• Journal of Korean Neurosurgical Society
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• 제42권1호
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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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• 제41권5호
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• pp.343-346
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• 2007

Hypoplasia of the internal carotid artery is a rare congenital anomaly. Agenesis, aplasia, and hypoplasia of the internal carotid artery [ICA] are frequently associated with cerebral aneurysms in the circle of Willis. Authors report two cases with congenital hypoplasia of the ICA accompanying with the aneurysms. Transfemoral cerebral angiography [TFCA] in one patient identified nonvisualization of the left ICA. Bilateral anterior cerebral artery [ACA] and middle cerebral artery [MCA] were supplied from the right ICA accompanying with two aneurysms at anterior communicating artery [AcoA] and A1 portion of the left ACA. TFCA in another patient demonstrated hypoplastic left ICA and left ACA filled from the right ICA accompanying with AcoA aneurysm. Left MCA was filled from basilar artery via posterior communicating artery [PcoA]. Skull base computed tomography [CT] in two patients showed hypoplastic carotid canal. Authors performed direct aneurysmal neck clipping. Follow up CT angiography [CTA] at one year after surgery did not show regrowth or new development of the aneurysm. In patients with hypoplastic ICA, neurosurgeons should be aware of the possibility of development of the aneurysms, presumably because of hemodynamic process. Direct aneurysmal neck clipping is a good treatment modality. After operation, regular CTA, magnetic resonance angiography [MRA] or TFCA is needed to find progressive lesion and to prevent cerebrovascular attack [CVA].

• Journal of Korean Neurosurgical Society
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• 제64권4호
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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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• 제61권2호
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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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• 제30권6호
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• pp.711-716
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• 2001

Objectives : Three-dimensional computed tomographic angiography(3D-CTA) is recently developed diagnostic imaging modality. We have studied this noninvasive method for possible role in replacing conventional angiography( CA) in the detection of aneurysms of the circle of Willis in patients with subarachnoid hemorrahge(SAH). Methods : We studied retrospectively, the 100 patients with SAH or unruptured aneurysms admitted to our hospital from October 1997 to December 1998. Among there, 85 patients underwent CTA, 82 patients underwent CA and 67 patients underwent both of CTA and CA. 3D-CTA was obtained using maximum intensity projection(MIP) and shaded-surface display(SSD) reconstruction. Results : Total 107 aneurysms were detected in 92 patients, and 64 aneurysms were detected in 67 patients underwent both CTA and CA. In five cases of those 67 cases, aneurysms were detected by CA but not by 3D-CTA. The detection rate of aneurysms(91.8%) and the detection rate of parent artery in cases of anterior communicating artery aneurysms(86.9%) with total 3D-CTA were relatively compatible with that of CA. But 3D-CTA was not enough in detection of posterior communicating artery aneurysms, internal carotid artery aneurysms as well as small sized aneurysm(<3mm). Conclusion : We consider CTA is valuable in as a screening test for cerebral aneurysm and follow-up test. And it is also valuable in early surgery for patients with aneurysmal rebleeding because of simple, quick, non-invasive method.

• Journal of Korean Neurosurgical Society
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• 제37권4호
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• pp.307-309
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• 2005

We report a rare case of tension pneumocephalus after eyebrow surgery for the treatment of a saccular aneurysm at posterior communicating artery. The patient's consciousness was suddenly aggravated due to the tension pneumocephalus on fifth postoperative day, which was treated by repairing the frontal sinus. The patient was recovered completely and uneventfully after this revision surgery.

• Journal of Korean Neurosurgical Society
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• 제38권1호
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• pp.28-34
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• 2005

