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Coil Embolization of a Ruptured Basilar Tip Aneurysm Associated with Bilateral Cervical Internal Carotid Artery Occlusion: A Case Report and Literature Review.

Sang Shin KIM ; Dong Hyuk PARK ; Nam Jun LEE ; Shin Hyuk KANG ; Dong Jun LIM ; Yong Gu CHUNG

Journal of Cerebrovascular and Endovascular Neurosurgery.2012;14(1):44-49. doi:10.7461/jcen.2012.14.1.44

We report here on a rare case of a ruptured basilar tip aneurysm that was successfully treated with coil embolization in the bilateral cervical internal carotid artery (ICA) occlusions with abnormal vascular networks from the posterior circulation. A 43-year old man with a familial history of moyamoya disease presented with subarachnoid hemorrhage. Digital subtraction angiography demonstrated complete occlusion of the bilateral ICAs at the proximal portion and a ruptured aneurysm at the basilar artery bifurcation. Each meningeal artery supplied the anterior cranial base, but most of both hemispheres were supplied with blood from the basilar artery and the posterior cerebral arteries through a large number of collateral vessels to the ICA bifurcation as well as the anterior cerebral and middle cerebral arteries. The perfusion computed tomography (CT) scans with acetazolamide (ACZ) injection revealed no reduction of cerebral blood flow and normal cerebrovascular reactivity to ACZ. An abdominal CT aortogram showed no other extracranial vessel abnormalities. A ruptured basilar tip aneurysm was successfully treated with coil embolization without complications. Endovascular embolization may be a good treatment option with excellent safety for a ruptured basilar tip aneurysm that accompanies proximal ICA occlusion with vulnerable collateral flow.
Acetazolamide ; Aneurysm ; Aneurysm, Ruptured ; Angiography, Digital Subtraction ; Basilar Artery ; Carotid Artery, Internal ; Collateral Circulation ; Glycosaminoglycans ; Meningeal Arteries ; Middle Cerebral Artery ; Moyamoya Disease ; Perfusion ; Posterior Cerebral Artery ; Skull Base ; Subarachnoid Hemorrhage

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Image Findings in Brain Developmental Venous Anomalies.

Mong LEE ; Myoung Soo KIM

Journal of Cerebrovascular and Endovascular Neurosurgery.2012;14(1):37-43. doi:10.7461/jcen.2012.14.1.37

OBJECTIVE: Developmental venous anomalies (DVAs) are benign anatomic variations; therefore, they are usually discovered incidentally. The aim of this article was to describe radiological findings of DVAs. METHODS: A retrospective search for DVAs of the brain was performed in 1899 patients who had undergone magnetic resonance imaging (MRI) with contrast enhancement between January 1, 2005 and April 25, 2011. We also reviewed the results of computed tomography (CT), magnetic resonance angiography (MRA), CT angiography, and transfemoral cerebral angiography (TFCA) studies performed in patients with DVAs. RESULTS: Thirty-two DVAs were identified in 31 of the 1899 patients (1.63%). These 31 patients underwent five enhanced CTs, three MRAs, two CT angiographies, and two TFCAs. Thirty of the 32 DVAs were supratentorial (ST) and two were infratentorial (IT). All enhanced MRI studies exhibited excellent resolution of DVAs. All DVAs had only one draining vein. The venous drainage system was an IT vein in three DVAs and an ST vein in 29 DVAs. Two out of five enhanced CTs presented good visualization of the draining vein. None of the MRAs, including the source image, revealed the presence of DVAs. The two CT angiographies exhibited good resolution of DVAs. One of the two TFCAs yielded an excellent illustration of the DVA. CONCLUSION: CT angiography and MRI with contrast enhancement yielded detailed findings of DVAs. In contrast, MRA did not identify the DVAs. Enhanced CT presented only the draining vein of DVAs.
Angiography ; Brain ; Cerebral Angiography ; Drainage ; Humans ; Magnetic Resonance Angiography ; Magnetic Resonance Imaging ; Retrospective Studies ; Veins

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Endovascular and Microsurgical Treatment of Superior Cerebellar Artery Aneurysms.

