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Angiographic and Clinical Results of Indirect Bypass Surgery for Moyamoya Disease.

Jung pyo LEE ; Sung Jin CHO ; Hyung Ki PARK ; Sukh Que PARK ; Jae Chil CHANG ; Soon Kwan CHOI

Korean Journal of Cerebrovascular Surgery.2010;12(4):250-258.

OBJECTIVE: This study aimed to verify the validity and effectiveness of indirect bypass surgery as a treatment for Moyamoya disease. The development of post-surgical collateral circulation was investigated, and the clinical effectiveness of the surgery was confirmed. METHODS: Of 45 patients (66 hemispheres) with Moyamoya disease, 28 (42 hemispheres) were followed by cerebral angiography for at least 6 months after surgery, between May 2002 and May 2009. There were eight men (13 hemispheres) and 20 women (29 hemispheres) with an average age of 24 +/- 17.1 years (range, 2-62 years) at the time of diagnosis. The average follow-up period was 23 +/- 18.6 months (range, 6-67 months). Indirect revascularization surgery was performed as encephaloduroarteriomyosynangiosis (EDAMS) in 39 cases, encephaloduroarteriosynangiosis (EDAS) in three cases, and bifrontal encephalogaleoperiosteal synangiosis (BEGPS) in 21 cases. The development of collateral circulation was assessed by cerebral angiography at least 6 months after surgery to evaluate the results of the indirect revascularization surgery. For the classification, good indicated collateral circulation of more than two-thirds of the middle cerebral artery distribution; fair between one- and two-thirds; and poor very weak or no collateral circulation. The development of collateral circulation was compared according to age, gender, clinical feature, surgical method, and Suzuki stage. RESULTS: Cerebral infarction was the most frequent clinical feature at the time of incidence (27 cases; 64.4%), and Suzuki stage 3 was most common (15 cases; 35.7%). Based on cerebral angiography, 85.7% of patients showed good or fair development of collateral circulation, which was better among pediatric patients (< or =15-years-of-age) than adult patients (>15-years-of-age; p = 0.0344). Compared with EDAS, EDAMS tended to show better surgical results, but the difference was not statistically significant. Gender, clinical feature, or Suzuki stage did not influence the results. Among 21 patients in whom BEGPS was performed, 15 (71.4%) showed good or fair development of collateral circulation. CONCLUSION: Among the Moyamoya disease patients who received indirect bypass surgery, about 85% showed good or fair results, with collateral circulation involving more than one-third of the middle cerebral artery area. In addition to its effect in pediatric patients younger than 15-years-of-age, indirect bypass surgery also resulted in the development of collateral circulation in adults. EDAMS showed better effectiveness than EDAS as a surgical method. It is speculated that multiple, open arachnoid membranes stimulate the development of collateral circulation. One shortcoming of indirect bypass surgery for Moyamoya disease is that several months are required for the development of collateral circulation. One advantage is that it enables sufficient collateral circulation to develop in those who cannot endure direct bypass surgery. More effective results are expected with BEGPS.
Adult ; Arachnoid ; Cerebral Angiography ; Cerebral Infarction ; Cerebral Revascularization ; Collateral Circulation ; Female ; Follow-Up Studies ; Humans ; Imidazoles ; Incidence ; Male ; Membranes ; Middle Cerebral Artery ; Moyamoya Disease ; Nitro Compounds

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Contrast Medium-Induced Transient Neurologic Deteriorations Following Cerebral angiography and Coil Embolization for Unruptured Aneurysm: Report of Two Cases.

Young Jun SEO ; Chang Hwa CHOI

Korean Journal of Cerebrovascular Surgery.2010;12(4):245-249.

Cerebral angiography with contrast medium (CM) is a key method for diagnosis and interventional treatment of intracranial cerebral vascular lesions. Cerebral angiography causes few neurologic complications. There have been rare reports of complications related to disruption of the blood-brain barrier due to the administration of nonionic CM. We observed two patients with transient neurologic complications following cerebral angiography and coil embolization for unruptured aneurysm.
Aneurysm ; Blood-Brain Barrier ; Cerebral Angiography ; Humans

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A Retrieval Thrombectomy Technique with the Solitaire Stent: Two Case Reports.

