• Journal of Korean Neurosurgical Society
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• v.64 no.6
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• pp.891-900
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• 2021

Objective : Vertebral artery dissecting aneurysm (VADA) is a very rare subtype of intracranial aneurysms; when ruptured, it is associated with significantly high rates of morbidity and mortality. Despite several discussions and debates, the optimal treatment for VADA has not yet been established. In the last 10 years, flow diverter devices (FDD) have emerged as a challenging and new treatment method, and various clinical and radiological results have been reported about their safety and effectiveness. The aim of our study was to evaluate the clinical and radiological results with the use of FDD in the treatment of unruptured VADA. Methods : We retrospectively evaluated the data of all patients with unruptured VADA treated with FDD between January 2018 and February 2021 at our hybrid operating room. Nine patients with unruptured VADA, deemed hemodynamically unstable, were treated with FDD. Among other parameters, the technical feasibility of the procedure, procedure-related complications, angiographic results, and clinical outcomes were evaluated. Results : Successful FDD deployment was achieved in all cases, and the immediate follow-up angiography showed intra-aneurysmal contrast stasis with parent artery preservation. A temporary episode of facial numbness and palsy was noted in one patient; however, the symptoms had completely disappeared when followed up at the outpatient clinic 2 weeks after the procedure. The 3-6 months follow-up angiography (n=9) demonstrated complete/near-complete obliteration of the aneurysm in seven patients, and partial obliteration and segmental occlusion in one patient each. In the patient who achieved only partial obliteration, there was a sac 13 mm in size, and there was no change in the 1-year follow-up angiography. In the patient with segmental occlusion, the cause could not be determined. The clinical outcome was modified Rankin Scale 0 in all patients. Conclusion : Our preliminary study using FDD to treat hemodynamically unstable unruptured VADA showed that FDD is safe and effective. Our study has limitations in that the number of cases is small, and it is not a prospective study. However, we believe that the study contributes to evidence regarding the safety and effectiveness of FDD in the treatment of unruptured VADA.

• Journal of Chest Surgery
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• v.47 no.2
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• pp.152-154
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• 2014

Vieussens' arterial ring (VAR) is the connection between the conus branch of the right coronary artery and the proximal right ventricular branch of the left anterior descending coronary artery. VARs are found in 48% of the population; however, pathologic VAR is rare. We experienced a case of pathologic VAR that involved a fistula connecting to the main pulmonary artery.

• Journal of Chest Surgery
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• v.20 no.4
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• pp.847-850
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• 1987

Traumatic arteriovenous fistula is relatively uncommon. The proper designation for what is called a false aneurysm is pulsating hematoma, which occurs when there is a small laceration of the wall of a large artery will continuing leakage of blood from the artery into surrounding tissues. The extent of growth of the pulsating hematoma depends on the strength of the surrounding fascial tissues. We experienced one case of arteriovenous fistula with hematoma, due to operative injuries, and operated successfully, and report the case.

• Journal of Korean Neurosurgical Society
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• v.30 no.6
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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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• v.50 no.2
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• pp.81-88
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• 2011

Objective : The purpose of this study was to analyze the clinical and anatomic features involved in determining treatment modalities for anterior communicating artery (AcoA) aneurysms. Methods : The authors retrospectively evaluated 112 AcoA aneurysms with pretreatment clinical features including age, Hunt and Hess grade, medical or neurological comorbidity, and anatomical features including aneurysm size, neck size, dome-to-neck ratio, vessel incorporation, multiple lobulation, and morphologic scoring system. Post-treatment clinical results were classified according to the Glasgow Outcome Scale, and anatomic results in coiled patients were classified according to the modified Raymond scale. Using multivariate logistic regression, the probabilities for decision making between surgical clipping and coil embolization were calculated. Results : Sixty-seven patients (60%) were treated with surgical clipping and 45 patients (40%) with endovascular coil embolization. The clinical factor significantly associated with treatment decision was age (${\geq}$65 vs. <65 years) and anatomical factors including aneurysm size (small or large vs. medium), dome-to-neck ratio (<2 vs. ${\geq}$2), presence of vessel incorporation, multiple lobulation, and morphologic score (${\geq}$2 vs. <2). In multivariate analysis, older patients (age, 65 years) had significantly higher odds of being treated with coil embolization relative to clipping (adjusted OR=3.78; 95% CI, 1.39-10.3; p=0.0093) and higher morphological score patients (${\geq}$2) had a higher tendency toward surgical clipping than endovascular coil embolization (OR=0.23; 95% CI, 0.16-0.93; p=0.0039). Conclusion : The optimal decision for treating AcoA aneurysms cannot be determined by any single clinical or anatomic characteristics. All clinical and morphological features need to be considered, and a collaborative neurovascular team approach to AcoA aneurysms is essential.

