Objective: : Vertebral artery dissecting aneurysm (VADA) is a very rare subtype of intracranial aneurysms; when ruptured, it is associated with significantly high rates of morbidity and mortality. Despite several discussions and debates, the optimal treatment for VADA has not yet been established. In the last 10 years, flow diverter devices (FDD) have emerged as a challenging and new treatment method, and various clinical and radiological results have been reported about their safety and effectiveness. The aim of our study was to evaluate the clinical and radiological results with the use of FDD in the treatment of unruptured VADA. Methods: : We retrospectively evaluated the data of all patients with unruptured VADA treated with FDD between January 2018 and February 2021 at our hybrid operating room. Nine patients with unruptured VADA, deemed hemodynamically unstable, were treated with FDD. Among other parameters, the technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcomes were evaluated. Results: : Successful FDD deployment was achieved in all cases, and the immediate follow-up angiography showed intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of facial numbness and palsy was noted in one patient; however, the symptoms had completely disappeared when followed up at the outpatient clinic 2 weeks after the procedure. The 3–6 months follow-up angiography (n=9) demonstrated completeear-complete obliteration of the aneurysm in seven patients, and partial obliteration and segmental occlusion in one patient each. In the patient who achieved only partial obliteration, there was a sac 13 mm in size, and there was no change in the 1-year follow-up angiography. In the patient with segmental occlusion, the cause could not be determined. The clinical outcome was modified Rankin Scale 0 in all patients. Conclusion : Our preliminary study using FDD to treat hemodynamically unstable unruptured VADA showed that FDD is safe and effective. Our study has limitations in that the number of cases is small, and it is not a prospective study. However, we believe that the study contributes to evidence regarding the safety and effectiveness of FDD in the treatment of unruptured VADA.

Objective: Ventriculoatrial shunt (VAS) remains an alternate option for treatment of hydrocephalus in patients with ventriculoperitoneal shunt (VPS) failure. Unfamiliar anatomy for a neurosurgeon has resulted in the VAS falling out of favor as a treatment option. However, there are unsatisfactory reports on the long-term result of VPS, and VAS has been recently re-evaluated. We are to report the simple way to do the VAS using a peel-away sheath in a hybrid operation room. Methods: A jugular vein path was drawn by ultrasound, a small incision was made above the clavicle, and a shunt catheter was tunneled into it. The jugular vein was punctured beside the tunneled catheter with a Seldinger needle under ultrasound guidance. A flexible guide wire was introduced into the vein and 6-Fr peel-away sheath was advanced into the vein along the wire. Under fluoroscopic guidance, the catheter was cut to position approximately midlevel in the atrium. After the guide wire was removed, the distal shunt catheter was passed down. After confirming proper position of the distal catheter under the fluoroscope, the catheter-guiding sheath was pulled out as a peeling-away manner. We performed this surgical procedures in 5 cases. Results: All the procedures of the VAS using a peel-away sheath were performed in a hybrid operation room Of 5 patients, 3 patients had the distal catheter failures in the peritoneal cavity and 2 patients had shunt A distal catheter was successfully indwelling in all the cases without any difficulties. After the surgery, neither shunt infection nor thromboembolic event happened. Conclusion VAS using fluoroscopy and a peel-away sheath is a good alternative option for hydrocephalus patients with shunt failure related to peritoneal cavity complications.

