Surgical treatment of vertebral artery and posterior inferior cerebellar artery aneurysms via transcondylar approach or transcondylar fossa approach

후순환계 혈관 병변은 뇌간 및 하부 뇌신경 등의 중요한 구조물과 인접하고 있어 수술적 치료시 정확한 해부학적 지식의 습득과 신중한 접근법의 선택이 필수적이다. 추골동맥 동맥류, 후하소뇌동맥 동맥류의 치료를 위해 뇌간의 견인 없이 병변의 노출이 가능한 최외측 후두하 접근법의 특징과 적응증에 대해 알아보고, 접근법의 결정을 위한 가장 좋은 검사를 제시한다. 2005년부터 2011년까지 본원에서 추골동맥 동맥류와 후하소뇌동맥 동맥류에 대해 수술 치료를 받은 11명의 환자들을 후향적으로 검토하였다. 동맥류와 설하신경관 사이의 위치 관계를 알아보기 위하여 모든 환자들에게 수술 전 삼차원 영상 전산 촬영을 시행하였다. 총 11명의 환자 중 동맥류의 근위부가 설하신경관보다 근위부에 위치해 경후두과와 접근법(transcondylar fossa approach)을 시행 받은 8명과 설하신경관보다 원위부에 위치하여 경후두과 접근법(transcondylar approach)을 시행 받은 3명이 있었다. 이 중 경후두과 접근법을 시행 받은 환자 중 1명에서 부신경의 마비가 일시적으로 있었으며 그 외 환자들은 신경학적 결손 없이 회복 하였다. 수술 전 삼차원 영상 전산 단층 촬영은 동맥류와 설하신경관 사이 위치 관계를 잘 보여주었다. 경후두과와 접근법과 경후두과 접근법은 뇌간의 견인 없이 병변을 노출할 수 있는 좋은 접근법이다. 추골동맥 동맥류와 후하소뇌동맥 동맥류의 수술적 치료를 위한 접근법 결정을 위해 수술 전 삼차원 영상 전산 단층 촬영을 이용하는 것이 설하신경관과 병변 간의 위치 관계 파악에 유리하며, 실제 수술 시 후후두과도출정맥(posterior condylar emissary vein)이 지나는 후관절융기관을 해부학적 표지로 이용하여 경후두과와 접근법을 시행할 수 있다. 경후두과와 접근법은 관절융기의 절제를 하지 않아 머리목 불안정을 피할 수 있다.;Since posterior circulation vascular lesions are adjacent to important structures such as the brain stem and lower cranial nerves, the acquisition of anatomical knowledge and the careful selection of approaches are essential for the surgical treatment of these lesions. We examined the characteristics and the indications of the far lateral suboccipital approach that exposes lesions without retraction of the brain stem in the treatment of vertebral artery (VA) or posterior inferior cerebellar artery (PICA) aneurysm. We present the best diagnostic tool to determine the approaches. We have reviewed 11 patients who received surgical treatments between 2005 and 2011 for VA or PICA aneurysms. All of the patients performed 3 dimensional computed tomography angiography (3D CT angiography) to investigate the relation of the location between aneurysm and hypoglossal canal. These 11 patients include eight who were treated with the transcondylar fossa approach (TCFA) as their lesions were located below the hypoglossal canal and three who were treated with the transcondylar approach (TCA) as their lesions were located above the hypoglossal canal. Of the three patients treated with the TCA, one had temporary 11th cranial nerve palsy and the others recovered without any neurological defects. 3D CT angiography showed the relation of the location between the aneurysm and hypoglossal canal. The TCFA and the TCA are good approaches to expose lesions without retraction of the brain stem. To determine the approaches for the surgery of VA or PICA aneurysms, using 3-dimensional computed tomography before surgery is advantageous in understanding the positional relations between the hypoglossal canal and the lesions. During the actual surgery, the posterior condylar canal through which the posterior condylar emissary vein passes can be used as an anatomical landmark when TCFA. With this approach, craniocervical instability can be avoided.I. 서론 1 II. 대상 및 방법 3 A. 연구대상 3 B. 수술 접근법 3 III. 결과 6 IV. 고찰 8 V. 결론 12 표 13 사진 및 설명 14 참고문헌 17 영문초록 2

Differences in morphologic features of cerebral arteries between ruptured and unruptured aneurysms

