• Korean Journal of Radiology
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• v.22 no.9
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• pp.1537-1546
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• 2021

Objective: To assess the role of arterial spin-labeling (ASL) perfusion MRI in identifying cerebral perfusion changes after indirect revascularization in children with moyamoya disease. Materials and Methods: We included pre- and postoperative perfusion MRI data of 30 children with moyamoya disease (13 boys and 17 girls; mean age ± standard deviation, 6.3± 3.0 years) who underwent indirect revascularization between June 2016 and August 2017. Relative cerebral blood flow (rCBF) and qualitative perfusion scores for arterial transit time (ATT) effects were evaluated in the middle cerebral artery (MCA) territory on ASL perfusion MRI. The rCBF and relative time-to-peak (rTTP) values were also measured using dynamic susceptibility contrast (DSC) perfusion MRI. Each perfusion change on ASL and DSC perfusion MRI was analyzed using the paired t test. We analyzed the correlation between perfusion changes on ASL and DSC images using Spearman's correlation coefficient. Results: The ASL rCBF values improved at both the ganglionic and supraganglionic levels of the MCA territory after surgery (p = 0.040 and p = 0.003, respectively). The ATT perfusion scores also improved at both levels (p < 0.001 and p < 0.001, respectively). The rCBF and rTTP values on DSC MRI showed significant improvement at both levels of the MCA territory of the operated side (all p < 0.05). There was no significant correlation between the improvements in rCBF values on the two perfusion images (r = 0.195, p = 0.303); however, there was a correlation between the change in perfusion scores on ASL and rTTP on DSC MRI (r = 0.701, p < 0.001). Conclusion: Recognizing the effects of ATT on ASL perfusion MRI may help monitor cerebral perfusion changes and complement quantitative rCBF assessment using ASL perfusion MRI in patients with moyamoya disease after indirect revascularization.

• Nuclear Medicine and Molecular Imaging
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• v.43 no.4
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• pp.280-286
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• 2009

Purpose: The aim of this study was to evaluate the hemodynamic changes after endovascular stenting in patients with unilateral middle cerebral artery (MCA) stenosis using statistical probabilistic anatomical mapping (SPAM) analysis of basal/acetazolamide (ACZ) Tc-99m ECD brain perfusion SPECT. Materials and Methods: Eight patients (3 men and 5 women, 64.8$\pm$10.5 years) who underwent endovascular stenting for unilateral MCA stenosis were enrolled. Basal/ACZ Tc-99m ECD brain perfusion SPECT studies were performed by one-day protocol before and after stenting. Using SPAM analysis, we compared basal cerebral perfusion (BCP) counts and cerebrovascular reserve (CVR) index of the MCA territory before stenting with those after stenting. Results: After stenting, no patient had any complication nor additional stroke. In SPAM analysis, 7 out of the 8 patients had improved BCP counts of the MCA territory and 7 out of the 8 patients had improved CVR index of the MCA territory after stenting. Before stenting, the mean BCP counts and CVR index in the affected MCA territory were 47.1$\pm$2.2 ml/min/100 g and -2.1$\pm$2.9%, respectively. After stenting, the mean BCP counts and CVR index in the affected MCA territory were improved significantly (48.3$\pm$2.9 ml/min/100 g, p =0.025 and 0.1$\pm$1.3%, p =0.036). Conclusion: This study revealed that SPAM analysis of basal/ACZ brain perfusion SPEG would be helpful to evaluate hemodynamic efficacy of endovascular stenting in unilateral MCA stenosis.

