• Journal of Korean Neurosurgical Society
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• 제29권12호
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• pp.1563-1569
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• 2000

Objective : Delayed ischemic neurologic deficit(DIND) is one of the major complications following aneurysmal subarachnoid hemorrhage(SAH). However, the correlation between angiographic vasospasm(AV) and DIND after SAH is not precisely known. The authors investigated the timing, incidence, characteristics of DIND, and analyzed correlation between AV and DIND. Patients and Methods : A series of 126 patients with SAH and performed cerebral angiography which, confirmed anterior circulation aneurysm, admitted to between January 1996 to December 1998, were studied retrospectively. A comparative analysis between group 1(G1) in which AV patients presented with DIND, and group 2(G2) patients did not DIND, were done. AV was graded according to location, distribution and degree. Location of vasospasm was classified as basal type(BT), distal type(DT). BT was involved horizontally and include the bilateral carotid systems, proximal middle cerebral artery(MCA) and proximal anterior cerebral artery(ACA). DT was involved vertically and include the MCA branches as they become vertically or posteriorly oriented and the ACA distal to the anterior communicating artery. BT and DT all defined ether as localized type(LT) or combined type(CT). Distribution of vasospasm was classified as type I, type II and type III. Type I represents the involvement of bilateral carotid systems and bilateral anterior cerebral artery, type II was designed as one carotid system without involving anterior cerebral artery, and type III when only some portions of the anterior cerebral artery were involved, bilaterally. Degree of vasospasm was classified as mild(less than 25%), moderate(between 25-50%), severe(greater than 50%), and those were determined by comparing the caliber of the artery in vasospasm to that of the nearest area of apparently normal vessel. Results : The incidence of AV & DIND was 57/126(45.2%), 29/126(23.0%), and timing of DIND was 9 days(${\pm}4.1$) after initial hemorrhage. As for the location, BT was seen in 12 cases(40.0%), DT 11 cases(36.7%) and CT 7 cases (23.3%), respectively. Where as G1, BT was seen 5 cases(18.5%), DT 5 cases(18.5%) and CT 17 cases(63.0%), respectively in G2. CT AV was more correlated with DIND than LT AV(p<0.05). For distribution, type I was seen in 16 cases(59.2%), type II 4 cases(14.8%), type III 7 cases(25.9%) in G1 where as type I was seen in 7 cases(23.3%), type II 10 cases(33.3%), type III 13(43.3%) in G2. Type I AV was well correlated with DIND unlike to type II or type III(p<0.05). As for the degree, mild was seen in 4 cases(14.8%), moderate 14 cases(51.9%), severe 9 cases (33.3%) in G1, and mild 16 cases(18.5%), moderate 11 cases(36.7%) and severe 3 cases(10.0%) in G2. Moderate to severe type AV was well correlated with DIND(p<0.05). Conclusion : These results indicate that it may be possible to predict DIND according to careful analysis of location, distribution, degree of AV in patients with aneurysmal SAH.

• Journal of Korean Neurosurgical Society
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• 제40권3호
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• pp.159-163
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• 2006

Objective : Unique Internal carotid artery angiographic findings have been found especially in very poor grade aneurysmal subarachnoid hemorrhage[SAH] patients before and during the endovascular coiling. The author investigates their patterns and classifies them into lour subtypes. Methods : Among Hunt&Hess grade IV, V SAH patients, the author could gather eight patients who showed abnormal intracranial circulation in cerebral catheter-based angiography. Results : The author introduces new term 'misery collaterals' first and has classified them into four types with the case illustrations. Type 1 is the worst condition defined as almost no intracranial circulation. Type 2 is the condition of little intracranial circulation with contrast filling just only at vessels of brain base, type 3 is of no or little cortical circulation with contrast filling at bilateral large vessels of brain base through circle of Willis channel and type 4 is of visible bilateral cortical circulation but delayed intracranial circulation time. The prognosis of these eight patients showed misery collaterals were disappointed. Conclusion : These finding can be used as the supportive information in deciding a management plan in poor grade SAH patients.

• Journal of Korean Neurosurgical Society
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• 제46권4호
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• pp.417-420
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• 2009

The purpose of this report is to describe our surgical experiences in the treatment of cerebral decompression with in situ floating resin cranioplasty. We included in this retrospective study 7 patients who underwent in situ floating resin cranioplasty for cerebral decompression between December 2006 and March 2008. Of these patients, 3 patients had traumatic brain injury, 3 cerebral infarction, and one subarachnoid hemorrhage due to aneurysmal rupture. In situ floating resin cranioplasty for cerebral decompression can reduce complications related to the absence of a bone flap and allow reconstruction by secondary cranioplasty without difficulty. Furthermore, it provides cerebral protection and selectively eliminates the need for secondary cranioplasty in elderly patients or patients who have experienced unfavorable outcome.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제26권2호
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• pp.174-180
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• 2024

When aneurysmal subarachnoid hemorrhage due to multiple aneurysms is suspected, identifying the rupture site is essential to determine the exact surgical site, but it may not be easy. Even if embolization is adequately performed, complications may remain. Typical complications include rebleeding and hydrocephalus in the early phase and delayed cerebral ischemia in the delayed phase. Herein, we describe a case of rupture of an intracranial aneurysm after performing embolization for a different ruptured intracranial aneurysm in a patient with multiple intracranial aneurysms. Patients with multiple intracranial aneurysms need to be considered for closer observation than those with a single ruptured intracranial aneurysm, even if the patient's prognosis is good.