Background and Objectives: The aneurysm of the cerebral artery is a cerebrovascular disease that is enlarged locally due to weakened vessel walls. A ruptured cerebral aneurysm is a fatal disease, but not all unruptured aneurysms are ruptured. According to the natural history of unruptured cerebral aneurysms, the annual rupture rate is about 1.1%. Considering the morbidity and mortality associated with unruptured intracranial aneurysms to be around 10%, careful treatment decisions are essential. In addition to the morphological features of the cerebral aneurysms, the morphological characteristics of the cerebral arteries, which are the causes and consequences of genetic and hemodynamic factors, this may be the factor that distinguishes the rupture from the ruptured aneurysm. This research began under these hypotheses. The purpose of this study was to provide information on the morphologic features of the cerebral arteries in patients with cerebral aneurysms and to identify the ruptured / unruptured cerebral aneurysms according to the morphological characteristics of the cerebral arteries. And to explore the possibilities for the development of clinical decision support systems. Materials and Methods : We analyzed CT angiography before treatment in patients with cerebral aneurysms from January 2014 to December 2016 as a single institutional and retrospective study. To analyze the morphologic characteristics of A1 segment, M1 segment, V4 segment, and basilar artery in CT angiography, DICOM file was used to analyze the proximal distal diameter, area, length, and tortuosity of each segment. The age, sex, presence of rupture of the aneurysm, and history of the patients were also investigated. The morphologic characteristics and clinical factors of each vessel to distinguish between unruptured and ruptured aneurysms were identified by univariate analysis and multivariate analysis. Also, machine learning method which is a kind of artificial intelligence was used to distinguish between unruptured and ruptured aneurysms. As a machine learning, support vector machine (SVM), which is a kind of supervised learning, was used. K-fold cross validation was performed to validate the results. Results : A total of 316 CT angiographies were analyzed. Univariate analysis showed that the proximal, distal, proximal A1, V4, and basilar artery diameters on both sides of the unruptured cerebral artery aneurysm were significantly larger than those of the ruptured aneurysm. The degree of flexion was not statistically different. Hypertension, smoking, alcohol use, and family history of stroke were statistically significant clinical factors. In multivariate analysis, the factors that distinguished the unruptured / ruptured aneurysm were smoking, the mean diameter of the proximal left A1, and the minimum diameter of the distal basal artery. Excluding clinical factors, the mean diameter of the distal portion of the left A1, the minimum diameter of the proximal portion of the basilar artery, and the minimum diameter of the distal portion of the basilar artery were the factors that distinguished the ruptured / unruptured aneurysm. The accuracy of the discrimination through SVM based machine learning was confirmed to be 77.8-98.9% in training set and 73.9-78.4% in testing accuracy. Conclusion : The data of this study will be useful for pre-treatment evaluation of patients with cerebral aneurysm. In addition, simple clinical data and morphologic features of cerebral arteries could be used to distinguish individual cerebral aneurysm rupture.;연구배경 및 목적 : 뇌동맥류는 혈관벽이 약해져서 국소적으로 늘어난 뇌혈관의 병이다. 파열되면 치명적인 질환이지만, 모든 비파열 뇌동맥류가 파열되는 것은 아니다. 비파열 뇌동맥류의 자연사를 보면, 연간 파열율은 1.1% 정도이다. 비파열 뇌동맥류 치료에 따르는 이환율과 사망률이 약 10% 전후인 것을 고려한다면, 신중한 치료 결정은 필수적이다. 비파열 뇌동맥류 파열과 연관된 뇌동맥류의 형태학적 특성을 비롯한 여러 요소들이 있는데, 뇌동맥류의 형태학적 특성 외에, 유전적 요소와 혈역학적 요소의 원인과 결과가 되는 뇌동맥의 형태학적 특성도 비파열 뇌동맥류와 파열 뇌동맥류를 구분하는 요소가 될 수 있다는 가설 하 연구를 시작하게 되었다. 본 연구는 뇌동맥류 수술이나 중재 치료 전에 필요한 뇌동맥류 환자의 뇌동맥의 형태학적 특징에 관한 정보를 제공하고, 뇌동맥의 형태학적 특징에 따라 파열/비파열 뇌동맥류를 구분하며, 인공지능 기법을 통한 구분을 시도하여, 임상 결정 보조 시스템의 개발에 대한 가능성을 모색하는 것이 목적이다. 실험 재료 및 방법: 단일기관, 후향적 연구로서, 2014년 1월부터 2016년 12월까지 시행된 뇌동맥류 환자의 치료 전 CT angiography 를 분석하였다. CT angiography 에서 A1 분절, M1 분절, V4 분절 및 기저동맥의 형태학적 특성을 분석하기 위해, DICOM 파일을 의료영상 후처리 프로그램을 이용하여 각 분절의 근위부 원위부 직경, 면적, 길이, 굴곡도 등을 조사하였다. 또한 환자들의 나이, 성별, 뇌동맥류 파열 유무, 과거력 등을 조사하였다. 각 혈관의 형태학적 특성과 임상 요소는 단변량 분석과 다변량 분석을 통해 비파열 뇌동맥류와 파열 뇌동맥류를 구별하는 요소를 확인하였다. 그리고 동맥류 파열 유무를 구별하기 위해 일반 통계와 더불어 인공지능 기법인 기계학습 방법을 사용하여 두 결과치를 비교하였다. 기계학습은 지도학습의 일종인 서포트 벡터 머신 (Support vector machine, SVM) 을 사용하였다. 학습 성과 평가를 위해서 k 겹 교차검증 (k-fold cross validation) 을 시행하였다. 결과: 총 316개의 CT angiography 를 분석하였다. 단변량 분석을 통해 비파열 뇌동맥류 환자의 양측 M1 의 근위부, 원위부, A1 의 근위부 원위부, V4, 기저 동맥의 내경이 파열 동맥류 환자에 비해 통계적으로 유의하게 컸다는 것을 알 수 있었다. 굴곡도는 통계적으로 차이를 보이지 않았다. 고혈압, 흡연, 알코올 사용 및 뇌졸중 가족력은 통계적으로 유의한 임상 요인이었다. 다변량 분석에서 비파열/파열 뇌동맥류를 구분하는 요인은 흡연, 좌측 근위부 A1 의 평균 직경, 기저 동맥 원위부의 최소 직경이었다. 임상 요소를 제외했을 때에는 좌측 A1 원위부의 평균 직경, 기저동맥 근위부의 최소 직경, 기저동맥 원위부의 최소 직경이 파열/비파열 뇌동맥류를 구분하는 요소였다. SVM 기반의 기계학습을 통해 알아본 구분의 정확도는 훈련 세트시의 학습 정확도는 77.8-98.9% 로 확인되었고, 테스트시의 정확도는 73.9-78.4% 였다. 결론: 본 연구의 데이터는 뇌동맥류 환자의 치료 전 평가에 유용할 것이다. 또한 뇌동맥류 환자의 간단한 임상 데이터와 뇌혈관의 형태학적 특징을 이용하여 개인별 뇌동맥류 파열 유무를 구별할 수 있었다.Ⅰ. 서론 1 Ⅱ. 연구 대상 및 방법 6 A. 임상인자 6 B. CT angiography 6 C. 뇌동맥의 형태학적 요소 7 D. 통계분석 13 E. 기계학습 13 Ⅲ. 결과 17 A. 기본정보 (Demographic findings) 17 B. 뇌동맥류 환자의 뇌동맥 형태학적 요소 19 C. 뇌동맥류 파열 여부와 관련 있는 인자 28 D. 기계학습 결과 31 Ⅳ. 고찰 37 A. 뇌동맥류 환자의 뇌동맥의 형태학적 특징 37 1. M1 분절 37 2. A1 분절 38 3. V4 분절과 BA 39 B. 뇌동맥류 파열과 관련된 인자 40 C. 기계학습 결과에 대한 고찰 41 D. 제한점 및 미래과제 42 Ⅴ. 결론 44 참고문헌 45 ABSTRACT 5