Hyun PARK ; Gyo jun HWANG ; Jae Seung BANG ; In Sung PARK ; Chang Wan OH ; O Ki KWON

Korean Journal of Cerebrovascular Surgery.2010;12(4):240-244.

Two male patients who presented with altered mental states and hemiparesis were treated by retrieval thrombectomy. The occlusion sites were M1 in both patients. During each thrombectomy, a self-expanding and fully retrievable Solitaire stent was partially deployed to cover the whole intra-arterial clot and then was retrieved slowly while occluding the internal cerebral artery with a balloon-guiding catheter. Complete recanalization (defined as thrombolysis of cerebral infarction grade 2b or 3) was achieved in both patients. The procedural time from groin puncture to recanalization was 17 min and 30 min, respectively. Immediate post-operative National Institutes of Health Stroke scores improved to 17 from 22 in one patient and to 19 from 24 in the other patient. There were no procedure-related complications including distal embolisms or post-operative intracranial hemorrhages. We suggest that this technique may be a simple, rapid, and safe thrombolytic method for acute ischemic stroke patients with large artery occlusions.
Arteries ; Catheters ; Cerebral Arteries ; Cerebral Infarction ; Embolism ; Groin ; Humans ; Intracranial Hemorrhages ; Male ; National Institutes of Health (U.S.) ; Paresis ; Punctures ; Stents ; Stroke ; Thrombectomy

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Intraventricular Hemorrhage and Ischemic Heart Disease as Initial Presentation of Polycythemia Vera: Case Report.

Seung Ho YOO ; Hyung Shik SHIN ; Jun Jae SHIN ; Tae Hong KIM ; Yong Soon HWANG ; Sang Keun PARK

Korean Journal of Cerebrovascular Surgery.2010;12(4):237-239.

Polycythemia vera (PV) is a myeloproliferative disorder characterized by clonal proliferation of hematopoietic stem cells leading to an accumulation of erythrocytes, leukocytes and platelets within the circulation. Thrombosis and hemorrhage are the most common serious complications of PV, and occur in 30-50% of patients. We report an unusual case of PV initially presenting with intraventricular hemorrhage, with concomitant ischemic heart disease.
Blood Platelets ; Erythrocytes ; Hematopoietic Stem Cells ; Hemorrhage ; Humans ; Leukocytes ; Myeloproliferative Disorders ; Myocardial Ischemia ; Polycythemia ; Polycythemia Vera ; Thrombosis

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Giant Intracranial Aneurysm with Blind Sac on Middle Cerebral Artery: Case Report.

Sung Jin CHO ; Sukh Que PARK ; Hyung Ki PARK ; Jae Chil CHANG ; Soon Kwan CHOI

Korean Journal of Cerebrovascular Surgery.2010;12(4):233-236.

A case of a giant intracranial aneurysm (GIA) with a blind sac on the left middle cerebral artery (MCA) accompanied by mural thrombosis is described. A 62-year-old male presented with headache and motor dysphasia. Magnetic resonance imaging and digital subtraction angiography revealed a GIA that arose from the proximal MCA. The M2 segment of the MCA was not visualized due to intramural thrombosis. The patient was treated with an extracranial-intracranial arterial bypass and trapping of the aneurysm. Literature relevant to the management of this rare lesion is reviewed and discussed.
Aneurysm ; Angiography, Digital Subtraction ; Aphasia ; Cerebral Revascularization ; Headache ; Humans ; Intracranial Aneurysm ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Middle Cerebral Artery ; Thrombosis

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Pathophysiology of Spontaneous Intracerebral Hemorrhage.

