뇌동맥류내 코일색전술 실패 후 수술을 통한 코일 제거 및 뇌동맥류 결찰

Despite modern advances in endovascular techniques, intraaneurysmal coil embolization may be associated with serious complications such as parent artery occlusion by thromboembolism and coil migration or incomplete treatment, which require surgery. We report 5 cases in which surgical interventions had been necessary following coil embolization with Guglielmi Detachable Coil, either due to incomplete aneurysm obliteration or acute complication of parent artery occlusion by coil migration and throm-boembolism. Surgical intervention include removal of the coils and clipping of the aneurysm. Immediate recanalization of the occluded artery by use of intra-arterial thrombolytics and surgery is very important. The role of neurosurgical management in the care of the patients suffering from unsuccessful endovascular therapy of aneurysm is demonstrated.ope

Endovascular Management of Intracranial Dural Arteriovenous Fistula

성인에서 발생하는 경막동정맥루는 여러 요인에 의하여 유발되는 후천적인 질환으로 혈관촬영에서 관찰되는 병변의 정맥유출 양상은 임상 양상 및 예후가 결정하는 가장 중요한 인자로 알려졌다. 특히, 피질 정맥으로의 역행성 정맥 유출은 두개내 출혈 및 신경학적 결손의 가능성을 강력히 시사하며, 뇌실질내 출혈 또는 신경학적 결손으로 처음 발현한 경우 재출혈의 가능성이 높기 때문에 이런 환자 군의 경우 완치를 목표로 하는 적극적인 치료를 필요로 한다. 반대로 정상적인 전향적 혈류 흐름을 유지한 채 경막정맥동으로 직접 유출되는 경막동정맥루의 예후는 비교적 양호하며 증상이 자연적으로 소실되거나 변화가 없을 가능성이 높다. 그러므로 치료는 이명이나 복시의 증상을 완화하기 위한 경우를 제외하고는 적응증이 되는 경우는 매우 드물다. 치료의 적응이 되는 경우 일차적으로 경혈관적 색전술이 시도되는 방법으로, 치료 목적에 따라 달라질 수 있으나, 정맥, 동맥, 또는 혼합 접근법은 모두 적용 가능한 혈관내 색전 접근법이다. 완치가 목적이나 혈관내 치료가 완치에 실패하거나 기술적으로 불가능한 경우 수술을 선택할 수 있다.ope

Assessment of Flow Dynamics of Cerebrospinal Fluid with Phase-contrast Cine MR Image

Phase contrast magnetic resonance imaging techniques can be used to evaluate the to-and-fro motion of cerebrospinal fluid(CSF) throughout CSF pathways between the ventricles and subarachnoid space of the brain and spine. This CSF motion is due to transmitted cardiac pulsation from systolic expansion of the cerebral hemispheres. To cover the entire cardiac cycle, peripheral cardiac triggering was used. Using this technique, we analyzed quantitative CSF motion over a cardiac cycle to distinguish normal CSF flow from that seen in hydrocephalus. We tested the reproducibility of the aqueductal CSF signal intensity on a phase contrast cine MR sequence in 28 patients with normal ventricle. Sixteen patients with obstructive hydrocephalus and 11 patients with normal pressure hydrocephalus(NPH) were investigated with the sequence before and after CSF diversion. The peak CSF flow velocity in aqueduct was significantly increased in patients with NPH and significantly decreased in patients with obstructive hydrocephalus(NPH group：6.71cm/sec, control group：2.94cm/sec, obstructive group；less than 1.0cm/sec). After LP shunting in NPH group, retrograde flow signal curves were anterogradely converted and the peak flow velocities were somewhat decreased(mean：5.10cm/sec). The clinical diagnosis of NPH was well correlated with the results of cine MRI. After endoscopic third ventriculostomy in obstructive group, we could note increased CSF flow velocity both at prepontine cistern and precordal subarachnoid space with markedly increased flow at prepontine cistern. Phase contrast cine MRI is useful in evaluatng the CSF dynamics in patients with hyperdynamic aqueductal CSF(NPH) or aqueductal obstruction(obstructive hydrocephalus).ope

A Case of Postpartum Cerebral Angiopathy

Postpartum cerebral angiopathy is a benign, reversible clinicoradiologic syndrome. The clinical significance of this syndrome is the difficulty in differentiating it from other severe disorders such as subarachnoid hemorrhage and cere-bral vasculitis. A 25-year-old woman who developed a severe headache, transient total blindness ,and generalized tonic clonic seizures 14 days postpartum was admitted to our hospital. A MRI of the brain revealed a bilateral anterior cere-bral artery (ACA) infarction. A cerebral angiography showed the narrowing of the M1 and M2 segments of the left middle cerebral artery (MCA), the right MCA M1 segment, and the A1 and proximal A2 segments of the right ACA. Also, it showed the narrowing of the proximal basilar artery portion from which the anterior inferior cerebellar artey arose, P1, P2, and P3 segments of the left posterior cerebral artery (PCA), and the right PCA P1 segment. With the treatment of nimodipine, the abnormalities on these studies were markedly improved two weeks later.ope