Is nontraumatic intracerebral hemorrhage different between young and elderly patients?

Only a few studies have reported nontraumatic intracerebral hemorrhage in young patients notwithstanding its fatal and devastating characteristics. This study investigated the clinical characteristics and outcome of nontraumatic intracerebral hemorrhage in young patients in comparison to those of the elderly. A retrospective review of consecutive patients admitted at the department of neurosurgery of two tertiary care medical centers presenting with first-ever nontraumatic intracerebral hemorrhage was performed. We identified and compared the demographics, etiologies, risk factors, and laboratory, radiological, and clinical findings between elderly and young patients. Additionally, logistic regression analyses of independent prognostic factors associated with 1-month mortality and favorable functional outcome were performed. Altogether, 247 patients including 69 young patients and 178 elderly patients were enrolled. On multivariate analysis, young patients exhibited significantly more often an infratentorial hematoma location, excessive alcohol consumption, and high body mass index (BMI), but less frequent systemic hypertension. There was no statistical difference between the two groups in 1-month mortality (17.46% and 18.01% for young and elderly patients, respectively), but the favorable functional outcome based on modified Rankin scale score of 0 or 1 was significantly different between the two groups (favorable outcome in 51.79% and 29.93% of patients, respectively). Predictors of 1-month mortality was the presence of herniation in the young group, and lower Glasgow Coma Scale score, renal or heart disease, and leukocytosis (WBC > 10,000) in the elderly group. Lower National Institutes Health Stroke Scale score was associated with favorable functional outcome in both groups. Nontraumatic intracerebral hemorrhage in younger patients appears to be associated with excessive alcohol consumption and high BMI. Younger patients had similar short-term mortality but more favorable functional outcome than the elderly