Sung Chul JIN ; Eun Suk PARK ; Do Hoon KWON ; Jae Sung AHN ; Byung Duk KWUN ; Chang Jin KIM ; Choong Gon CHOI

Journal of Cerebrovascular and Endovascular Neurosurgery.2012;14(1):29-36. doi:10.7461/jcen.2012.14.1.29

OBJECTIVE: Superior cerebellar artery (SCA) aneurysms are regarded as being as difficult to treat surgically as posterior circulation aneurysms. We describe here a series of 33 of these aneurysms treated with microsurgery or embolization. METHODS: Between June 1997 and August 2007, 33 patients (9 men, 24 women; age, 29 to 76 years) with SCA aneurysms underwent microsurgical (n = 12) or endovascular (n = 21) treatment. Twenty two patients presented with subarachnoid hemorrhage. Thirty aneurysms were located in the junction between the SCA and the basilar artery (BA), two in the proximal SCA (S1) and one in the distal SCA (S2-3). RESULTS: Of the 29 SCA aneurysms, located in the junction between the SCA and BA, which were available on conventional angiography, 20 were lateral-superior, six lateral-horizontal, two lateral inferior, and one posterior type. Of the 12 patients treated microsurgically, eight had clinically excellent or good outcomes. Causes of poor outcomes included initial poor clinical status (n = 2), infarction due to parent artery compromise (n = 1), and artery of Heubner injury due to surgery for a coexisting anterior communicating artery aneurysm (n = 1). Of the 21 patients treated endovascularly, 17 had clinical good or excellent outcomes. Causes of clinically poor outcomes included initial poor clinical status (n = 2) and infarction due to thrombosis of exposed coil mesh (n = 1). One patient underwent embolization resulted in death due to vasospasm. Three patients required additional embolization for coil compaction. CONCLUSION: There was no morbidity related to perforator injury, regardless of the treatment modality. Embolization or microsurgery is an effective modality, with relatively low procedural morbidity and mortality rates.
Aneurysm ; Angiography ; Arteries ; Basilar Artery ; Humans ; Infarction ; Intracranial Aneurysm ; Male ; Microsurgery ; Parents ; Subarachnoid Hemorrhage ; Thrombosis

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Clinical Analysis of Giant Intracranial Aneurysms with Endovascular Embolization.

Sang Woo HA ; Suk Jung JANG

Journal of Cerebrovascular and Endovascular Neurosurgery.2012;14(1):22-28. doi:10.7461/jcen.2012.14.1.22

OBJECTIVE: The purpose of this study was to perform a clinical analysis of nine patients with giant aneurysms managed with endovascular embolization. METHODS: From March 2000 to September 2009, nine cases of giant intracranial aneurysms were treated (five unruptured and four ruptured). The nine patients included two males and seven females who were 47 to 72 years old (mean, 59.2 years old). The types of giant intracranial aneurysms were eight internal carotid artery aneurysms and one vertebral artery aneurysm. Treatment for each aneurysm was chosen based on anatomic relationships, aneurysmal factors, and the patients' clinical state. Three patients underwent endovascular coiling with stent and six initially underwent endovascular coiling alone. Medical records, operation records, postoperative angiographies, and follow-up angiographies were reviewed retrospectively. RESULTS: Eight out of nine patients showed good clinical outcomes. (six were excellent and two were good) after a mean follow-up period of 27.9 months. Six (67%) of the nine patients had a near-complete occlusions on the post-operative angiogram (mean, 13.5 months after the procedure). Occlusion rates of 90% or higher were obtained for eight (89%) of all the patients. One patient died due to multiple organ failure. Stents were ultimately required at some point for managing four aneurysms. Two patients needed additional procedures because of aneurysm regrowth. CONCLUSION: Endovascular treatment could be an alternative option for managing giant aneurysms adjuvant to surgical intervention.
Aneurysm ; Angiography ; Carotid Artery, Internal ; Female ; Follow-Up Studies ; Humans ; Intracranial Aneurysm ; Male ; Medical Records ; Multiple Organ Failure ; Stents ; Vertebral Artery

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Cognitive Function of Korean Neurosurgical Patients: Cross-sectional Study Using the Korean Version of the Mini-mental Status Examination.

