• Journal of Korean Neurosurgical Society
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• v.61 no.2
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• pp.212-218
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• 2018

Objective : Surgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them. Methods : From January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed. Results : All recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge. Conclusion : This study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.

• Journal of Korean Neurosurgical Society
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• v.49 no.5
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• pp.257-261
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• 2011

Objective : Successful coil embolization of anterior communicating (A-com) artery aneurysms requires good visualization and understanding of the entire H complex. Bilateral carotid angiography may optimize anatomical understanding and visualization of the H complex. We therefore assessed the efficacy of simultaneous bilateral internal carotid angiography during coil embolization for A-com artery aneurysms. Methods : Of the 153 patients with intracranial saccular aneurysms who underwent embolization between July 2008 and December 2009, 12 had A-com artery aneurysms and were embolized under bilateral carotid angiography. Patients were evaluated angiographically, immediately and 6 months (n=11) after embolization, using a 3-point scale (complete, residual neck, residual aneurysm). The safety, performance and efficacy of this approach were retrospectively evaluated. Results: In all patients, bilateral internal carotid artery angiography provided more detailed anatomical information and understanding around the A-com artery, and, in complex situations, it allowed for more effective coil embolization through bilateral routes to the A-com artery. Angiography immediately after embolization showed occlusion of 11 of the 12 (92%) aneurysms, with none of these 11 showing evidence of recanalization at 6 months. Conclusion : These findings indicate that simultaneous bilateral carotid angiography during coil embolization of selected complex A-com artery aneurysms provided improved anatomical understanding, and resulted in more effective and safer procedures than typical unilateral angiography.

• Journal of Korean Neurosurgical Society
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• v.42 no.1
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• pp.59-63
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• 2007

Operative clipping after previous endovascular coiling in an aneurysm is a different problem from primary clipping procedure for neurosurgeons. With the increasing use of coil embolization, neurosurgeons will more and more face the similar situation. We report surgical clipping cases of intracranial aneurysm regrown after endovascular coiling. Three patients with a history of subarachnoid hemorrhage due to ruptured aneurysm underwent endovascular treatment (EVT) with detachable coils. The aneurysms were in the posterior communicating artery, the middle cerebral artery and distal anterior cerebral artery (DACA). Two near-total occlusions and one partial occlusion were achieved by EVT. After several months, angiographic follow-up revealed regrowth of the aneurysm requiring surgical clipping. Here, we report three cases in which surgical clipping was more difficult than a usual clipping procedure performed several months after EVT, because of adhesion and coil bulging into the aneurysmal neck. The difficulty of the treatment of the residual aneurysm after coiling is discussed, as are the surgical complications and limitations of clipping.

• Journal of Korean Neurosurgical Society
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• v.44 no.3
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• pp.136-140
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• 2008

Objective : Numerous studies have compared the characteristics of familial intracranial aneurysms with those of non-familial aneurysms. To better understand familial subarachnoid hemorrhage (SAH), we studied a series of patients with SAH who had at least one first-degree relative with SAH, and compared our results with those of previous studies. Methods : We identified patients treated for SAH at our hospital between January 1993 and October 2006 and analyzed those patients with one or more first-degree relatives with SAH. We retrospectively collected data from patients with a family history and searched for patients who had relatives with aneurysms or who had been treated at other hospitals for SAH. Results : We identified 12 patients from six families with at least two first-degree relatives with SAH. All patients had affected first-degree relatives; in five families, they were siblings. The mean age at the time of rupture was 49.75 years; in four families, the age difference was within 5 years. In five patients (42%), the aneurysm was located in the middle cerebral artery. Only one patient had an aneurysm in the anterior communicating artery. Conclusion : In agreement with previous studies, our results showed that familial aneurysms, in comparison with non-familiar aneurysms, ruptured at a younger age and smaller size, had a high incidence in the middle cerebral artery, and were underrepresented in the anterior communicating artery. Interestingly, the age at the time of rupture was similar between relatives. Screening should be considered in the fifth or sixth decade for those who have a sibling with SAH.