A Study on Henry Purcells Incidental Music From Rosy Bowers

학위논문 (석사)-- 서울대학교 대학원 : 음악과, 2014. 8. 연광철.헨리 퍼셀은 17세기 후반 가장 다재다능한 작곡가 중 한 사람으로 손꼽힌다. 퍼셀은 영국 음악의 중심축 역할을 하며 자국의 음악을 이끌었고, 300년 이상 지난 현재까지도 영국에서 가장 위대한 작곡가로 추앙된다. 퍼셀은 36의 이른 나이에 세상을 떠났지만 그럼에도 불구하고 수많은 작품을 남겼으며 그 중에는 49개의 연극을 위한 부수음악을 포함한 53개의 극음악 또한 포함된다. 교회음악, 무대음악 및 독창곡을 포함하는 퍼셀의 성악곡들은 자국의 언어인 영어를 정교하게 음악으로 묘사한 작품들이며, 아름다운 멜로디와 강렬한 표현 방식까지 더해져 당대뿐 아니라 현재까지도 걸작으로 찬사를 받고 있다. 퍼셀은 언어를 음악으로 묘사하기 위해 멜리스마 음형, 상향 혹은 하강하는 멜로디, 단어와 문장의 반복 등의 기법을 적극적으로 사용하였다. 트레몰로와 같은 장식음의 사용, 중요한 단어 전후의 쉼표 배치 또한 단어의 의미를 강조하기 위한 장치였다. 이와 같이 퍼셀은 영어의 아름다움을 가사그리기로 묘사하는 데에 누구보다 능통했으며, 그의 성악 작품들은 영어의 구어체 패턴을 그대로 보여주는 작품이 될 수 있었다.Henry Purcell was one of the most versatile composers of the late 17th century. Purcell occupies a central position in British music and more than 300 years after his death he is still arguably the countrys greatest composer. He died with age of 36 and left a lot of works in spite of his short lifetime, especially 53 pieces of theatre music included 49 pieces of incidental music. Apparent in his church music, stage works and solo songs alike are an exquisite talent for English word-setting, attractive melody and a capacity for searing expressiveness that have attracted commendation from his own time to ours. The use of melismatic devices is used by Purcell to emphasize certain words. Other things he has in common when word-painting is the descending notes and to repeat certain words or sentences. Purcell also uses tremólos and having a break before/after the words which are to be emphasized. Through these processes he bacame a master of setting English words to music and perfectly preserved natural speech patterns, even when the music is highly decorated.- 목 차 – Ⅱ. 서론 Ⅱ. 본론 1. 이론적 배경 (1) 바로크 음악의 흐름 및 특징 (2) 바로크 시대 영국의 음악 2. 작곡가 Henry Purcell (1) Henry Purcell의 생애 (2) Henry Purcell 성악곡의 특징 (3) Henry Purcell의 부수음악 3. From Rosy Bowers 분석 Ⅲ. 결론 참고문헌 AbstractMaste

Atypical cerebral manifestations of disseminated Mycobacterium tuberculosis

Background: We investigated the patterns of cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis or disseminated tuberculosis. Materials and methods: From January 2010 to September 2016, brain magnetic resonance imaging (MRI) scans were obtained to evaluate cerebral manifestations in patients with underlying pulmonary or extrapulmonary tuberculosis. We also included patients with drug-resistant tuberculosis or disseminated tuberculosis. MRI findings of tuberculous meningitis and tuberculoma were classified as typical; other MRI findings were classified as atypical. Demographic data, risk factors, and drug regimens were collected and analyzed. Results: Twenty-two patients were diagnosed with cerebral tuberculosis. Cerebral tuberculosis was due to hematogenous spread from pulmonary tuberculosis (10 patients), spinal tuberculosis (8 patients), disseminated tuberculosis (3 patients), and unknown causes (1 patient). There were six patients with typical MRI findings (three patients with typical meningitis involving the basal cistern and supratentorium, one patient with tuberculomas, and two patients with both) and seven patients with atypical MRI findings [five patients with evidence of early meningitis, such as high signal intensity on fluid-attenuated inversion recovery (FLAIR) along the cerebellar folia, and two patients with only hydrocephalus]. Conclusion: Besides the typical sites of meningeal involvement, overlooked findings such as FLAIR abnormalities along the cerebellar folia or hydrocephalus should be checked for early detection of cerebral tuberculosis and initiation of the appropriate treatment against disseminated tuberculosis. © 2017 Hwang, Lee, Park, Kim, Kim, Choi and Yang

