OBJECTIVE: Multidetector-Row computed tomographic angiography (MDCTA) is a promising method for detection and surgical planning of intracranial vascular abnormalities. However, there are several problems, such as image degradation due to inevitable patients movement, venous contamination, kissing vessel artifact, demonstration of venous structures mimicking aneurysm and bone artifacts. The purpose of our study is to review our recent experience with false negative or positive cases on MDCTA. METHODS: Between May 2007 and May 2010, 259 consecutive patients, who were diagnosed with intracranial aneurysms or other vascular abnormalities by MDCTA, were retrospectively reviewed. Among the 259 patients, 172 patients who underwent digital subtraction angiography (DSA), which was considered as the standard of reference, were included in the study. Two neuroradiologists and two neurosurgeons evaluated independently and separately all of the MDCTA images. RESULTS: A total 26 cases (15.3%) were revealed abnormal vascular findings on MDCTA. There were 11 false negatives on MDCTA including incomplete scanning range of lesion site (n=3), a blood blister aneurysm (n=1), severe vasospasm (n=4) and bone artifacts (n=3). Also there were 15 false positives on MDCTA; venous contamination over the lesion site (n=6), focal dilation of the bifurcation or branching site of major vessels (n=6) and poor quality of the images due to inevitable patients movement (n=3). CONCLUSIONS: MDCTA is clearly not the total answer for aneurysm diagnosis. We recommend that MDCTA scanning range is planned to encompass the whole intracerebral vasculature. Close attention to image acquisition and interpretation are required to reduce errors in MDCTA of intracranial aneurysms.
Aneurysm ; Angiography ; Angiography, Digital Subtraction ; Artifacts ; Blister ; Glycosaminoglycans ; Humans ; Intracranial Aneurysm ; Retrospective Studies

OBJECTIVE: Direct surgical clipping of paraclinoid aneurysms is challenging due to nearby anatomic structures. However, as endovascular techniques advance, endovascular coil embolizations for paraclinoid aneurysms are more frequently performed. We reviewed our experience with endovascular coil embolization of paraclinoid aneurysms to evaluate its safety and efficacy. METHODS: From 2005 to 2011, 78 patients underwent endovascular procedures with detachable coils for 86 paraclinoid aneurysms at our institute. A retrospective review of the medical records was performed. RESULTS: Seventy-eight patients with 86 paraclinoid aneurysms were evaluated. Thirteen patients (16.7%) were men and 65 (83.3%) were women. Patient age ranged from 23 to 78 years (mean age, 48 years). Five patients (6.4%) presented with subarachnoid hemorrhage (SAH) with decreased consciousness and visual field defects. In the 86 treated aneurysms, the immediate post procedural angiogram demonstrated complete occlusion in 73 aneurysms (84.9%), near-complete occlusion in eight aneurysms (9.3%) and partial occlusion in five aneurysms (5.8%). We obtained angiographic follow-up in 46 cases. Minor recanalization occurred in two cases and major recanalization occurred in one case. One thromboembolic complication and one blurred vision occurred among the 78 patients. CONCLUSION: Despite difficulties with surgical approaches for paraclinoid aneurysms, these lesions can be successfully managed by endovascular treatment. Favorable outcomes with a low morbidity suggest endovascular techniques as alternatives to microsurgical therapy for treating paraclinoid aneurysms.
Aneurysm ; Consciousness ; Endovascular Procedures ; Female ; Follow-Up Studies ; Humans ; Male ; Medical Records ; Retrospective Studies ; Subarachnoid Hemorrhage ; Surgical Instruments ; Vision, Ocular ; Visual Fields

