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Surgical Recanalization of Distal Middle Cerebral Artery Occlusion Due to a Coil Migration During Endovascular Coil Embolization: A Case Report.

Hyung Seok KIM ; Jong Myong LEE ; Eun Jeong KOH ; Ha Young CHOI

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):287-292. doi:10.7461/jcen.2014.16.3.287

Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.
Aneurysm ; Arteries ; Embolization, Therapeutic* ; Emergencies ; Follow-Up Studies ; Humans ; Infarction, Middle Cerebral Artery* ; Jeollabuk-do ; Middle Aged ; Middle Cerebral Artery ; Neck ; Neurosurgical Procedures ; Parents ; Specialization ; Thromboembolism ; Thrombosis

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Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up.

Hyung Seok KIM ; Choon Woong HUH ; Dal Soo KIM ; Jin Ho MOK ; In Soo KIM ; Se Hwan KIM

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):281-286. doi:10.7461/jcen.2014.16.3.281

Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment. The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.
Angioplasty* ; Arteries ; Compensation and Redress ; Constriction, Pathologic* ; Embolism ; Follow-Up Studies* ; Hemodynamics ; Humans ; Ischemia ; Risk Factors ; Stroke ; Vertebral Artery*

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Delayed Vascular Claudication Following Diagnostic Cerebral Angiography: A Rare Complication of the AngioSeal Arteriotomy Closure Device.

Jacquelyn A CORLEY ; Manish K KASLIWAL ; Lee A TAN ; Demetrius K LOPES

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):275-280. doi:10.7461/jcen.2014.16.3.275

With rapidly increasing numbers of neuroendovascular procedures performed annually in recent years, use of arterial closure devices after femoral artery access has been exceedingly common secondary to reduced time to hemostasis, decreased patient discomfort, earlier mobilization, and shortened hospital stay. Although uncommon, use of these devices can lead to a different spectrum of complications, as compared to manual compression. Ischemic symptoms following the use of these devices can have unexpected clinical sequelae and can occur in a delayed fashion. Awareness and recognition of such complications is important with the dramatically increased use of these devices in recent years. We report on a case of delayed vascular complication manifesting as vascular claudication following use of the AngioSeal closure device.
Cerebral Angiography* ; Femoral Artery ; Hemostasis ; Humans ; Length of Stay

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Retrieval of Unintended Migrated Detached Coil: Case Report.

Jiwoong OH ; Jongyun KIM ; Sunki HONG ; Chul HU ; Jinsu PYEN ; Kum WHANG ; Sungmin CHO ; Do Sung YOU

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):268-274. doi:10.7461/jcen.2014.16.3.268

Owing to the rapid development of intervention techniques and devices, endovascular coil embolization of cerebral arteries has become standardized. It is particularly preferred when a patient presents with an unruptured intracranial aneurysm of the posterior communicating artery (PcomA). However, the risk of thrombogenic complications of the coil migration may also result in a large cerebral infarction. When coil migration occurs during embolization, a procedure for removal of the embolic coil should be performed immediately. We experienced a clinically rare case of migration of a framing coil to the distal middle cerebral artery aneurysm during endovascular embolization of an unruptured PcomA aneurysm. The migrated coil was barely retrieved using snare techniques.
Aneurysm ; Arteries ; Cerebral Arteries ; Cerebral Infarction ; Embolization, Therapeutic ; Humans ; Intracranial Aneurysm ; SNARE Proteins

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Endovascular Coil Embolization After Clipping: Endovascular Treatment of Incompletely Clipped or Recurred Cerebral Aneurysms.

Jaehwan CHUNG ; In Sung PARK ; Hyun PARK ; Soo Hyun HWANG ; Jin Myung JUNG ; Jong Woo HAN

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):262-267. doi:10.7461/jcen.2014.16.3.262

OBJECTIVE: The presence of a cerebral aneurysm remnant after surgical clipping is associated with a risk of regrowth or rupture. For these recurred aneurysms, coil embolization can be considered as a treatment option. We retrospectively reviewed cases of ruptured or regrown aneurysms after clipping treated by endovascular coil embolization. MATERIALS AND METHODS: We conducted a retrospective review of patients with ruptured or recurred aneurysm after clipping, who underwent coil embolization between January 1995 and December 2013. We evaluated clinical information and the outcomes of these cases. RESULTS: Eight patients were treated by endovascular coil embolization after surgical clipping. Six aneurysms were located in the anterior communicating artery, one in the posterior communicating artery, and one in the middle cerebral artery bifurcation. All patients were initially treated by surgical clipping because of a ruptured aneurysm. Aneurysm recurrence at the initial clipping site was detected in all cases. The median interval from initial to second presentation was 42 months. In four patients, aneurysms were detected before rupture and the four remaining patients presented with recurrent subarachnoid hemorrhage. All patients were treated by coil embolization and showed successful occlusion of aneurysms without complications. CONCLUSION: Endovascular coil embolization can be a safe and successful treatment option for recurred aneurysms after clipping.
Aneurysm ; Aneurysm, Ruptured ; Arteries ; Embolization, Therapeutic* ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery ; Recurrence ; Retrospective Studies ; Rupture ; Subarachnoid Hemorrhage ; Surgical Instruments

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Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression.

