• Journal of Korean Neurosurgical Society
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• 제30권6호
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• pp.699-704
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• 2001

Objectives : The rupture of middle cerebral artery(MCA) aneurysm usually cause or is associated with higher incidence of intracerebral hemorrhages(ICH) than any other aneurysmal ruptures. Also, the outcome of patients who had ICH is known to be worse than patients who had subarachnoid hemorrhage(SAH) only. The authors report the bleeding pattern and outcome of ruptured MCA aneurysm patients. Patients and Methods : A total 106 ruptured MCA aneurysm patients who were surgically treated were included and they were divided into 2 groups by the initial brain CT findings according to the presence or absence of ICH over 10cc in amount. The clinical data were analysed retrospectively. Results : The overall mortality was 18.9%. Among 81 patients(76.4%) who had subarachnoid hemorrhage(SAH) only, 68 patients(84%) showed favorable outcome. Twenty five patients(23.6%) had ICH over 10cc in amount with or without SAH, and among them, 11 patients(44%) showed favorable outcome. The ICH was located in temporal lobe(15 patients, 60%), frontal lobe(3, 12%), sylvian fissure(6, 24%) and frontal-temporal lobe(1, 4%). Among 15 patients who had ICH in temporal lobe, only 4 patients(26.6%) showed favorable outcome and all 3 patients who had ICH in frontal lobe showed favorable outcome. Conclusion : ICH was presented in 23.6% of ruptured MCA aneurysm patients and the prognosis of patients with ICH was worse than patients with SAH only. The ICH was located mainly in the temporal lobe and sylvian fissure.

• Journal of Korean Neurosurgical Society
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• 제64권2호
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• pp.207-216
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• 2021

Objective : Rapid dissolution of blood clots reduces vasospasm and hydrocephalus after subarachnoid hemorrhage (SAH), and locally administered fibrinolytic drugs (LAFDs) could facilitate the dissolution. However, the efficacy of LAFDs remains controversial. The aim of this meta-analysis was to determine the efficacy of LAFDs for vasospasm and hydrocephalus and in clinical outcomes. Methods : From PubMed, EMBASE, and Cochrane database, data were extracted by two authors. Meta-analysis was performed using a random effect model. Inclusion criteria were patients who had LAFDs with urokinase-type or recombinant tissue-plasminogen activator after SAH in comparison with medically untreated patients with fibrinolytic drugs. We only included randomized controlled trials (RCTs) in this analysis. The outcomes of interest were vasospasm, hydrocephalus, mortality, and 90-day unfavorable functional outcome. Results : Data from eight RCTs with 550 patients were included. Pooled-analysis revealed that the LAFDs were significantly associated with lower rates of vasospasm (LAFDs group vs. control group, 26.5% vs. 39.2%; odds ratio [OR], 0.48; 95% confidence interval [CI], 0.32-0.73); hydrocephalus (LAFDs group vs. control group, 26.0% vs. 31.6%; OR, 0.54; 95% CI, 0.32-0.91); and mortality (LAFDs group vs. control group, 10.5% vs. 15.7%; OR, 0.58; 95% CI, 0.34-0.99). The proportion of 90-day unfavorable outcomes was lower in the LAFDs group (LAFDs group vs. control group, 32.7% vs. 43.5%; OR, 0.55; 95% CI, 0.37-0.80). Conclusion : This meta-analysis with eight RCTs indicated that LAFDs were significantly associated with lower rates of vasospasm and hydrocephalus after SAH. Thus, LAFDs could consequently reduce mortality and improve clinical outcome after SAH.

