CONCLUSION: Vascular reconstruction is an important part of the treatment of complex intracranial aneurysms. We report our clinical experience using vascular reconstruction techniques without an extracranial arterial stump for the treatment of complex intracranial aneurysms. METHODS: We conducted a retrospective review of five patients who underwent in situ bypasses and two patients who underwent direct neck suture secondary to clip reinforcement for the treatment of complex intracranial aneurysms between January 1999 and May 2008. RESULTS: Five of the aneurysms were fusiform and the other two were blood blister-like aneurysms (BBAs). Fusiform aneurysms were located at the anterior cerebral artery (ACA) in two patients and the middle cerebral artery (MCA) in three patients. The aneurysms were treated with end-to-side anastomosis after aneurysm excision in three cases and end-to-end anastomosis after aneurysm excision in two cases. Two cases of BBA on the dorsal intracranial artery (ICA) wall were treated by direct suture secondary to the wrapping-clipping method. Follow-up angiography was performed in five patients and revealed patent bypasses in four patients. Follow-up angiography was not performed in two patients due to their poor postoperative condition, and it revealed delayed occlusion due to granuloma formation in one patient with BBA. The patient outcomes were excellent in five patients and poor in two patients whose clinical condition was Hunt- Hess grade V preoperatively. CONCLUSION: In situ bypass is an effective alternative to extracranial-intracranial bypass for distally located fusiform aneurysms. In addition, arterial suturing followed by the wrapping-clipping method is a useful technique for fragile aneurysms unamenable to direct clip or encircled clip for true ICA trunk aneurysms. Although technically challenging, this technique of vascular reconstruction without extracranial arterial graft should be considered for appropriate candidates.
Aneurysm ; Angiography ; Anterior Cerebral Artery ; Arteries ; Follow-Up Studies ; Granuloma ; Humans ; Intracranial Aneurysm ; Middle Cerebral Artery ; Neck ; Reinforcement (Psychology) ; Retrospective Studies ; Sutures ; Transplants

OBJECTIVE: Vasospasm is known to play the key role in determining the prognosis of aneurysmal subarachnoid hemorrhage (SAH). We have experienced a higher incidence of vasospasm in the cases of SAH caused by rupture of an anterior choroidal artery (AChA) aneurysm than aneurysms of other area. The purpose of this study is to analyze the ischemic complications in patients with a ruptured AChA aneurysm. METHODS: We retrospectively reviewed 13 patients who were treated for ruptured AChA aneurysm from 1994 to 2007 at our hospital. The prognosis and complications were analyzed based on the institution's data, gender, age, the Hunt and Hess grade, the Glasgow coma scale, the Glasgow outcome scale, the symptoms and neurological examinations, the medical treatment, the digital subtraction angiography (DSA), the computed tomography (CT) and the magnetic resonance imaging (MRI). RESULTS: Forty-one (6%) out of 678 SAH patients had ischemic complications. Thirteen cases (2%) were caused by rupture of an anterior choroidal artery (AChA) aneurysm and 3 of these 13 cases (23.1%) had ischemic complications. Two of these 3 cases (15.4%) had neurological abnormality. Twelve out of the 13 AchA aneurysms had the saccular form. CONCLUSION: In cases of SAH from ruptured AchA aneurysm, the probability of ischemic complications was higher than that of general aneurysmal SAH. This seems to be due to the thin AChA and that the vascular territory of AChA is the area where ischemic brain damage can occur even by a mild vasospasm. So, when operating on a AChA aneurysm, maximum effort should be done to preserve the AChA. However, in the exceptional case with multiple AChAs, one AChA can be trapped without a definitive neurological deficit.
Adenosine ; Aneurysm ; Angiography, Digital Subtraction ; Arteries ; Brain ; Choroid ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Humans ; Incidence ; Magnetic Resonance Imaging ; Neurologic Examination ; Prognosis ; Retrospective Studies ; Rupture ; Subarachnoid Hemorrhage