Jiha KIM ; Chi Heon KIM ; Hyun Seung KANG ; Chul Kee PARK ; Chun Kee CHUNG

Journal of Cerebrovascular and Endovascular Neurosurgery.2012;14(1):11-21. doi:10.7461/jcen.2012.14.1.11

OBJECTIVE: As interest in life quality and expectancy increases, cognitive dysfunction is becoming an important topic. Although there are many foreign articles on this topic, they require cultural interpretation to be applicable to Koreans. The purpose of this study was to assess cognitive function in Korean neurosurgical patients. METHODS: We recruited 214 adult Korean patients with various cerebral pathologies and treatments from an outpatient clinic. The male-to-female ratio was 88:126, and their ages ranged from 28 to 81 years (mean: 57.9 years). The Korean version of the mini-mental status examination (K-MMSE) was adopted as an instrument for measuring cognitive function, and a score < or =23 was defined as cognitive dysfunction. K-MMSE scores were analyzed considering the patients' gender, age, time elapsed since treatments, pathology and treatment modality. A serial analysis was performed for 59 patients who completed the K-MMSE more than once. RESULTS: The mean K-MMSE score of 214 patients was 22.3, and 133 patients (62.1%) had a score < or =23. Cognitive dysfunction was common regardless of age, gender, pathology or treatment modality. Serial analysis revealed K-MMSE score improvement in 45 of 59 patients (76.3%). The mean time interval between two tests was 11.9 months, and the mean K-MMSE score improvement was 2.7, which was statistically significant (P = 0.000). However, many still had cognitive impairment. CONCLUSION: Most Korean neurosurgical patients showed cognitive dysfunction despite improvement after several months. Patients with trauma or ischemic disease were more vulnerable. More attention should be paid to neuropsychological complications such as cognitive dysfunction.
Adult ; Ambulatory Care Facilities ; Craniotomy ; Cross-Sectional Studies ; Humans ; Korea ; Neurosurgery ; Quality of Life

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Intraarterial Tirofiban Thrombolysis for Thromboembolisms During Coil Embolization for Ruptured Intracranial Aneurysms.

Jin Sue JEON ; Seung Hun SHEEN ; Gyojun HWANG ; Suk Hyung KANG ; Dong Hwa HEO ; Yong Jun CHO

Journal of Cerebrovascular and Endovascular Neurosurgery.2012;14(1):5-10. doi:10.7461/jcen.2012.14.1.5

OBJECTIVE: Thromboembolus can occur during endovascular coil embolization. The aim of our study was to show our experience of intraarterial (IA) tirofiban infusion for thromboembolism during coil embolization for ruptured intracranial aneurysms. METHODS: This retrospective analysis was conducted in 64 patients with ruptured aneurysms who had emergent endovascular coil embolization from May 2007 to April 2011 at a single institute. Thromboembolic events were found in ten patients (15.6%). Anticoagulation treatment with intravenous heparin was started after the first coil deployment in ruptured aneurysmal sac. When a thrombus or embolus was found during the procedure, we tried to resolve them without delay with an initial dosage of 0.3 mg of tirofiban up to 1.2 mg. RESULTS: Three patients of four with total occlusion had recanalizations of thrombolysis in myocardial infarction (TIMI) grade III and five of six with partial occlusion had TIMI grade III recanalizations. Eight patients showed good recovery, with modified Rankin Scale (mRS) score of 0 and one showed poor outcome (mRS 3 and 6). There was no hemorrhagic or hematologic complication. CONCLUSION: IA tirofiban can be feasible when thromboembolic clots are found during coil embolization in order to get prompt recanalization, even in patients with subarachnoid hemorrhage.
Aneurysm, Ruptured ; Embolism ; Heparin ; Humans ; Intracranial Aneurysm ; Myocardial Infarction ; Retrospective Studies ; Subarachnoid Hemorrhage ; Thromboembolism ; Thrombosis ; Tyrosine

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Transarterial Balloon-assisted Onyx Embolization of Intracranial Arteriovenous Malformations Using a Dual-lumen Balloon Microcatheter: Two Case Reports.