• Journal of Korean Neurosurgical Society
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• v.64 no.1
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• pp.23-29
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• 2021

Objective : Although stent-assisted coiling (SAC) has been reported to be safe and effective in treating wide-necked aneurysms, the technique has procedure-related complications. Thus, we reported our experiences of SAC using the Neuroform Atlas stent in treating wide-necked aneurysms and evaluated the incidence of and risk factors for procedure-related complications. Methods : From March 2018 to August 2019, we treated 130 unruptured wide-necked aneurysms in 123 patients with Neuroform Atlas stents. Angiographic results and clinical outcomes were reviewed retrospectively. Clinical and angiographic follow-up were performed in all cases (mean, 12.4 months) after the procedure. Results : There were eight cases (6.2%) of procedure-related complications (two dissections, five thromboembolisms, and one hemorrhage) and two (1.5%) of delayed complications (one ischemia and one hemorrhage). There was one case (0.8%) of failure of stent deployment and one (0.8%) of suboptimal positioning of the stent. Follow-up angiography showed complete obliteration in 103 (79.2%), residual neck in 16 (12.3%), and residual aneurysm in 11 cases (8.5%). Aneurysm locations in the middle cerebral artery (odds ratio [OR], 2.211; p=0.046) and the anterior communicating artery (OR, 2.850; p=0.039) were associated with procedure-related complications on univariate analysis. However, no independent risk factor for procedure-related complications was noted in multivariate analysis. Conclusion : The Neuroform Atlas showed a high rate of technical success. Good clinical and radiographic outcomes in early follow-up suggests that the device is feasible and safe. SAC of aneurysms on the middle cerebral artery or anterior communicating artery may require more attention to prevent possible procedure-related complications.

• Journal of Korean Neurosurgical Society
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• v.64 no.4
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• pp.665-670
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• 2021

Symptomatic cerebral vasospasm (CVS) and delayed ischemic neurologic deficit (DIND) after unruptured aneurysm surgery are extremely rare. Its onset timing is variable, and its mechanisms are unclear. We report two cases of CVS with DIND after unruptured aneurysm surgery and review the literature regarding potential mechanisms. The first case is a 51-year-old woman with non-hemorrhagic vasospasm after unruptured left anterior communicating artery aneurysm surgery. She presented with delayed vasospasm on postoperative day 14. The second case is a 45-year-old woman who suffered from oculomotor nerve palsy caused by an unruptured posterior communicatig artery (PCoA) aneurysm. DIND with non-hemorrhagic vasospasm developed on postoperative day 12. To our knowledge, this is the first report of symptomatic CVS with oculomotor nerve palsy following unruptured PCoA aneurysm surgery. CVS with DIND after unruptured aneurysm surgery is very rare and can be triggered by multiple mechanisms, such as hemorrhage, mechanical stress to the arterial wall, or the trigemino-cerebrovascular system. For unruptured aneurysm surgery, although it is rare, careful observation and treatments can be needed for postoperative CVS with DIND.

• Journal of Korean Neurosurgical Society
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• v.48 no.1
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• pp.53-58
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• 2010

Objective : The purpose of this study was to review the safety and durability of aneurysms treated with stent-assisted coiling of ruptured anterior communicating artery aneurysms with small parent vessels (< 2.0 mm). Methods : Retrospective review of all ruptured aneurysm treated with stent assisted endovascular coiling between March 2005 and March 2009 at our institution was conducted. We report 11 cases of the Neuroform stent placement into cerebral vessels measuring less than 2.0 mm in diameter (range, 1.3-1.9 mm) in anterior cerebral artery. Clinical follow-up ranged from 3 to 12 months and imaging follow-up was performed with cerebral angiography at 6 months and 12 months after discharge. Results : Complete occlusion was achieved in 10 patients, and a remnant neck was evident in one. No stent displacement or no dislodgement occurred during stent placement. There was no evidence of thromboembolic complication, arterial dissection and spasm during procedure. We performed follow-up angiography in all patients at 6 months and/or 12 months from the first procedure. The follow-up angiographic data showed successfully results except one in-stent stenosis case. All patients improved clinical performances except one patient with severe vasospasm who showed poor clinical condition initially. Conclusion : We have safely and successfully treated 11 vessels smaller than 2.0 mm in diameter with self-expanding stents with good short and intermediate term results. More clinical data with longer follow-ups are needed to establish the role of stent-assisted coiling in ruptured aneurysms with small parent vessels.