Local Anesthesia for Endovascular Treatment of Unruptured Intracranial Aneurysms: Feasibility, Safety, and Periprocedural Complications

Objective The aim of the study is to report the feasibility, safety, and outcomes associated with endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) under local anesthesia. Methods Between March 2011 and December 2016, 184 consecutive patients with 198 UIAs were treated with coil embolization under local anesthesia at the author's center. The data about medical comorbidities according to American Society of Anesthesiologists grade, procedural details, and clinical and radiographic outcomes were reviewed. Results A total of 388 procedures were performed under local anesthesia, and 198 procedures with UIA were included. The mean age was 63.8 ± 12.5 years, and 118 (59.6%) cases had a risk status of American Society of Anesthesiologists class III or IV. Of those 198 procedures, 196 procedures (99.0%) were completed successfully. The overall procedure-related event rate was 5% (10/198). The rates of morbidity and mortality were 0.5% (1 of 198) and 0% at 1 month, respectively. Among the 3 recurred cases (1.5%), two (1%) underwent EVT again. The mean intensive care unit stay was 0.99 ± 0.1 days, and the mean postoperative hospital stay was 3.6 ± 7.2 days. Conclusions Local anesthesia in the EVT of UIA is feasible and safe. It could be considered as an alternative for the patients with high risk of general anesthesia. © 2017 Elsevier Inc

Treatment Outcomes with Selective Coil Embolization for Large or Giant Aneurysms : Prognostic Implications of Incomplete Occlusion

Objective : The objectives of this study were to evaluate the immediate and long-term efficacy and safety of coil embolization for large or giant aneurysms. Methods : One hundred and fifty large or giant aneurysm cases treated with endovascular coil embolization between January 2005 and February 2014 at a single institute were included in this study. Medical records and imaging findings were reviewed. Statistical analysis was performed to evaluate prognostic factors associated with major recurrence (major recanalization or rupture) and delayed thromboembolism after selective coil embolization. Results : Procedure-related symptomatic complications occurred in five (3.3%) patients. The mean clinical and radiological follow-up periods were 38 months (range, 2-110) and 26 months (range, 6-108), respectively. During the follow-up period, the estimated recurrence rate was 4.6% per year. Multivariate analysis using Cox regression showed the degree of occlusion to be the only factor associated with recurrence (p=0.008, hazard ratio 3.15, 95% confidence interval 1.34-7.41). The patient's history of rupture in addition to the size and location of the aneurysm were not associated with recurrence in this study. Delayed infarction occurred in eight cases, and all were incompletely occluded. Conclusion : Although immediate postprocedural safety profiles were reasonable, longterm results showed recanalization and thromboembolic events to occur continuously, especially in patients with incomplete occlusion. In addition, incomplete occlusion was associated with delayed thromboembolic complications. Patients with incomplete occlusions should be followed carefully for delayed recurrence or delayed thromboembolic events

Vestibular Schwannoma Atypically Invading Temporal Bone

Vestibular schwannoma (VS) usually present the widening of internal auditory canal (IAC), and these bony changes are typically limited to IAC, not extend to temporal bone. Temporal bone invasion by VS is extremely rare. We report 51-year-old man who revealed temporal bone destruction beyond IAC by unilateral VS. The bony destruction extended anteriorly to the carotid canal and inferiorly to the jugular foramen. On histopathologic examination, the tumor showed typical benign schwannoma and did not show any unusual vascularity or malignant feature. Facial nerve was severely compressed and distorted by tumor, which unevenly eroded temporal bone in surgical field. Vestibular schwannoma with atypical invasion of temporal bone can be successfully treated with combined translabyrinthine and lateral suboccipiral approach without facial nerve dysfunction. Early detection and careful dissection of facial nerve with intraoperative monitoring should be considered during operation due to severe adhesion and distortion of facial nerve by tumor and eroded temporal bone

Spontaneous resolution of nontraumatic acute spinal subdural hematoma

Spinal subdural hematoma (SSDH) is an extremely uncommon condition. Causative factors include trauma, anticoagulant drug administration, he-mostatic disorders, and vascular disorders such as arteriovenous malformations and lumbar punctures. Of SSDH cases, those that do not have any traumatic event can be considered cases of nontraumatic acute spinal subdural hematoma, which is known to have diverse clinical progress. Treatment typically consists of surgical decompression and cases in which the condition is relieved with conservative treatment are rarely reported. We report two nontraumatic acute spinal subdural hematoma patients who were successfully treated without surgery. © 2011 The Korean Neurosurgical Society