• Journal of Korean Neurosurgical Society
• /
• v.30 no.8
• /
• pp.1013-1018
• /
• 2001

Objective : About 40% of patients who admit to the hospital after subarachnoid hemorrhage are poor clinical grade(Hunt-Hess grade IV, V). The majority of these patients have been excluded from early, aggressive treatment. The current study was undertaken to evaluate the outcome of urgent surgery for Hunt-Hess grade IV aneurysmal subarachnoid hemorrhage. Materials and Methods : We reviewed hospital records and radiographic studies of 36 patients who were Hunt-Hess grade IV among 201 cases with ruptured intracranial aneurysm admitted between Sep. 1995 and Dec. 2000. Operated patients were treated with urgent angiography and surgery within 24 hours of presentation, except six patients, and medical records of these patients were reviewed for the clinical course and Glasgow outcome scale(GOS). Results : Overall management results of the 36 patients were good recovery in 13(36.1%), moderate disability in 12 (33.3%), severe disability in 1(2.8%), vegetative state in 1(2.8%) and 9(25.0%) of surgically treated patients had died. Conclusion : Although with limited number of patients, we conclude that urgent surgery for Hunt-Hess grade IV patients results in a better neurologic outcome and urgent surgery combined with aggressive postoperative management can minimize mortality.

• Journal of Korean Neurosurgical Society
• /
• v.37 no.5
• /
• pp.375-379
• /
• 2005

Rarely, rupture of a cerebral aneurysm causes an acute subdural hematoma(SDH) in addition to subarachnoid hemorrhage(SAH). We report clinical and radiological characteristics of five cases, as well as potential pitfalls in the diagnosis and the treatment of this life-threatening condition. The patients ranged in age from 42 to 76 years. The Hunt-Hess grade on admission was grade III in one patient, grade IV in two, and grade V in two. All five patients un-derwent one-stage operation (both SDH evacuation and clipping of the aneurysm). The outcome was good recovery in two patients, persistent vegetative state in two, and death in one. Patients with a good outcome had a better Hunt-Hess grade on admission, with less amount of SDH.

• Journal of Korean Neurosurgical Society
• /
• v.40 no.5
• /
• pp.357-362
• /
• 2006

Objective : The incidence of aneurysmal subarachnoid hemorrhage has been increasing. At the same time, surgical results for elderly patients are unsatisfactory and no guidelines of treatment are available. We carried out a study comparing variable factors and surgical results between young and old age groups to find ways to improve prognosis. Methods : A retrospective study was carried out on 754 patients who were operated on between 1990 and 2004 by the same surgeon in our hospital. The patients were divided into seven groups according to age : 93 patients below 40 years of age [Group I], 419 patients aged $40{\sim}59$ [Group II], 115 patients aged $60{\sim}64$ [Group III], 82 patients aged $65{\sim}69$ [Group IV], 28 patients aged $70{\sim}74$ [Group V], 12 patients aged $75{\sim}79$ [Group VI] and 5 patients over the age of 80 [Group VII]. We then checked their medical history, Fisher's grade, Hunt-Hess grade, postoperative complications, and Glasgow Outcome Scale. Results : Age was not a statistically significant factor among patients below 70 years of age [P $value{\ge}0.05$]. But for those aged 70 and older, the age factor had a statistical value [P $value{\le}0.001$]. In addition, there was a close correlation between Hunt-Hess grade IV and V patients, and those with vasospasm, and hydrocephalus after surgery, with poor prognosis in elderly patients as well as young patients [P $value{\le}0.001$]. Conclusion : Advanced age [under the age of 70] dose not precluded adequate surgical treatment in patient with AN SAH, and we should be also alert to preventable causes of delayed neurological deterioration for improving the outcome in all elderly groups.