• Journal of Korean Neurosurgical Society
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• v.47 no.3
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• pp.185-190
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• 2010

Objective : The aneurysm remnants rate was evaluated via three-dimensional digital subtraction angiography (3D-DSA) in the postoperative evaluation of clipped aneurysms. Methods : Data on surgically clipped aneurysms of anterior circulation obtained via postoperative 3D-DSA from February 2007 to March 2009 were gathered. The results of the postoperative 3D-DSA and of two-dimensional digital subtraction angiography (2D-DSA) for the detection of aneurysm remnants were compared, and an investigation was performed as to why 2D-DSA had missed some aneurysm remnants that were detected in the 3D-DSA. Various surgical factors that revealed aneurysm remnants in the 3D-DSA were also evaluated. Results : A total of 39 neck remnants of 202 clipped aneurysms (19.3%) were confirmed in 3D-DSA, and these were classified according to Sindou's classification of aneurysm remnants. Patients with only a neck remnant found in the 3D-DSA represented 17.3% (35/202 aneurysms) of the whole series, and those with a residuum of neck plus sac found in the 3D-DSA represented 1.9% (4/202 aneurysms). The causes of aneurysm remnants were no full visualization (14/39, 35.9%), parent and perforator artery protection (10/39, 25.6%), clip design problems (8/39, 20.5%), and broadnecked aneurysm (7/39, 17.9%). Conclusion : Patients with ${\leq}2$mm aneurysm remnants showed an increased risk of undetectable aneurysm remnants in the 2D-DSA. The most frequent location of the missed aneurysm in 2D-DSA was the anterior communicating artery. 3D-DSA showed more aneurysm remnants than what is indicated in the existing literature, the 2D-DSA.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.447-451
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• 2023

Developmental anomalies of internal carotid artery (ICA), being rare entities, are mostly asymptomatic by themselves because of good collateral supply. However, when present with other associated intracranial anomalies requiring treatment, there can be catastrophic consequences, if special attention is not paid to this condition. We present a case of 36 years old male, who reported to our emergency department with complaints of headache and loss of consciousness. He was diagnosed as a case of ruptured anterior communicating aneurysm with subarachnoid hemorrhage and agenesis of left ICA with trans-cavernous anastomosis. He underwent clipping of aneurysm and was discharged uneventfully. This report highlights the importance of skillful microsurgical clipping in extremely high-risk conditions, in contemporary era of hybrid neurosurgeons.

• Journal of Korean Neurosurgical Society
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• v.58 no.3
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• pp.184-191
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• 2015

Objective : Anterior communicating artery (AcomA) aneurysms represent the most common intracranial aneurysms and challenging to treat due to complex vascularity. The purpose of this study was to report our experience of endovascular treatment of AcomA aneurysms. Methods : Between January 2003 and December 2013, we retrospectively reviewed the medical records of 134 AcomA aneurysm patients available more than 6 months conventional angiographic and clinical follow-up results. We focused on aneurismal or AcomA vascular characters, angiographic and clinical follow-up results, and retreatment. Results : The rate of ruptured cases was 75.4%, and the small (<10 mm) aneurysms were 96.3%. Based on the subtypes defined by dominance of A1, 79 patients (59%) had contralateral A1 hypoplasia or agenesis. The immediate post-procedural angiography confirmed complete occlusion in 75.4%, partial occlusion in 24.6%. Procedure related complications were observed in 25 (18.6%) patients. Most of the adverse events were asymptomatic. Follow-up conventional angiography at ${\geq}6$ months was performed in all patients (mean 16.3 months) and major recanalization was noted in 6.7% and regrowth in one case. The aneurysm size (p=0.016), and initial treatment results (p=0.00) were statistically significant risk factors related to aneurysm recurrence. An overall improvement in mRS was observed during the clinical follow-up period and no rebleeding episode occurred. Conclusion : This study demonstrated that endovascular treatment is an effective treatment modality for AcomA aneurysms with low morbidity. Patients should take long term clinical and angiographic follow-up in order to assess the recurrence and warrant retreatment, especially ruptured, large, and initially incomplete occluded aneurysms.