Akinetic mutism (AM) is a rare complication of spontaneous subarachnoid hemorrhage (SAH). It is characterized by mutism and general hypokinesis in a patient superficially fully awake in that the eyes remain open and follow objects. Most common cause of AM in patients with SAH is secondary infarction in the distal anterior cerebral artery (DACA) territory. Sometimes post-SAH hydrocephalus has also been implicated in a delayed form of AM because of disruption of dopaminergic pathway. We report a case of 64-year-old woman who presented with sudden bursting headache without neurologic deficit. She was referred from the other hospital with a diagnosis of spontaneous SAH on head computed tomography (CT) which showed high density on sylvian, interhemispheric fissures and basal cistern. We performed computed tomographic cerebral angiography (CTA) and trans-femoral catheter cerebral angiography (TFCA), that revealed no definitive intracranial aneurysm, arterial dissection, or other vascular abnormality of the SAH. During admission period, she developed mutism and motor weakness of all limbs without spontaneous movement. We performed brain magnetic resonance (MR) image and RI cisternography. Also we prescribed levodopa. On the 33th hospital day, she had neurological recovery with drowsy mentality and grade 4 weakness of all limbs, but she was observed to suddenly develop general weakness and became cardiac arrest on the 55th hospital day. Efforts to resuscitate her failed, no more treatment could not be applied. In our case, we couldn't find infarction in the DACA terriority, midbrain or cerebellum except communicating hydrocephalus. This case may alert neurosurgeon to recognize the possibility of such rare complication after spontaneous SAH.
Akinetic Mutism ; Anterior Cerebral Artery ; Brain ; Catheters ; Cerebellum ; Cerebral Angiography ; Extremities ; Eye ; Female ; Head ; Headache ; Heart Arrest ; Humans ; Hydrocephalus ; Infarction ; Intracranial Aneurysm ; Levodopa ; Magnetic Resonance Spectroscopy ; Mesencephalon ; Middle Aged ; Mutism ; Neurologic Manifestations ; Subarachnoid Hemorrhage

OBJECTIVE: We investigated clinical characteristics and independent outcome predictors of hypertensive intracerebral hemorrhage(ICH) in the very elderly patients. METHODS: From January 2001 to December 2005, we analyzed retrospectively 28 very elderly patients(> or = 80 years) with hypertensive ICH admitted to our neurosurgical department. As a control group, 200 younger patients(< 80 years) with hypertensive ICH were selected. We analyzed risk factors, clinical and radiologic characteristics, outcomes of hypertensive ICH in very elderly. Multivariate logistic regression analyses were performed to find out independent predictors of 30-day mortality. RESULTS: Diastolic blood pressure, white blood cell counts and serum albumin on admission were significantly lower among patients < or = 80 years than in the control group(all p < 0.05). Thirty-day mortality was higher among patients > or = 80 years than in the control group(35.7% vs. 19.0%, respectively, p = 0.005). By multivariate analysis, in ICH patients > or = 80 years, only coma(Glasgow coma scale score < or = 8) was independently associated with 30-day mortality(odds rati[OR]25.5, 95% confidence interva[CI]2.36 - 275.74, p < 0.001). CONCLUSION: Our result suggests that the very elderly patients with hypertensive ICH may present some different clinical characteristics from those in their younger counterparts.
Aged ; Blood Pressure ; Cerebral Hemorrhage ; Coma ; Humans ; Intracranial Hemorrhage, Hypertensive ; Leukocyte Count ; Logistic Models ; Multivariate Analysis ; Retrospective Studies ; Risk Factors ; Serum Albumin

From December 2001 to December 2007, twenty one patients with symptomatic brainstem cavernous angioma were treated using the Leksell gamma knife. The median marginal dose was 15 Gy (range 13~18 Gy) at 50% isodose (range 45~80%). Mean follow up period was 33 months (range 4~67 months). Symptomatic improvement was achieved in 14 (66.6%) patients. There were 5 (23.8%) patients with neurological deterioration during follow-up period. Among them one patient aggravated due to overt bleeding and radiation effect was thought be the cause of deterioration in the others. Two patients needed surgical treatment subsequently and the other three patients improved with conservative management. Digital volumetry was performed before and after GKS with mean interval of 17 months (range 5~51 months). Mean volume of the lesions was 1155.6 mm3 (range 130.7~3800 mm3) before GKS and 724.8mm3 (range 36.8~1322 mm3) at the last follow-up. Volume of the lesion decreased in 17 patients (81.0%). GKS is an effective treatment modality for brainstem cavernous angioma in surgically unfavorable location. However, neurological deterioration after GKS was not rare (23%), particularly within 1 yr after GKS. It is necessary to be cautious in dose prescription.
Brain ; Brain Stem ; Caves ; Follow-Up Studies ; Hemangioma, Cavernous ; Hemorrhage ; Humans ; Radiosurgery