OBJECTIVE: Endovascular treatment of cerebral aneurysms with detachable coils has proved to be a safe and effective. However, long term result was not satisfactory in less than 30% for regrowth or coil compaction. This paper highlighted the safety and technique of microsurgical clipping and coil removal in previously coiled aneurysms showing recurrence or remnant growth. METHODS: Sixty two patients from 2007 to 2010 were treated by endovascular coiling. Among them, six patients (9.6%) showed recurrence, who had near complete obliteration initially. We retrospectively analyzed the clinical data and radiographic images of these patients (male 2, female 4, mean age 46.6) who underwent microsurgical clipping with partial (4 cases) or complete (2 cases) coil removal. Computerized tomographic angiogram (CTA) was performed soon after microsurgical clipping for the evaluation. RESULTS: Four aneurysms were located at anterior circulation and two were at the posterior circulation. Four patients were detected by routine followed CTA or angiography and one had recurrent subarachnoid hemorrhage and another one had severe eyeball pain. Microsurgical treatment were performed about 12.9 months (range: 2~26) after coiling. Complete coil removal was done in two patients. Complete obliteration was performed in all, which were confirmed by postoperative CTA with less coil artifact. All patients attained the same neurological state presented prior to surgery (the Glasgow Outcome Scale (GOS) 4~5). CONCLUSION: Microsurgical clipping and coil removal following a previous endovascular coil embolization are not so common. However, these would be permanent treatment options without any morbidity in properly selected patients. These are challenging and risky procedure, but necessary to avoid postoperative coil artifact on the follow-up radiologic evaluation.
Aneurysm ; Angiography ; Artifacts ; Female ; Follow-Up Studies ; Glasgow Outcome Scale ; Humans ; Intracranial Aneurysm ; Recurrence ; Retrospective Studies ; Subarachnoid Hemorrhage

Acute vertebrobasilar artery occlusion is a fatal event, even after intra-arterial thrombectomy and thrombolysis. We are reporting a case of acute vertebral artery (VA) occlusion. A 37-year-old man was admitted with mild dizziness, but cardiopulmonary arrest suddenly developed after eleven hours. We performed cardiopulmonary resuscitation immediately and his mental and vital state was recovered. Thus we performed intra-arterial thrombectomy, thrombolysis and balloon angioplasty for left vertebral artery occlusion. But pre-existing stenosis of VA was revealed during intervention so we inserted a stent to the stenotic area. Conclusively, we obtained the good angiographical and clinical outcomes.
Adult ; Angioplasty ; Angioplasty, Balloon ; Arteries ; Cardiopulmonary Resuscitation ; Constriction, Pathologic ; Dizziness ; Emergencies ; Heart Arrest ; Humans ; Stents ; Thrombectomy ; Vertebral Artery

Carotid artery angioplasty and stenting (CAS) has become increasingly accepted as an alternative therapy to carotid endarterectomy for treatment of carotid artery stenosis. Central retinal artery occlusion (CRAO) is one of the diseases presented due to carotid artery stenosis. But CRAO without cerebral ischemia after CAS is uncommon. An 80-year-old man was admitted to the hospital with the right centrum ovale ischemic stroke and right proximal carotid artery stenosis. We performed CAS with a distal protection device after pre-ballooning 3 times, without post-ballooning. Then, 12 hours after the CAS, the patient complained of blindness in the right eye and was diagnosed with CRAO. However, Diffusion weighted magnetic resonance imaging (DW-MRI) showed no significant findings in the brain. CRAO after CAS without intracranial infarction is a rare complication.
Aged ; Aged, 80 and over ; Angioplasty ; Arteries ; Blindness ; Brain ; Brain Ischemia ; Carotid Arteries ; Carotid Stenosis ; Diffusion ; Endarterectomy, Carotid ; Eye ; Humans ; Infarction ; Magnetic Resonance Imaging ; Retinal Artery ; Retinal Artery Occlusion ; Stents ; Stroke