• Journal of Korean Neurosurgical Society
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• 제56권5호
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• pp.395-399
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• 2014

Objective : Blood blister-like aneurysms (BBAs) resemble arterial dissections. The purpose of this study was to investigate the relationship between these two disease entities and highlight commonalities and distinct features. Methods : Among 871 consecutive patients with aneurysmal subarachnoid hemorrhage, 11 BBAs of internal carotid artery and seven vertebral artery dissections (VADs) with a short segmental eccentric dilatation (Mizutani type 4), which is morphologically similar to a BBA, were selected. The following clinical factors were studied in each group : age, gender, risk factors, Hunt and Hess grade (HHG), Fisher grade (FG), vasospasms, hydrocephalus, perioperative rebleeding rate, and treatment outcome. Results : The mean age was 47.9 years in the BBAs group and 46.4 years in the type 4 VADs group. All the BBA patients were female, whereas there was a slight male predominance in the type 4 VAD group (male : female ratio of 4 : 3). In the BBA and type 4 VAD groups that underwent less aggressive treatment to save the parent artery, 29% (n=2/7) and 66.6% (n=2/3), respectively, eventually required retreatment. Perioperative rebleeding occurred in 72.7% (n=8) and 28.6% (n=2) of patients in the BBA and type 4 VAD groups, respectively. There was no statistical difference in the other clinical factors in both groups, except for the male dominancy in the type 4 VAD group (p=0.011). Conclusion : BBAs and ruptured type 4 VADs have a similar morphological appearance but there is a distinct clinical feature in gender and perioperative rebleeding rates. Complete isolation of an aneurysm from the parent artery might be the most important discipline for the treatment of these diseases.

• Journal of Korean Neurosurgical Society
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• 제39권5호
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• pp.347-354
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• 2006

Objective : We evaluate the role of multislice computerized tomographic angiography[MCTA] in the diagnosis of intracranial vasospasm following subarachnoid hemorrhage[SAH] in patients suspected of having vasospasm on clinical ground. Methods : Between October 2003 and June 2005, patients with ruptured cerebral aneurysms of the anterior circulation clipped within 3 days of the onset were included. We performed follow-up MCTAs in patients who were suspected to have vasospasm on transcranial doppler sonography[TCD] findings and clinical grounds. Based on the clinical presentation of symptomatic vasospasm, we investigated the correlation between clinical, TCD, and MCTA signs of vasospasm and evaluated the role of MCTA in vasospasm. Results : One hundred one patients met the inclusion criteria and symptomatic vasospasm developed in 25 patients [24.8%]. We performed follow-up MCTAs in 28 patients. MCTA revealed spasm in the vessels of 26 patients. The sensitivity of MCTA was 100%. Among the 26 patients with MCTA evidence of vasospasm, 3 patients had TCD signs of vasospasm after symptomatic vasospasm presentation. Another 3 patients with symptomatic vasospasm had no TCD signs of vasospasm in daily serial recordings. Six other patients without symptomatic vasospasm showed MCTA evidence of vasospasm [false positive result] but these patients had also positive TCD signs of vasospasm. Volume rendering[VR] images tended to show significantly more exaggerated vasospasm than maximum intensity projection[MIP] images. The mean cerebral blood flow velocity of both proximal segment of the middle cerebral artery [M1] was significantly correlated with each reduced M1 diameter on MCTA [P<005]. Conclusion : MCTA could be a useful tool for evaluation and planning management of critically ill patients suspected of having vasospasm; however, more randomized controlled trials are necessary to assess these points definitively.

• Journal of Korean Neurosurgical Society
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• 제50권1호
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• pp.6-10
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• 2011

Objective : Spontaneous acute subdural hematomas (aSDH) secondary to ruptured intracranial aneurysms are rarely reported. This report reviews the clinical features, diagnostic modalities, treatments, and outcomes of this unusual and often fatal condition. Methods : We performed a database search for all cases of intracranial aneurysms treated at our hospital between 2005 and 2010. Patients with ruptured intracranial aneurysms who presented with aSDH on initial computed tomography (CT) were selected for inclusion. The clinical conditions, radiologic findings, treatments, and outcomes were assessed. Results : A total of 551 patients were treated for ruptured intracranial aneurysms during the review period. We selected 23 patients (4.2%) who presented with spontaneous aSDH on initial CT. Ruptured aneurysms were detected on initial 3D-CT angiography in all cases. All ruptured aneurysms were located in the anterior portion of the circle of Willis. The World Federation of Neurosurgical Societies grade on admission was V in 17 cases (73.9%). Immediate decompressive craniotomy was performed 22 cases (95.7%). Obliteration of the ruptured aneurysm was achieved in all cases. The Glasgow outcome scales for the cases were good recovery in 5 cases (21.7%), moderate disability to vegetative in 7 cases (30.4%), and death in 11 cases (47.8%). Conclusion : Spontaneous aSDH caused by a ruptured intracranial aneurysm is rare pattern of aneurysmal subarachnoid hemorrhage. For early detection of aneurysm, 3D-CT angiography is useful. Early decompression with obliteration of the aneurysm is recommended. Outcomes were correlated with the clinical grade and CT findings on admission.