Endovascular treatment of ethmoidal dural arteriovenous fistula (DAVF) has not been widely performed because of the technical difficulty of the procedure and the potential risk of central retinal artery occlusion. We report the case of a patient who underwent Onyx embolization through the ophthalmic artery in bilateral ethmoidal DAVF; to our best knowledge this is the first report.
Central Nervous System Vascular Malformations ; Humans ; Ophthalmic Artery ; Retinal Artery Occlusion

OBJECTIVE: The authors evaluated the effects of direct revascularization (superficial temporal artery-middle cerebral artery bypass) in the prevention of further stroke, including recurrent ischemic event or bleeding in patients with ischemic type of adult moyamoya disease by clinical, pathophysiological and angiographical studies. MATERIALS AND METHODS: Twenty four patients who had ischemic symptoms in adult moyamoya disease were investigated. The mean age of the patients was 40.8 years. The follow up period ranged from 6 months to 8 years. In 24 patients who were surgically treated, thirty one sides (both sides in 7 patients) were performed to superficial temporal artery-middle cerebral artery anastomosis and dura splitting. RESULT: Average follow up period was 4.12 years. Perioperative and postoperative course was uneventful in 16 patients. 2 patients had new ischemic attack probably due to intracerebral steal phenomenon during operation, 6 patients had neurologic symptoms due to change of hemodynamic flow pattern after successful EC-IC bypass that included temporary neurologic deficit in 4, postbypass occlusion of the preoperative stenosis of anterior cerebral artery in one and focal seizure in one. Long term follow up results of 24 patients were showing major deficit in one and minor deficit in two. All patients experienced no further ischemic or hemorrhagic events during follow up period. In postoperative angiogram, drastic diminution of basal moyamoya vessels, which are supposed to be responsible for hemorrhage, was observed in 15 of 18 patients(83%) who were capable of postoperative 3-6 months follow up angiogram. CONCLUSION: In case of adult moyamoya disease, direct bypass surgery is particularly important on the prevention of recurrent ischemic or hemorrhagic events. And a decrease in basal moyamoya vessels was induced significantly by direct bypass surgery, which may reduce the expected risk of hemorrhage effectively. But direct bypass in moyamoya disease had operative morbidity in high frequence. So, moyamoya disease patients who undergo direct revascularization should be monitored carefully during the perioperative and postoperative period.
Adult ; Anterior Cerebral Artery ; Cerebral Arteries ; Constriction, Pathologic ; Follow-Up Studies ; Hemodynamics ; Hemorrhage ; Humans ; Moyamoya Disease ; Neurologic Manifestations ; Seizures ; Stroke

OBJECTIVE: The purpose of this study was to review factors used to determine whether a patient with an unruptured intracranial aneurysm is treated using surgical therapy or endovascular therapy. METHODS: We retrospectively reviewed the records of 68 patients with 74 unruptured intracranial aneurysms who underwent embolization with Guglielmi Detachable Coil (GDC) or surgical occlusion at our institution between April 1990 and December 2005. Surgical clipping was performed in 58 consecutive patients (16 men and 42 women) with 63 unruptured intracranial aneurysms, and endovascular coiling was performed in 10 consecutive patients (4 men and 6 women) with 11 unruptured intracranial aneurysms. There were no standard selection criteria, irrespective of whether the patient was treated with endovascular coil therapy or with neurosurgical clip occlusion. RESULTS: Out of 58 patients who underwent surgical treatment, 3 (5.2%) had fair outcome. Each of these 3 had risk factors for surgical intervention: calcification, wide neck, or thrombosed giant aneurysm. GDC embolization in 1 (10%) patient with an unruptured pericallosal artery aneurysm resulted in a fair outcome due to infarction. CONCLUSION: Management decisions in patients with unruptured intracranial aneurysms require accurate assessment of the risk factors (such as aneurysm size, location, presence of calcification and/or atheroma, and patient age).
Aneurysm ; Arteries ; Humans ; Intracranial Aneurysm ; Male ; Neck ; Patient Selection ; Plaque, Atherosclerotic ; Retrospective Studies ; Risk Factors ; Surgical Instruments

Cerebral aneurysms are common lesions. In most populations, the incidence of subarachnoid hemorrhage (SAH) is 10 per 100,000 personyears. The case fatality rate of SAH is about 50 percent in population-based studies, with a trend toward gradual improvement. Associated conditions include autosomal dominant polycystic kidney disease, fibromuscular dysplasia, Marfan's syndrome, Ehlers-Danlos syndrome, and arteriovenous malformations of the brain. The risk factors for the rupture of cerebral aneurysms include increasing size, specific site, smoking, and hypertension. Cerebral aneurysms can be divided into two different categories: saccular (atherosclerotic) and dissecting (nonatherosclerotic). The most common histologic finding in saccular aneurysms is a decrease in the tunica media, the middle muscular layer of the artery, causing structural defects. These defects combined with hemodynamic factors, lead to aneurysmal outpouchings at arterial branch points in the subarachnoid space at the base of the brain. Dissecting aneurysms are characterized by widespread disruption of the internal elastic lamina that leads to mural thrombus formation and causes ischemic or hemorrhagic symptoms. Ultimately, therapeutic strategies should be based on the epidemiology, natural history, and pathogenesis of the cerebral aneurysms.
Aneurysm ; Aneurysm, Dissecting ; Arteries ; Arteriovenous Malformations ; Brain ; Ehlers-Danlos Syndrome ; Fibromuscular Dysplasia ; Hemodynamics ; Hypertension ; Incidence ; Intracranial Aneurysm ; Marfan Syndrome ; Natural History ; Polycystic Kidney, Autosomal Dominant ; Risk Factors ; Rupture ; Smoke ; Smoking ; Subarachnoid Hemorrhage ; Subarachnoid Space ; Thrombosis ; Tunica Media

