OBJECTIVE: Distal anterior cerebral artery (DACA) aneurysms are relatively uncommon, and operative management is usually difficult because of narrow operative fields, deep exposure, interhemispheric adhesions, and problems in achieving proximal vessel control. We present our experience with 26 DACA aneurysm cases and analyze the clinical features and surgical outcomes retrospectively. METHODS: From 1998 to 2008, surgical clipping of DACA aneurysms was carried out in 26 patients among a total of 504 patients with intracranial aneurysms. In each case, the clinical and radiological features were carefully reviewed through angiograms, medical records, and intraoperative findings. RESULTS: The most common location of DACA aneurysms was the junction of the pericallosal and callosomarginal arteries: 23 occurred at pericallosal-callosomarginal (PC-CM) junctions while three occurred in the pericallosal-frontopolar (PC-FP) region. Multiple aneurysms were found in 15 cases (58%), and associated vascular anomalies were noted in three cases (12%). Eleven (64.7%) of the 17 ruptured aneurysms and seven (77.8%) of the nine unruptured aneurysms were smaller than 7 mm; only two aneurysms (7.7%) were larger than 10 mm. Seven cases (26.9%) underwent minor premature rupture with proximal artery control. CONCLUSION: Despite the small patient group, our data suggest that in general, DACA aneurysms tend to rupture at a smaller size than do intracranial aneurysms. Thus, unruptured DACA aneurysms require aggressive treatment, even when they are small.
Aneurysm ; Aneurysm, Ruptured ; Anterior Cerebral Artery ; Arteries ; Glycosaminoglycans ; Humans ; Intracranial Aneurysm ; Medical Records ; Retrospective Studies ; Rupture ; Surgical Instruments

OBJECTIVE: Transfusion-related acute lung injury (TRALI) is a poorly understood, but life-threatening complication after transfusion of blood components. The present study was conducted to identify the incidence of TRALI in patients with aneurysmal subarachnoid hemorrhage (SAH) as well as to determine the risk factors for TRALI. METHODS: This retrospective study was carried out on our institute, during the period of Jan. 2006 and Dec. 2008 to a total of 237 patients who underwent microsurgical treatment for aneurysmal SAH. In this time period, 154 patients were finally enrolled in this study. Patients' demographics, clinical and radiographic factors relevant to the aneurysms and SAH, and parameters regarding transfusion were analyzed and compared. RESULTS: A total of 9 patients had TRALI among a total of 154 patients. The incidence of TRALI was 0.01% (9 in 836) for all transfused blood component, and 0.06% (9 in 154) for all transfused patients. Statistical analysis showed that Fisher grade III and IV (OR, 1.88; 95% CI, 1.13-3.07) and total amount of transfused units exceeding 1,200cc (OR 1.72; 95% CI, 1.22-2.65) were associated with the development of TRALI. On the other hand, sex, poor Hunt-Hess Grade (IV and V), preoperative hemoglobin less than 13, postoperative hemoglobin less than 11, use of volume expander, premorbid disease (hypertension, diabetes) were not associated with TRALI. CONCLUSIONS: The results of present study indicate that large amount SAH and transfusion of blood components more than 1,200cc are risk factors for the development of TRALI. Prospectively designed study with a larger cohort is mandated to confirm the etiology and risk factors of TRALI in stroke practice.
Acute Lung Injury ; Aneurysm ; Cohort Studies ; Demography ; Hand ; Hemoglobins ; Humans ; Incidence ; Retrospective Studies ; Risk Factors ; Stroke ; Subarachnoid Hemorrhage

Simultaneous occurrence of remote intracerebral hemorrhage (ICH) and intracranial aneurysmal subarachnoid hemorrhage is very rare. We report on a case of concurrent hypertensive ICH at the left thalamus and rupture of an intracranial aneurysm at the bifurcation of the single A2 segment of the anterior cerebral artery in a 64-year-old woman, which was clipped previously, with review of the literature. To our knowledge, this is the first case report demonstrating bleeding of previously clipped aneurysm with simultaneous hypertensive ICH. Hypertensive crisis following ICH seems to have provoked rupture of the residual aneurysm.
Aneurysm ; Anterior Cerebral Artery ; Cerebral Hemorrhage ; Female ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Intracranial Hemorrhage, Hypertensive ; Middle Aged ; Rupture ; Subarachnoid Hemorrhage ; Thalamus

