• Journal of Korean Neurosurgical Society
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• v.43 no.2
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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.

• Journal of Korean Neurosurgical Society
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• v.29 no.12
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• pp.1657-1663
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• 2000

The authors report a case of a 72-year-old woman who presented with intraventricular and subarachnoid hemorrhage of Hunt and Hess grade IV after the rupture of a giant aneurysm arising from the right internal carotid artery. The aneurysm was clipped successfully with the aid of cardiopulmonary bypass(closed chest method), deep hypothermic circulatory arrest, and cerebral protection with barbiturate resulting in moderate disability. We discuss the usefulness and problems related to technique of circulatory arrest and cardiopulmonary bypass using closed chest method, and suggest the possible benefits of open chest method in elderly people and the importance of preoperative plan to coordinate anesthesia and operation.

• Journal of Korean Neurosurgical Society
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• v.43 no.4
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• pp.177-181
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• 2008

Objective : Hydrocephalus is a common sequelae of aneurysmal subarachnoid hemorrhage (SAH) and patients who develop hydrocephalus after SAH typically have a worse prognosis than those who do not. This study was designed to identify factors predictive of shunt-dependent chronic hydrocephalus among patients with aneurysmal SAH, and patients who require permanent cerebrospinal fluid diversion. Methods : Seven-hundred-and-thirty-four patients with aneurysmal SAH who were treated surgically between 1990 and 2006 were retrospectively studied. Three stages of hydrocephalus have been categorized in this paper, i.e., acute (0-3 days after SAH), subacute (4-13 days after SAH), chronic (${\geqq}14$ days after SAH). Criteria indicating the occurrence of hydrocephalus were the presence of significantly enlarged temporal horns or ratio of frontal horn to maximal biparietal diameter more than 30% in computerized tomography. Results : Overall, 66 of the 734 patients (8.9%) underwent shunting procedures for the treatment of chronic hydrocephalus. Statistically significant associations among the following factors and shunt-dependent chronic hydrocephalus were observed. (1) Increased age (p < 0.05), (2) poor Hunt and Hess grade at admission (p < 0.05), (3) intraventricular hemorrhage (p < 0.05), (4) Fisher grade III, IV at admission (p < 0.05), (5) radiological hydrocephalus at admission (p < 0.05), and (6) post surgery meningitis (p < 0.05) did affect development of chronic hydrocephalus. However the presence of intracerebral hemorrhage, multiple aneurysms, vasospasm, and gender did not influence the development of shunt-dependent chronic hydrocephalus. In addition, the location of the ruptured aneurysms in posterior cerebral circulation did not show significant correlation of development of shunt-dependent chronic hydrocephalus. Conclusion : Hydrocephalus after aneurysmal subarachnoid hemorrhage seems to have a multifactorial etiology. Understanding predisposing factors related to the shunt-dependent chronic hydrocephalus may help to guide neurosurgeons for better treatment outcomes.

• Journal of Korean Neurosurgical Society
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• v.30 no.1
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• pp.33-40
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• 2001

Objective : Aneurysms of vertebral artery and its branches make up approximately 3% of all intracranial aneurysms. As the aneurysm have an intimate relationship with lower cranial nerves and medulla, surgical management of the aneurysms are one of the challenging neurosurgical problems. The authors analyzed the management outcomes for aneurysms arising from vertebral artery and its branches. Methods : At the authors' institution between May 1989 and Jan. 2000, 42 patients were treated with transcranial and endovascular surgery for aneurysms of vertebral artery and its branches. The medical records and neuroimaging studies of the patients were reviewed retrospectively. Results : Forty two patients were comprised of 28 female and 14 male patients aged from 26-80 year old(mean : 51.8). Of the 42 patients, 37 patients(88%) had subarachnoid hemorrhage. Of the 37 patients with subarachnoid hemorrahge, 35 patients(95%) were in good neurological status(Hunt Hess grade I-III), 2 patients(5%) in poor grade(H-H grade IV-V) before operation. Location of the aneurysm were 16 in vertebral artery, 12 in vertebro-PICA junction, and 14 in the peripheral PICA. Twenty nine patients were treated with transcranial surgery and 13 patients with endovascular surgery. The management outcome of the transcranial surgery was : Glasgow outcome scale(GOS) I and II ; 24, GOS III ; 2, GOS IV ; 1 and GOS V(death) ; 2. The causes of mortality related to transcranial surgery were rebleeding after failure in clipping in one and suspected brainstem infarct in one. Morbidity was attributed to vasospasm(3), lower CN palsy(7, including temporary dysfunction) and pseudomeningocele(1). The management outcome of the endovascular surgery was : Glasgow outcome scale(GOS) I-II ; 9, GOS III ; 1, GOS IV ; 1, and GOS V(death) ; 2. The causes of mortality related to endovascular surgery were sepsis from pneumonia(1) and vasospasm(1). There were one cerebellar infarct and one lateral medullary syndrome. Conclusion : Excellent and good surgical results can be expected in 80% of the patients with aneurysms of vertebral arery and its branches. The outcomes of endovascular surgery in treating vertebral artery aneurysm were satisfactory and endovascular surgery may offer a therapeutic alternative especially in vertebral dissecting aneurysm.

