Pedicled frontal periosteal rescue flap via eyebrow incision for skull base reconstruction (SevEN-002)

Purpose: Cerebrospinal fluid (CSF) leakage is one of the major complications after endoscopic endonasal surgery. The reconstructive nasoseptal flap is widely used to repair CSF leakage. However, it could not be utilized in all cases; thus, there was a need for an alternative. We developed a pericranial rescue flap that could cover both sellar and anterior skull base defects via the endonasal approach. A modified surgical technique that did not violate the frontal sinus and cause cosmetic problems was designed using the pericranial rescue flap. Methods: We performed 12 cadaveric dissections to investigate the applicability of the lateral pericranial rescue flap. An incision was made, extending from the middle to the lateral part of the eyebrow. The pericranium layer was dissected away from the galea layer, from the supraorbital region towards the frontoparietal region. With endoscopic assistance, the periosteal flap was raised, the flap base was the pericranium layer at the eyebrow incision. After a burr-hole was made in the supraorbital bone, the pericranial flap was inserted via the intradural or extradural pathway. Results: The mean size of the pericranial flap was 11.5 cm × 3.2 cm. It was large enough to cross the midline and cover the dural defects of the anterior skull base, including the sellar region. Conclusion: We demonstrated a modified endoscopic technique to repair the anterior skull base defects. This minimally invasive pericranial flap may resolve neurosurgical complications, such as CSF leakage.ope

Intraventricular hemorrhage clot clearance rate as an outcome predictor in patients with aneurysmal subarachnoid hemorrhage: A retrospective study

Background: The development of intraventricular hemorrhage (IVH) in aneurysmal subarachnoid hemorrhage (aSAH) is linked with higher mortality and poor neurological recovery. Previous studies have investigated the effect of the amount and distribution of the initial IVH on the prognosis of aSAH. However, no studies have assessed the relationship between the changes in IVH over time and the prognosis of aSAH. The aim of this study was to analyze the effect of the clearance rate of IVH, which can be represented by the IVH clot clearance rate (CCR), on the outcomes of aSAH. Methods: The IVH CCR was calculated based on the difference between the initial and follow-up modified Graeb scores (mGS), which were assessed by initial and 7-day follow-up brain computed tomography, respectively. Poor functional outcome was defined as a modified Rankin Scale score of 3-6. Univariate and multivariable analyses were performed to assess the relationships between IVH CCR and other risk factors and the prognosis of patients. Receiver operating characteristic curve analysis was performed to identify cut-off values of IVH CCR for predicting poor functional outcome. Results: In total, 196 consecutive patients were diagnosed with aSAH between January 2014 and March 2018. According to the inclusion and exclusion criteria, 67 patients were finally included in the study. The univariate analysis revealed that a lower IVH CCR (p<0.001), higher initial mGS (p<0.001), older age (p<0.001), higher initial Hunt and Hess grade (p<0.001), presence of delayed infarction (p=0.03), and presence of shunt-dependent hydrocephalus (p=0.004) were significantly related to poor functional outcome. The multivariable analysis revealed that IVH CCR (odds ratio [OR] 0.941; p=0.029), initial mGS (OR 1.632; p=0.043), age (OR 1.561; p=0.007), initial Hunt and Hess grade (OR 227.296; p=0.030), and delayed infarction (OR 5310.632; p=0.023) were independent predictors of poor functional outcome. Optimal cut-off values of IVH CCR and mGS for poor outcome were 36.27%, and 13.5, respectively (all p< 0.001). Conclusions: The IVH CCR might have an important predictive value on poor functional outcome in patients with aSAH and IVH, along with initial mGS, age, initial Hunt and Hess grade, and delayed infarction.ope

Recurrence and retreatment of anterior communicating artery aneurysms after endovascular treatment: a retrospective study

