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Posttraumatic Carotid-cavernous fistula Combined with Intracavernous False Aneurysm.

Jong Won CHOE ; Kum WHANG ; Hyun Ho JUNG ; Yong Pyo HAN ; Hun Joo KIM ; Soon Ki HONG ; Chul HU ; Jhin Soo PYEN

Korean Journal of Cerebrovascular Surgery.2007;9(3):216-220.

Posttraumatic high-flow communications between the intracavernous internal carotid artery (ICA) and the cavernous sinus may give rise to two different pathological entities. A connection from the intracavernous ICA system can theoretically connect with two different structures; the vein of the plexus (CCF) or the perivascular bare spaces between the veins (pseudoaneurysm). A CCF and a pseudoaneurysm can be present in the same patient. A 24-year-old man was admitted to our hospital due to sudden mental deterioration. Carotid angiography revealed a CCF, which had occurred after a trauma 5 years earlier, associated with left visual disturbance and skull base fractures. The treatment of choice was permanent coil occlusion of the intracavernous ICA at the level of the lesion. The collateral circulation was evaluated before the endovascular treatment using a balloon test occlusion (BTO). During the BTO, adequate collateral circulation was defined as symmetric angiographic filling of both hemispheres. A continuous neurological examination was performed during the procedure. The follow-up angiography showed a persistent aneurysm occlusion. We report our experience of the successful endovascular treatment of combined lesions with a review of the relevant literature.
Aneurysm ; Aneurysm, False* ; Angiography ; Carotid Artery, Internal ; Cavernous Sinus ; Collateral Circulation ; Fistula* ; Follow-Up Studies ; Humans ; Neurologic Examination ; Skull Base ; Veins ; Young Adult

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Clinical Analysis of Patients with Ruptured Cerebral Aneurysms associated with Polycystic Kidney Disease.

Hoon KIM ; Jae Whan LEE ; Tae Hyung KWON ; Seung Kon HUH ; Kyu Chang LEE

Korean Journal of Cerebrovascular Surgery.2007;9(3):212-215.

OBJECTIVE: This study is to define the clinical characteristics and formulate the management strategies of the patients with ruptured cerebral aneurysms associated with polycystic kidney diseases (PKD). METHODS: During the past 30 years, among of 3,013 patients who were treated with intracranial aneurysms, 7 patients had ruptured cerebral aneurysms associated with PKD. The authors retrospectively reviewed the database and imaging studies of such patients as sources for identification and analysis. RESULTS: All 7 patients presented with subarachnoid hemorrhage (SAH). One patient showed Hunt and Hess grade I, 4 of grade II, and 2 of grade III. Six patients showed Fisher group II and 1 patient of group III. Four aneurysms were located at anterior cerebral artery, 2 at middle cerebral artery, and 1 at internal carotid artery. Five patients had small aneurysms and the remaining 2 had large (diameter > or = 10 mm) aneurysms. All aneurysms were in saccular shape. Two of the 7 patients (28.6%) had multiple aneurysms. One patient suffered delayed ischemic neurological deficit. All patients were treated by microsurgery and showed favorable outcome (good: 7). CONCLUSIONS: The patients harboring PKD had high probability of hypertension. So, intact aneurysms in those patients were exposed to higher rate of being ruptured. Surgery was necessary for ruptured lesions, as well as unruptured lesions which size was increased at follow up imaging study. Multimodality management approach with nephrologist and neuroradiologist are very necessary. The ultimate management outcome was satisfactory.
Aneurysm ; Anterior Cerebral Artery ; Carotid Artery, Internal ; Follow-Up Studies ; Humans ; Hypertension ; Intracranial Aneurysm* ; Microsurgery ; Middle Cerebral Artery ; Polycystic Kidney Diseases* ; Retrospective Studies ; Subarachnoid Hemorrhage

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Stent Angioplasty for Intracranial Vertebral Dissections: Single Stent versus Double Stent Placement.