There are not many reports of a spontaneous acute subdural hematoma (ASDH) without the presence of a subarachnoid hemorrhage as a result of a ruptured aneurysm. A 66-year-old woman presented with acute subdural hematoma secondary to a ruptured intracranial aneurysm. She was admitted with an acute onset of bursting headache and nausea. There was no past history of head trauma. The CT scan demonstrated a left subdural hematoma with extension along the tentorium in the absence of subarachnoid or intraparenchymal hemorrhage. CT angiography revealed an aneurysm of the left posterior communicating aneurysm, which was directed posterolaterally. Uneventful clipping was performed without any neurological deficits. The possibility of aneurysmal subdural hemorrhage should be considered in all cases of ASDH that present with a sudden bursting headache without any history of trauma. Therefore, CT angiography can be an indispensable tool for detecting the aneurysm that has an unusual pattern of subdural hematoma.
Aged ; Aneurysm ; Aneurysm, Ruptured ; Angiography ; Craniocerebral Trauma ; Female ; Headache ; Hematoma, Subdural ; Hematoma, Subdural, Acute ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Nausea ; Subarachnoid Hemorrhage

OBJECTIVE: The goal of this study was to determine the effect of short-term usage of tranexamic acid (TXA), which is an antifibrinolytic agent, on patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS: We prospectively analyzed 80 consecutive patients who had undergone surgery for aSAH between January 2004 and December 2006. The patients were placed either in the TXA group for those who were treated with TXA (N=38) or in the n-TXA group for those who were not (N=42). The incidences of rebleeding and vasospasm (with using the transcranial Doppler (TCD) criteria), symptomatic vasospasm and hydrocephalus were compared between the two groups. RESULTS: Preoperative rebleeding occurred only in one patient in each group (2.6% of the TXA group and 2.3% of the n-TXA group (p>0.05). Vasospasm developed in 18 (47.4%) of the TXA patients and in 20 (47.6%) of the n-TXA patients (p>0.05). Among the patients with vasospasm, the number of symptomatic vasospasms was 16 (89%) in the TXA group and 11 (55%) in the n-TXA group (p<0.05). The patients with symptomatic vasospasm in the TXA group seemed to have worse outcomes than those in the n-TXA group (p>0.05). The incidence of hydrocephalus was not different between the two groups. CONCLUSION: We conclude that the preoperative short-term use of TXA can increase the risk of postoperative symptomatic vasospasm, although the incidence of vasospasm was not different between the two groups. According to our results, we recommend being very cautious of vasospasm and ischemic events when TXA is used preoperatively in patients with aSAH.
Aneurysm ; Humans ; Hydrocephalus ; Incidence ; Prospective Studies ; Subarachnoid Hemorrhage ; Tranexamic Acid

OBJECTIVE: In the case of internal carotid-posterior communicating (ICPCom) artery aneurysm it is possible to successfully clip the aneurysmal neck without any difficulty. However, if the aneurysmal neck is wide, the aneurysmal sac is giant, the aneurysmal sac is hidden by the anterior clinoid process (ACP), or its dome is located in ventral portion or low-lying ICPCom aneurysm, it is difficult to open the proximal aneurysmal neck and we encounter a barrier in controlling bleeding in case of premature rupture of the aneurysm. They need to be resected the ACP for successful aneurysmal clipping. We propose angiographic criteria for predicting necessity of resection of the ACP before clipping of the ICPCom artery aneurysm. METHODS: Between 1999 and 2003, 16 patients with ICPCom artery aneurysm were treated with the resection of the ACP prior to applying the clip on the neck of the aneurysm. We retrospectively analyzed the preoperative cerebral angiographies, and the clinical and operative findings. We measured various radiometric parameters to reveal the angiographic characteristics. RESULTS: The mean value of the radiographic measurement in case of the cerebral angiography in 16 patients is as follows: angle A (the angle between the midline of the skull and the axis of the C1 segment on A-P view) ranged from 15 to 80 degrees (mean+/-SD, 42+/-5 degrees), angle B (the angle between the axes of the C1 and C2 segments on A-P view) ranged from 70 to 150 degrees (mean+/-SD, 110+/-15 degrees), and distance C (the distance between the tip of the ACP and the most proximal portion of the aneurysmal neck on the lateral view) ranged from 2 to 9 mm (mean+/-SD, 4.5+/-1 mm). CONCLUSION: We have resected the ACP in 16 of the 40 ICPCom aneurysms. The mean values of angle A, angle B, and distance C is 42+/-5 degrees, 110+/-15 degrees, and 4.5+/-1 mm, respectively. We did not encounter any difficulty in clipping in all the cases in which there was no premature rupture of the aneurysm. Most of cases had a good outcome.
Aneurysm* ; Arteries* ; Axis, Cervical Vertebra ; Cerebral Angiography ; Hemorrhage ; Humans ; Neck ; Retrospective Studies ; Rupture ; Skull