Endovascular Treatment of Occlusive Cerebrovascular Diseases

Carotid atherosclerosis is one the main risk factors for ischemic stroke. Based on NASCET and ECST results, carotid endarterectomy is strongly recommended for severe symptomatic stenosis. However, in the past several years, carotid artery stenting has emerged as a potential therapeutic alternative to carotid endarterectomy. The main limitation of carotid stenting is the potential risk of thromboembolic complication. Recently, cerebral protection during carotid stenting is technically feasible and clinically safe. In the published data of prospective registry with cerebral protection, the incidence of periprocedural neurologic complications was lower than in registries without cerebral protection and similar to the best results reported for carotid endarterectomy. The future status of the endovascular approach will be determined by randomized trials directly comparing carotid artery stenting with cerebral protection and endarterectomy. Occlusive atherosclerotic disease involving the intracranial cerebral vessels can be managed medically with antiplatelet and anticoagulant drug therapy or surgically. However, in patients who are unresponsive to medical therapy or who have unacceptable surgical risks, percutaneous angioplasty with stenting is an attractive alternative that can be performed in selected patients with relatively low risk and good clinical outcome.ope

Unruptured Intracranial Aneurysms in Patients with Ischemic Stroke

Background: Intracranial aneurysms are often found in patients with ischemic stroke. Acute or chronic hemodynamic alterations of intracranial arteries, which frequently occur in patients with ischemic stroke, may affect on the characteristics of the aneurysms. Methods: Of 1655 patients with ischemic stroke registered in Yonsei Stroke Registry, 578 patients who underwent cerebral angiography were enrolled in this study. Those with intracranial aneurysms were identified from this prospective registry. Patients with dissecting, fusiform, and mycotic aneurysms were excluded. Distribution and size of aneurysms, and clinical characteristics were investigated. Results: Intracranial aneurysms were found in 24 patients(4.2%; 14 men and 10 women; aged 44 to 77 years, mean: 64) out of the 578 patients. Eighteen patients(75%) were hypertensives, eight(33%) were smokers, four(17%) had cardiac diseases, and three(12.5%) were diabetics. Aneurysms were single in 21 patients and multiple in 3. The aneurysms were most frequently found in the internal carotid artery(36%), followed by the middle cerebral artery(18%), posterior communicating artery(18%), anterior communicating artery(14%), anterior cerebral artery(11%), and superior cerebellar artery(3%). The aneurysms were less than 10 ㎜ in diameter in 26 patients(93%), and 10 ㎜ or more in 2(7%). Conclusions: Unruptured aneurysms, incidentally found during cerebral angiography in acute inchemic stroke, are characteristically small, single, and located in the anterior circulation. However, the frequency and the distribution of them are similar to those reported in the general populationope

MR-DWI–Positive Lesions and Symptomatic Ischemic Complications After Coiling of Unruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE: The aims of this study are to evaluate the risk factors for symptomatic ischemic complication (symptomatic ischemic complication [SIC], transient ischemic attack, or stroke) and microembolisms detected as MR diffusion-weighted imaging (MR-DWI)-positive (DWI(+)) lesions, and the relationship between DWI(+) and SIC after coiling of unruptured intracranial aneurysm. METHODS: Between March 2009 and November 2011, 382 unruptured intracranial aneurysms in 343 patients underwent both coiling and posttreatment MR-DWI. The incidence of and risk factors for SIC and DWI(+), and the relationship between DWI(+) and SIC were retrospectively analyzed. RESULTS: The incidence of SIC was 4.1%. The incidence of DWI(+) was 54.5%. The number of DWI(+) lesions was significantly larger in the SIC group, than in the asymptomatic one (12.1±10.4 versus 5.0±8.7, P<0.00). The cutoff value of DWI(+) for predicting SIC was ≥6 (sensitivity 85.7%, specificity 70.7%). The patients with DWI(+) ≥6 was 28.6%. Of the patients with SIC, the patients with DWI(+) ≥6 was 78.6%. Patients aged≥65 years had a trend for SIC, and it was the only independent risk factor for DWI(+) ≥cutoff (n=6; 95%CI, 1.167-3.083). CONCLUSIONS: The number of DWI(+) lesions was significantly larger in the SIC group than in the asymptomatic one after coiling of unruptured intracranial aneurysm. Patients aged≥65 had a trend for SIC, and it was the only independent risk factor for the number of DWI(+) ≥cutoff value (n=6) for predicting SIC.ope

