hess grade (HHG) and Fisher grade (FG) on admission, specific management components, and clinical outcomes were recorded. RESULTS: HHG I to III on admission were in 11 patients (61.1%) and FG III to IV on admission were in 15 patients (83.3%). The 4-vessel angiography was performed in 13 patients and 18 aneurysms were detected with the highest percentage of posterior communicating artery aneurysm (22.8%). Aneurysm repair was performed in 12 patients; 7 patients underwent surgical repair, 5 patients underwent Guglielmi detachable coil (GDC) embolization but 1 patient failed because of tortuous vessel. Preexisting medical conditions, such as hypertension (33.8%), diabetes (16.7%), myocardial disease (11.1%), cerebrovascular disease (11.1%), bronchial asthma (5.6%), were related with poor outcomes. Overall Glasgow outcome scale (GOS) were death 6 (33.3%), vegetative state and severe disability 5 (27.8%), moderate disability 0 (0%), and good recovery 7 (38.9%). Favorable outcomes of active management were 6 (50%), and favorable outcomes of GDC embolization were 3 (60%). 3 patients who had favorable clinical grade refused treatment and discharged. CONCLUSION: Elderly patients with subarachnoid hemorrhage can be treated successfully and results are still improving. The development of GDC embolization may have contributed to the improved outcome. So we think that elderly patients of favorable clinical grade would have a chance of returning to an active, independent life, if treated actively.
Aged* ; Aged, 80 and over ; Aneurysm ; Angiography ; Asthma ; Cardiomyopathies ; Female ; Glasgow Outcome Scale ; Humans ; Hypertension ; Intracranial Aneurysm* ; Persistent Vegetative State ; Subarachnoid Hemorrhage

Options for extracranial-intracranial bypass surgery of anterior circulation include saphenous vein grafts, occipital to middle cerebral artery (MCA) anastomosis, and most commonly superficial temporal artery (STA) to MCA anastomosis. Although less common, posterior circulation revascularization has been successfully peformed. The operative techniques and perioperative management such as anesthetic techniques and electrophysiologic monitoring are reviewed. Finally the author's surgical experiences of STA-MCA anastomosis in 30 patients with symptomatic internal carotid artery or MCA stenoocclusion are reported.
Carotid Artery, Internal ; Humans ; Middle Cerebral Artery ; Saphenous Vein ; Temporal Arteries ; Transplants

OBJECTIVE: To know the indications and logics of surgical and endovascualar treatment for patients with carotid stenosis. METHODS: The surgical indications and logics of symptomatic and asymptomatic carotid stenosis, and indication of angioplasty and stenting for carotid stenosis are discussed with the review of literatures. RESULTS: Carotid endarterectomy is indicated in patients with asymptomatic carotid artery stenosis of 60% or greater reduction in diameter and patients with symptomatic (recent transient ischemic attacks or nondisabling strokes) high-grade carotid stenosis (70 to 99%) with or without contralateral carotid stenosis or occlusion. The angioplasty and stenting for carotid stenosis may be indicated in patients who have the significant medical comorbidity, recurrent high-grade stenosis after endarterectomy, contralateral carotid occlusion, radiation induced stenosis, surgically difficult to access high-cervical stenosis and tandem lesion. CONCLUSION: Neurologists who have the primary management role for the cerebral ischemic patient in our country should be familiar with the surgical indications of carotid stenosis. They should try to find the patients who need the carotid endarterectomy and recommend them to surgeon to have the surgery. The cooperation among neurologist, neuroradiologist, vascular surgeon and neurosurgeon will improve the management results of patients with cerebral ischemic disease.
Angioplasty ; Carotid Stenosis ; Comorbidity ; Constriction, Pathologic ; Endarterectomy ; Endarterectomy, Carotid ; Humans ; Ischemic Attack, Transient ; Logic ; Stents ; Stroke*

Carotid arterial disease is the most common extracranial origin of brain infarction and accounts for about 10-20% of stroke and 50% of transient ischemic attacks (TIAs). Significant changes in the treatment of this disease have occurred over past few years and relative importance of carotid surgery is on the increase in the prevention of ischemic stroke. In this article, we aim to review the basics and the recent controversies of carotid endarterectomy.
Brain Infarction ; Carotid Artery Diseases ; Endarterectomy, Carotid* ; Ischemic Attack, Transient ; Stroke