Keun Young PARK ; Jun Hyung CHO ; Chang Ki HONG ; Sang Hyun SUH ; Jung Yong AHN

Korean Journal of Cerebrovascular Surgery.2007;9(3):206-211.

OBJECTIVE: The reduced stent porosity caused by a double stent may accelerate the intraaneurysmal thrombosis and be helpful in achieving a more rapid complete occlusion compared with that achieved by single stent placement. This study examined the safety and efficacy of stent angioplasty according to two different stent techniques (single versus double stent placement). METHODS: Twenty two patients who underwent stent angioplasty for vertebral dissections were reviewed retrospectively. RESULTS: In the 22 patients, 23 intracranial vertebral artery dissections were treated using stent placement. Among them, 12 dissections were treated with single stent placement. The immediate and follow-up angiography showed a complete occlusion in only one case(8.3%). Eleven dissections were treated using a double stent method. Although an immediate complete occlusion was performed in only one case, the follow-up angiography revealed a complete occlusion in six cases(54.6%). Complications were encountered in only one case (4.3%, acute thrombosis) in the double stent placement group. On the modified Rankin scale applied in the follow-up, all the patients were assessed as being functionally improved or of a stable clinical status in both groups except for one patient with a severe subarachnoid hemorrhage who underwent a double stent placement. CONCLUSIONS: Intracranial vertebral artery dissections can be treated alternatively using an endovascular method with a stent. Double stent placement is superior to the single stent method. However, there are some limitations and complications associated with stent angioplasty.
Aneurysm, Dissecting ; Angiography ; Angioplasty* ; Follow-Up Studies ; Humans ; Porosity ; Retrospective Studies ; Stents* ; Subarachnoid Hemorrhage ; Thrombosis ; Vertebral Artery ; Vertebral Artery Dissection

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Prognostic factors influencing outcomes in elderly patients with aneurysmal subarachnoid hemorrhage.

Se Hyun JOUNG ; Dong Youl RHEE ; Hwa Seung PARK ; Joon Suk SONG ; Weon HEO ; Do Hyung KIM

Korean Journal of Cerebrovascular Surgery.2007;9(3):198-205.

OBJECTIVE: This study evaluated the prognostic factors that influence the surgical outcomes of elderly patients older than 65 years old with an aneurysmal subarachnoid hemorrhage. METHODS: Ninety-two patients older than 65 years old, who were operated in our hospital between 1998 and 2005, were reviewed retrospectively. The clinical outcomes were evaluated using the modified Rankin Scale three months after surgery. RESULTS: The preoperative neurological status, such as the Hunt-Hess grade (p<0.001), World Federation of Neurological Surgeons (WFNS) grade (p<0.001), and the Fisher grade (p=0.001), was significantly associated with the surgical outcomes in this series. The vasospasm (0.016) and ventriculostomy (0.039) are factors influencing the surgical outcomes. However, the other factors including hypertension (0.831), smoking (0.228), accompanying disorder (0.706), size of aneurysms (0.177), location of aneurysms (0.755), shunt operation (0.356), and timing of surgery (0.194) had no influence on the surgical outcome. CONCLUSION: In elderly patients with intracranial aneurysms, the preoperative neurological status, vasospasm, and ventriculostomy are the most significant prognostic factors.
Aged* ; Aneurysm* ; Humans ; Hypertension ; Intracranial Aneurysm ; Retrospective Studies ; Smoke ; Smoking ; Subarachnoid Hemorrhage* ; Ventriculostomy

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Clinical Characteristics of Pediatric Cerebral Aneurysms.

Chung Won YANG ; Jae Whan LEE ; Jin Young JUNG ; Seung Kon HUH ; Kyu Chang LEE ; Dong Ik KIM

Korean Journal of Cerebrovascular Surgery.2007;9(3):193-197.