• Journal of Korean Neurosurgical Society
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• v.29 no.6
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• pp.786-793
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• 2000

Objectives : A clinical analysis was performed to provide management strategy and to improve management outcome of elderly patients with intracranial aneurysm. Patients and Methods : We reviewed medical records of 746 consecutive patients with intracranial aneurysm who were admitted from July 1991 to December 1996. They were divided into two age groups : elderly(120 patients aged 65 years or older) and non-elderly(626 patients aged 64 years or younger). We investigated the differences between the two groups in clinical characteristics, management outcome and surgical results. Results : Female(80.0%), internal carotid artery aneurysm(48.9%), poor clinical grade(Hunt and Hess Grade IV, V : 39.8%), postoperative subdural fluid collection(38.2%), and postoperative hydrocephalus(39.7%) were more frequent in the elderly patients. There were no significant differences in the incidence of hypertension, multiple aneurysm, unruptured aneurysm, rebleeding, delayed ischemic neurological deficits, postoperative hemorrhage, and low density on the postoperative brain CT scan. In some cases, surgical clipping of ruptured aneurysm could not be performed due to moribund state or refusal of surgery by the elderly patient's family. Both management outcome and surgical results in elderly aneurysm patients at 3 months after rupture were worse than those of the non-elderly group. The most common reason of unfavorable outcome was poor clinical grade in both groups, while serious medical illness causing unfavorable outcome was more common in the elderly group. Conclusion : Surgical treatment of a ruptured aneurysm should not be avoided in elderly patient solely on the basis of advanced age. If the patients are in good clinical grade, early aneurysm surgery followed by early ambulation should be recommended. Further improvements in outcome may be achieved by thorough knowledge of poor resilience of brain, CSF flow dynamics, and diminished cardiopulmonary reserve in elderly patients with intracranial aneurysm.

• Journal of Korean Neurosurgical Society
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• v.30 no.5
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• pp.592-599
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• 2001

Objective : The anterior communicating artery(ACoA) is known to be the most frequent location of intracranial aneurysms, but the complex arterial anatomy of the ACoA region makes this aneurysm among the most difficult one to treat. In the treatment of ACoA aneurysms, the direction of aneurysmal fundus is known to be very important in the surgical tactics. All ACoA aneurysms in our series were classified according to its direction, and analyzed the clinical features in order to investigate the prognostic factors influencing upon the surgical outcome. Methods : The authors reviewed 236 cases of ruptured ACoA aneurysms that were operated from 1990 to 1997, were classified according to Pia's classification. Results : The incidence rate of the ACoA aneurysm was 35.1%(236/672). Ventral group was more common than dorsal group, especially in ventro-caudal projection subgroup(36.0%). Poor preoperative clinical grade(Hunt-Hess grade IV and V) patients were more common in dorsal group(13.1%) than ventral group(2.6%). Rebleeding and intracerebral hematoma were more commonly seen in ventral group. However, vasospasm, hydrocephalus, hyponatremia, and intraventricular hemorrhage were observed more frequently in dorsal group. Worse outcome was more common in dorsal group than ventral group, especially in dorso-caudal projection subgroup. Also, poor outcome was identified in patients with intracerebral hematoma, intraventricular hemorrhage, hyponatremia, and hypertension, although statistically insignificant. In cases with the A1 dominancy, there was no difference in surgical outcome between the right and left side approach. The higher the aneurysmal neck from the planum sphenoidale, the worse outcome via pterional approach. Conclusion : It seems that the preoperative clinical grade, aneurysmal direction, and the height of aneurysmal neck, especially in the pterional approach, would be the major prognostic factors, and that intracerebral hematoma, intraventricular hemorrhage, hyponatremia, hydrocephalus and the intraoperative aneurysmal rupture would be the minor prognostic factors.