The objective of this study was to compare changes in the simplified disease activity index (SDAI) between biologic (b) and conventional (c) disease-modifying antirheumatic drugs (DMARD) users with seropositive rheumatoid arthritis (RA) in daily clinical practice. Methods: This was a nationwide multicenter observational study. Patients who had three or more active joint counts and abnormal inf lammatory marker in blood test were enrolled. The selection of DMARDs was determined by the attending rheumatologist. Clinical parameters, laboratory findings, and Health Assessment Questionnaire (HAQ) scores were obtained at baseline and at 6 and 12 months. Serial SDAI changes and clinical remission rate at 6 and 12 months were assessed. Results: A total of 850 patients participated in this study. The mean baseline SDAI score in bDMARD group was higher than that in cDMARD group (32.08 ± 12.98 vs 25.69 ± 10.97, p < 0.0001). Mean change of SDAI at 12 months was –19.0 in the bDMARD group and –12.6 in the cDMARD group (p < 0.0001). Clinical remission rates at 12 months in bDMARD and cDMARD groups were 15.4% and 14.6%, respectively. Patient global assessment and HAQ at 12 months were also significantly improved in both groups. Multivariate logistic regression showed that baseline HAQ score was the most notable factor associated with remission. Conclusions: There was a significant reduction in SDAI within 12 months after receiving DMARDs in Korean seropositive RA patients irrespective of bDMARD or cDMARD use in real-world practice. Clinical remission was achieved in those with lower baseline HAQ scores.

Objective: To report on combined surgical and/or endovascular procedures for cerebrovascular disease in a hybrid operating room (OR). Methods: Between October 2016 and June 2020, 1832 neurosurgical procedures were performed in a hybrid OR. Our institution’s hybrid OR consists of a multi-axis robotic C-arm monoplane digital subtraction angiography (DSA) system with an operating table, 3D-rotational DSA, cone-beam computed tomography (dyna CT), and real-time navigation software. Procedures were categorized into six categories according to purpose: (1) simple diagnosis and follow-up, (2) simple endovascular procedure, (3) combination of surgery and endovascular procedures, (4) rescue surgery after endovascular procedures, (5) frameless stereotactic procedure, and (6) other surgeries requiring C-arm. Results: Of 1832 neurosurgical procedures in the hybrid OR, 1430 were simple diagnosis and follow-up cases, 330 simple endovascular procedures, 8 combination of surgery and endovascular procedures, 15 rescue after endovascular procedure, 40 frameless stereotactic procedures, and 9 other surgeries. Eight cases of combination of surgery and endovascular procedures, safely performed without wasting time on patient transfer, were performed in seven bypass end endovascular procedures and one case of bow-hunter syndrome in complex cerebrovascular disease. After embolization, craniotomy (or craniectomy) and intracerebral hemorrhage removal were performed in eight patients in-situ. Of the 40 frameless stereotactic procedure, 37 were extraventricular drainage before/after coil embolization in subarachnoid hemorrhage patients. They all mounted conduits in their planned locations. Conclusions A hybrid OR for combined endovascular and surgical procedures represents a safe and useful strategy for cerebrovascular disease. In hybrid ORs various neurosurgical procedures can be safely and conveniently performed. Hybrid OR will pioneer a new era in neurosurgical procedures.

Objective: : Stent-assisted coil embolization (SAC) is commonly used for treating wide-neck intracranial aneurysms. In this study, we aimed to assess the clinical safety and efficacy of the NeuroForm Atlas Stent during SAC of intracranial aneurysms. Methods: : We retrospectively analyzed data from patients with ruptured and unruptured cerebral aneurysms, who underwent SAC using the NeuroForm Atlas between February 2018 and July 2018. Favorable clinical outcomes and degree of aneurysm occlusion were defined as a modified Rankin scale score of ≤2 and a Raymond-Roy occlusion classification (RROC) class I/II during the immediate postoperative period and at the 6-month follow-up, respectively. Results: : Thirty-one consecutive patients with 33 cases, including 11 ruptured and 22 unruptured cases were treated via NeuroForm Atlas SAC. Among the 22 unruptured cases with 24 unruptured aneurysms had favorable clinical outcome. Complete occlusion (RROC I) was achieved in 16 aneurysms (66.7%), while neck remnants (RROC II) were observed in six aneurysms (25%). Among the 11 patients with ruptured aneurysms, two died due to re-bleeding and diabetic ketoacidosis. In ruptured cases, RROC I was observed in eight (72.7%) and RROC II was observed in three cases (27.3%). At the 6-month follow-up, no clinical events were observed in the 22 unruptured cases. In the ruptured nine cases, five patients recovered without neurologic deficits, while four experienced unfavorable outcomes at 6 months. Of the 29 aneurysms examined via angiography at the 6-month follow-up, 19 (65.5%) were RROC I, eight (27.6%) were RROC II and two (6.9%) were RROC III. There were no procedure-related hemorrhagic complications. Conclusion : In this study, we found that stent-assisted coil embolization with NeuroForm Atlas stent may be safe and effective in the treatment of wide-neck intracranial aneurysms. NeuroForm Atlas SAC is feasible for the treatment of both ruptured and unruptured wide-neck aneurysms.