OBJECTIVE: Computed tomographic angiography (CTA) is useful for rapid and relatively noninvasive detection of aneurysms in the circle of Willis. The purpose of this study is to compare CTA with conventional cerebral angiography (CCA) and to assess usefulness of CTA in detection of the anatomic delination of intracranial aneurysms of the circle of Willis in subarachnoid hemorrhage. PATEINTS AND METHODS: 126 consecutive patients with known SAH or suspected intracranial saccular aneurysms underwent CTA and CCA from January 2002 to June 2003. Using surface shaded display post-processing technique, CTA was interpreted for the presence, location and anatomic features of the aneurysms and also the image obtained with CTA was compared with CCA image. RESULTS: In 112 operated patients, 125 aneurysms were detected. CCA revealed 123 cerebral aneurysms and CTA revealed 113 aneurysms. Two of the 125 cerebral aneurysms were located outside of the imaging volume of CTA, 10 cases were not detected and false positive were 2 cases. The sensitivity of CTA was 90.3%. The results obtained with CTA comparing with that of CCA were almostly equal in detection of aneurysm location and delineation of aneurysmal neck. However, CTA provided a 3-dimensional representation of aneurysm and also it was very useful for surgical planning. CONCLUSION: CTA can be a diagnostic tool for the patients with acute subarachnoid hemorrge due to a ruptured aneurysm of the circle of Willis and provides adequate anatomic detail for surgical planning especially to complex cerebral aneurysms. However, it is obvious that CCA is necessary because of the limitations of CTA including its difficulty in detecting unusually located aneurysms including those in cavernous sinus or distal artery, and acquiring dynamic flow information.
Aneurysm ; Aneurysm, Ruptured ; Angiography* ; Arteries ; Cavernous Sinus ; Cerebral Angiography* ; Circle of Willis ; Humans ; Intracranial Aneurysm* ; Neck ; Subarachnoid Hemorrhage

Over the past 50 years, more advancement has been made in cerebrovascular surgery (CVS) than in any other field of medicine. The author was to describe development of CVS in Korea by reviewing this country's history of neurosurgery, and his own personal experience as a vascular neurosurgeon. The first CVS was performed in 1948 on a patient with an intracerebral hematoma. Open carotid angiography was first performed in 1956, but was soon replaced with a percutaneous procedure. In the 1960s, several passionate neurosurgeons made attempts to treat ruptured cerebral aneurysms by carotid ligation in the neck or by a direct approach, however the outcomes were less than optimal. Aneurysm clips with springs were not available until late in that decade. In the 1970s, great strides were made in aneurysm surgery, thanks to the revolutionary introduction of the surgical microscope and refined microsurgical techniques. Microvascular anastomosis also became possible for cerebral blood flow augmentation. In the late 1970s, CT scan and 4-vessel angiography were introduced to improve the diagnosis of cerebrovascular disease. Also at this time, there was great interest among vascular neurosurgeons in the treatment of arteriovenous malformations (AVMs) and intracerebral hemorrhage. Korean vascular neurosurgeons began presenting their papers at international meetings. At that time, most of the basic researches were focused on cerebral vasospasm and ischemia. By the 1980s, major health care centers in the country had the resources to perform both aneurysm and AVMs surgery. Surgery of the posterior circulation aneurysms became commonplace. In addition, radiosurgery became available for the treatment of AVMs. In 1986, vascular neurosurgeons organized a study group on cerebrovascular disease, which eventually developed into the Korean Society of CVS. A partnership was formed with Japanese neurosurgeons to create a biannual Korean-Japanese Friendship Conference on Surgery for Cerebral Stroke. In the 1990s, a new era in CVS was opened with advanced neuro-imaging technology, skull base surgery, endovascular surgery, neuro-navigation, and reappraisal of carotid surgery. The International Workshop on CVS was proudly hosted in Seoul in the year 2000. The present advanced state of CVS in Korea was made possible only by the selfless efforts of devoted neurosurgeons, neurologists, and neuroradiologists who had limited resources to work with. Long recognized as possibly the most technically challenging medical field requiring the most precision, CVS has come of age in the struggle to improve the outcome of patients with cerebrovascular disease.
Aneurysm ; Angiography ; Arteriovenous Malformations ; Asian Continental Ancestry Group ; Cerebral Hemorrhage ; Delivery of Health Care ; Diagnosis ; Education ; Friends ; Hematoma ; Humans ; Intracranial Aneurysm ; Ischemia ; Korea* ; Ligation ; Neck ; Neurosurgery ; Radiosurgery ; Seoul ; Skull Base ; Stroke ; Tomography, X-Ray Computed ; Vasospasm, Intracranial