We describe our experience in which the migration of a coil into the parent artery occurred during the coil embolization. A feared complication during coil embolization of cerebral aneurysm is parent artery occlusion by migration of a detachable coil. Obstruction with migration of the coil into the parent artery may be especially hard to solve with an endovascular procedure. The patient had an unruptured internal carotid artery trunk aneurysm where endovascular treatment was performed with detachable coils. One of the packed coils escaped from the sac and migrated into the distal middle cerebral artery (MCA). Cerebral angiography demonstrated non-filling of a number of MCA branches. Repeated attempts at endovascular retrieval of the migrated coil were unsuccessful. Only after an emergent arteriotomy the migrated coil could be successfully removed. Subsequently, endovascular intra-arterial thrombolysis was required to dissolve the thrombus formed postoperatively in the distal MCA. The patient fully recovered with no neurological deficit. In our case a combined surgical and endovascular treatment of coil migration were performed.
Aneurysm ; Arteries ; Carotid Artery, Internal ; Cerebral Angiography ; Endovascular Procedures ; Humans ; Intracranial Aneurysm ; Middle Cerebral Artery ; Parents ; Thrombosis ; United Nations

OBJECTIVE: Detection of intracranial multiple aneurysms, including mirror-image aneurysms, have recently been increasing with the development of diagnostic techniques. However, studies of mirror-image aneurysms have been rare in South Korea. Thus, we intend to report our hospital's experience with mirror-image aneurysms during the past 20 years along with a review of relevant literature. METHODS: We analyzed medical records and image data from patients with cerebral aneurysms who had been admitted to our institution from January 1988 to June 2007. We divided the patients into three groups and investigated the clinical patterns of mirror-image aneurysms (Group 1). We then compared them with patients exhibiting non-mirror multiple aneurysms (Group 2) and the patients with solitary aneurysms (Group 3). We also statistically analyzed the age, sex, smoking habits, medical histories, and prognoses of the patients. RESULTS: Mirror-image aneurysms were found in 62 (5.1%) of the 1,209 patients admitted for cerebral aneurysms over the past 20 years. Of the mirror-image aneurysms, 48% were located in the posterior communicating artery (PcoA), and 40% were in the middle cerebral artery (MCA). Ruptures of aneurysms occurred slightly more frequently on the right side and when the aneurysm was larger and its shape was more irregular. Women, particularly menopausal women aged 50 and older, were shown to be at higher risk. Smoking was also a risk factor. However, there were no significant differences in prognoses among the three groups. CONCLUSION: We should pay attention to the possibility of mirror-image or multiple aneurysms when diagnosing and treating menopausal women and smokers, particularly if the cerebral aneurysm is located in the MCA or PcoA.
Aged ; Aneurysm ; Arteries ; Female ; Humans ; Intracranial Aneurysm ; Medical Records ; Middle Cerebral Artery ; Prognosis ; Republic of Korea ; Risk Factors ; Rupture ; Smoke ; Smoking

OBJECTIVE: The purpose of this study is to evaluate the feasibility of neuronavigation system for side selection of pterional approach in anterior type anterior communicating aneurysm. METHODS: Forty six anterior type aneurysms were evaluated with neuronavigation system based on computed tomography angiography from October 2005 to September 2008. According to neuronavigation system images the approach were subdivided into two groups. The approach in open standing group defined as the craniotomy was done in the A2 of the approach side located more posteriorly than the contralateral A2. The approach in closed standing group was defined as craniotomy was done in the ipsilateral A2 located more anteriorly than the contralateral A2. We analyzed operation time, premature rupture rate, temporary clipping time, perforator injury on postoperative CT scan and Glasgow outcome scale (GOS) of two groups. RESULTS: Thirty-three cases of approaches in open standing group and thirteen cases of approaches in closed standing group were evaluated. In operation time, premature rupture rate, temporary clipping time and GOS, no significant difference was observed between approaches in closed standing group and open standing group. But, in closed standing group, the perforator injury on CT scan was occurred more frequently than open standing group (p=0.001) in postoperative 7 days. CONCLUSION: With the neuronavigation system, three dimensional angiographic images were reconstructed by the operator and actively used to side selection of pterional approach for the aneurysm neck clipping. The perforator injury could be avoided with this policy.
Aneurysm ; Angiography ; Arteries ; Craniotomy ; Glasgow Outcome Scale ; Intracranial Aneurysm ; Neck ; Neuronavigation ; Rupture