Sang Heum KIM ; Tae Gon KIM ; Min Ho KONG

Journal of Cerebrovascular and Endovascular Neurosurgery.2017;19(3):223-230. doi:10.7461/jcen.2017.19.3.223

The Onyx system has been well established in recent years as a very important material in the treatment of arteriovenous malformations (AVMs). When using the Onyx, it is essential to wait for the creation of a plug around the tip of the catheter, which enables the effective forward penetration of Onyx. Recent reports have shown that the introduction of a dimethyl sulfoxide compatible dual-lumen balloon microcatheter improves the efficiency of AVM embolization. We report our recent experience of two cases of intracranial AVM embolization using Onyx and the transarterial balloon-assisted technique. In both cases, the procedures were successfully performed and the nidus of the AVM was totally occluded in a relatively short time. This technique may enable immediate forward flow and penetration of Onyx without concern about reflux. It may also reduce the procedure time and increase the angiographic occlusion rate. Navigation of the dual-lumen balloon microcatheter nevertheless remains a challenge.
Arteriovenous Malformations ; Catheters ; Dimethyl Sulfoxide ; Intracranial Arteriovenous Malformations*

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Usefulness of Plaque Magnetic Resonance Imaging in Identifying High-Risk Carotid Plaques Irrespective of the Degree of Stenosis.

Jinseong LEE ; Jinsang KIL ; Dae Won KIM ; Sung Don KANG

Journal of Cerebrovascular and Endovascular Neurosurgery.2017;19(4):291-300. doi:10.7461/jcen.2017.19.4.291

OBJECTIVE: Measurement of the degree of stenosis is not enough to decide on the treatment strategy for patients with carotid stenosis. Plaque morphology examination is needed for such a decision-making. Thus, we evaluated the usefulness of plaque magnetic resonance imaging (MRI) to decide on the modality of treatment for patients with carotid atherosclerotic plaques. MATERIALS AND METHODS: Fifteen patients presenting with carotid stenosis between 2014 and 2016 were included. They underwent angiography for measurement of the degree of stenosis. Carotid plaques were visualized using MRI. RESULTS: There were six (40%) stable and nine (60%) unstable plaques. Seven symptomatic patients (77.7%) had unstable lesions and two symptomatic patients (33.3%) had stable lesions (p = 0.096). There were six (40%) intraplaque hemorrhage (IPH) cases. There were six symptomatic patients (100%) in the IPH group and three symptomatic patients (33.3%) in the non-IPH group (p = 0.013). The mean stenosis degree was 58.9% in the IPH group and 70.4% in the non-IPH group (p = 0.094). Symptoms occurred irrespective of the degree of the stenosis in the IPH groups. In the IPH group, the recurrent ischemic cerebrovascular event rate was 33.3%. Particularly, the recurrent ischemic cerebrovascular event rate was 66.7% in the IPH group with mild stenosis treated with medications. CONCLUSION: IPH in plaque MRI is significantly associated with ischemic symptoms and has a high risk for subsequent ischemic cerebrovascular events irrespective of the degree of stenosis. Plaque MRI is a useful tool in predicting symptomatic risks for carotid stenosis irrespective of the degree of such stenosis.
Angiography ; Carotid Stenosis ; Constriction, Pathologic* ; Hemorrhage ; Humans ; Magnetic Resonance Imaging* ; Plaque, Atherosclerotic

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Tentorial Dural Arteriovenous Fistulas: A Single-Center Cohort of 12 Patients.

