• Journal of Korean Neurosurgical Society
• /
• 제59권3호
• /
• pp.269-275
• /
• 2016

Objective : Although middle cerebral artery (MCA) aneurysms are less amenable to coil embolization, an increasing number of studies support favorable endovascular treatment for them. The purpose of this study is to compare the outcomes of two different treatments (surgery versus coiling) and evaluate the benefits of surgical clipping for MCA aneurysms. Methods : Here we retrospectively analyzed the outcomes of 178 ruptured and unruptured MCA aneurysms treated in patients between September 2008 and April 2012. Parameters assessing treatment outcomes include degree of aneurysm occlusion, presence of regrowth, clinical status, and complications. Results : Among 178 MCA aneurysms, 153 were treated surgically. After a mean follow-up of 12 months, the surgery group showed a clinically significant complete occlusion rate (98%) compared with the coiling group (56%) (p<0.001). Follow-up radiologic evaluation showed a higher regrowth rate (four of 16 cases) in the coiling group than in the surgery group (one of 49 cases) (p=0.003). There was no statistically significant difference in favorable clinical outcome rate between the two groups. The procedure-related permanent morbidity and mortality rates were 2% (three of 153 cases) in the surgery group and 0% (0 of 25 cases) in the coiling group. Conclusion : Compared to endovascular treatment, surgical neck clipping for both ruptured and unruptured MCA aneurysms results in a significantly higher complete obliteration rate and less regrowth. Therefore, even in this endovascular era, we still recommend surgical clipping as the primary treatment option for MCA aneurysms rather than coil embolization.

• Journal of Cerebrovascular and Endovascular Neurosurgery
• /
• 제25권2호
• /
• pp.150-159
• /
• 2023

Objective: The aim of this study was to investigate the efficacy of intraoperative indocyanine green videoangiography (ICG-VA) and intraoperative neuromonitoring (IONM) to prevent postoperative ischemic complications during microsurgical clipping of unruptured anterior choroidal artery (AChA) aneurysms. Methods: We retrospectively reviewed the clinical and radiological records of all patients who had undergone microsurgical clipping for unruptured AChA aneurysms at our institution between April 2001 and December 2019. We compared the postoperative complication rate of the group for which intraoperative ICG-VA and IONM were utilized (group B; n=324) with that of the group for which intraoperative ICG-VA and IONM were not utilized (group A; n=72). Results: There were no statistically significant differences in demographic data between the two groups. Statistically significant differences were observed in the rate of overall complications (p=0.014) and postoperative ischemic complications related to AChA territory (p=0.039). All the cases (n=4) in group B who had postoperative infarctions related to AChA territory showed false-negative results of intraoperative ICG-VA and IONM. Conclusions: Preserving the patency of the AChA is essential to minimize postoperative complications. Intraoperative monitoring tools including ICG-VA and IONM can greatly contribute to lowering complication rates. However, their pitfalls and false-negative results should always be considered.

• Journal of Cerebrovascular and Endovascular Neurosurgery
• /
• 제25권4호
• /
• pp.390-402
• /
• 2023

Objective: Chronic subdural hematoma (CSDH) is a neurological complication following clipping surgery. However, the natural course and ideal approach for the treatment of clipping-related-CSDH (CR-CSDH) have not been clearly established. We aimed to investigate the course of CR-CSDH using chronological radiological findings. Methods: We performed a retrospective analysis of 28 (3.8%) patients who developed CSDH among 736 patients who underwent surgical clipping using pterional approach for unruptured aneurysms at our institution between December 2010 and December 2018. Patients underwent follow-up CT scan 6-8 weeks after clipping surgery and decision to pursue surgical intervention rests upon the patient's symptom based on the Markwalder's grading scale (MGS) and numeric rating scale (NRS). Results: Of the 28 patients, 3 patients (10.7%) underwent surgery, while 25 (89.2%) showed spontaneous resolution of CR-CSDH. Eighteen patients (64.2%) had mild headache with MGS of 0-1. The mean maximum hematoma volume was 41.9±30.9 ml (5.8-135 ml), and 26 patients (92.8%) had homogeneous hematoma. The mean time to hematoma resolution was 126.7±52.9 days (46-228 days). Comparing group of CR-CSDH volume ≥43 ml or a midline shift ≥5 mm, the difference in presence of linear low-density area (p=0.002) and age (p=0.026) between the conservative and operative groups were found to be statistically significant. Conclusions: Most CR-CSDH cases spontaneously resolved within 4 months. Therefore, we suggest that close observation should be performed if patient's symptoms are mild and special radiologic findings are present, despite its relatively large volume and midline shifting.