Intracranial aneurysmal rupture causes subarachnoid hemorrhage which usually leads to fatality or severe disability. Treatment of unruptured intracranial aneurysms (UIAs) can substantially reduce the risk of rupture and prevent the grave consequences, but the risk of prophylactic treatment cannot be ignored. UIAs have diverse characteristics and management strategy needs to be tailored according to their location, size and clinical status. In the absence of level I evidence, the treatment guidance often relied on expert's opinions and experience. Knowledge of the natural course and management risks of individual aneurysms can help to guide treatment decision, but the natural history is still controversial and risks are not clearly defined. The Korean Society of Cerebrovascular Surgeons (KSCVS) decided to issue a Korean version of UIA management guideline as a framework for the treatment decision and as a basis for future studies, following 'Guideline Development Manual' of the Clinical Research Center for Stroke (CRCS). The organized committee systematically reviewed relevant literature and major guidelines published between January 2000 and July 2010 and took a developmental strategy of adaptation rather than de novo methods. On the basis of interpretation of the published evidences, recommendations were synthesized, and the level of evidence and the grade of recommendation were determined using the methods adapted from those of the US Agency for Healthcare Policy and Research and CRCS. The current guideline focuses on three domains of natural history, diagnosis and treatment of UIAs. The hierarchy of evidence and the recommendation grading indicate the current level by the literature and do not indicate the necessity or the prohibition of a certain clinical practice. Accordingly, this guideline cannot provide the answer for every clinical situation and should not take precedence over the clinical judgment of responsible physicians for individual patients. The final judgment regarding the care of a particular patient must be made by the physician and patient in light of circumstances specific to that patient. This is the first version of the UIA management guideline in Korea and new evidences will be timely and continuously updated in the future guidelines.
Aneurysm ; Calcium Hydroxide ; Delivery of Health Care ; Humans ; Intracranial Aneurysm ; Judgment ; Korea ; Light ; Natural History ; Risk Management ; Rupture ; Stroke ; Subarachnoid Hemorrhage ; Zinc Oxide

OBJECTIVE: Cranial nerve dysfunction is common after endovascular treatment of a cavernous sinus dural arteriovenous fistula and sometimes this symptom persists. We reviewed the treatment outcomes of the patients with cavernous sinus dural arteriovenous fistula and who were treated with endovascular technique, and we analyzed the characteristics of those patients who had cranial nerve palsy after treatment. METHODS: Between May 2003 and July 2010, 25 patients were treated by an endovascular technique at our institution. Their medical records were reviewed and we analyzed their data, including the clinical presentation, the neurological deficits, the radiographic features and the treatment outcomes. RESULTS: In our series, a total of 25 patients (28 cases) received endovascular treatment. There were four male patients and twenty one female patients with an age range of 26-78 years (mean age : 57.4 years). Complete occlusion was observed in nineteen cases (67.9%) and 5 cases (17.9%) showed near complete occlusion. Additional procedures were required for four cases with fistulas that were partially occluded by previous treatment. Twenty four patients (96%) showed improved symptoms during the follow up and only one patient suffered from persistent symptoms. Procedure-related complications were observed in 2 cases. New cranial nerve palsy was observed in four patients (16%) and two patients experienced aggravation of their existing cranial nerve palsy. One of them had persistent deficits at the final follow up. CONCLUSION: Sufficient occlusion and avoidance of over-compaction of coils are important to prevent cranial nerve palsy when performing endovascular treatment of cavernous sinus dural arteriovenous fistulas.
Cavernous Sinus ; Caves ; Central Nervous System Vascular Malformations ; Cranial Nerve Diseases ; Cranial Nerves ; Endovascular Procedures ; Female ; Fistula ; Follow-Up Studies ; Humans ; Male ; Medical Records ; Retrospective Studies

OBJECTIVE: This study is aimed to describe our experience with performing hemicraniectomy for treating patients with malignant cerebral infarction. This study also aimed at describing the difference between our experience and that of the published articles. METHODS: Ten patients who had anterior circulation territory cerebral infarction underwent decompressive hemicraniectomy for treating their life threatening brain swelling between August 2004 and October 2007. We retrospectively analyzed the patients' medical records and radiological films and we described the patients' clinical and radiological details. The outcomes were measured according to the case fatality rate at 2 weeks and the modified Rankin scale (mRS) at 9 months. We compared our institution's outcomes with the pooled analysis result of three randomized controlled trials (DESTINY, DECIMAL, HAMLET trial). RESULTS: Nine men and one woman were included in this study. Their mean age was 61.5 +/- 11.9 years, and the mean National Institute of Health Stroke Scale (NIHSS) score on admission was 17.3 +/- 6.0. Five patients died within 2 weeks after operation. Four patients had a mRS of 5 and one had a mRS of 4 at 9 months. Our series included elder patients (mean difference : 9.9~18.3 years) who had a low NIHSS score on admission (mean difference : -4.8~-6.8) as compared to that of the pooled analysis group. Our series revealed a higher proportion of an unfavorable outcome (mRS > or = 4) compared to that of the pooled analysis results (p=0.01). No patient in our series would have been eligible, according to the inclusion criteria, for inclusion in the pooled analysis studies. CONCLUSION: We think that the higher proportion of an unfavorable outcome in our series was a consequence of the elder age of our patients.
Brain Edema ; Cerebral Infarction ; Female ; Humans ; Male ; Medical Records ; Retrospective Studies ; Stroke