OBJECTIVE: Massive intracerebral hemorrhage (ICH) is devastating neurosurgical disease. Decompression surgery has been performed to manage the uncontrolled increased intracranial pressure and good clinical result has been reported. Authors analyze the ICP trend after the decompression surgery and report the clinical usefulness. METHODS: Thirty patients data with massive ICH were analyzed retrospectively. Surgical indication was constantly followed in these patient ; Glasgowcoma scale score less than 8, midline shift more than 6 mm on brain CT. In all patients ventricular puncture was done before the decompression and monitored the ventricular pressure changes during and after the surgery. RESULTS: In massive ICH patients, the ICP was maintained in physiological range if the hematoma was removed more than 80%. And when we tried additional therapies like hypothermia or coma therapies in another group, the ICP was elevated at the time of the additional therapy. CONCLUSION: From this study, if the ICH removed more than 80% and The ICP was not exceed 20 mmHg during the first post-operation day, the ICP hardly exceed 20 mmHg after than. Authors thought that decompression surgery is not an essential treatment for the massive ICH patient if their hematoma removed enough.
Brain ; Cerebral Hemorrhage ; Coma ; Decompression ; Decompressive Craniectomy ; Hematoma ; Humans ; Hypothermia ; Intracranial Pressure ; Punctures ; Retrospective Studies ; Ventricular Pressure

OBJECTIVE: The number of elderly patients with cerebral aneurysm has markedly increased. We investigated the clinical characteristics and the surgical outcomes of cerebral aneurysms among elderly patients more than 65 years of age compared to a control group including patients less than 65. MATERIALS AND METHODS: From March 2001 to May 2007, 590 patients with aneurysmal subarachnoid hemorrhage (SAH) were treated; among them, 88 patients (14.9%) more than 65 were candidates for this study. The variables included in the analysis were: age, gender, size and site of the aneurysm, the Hunt-Hess grade, size of the hematoma on the CT scan, and comorbidities. RESULTS: The mean age was 69 (range 65-84 years), 72 patients (81%) were female, 72 of the patients had a Hunt-Hess grade of I-III, 37 patients (42%) had anterior communicating artery bleeds, and 13 patients (16.7%) had multiple aneurysms. The treatments consisted of neck clipping for 77 aneurysms and endovascular therapy for 11 aneurysms. Fifty eight patients (65.9%) had a favorable outcome and the overall mortality was 11.4%. The main causes of unfavorable outcomes among the elderly patients included a poor Hunt-Hess grade on admission and a concurrent intracerebral hematoma. CONCLUSIONS: The results of this study showed that advanced age was not a contra-indication to aneurysm surgery and early craniotomy can lead to a better outcome in elderly patients.
Aged ; Aneurysm ; Arteries ; Comorbidity ; Craniotomy ; Female ; Hematoma ; Humans ; Intracranial Aneurysm ; Neck ; Subarachnoid Hemorrhage

OBJECTIVES: We sought to examine the diverse factors associated with aneurysms of the posterior circulation. In addition, the results of conventional craniotomy were compared with those of endovascular treatment. METHODS: One hundred and one patients with posterior circulation aneurysms were selected for study inclusion. The factors that might affect the clinical outcomes were studied , such as the initial Hunt-Hess (H-H) grade, aneurysm location, size of the aneurysm, and therapeutic modalities. In addition, the morbidity and mortality rates were analyzed. The treatment outcomes were evaluated using the Glasgow Outcome Scale (GOS) 6 months after the initial insult. RESULTS: The patient population consisted of 67 women and 34 men, with a mean age of 52 (range 28-81 years). The overall morbidity and mortality rates at 6 months were 13.9% (14/101) and 17.8% (18/101), respectively. Sixty-one operations (60.3%) were performed, and 32 patients were treated with endovascular therapy. Forty-two (85.7%) of the 49 patients that had initial H-H grades of I and II had a better prognosis (GOS more than 4) than those with poor H-H grades (P<0.001). Patients that underwent endovascular treatment had better outcomes than those that had clipping (P=0.032). There was no significant difference in outcome according to the size of the aneurysm, location of the aneurysm, or the age of the patients. CONCLUSIONS: The results of this study showed that the factors affecting the prognosis were the initial HH grade and treatment modality. Considering the very high mortality rate in patients with rebleeding, early management may help improve the prognosis of patients with posterior circulation aneurysms. Endovascular therapy should be considered the primary treatment modality in patients with posterior circulation aneurysms.
Aneurysm ; Craniotomy ; Female ; Glasgow Outcome Scale ; Humans ; Intracranial Aneurysm ; Male ; Prognosis