OBJECTIVE: The aim of this study was to define the clinical characteristics of pediatric cerebral aneurysms. METHODS: During the past 30 years, among a total of 3,330 patients treated for cerebral aneurysms, 12 patients were under the age of 18. The authors reviewed the database and imaging studies as sources for identification and analysis. RESULTS: Seven patients were male and 5 were female. The mean age was 12.9 years old (range: 3~18). Nine patients had ruptured lesions and the remaining 3 had unruptured lesions. Four patients presented with a subarachnoid hemorrhage, and the other 5 patients presented with an intracerebral hemorrhage (ICH). Five aneurysms were located at the posterior cerebral artery or vertebrobasilar artery, 4 at the middle cerebral artery, and 3 at the internal carotid artery, respectively. The giant aneurysm was observed in 2 (18%) patients. Eleven aneurysms were saccular, and 1 was serpentine in shape. No patient had multiple aneurysms. Rebleeding was observed in 3 cases (33%). No child suffered from clinical vasospasm. All but one patient showed a favorable outcome (good: 11, dead: 1). CONCLUSIONS: Pediatric cerebral aneurysms in this study showed a male predominance, a high incidence of presentation with ICH, a location on the distal circulation of the major arteries or on the posterior circulation, and a large or giant aneurysm, high rebleeding rate and a low incidence of vasospasm. The overall clinical outcome was excellent in 91.7% in this study. With the knowledge of these features, aneurysmal obliteration and active brain resuscitation can improve the clinical outcome and prognosis.
Aneurysm ; Arteries ; Brain ; Carotid Artery, Internal ; Cerebral Hemorrhage ; Child ; Female ; Humans ; Incidence ; Intracranial Aneurysm* ; Male ; Middle Cerebral Artery ; Posterior Cerebral Artery ; Prognosis ; Resuscitation ; Subarachnoid Hemorrhage

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Long Term Magnetic Resonance Angiography Follow-up in Moyamoya Disease.

Nam Kyu YOU ; Kyu Won SHIM ; Young Seok PARK ; Jung Hee KIM ; Dong Seok KIM ; Joong Uhn CHOI

Korean Journal of Cerebrovascular Surgery.2007;9(3):188-192.

OBJECTIVE: Revascularization is an effective treatment for the ischemic symptom of moyamoya disease. Indirect revascularization is also effective. Magnetic resonance angiography (MRA) has the ability for collateral formation that is equivalent to conventional angiography. This study analyzed the results of indirect revascularization by MRA. METHODS: A total of 25 patients underwent bilateral EDAS for the management of moyamoya disease. All patients underwent MRA after surgery more than 24 months later. The collateral formation was graded as Good, Fair, and Poor. The clinical outcome was assessed as Excellent, Good, Fair, and Poor. RESULTS: Good collateral formation was 32 sides of the EDAS, and fair was 18. An excellent clinical outcome was obtained in 15 patients, Good in 8, Fair in 1, and Poor in 1. There was a significant correlation between the preoperative symptom, gender, and the clinical outcome. CONCLUSION: In the management of ischemic moyamoya disease, indirect revascularization has been the golden standard with remarkably low morbidity and mortality. Moreover, and MRA can replace conventional angiography in the follow-up of moyamoya patients.
Angiography ; Follow-Up Studies* ; Humans ; Magnetic Resonance Angiography* ; Mortality ; Moyamoya Disease*

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Clinical Characteristics of Pediatric Cerebral Aneurysms.

Tae Yong KIM ; Jae Hyuk KIM ; Su Hyun KIM ; Eun Kwang LIM ; Kee Hyung PARK ; Young Hui SUNG ; Hyeon Mi PARK ; Dong Jin SHIN ; Yeong Bae LEE

Korean Journal of Cerebrovascular Surgery.2007;9(3):183-187.