• Journal of Korean Neurosurgical Society
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• 제30권sup1호
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• pp.68-72
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• 2001

Objective : The goal of this study was to document the influence of the treatment modality(surgery versus endovascular treatment) on the development of chronic shunt-dependent hydrocephalus in a series of 296 patients treated after aneurysmal subarachnoid hemorrhage(SAH). Methods : The following parameters were retrospectively analyzed for association with chronic shunt-dependent hydrocephalus : 1) Age and Sex, 2) Hunt and Hess grade, 3) Fisher computed tomographic grade, 4) aneurysm location, and 5) treatment modality(surgery versus endovascular treatment). Results : Thirty-six of 251 patients(14.3%) who survived the SAH and its neurological and/or medical sequelae underwent definitive shunting for treatment of chronic hydrocephalus. The rate of shunt dependency was positively correlated with a higher age, a higher Hunt and Hess grade, a higher Fisher computed tomographic grade, and aneurysms arising at the anterior communicating artery(p<0.05). Conclusion : The results of the present study indicate that the treatment modality used does not affect the risk of the later development of chronic shunt-dependent hydrocephalus(surgery, 16.2% [25 of 154] ; endovascular treatment, 11.3% [11 of 97] ; p=0.45).

• Journal of Korean Neurosurgical Society
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• 제29권3호
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• pp.345-352
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• 2000

Objective : The purpose of this study was to compare computed tomographic angiography(CTA) with conventional cerebral angiography(CCA) and to assess usefulness of CTA in detection and anatomic definition of intracranial aneurysms of the circle of Willis in subarachnoid hemorrhage. Patients and Methods : Fifty consecutive patients with known or suspected intracranial saccular aneurysms underwent CTA with preoperative CCA from 1997 to 1999. Using surface shaded display post-processing technique, CTA was interpreted for the presence, location of aneurysms and anatomic features. The image obtained with CTA was then compared with CCA image. Results : In 47 patients, CCA revealed 57 cerebral aneurysms and CTA revealed 54 aneurysms. Two of the 57 cerebral aneurysms were located outside of the imaging volume of CTA and one case was misdiagnosed. The sensitivity of CTA was 94.7% and the specificity was 100%. The results obtained with CTA were, compared with the results obtained with CCA, equal in determining dome shape, direction and lobularity. However, CTA provided a 3-dimensional representation of aneurysmal lesion very useful for surgical planning. Moreover, CTA was useful for rapid and relatively noninvasive detection of aneurysms in the circle of Willis. Conclusion : CTA can be a diagnostic tool for the patients with acute subarachnoid hemorrhage due to a ruptured aneurysm of the circle of Willis and provides adequate anatomic detail for surgical planning, especially to complex cerebral aneurysms. However, we think CCA is necessary because of CTA limitations including its difficulty in detecting unusually located aneurysms(including those in cavernous sinus or distal artery) and combined vascular lesion (including arteriovenous malformation) and acquiring dynamic flow information.

• Journal of Korean Neurosurgical Society
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• 제43권2호
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• pp.90-96
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• 2008

Objective: Delayed ischemic deficit or cerebral infarction is the leading cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study is to reassess the prognostic impact of intraoperative elements, including factors related to surgery and anesthesia, on the development of cerebral infarction in patients with ruptured cerebral aneurysms. Methods: Variables related to surgery and anesthesia as well as predetermined factors were all evaluated via a retrospective study on 398 consecutive patients who underwent early microsurgery for ruptured cerebral aneurysms in the last 7 years. Patients were dichotomized as following; good clinical grade (Hunt-Hess grade I to III) and poor clinical grade (IV and V). The end-point events were cerebral infarctions and the clinical outcomes were measured at postoperative 6 months. Results: The occurrence of cerebral infarction was eminent when there was an intraoperative rupture, prolonged temporary clipping and retraction time, intraoperative hypotension, or decreased $O_2$ saturation, but there was no statistical significance between the two different clinical groups. Besides the Fisher Grade, multiple logistic regression analyses showed that temporary clipping time, hypotension, and low $O_2$ saturation had odds ratios of 1.574, 3.016, and 1.528, respectively. Cerebral infarction and outcome had a meaningful correlation (${\gamma}$=0.147, p=0.038). Conclusion: This study results indicate that early surgery for poor grade SAH patients carries a significant risk of ongoing ischemic complication due to the brain's vulnerability or accompanying cardio-pulmonary dysfunction. Thus, these patients should be approached very cautiously to overcome any anticipated intraoperative threat by concerted efforts with neuro-anesthesiologist in point to point manner.