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Management of The Poor Grade Aneurysm Patient.

Korean Journal of Cerebrovascular Disease.1999;1(1):28-32.

Patients who suffer a severe aneurysmal subarachnoid hemorrhage(SAH) and who have arrived in the emergency room with devastated neurological or medical condition by this event are categorized as poor grade(Grade IV or V) aneurysm patients. As the poor grade patients are more prone to develop rebleeding, acute hydrocephalus, intracerebral and intraventricular hematoma, and delayed ischemic neurological deficits, the management of these patients remains challenging and controversial. However, it is now becoming evident that a significant number of the poor grade patients can be salvaged with an aggressive management from the moment of patient's arrival to the hospital. Initial management for the poor grade patients should be directed to the life threatening conditions such as cardiopulmonary depression, seizure, acute intracranial hypertension and rebleeding. The authors suggest that: 1) the Grade IV patients should be treated aggressively with direct clipping for patients with non-complex aneurysms, acute hydrocephalus, or significant amount of intracerebral hematoma; 2) The Grade V patients who show neurological improvement with supportive care could be the patients for an aggressive management; 3) Intra-aneurysmal treatment with Guglielmi Detachable Coil would be an alternative therapeutic option in the poor grade patients with advanced age, poor general physical condition, or complex aneurysm such as aneurysm of the posterior circulation or paraclinoid segment of the internal carotid artery.
Aneurysm* ; Carotid Artery, Internal ; Depression ; Embolization, Therapeutic ; Emergency Service, Hospital ; Hematoma ; Humans ; Hydrocephalus ; Intracranial Hypertension ; Seizures ; Subarachnoid Hemorrhage

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Intracranial Giant Aneurysms.

Hyung Dong KIM

Korean Journal of Cerebrovascular Disease.1999;1(1):17-27.

Intracranial giant aneurysms(GANs), approximately 5% of all intracranial aneurysms, represent a subgroup of diverse intracranial artery aneurysms(ANs) with a maximum sac diameter reaching or exceeding 25 mm. This size has been used arbitrarily to define this clinicopathological entity because smaller lesions have been shown to differ significantly with regard to the rate of rupture, the incidence of presentation with mass effect, and, most importantly, the difficulty of surgical treatment. And GANs also are a unique biological entity. The goals of therapy may include protection from hemorrhage, prevention and treatment of thromboembolic complications and relief of symptomatic mass effect. The treatment of all GANs has benefited from advances in angiography and imaging, endovascular techniques, intraoperative angiography, and collaborative advances in anesthetic technique, brain resuscitation and protection, critical care and rehabilitation. GANs present formidable surgical challenges due to their size, management strategies, brain protection and proximal control. Therefore dynamic and multidisciplinary strategy of therapy is optimally executed by a clinical team dedicated to interaction and collaboration, these clinical team should include diagnostic and interventional neuroradiology expertise and a technical competence geared toward realistic and individualized therapeutic options. The author reviewed the literature for clinical manifestation, diagnostic evaluation, therapeutic stategies including the method of brain protection of GANs.
Aneurysm* ; Angiography ; Arteries ; Brain ; Cooperative Behavior ; Critical Care ; Endovascular Procedures ; Hemorrhage ; Incidence ; Intracranial Aneurysm ; Mental Competency ; Rehabilitation ; Resuscitation ; Rupture

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Management of Cerebral Aneurysms in Elderly Patientsc.

Jae Hong SIM

Korean Journal of Cerebrovascular Disease.1999;1(1):7-16.

In many countries, the percentage of seninor citizens is expanding. Direct operation for ruptured aneurysm should be the choice of treatment in elderly patients of Hunt-Hess grade I through III, but should not be performed in cases of grade V. To evaluate the risk of early operation of elderly patients with ruptured cerebral aneurysm, conducted a retrospective analysis 464 elderly patients with ruptured aneurysms who were over aged 60 years between Jan 1980 to June 1999. Of these, 334 cases were performed early operation in which the direct intracranial operation was carried out within 3 days after last subarachnoid hemorrhage. The female: male ratio is 4.87: 1. The location of aneurysms are 144 anterior communicating artery aneurysms, 139 internal carotid artery aneurysms, 117 middle cerebral artery aneurysms, 35 multiple aneurysms, etc. Associated conditions are hypertension, diabetes mellitus, pulmonary problem, etc. Operation methods are 404 clippings, 53 coatings, 1 endovascular treatment, etc. Problems during operation are 29 broad aneurysms, 22 giant aneurysms, 21 tight brains, etc. In early operative group(within 3 days), 79% had favorable outcome, 11% unfavorable outcome and 10% died. The early operation is an effective and reliable method to reduce the occurrence of rebleeding, vasospasm, ischemic complication, medical complication and to shorten lengths of hospitalization.
Aged* ; Aneurysm ; Aneurysm, Ruptured ; Brain ; Carotid Artery, Internal ; Diabetes Mellitus ; Female ; Hospitalization ; Humans ; Hypertension ; Intracranial Aneurysm* ; Male ; Retrospective Studies ; Subarachnoid Hemorrhage

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A Case of Lateral Medullary Infarction Combined with Sudden Hearing Loss.