BACKGROUND: Hypercholesterolemia is a major risk factor for ischemic stroke. It was reported that a low triglyceride (TG), not a low cholesterol concentration, was independently associated with the poor outcome of ischemic stroke. There are no reports on relationship between the serum TG level and the clinical outcome of acute stage of ischemic stroke. Moreover, the differences in clinical outcome of each subtype of ischemic stroke in relation to the serum TG level are unknown. This study examined relationship between the serum TG level upon admission and the clinical outcome at discharge in each subtype of acute ischemic stroke. METHODS: Four hundred and fifty consecutive patients with their first-ever ischemic stroke, who admitted between January 2004 and December 2006, were examined retrospectively. The serum TG level was measured within 24 hours after stroke onset. The subtypes of stroke were classified according to the Trial of ORG 10172 in the Acute Stroke Treatment (TOAST) classification. The severity and outcome of stroke were assessed using the National Institutes of Health Stroke Scale (NIHSS) score upon admission, at discharge, and 4 weeks after discharge. The population was divided into 3 groups according to the serum TG level (Normal TG group : serum TG level 150mg/dl, Borderline-high TG group : 150 degrees ¬ TG< 200mg/dl, High TG group : serum TG level 200mg/dl) and 2 groups by NIHSS score (Improved outcome group: NIHSS score decreased or unchanged, Worsened outcome group: NIHSS score increased). The relationship between the level of TG of each stroke subtype and the clinical outcome of those patients was analyzed. RESULTS: The study population was divided into three groups, according to the serum TG level. The Normal TG group consisted of 128 patients (mean serum TG level : 74.0 17.2mg/dl). The borderline-high TG group consisted of 230 patients (mean serum TG level : 168.9 20.4 mg/dl). The high TG group consisted of 92 patients (mean serum TG level : 474.5 197.0 mg/dl). Hypertension and diabetes are prevalent in the high TG group, which also had higher incidence of large artery disease in the TOAST classification. The normal TG group showed more severe stroke upon admission and a poor clinical outcome after 4 weeks than the other two groups (p<0.05). Each TOAST classification of TG group showed a similar clinical outcome. CONCLUSION: The normal TG group had a more severe the stroke and poorer clinical outcome than the other groups. TG may play a role as a protective factor in the acute stage of ischemic stroke.
Arteries ; Cholesterol ; Classification ; Humans ; Hypercholesterolemia ; Hypertension ; Incidence ; Intracranial Aneurysm* ; National Institutes of Health (U.S.) ; Retrospective Studies ; Risk Factors ; Stroke ; Triglycerides

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Navigation-assisted Aspiration and Thrombolysis of Deep Intracerebral Hemorrhage.

Nam Kyu YOU ; Jung Yong AHN ; Jun Hyung CHO ; Chang Ki HONG ; Jin Yang JOO

Korean Journal of Cerebrovascular Surgery.2007;9(3):172-176.

OBJECTIVE: Frame-based stereotatic catheter placement and subsequent thrombolysis is one treatment option for the management of a deep intracerebral hemorrhage. Recently, frameless stereotactic surgery with a navigation system has been introduced to reduce the hematoma volume. This study was designed to evaluate the effectiveness of frameless stereotactic ICH catheterization using a navigation system. METHODS: From January 2006 to November 2006, we identified 27 patients who were diagnosed with deep ICH and underwent navigationassisted frameless stereotactic catheter insertion with/without thrombolysis by urokinase irrigation. RESULTS: The mean length between the center of the hematoma and the tip of the catheter was 6.8 mm (range between 0 and 15 mm). The catheter tip and target matched in 8 patients (29.6%). In cases of an inappropriately located catheter tip (70.4%), most of the hematomas were thalamic in location due to the long trajectory (9 of 10 thalamic locations). The preoperative hematoma volume showed a statistically significant correlation with the final hematoma volume. There was no mortality reported. Multiple regression analysis showed a statistically significant correlation between the initial Glasgow coma scale score and the outcome. CONCLUSIONS: Navigation-assisted frameless stereotactic ICH catheterization has limited accuracy but is effective in reducing the ICH volume reduction.
Catheterization ; Catheters ; Cerebral Hemorrhage* ; Glasgow Coma Scale ; Hematoma ; Humans ; Mortality ; Urokinase-Type Plasminogen Activator

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Clipping of Upward Projection Anterior Communicating Artery Aneurysms Adhering Tightly to the A2 Segment.

Ji Myoung HONG ; Sung Don KANG ; Jong Moon KIM

Korean Journal of Cerebrovascular Surgery.2007;9(3):168-171.