• 대한핵의학회지
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• 제35권4호
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• pp.241-250
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• 2001

목적: 뇌동맥류파열에 의한 지주막하출혈에 동반되는 뇌혈관수축에 따른 뇌허혈 상태는 환자의 예후에 영향을 미치게 되므로 조기에 진단, 치료하는 것이 중요하다. 본 연구에서는 뇌동맥류파열에 의한 지주막하출혈 환자에서 기저/아세타졸아미드 부하 뇌혈류 SEPCT에서의 혈관예비능 유지여부가 환자의 예후를 예측하는데 도움이 되는지 알아보고자 하였다. 대상 및 방법: 대뇌동맥류 파열에 의한 지주막하출혈이 있는 환자 21명을 대상으로 하였다. CT와 뇌혈관촬영으로 혈관수축여부를 진단하였으며, 기저/아세타졸아미드 부하 Tc-99m ECD SPECT로 혈관예비능 감소 유무를 평가하였고 GOS (glasgow outcome scale)로 임상경과를 평가하였다. 혈류예비능 감소와 혈관수축의 상관 관계를 알아보고, 혈류예비능감소, 혈관수축, 기저 SPECT의 혈류결손과 Hunt-Hess 등급, CT상 지주막하 출혈량, GOS등급과의 관계를 Fishers exact test로 분석하였다. 결과: 기저 SPECT에서 혈류결손은 81% (17/21)에서 관찰되었으며, 아세타졸아미드 투여 SEPCT에서 혈관예비능 감소는 38% (8/21)에서 관찰되었고, 혈관수축도 38% (8/21)에서 관찰되었다. 혈관예비능은 임상경과(GOS로 평가)가 양호한 군에서 유지되었고(92%,12/13) 불량한 군에서 감소되어(62.5%, 5/8) (p=0.014), 환자의 임상경과를 잘 반영하였다. 또한 혈관예비능 감소군에서 지주막하출혈정도가 심하였으며(p=0.017), Hunt-Hess 등급도 불량하였다(p=0.041). 혈관예비능과 혈관수축의 상관관계를 보면 서로 일치하는 경우가 71% (15/21)였으며, 혈관수축이 없이 혈관예비능이 감소된 경우가 23% (3/13), 혈관수축을 보이면서 혈관예비능이 유지되어 있는 경우가 8예 중 3예에서 관찰되었는데 환자들의 임상결과는 혈관예비능 보존유무와 일치하였다. 결론: 혈관촬영으로 진단한 뇌혈관수축은 실제 뇌혈류못하였고 기저/아세타졸아미드 부하 뇌혈류 SPECT는 뇌의 기능과 혈류 및 뇌혈관예비능을 평가함으로써 뇌동맥류파열에 의한 지주막하출혈 환자의 예후를 예측하는데 유용한 검사라고 생각된다.

• Journal of Korean Neurosurgical Society
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• 제29권7호
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• pp.923-928
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• 2000

Objective : The reliability of transcranial doppler sonography(TCD) for predicting delayed ischemic neurologic deficit( DIND) was investigated in patients with aneurysmal subarachnoid hemorrhage(SAH). Methods : The velocity of blood flow through the middle cerebral artery was measured by TCD in 70 patients treated surgically within 72 hours due to ruptured cerebral aneurysm. A correlation between measured maximal mean blood flow velocities and clinical factors including age, hypertension, Hunt-Hess grade, Fisher grade, DIND, and outcome was made. Results : An age-dependent reduction of the measured maximal mean velocities was found(r＝-0.4043, p<0.001). Flow velocities in hypertensive patients were significantly lower than in the normotensive individuals(two-tailed T test, p<0.05). There was no significant difference between the flow velocities and evaluated other clinical factors. When the flow velocities of 14 patients who developed DIND were compared with those of patients without deficits, no significant difference was seen. A significant increase in flow velocities in the days before the onset of DIND was found only in 4 of 14 cases. High flow velocities did not necessarily mean impending neurological deficits : 6 of 70 patients tolerated flow velocities over 160cm/s. Conclusion : We suggest that TCD readings have limited utility for predicting DIND following SAH, especially in older or hypertensive patients. More direct measurements of blood flow are necessary to adequately predict which patients are at high risk of DIND.