• Journal of Korean Neurosurgical Society
• /
• v.48 no.6
• /
• pp.480-484
• /
• 2010

Objective : To evaluate the role of lumbar drainage in the prevention of shunt-dependent hydrocephalus after treatment of ruptured intracranial aneurysms by coil embolization in good-grade patients. Methods : One-hundred-thirty consecutive patients with aneurysmal subarachnoid hemorrhage in good-grade patients (Hunt & Hess grades I-III), who were treated by coil embolization between August 2004 and April 2010 were retrospectively evaluated. Poor-grade patients (Hunt & Hess grades IV and V), a history of head trauma preceding the development of headache, negative angiograms, primary subarachnoid hemorrhage (SAH), and loss to follow-up were excluded from the study. We assessed the effects on lumbar drainage on the risk of shunt-dependent hydrocephalus related to coil embolization in patients with ruptured intracranial aneurysms. Results : One-hundred-twenty-six patients (96.9%) did not develop shunt-dependent hydrocephalus. The 2 patients (1.5%) who developed acute hydrocephalus treated with temporary external ventricular drainage did not require permanent shunt diversion. Overall, 4 patients (3.1%) required permanent shunt diversion; acute hydrocephalus developed in 2 patients (50%). There was no morbidity or mortality amongst the patients who underwent a permanent shunt procedure. Conclusion : Coil embolization of ruptured intracranial aneurysms may be associated with a lower risk for developing shunt-dependent hydrocephalus, possibly by active management of lumbar drainage, which may reflect less damage for cisternal anatomy than surgical clipping. Coil embolization might have an effect the long-term outcome and decision-making for ruptured intracranial aneurysms.

• Journal of Korean Neurosurgical Society
• /
• v.39 no.2
• /
• pp.120-124
• /
• 2006

Objective : This study is aimed to assess the clinical outcome in early and minimally invasive surgery using incision for the patients with poor grade aneurysm. Methods : The authors retrospectively reviewed all 46 poor grade patients of Hunt and Hess[H-H] grade IV and V who suffered aneurysmal subarachnoid hemorrhage[SAH] between 1999 and 2004. All 35 patients harboring 43 aneurysms who underwent early surgery within 72 hours were included in this study. Clinical outcome was assessed by Glasgow outcome scale[GOS] and compared with that of conventional pterional approach. Results : Twenty four patients were operated with conventional pterional approach and 11 with eyebrow approach within 72 hours after SAH. Seven multiple aneurysm patients harbor 15 aneurysms, Forty one aneurysms were treated with clippings. All 11 patients of eyebrow surgery group[ESG] were in H-H grade IV, 3 in Fisher grade III and 8 in Fisher grade IV. Among 24 patients of pterional approach group[PAG]. 20 were in H-H grade IV and 4 in H-H grade V, 3 were in Fisher grade III and 21 in Fisher grade IV. Overall favorable outcome was achieved in 41.7% and 54.5% in PAG and ESG, respectively. Favorable outcome of H-H grade IV in PAG showed 45.0%. Overall mortality rate was 14.3%. Conclusion : It is concluded that the clinical outcome of early and minimally invasive aneurysmal surgery using eyebrow incision in the selected poor grade aneurysm patients can be compatible with that of conventional pterional surgery.

• Journal of Korean Neurosurgical Society
• /
• v.40 no.3
• /
• pp.159-163
• /
• 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
• /
• v.30 no.4
• /
• pp.425-429
• /
• 2001

Objective : Patients with poor grade aneurysm usually present with increased intracranial pressure(ICP), even those without an intracranial clot. Based on this fact, the present study investigated a significance of intracranial pressure monitoring in those patients. Patients and Methods : A total of 60 patients with Hunt and Hess Grade IV(50 patients) or V(10 patients) were treated for aneurysmal subarachnoid hemorrhage(SAH) during a 3-year-period, and intraparenchymal ICP was measured in the majority, immediately after arrival to the emergency room. Early surgery including intraoperative ventriculostomy was undertaken within 3 days after SAH. An ultraearly surgery was performed without preceding angiogram or ICP monitoring in patients with large sylvian hematomas, highly suggestive of middle cerebral artery aneurysm. Outcomes were assessed by the Glasgow Outcome Scale(GOS) at 6 months. Results : In overall, favorable outcome(GOS scores 1-2) was seen in 27(54.0%) of admission Grade IV and 1(10.0%) of admission Grade V patients. Of the 38 surgical patients with preoperative ICP monitorings, 25 patients (80.6%) exhibiting ICP values of less than 40mmHg showed favorable outcome, however, no patients with ICP values above 40mmHg recovered(Fisher's exact test, p=0.0001). Conclusion : It is concluded that a preoperative ICP above 40mmHg before ventriculostomy indicate significant vital brain destruction as intractable intracranial hypertension, and Grade IV patients at admission with an ICP below 40mmHg can be of benefit from early surgical intervention while Grade V patients still remains unfavorable.