• Journal of Korean Neurosurgical Society
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• v.42 no.4
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• pp.331-336
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• 2007

Objective : The aim of this study was to analyze the treatment results and prognostic factors in patients with massive cerebral infarction who underwent decompressive craniectomy. Methods : From January 2000 to December 2005, we performed decompressive craniectomy in 24 patients with massive cerebral infarction. We retrospectively reviewed the medical records, radiological findings, initial clinical assessment using the Glasgow Coma Scale, serial computerized tomography (CT) with measurement of midline and septum pellucidum shift, and cerebral infarction territories. Patients were evaluated based on the following factors : the pre- and post-operative midline shifting on CT scan, infarction area or its dominancy, consciousness level, pupillary light reflex and Glasgow Outcome Scale. Results : All 24 patients (11 men, 13 women; mean age, 63 years; right middle cerebral artery (MCA) territory, 17 patients; left MCA territory, 7 patients) were treated with large decompressive craniectomy and duroplasty. The average time interval between the onset of symptoms and surgical decompression was 2.5 days. The mean Glasgow Coma Scale was 12.4 on admission and 8.3 preoperatively. Of the 24 surgically treated patients, the good outcome group (Group 2 : GOS 4-5) comprised 9 cases and the poor outcome group (Group1 : GOS 1-3) comprised 15 cases. Conclusion : We consider decompressive craniectomy for large hemispheric infarction as a life-saving procedure. Good preoperative GCS, late clinical deterioration, small size of the infarction area, absence of anisocoria, and preoperative midline shift less than 11mm were considered to be positive predictors of good outcome. Careful patient selection based on the above-mentioned factors and early operation may improve the functional outcome of surgical management for large hemispheric infarction.

• Korean Journal of Radiology
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• v.1 no.1
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• pp.5-10
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• 2000

Objective: To describe the neuroradiologic findings of primary antiphospholipid antibody syndrome (PAPS). Materials and Methods: During a recent two-year period, abnormally elevated antiphospholipid antibodies were detected in a total of 751 patients. In any cases in which risk factors for stroke were detected - hypertension, diabetes mellitus, hyperlipidemia, smoking, and the presence of SLE or other connective tissue diseases - PAPS was not diagnosed. Neuroradiologic studies were performed in 11 of 32 patients with PAPS. We retrospectively reviewed brain CT (n = 7), MR (n = 8), and cerebral angiography (n = 8) in 11 patients with special attention to the presence of brain parenchymal lesions and cerebral arterial or venous abnormalities. Results: CT or MR findings of PAPS included nonspecific multiple hyper-intensity foci in deep white matter on T2-weighted images (5/11), a large infarct in the territory of the middle cerebral artery (4/11), diffuse cortical atrophy (2/11), focal hemorrhage (2/11), and dural sinus thrombosis (1/11). Angiographic findings were normal (5/8) or reflected either occlusion of a large cerebral artery (2/8) or dural sinus thrombosis (1/8). Conclusion: Neuroradiologic findings of PAPS are nonspecific but in young or middle- aged adults who show the above mentioned CT or MR findings, and in whom risk factors for stroke are not present, the condition should be suspected.

• Journal of Chest Surgery
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• v.51 no.2
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• pp.149-152
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• 2018

A 76-day-old infant weighing 3.4 kg was referred for surgical intervention for severe mitral valve stenoinsufficiency caused by leaflet fibrosis and calcification. He had ex perienced a cerebral infarction in the left middle cerebral artery territory, which was deemed attributable to an embolism of a calcified particle from the dysmorphic mitral valve. Because mitral valve replacement using a prosthetic valve was not feasible in this small baby, mitral valve replacement with a pulmonary autograft was performed. After a brief period of extracorporeal membrane oxygenation (ECMO) support, he was weaned from ECMO and was discharged home without further cardiovascular complications.

