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Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature.

Osama AHMED ; Piyush KALAKOTI ; Matthew HEFNER ; Hugo CUELLAR ; Bharat GUTHIKONDA

Journal of Cerebrovascular and Endovascular Neurosurgery.2015;17(2):113-119. doi:10.7461/jcen.2015.17.2.113

Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.
Aneurysm ; Arteries ; Craniotomy ; Decision Making ; Female ; Headache ; Humans ; Intracranial Aneurysm* ; Middle Aged ; Middle Cerebral Artery ; Paresis ; Subarachnoid Hemorrhage ; Surgical Instruments

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Endovascular Treatment in Ruptured Middle Cerebral Artery Dissection Preservation of Arterial Continuity.

Dong Hyuk NAM ; Sang Kyu PARK

Journal of Cerebrovascular and Endovascular Neurosurgery.2015;17(2):108-112. doi:10.7461/jcen.2015.17.2.108

Rupture of spontaneous dissecting aneurysms of the middle cerebral artery (MCA) is rare and its etiology remains obscure, although the risk of rebleeding is greater than with saccular aneurysms. Most reports concerning the treatment of a ruptured dissecting aneurysm of the anterior circulation involve surgical trapping or wrapping. Here, we report on a case of an MCA dissecting rupture treated with endovascular procedures. A 22-year-old female presented with sudden stuporous mental change following severe headache and left side hemiparesis. A computed tomography scan showed a diffuse subarachnoid hemorrhage and diffusion MR showed diffusion restriction at the right putamen and internal capsule. A 3-hour follow-up digital subtraction angiography (DSA) showed a dissecting aneurysm, which was not seen on an initial DSA. A stent assisted coil embolization was performed and double stents were applied to achieve flow diversion effects. A small remnant area of the dissecting aneurysm had disappeared at 60-day and was not observed on 12-month follow-up DSA.
Aneurysm ; Aneurysm, Dissecting ; Angiography, Digital Subtraction ; Diffusion ; Embolization, Therapeutic ; Endovascular Procedures ; Female ; Follow-Up Studies ; Headache ; Humans ; Internal Capsule ; Middle Cerebral Artery* ; Paresis ; Putamen ; Rupture ; Stents ; Stupor ; Subarachnoid Hemorrhage ; Young Adult

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A Protocol-Based Decision for Choosing a Proper Surgical Treatment Option for Carotid Artery Stenosis.

E Wook JANG ; Joonho CHUNG ; Kwon Duk SEO ; Sang Hyun SUH ; Yong Bae KIM ; Kyung Yul LEE

Journal of Cerebrovascular and Endovascular Neurosurgery.2015;17(2):101-107. doi:10.7461/jcen.2015.17.2.101

OBJECTIVE: There are two established surgical treatment options for carotid artery stenosis. Carotid endarterectomy (CEA) has been accepted as a gold standard for surgical treatment while carotid artery stenting (CAS) has recently become an alternative option. Each treatment option has advantages and disadvantages for the treatment outcomes. We propose a protocol for selection of a proper surgical treatment option for carotid artery stenosis. MATERIALS AND METHODS: A total of 192 published articles on management of carotid artery stenosis were reviewed. Preoperatively considerable factors which had been repeatedly noted in those articles for the risk/benefits of CEA or CAS were selected. According to those factors, a protocol with four categories was established. RESULTS: CEA or CAS is indicated when the patient has a symptomatic stenosis > or = 50%, or when the patient has an asymptomatic stenosis > or = 80%. Each treatment option has absolute indications and favorable indications. Each absolute indication is scored with three points, and each favorable indication, one point. Based on the highest scores, a proper treatment option (CEA or CAS) is selected. CONCLUSION: We have been treating patients according to this protocol and evaluating the outcomes of our protocol-based decision because this protocol might be helpful in assessment of risk/benefit for selection of a proper surgical treatment option in patients with carotid artery stenosis.
Carotid Arteries ; Carotid Stenosis* ; Constriction, Pathologic ; Endarterectomy, Carotid ; Humans ; Stents

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A Simple Method for Reconstruction of the Temporalis Muscle Using Contourable Strut Plate after Pterional Craniotomy: Introduction of the Surgical Techniques and Analysis of Its Efficacy.