• Journal of Korean Neurosurgical Society
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• v.30 no.8
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• pp.970-975
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• 2001

Objective : By conducing a review of clinical outcomes for patients with aneurysm treated using current microneurosurgical techniques and intensive care unit management, we speculated that grading systems based only on clinical condition or CT finding after admission failed to provide a significant stratification of outcome between individual grades of patients, because these systems did not include the factor for postoperative vasospasm. We hypothesized that postoperative blood flow velocity could have a significant impact on outcome prediction for patients surgically treated for intracranial aneurysms. Methods : We conducted a analysis on patient- and lesion-specific factors that might have been associated with outcome in a series of 55 aneurysm operations performed with measurements of blood-flow velocity with transcranial Doppler ultrasonography(TCD). In the new scale(NS) score system, 1 point is assigned additionally for the case with Hunt and Hess(H-H)/World Federation of Neurological Surgeons(WFNS) Grade IV or V, Fisher Scale(FS) score 3 or 4, aneurysm size greater than 10mm, patient age older than 60 years, blood-flow velocity higher than 120cm/sec, and posterior circulation lesion. By adding the total points, a 6-point scale score(score 0-6) is obtained. Results : Age of patient, size of aneurysm, clinical condition(H-H grade and WFNS), FS score, and blood flow velocity(TCD 1day after operation) were independently and strongly associated with long-term outcome. When NS scores were applied to 55 patients with at least 6 months follow-up, the correlation of individual scores with outcome was strongly validated the retrospective findings. Conclusion : It was speculated that TCD could be used to assess postoperative vasospasm and to monitor noninvasively the patients with aneurysmal SAH. This NS score system is easy to apply, divide patients into groups with different outcome, and is comprehensive, allowing for more accurate prediction of surgical outcome.

• Journal of Korean Neurosurgical Society
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• v.30 no.9
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• pp.1086-1093
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• 2001

Object : With the recent variable treatment modalities and the development of microsurgical techniques, outcomes of surgical and medical management of aneurysm have shown much progress in the last 10 years. However, the management of posterior circulation aneurysm is still a debatable due to its difficulty in limited surgical approach, complicated anatomical structure and many small perforators to vital structure. The purpose of this study is to compare the results of clinical manifestation and outcome of surgery with respect to anterior and posterior circulation aneurysms. Material and Methods : We evaluated the 33 patients with PCAs(posterior circulation aneurysm) and 359 patients with ACAs(anterior circulation aneurysm) treated between 1994 and 1999, retrospectively. Results : Posterior circulation aneurysms showed higher tendency(5 cases, 14.7%) to have unusual shapes, such as dissecting or fusiform compared with anterior circulation aneurysm(15 cases, 4.2%). There were more multiple aneurysms in posterior circulation aneurysm(8 cases, 26.5%) than anterior circulation aneurysm(59 cases, 16.2%). The number of patients with Hunt-Hess grade III or IV on admission were 91(25.3%) in anterior circulation aneurysms, and 14(42.4%) in posterior circulation aneurysms. There were higher incidences of vasospasm and acute hydrocephalus in patients with posterior circulation aneurysm. In cases of anterior circulation aneurysm, neck clipping was possible in 97%. But, in posterior circulation aneurysm, neck clipping was possible only in 67.7% of each. Two hundred forty four cases(85.0%) of all anterior circulation aneurysms and 22 cases(78.6%) of all posterior circulation aneurysms showed good recovery(GR) or moderate disability(MD). The postoperative mortality rates of anterior and posterior circulation aneurysms were 4.9% and 10.7%, respectively. Conclusion : These results indicate that there exist substantial differences with respect to that there were few difference in the aspect of surgery and management outcome between posterior circulation aneurysms and anterior circulation aneurysms.

• Journal of Neurocritical Care
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• v.11 no.2
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• pp.93-101
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• 2018

Background: At most centers, general anesthesia (GA) has been preferred for endovascular treatment (EVT) of ruptured intracranial aneurysms (RIAs). In this study, we analyzed procedural results, clinical outcomes, and follow-up angiographic findings for patients undergoing EVT for RIA under local anesthesia (LA) with conscious sedation (CS). Methods: We retrospectively evaluated 308 consecutive patients who underwent EVT for RIAs at a single institution between June 2009 and February 2017. EVT under LA with CS was considered for all patients with aneurysmal subarachnoid hemorrhage, regardless of Hunt and Hess (HH) scale score. Results: EVT was performed for 320 aneurysms in 308 patients with subarachnoid hemorrhages. The mean patient age was $55.5{\pm}12.6$ years. Moderate (III) and poor (IV, V) HH grades were observed in 75 (24.4%) and 77 patients (25%), respectively. Complete occlusion immediately after EVT was achieved for 270 (84.4%) of 320 aneurysms. Thromboembolic complications and intraprocedural ruptures occurred in 25 (7.8%) and 14 cases (4.3%), respectively. The morbidity rate at discharge (as defined by a modified Rankin scale score of 3 or greater) was 27.3% (84/308), while the mortality rate was 11.7% (36/308). Follow-up angiographic results were available for 210 (68.1%) of 308 patients. Recanalization was observed in 64 (29.3%) of 218 aneurysms in 210 patients. Conclusion: Based on our experience, EVT for RIAs under LA with CS was feasible, regardless of the clinical grade of the subarachnoid hemorrhage. Complication rates and follow-up angiographic results were also comparable to those observed when GA was used to perform the procedure.