• Journal of Korean Neurosurgical Society
• /
• 제51권6호
• /
• pp.370-373
• /
• 2012

The intracranial stent functions primarily to prevent protrusion of coils into the parent vessel during the embolization of wide-necked cerebral aneurysms and might also reduce aneurysm recanalization rate. In spite of these advantages, little is known about the long-term interaction of the stent with the parent vessel wall. We present a rare case of severe in-stent stenosis occurring as a delayed complication of Neuroform stent-assisted coil embolization of an unruptured intracranial aneurysm.

• Journal of Korean Neurosurgical Society
• /
• 제48권2호
• /
• pp.115-118
• /
• 2010

Objective : Cerebral aneurysms which cause oculomotor nerve [cranial nerve (CN) III] palsy, are frequently found with a daughter sac of the aneurysm dome. We assumed that CN III might be compressed by the daughter sac and it would be more helpful not to fill the daughter sac with coils than vice versa during endosaccular embolization for recovering from CN III palsy, because it may give a greater chance for the daughter sac to shrink by itself later. We reviewed the initial results of our experiences of such cases. Methods : Among 9 aneurysms accompanied by CN III palsy, 7 (6 unruptured, 1 ruptured) showed a daughter sac. We tried to fill the main dome completely and spare the daughter sac from coil filling to increase the possibility of decompression. We evaluated the short-term effectiveness of this concept using medical records and angiograms. Results : After initial embolization, all of CN III palsy caused by unruptured aneurysms (6/6) resolved completely after various periods (3-90 days) of time. No adverse effects were noted during and after the procedures except for one case of harmless coil stretching during coil filling using double microcatheter. Conclusion : During the coil embolization of the cerebral aneurysm causing CN III palsy, sparing the daughter sac from coil packing while tightly packing the main dome, can be helpful in increasing the effectiveness of decompression. However, a long-term follow-up will be required.

• Journal of Korean Neurosurgical Society
• /
• 제59권5호
• /
• pp.458-465
• /
• 2016

Objective : The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA). Methods : We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data. Results : The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ${\geq}5mm$ and male sex in the UIA and A high HF unit for SFC and SFC ${\geq}5mm$ without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05). Conclusion : There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ${\geq}5mm$ were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ${\geq}5mm$ at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.

• Journal of Korean Neurosurgical Society
• /
• 제63권4호
• /
• pp.455-462
• /
• 2020

Objective : Recent studies have reported that arachnoid plasty (ARP) using gelatin sponges with fibrin glue reduced the occurrence of chronic subdural hematoma (CSDH) following clipping surgery for unruptured intracranial aneurysm (UIA). This meta-analysis was conducted to collate further evidence for the efficacy of ARP in preventing postoperative CSDH. Methods : Data of patients who underwent clipping surgery were extracted from PubMed, EMBASE, and Cochrane Central Register of Controlled Trials by two independent reviewers. A random effects model was used to investigate the efficacy of ARP by using odd ratios (ORs) and 95% confidence intervals (CIs). A meta-regression analysis for male sex was additionally preformed. Results : Data from six studies with 1715 patients were consecutively included. Meta-analysis revealed that ARP was significantly associated with lower rates of CSDH development after surgical clipping for UIA (ARP group vs. control group : 3.2% vs. 7.2%; OR, 0.40; 95% CI, 0.18-0.93; I²=44.3%; p=0.110). Meta-regression analysis did not highlight any modifying effect of the male sex on postoperative CSDH development (p=0.951). Conclusion : This meta-analysis indicated that ARP reduced the incidence rates of CSDH following clipping surgery for UIA. If feasible, ARP would be implemented as an additional surgical technique to prevent postoperative CSDH development during surgical clipping of UIA.