• Journal of Korean Neurosurgical Society
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• v.51 no.6
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• pp.334-337
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• 2012

Objective : The lateral supraorbital (LSO) approach is a modified method of the classic pterional approach and it has advantages of short skin incision and small craniotomy compared with the pterional approach. This study was designed to compare the two approaches in the surgical treatment of unruptured intracranial aneurysms. Methods : We retrospectively reviewed 122 patients with 137 unruptured intracranial aneurysms treated by clipping, from July 2009 to April 2011. Between August 2010 and April 2011, 61 patients were treated by clipping via the lateral supraorbital approach and the same number of patients treated by clipping via the pterional approach were retrospectively enrolled. We analyzed the two groups and compared demographic, radiologic and clinical variables. Results : The mean age of patients in the two groups was 54.6 years (LSO group) and 55.7 years (Pterion group). The mean duration of hospitalization was shorter in the LSO group than in the Pterion group (7.9 days vs. 9.0 days, p=0.125) and the mean operation time was also significantly shorter in the LSO group (117.1 minutes vs. 164.3 minutes, p<0.001). Furthermore, the mean craniotomy area was much smaller in the LSO group (1275.4 $mm^2$ vs. 2858.9 $mm^2$, p<0.001). The two groups showed similar distributions of aneurysm location and postoperative complications. Conclusion : The lateral supraorbital approach for the clipping of unruptured intracranial aneurysm could be a good alternative to the classic pterional approach.

• Biomolecules & Therapeutics
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• v.28 no.1
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• pp.98-103
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• 2020

Marfan syndrome (MFS), a connective tissue disorder caused by mutations in the fibrillin-1 (Fbn1) gene, has vascular manifestations including aortic aneurysm, dissection, and rupture. Its vascular pathogenesis is assumed to be attributed to increased transforming growth factor β (TGFβ) signaling and blockade of excessive TGFβ signaling has been thought to prevent dissection and aneurysm formation. Here, we investigated whether galunisertib, a potent small-molecule inhibitor of TGFβ receptor I (TβRI), attenuates aneurysmal disease in a murine model of MFS (Fbn1^C1039G/+) and compared the impact of galuninsertib on the MFS-related vascular pathogenesis with that of losartan, a prophylactic agent routinely used for patients with MFS. Fbn1^C1039G/+ mice were administered galunisertib or losartan for 8 weeks, and their ascending aortas were assessed for histopathological changes and phosphorylation of Smad2 and extracellular signal-regulated kinase 1/2 (Erk1/2). Mice treated with galunisertib or losartan barely exhibited phosphorylated Smad2, suggesting that both drugs effectively blocked overactivated canonical TGFβ signaling in Fbn1^C1039G/+ mice. However, galunisertib treatment did not attenuate disrupted medial wall architecture and only partially decreased Erk1/2 phosphorylation, whereas losartan significantly inhibited MFS-associated aortopathy and markedly decreased Erk1/2 phosphorylation in Fbn1^C1039G/+ mice. These data unexpectedly revealed that galunisertib, a TβRI inhibitor, showed no benefits in aneurysmal disease in MFS mice although it completely blocked Smad2 phosphorylation. The significant losartan-induced inhibition of both aortic vascular pathogenesis and Smad2 phosphorylation implied that canonical TGFβ signaling might not prominently drive aneurysmal diseases in MFS mice.

• Journal of Korean Neurosurgical Society
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• v.53 no.6
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• pp.349-355
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• 2013

Objective : Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. Methods : Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. Results : Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. Conclusion : ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery.

• Journal of Korean Neurosurgical Society
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• v.62 no.5
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• pp.526-535
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• 2019

Objective : While the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH. Methods : Patients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans. Results : In-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p=0.032). Cerebral angiography after SAH was performed on 88 patients ${\leq}3$ hours, 74 patients between 3-6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ${\leq}3$ hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography. Conclusion : Despite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.

• Journal of Korean Neurosurgical Society
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• v.58 no.6
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• pp.513-517
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• 2015

Objective : Microscopic indocyanine green (ICG) angiography is useful for identifying the completeness of aneurysm clipping and the preservation of parent arteries and small perforators. Neuroendoscopy is helpful for visualizing structures beyond the straight line of the microscopic view. We evaluated our prototype of endoscopic ICG fluorescence angiography in swine, which we developed in order to combine the merits of microscopic ICG angiography and endoscopy. Methods : Our endoscopic ICG system consists of a camera, a light source, a display and software. This system can simultaneously display real-time visible and near infrared fluorescence imaging on the same monitor. A commercially available endoscope was used, which was 4 mm in diameter and had an angle of $30^{\circ}$. A male crossbred swine was used. Results : Under general anesthesia, a small craniotomy was performed and the brain surface of the swine was exposed. ICG was injected via the ear vein with a bolus dose of 0.3 mg/kg. Visible and ICG fluorescence images of cortical vessels were simultaneously observed on the display monitor at high resolution. The real-time merging of the visible and fluorescent images corresponded well. Conclusion : Simultaneous visible color and ICG fluorescent imaging of the cortical vessels in the swine brain was satisfactory. Technical improvement and clinical implication are expected.