Jin Hack PARK ; Yoon Soo LEE ; Sang Jun SUH ; Jeong Ho LEE ; Kee Young RYU ; Dong Gee KANG

Journal of Cerebrovascular and Endovascular Neurosurgery.2015;17(2):93-100. doi:10.7461/jcen.2015.17.2.93

OBJECTIVE: Pterional craniotomy (PC) using myocutaneous (MC) flap is a simple and efficient technique; however, due to subsequent inferior displacement (ID) of the temporalis muscle, it can cause postoperative deformities of the muscle such as depression along the inferior margin of the temporal line of the frontal bone (DTL) and muscular protrusion at the inferior portion of the temporal fossa (PITF). Herein, we introduce a simple method for reconstruction of the temporalis muscle using a contourable strut plate (CSP) and evaluate its efficacy. MATERIALS AND METHODS: Patients at follow-ups between January 2014 and October 2014 after PCs were enrolled in this study. Their postoperative deformities of the temporalis muscle including ID, DTL, and PITF were evaluated. These PC cases using MC flap were classified according to two groups; one with conventional technique without CSP (MC Only) and another with reconstruction of the temporalis muscle using CSP (MC + CSP). Statistical analyses were performed for comparison between the two groups. RESULTS: Lower incidences of ID of the muscle (p < 0.001), DTL (p < 0.001), and PITF (p = 0.001) were observed in the MC + CSP than in the MC Only group. The incidence of acceptable outcome was markedly higher in the MC + CSP group (p < 0.001). ID was regarded as a causative factor for DTL and PITF (p < 0.001 in both). CONCLUSION: Reconstruction of the temporalis muscle using CSP after MC flap is a simple and efficient technique, which provides an outstanding outcome in terms of anatomical restoration of the temporalis muscle.
Congenital Abnormalities ; Craniotomy* ; Depression ; Follow-Up Studies ; Frontal Bone ; Humans ; Incidence ; Myocutaneous Flap

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Transsylvian-Transinsular Approach for Deep-Seated Basal Ganglia Hemorrhage: An Experience at a Single Institution.

Seung Hwan KIM ; Jung Soo KIM ; Hae Yu KIM ; Sun il LEE

Journal of Cerebrovascular and Endovascular Neurosurgery.2015;17(2):85-92. doi:10.7461/jcen.2015.17.2.85

OBJECTIVE: Treatment of spontaneous intracerebral hemorrhage (ICH) remains controversial. However, an extensive hemorrhage with a poor mental status is suitable for surgical evacuation. Our experience with the transsylvian-transinsular (TS-TI) microsurgical approach for deep-seated basal ganglia (BG) ICH was investigated. MATERIAL AND METHODS: A retrospective review was conducted on 86 patients with BG ICH who underwent an operation at the Department of Neurosurgery of our Hospital from September 2011 to October 2014. Thirteen patients underwent craniotomy and the TS-TI microsurgical approach for hematoma evacuation. Twenty-seven patients underwent conventional craniotomy with the trans-cortical transtemporal (TC-TT) approach, and 46 patients underwent a burrhole operation and hematoma drainage using a frameless stereotaxic device (ST). RESULTS: The average age distribution was similar. The preoperative Glasgow coma scale (GCS) was similar for the TC-TT and TS-TI groups. The pre-operative hematoma levels were higher in the TC-TT (109.4 +/- 48.6 mL) and TS-TI (96.0 +/- 39.0 mL) groups than in the ST group (46.5 +/- 23.5 mL). The hematoma removal rate was 77% in the TC-TT group, 88% in the TS-TI group, and 34% in the ST group. The mean maintenance period of a hematoma catheter was 3.6 days in the ST group. The clinical outcome showed correlation with the preoperative neurological symptoms. CONCLUSION: The TS-TI group was superior to the TC-TT group for evacuation of an intracerebral hematoma.
Age Distribution ; Basal Ganglia ; Basal Ganglia Hemorrhage* ; Catheters ; Cerebral Hemorrhage ; Craniotomy ; Drainage ; Glasgow Coma Scale ; Hematoma ; Hemorrhage ; Humans ; Neurosurgery ; Retrospective Studies

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Traumatic Pseudoaneurysm Related to Calcified Nodules of Cerebral Convexity Dura Mater in an American College Football Player.

Yoo Sung JEON ; Jong Gon LEE ; Young Il CHUN ; Joon CHO ; Woo Jin CHOE

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(3):322-326. doi:10.7461/jcen.2016.18.3.322

Repeated concussion is common among football players; however, these minor blunt head trauma rarely result in serious complications. We report a case of a young college football player who presented acute subdural hematoma, cerebral edema, and seizure due to pseudoaneurysm rupture. The pseudoaneurysm, located at the cortical branch of the middle cerebral artery, was speculated to be formed by dural calcification and adhesion with the underlying brain, possibly due to repeated concussions. Following successful excision of the pseudoaneurysm and control of brain swelling, the patient recovered without sequelae and was discharged after a short while.
Aneurysm, False* ; Athletic Injuries ; Brain ; Brain Edema ; Craniocerebral Trauma ; Dura Mater* ; Football* ; Hematoma, Subdural, Acute ; Humans ; Middle Cerebral Artery ; Rupture ; Seizures

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Subdural Hematoma without Subarachnoid Hemorrhage Caused by the Rupture of Middle Cerebral Artery Aneurysm.