Moyamoya disease is a rare occlusive cerebrovascular disease characterized by stenosis or occlusion of the main cerebral arteries. It has a tendency for multifactorial inheritance and familial occurrence, although its pathogenesis is not clear. We observed this disease in two girls from the same family:one was eight years old and the other was 45 months. They presented with transient ischemic attacks. We performed cerebral angiography on both patients and magnetic resonance angiography (MRA) on the younger. Both approaches showed the typical features of moyamoya disease, and MRA successfully revealed abnormal findings specific for the disease in the second child. Both children received encephaloduroarteriosynangiosis (EDAS) and this produced good results. MRA is thus a powerful and noninvasive way of detecting individuals at high risk of developing this disease. Considering the reported familial incidence of moyamoya disease in Japan, a careful search for family members using MRA would probably reveal many more such cases in Korea.
Cerebral Angiography ; Cerebral Arteries ; Child ; Constriction, Pathologic ; Female ; Humans ; Incidence ; Ischemic Attack, Transient ; Japan ; Korea ; Magnetic Resonance Angiography ; Moyamoya Disease* ; Multifactorial Inheritance

OBJECT: Transforming growth factor-beta (TGF-beta) is involved in many physiological and pathophysiological processes, such as cell growth, differentiation, inflammation, and tissue repair. It is not yet clear whether the presence of this cytokine has deleterious or protective effects for neurons in a given pathophysiological condition. Several authors have demonstrated that TGF-beta has been shown to rescue cultured neurons from excitotoxic and hypoxic cell death and to reduce infarct size after focal cerebral ischemia in mice and rabbits. The present study investigated the effect of diazepam on the expression of TGF-beta in rat brain tissue after inducing transient cerebral ischemia. METHODS: Ten male rats were killed after a mild and reversible ischemic damage produced by a 15-minutes occlusion of both carotid arteries without occlusion of the vertebral arteries. Five ischemia-treated and 5 sham-operated rats were injected with 10 mg/kg diazepam and vehicle, respectively at 30 minutes, and again 90 minutes following the onset of reperfusion. After 1, 2 and 7 days following the reperfusion, brains were removed from control, sham-operated, and ischemia-treated with or without diazepam-injected groups, then immunohistochemistry and Western blotting for TGF-beta were performed. Cerebral cortices and hippocampi were sectioned from ischemia-treated, shamoperated and control group rats, and stained using cresyl violet. RESULTS: When the immunoblot-results of TGF-beta expression were analyzed using a image analysis system, TGF-beta expression were increased in ischemia-treated without diazepam-injected rats, and decreased in ischemia-treated with diazepam-injected rats at 2 and 7 days after reperfusion compared to control and sham-operated groups. Cresyl violet staining became intense in ischemia-treated without diazepam-injected group and became unclear in ischemia-treated with diazepam-injected group compared to sham-operated and control groups, respectively. CONCLUSION: Diazepam influenced the TGF-beta expression in the brain of ischemia-treated rats.
Animals ; Blotting, Western ; Brain Ischemia ; Brain* ; Carotid Arteries ; Cell Death ; Cerebral Cortex ; Diazepam* ; Humans ; Immunohistochemistry ; Inflammation ; Ischemic Attack, Transient* ; Male ; Mice ; Neurons ; Rabbits ; Rats* ; Reperfusion ; Transforming Growth Factor beta ; Vertebral Artery ; Viola