OBJECTIVE: Spontaneous intracerebral hemorrhage (ICH) is caused by the rupture of small blood vessels and other health problems. In ICH patients, hematoma enlargement is the most critical risk factor for poor outcomes. Tranexamic acid, an anti-fibrinolytic agent, has been used to reduce hematoma expansion. We analyzed the risk factors for hematoma expansion in ICH patients and compared the predictability of hematoma expansion in ICH patients with the use of tranexamic acid. METHODS: We performed retrospective analysis of ICH patients who underwent follow-up computed tomography scans from October 2008 to October 2018. Of the 329 included patients, 67 who received tranexamic acid and 262 who did not receive tranexamic acid were compared. We also analyzed the risk factors of 45 and 284 patients who did and did not experience hematoma expansion, respectively. RESULTS: Hematoma expansion was observed in 7 (10.4%) of 67 patients in the tranexamic acid group and 38 (14.5%) of the 262 patients who did not receive tranexamic acid. There was no statistically significant difference between patients who did and did not received tranexamic acid (p=0.389). In the multivariate logistic regression analysis of risk factors for hematoma expansion, spot sign and a maximal diameter of 40 mm were identified as risk factors. CONCLUSION: We could not confirm the effect of tranexamic acid on hematoma expansion in ICH patients. Spot sign and the maximal diameter of hematomas were confirmed as risk factors of hematoma expansion. If the maximal diameter is greater than 40 mm, the hematoma should be closely monitored.
Antifibrinolytic Agents ; Blood Vessels ; Cerebral Hemorrhage ; Follow-Up Studies ; Hematoma ; Humans ; Logistic Models ; Retrospective Studies ; Risk Factors ; Rupture ; Tranexamic Acid

Chronic subdural hematoma (CSDH) and symptomatic subdural hygroma are common diseases that require neurosurgical management. Burr hole trephination is the most popular surgical treatment for CSDH and subdural hygroma because of a low recurrence rate and low morbidity compared with craniotomy with membranectomy, and twist-drill craniotomy. Many reports suggest that placing a catheter in the subdural space for drainage can further reduce the rate of recurrence; however, complications associated with this type of drainage include acute subdural hematoma, cortical injury, and infection. Remote hemorrhage due to overdrainage of cerebrospinal fluid (CSF) is another possible complication of burr hole trephination with catheter drainage that has rarely been reported. Here, we present 2 cases of remote hemorrhages following burr hole trephination with catheter drainage for the treatment of CSDH and symptomatic subdural hygroma. One patient developed intracerebral hemorrhage and subarachnoid hemorrhage in the contralateral hemisphere, while another patient developed remote hemorrhage 3 days after the procedure due to the sudden drainage of a large amount of subdural fluid over a 24-hour period. These findings suggest that catheter drainage should be carefully monitored to avoid overdrainage of CSF after burr hole trephination.
Catheters ; Cerebral Hemorrhage ; Cerebrospinal Fluid ; Craniotomy ; Drainage* ; Hematoma, Subdural, Acute ; Hematoma, Subdural, Chronic* ; Hemorrhage* ; Humans ; Recurrence ; Subarachnoid Hemorrhage ; Subdural Effusion ; Subdural Space ; Trephining