Objective : This study is performed to compare older with younger groups about clinical characteristics and overall outcome of treatments for the intracranial aneurysms. Methods : We retrospectively investigated 633 patients with cerebral aneurysms who were admitted to our institute from January 2000 to May 2004. The authors divided the patients of cerebral aneurysm into two groups, one the third, fourth decades and the other eighth, ninth decades, analyzed clinical characteristics and overall outcome of treatments. Results : There were 57 patients [9.0%] under 39years old and 58 patients [9.2%] over 70. The female to male sex ratio was 0.5 : 1 in the younger group[YG] and 7.3 : 1 in the older group[OG], showing a female predominance with increasing age. In the YG, aneurysms were found in anterior communicating artery[A-com] [44.8%], middle cerebral artery [31.0%]. In the OG, aneurysm of posterior communicating artery [30.1%] was most common followed by that of A-com [26.9%]. More smokers and alcoholics were found in the YG. Older age was related to poor Hunt-Hess grade, Fisher's grade on admission, high incidence of unruptured aneurysms, and endovascular surgery. There was a higher prevalence of hypertension, intraventricular hematoma, hydrocephalus, and rebleeding in the preoperative state in the OG and postoperative complications including hydrocephalus, subdural fluid collection, and systemic complications. Overall outcome was poorer with advancing age [p=0.01]. Conclusion : The patients with aneurysms in the YG have distinct characteristics compared to those in the OG. Because of a good clinical grade on admission, a thin subarachnoid clot, and Low incidence of perioperative complications, the overall outcomes of the young patients were better than those of the old patients.

• Journal of Korean Neurosurgical Society
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• 제53권3호
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• pp.187-189
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• 2013

We report an unusual case of cerebral aneurysmal subarachnoid hemorrage (SAH) with Fabry's disease. A 42-year-old woman presented with aneurysmal SAH originated from a saccular aneurysm of the right posterior communicating artery. The patient was treated by an endovascular coil embolization of aneurysm. Postoperatively the patient recovered favorably without any neurological deficit. During her admission, the patient had a sign of proteinuria in urine analysis. The pathologic findings of kidney needle biopsy implied nephrosialidosis (mucolipidosis of lysosomal stroage disease), which is consistent with a Fabry's disease. It is uncommon that Fabry's disease is presented with aneurysmal SAH, especially in middle-aged patients, but could be a clinical concern. Further investigations are needed to reveal risk factors, vascular anatomy, and causative mechanisms of Fabry's disease with aneurysmal SAH.

• Journal of Korean Neurosurgical Society
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• 제62권2호
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• pp.183-192
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• 2019

Objective : The objective of this study was to analyze patient-specific blood flow in ruptured aneurysms using obtained non-Newtonian viscosity and to observe associated hemodynamic features and morphological effects. Methods : Five patients with acute subarachnoid hemorrhage caused by ruptured posterior communicating artery aneurysms were included in the study. Patients' blood samples were measured immediately after enrollment. Computational fluid dynamics (CFD) was conducted to evaluate viscosity distributions and wall shear stress (WSS) distributions using a patient-specific geometric model and shear-thinning viscosity properties. Results : Substantial viscosity change was found at the dome of the aneurysms studied when applying non-Newtonian blood viscosity measured at peak-systole and end-diastole. The maximal WSS of the non-Newtonian model on an aneurysm at peak-systole was approximately 16% lower compared to Newtonian fluid, and most of the hemodynamic features of Newtonian flow at the aneurysms were higher, except for minimal WSS value. However, the differences between the Newtonian and non-Newtonian flow were not statistically significant. Rupture point of an aneurysm showed low WSS regardless of Newtonian or non-Newtonian CFD analyses. Conclusion : By using measured non-Newtonian viscosity and geometry on patient-specific CFD analysis, morphologic differences in hemodynamic features, such as changes in whole blood viscosity and WSS, were observed. Therefore, measured non-Newtonian viscosity might be possibly useful to obtain patient-specific hemodynamic and morphologic result.

• Journal of Korean Neurosurgical Society
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• 제41권4호
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• pp.246-247
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• 2007

The most common cause of isolated oculomotor nerve palsy is ischemia of the peripheral nerve caused by a disease, such as diabetes mellitus. Another common cause of isolated oculomotor nerve palsy is compression by an intracranial aneurysm, usually an posterior communicating artery aneurysm. However, it is extremely rare in the pituitary tumor. We report an unusual case of pituitary adenoma presenting with isolated oculomotor nerve palsy in the setting of pituitary apoplexy. We suggest that pituitary apoplexy should be included in the differential diagnosis of a patient with isolated oculomotor nerve palsy and early surgery should be considered for preservation of oculomotor nerve function.