OBJECTIVE: Although there are many reports describing the risk of rebleeding in hospitalized patients with subarachnoid hemorrhage (SAH), it is common for these patients to deteriorate during transportation or while waiting for surgery. The aim of this study was to estimate the possible causes of neurological deterioration in patients with a ruptured aneurysm prior to hospitalization and management and the effect on patient prognosis. METHODS : Two hundred and thirty patients with aneurysmal SAH that arrived to the hospital within 24 hours after the initial bleeding were recruited. The course of neurological deterioration, age, gender, Hunt and Hess grade, Fisher grade, the arterial blood pressure, the clinical findings when neurological deterioration occurred, aneurysm location and size, treatment and the outcome were analyzed. RESULTS: Among the 230 patients, 32 (13.9%) patients had neurological aggravation prior to management. Fifteen (46.8%) patients had definite rebleeding, 5 (15.6%) acute hydrocephalus and 2 (6.3%) intracerebral hematomas. Two (6.3%) patients had a cardiac arrest, and another 8 (25%) patients likely had rebleeding. Such deterioration occurred in 15 (46.8%) patients within 3 hours after the initial event and in 21 (84%) patients within 6 hours. The patients experiencing neurological deterioration had a more severe Hunt and Hess grade, higher rates of intracerebral hematoma and intraventricular hematoma, reduced operability, and a poorer prognosis. CONCLUSION: The findings showed that neurological deterioration occurred much earlier than expected. Thus, more rapid and careful preoperative management and earlier neurosurgical intervention might prevent neurological deterioration and improve patient outcome.
Aneurysm ; Aneurysm, Ruptured ; Arterial Pressure ; Heart Arrest ; Hematoma ; Hemorrhage ; Hospitalization ; Humans ; Hydrocephalus ; Prognosis ; Subarachnoid Hemorrhage ; Transportation

OBJECTIVES: This study was performed to evaluate the relationship between radiation induced senescence-like changes of endothelial cells and blood-brain barrier disruption. MATERIALS AND METHODS: Radiation of 15 Gy was applied to a monolayer culture of bovine aortic endothelial cells (BAEC). The morphological changes were observed over 19 weeks. An artificial blood-brain barrier (BBB) model was constructed using the Transwell(R) and co-culture of the BAEC with C6 glioma cells. After treatment with the same dose of radiation, changes in the BBB were observed by measurement of the trans-endothelial electrical resistance (TEER). RESULTS: Senescence-like changes of the endothelial cells appeared 1 week after irradiation; it was most prominent during the third week and replacement by normal endothelial cells was noted from the seventh week. The recovered normal endothelial monolayer was maintained until the 19th week. Senescence-like endothelial cells showed positive staining with senescence-associated beta-galactosidase (SA-beta-gal). In the Transwell(R), the TEER began to decrease 1 week after irradiation, and the decreased resistance reached its peak 18 days after irradiation, and then began to recover to some degree. CONCLUSION : After application of radiation (15 Gy), senescence-like changes of the endothelial cells were observed in the monolayer culture. These findings demonstrated good correlation with the disruption of blood-brain barrier in an in-vitro model of the BBB.
Aging ; beta-Galactosidase ; Blood-Brain Barrier ; Coculture Techniques ; Electric Impedance ; Endothelial Cells ; Glioma