Bum Tae KIM ; Chul Woo LEE ; Sun Chul HWANG ; Soo Bin IM ; Won Han SHIN

Korean Journal of Cerebrovascular Surgery.2006;8(1):63-65.

Chronic hypertension causes pathologic changes within the tunica media, termed lipohyalinosis. The most prominent changes were seen at bifurcation point within the vessels and middle and distal portion of the vessels. The role of microaneursyms in spontaneous intracerebral hemorrhage (ICH) secondary to hypertension is not well understood. A cerebral amyloid angiopathy is associated with fibrinoid necrosis and affects the small to medium sized vessels and it may account for a higher percentage of spontaneous ICH in the elderly. Neurologic dysfunction secondary to ICH is caused by initial hemorrhage with its associated mass effect, and tissue destruction with hematoma enlargement. Consequently, the further deterioration may be due to cerebral edema. The exact role of CBF changes is not unproved in the pathogenesis of neuronal injury. However, much has been learned about the mechanisms involved the brain edema formation after ICH. A number of components of blood are capable of inducing brain injury and brain edema formation. The hematoma exerts its effects not only by mechanical but also by chemical influences.
Aged ; Brain Edema ; Brain Injuries ; Cerebral Amyloid Angiopathy ; Cerebral Hemorrhage* ; Hematoma ; Hemorrhage ; Humans ; Hypertension ; Necrosis ; Neurologic Manifestations ; Neurons ; Tunica Media

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Risk Factors for Ischemic Lesions on Computed Tomography in Aneurysmal Subarachnoid Hemorrhage.

Seung Jae HYUN ; Jong Sik SUK ; Jeong Taik KWON ; Hyun Jong HONG ; Young Baeg KIM

Korean Journal of Cerebrovascular Surgery.2006;8(1):56-62.

OBJECTIVE: The aim of this study was to investigate predictive risk factors for permanent ischemic lesions visible on follow-up computerized tomography scans obtained after subarachnoid hemorrhage (SAH). METHODS: A hundred and two patients who were treated with surgery for aneurysmal SAH from November 2002 to February 2005 were retrospectively analyzed. The predictive risk factors for permanent ischemic lesions used in this study were as follows ; age, sex, obesity, preoperative clinical condition, amount of SAH (Fisher grade), location of aneurysm, intracerebral hemorrhage (ICH), intraventricular hemorrhage, symptomatic vasospasm, duration of temporary artery occlusion, transfusion, hypertension, diabetes mellitus, cigarette smoking and time of SAH. RESULTS: Permanent ischemic lesions developed in 55 (60%) patients. The presence of lesions correlated highly with preoperative clinical condition (p=0.032), amount of subarachnoid blood (p=0.007), middle cerebral artery aneurysms (p=0.041), ICH (p=0.039), symptomatic vasospasm (p=0.027), duration of temporary artery occlusion during surgery (p=0.004), diabetes mellitus (p=0.043), excessive alcohol drinking (p=0.040), cigarette smoking (p=0.037) and nocturnal occurrence of SAH (that is, between 12:01 a.m. and 8:00 a.m., p=0.044). Hypertension, obesity and other factors were not associated with the lesions. CONCLUSION: The presence of ischemic lesions can be predicted by preoperative clinical condition, amount of SAH, the location of aneurysm, ICH, symptomatic vasospasm, duration of temporary artery occlusion, diabetes mellitus, excessive alcohol drinking, cigarette smoking and time of aneurysm rupture.
Alcohol Drinking ; Aneurysm* ; Arteries ; Cerebral Hemorrhage ; Cerebral Infarction ; Diabetes Mellitus ; Follow-Up Studies ; Hemorrhage ; Humans ; Hypertension ; Intracranial Aneurysm ; Obesity ; Retrospective Studies ; Risk Factors* ; Rupture ; Smoking ; Subarachnoid Hemorrhage*

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Influence of Intraoperative Ventriculostomy on the Occurrence of Shunt-Dependent Hydrocephalus in Aneurysmal Subarachnoid Hemorrhage.