Background: Surgical treatment of anterior communicating artery (Acom) aneurysm is challenging due to anatomic complexity. We aimed to describe our experiences with endovascular treatment (EVT) of Acom aneurysms, and to evaluate the incidence and risk factors of recurrence and retreatment. Methods: The study comprised 260 patients who were treated at a single center between January 2010 and December 2018. Patients who had EVT, including stent-assisted coiling of Acom aneurysms, were included. All medical records were retrospectively reviewed. The incidence and risk factors of recurrence and retreatment were evaluated. Univariate and multivariate analysis were conducted. Results: Recurrence of Acom aneurysms occurred in 38 (14.6%) patients. Mean follow-up duration was 27 months (range 1-110). Multivariate logistic regression indicated that ruptured aneurysm (odds ratio [OR] 3.55, P = 0.001), dome direction (anterior) (OR 3.86, P = 0.002), maximal diameter (OR 1.19, P = 0.02), and mean age (OR 0.96, P = 0.02) were independent risk factors for aneurysm recurrence. Of 38 cases of recurrence, 10 (3.8%) patients underwent retreatment. Ruptured aneurysm (OR 14.7, P = 0.004), maximal diameter (OR 1.56, P = 0.02), inflow angle (OR 1.04, P = 0.03), and Raymond-Roy classes II and III (OR 6.19, P = 0.03) showed significant relation to retreatment in multivariate logistic regression analysis. Conclusions: In our study, recurrence rate of Acom aneurysms after EVT was 14.6%. Rupture, anterior dome direction, maximal diameter, and mean age were significantly associated with recurrence. Retreatment rate of recurrent Acom aneurysms after EVT was 3.8%. Patients with Acom aneurysms with large inflow, rupture, large size, or incomplete occlusion may be at a high risk of retreatment of recurring aneurysm.ope

Long-Term Results of Gamma Knife Radiosurgery for Intracranial Meningioma

BACKGROUND: The predominant treatment modality for meningioma is surgical resection. However, gamma knife radiosurgery is also an important treatment modality for meningioma that is small or cannot be completely removed because of its location. In this study, we evaluated the effectiveness and long-term results of radiosurgical treatment for meningioma in our institution. METHODS: We studied 628 patients (130 men and 498 women) who underwent gamma knife radiosurgery for intracranial meningioma, which is radiologically diagnosed, from Jan 2008 to Nov 2012. We included patients with single lesion meningioma, and followed up after 6 months with imaging, and then at 24 months with a clinical examination. Patients with high-grade meningioma or multiple meningiomas were excluded. We analyzed each of the factors associated with progression free survival. The median patient's age was 56.8 years. Maximal dosage was 27.8 Gy and marginal dosage was 13.9 Gy. RESULTS: The overall tumor control rate was 95%. Twenty-eight patients (4.4%) showed evidence of tumor recurrence. Ninety-eight patients (15%) developed peritumoral edema (PTE) after gamma-knife surgery; two of them (2%) underwent surgical resections due to PTE. Nine patients had craniotomy and tumor removal after gamma knife surgery. CONCLUSION: Gamma knife surgery for intracranial meningioma has proven to be a safe and effective treatment tool with successful long-term outcomes. Gamma knife radiosurgery can be especially effective in cases of remnant meningioma after surgical resection or where PTE is not present.ope

Coil-Protected Technique for Liquid Embolization in Neurovascular Malformations

OBJECTIVE: To evaluate the safety and efficacy of the coil-protected technique for liquid embolization in neurovascular malformations. MATERIALS AND METHODS: Twenty-two patients who underwent coil-protected liquid embolization for symptomatic cranial (n = 13) and spinal (n = 9) arteriovenous fistula (AVF) or arteriovenous malformations (AVMs) were identified. A total of 36 target feeder vessels were embolized with N-butyl cyanoacrylate and/or Onyx (Medtronic). This technique was used to promote delivery of a sufficient amount of liquid embolic agent into the target shunt or nidus in cases where tortuous feeding arteries preclude a microcatheter wedging techniqu and/or to prevent reflux of the liquid embolic agent in cases with a short safety margin. The procedure was considered technically successful if the target lesion was sufficiently filled with liquid embolic agent without unintentional reflux. Angiographic and clinical outcomes were retrospectively evaluated. RESULTS: Technical success was achieved for all 36 target feeders. Post-embolization angiographies revealed complete occlusion in 16 patients and near-complete and partial occlusion in three patients each. There were no treatment-related complications. Of the six patients who showed near-complete or partial occlusion, five received additional treatments: two received stereotactic radiosurgery for cerebral AVM, two underwent surgical removal of cerebral AVM, and one underwent additional embolization by direct puncture for a mandibular AVM. Finally, all patients showed complete (n = 19) or near-complete (n = 3) occlusion of the target AVF or AVM on follow-up angiographies. The presenting neurological symptoms improved completely in 15 patients (68.2%) and partially in seven patients (31.8%). CONCLUSION: The coil-protected technique is a safe and effective method for liquid embolization, especially in patients with various neurovascular shunts or malformations who could not be successfully treated with conventional techniques.ope