OBJECTIVE: Middle cerebral artery (MCA) aneurysm, which takes up about 25% of all intracranial aneurysms, usually occurs in MCA bifurcation, and 10% occurs in proximal MCA, and about 1% occurs in distal MCA. For that reason, it is rare to find an understanding and report on distal MCA aneurysm in its clinical aspect and radiological characteristics. In this class, four people experienced distal MCA aneurysm with subarachnoid hemorrhage (SAH), and it was reported along with document research. METHODS: Among the 214 intracranial aneurysm operations carried out in this class from May 2001 to May 2004, We report four ruptured distal MCA aneurysms. RESULTS: Distal MCA aneurysm was equal male to female ratio, and manifested in M2 segment mainly. In the case of ruptured distal MCA aneurysm, intracerebral hematoma (ICH) is usually accompanied, showing poor pre-operation grade, and no intracranial aneurysm was found on other regions. Except one case of mycotic aneurysm, all were saccular types. Aneurysm clipping was carried out in trans-sylvian approach, and except one case of Glasgow Coma Scale (GCS) of 3 points before operation, all showed good recovery. CONCLUSION: Distal MCA aneurysm is usually accompanied by ICH and shows poor preoperative grade, but early surgery draws favorable outcome. Distal aneurysm is not anatomically well known and has problems in dissection, therefore intraoperative angiography can be helpful to the surgery, and in case distal MCA aneurysm should be discovered, it is wise to carry out an evaluation on the possibility of mycotic aneurysm.
Aneurysm ; Aneurysm, Infected ; Angiography ; Female ; Glasgow Coma Scale ; Hematoma ; Humans ; Intracranial Aneurysm* ; Male ; Middle Cerebral Artery* ; Subarachnoid Hemorrhage

MELAS syndrome is characterized by mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes. A 14-year-old male presented with symptoms that resemble stroke including headache, seizure, visual disturbance and slight left hemiparesis. Laboratory investigation showed elevated lactate level in the blood. Brain computed tomography and magnetic resonance image revealed acute infarction in the right occipitoparietal lobe, which was not restricted to a specific vascular territory. Magnetic resonance spectroscopy showed decreased N-acetyl aspartate and increased lactate level in the affected lobe. A molecular genetic analysis identified A3243G point mutation in the peripheral blood leukocytes and confirmed MELAS syndrome. We describe clinical, radiological and molecular genetic findings in the patient with MELAS syndrome presenting occipital brain infarct.
Acidosis, Lactic ; Adolescent ; Aspartic Acid ; Brain* ; Headache ; Humans ; Infarction ; Lactic Acid ; Leukocytes ; Magnetic Resonance Spectroscopy ; Male ; MELAS Syndrome* ; Mitochondrial Myopathies ; Molecular Biology ; Paresis ; Point Mutation ; Seizures ; Stroke

Two cases of intracranial dissecting aneurysms of the A1 segment of the anterior cerebral artery(ACA) associated with subarachnoid hemorrhage(SAH) are described. Two patients presented with a ruptured dissecting aneurysm manifesting as sudden bursting headache. Computerized tomography(CT) revealed subarachnoid hemorrhage. In the first case, cerebral angiography revealed a diffuse dilatation of left A1 segment with pooling of contrast medium and poor collateral flow through the anterior communicating artery(AcomA). The dissecting aneurysm was wrapped with a trousers shaped artificial dura, fixed with an aneurysmal clip and coated with fibrin glue. He was discharged without neurological deficit. In the second case, 3 dimensional computerized tomography(3D CT) was checked because the diagnostic angiography was not available due to poor patient's condition. 3D CT showed fusiform dilatation of right A1 segment, focal severe stenosis of proximal A1 segment of ACA, AcomA within normal shape and no laterality of A1 dominance. Trapping surgery was done successfully and she had no neurological deficit at discharge. In the case of SAH of unknown origin, dissecting aneurysm should be kept in mind and surgical treatment might be beneficial.
Aneurysm ; Aneurysm, Dissecting* ; Angiography ; Anterior Cerebral Artery* ; Cerebral Angiography ; Constriction, Pathologic ; Dilatation ; Fibrin Tissue Adhesive ; Headache ; Humans ; Subarachnoid Hemorrhage*