• Journal of Korean Neurosurgical Society
• /
• v.42 no.3
• /
• pp.235-237
• /
• 2007

We describe a case of an unruptured basilar top aneurysm that was associated with early rupture after incomplete coiling. A 62-year-old woman with a history of several small infarctions has undergone coiling of unruptured basilar top aneurysm. Two weeks after initial coiling the patient presented with Hunt and Hess grade IV subarachnoid hemorrhage consistent with a ruptured basilar top aneurysm. Repeat angiography revealed a rupture of recanalized basilar top aneurysm. Second embolization with additional coils resulted in complete occlusion. However, her neurological status was not improved afterward and she was transferred to department of rehabilitation one month after hemorrhage with comatous state. To our knowledge, this is the first case of fatal early rupture after coiling of unruptured aneurysm. It has been speculated that coiling could cause injury to aneurysmal wall and facilitate rupture.

• Journal of Korean Neurosurgical Society
• /
• v.37 no.6
• /
• pp.405-409
• /
• 2005

Objective: The purpose of this study is to assess the factors related to the outcome of 84 patients who underwent surgery for anterior communicating Artery(ACoA) aneurysms. Methods: The authors review 84 patients who were undertaken from January 1998 to May 2004. In the management of ACoA aneurysms, the outcome was based on several factors: Clinical condition, Distribution of hemorrhage, Time between aneurysmal rupture and surgery, Direction and shape of the aneurysm. Results: The incidence rate of the ACoA aneurysm was 35%. Seventy four patients were classified as those having a good recovery, but 5 patients suffered from some morbidity and 5 patients died. The rate of good outcome for the patients with Hunt and Hess grade was as follows 100% in grade I, 95% in grade II, 80% in grade III, IV and V. The rate of good outcome for the patients with Fisher grade was as follows 98% in grade I, II and 81% in grade III, IV. Nineteen of 22 patients who underwent early surgery were rated as good, while twenty six of 30 patients for whom surgery was delayed showed a favorable result. The unfavorable outcomes were also attributed by vasospasm or other medical problems. Conclusion: For further improvement of the overall surgical outcome: First, early surgical intervention is recommended for good grade patients. Second, active management of poor grade patients should be scrutinized with early surgery. Third, it is also important to step up the effort to minimize the risk of medical complications to enhance surgical results on top of the mainstay of prevention efforts for vasospasm and rebleeding.

• Journal of Korean Neurosurgical Society
• /
• v.29 no.7
• /
• pp.918-922
• /
• 2000

Objective : The authors analyzed the results of management outcomes for basilar bifurcation aneurysms treated with transcranial surgery and endovascular surgery. Methods : At the authors' institution between May 1989 and December 1998, 47 aneurysms with 45 patients were treated with transcranial surgery including surgical clipping/wrapping and endovascular surgery for basilar bifurcation aneurysms. The medical records and neuroimaging studies of the patients were reviewed retrospectively. Results : Of the 45 patients, 87 percent of the aneurysms were ruptured and 13% unruptured. Forty six percent of the patients had multiple aneurysms including basilar bifurcation aneurysm. Of the 39 patients with subarachnoid hemorrahge, 77% were in good neurological status(Hunt Hess grade I-III), 23% were in poor grade(H-H grade IV-V). Thirty two patients were treated with transcranial surgery and 15 patients were treated with endovascular surgery. Two patients who had treated with wrapping surgery later bled during follow-up period and treated with endovascular surgery. The management outcome of the transcranial surgery was : Glasgow outcome scale(GOS) I 66%, GOS II 12.5%, GOS III 6.3%, GOS IV 6.3% and GOS V(death) 9.4%. The major causes of morbidity related to transcranial surgery were perforator occlusion, vasospasm and retraction injury. The management outcome of the endovascular surgery was : GOS I 66.7%, GOS II 6.7%, and GOS V 26.7%. The major causes of mortality related to endovascular surgery were related to intraoperative aneurysmal bleeding. Conclusion : This report documents that more than 75% of patients undergoing treatment either transcranial or endovascular surgery can expect good clinical outcomes. Treatment modality in management of basilar bifurcation aneurysm must be carefully selected based on various considering factors.