Preliminary experience of stent-assisted coiling of wide-necked intracranial aneurysms with a single microcatheter

BACKGROUND: The purpose of this study was to report our preliminary experience of stent-assisted coiling (SAC) of wide-necked intracranial aneurysms with a single microcatheter in patients with parent arteries that were small-caliber, with stenosis, or a very tortuous course. METHODS: Between March 2018 and December 2018, we treated 394 aneurysms in 359 patients with endovascular treatment. Among 197 aneurysms treated by SAC, there were 16 cases (all wide-necked unruptured aneurysms) treated by SAC with a single microcatheter and a Neuroform Atlas stent. Follow-up angiography was performed at 6 to 12 months after SAC, and clinical follow-up was performed from 6 to 12 months in all patients. RESULTS: The reasons for SAC with a single 0.0165-in. microcatheter were small-caliber (n = 4), stenosis (n = 2), and very tortuous course (n = 10) of the parent arteries. There was no complication related to delivering or deploying the Neuroform Atlas stent as well as no failure of selecting aneurysm by cell-through technique. All patients had a modified Rankin score of 0 at discharge and at follow-up. Initial angiographic results showed six cases (37.5%) of complete occlusion. In follow-up angiographies, 12 cases (75.0%) achieved compete occlusion. CONCLUSION: When performing SAC of wide-necked intracranial aneurysms in parent arteries with small-caliber, stenosis, or a very tortuous course, cell-through SAC using a single microcatheter and a Neuroform Atlas stent within a 5 Fr- (or smaller) guiding or intermediate catheter might be a useful option.ope

Spontaneous Acute Subdural Hemorrhage in a Patient with a Tick Borne Bunyavirus-Induced Severe Fever with Thrombocytopenia Syndrome

We report the first case of severe fever with thrombocytopenia syndrome (SFTS) and a spontaneous acute subdural hematoma (SDH) in Korea. A 79-year-old male presented with fever and thrombocytopenia. On the third day of hospitalization, his mental changed from drowsy to semi-coma. Brain computed tomography indicated an acute subdural hemorrhage on the right convexity. He was given early decompressive craniectomy, but did not survive. Real-time reverse transcription polymerase chain reaction analysis of a blood sample indicated the presence of SFTS virus (SFTSV). This is the first reported case with intracranial hemorrhage and SFTS. This case report describes our treatment of a patient with acute SDH and an infection from a tick-borne species of Bunyaviridae.ope

Scepter dual-lumen balloon catheter for Onyx embolization for dural arteriovenous fistula