Ui Seung HWANG ; Hee Sup SHIN ; Seung Hwan LEE ; Jun Seok KOH

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):254-261. doi:10.7461/jcen.2014.16.3.254

OBJECTIVE: In addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression. MATERIALS AND METHODS: In 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality. RESULTS: Aneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05). CONCLUSION: In this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.
Aneurysm ; Decompression* ; Decompressive Craniectomy ; Demography ; Embolization, Therapeutic* ; Glasgow Outcome Scale ; Hematoma ; Humans ; Intracranial Aneurysm ; Intracranial Hypertension ; Intracranial Pressure ; Microsurgery ; Middle Cerebral Artery ; Mortality ; Subarachnoid Hemorrhage*

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Clinical Analysis and Surgical Considerations of Atherosclerotic Cerebral Aneurysms: Experience of a Single Center.

Chang Kyu PARK ; Hee Sup SHIN ; Seok Keun CHOI ; Seung Hwan LEE ; Jun Seok KOH

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):247-253. doi:10.7461/jcen.2014.16.3.247

OBJECTIVE: Atherosclerotic cerebral aneurysms are known to increase occurrence of thromboembolic events and occlusion of perforator vessels intraoperatively due to pathological changes in the vessels themselves. In the current study, we analyzed the points to be considered during surgery for atherosclerotic cerebral aneurysms and the postoperative results. MATERIALS AND METHODS: We retrospectively reviewed the medical records, radiological results, and surgical records, including intraoperative video recordings and photographs, of 262 patients who underwent cerebral aneurysm surgery. We then performed a detailed analysis of aneurysm features, surgical methods, and clinical outcomes. RESULTS: Among 278 aneurysms in 262 patients, 73 aneurysms in 67 patients showed atherosclerotic features (atherosclerotic group, AG), and 205 aneurysms in 195 patients showed no evidence of atherosclerosis (non-atherosclerotic group, NAG). In the AG, clipping with multiple permanent clips was performed in 14 aneurysms, and clip slippage was found in four cases. Six AG cases had a remnant neck after clipping, which was significantly more frequent than in the NAG (p < 0.05). Clinical outcomes and surgery-related complications did not differ significantly between the two groups. CONCLUSION: In the surgical repair of aneurysms, the incidence of ischemia, which is irreversible or severe, might be greater in atherosclerotic than in non-atherosclerotic aneurysms. In addition, multiple clips might be applied to atherosclerotic aneurysms for effective obliteration and an aneurysm neck might be left to avoid a region of atheroma.
Aneurysm ; Atherosclerosis ; Humans ; Incidence ; Intracranial Aneurysm* ; Ischemia ; Medical Records ; Neck ; Plaque, Atherosclerotic ; Retrospective Studies ; Video Recording

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Clinicoepidemiological Features of Asymptomatic Moyamoya Disease in Adult Patients.

Jeyul YANG ; Joo Chul HONG ; Chang Wan OH ; O Ki KWON ; Gyojun HWANG ; Jeong Eun KIM ; Hyun Seung KANG ; Won Sang CHO ; Tackeun KIM ; Jong Un MOON ; Seong Yeol AHN ; Jun Hak KIM ; Jae Seung BANG

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):241-246. doi:10.7461/jcen.2014.16.3.241

OBJECTIVE: The aim of this study was to document the natural course of asymptomatic adult moyamoya disease (MMD) and the factors related to disease progression to aid in treatment decisions. MATERIALS AND METHODS: Among 459 adult MMD patients (aged > or = 20 years), 42 patients were included in this retrospective cohort study. Clinical records of adult asymptomatic MMD patients (n = 42) and follow-up data from September 2013 were reviewed to determine the factors related to disease progression. RESULTS: The mean age of patients at the time of diagnosis was 41.2 years (range, 23-64 years), and the mean follow-up period was 37.3 months (range, 7.4-108.7 months). Of the 42 patients and 75 hemispheres, there were 12 patients (28.6%) and 13 hemispheres (17.3%) with disease progression. There were four hemispheres (5.3%) with symptomatic progression (three hemorrhage, one transient ischemic attack) and nine hemispheres (12.0%) with asymptomatic radiographic progression. There were no relationships with sex, diabetes, hypertension, thyroid disease, family history of MMD, or family history of stroke. However, reduced initial cerebrovascular reserve capacity was observed in seven hemispheres (9.3%) in patients with disease progression. A relationship was found between disease progression and initial cerebrovascular reserve capacity (p = 0.05). None of the patients underwent bypass surgery during the follow-up period. CONCLUSION: It appears that asymptomatic adult MMD is not a permanent stable disease. In particular, reduced cerebrovascular reserve capacity is an indication of MMD progression, so close regular observation is needed.
Adult* ; Asymptomatic Diseases ; Cerebrovascular Disorders ; Cohort Studies ; Diagnosis ; Disease Progression ; Follow-Up Studies ; Hemorrhage ; Humans ; Hypertension ; Moyamoya Disease* ; Retrospective Studies ; Stroke ; Thyroid Diseases