• The Korean Journal of Physiology and Pharmacology
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• v.1 no.6
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• pp.665-672
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• 1997

This study aimed to investigate the mechanism of cerebroprotection of platelet-activating factor(PAF) antagonists in transient cerebral ischemia of rat. Right middle cerebral artery(MCA) of Sprague-Dawley rat was occluded for 2 hours using an intraluminal filament technique. After 22 hours of reperfusion, morphometrically detectable infarct was developed in the cortex and striatum identical to the territory of MCA. The infarct size was significantly reduced by PAF antagonists, BN 52021 and CV-6209, as well as an inducible nitric oxide synthase(iNOS) inhibitor aminoguanidine(1 mg/kg, i.p., respectively) administered 5 min after MCA occlusion. PAF antagonists significantly inhibited the enzymatic activities of both myeloperoxidase and iNOS in the cerebral hemisphere ipsilateral to ischemia, whereas aminoguanidine did not inhibit myeloperoxidase activity but significantly inhibited the iNOS activity. These results suggest that PAF antagonists exert a cerebroprotective effect against ischemic brain damage through inhibition of leukocyte infiltration and iNOS activity in the postischemic brain.

• The Journal of Korean Medicine
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• v.19 no.2
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• pp.59-74
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• 1998

Clinical observation was done on 272 cases of patients who were diagnosed as CVA with brain CT, TCD, MRI scan and clinical observation. They were hospitalized in the oriental medical hospital of Kyung-Won University from 1st January to 31st December in 1997. 1. The cases were classified into the following kinds: cerebral infarction, cerebral hemorrhage. and transient ischemic attack. The most case of them was the cerebral infarction. 2. There is no significant difference in the frequency of strokes in male and female. And the frequency of strokes was highest in the aged over 50. 3. In cerebral infarction the most frequent lesion was the territory of middle cerebral artery, and in cerebral hemorrhage the most frequent lesion was the basal ganglia. 4. The most ordinary preceding disease was hypertension. and the next was diabetes. 5. The rate of recurrence was high in cerebral infarction. 6. The cerebral infarction occurred usually in resting and sleeping, and the cerebral hemorrhage in acting. 7. The common symptoms were motor disability and verbal disturbance. 8 The average time to start physical therapy was 1l.3rd day after stroke in cerebral infarction and it was 15.2th day after stroke in cerebral hemorrhage. 9. The common complications were urinary tract infection, pneumonia, myocardial infarction. 10. Hypercholesterolemia and hypertriglyceridemia are usually found more frequently in cerebral infarction than in hemorrhage. 11. In acute or subacute stage, the methods of smoothening the flow of ki(順氣), dispelling phlegm(祛痰), clearing away heat(淸熱) or purgation(瀉下) were frequently used. and in recovering stage, the methods of replenishing ki(補氣), tonifying the blood(補血) or tranquilization(安神) were frequently used.

• Nuclear Medicine and Molecular Imaging
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• v.42 no.1
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• pp.8-16
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• 2008

Purpose: To assess the effect of extracranial-intracranial (EC-IC) bypass surgery on hemodynamic improvement, we evaluated serial regional cerebral hemodynamic change of the middle cerebral artery (MCA) in symptomatic patients with atherosclerotic occlusion of the internal carotid artery (ICA) or MCA using $^{99m}Tc$-ECD acetazolamide stress brain perfusion SPECT (Acetazolamide SPECT). Materials and Methods: The patients who had suffered a recent stroke with atherosclerotic ICA or MCA occlusion underwent EC-IC bypass surgery and Acetazolamide SPECT at 1 week before and three to six months after surgery. For image analysis, attenuation corrected images were spatially normalized to SPECT templates with SPM2. Anatomical automated labeling was applied to calculate mean counts of each Volume-Of-Interest (VOI). Seven VOIs of bilateral frontal, parietal, temporal regions of the MCA territory and the ipsilateral cerebellum were defined. Using mean counts of 7 VOIs, cerebral perfusion index and perfusion reserve index were calculated. Results: Seventeen patients (M:F =12:5, mean age $53{\pm}2yr$) were finally included in the analysis. The cerebral blood flow of the parietal region increased at 1 week (p = 0.003) and decreased to the preoperative level at 3-6 months (p = 0.003). The cerebrovascular reserve of the frontal and parietal regions increased significantly at 1 week after surgery (p<0.01) and improved further at 3-6 months. Conclusion: Cerebrovascular reserve of the MCA territory was significantly improved at early postoperative period after EC-IC bypass and kept improved state during long-term follow-up, although cerebral blood flow did not significantly improved. Therefore, cerebrovascular reserve may be a good indicator of postoperative hemodynamic improvement resulted from bypass effect.