Tae Koo CHO ; Jae Min KIM ; Sung Soo KIM ; Hyeong Joong YI ; Jin Hwan CHEONG ; Koang Hum BAK ; Choong Hyun KIM

Korean Journal of Cerebrovascular Surgery.2006;8(1):48-55.

OBJECTIVE: Neurosurgeons occasionally advocated intraoperative ventriculostomy to prevent traumatic brain retraction because of severe brain swelling in an acute stage of aneurysmal subarachnoid hemorrhage (SAH) surgery. The authors investigated the impact of the intraoperative ventriculostomy on the occurrence of shunt-dependent hydrocephalus in acute SAH. METHODS: The data of 141 ruptured aneurysm patients who underwent aneurysmal neck clipping in an acute stage were retrospectively reviewed. The patients were divided into three groups according to the cerebrospinal fluid (CSF) drainage amount via intraoperative ventriculostomy. Group 1 (n=44) included the patients who were not performed the intraoperative ventriculostomy, Group 2 (n=34) consisted of patients who were drained the CSF less than 40 cc (< 40 cc) via intraoperative ventriculostomy, and Group 3 (n=63) drained the CSF more than 40 cc (> or = 40 cc). By using statistical methods, the authors analyzed the influences of various variables including Hunt-Hess grade, Fisher grade, Glasgow coma scale, Glasgow outcome scale, presence of acute hydrocephalus and intraventricular hemorrhage (IVH) at admission on the occurrence of hydrocephalus. And also, we analyzed the relationships among the cisternal drainage, lamina terminalis fenestration, and the shunt-dependent hydrocephalus. RESULTS: Concerning the amount of CSF drainage via intraoperative ventriculostomy, the incidence of shunt-dependent hydrocephalus did not show any difference in three groups (p=0.146). Presence of the acute hydrocephalus, lamina terminalis fenestration, and cisternal drainage did not exert any influence on the incidence of shunt-dependent hydrocephalus, respectively (p=0.124, p=0.168, p=0.452). However, the incidence of shunt-dependent hydrocephalus in patients who had IVH at admission was significantly higher than in who did not have (p=0.010). CONCLUSIONS: Routine intraoperative ventriculostomy dose not increase the incidence of shunt-dependent hydrocephalus. Moreover, it obtains an adequate intraoperative brain relaxation, which results in the decrease of the brain retraction injury and the operation time.
Aneurysm* ; Aneurysm, Ruptured ; Brain ; Brain Edema ; Cerebrospinal Fluid ; Drainage ; Glasgow Coma Scale ; Glasgow Outcome Scale ; Hemorrhage ; Humans ; Hydrocephalus* ; Hypothalamus ; Incidence ; Neck ; Relaxation ; Retrospective Studies ; Subarachnoid Hemorrhage* ; Ventriculostomy*

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Cerebral Arteriovenous Malformations in Pediatric Age:A Clinical Analysis of 164 Consecutive Cases.

Jae Keun OH ; Jin Young JUNG ; Jae Whan LEE ; Seung Kon HUH ; Dong Ik KIM ; Young Gou PARK ; Kyu Chang LEE

Korean Journal of Cerebrovascular Surgery.2006;8(1):41-47.