Background: This study aimed to evaluate the efficacy and safety of Scepter dual-lumen balloon catheter for transarterial Onyx embolization of dural arteriovenous fistula (DAVF). Methods: Transarterial Onyx embolization using a Scepter dual-lumen balloon catheter (Scepter-assisted Onyx embolization) for DAVF was attempted in a total of 35 patients (mean age, 52.5 years; M:F = 24:11) between October 2012 and December 2018. The results of Scepter-assisted Onyx embolization were evaluated with respect to total procedural and Onyx injection times, the types and number of feeders requiring embolization, angiographic and clinical outcomes, and treatment-related complications. Results: Initial presentations were non-hemorrhagic neurological deficits in 10, intracranial hemorrhage in 8, seizure in 7, headache in 7, and intractable tinnitus in 3. All DAVF were aggressive type (Borden type 2, 14.3 %; type 3, 85.7 %). Scepter-assisted Onyx embolization resulted in immediately complete occlusion in 33 patients (94.3 %) and near complete occlusion in 2 patients. Middle meningeal artery (51.4 %) was the most commonly used for Scepter-assisted technique, followed by occipital artery (42.9 %), ascending pharyngeal artery (2.9 %) and superficial temporal artery (2.9 %). There was no difference in complete occlusion rate between middle meningeal artery and the other arteries (94.4 % versus 94.1 %). The median number of total feeders embolized was 1 (range, 1-3). The median total procedural time was 45 minutes (range, 21 minutes - 127 minutes) and the median Onyx injection time was 11 minutes (range, 3 minutes - 25 minutes). All patients recovered completely (n = 31) or partially (n = 4) from presenting symptoms. Treatment-related complications occurred in 2 patients, of whom one had a permanent morbidity (2.8 %, ipsilateral facial nerve palsy). No patient showed a recurrence on follow-up imaging (median, 15 months; range, 3-56 months). Conclusions: Scepter-assisted transarterial Onyx embolization showed a very high complete occlusion rate with a low morbidity and no recurrence in aggressive type DAVF. Scepter dual-lumen balloon catheter seems to be a useful tool for transarterial Onyx embolization of DAVF.ope

Delays in Intracerebral Hemorrhage Management Is Associated with Hematoma Expansion and Worse Outcomes: Changes in COVID-19 Era

Purpose: The coronavirus disease 2019 (COVID-19) pandemic disrupted the emergency medical care system worldwide. We analyzed the changes in the management of intracerebral hemorrhage (ICH) and compared the pre-COVID-19 and COVID-19 eras. Materials and methods: From March to October of the COVID-19 era (2020), 83 consecutive patients with ICH were admitted to four comprehensive stroke centers. We retrospectively reviewed the data of patients and compared the treatment workflow metrics, treatment modalities, and clinical outcomes with the patients admitted during the same period of pre-COVID-19 era (2017-2019). Results: Three hundred thirty-eight patients (83 in COVID-19 era and 255 in pre-COVID-19 era) were included in this study. Symptom onset/detection-to-door time [COVID-19; 56.0 min (34.0-106.0), pre-COVID-19; 40.0 min (27.0-98.0), p=0.016] and median door to-intensive treatment time differed between the two groups [COVID-19; 349.0 min (177.0-560.0), pre-COVID-19; 184.0 min (134.0-271.0), p<0.001]. Hematoma expansion was detected more significantly in the COVID-19 era (39.8% vs. 22.1%, p=0.002). At 3-month follow-up, clinical outcomes of patients were worse in the COVID-19 era (Good modified Rankin Scale; 33.7% in COVID19, 46.7% in pre-COVID-19, p=0.039). Conclusion: During the COVID-19 era, delays in management of ICH was associated with hematoma expansion and worse outcomes.ope

Source Image Based New 3D Rotational Angiography for Differential Diagnosis between the Infundibulum and an Internal Carotid Artery Aneurysm : Pilot Study

Objective: Distinguishing between an infundibulum and a true aneurysm is clinically important. This study aimed to evaluate whether using source image based new three-dimensional rotational angiography (S-n3DRA) can increase the rate of aneurysm detection and improve distinction between a true aneurysm and an infundibulum. Methods: Twenty-two consecutive patients with 23 lesions, were evaluated by time-of-flight (TOF) magnetic resonance angiography (MRA), S-n3DRA, and digital subtraction angiography (DSA). The data were retrospectively and independently reviewed by two neurointerventionists, and the diagnoses based on TOF MRA, S-n3DRA, and DSA were compared. The diagnostic efficacy (interobserver agreement and diagnostic performance) of S-n3DRA was compared with that of TOF MRA. Results: S-n3DRA showed higher interobserver agreement (κ=0.923) than TOF MRA (κ=0.465) and significantly higher accuracy than MRA in distinguishing an aneurysm from an infundibulum (p=0.0039). Conclusion: Compared to MRA, S-n3DRA could provide better screening accuracy and information for distinguishing an aneurysm from an infundibulum. Therefore, S-n3DRA has the potential to reduce the need for DSA.ope