• Journal of Korean Neurosurgical Society
• /
• 제47권6호
• /
• pp.437-441
• /
• 2010

Objective : The precise intra- vs. extradural localization of aneurysms involving the paraclinoid internal carotid artery is critical for the evaluation of patients being considered for aneurysm surgery. The purpose of this study was to investigate the clinical usefulness of T2-weighted threedimensional (3-D) fast spin-echo (FSE) magnetic resonance (MR) imaging in the evaluation of unruptured paraclinoid aneurysms. Methods : Twenty-eight patients with unruptured cerebral aneurysms in their paraclinoid regions were prospectively evaluated using a T2- weighted 3-D FSE MR imaging technique with oblique coronal sections. The MR images were assessed for the location of the cerebral aneurysm in relation to the dural ring and other surrounding anatomic compartments, and were also compared with the surgical or angiographic findings. Results : All 28 aneurysms were identified by T2-weighted 3D FSE MR imaging, which showed the precise anatomic relationships in regards to the subarachnoid space and the surrounding anatomic structures. Consequently, 13 aneurysms were determined to be intradural and the other 15 were deemed extradural as they were confined to the cavernous sinus. Of the 13 aneurysms with intradural locations, three superior hypophyseal artery aneurysms were found to be situated intradurally upon operation. Conclusion : High-resolution T2-weighted 3-D FSE MR imaging is capable of confirming whether a cerebral aneurysm at the paraclinoid region is intradural or extradural, because of the MR imaging's high spatial resolution. The images may help in identifying patients with intradural aneurysms who require treatment, and they also can provide valuable information in the treatment plan for paraclinoid aneurysms.

• Journal of Korean Neurosurgical Society
• /
• 제64권1호
• /
• pp.23-29
• /
• 2021

Objective : Although stent-assisted coiling (SAC) has been reported to be safe and effective in treating wide-necked aneurysms, the technique has procedure-related complications. Thus, we reported our experiences of SAC using the Neuroform Atlas stent in treating wide-necked aneurysms and evaluated the incidence of and risk factors for procedure-related complications. Methods : From March 2018 to August 2019, we treated 130 unruptured wide-necked aneurysms in 123 patients with Neuroform Atlas stents. Angiographic results and clinical outcomes were reviewed retrospectively. Clinical and angiographic follow-up were performed in all cases (mean, 12.4 months) after the procedure. Results : There were eight cases (6.2%) of procedure-related complications (two dissections, five thromboembolisms, and one hemorrhage) and two (1.5%) of delayed complications (one ischemia and one hemorrhage). There was one case (0.8%) of failure of stent deployment and one (0.8%) of suboptimal positioning of the stent. Follow-up angiography showed complete obliteration in 103 (79.2%), residual neck in 16 (12.3%), and residual aneurysm in 11 cases (8.5%). Aneurysm locations in the middle cerebral artery (odds ratio [OR], 2.211; p=0.046) and the anterior communicating artery (OR, 2.850; p=0.039) were associated with procedure-related complications on univariate analysis. However, no independent risk factor for procedure-related complications was noted in multivariate analysis. Conclusion : The Neuroform Atlas showed a high rate of technical success. Good clinical and radiographic outcomes in early follow-up suggests that the device is feasible and safe. SAC of aneurysms on the middle cerebral artery or anterior communicating artery may require more attention to prevent possible procedure-related complications.

• Journal of Korean Neurosurgical Society
• /
• 제43권3호
• /
• pp.131-134
• /
• 2008

Objective: The surgical approach for anterior choroidal artery (AChA) aneurysm is typically similar to those used for other supraclinoid internal carotid artery (ICA) lesions. However, the surgical clipping of this aneurysm is complicated and as a result. can result in postoperative ischemic complications. The purpose of this study was to clarify the risk of clip-induced ischemic complication in AChA aneurysm and to get the benefits for helping decision making. Methods: We retrospectively investigated 53 cases (4.0%) of AchA aneurysm treated surgically. We divided the AChA aneurysm to 3 subtype according to the origin of aneurysmal neck; A type originating from the AChA itself. J type from junction of AChA and ICA and I type from the ICA itself. We evaluated brain CT about 1 week post-operative day to confirm the low density in AChA territory. Results: Ruptured aneurysm was 26 cases and unruptured aneurysm 27 cases. The aneurysmal subtype of A, J, and I was 13, 17, and 23 cases. Of the 53 cases who performed surgical neck clipping, twelve (22.6%) had postoperative AChA distribution infarcts. Increased infarct after neck clipping had statistic significance in non-I subtype (r=0.005) Conclusion: AChA aneurysm surgery carries a significant risk of postoperative stroke. Don't always stick to clipping only, especially in non-I type of incidental small aneurysm, which has high risk of post-clip ischemic complications.