Joong Seok KIM ; Si Ryung HAN ; Young Bin CHOI ; Kwang Soo LEE

Korean Journal of Cerebrovascular Disease.2000;2(2):215-217.

We report a 62-year-old female with ischemic disturbance of left inner ear. The patient had a sudden onset episode of vertigo, tinnitus and hearing loss. Neurologic examination revealed incomplete Honor syndrome, left facial sensory impairment and sensorineural hearing loss. Brain MRI showed subacute infarct on medial aspect of left lateral medulla. Ischemic disturbance of inner ear have been reported only in patients with the anterior inferior cerebellar artery syndrome. Therefore, this patient who had only acute ischemic disturbance of inner ear and lateral medulla was considered to be very rare. This phenomenon may be due to variations of anterior inferior cerebellar artery anatomy.
Arteries ; Brain ; Ear, Inner ; Female ; Hearing Loss ; Hearing Loss, Sensorineural ; Hearing Loss, Sudden* ; Humans ; Infarction* ; Lateral Medullary Syndrome ; Magnetic Resonance Imaging ; Middle Aged ; Neurologic Examination ; Tinnitus ; Vertigo

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Time Responses to Nitric Oxide and Endothelin-1 in the Rabbit Basilar Artery with Vasospasm.

Soo Hyun HWANG ; Sun Ha PAEK ; Ki Jeong KIM ; In Sung PARK ; Eun Sang KIM ; Jin Myung JUNG ; Jong Woo HAN

Korean Journal of Cerebrovascular Disease.2000;2(2):205-214.

OBJECTIVES: This study aimed at clarifying the character of cerebral artery vasospasm on rabbit model by observing the vascular responses to nitric oxide and endothelin-1 treatment at different time points. MATERIALS AND METHODS: Twenty-eight rabbits undertook vertebrobasilar angiographies on the postoperative 2nd day and the 7th day after subarachnoid hemorrhage operation. The animals were divided into the vasospasm and the non-vasospasm group accroding to the result of vertebrobasilar angiographies. After sacrificing the animal, the vascular ring of harvested basilar artery was suspended in Krebs solution organ chamber for observation of isometric tension change in response to nitric oxide (NO) and endothelin-1 under high (95% O2 / 5% CO2) and low (95% N2 / 5% CO2) O2 tension. To investigate NO-dependent the vascular relaxation response, acetylcholine (10-7-3x10-4 M) was applied to basilar artery ring preconcentrated with histamine (10-6-10-5 M) in the organ chamber. The vascular contraction response was observed by applying endothelin-1 (10-11-3x10-8 M) into the organ chamber. RESULTS: The angiography showed vasospasm in seven of fifteen rabbits of the postoperative-2-day group (64.3+/-11.2%) and seven of fifteen rabbits of the postoperative-7-day (64.9+/-10.9%). On the postoperative-2-day, all the vascular response to NO and endothelin-1 under both high and low O2 tension was not significantly different between the vasospasm developed basilar artery and the vasospasm undeveloped one. On the postoperative-7-day, the vascular relaxation response to NO under high O2 tension was significantly different between the vasospasm developed basilar artery and the vasospasm undeveloped one (p=0.029). However, the vascular relaxation response to NO under low O2 tension was not significantly different. The vascular contraction response to endothelin-1 under high O2 tension was significantly different between the vasospasm developed basilar artery and the vasospasm undeveloped one (p=0.032). However, the vascular contraction response to endothelin-1 under low O2 tension was not significantly different. CONCLUSION: This experiment suggest that the vasospasm of the postoperative-2-day have different character from that of the postoperative-7-day in the rabbits. This suggestion may play some roles in the future study of the subarachnoid hemorrhage model. the study of the vasospasm mechanism of human, and developing antispasmodic drugs.
Acetylcholine ; Angiography ; Animals ; Basilar Artery* ; Cerebral Arteries ; Endothelin-1* ; Histamine ; Humans ; Nitric Oxide* ; Parasympatholytics ; Rabbits ; Relaxation ; Subarachnoid Hemorrhage

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Arteriovenous Malformation at Cerebellopontine Angle Associated with a Fenestration of the Vertebral Artery.

Jung Yong AHN ; Seong Oh KWON

Korean Journal of Cerebrovascular Disease.2000;2(2):200-204.

A fenestration of the vertebral artery is considered to be an unusual vascular variation that is defined as a bypass artery along the extracranial or at intracranial segment of the artery. A fenestration of the vertebral artery associated with an arteriovenous malformation at the cerebellopontine angle is extremely rare. We report a case of the ruptured arteriovenous malformation with a fenestration of vertebral artery. The embryologic genesis and clinical significance of a fenestration of the vertebral artery are discussed.
Arteries ; Arteriovenous Malformations* ; Cerebellopontine Angle* ; Vertebral Artery*

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Far Lateral Approaches for Intracranial Aneurysms.

Han Kyu KIM

Korean Journal of Cerebrovascular Disease.2000;2(2):190-199.