• Journal of Korean Neurosurgical Society
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• 제30권1호
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• pp.60-65
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• 2001

Objective : The popular grading systems in use, such as Hunt-Hess grade and Fisher scale score, are based primarily on the patient's clinical conditions or computerized tomography score after aneurysmal subarachnoid hemorrhage(SAH). The author investigated whether the need for ventriculoperitoneal(VP) shunt for chronic hydrocephalus and outcome can be predicted by Hunt-Hess grade and Fisher scale. Methods : A series of 146 patients admitted to our hospital from August 1991 to July 1999, who presented with SAH and underwent craniotomy for aneurysm clipping were studied retrospectively. Chronic hydrocephalus was defined as clinically and radiographically demonstrated hydrocephalus that lasted 2 weeks or longer after initial hemorrhage which required shunting. Patients were evaluated based on following factors : Hunt-Hess grade, Fisher scale, age, sex, hypertension, aneurysm location, and intervals from aneurysm rupture to operation. Results : The overall mortality rate of the study group was 8.2%. Hunt-Hess grade(p=0.001) or Fisher scale (p=0.001) at all pretreatment times was significantly correlated with outcome. In addition, there was an increased risk of poor outcome in older age(65<). However, there were statistically no significant relationship between outcome and sex, location of aneurysm, hypertension, and interval from aneurysmal rupture to operation(p>0.05). Of 134 surviving patients, 16 patients(12%) underwent VP shunt placement secondary to chronic hydrocephalus. Hunt-Hess grade(p=0.001) is more predictive of chronic hydrocephalus than Fisher scale(p=0.146). Aneurysm location was significantly correlated with development of chronic hydrocephalus (p<0.05), without significant correlations in sex, age, hypertension. IVH, and ICH. Conclusion : This study suggests that there is a high clinical correlation between outcome and Hunt-Hess grades and Fisher scales on admission, but Hunt-Hess grade is more predictive for chronic hydrocephalus than Fisher scale. In addition, age(<65 yrs) is the significant factor for prediction of outcome. There was a trend of increasing risk for chronic hydrocephalus according to aneurymal location.

• Journal of Korean Neurosurgical Society
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• 제59권1호
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• pp.11-16
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• 2016

Objective : We conducted a retrospective cohort study to elucidate the natural course of unruptured intracranial aneurysms (UIAs) at a single institution. Methods : Data from patients diagnosed with UIA from March 2000 to May 2008 at our hospital were subjected to a retrospective analysis. The cumulative and annual aneurysm rupture rates were calculated. Additionally, risk factors associated with aneurysmal rupture were identified. Results : A total of 1339 aneurysms in 1006 patients met the inclusion criteria. During the follow-up period, 685 aneurysms were treated before rupture via either an open surgical or endovascular procedure. Six hundred fifty-four UIAs were identified and not repaired during the follow-up period. The mean UIA size was $4.5{\pm}3.2mm$, and 86.5% of the total UIAs had a largest dimension <7 mm. Among these UIAs, 18 ruptured at a median of 1.6 years (range : 27 days to 9.8 years) after day 0. The annual rupture risk during a 9-year follow-up was 1.00%. A multivariate Cox proportional hazards analysis revealed that the aneurysm size and a history of subarachnoid hemorrhage (SAH) were statistically significant risk factors for rupture. For an aneurysms smaller than 7 mm in the absence of a history of SAH, the annual rupture risk was 0.79%. Conclusion : In our study, the annual rupture risk for UIAs smaller than 7 mm in the absence of a history of SAH was higher than that of Western populations but similar to that of the Japanese population.

• Journal of Korean Neurosurgical Society
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• 제30권9호
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• pp.1065-1071
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• 2001

파열된 뇌동맥류의 조기수술이 계획된 환자에서 수술전까지 단기간에 걸친 항섬유소용해제 투여의 효과를 알아보기 위해 뇌동맥류성 지주막하출혈 환자 137례에 대하여 60례를 AMCA 투여군으로, 77례를 비 투여군으로 분류하여 재출혈, 증상적 혈관연축, 뇌수두증의 발생빈도 및 전체적인 치료성적을 비교, 분석하였다. 재출혈의 발생빈도는 AMCA 비 투여군에 비해 투여군에서 통계학적으로 유의하게 낮게 나타났고 AMCA의 장기투여에서 증가를 보인 증상적 혈관연축과 뇌수두증의 발생빈도는 양군에서 유의한 차이를 보이지 않았으며 전체적인 치료성적은 AMCA 투여군에서 비 투여군에 비해 보다 양호한 결과를 보였다. 따라서 조기수술이 계획된 뇌동맥류성 지주막하출혈 환자에서 AMCA의 단기간 투여는 재출혈율을 감소시켜 전체적인 치료결과를 향상시키는데 도움이 될 것으로 생각된다.