OBJECTIVE: The objective of this study was to determine whether postoperative conventional angiography conducted during the early stage after aneurysm clipping is useful in patients with ruptured aneurysm. METHODS: Between May 2008 and November 2009, 57 patients who presented with ruptured cerebral aneurysms were treated with surgical clipping. Among them, a consecutive series of 45 patients who underwent postoperative angiography was analyzed retrospectively. Parameters of the postoperative angiography were categorized as incomplete clippings, vasospasms, vascular compromises, or other aneurysms. RESULTS: The average age of the patients was 49.2 years and ranged from 18 to 72 years. The average timing of the postoperative angiography after the onset of hemorrhage was 11.1 (+/- 5.6) days. Complete aneurysm closure was achieved in 43 (95%) patients. A neck remnant aneurysm was discovered in two patients and a fundus remnant was revealed in one patient. Twelve (27%) patients showed angiographic vasospasms and seven needed angioplasty. Four cases (9%) revealed either parent artery stenosis or branch occlusions, and two of them (4%) were clinically significant. Two cases showed aneurysms at another location, one of which was a ruptured aneurysm. Overall, 21 (47%) patients exhibited significant findings on the postoperative angiography. CONCLUSIONS: Our retrospective analysis revealed that postoperative angiography might be valuable in patients with ruptured aneurysms, especially in the acute stage, in order to determine the presence of vasospasms, incomplete clippings, vascular compromises, or other aneurysms that were missed at the initial cerebral angiography.
Aneurysm ; Aneurysm, Ruptured ; Angiography ; Angioplasty ; Arteries ; Cerebral Angiography ; Constriction, Pathologic ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Neck ; Parents ; Retrospective Studies ; Subarachnoid Hemorrhage ; Surgical Instruments

OBJECTIVE: Fusiform and dissecting aneurysms cannot be treated with conventional clipping or coiling surgery. Various methods are used for treating these aneurysms, including proximal occlusion of the parent artery or trapping the aneurysms with or without cerebral revascularization. We report here on our experience with treating unclippable and uncoilable aneurysms and we present the clinical and angiographic outcomes. METHODS: Nine patients with unclippable and uncoilable aneurysms were managed during a 5 year period at our institution. We retrospectively reviewed all the patients with aneurysms and who underwent multimodal techniques. The mean age of the 9 patients was 56.5 years. The mean clinical follow-up period was 28.1 months. Six patients presented with subarachnoid hemorrhage and 2 had diplopia. Of these patients, 3 had aneurysms arising from the posterior inferior cerebellar artery (PICA), 2 had vertebral artery (VA) aneurysms, 2 had internal carotid artery aneurysms and 2 had middle cerebral artery aneurysms. Eight aneurysms were fusiform and 1 was a giant saccular aneurysm. RESULTS: The treatment included surgical trapping with bypass in 4 patients, endovascular trapping with bypass in 4 patients and vein graft bypass in 1 patient. Among the bypass surgeries, high-flow bypass was performed for a giant internal cerebral artery (ICA) aneurysm. Trapping of the aneurysms with coil and occipital artery (OA)-PICA bypass were performed for 2 VA aneurysms of the PICA origin. There was no recurrent bleeding or ischemic symptoms during the follow-up periods. CONCLUSION: The cerebral bypass technique is a useful, safe for the treatment of dissecting and otherwise unclippable/uncoilable aneurysms.
Aneurysm ; Aneurysm, Dissecting ; Arteries ; Carotid Artery, Internal ; Cerebral Arteries ; Cerebral Revascularization ; Diplopia ; Follow-Up Studies ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Parents ; Pica ; Retrospective Studies ; Subarachnoid Hemorrhage ; Transplants ; Veins ; Vertebral Artery