HG KORTMAN ; I BOUKRAB ; G BLOEMSMA ; JP PELUSO ; M SLUZEWSKI ; B VAN DER POL ; GN BEUTE ; CB MAJOIE ; WJ VAN ROOIJ

Journal of Cerebrovascular and Endovascular Neurosurgery.2017;19(4):284-290. doi:10.7461/jcen.2017.19.4.284

OBJECTIVE: Tentorial dural arteriovenous fistulas usually drain into cortical veins and often present with hemorrhage. Treatment goal is occlusion of the draining vein, either by surgery or endovascular techniques. We present the multimodality treatment results of 12 patients with tentorial dural arteriovenous fistulas. MATERIALS AND METHODS: Between January 2007 and January 2017, 12 consecutive patients with tentorial dural arteriovenous fistulas were treated. There were 11 men and 1 woman with a mean age of 62 years (range 44–85). Clinical presentation was hemorrhage in 8 (67%), pulsatile tinnitus in 2 (17%) and an incidental finding in 2 (17%). The fistula location was at the tentorium cerebelli in 5 (42%), the torcula Herophilii in 4 (33%) and petroclival in 3 (25%). RESULTS: In 11 patients, arterial embolization with Onyx or PHIL was the primary treatment. Complete obliteration was achieved in one session in 5 (45%) and in 2 sessions in 4 (36%). In 2 patients additional surgery was needed. Primary surgery was performed in 1 patient followed by endovascular coil occlusion via the venous route. One patient with exclusive pial feeders from the posterior inferior cerebellar artery had a clinically silent P3 occlusion during trans arterial embolization. Finally, all 12 fistula were completely occluded, confirmed with angiography after 8–12 weeks. There were no permanent procedural complications. CONCLUSION: Patients with tentorial dural arteriovenous fistulas were effectively and safely cured with a strategy of endovascular treatment with various techniques and surgery. Surgical and endovascular techniques are complementary in the treatment of these challenging vascular disorders.
Angiography ; Arteries ; Central Nervous System Vascular Malformations* ; Cohort Studies* ; Endovascular Procedures ; Female ; Fistula ; Hemorrhage ; Humans ; Incidental Findings ; Male ; Spinal Cord ; Tinnitus ; Veins

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Prepuncture Ultrasound Examination Facilitates Safe and Accurate Common Femoral Artery Access for Transfemoral Cerebral Angiography.

Seon Yong SON ; Kwang Chun CHO ; Pyunggoo CHO ; Ju Hyung LEE ; Seong Uk MYOUNG ; Jai Ho CHOI

Journal of Cerebrovascular and Endovascular Neurosurgery.2017;19(4):276-283. doi:10.7461/jcen.2017.19.4.276

OBJECTIVE: We aimed to introduce our method involving prepuncture ultrasound scan for cannulation of the common femoral artery (CFA) during transfemoral cerebral angiography (TFCA), and to assess the clinical and radiological outcomes. MATERIAL AND METHODS: Our study included 90 patients who underwent prepuncture ultrasound examination of the inguinal area for TFCA between April 2015 and June 2015. Prior to skin preparation and draping of the inguinal area, we identified the CFA and its bifurcation using ultrasound. Based on the ultrasound findings, we marked cruciate lines in the inguinal area. Thereafter, we inserted a puncture needle at the interface between the horizontal and vertical lines at a 30–45° angle, simultaneously palpating the pulsation of the femoral artery. After TFCA was completed, femoral artery angiography was performed in the anteroposterior and oblique directions. Clinical and radiological parameters, including CFA cannulation, the ultrasound scan time, the first pass success rate, the time required for the passage of the wire, and complications, were evaluated. RESULTS: The mean ultrasound scan time of the CFA and its bifurcation was 72.6 seconds, and the mean time between administration of local anesthesia and wire passage was 67.44 seconds. The first pass success rate was 77.8% (70/90 patients), and the CFA puncture rate was 98.8% (89/90 patients). Although minor complications were noted in 7 patients, no patient reported serious complications (a large hematoma [≥ 5 cm], pseudoaneurysms, dissection, and/or a retroperitoneal hematoma.) CONCLUSION: Prepuncture ultrasound examination might be a simple, safe, and accurate technique for cannulation of the CFA during TFCA.
Anesthesia, Local ; Aneurysm, False ; Angiography ; Catheterization ; Cerebral Angiography* ; Femoral Artery* ; Hematoma ; Humans ; Methods ; Needles ; Punctures ; Skin ; Ultrasonography*

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