Jinsol HAN ; Dong Jun LIM ; Sang Dae KIM ; Sung Kon HA ; Seung Hwan LEE ; Se Hoon KIM

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(3):315-321. doi:10.7461/jcen.2016.18.3.315

Pure subdural hematomas caused by a ruptured intracranial aneurysm are extremely rare. We describe the case of a 42-year-old woman who presented with headache without evidence of head trauma. Magnetic resonance angiography and conventional cerebral angiography revealed a ruptured aneurysm at the right middle cerebral artery bifurcation. The patient underwent surgical treatment and had a good outcome without any neurological deficit. The mechanisms and clinical characteristics of this condition are discussed.
Adult ; Aneurysm, Ruptured ; Cerebral Angiography ; Craniocerebral Trauma ; Female ; Headache ; Hematoma, Subdural* ; Humans ; Intracranial Aneurysm* ; Magnetic Resonance Angiography ; Middle Cerebral Artery* ; Rupture* ; Subarachnoid Hemorrhage*

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Recurrent Carotid Cavernous Fistula Originating from a Giant Cerebral Aneurysm after Placement of a Covered Stent.

Jung Wook BAEK ; Sung Tae KIM ; Young Seo LEE ; Young Gyun JEONG ; Hae Woong JEONG ; Jin Wook BAEK ; Jung Hwa SEO

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(3):306-314. doi:10.7461/jcen.2016.18.3.306

We report the case of a recurrent carotid cavernous fistula (CCF) originating from a giant cerebral aneurysm (GCA) after placement of a covered stent. A 47-year-old woman presented with sudden onset of severe headache, and left-sided exophthalmos and ptosis. Cerebral angiography revealed a CCF caused by rupture of a GCA in the cavernous segment of the left internal carotid artery. Two covered stents were placed at the neck of the aneurysm. The neurological symptoms improved at first, but were aggravated in the 6 months following the treatment. Contrast agent endoleak was seen in the distal area of the stent. Even though additional treatments were attempted via an endovascular approach, the CCF could not be cured. However, after trapping the aneurysm using coils and performing superficial temporal artery-middle cerebral artery bypass, the neurological symptoms improved. In cases of recurrent CCF originating from a GCA after placement of a covered stent, it is possible to treat the CCF by endovascular trapping and surgical bypass.
Aneurysm ; Carotid Artery, Internal ; Carotid-Cavernous Sinus Fistula ; Cerebral Angiography ; Cerebral Arteries ; Endoleak ; Exophthalmos ; Female ; Fistula* ; Headache ; Humans ; Intracranial Aneurysm* ; Middle Aged ; Neck ; Rupture ; Stents*

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Pure Subdural Hemorrhage Caused by Internal Carotid Artery Dorsal Wall Aneurysm Rupture.

Young Woon LEE ; Taek Min NAM ; Jong Soo KIM ; Seung Chyul HONG ; Je Young YEON

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(3):302-305. doi:10.7461/jcen.2016.18.3.302

A 37-year-old woman was admitted to our hospital with altered mentality. The patient was diagnosed an internal carotid artery (ICA) dorsal wall aneurysm leading to acute subdural hemorrhage (SDH) without occurring subarachnoid hemorrhage and/or internal parenchymal hemorrhage. An aneurysmal neck clipping and hematoma evacuation were performed at once. A pure SDH by ruptured aneurysm is unusual, but it is important to consider it if a SDH patient has no other medical history.
Adult ; Aneurysm* ; Aneurysm, Ruptured ; Carotid Artery, Internal* ; Female ; Hematoma ; Hematoma, Subdural* ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Neck ; Rupture* ; Subarachnoid Hemorrhage

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Pseudoaneurysm Formation after Repetitive Suction Thrombectomy Using a Penumbra Suction Catheter.

Eun Oh JEONG ; Hyon Jo KWON ; Seung Won CHOI ; Hyeon Song KOH

Journal of Cerebrovascular and Endovascular Neurosurgery.2016;18(3):296-301. doi:10.7461/jcen.2016.18.3.296

With the recent advent of suction catheters, the use of manual aspiration thrombectomy (MAT) for patients with acute ischemic stroke with large vessel occlusion has increased. Although contrast leakage and subarachnoid hemorrhage have been reported during MAT procedures, pseudoaneurysm formation due to vessel injury by suction catheters has not been. We discuss the case of a 60-year-old woman who presented to our emergency room with dysarthria and left-sided weakness. She underwent suction thrombectomy 5 times for acute middle cerebral artery occlusion and significant contrast leakage occurred during the procedure. On follow-up angiogram on post-operative day 15, we noticed a pseudoaneurysm, which was treated with detachable coil embolization. Surgeons who perform suction thrombectomy should keep in mind the possibility of vessel injury that results in the formation of a pseudoaneurysm, especially at the branching site or tortuous segments.
Aneurysm, False* ; Catheters* ; Dysarthria ; Embolization, Therapeutic ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Humans ; Infarction, Middle Cerebral Artery ; Middle Aged ; Stroke ; Subarachnoid Hemorrhage ; Suction* ; Surgeons ; Thrombectomy*

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