• Journal of Korean Neurosurgical Society
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• 제62권6호
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• pp.643-648
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• 2019

Objective : Shunt-dependent hydrocephalus (SdHCP) is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH). The risk factors for SdHCP have been widely investigated, but few risk scoring systems have been established to predict SdHCP. This study was performed to investigate the risk factors for SdHCP and devise a risk scoring system for use before aneurysm obliteration. Methods : We reviewed the data of 301 consecutive patients who underwent aneurysm obliteration following SAH from September 2007 to December 2016. The exclusion criteria for this study were previous aneurysm obliteration, previous major cerebral infarction, the presence of a cavum septum pellucidum, a midline shift of >10 mm on initial computed tomography (CT), and in-hospital mortality. We finally recruited 254 patients and analyzed the following data according to the presence or absence of SdHCP : age, sex, history of hypertension and diabetes mellitus, Hunt-Hess grade, Fisher grade, aneurysm size and location, type of treatment, bicaudate index on initial CT, intraventricular hemorrhage, cerebrospinal fluid drainage, vasospasm, and modified Rankin scale score at discharge. Results : In the multivariate analysis, acute HCP (bicaudate index of ${\geq}0.2$) (odds ratio [OR], 6.749; 95% confidence interval [CI], 2.843-16.021; p=0.000), Fisher grade of 4 (OR, 4.108; 95% CI, 1.044-16.169; p=0.043), and an age of ${\geq}50years$ (OR, 3.938; 95% CI, 1.375-11.275; p=0.011) were significantly associated with the occurrence of SdHCP. The risk scoring system using above parameters of acute HCP, Fisher grade, and age (AFA score) assigned 1 point to each (total score of 0-3 points). SdHCP occurred in 4.3% of patients with a score of 0, 8.5% with a score of 1, 25.5% with a score of 2, and 61.7% with a score of 3 (p=0.000). In the receiver operating characteristic curve analysis, the area under the curve (AUC) for the risk scoring system was 0.820 (p=0.080; 95% CI, 0.750-0.890). In the internal validation of the risk scoring system, the score reliably predicted SdHCP (AUC, 0.895; p=0.000; 95% CI, 0.847-0.943). Conclusion : Our results suggest that the herein-described AFA score is a useful tool for predicting SdHCP before aneurysm obliteration. Prospective validation is needed.

• Journal of Korean Neurosurgical Society
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• 제30권6호
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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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• 제30권4호
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• pp.425-429
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• 2001

Objective : Patients with poor grade aneurysm usually present with increased intracranial pressure(ICP), even those without an intracranial clot. Based on this fact, the present study investigated a significance of intracranial pressure monitoring in those patients. Patients and Methods : A total of 60 patients with Hunt and Hess Grade IV(50 patients) or V(10 patients) were treated for aneurysmal subarachnoid hemorrhage(SAH) during a 3-year-period, and intraparenchymal ICP was measured in the majority, immediately after arrival to the emergency room. Early surgery including intraoperative ventriculostomy was undertaken within 3 days after SAH. An ultraearly surgery was performed without preceding angiogram or ICP monitoring in patients with large sylvian hematomas, highly suggestive of middle cerebral artery aneurysm. Outcomes were assessed by the Glasgow Outcome Scale(GOS) at 6 months. Results : In overall, favorable outcome(GOS scores 1-2) was seen in 27(54.0%) of admission Grade IV and 1(10.0%) of admission Grade V patients. Of the 38 surgical patients with preoperative ICP monitorings, 25 patients (80.6%) exhibiting ICP values of less than 40mmHg showed favorable outcome, however, no patients with ICP values above 40mmHg recovered(Fisher's exact test, p=0.0001). Conclusion : It is concluded that a preoperative ICP above 40mmHg before ventriculostomy indicate significant vital brain destruction as intractable intracranial hypertension, and Grade IV patients at admission with an ICP below 40mmHg can be of benefit from early surgical intervention while Grade V patients still remains unfavorable.