• Clinical and Experimental Pediatrics
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• v.54 no.1
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• pp.40-44
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• 2011

We present a case of tacrolimus-induced encephalopathy after successful kidney transplantation. An 11-year-old girl presented with sudden onset of neurologic symptoms, hypertension, and psychiatric symptoms, with normal kidney function, after kidney transplantation. The symptoms improved after cessation of tacrolimus. Magnetic resonance imaging (MRI) showed acute infarction of the middle cerebral artery (MCA) territory in the right frontal lobe. Three days later, she had normal mental function and maintained normal blood pressure with left hemiparesis. Follow-up MRI was performed on D19, showing new infarct lesions at both cerebral hemispheres. Ten days later, MRI showed further improvement, but brain single photon emission computed tomography (SPECT) showed mild reduction of uptake in both the anterior cingulate gyrus and the left thalamus. One month after onset of symptoms, angiography showed complete resolution of stenosis. However, presenting as a mild fine motor disability of both hands and mild dysarthria, what had been atrophy at both centrum semiovale at 4 months now showed progression to encephalomalacia. There are two points of interest in this case. First, encephalopathy occurred after administration of tacrolimus and improved after discontinuation of the drug. Second, the development of right-side hemiplegia could not be explained by conventional MRI; but through diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) of white matter tract, visualization was possible.

• Journal of Korean Neurosurgical Society
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• v.61 no.2
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• pp.267-276
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• 2018

Objective : The beneficial effect of hypothermia after hemicraniectomy in malignant middle cerebral artery (MCA) infarction has been controversial. We aim to investigate the safety and clinical efficacy of hypothermia after hemicraniectomy in malignant MCA infarction. Methods : From October 2012 to February 2016, 20 patients underwent hypothermia (Blanketrol III, Cincinnati Sub-Zero, Cincinnati, OH, USA) at $34^{\circ}C$ after hemicraniectomy in malignant MCA infarction (hypothermia group). The indication of hypothermia included acute cerebral infarction >2/3 of MCA territory and a Glasgow coma scale (GCS) score <11 with a midline shift >10 mm or transtentorial herniation sign (a fixed and dilated pupil). We retrospectively collected 27 patients, as the control group, who had undergone hemicraniectomy alone and simultaneously met the inclusion criteria of hypothermia between January 2010 and September 2012, before hypothermia was implemented as a treatment strategy in Dong-A University Hospital. We compared the mortality rate between the two groups and investigated hypothermia-related complications, such as postoperative bleeding, pneumonia, sepsis and arrhythmia. Results : The age, preoperative infarct volume, GCS score, National institutes of Health Stroke Scale score, and degree of midline shift were not significantly different between the two groups. Of the 20 patients in the hypothermia group, 11 patients were induced with hypothermia immediately after hemicraniectomy and hypothermia was initiated in 9 patients after the decision of hypothermia during postoperative care. The duration of hypothermia was $4{\pm}2days$ (range, 1 to 7 days). The side effects of hypothermia included two patients with arrhythmia, one with sepsis, one with pneumonia, and one with hypotension. Three cases of hypothermia were discontinued due to these side effects (one sepsis, one hypotension, and one bradycardia). The mortality rate of the hypothermia group was 15.0% and that of the control group was 40.7% (p=0.056). On the basis of the logistic regression analysis, hypothermia was considered to contribute to the decrease in mortality rate (odds ratio, 6.21; 95% confidence interval, 1.04 to 37.05; p=0.045). Conclusion : This study suggests that hypothermia after hemicraniectomy is a viable option when the progression of patients with malignant MCA infarction indicate poor prognosis.