Surgical approaches to the posterior circulation aneurysms are difficult and still remained as a matter of debate. Many skull base approaches has been developed to overcome the inadequate exposure of these aneurysm by conventional surgical approaches. Far lateral approaches are an extension of suboccipital approach to expose neurovascular structures around the lower clivus. Aneurysms locating at the vertebral arteries, vertebrobasilar junction and lower basilar artery could be exposed by these approach. However, it is not still evident which kind of far lateral approach is most appropriate for the aneurysms of various locations at these vascular territory. Among the 3 kinds of far lateral approaches, such as far lateral, far lateral transcondylar and extreme lateral transcondylar approach, far lateral approach is not recently used frequently. Far lateral transcondylar approach is good far the aneurysm at the origin of posterior inferior cerebellar artery and the extreme lateral transcondylar approach is useful to expose aneurysms around vertebrobasilar junction. For an appropriate selection of surgical approaches, useful surgical guidelines are mandatory. The recent use of "intermeatal line" and "K lines" and others are of many help for the lower basilar and vertebral artery aneurysms. Surgical approach itself needs knowledge and experience for an adequate performance. Once exposed appropriately manipulation of aneurysms at these locations are not very complicated. Microsurgical anatomy of each surgical step is essential for the sucessful management of aneurysms locating at the lower clivus.
Aneurysm ; Arteries ; Basilar Artery ; Cranial Fossa, Posterior ; Intracranial Aneurysm* ; Skull Base ; Vertebral Artery

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Petrosal Approaches for Intracranial Aneurysm.

Chang Hwa CHOI

Korean Journal of Cerebrovascular Disease.2000;2(2):177-189.

Aneurysms of the vertebrobasilar trunk pose a most difficult anatomic problem to access because these lesions are located in a small restricted area encased with thick dense bone, with a limited subarachnoid space, and are filled with the most dense collection of vital cranial nerves and vascular structures. So, "exposure is everything" is very appropriate for these lesion. Furthermore, while achieving maximum exposure, there must be a minimum of brain retraction to protect the patient from the injury. For achieve these purpose, several techniques that maximize lateral skull removal to provide a relatively short and flat route of access to the front of the brain stem and basilar artery, were introduced but full satisfaction was not achieved. Recently, transpetrosal approaches were applied to access into the anterior brain stem and clival region through the petrosal bone removal without brain or brain stem retraction and excellent results were reported. In this paper, detailed summary of steps of each petrosal approaches and illustrations form Fukushima's manual of skull base dissection will be presented after reviewing some articles about petrosal approaches.
Aneurysm ; Basilar Artery ; Brain ; Brain Stem ; Cranial Nerves ; Humans ; Intracranial Aneurysm* ; Skull ; Skull Base ; Subarachnoid Space

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Modified Transsylvian Approach with Orbitozygomatic Resection for Distal Basilar Artery Aneurysms.

Jae Hong SIM ; Sun Il LEE

Korean Journal of Cerebrovascular Disease.2000;2(2):171-176.

Aneurysms arising from the distal basilar artery(BA) and relating to the origin of the superior cerebellar artery (SCA), posterior cerebral artery (PCA) account for more than 15% of all intracranial aneurysms and more than one-half of all aneurysms occurring in the vertebrobasilar circulation. The anatomic complexity of the interpeduncular cistern is directly related to the dangers of surgical manipulation in this region and it is undoubtedly difficult to operate on a distal basilar aneurysm which located deep in a very narrow operative field restricted by unremovable neural and vascular architectures. Although we can not choose no single operative approach suitable to this area because the indivisual patient's vascular, neural and bony anatomy is widly variable, using the modified transsylvian approach with orbitozygomatic resection the distal basilar artery aneurysms could be seen and clipped easily by upward and oblique viewing from below through the wide operative space consisting of the less retracted intracarotid artery, middle cerebral artery and oculomotor nerve. We have operated 64 distal basilar artery aneuysms. Among them, 27 patients were approached using the modified transsylvian approach with orbitozygomatic resection. The operative procedure is presented in detail and compared with other surgical approaches.
Aneurysm ; Arteries ; Basilar Artery* ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery ; Oculomotor Nerve ; Posterior Cerebral Artery ; Surgical Procedures, Operative

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Subtemporal Approach for Cerebral Aneurysm.

Jae Whan LEE ; Seung Kon HUH

Korean Journal of Cerebrovascular Disease.2000;2(2):163-170.

Only about 15% of intracranial aneurysms involve the posterior circulation and about 80% of distal basilar aneurysms have their origin at the level of or above the posterior clinoid process. Therefore, they are potentially approachable via the pterional or trans-sylvian route. This imply that most neurosurgeons will relatively rarely be required to perform this procedure. Especially basilar bifurcation aneurysms arising substantially below the level of the posterior clinoid process or projecting posteriorly could be successfully repaired via subtemporal approach. There are number of unique surgical problems that can be best attacked through a subtemporal approach, and for this reason it is important to have facility with its performance and a detailed understanding of its advantages and limitations. Surgical tactics and pitfalls of subtemporal approach will be described with a basis of experiences in Yonsei University and review of literatures.
Aneurysm ; Intracranial Aneurysm*

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