OBJECTIVE: The ideal treatment of intracranial aneurysms is an occlusion of the neck with a clip, which preserves the parent vessels. Upward projecting anterior communicating artery(Acom) aneurysms appear to be directed both above and below the plane formed by the two A2 segments, which usually conceal the contralateral A2 takeoff. It is difficult to perform complete clipping when these lesions are tightly adherent to the A2 segment. Neurosurgeons need to focus on the safe treatment of these lesions. A variety of clipping techniques can be used depending on the aneurysm anatomy, size, and morphology. The authors recommend a safe method of clipping these lesions safely. METHODS: The authors operated on 109 patients with upward projecting Acom aneurysms over the last 16 years. Among them, 34 aneurysms were clipped using fenestrated clips through the side of the dominant A1 segment, which were closely adhered to the A2 segment. RESULT: In each case, the aneurysm and both A2 segments formed a straight line in the narrow surgical field and were not easily separated, and consequently it was difficult to handle the aneurysm behind the ipsilateral A2. After partial identification of the Acom complex, careful dissection of the posterior aspect of the ipsilateral A2 and the aneurysm dome was continued to allow mobilization of both A2 segments and the aneurysm. All aneurysms were secured successfully without any surgery related complications. CONCLUSION: The authors recommend that fenestrated clip incorporating the ipsilateral A2 segment after complete mobilization of both A2 segments and the aneurysm may be useful for definitive clipping of upward projecting Acom aneurysm which is densely adherent to the A2 segment.
Aneurysm ; Humans ; Intracranial Aneurysm* ; Neck ; Parents

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The Eyebrow Approach to Anterior Communicating Artery Aneurysms.

Seng Oun SUNG ; Byung Chan JEON ; Young Su KIM ; Il Sup KIM

Korean Journal of Cerebrovascular Surgery.2007;9(3):161-167.

OBJECTIVE: This study reviewed the clinical outcomes of patients with anterior communicating artery (AComA) aneurysms that were treated surgically using an eyebrow approach. The indications and limitations of this approach for the treatment of AComA aneurysms are also suggested. METHODS: Between October 1999 and June 2006, 121 procedures were performed on 115 patients with 146 cerebral aneurysms via a superior orbital rim craniotomy through an eyebrow incision. Of them, 51 patients with AComA aneurysms were reviewed retrospectively according to the patient's age and gender, the Hunt-Hess grade upon admission, the Fisher grade of the subarachnoid hemorrhage, the size of the aneurysm, the direction of the aneurysmal sac, the outcome at 3-month follow-up period, complications and the intraoperative problems. RESULTS: Overall, excellent and good outcomes were achieved in 47 patients (92.1%) and one patient died (2.0%). Clinically, there were 7 patients with a poor grade (Hunt-Hess grade 4); 3 showed a good outcome, 2 fair, 1 poor and 1 died. Premature rupture of the aneurysm during surgery occurred in 5 patients. One procedure was converted to the pterional approach due to severe brain swelling. Postoperative subdural fluid collection was noted in 9 patients, of whom 2 patients required temporary drainage and 1 patient needed a permanent subdural fluid diversion. Vasospasm and a subsequent infarction were observed in 4 patients. Hydrocephalus that required a ventriculoperitoneal shunt was found in only 2 patients. CONCLUSIONS: The favorable indications for eyebrow surgery include good grade patients with a ruptured or unruptured AComA aneurysm, and patients with small and medium sized aneurysms. Furthermore, the poor grade or high Fisher grade patients with or without multiple concomitant aneurysms can also be treated with eyebrow surgery.
Aneurysm ; Arteries ; Brain Edema ; Craniotomy ; Drainage ; Eyebrows* ; Follow-Up Studies ; Humans ; Hydrocephalus ; Infarction ; Intracranial Aneurysm* ; Orbit ; Retrospective Studies ; Rupture ; Subarachnoid Hemorrhage ; Ventriculoperitoneal Shunt

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