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The Usefulness of the Frontolateral Approach as a Minimally Invasive Corridor for Clipping of Anterior Circulation Aneurysm.

Jeyul YANG ; Chang Wan OH ; O Ki KWON ; Gyojun HWANG ; Tackeun KIM ; Jong Un MOON ; Seong Yeol AHN ; Jun Hak KIM ; Jinseong KIM ; Jae Seung BANG

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):235-240. doi:10.7461/jcen.2014.16.3.235

OBJECTIVE: Several studies have reported on the effectiveness of fronto-lateral craniotomy in reducing the operating time and post-operative complications. However, no study has practically evaluated this method from the cosmetic point of view. MATERIALS AND METHODS: We designed this study for comparison of the clinical differences and cosmetic outcomes between the frontolateral craniotomy and the conventional pterional craniotomy for clipping of unruptured intracranial aneurysms. We performed a retrospective analysis of the two groups based on their medical records and radiologic findings juxtaposed with their length of hospital stay, intensive care unit day and operation time, and the emergence of postoperative complication, mean size of aneurysm, and temporal depression. RESULTS: After careful comparison of the thickness of temporalis muscle between the craniotomy side and the contralateral side, the results clearly showed that the conventional pterional craniotomy group was asymmetric by a p value of 0.152 and the frontolateral craniotomy group was symmetric by a p value of 0.002. CONCLUSION: Frontolateral craniotomy could be a practical alternative for patients with an unruptured intracranial aneurysm in the anterior circulation including the posterior communicating artery, particularly those who are in a medically poor state or who highly demand minimal aesthetic mutilation.
Aneurysm* ; Arteries ; Craniotomy ; Depression ; Humans ; Intensive Care Units ; Intracranial Aneurysm ; Length of Stay ; Medical Records ; Postoperative Complications ; Retrospective Studies

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Clinical Outcome of Paraclinoid Internal Carotid Artery Aneurysms After Microsurgical Neck Clipping in Comparison with Endovascular Embolization.

Dong Hyun BAE ; Jae Min KIM ; Yu Deok WON ; Kyu Sun CHOI ; Jin Hwan CHEONG ; Hyeong Joong YI ; Choong Hyun KIM

Journal of Cerebrovascular and Endovascular Neurosurgery.2014;16(3):225-234. doi:10.7461/jcen.2014.16.3.225

OBJECTIVE: Because of the complex anatomical association among vascular, dural, and bony structures, paraclinoid internal carotid artery (ICA) aneurysms remain a major challenge for vascular neurosurgeons. We studied the clinical outcomes of 61 paraclinoid ICA aneurysms after microsurgical clipping in comparison with endovascular coiling. MATERIALS AND METHODS: Between January 2008 and December 2012, we treated 61 paraclinoid ICA aneurysms created by surgical clipping or endovascular coiling. Preoperative neurologic status and postoperative outcome were evaluated using the Glasgow coma scale (GCS) and the modified Rankin scale (mRS). Postoperative hydrocephalus and vasospasm were reviewed using the patients' medical charts. RESULTS: Most patients were in good clinical condition before the operations and had good treatment outcomes. Clinical vasospasm was observed after the operation in five patients, and hydrocephalus occurred in six patients. No statistically significant difference regarding aneurysm size, sex, GCS score, H-H grade, and mRS was observed between the surgical clipping group and the endovascular coiling group. In addition, the treatment results and complications did not show statistically significant difference in either group. CONCLUSION: Surgical occlusion of paraclinoid ICA aneurysms is difficult; however, no significant differences were observed in the treatment results or complications when compared with coil embolization. In particular, use of an adequate surgical technique may lead to better outcomes than those for coil embolization in the treatment of large and/or wide-neck paraclinoid ICA aneurysms.
Aneurysm* ; Carotid Artery, Internal* ; Embolization, Therapeutic ; Glasgow Coma Scale ; Humans ; Hydrocephalus ; Neck* ; Surgical Instruments

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