OBJECTIVE: This study was designed to understand the clinical characteristics and to establish therapeutic options for arteriovenous malformations (AVM) in a pediatric age (1~8 year old) group. METHODS: We reviewed programmed clinical data, patients'medical records and imaging studies of the 164 pediatric AVM patients who were managed at Yonsei University Medical Center from 1975 to 2004. Clinical presentation, location, Spetzler-Marin grade, treatment modality and outcomes were analyzed. RESULTS: Ninety-one patients (55.5%) were male and seventy-three (44.5%) were female. The most common presenting symptom was hemorrhage (119 patients, 72.6%). In others the symptoms were seizure (26 patients, 15.9%), hemorrhage with seizure (6 patients, 3.6%), focal deficit (4 patients, 2.4%), headache (8 patients, 4.9%) and incidental (1 patients, 0.6%). The locations of AVMs were cerebral convexity (110 patients, 67.1%; 21 frontal, 40 parietal, 23 temporal, 23 occipital), basal ganglia and thalamus (24 patients, 14.6%), corpus callosum (12 patients, 7.3%), sylvian (3 patients, 1.8%), cerebellum (13 patients, 7.9%) and two patients had brain stem lesions (1.2%). According to the Spetzler-Martin grading system, at admission grade II and III AVMs were the most common lesions in our series (43.9% and 33.5%, respectively). The patients were treated with microsurgery in 70 patients (42.7%), radiosurgery in 87 patients, (53.0%), combined treatment in 5 patients (3.1%) and embolization in only 2 patients (1.2%). The average follow-up period was 4.8 years and the overall outcome was considered good in 139 patients (84.8%), fair in 18 patients (11.0%), and poor in 4 patients (2.4%), with 3 patients having died (1.8%). The causes of unfavorable outcomes were initial insult (4 patients), radiation necrosis (1 patient), bleeding during the latent interval (1 patient) and systemic complication (1 patient). CONCLUSION: Hemorrhagic presentation and deep brain (thalamus and ganglia) lesions were more common in the pediatric patients compared to adult patients. The treatment of choice for hemorrhagic pediatric AVMs is surgical excision, even for deep seated or eloquent area lesions. Radiosurgery is recommended especially for the non-hemorrhagic lesions, particularly in deep seated or eloquent area lesions. Regular imaging studies are necessary for detection of AVM regrowth, and signs of hemorrhage should be monitored during the latent period.
Academic Medical Centers ; Adult ; Arteriovenous Malformations ; Basal Ganglia ; Brain ; Brain Stem ; Cerebellum ; Corpus Callosum ; Female ; Follow-Up Studies ; Headache ; Hemorrhage ; Humans ; Intracranial Arteriovenous Malformations* ; Male ; Microsurgery ; Necrosis ; Rabeprazole ; Radiosurgery ; Seizures ; Thalamus

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A Clinical Experience of 72 Patients with Aneurysms arising from the Anomalous Cerebral Artery.

Poong Gee AHN ; Jin Young JUNG ; Jae Whan LEE ; Seung Kon HUH ; Kyu Chang LEE

Korean Journal of Cerebrovascular Surgery.2006;8(1):33-40.

OBJECTIVE: Aneurysm rupture at the anomalous artery is rare but inadvertent clip occlusion may cause critical complications. The aim of this study was to examine the frequency of the cerebral aneurysms associate with the vascular anomalies and the surgical considerations. METHODS: We analyzed 2802 patients with aneurysms treated from September,1976 to July,2004. A diagnosis of 'anomalous artery'was made on the basis of angiographic or surgical findings in 72 patients. Surgery was carried out in 68 patients and 4 were treated with endovascular methods. RESULTS: Fenestrated anterior communicating artery (A-com.) was the most common anomaly (33cases, 45.8%), 24 cases of 3rd A2 (33.3%), and 9 cases of azygous A2 (12.5%). fenestrated M1 was 1 cases (1.4%) and the one duplicated MCA (1.4%). 3 cases of fenestrated basilar artery (4.2%) and one primitive trigeminal artery aneurysm (1.4%) were treated with GDC. In our series vascular anomalies were found in 6% of the all Acom aneurysm cases. CONCLUSION: It is often difficult to recognize a fenestration or other anomalies of cerebral arteries prior to surgery, even with precise angiographic analysis. The Acom artery complex is one of most frequent sites of vascular anomalies. Preoperative and intraoperative concerns is required to avoid inadvertent occlusion of parent artery or misplacement of clip, which may result in critical complications or poor outcomes.
Aneurysm* ; Arteries ; Basilar Artery ; Cerebral Arteries* ; Diagnosis ; Humans ; Intracranial Aneurysm ; Parents ; Rupture

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