A 49 years old male patient who suffered from deterioration of posterior neck pain, left hand numbness, left lower limb pain and gait disturbance for 3 years visited our outpatient department. He had been diagnosed as non-dysraphic cervical intradural lipoma and operated in August 1990. On the radiologic images, we found the regrowth of non-dysraphic cervical intradural lipoma from C2 to C7 level, which surrounds and compresses the cervical spinal cord. Previous subtotal laminectomy from C2 to C7 and severe cervical lordosis were also found. Appropriate debulking of lipoma mass without duroplasty was successfully done with intraoperative neurophysiological monitoring (IONM). We are following up the patient for 24 months via outpatient department, his neurologic symptoms such as hand numbness, gait disturbance, left lower limb pain and posterior neck pain have improved. We describe a rare case of regrowth of non-dysraphic cervical intradural lipoma.
Animals ; Gait ; Hand ; Humans ; Hypesthesia ; Intraoperative Neurophysiological Monitoring ; Laminectomy ; Lipoma* ; Lordosis ; Lower Extremity ; Male ; Neck Pain ; Neurologic Manifestations ; Outpatients ; Spinal Cord ; Spinal Dysraphism*

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is often performed for the management of the patients wth chronic cerebral ischemic lesions or moyamoya disease. Postoperative aneurysm formation at the anastomosis site or its close proximity is a very rare complication. A 44-year-old female underwent bilateral STA-MCA bypass due to moyamoya disease. Approximately 2 years after bypass surgery, an aneurysm of the recipient cortical artery near the site of the anastomosis was found. Surgical exploration of the region demonstrated an 5.4 x 6.4 x 5 mm aneurysm arising near the site of the anastomosis. The aneurysm was clipped, taking care to keep the bypass flowing. This aneurysm had a thick wall and appeared to be a true saccular aneurysm caused by hemodynamic stress. The author present a case of this unusual complication and provide a brief review of literature.
Adult ; Aneurysm ; Arteries ; Cerebral Arteries* ; Cerebral Revascularization ; Female ; Hemodynamics ; Humans ; Middle Cerebral Artery* ; Moyamoya Disease

PURPOSE: The dosimetric advantages of multiple non-coplanar stationary fields for stereotactic radiotherapy or adiosurgery (SRT/S) are well known. However, this technique is not widely used due to the logistical problems associated with producing and testing customized collimators. We report our experience of SRT/S using multiple non-coplanar stationary fields (conformal SRT/ S). MATERIALS AND METHODS: Between August 1997 and February 2002, we performed frameless SRT/S in 63 patients. We chose conformal SRT/S when the tumor was of a very irregular shape or larger than 4 cm. We obtained three pieces of information: 1) the couch translations required to bring the target point to the isocenter, 2) the distance between the stereotaxic markers in the CT study, and the distance between the markers determined from orthogonal beam films, taken in the anterior- posterior and lateral directions, and 3) the rotational movement of the head position between the CT study and actual treatment position. We evaluated two kinds of data: 1) the precision of the isocenter setup, and 2) the reproducibility of the head position in the a) translational and b) rotational components. RESULTS: Twenty-six of the 63 patients receiving stereotactic treatment received conformal SRT/S. The precision of the isocenter setup for the conformal SRT/S was x=-0.03+/-0.26 mm, y=0.19+/-0.25 mm and z=-0.20+/-0.27 mm. The reproducibilities of the head position with the conformal SRT/S were 0.5 mm and less than 1degrees C, for the translational and rotational components, in any plane. CONCLUSION: We were able to apply conformal stereotactic irradiation, which has a dosimetric advantage, to irregularly shaped intracranial tumors, with precision and reproducibility of head position for the isocenter setup nearly equivalent to that of frame-based SRS or multiple-arc SRT/S.
Head ; Humans ; Radiotherapy* ; Translations