Specific Characteristics and Management Strategies of Posterior Cerebral Artery Aneurysms

Objective：This study was to define clinical characteristics and formulate the management strategies of the patients with posterior cerebral artery (PCA) aneurysms. Patients and Method：The authors reviewed the database and imaging studies as sources for identification and analysis. During the past 14 years, 16 consecutive patients with PCA aneurysms were treated either by surgery or neurointervention. Results：Ten patients had ruptured PCA aneurysms：4 patients were Hunt and Hess Grade I, 1 Grade II, 4 Grade III, and 1 Grade IV. Six patients had unruptured PCA aneurysms：one patient was Grade 1, and the other patient was Grade IV due to ruptured multiple aneurysms. Seven aneurysms were small, 9 (56.2%) were large or giant. Thirteen aneurysms were saccular, 2 were fusiform, and 1 was serpentine. Seven of the 16 patients (43.7%) had multiple aneurysms. Pterional (8) or subtemporal (5) approach was done in 13 patients. The obliteration methods of the aneurysms were neck clipping in 10 patients, and trapping in 3 patients. Endovascular treatment was performed in 3 patients. Five patients showed transient oculomotor nerve palsy and contralateral hemiparesis after the surgery. Persisting oculomotor nerve palsy occurred in one patient. All patients showed favorable outcome (food recovery 14, moderate disability 2). Conclusions：As a result, PCA aneurysms were characterized by high frequency of non - saccular shape, large or giant size with mass effect, and multiple aneurysms. Surgical treatment was necessary for large or giant aneurysm of the distal PCA to decompress midbrain. Wrapping and clipping technique were useful for treatment of fusiform aneurysms. Although ultimate management outcome of the patients with PCA aneurysms were better than the patients with aneurysms of the other location, intra-aneurysmal treatment with Guglielmi detachable coil would be useful for the proximal PCA aneurysms to avoid surgical injury of the P1 perforator or the oculomotor nerve.ope

Transvenous Coil Embolization of Traumatic Carotid-Cavernous Fistula Associated with a Persistent Primitive Trigeminal Artery

A 45-year-old male presented with left pulsatile tinnitus and left conjunctival chemosis after blunt head trauma. Cerebral angiography demonstrated a left carotid-cavernous sinus fistula associated with a persistent primitive trigeminal artery. The fistula was packed with detachable coils through the transvenous approach and was successfully occluded without complication, while preserving the patency of the persistent primitive trigeminal artery. The patient's symptoms resolved soon after treatment. Persistent primitive trigeminal artery can be associated with a traumatic cavernous sinus fistula and transvenous coil embolization can be a safe and effective method to immediately occlude the fistula.ope

Effect of intra-arterial papaverine infusion on the symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Objective：To clarify the benefits and therapeutic effects of intra-arterial papaverine infusion on the symptomatic cerebral vasospasm, we analyzed the results of treatment in 32 patients retrospectively. Methods：A total of 510 patients underwent surgical clipping or endovascular intra-aneurysmal treatment for ruptured intracranial aneurysm between May, 1996 and June, 1999. The delayed ischemic deficit(DID) was developed in 90 of 510 patients. Of these 90 patients, 32 developed symptomatic vasospasm inspite of using modest "3H therapy". The brain CT scan was taken before the intra-arterial infusion of papaverine. The 32 patients underwent 42 intra-arterial papaverine infusion. The symptomatic vasospasm was divided into three groups：deterioration of mental status(Group 1), appearance of a focal neurologic deficit(Group 2), or both(Group 3). We measured Glasgow Coma Scale(GCS), arterial diameters, and cerebral circulation time(CCT) at the time of pre- and postangioplasty. Results：The number of patients in group 1, 2 and 3 were 26, 7, 9 respectively. Eighteen cases showed improvement of GCS more than 2 scores, 16 more than 1, and 8 showed no change of GCS. Average cerebral circulation time(CCT) was decreased ranging from 0.0-67.5%, and arterial diameters were increased in 21 cases ranging from 1 to 4 folds. Conclusion：Intra-arterial papaverine infusion seemed to have therapeutic effects on symptomatic vasospasm by improving the neurological signs and increasing the arterial diameter. We suggest that intra-arterial papaverine infusion would be an useful adjunctive therapeutic modality in symptomatic vasospasm.ope