• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.1
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• pp.62-68
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• 2023

The treatment of complicated anterior cerebral artery aneurysms remains challenging. Here, the authors describe a case of ruptured complicated A3 aneurysm, which was treated with trapping and in-situ bypass. A 47-year-old man presented to the emergency department with severe headache and vomiting. Computed tomography illustrated acute intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) confirmed a ruptured fusiform A3 aneurysm with lobulation and a daughter sac. Trapping of the ruptured fusiform A3 aneurysm and distal end-to-side A4 anastomosis was performed. DSA on postoperative day 7 showed mild vasospasm to the afferent artery. However, 2 months later, DSA demonstrated that the antegrade flow through the anastomosis site had recovered. Thus, surgeons should be aware of the possibility of postsurgical vasospasm of anastomosed arteries, especially in cases of ruptured aneurysms.

• Investigative Magnetic Resonance Imaging
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• v.20 no.2
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• pp.105-113
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• 2016

Purpose: Susceptibility vessel sign (SVS) on gradient echo image, which is caused by MR signal loss due to arterial thrombosis, has been reported in acute middle cerebral artery (MCA) infarction. However, the reported sensitivity and diagnostic accuracy of SVS have been variable. Susceptibility-weighted imaging (SWI) is a newly developed MR sequence. Recent studies have found that SWI may be useful in the field of cerebrovascular diseases, especially for detecting the presence of prominent veins, microbleeds and the SVS. The purpose of this study was to evaluate the diagnostic values of SWI for the detection of hyperacute MCA occlusion. Materials and Methods: Sixty-nine patients (37 males, 32 females; 46-89 years old [mean, 69.1]) with acute stroke involving the MCA territory underwent MR imaging within 6 hours after the symptom onset. MR examination included T2, FLAIR (fluid-attenuated inversion recovery), DWI, SWI, PWI (perfusion-weighted imaging), contrast-enhanced MR angiography (MRA) and contrast-enhanced T1. Of these patients, 28 patients also underwent digital subtraction angiography (DSA) within 2 hours after MR examination. Presence or absence of SVS on SWI was assessed without knowledge of clinical, DSA and other MR imaging findings. Results: On MRA or DSA, 34 patients (49.3%) showed MCA occlusion. Of these patients, SVS was detected in 30 (88.2%) on SWI. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of SWI were 88.2%, 97.1%, 96.8%, 89.5% and 92.8%, respectively. Conclusion: SWI was sensitive, specific and accurate for the detection of hyperacute MCA occlusion.

• Journal of Korean Neurosurgical Society
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• v.40 no.4
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• pp.277-280
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• 2006

Extracerebral cavernous hemangiomas are rare vascular tumors that are very difficult to remove because of severe intraoperative bleeding. We report a case of 57-year-old male with extracerebral cavernous hemangioma with review of 126 cases in the literature. Patient presented with blurred vision, diplopia, numbness on the left side of his face. Magnetic resonance imaging revealed a well defined mass of $3{\times}4{\times}3cm$ size with heterogenous iso-or hypointensity on T1-weighted image showing strong homogenous contrast enhancement and marked hyperintensity on T2-weighted image. Digital subtraction angiography[DSA] revealed a faint tumor blush by feeders from the left internal carotid artery[ICA] and left external carotid artery[ECA] in the delayed phase. Even with profuse intratumoral bleeding, near total removal was achieved. In addition to preoperative neurologic deficits such as ophthalmoplegia, facial numbness in the V1-2 dermatomes, ptosis appeared postoperatively.

• Progress in Medical Physics
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• v.21 no.3
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• pp.274-280
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• 2010

The purpose of this study was to analyze the effect of single-fraction stereotactic radiosurgery (SRS) for the treatment of 15 cases of cerebral arteriovenous malformations (AVMs). Between 2002 and 2009, of the 25 patients who had SRS for the treatment of cerebral AVM, 15 patients (6 men, 9 women) taken a digital subtraction angiography (DSA) over 12 months after SRS were included. We retrospectively evaluated the size, location, hemorrhage of nidus, angiographic changes on follow-up on the MR angiography and DSA, and clinical complications during follow-up periods. At a median follow-up of 24 months (range 12-89), complete obliteration of nidus was observed in all patients (100%) while residual draining veins was observed in 3 patients (20%). There was no clinical complication during the follow-up period except seizure in 1 patient. The mean nidus volume was 4.7cc (0.5~11.7 cc, SD 3.7 cc). The locations of nidus were in cerebral hemisphere in 11 patients, cerebellum in 2 patients, basal ganglia in 1 patient, and pons in 1 patient respectively. 9 cases were hemorrhagic, and 6 cases were non-hemorrhagic AVMs. The SRS with LINAC is a safe and effective treatment for cerebral AVMs when the follow up period is over 4 years. However, it is recommended to continue to follow up until the draining vein on arterial phase of follow up DSA disappears completely.

• Journal of the Korean Society of Radiology
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• v.13 no.4
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• pp.613-621
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• 2019

The purpose of this study is to evaluate the effectiveness of supportive devices which are for minimizing the patient's movement during lower extremity angiography and to verify image quality of phantom by analyzing of Mask image, DSA image and Roadmap image into SNR and CNR. As a result of comparing SNR with CNR of mask image obtained by DSA technique using the phantom alone and phantom placed on the supportive devices, there was no significant difference between about 0~0.06 for SNR and about 0~0.003 for CNR. The study showed about 0.11~0.35 for SNR and 0.016~0.031 for CNR of DSA imaging by DSA technique about only water phantom of the blood vessel model and the water phantom placed on the device. Analyzing SNR and CNR of Roadmap technique about water phantom on the auxiliary device (hardboard paper, pomax, polycarbonate, acrylic) and water phantom alone, there was no significant difference between 0.02~0.05 for SNR and 0.002~0.004 for CNR. In conclusion, there was no significant difference on image quality by using supportive devices made by hardboard paper, pomax, polycarbonate or acryl regardless of whether using supportive devices or not. Supportive devices to minimize of the patient's movement may reduce the total amount of contrast, exam-time, radiation exposure and eliminate risk factors during angiogram. Supportive devices made by hardboard paper can be applied easily during angiogram due to advantages of reasonable price and simple processing. It is considered that will be useful to consider cost efficiency and types of materials and their properties in accordance with purpose and method of the study when the operator makes and uses supportive devices.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.26 no.1
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• pp.1-10
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• 2024

Objective: Endovascular coil embolization is the primary treatment modality for intracranial aneurysms. However, its long-term durability remains of concern, with a considerable proportion of cases requiring aneurysm reopening and retreatment. Therefore, establishing optimal follow-up imaging protocols is necessary to ensure a durable occlusion. This study aimed to develop guidelines for follow-up imaging strategies after endovascular treatment of intracranial aneurysms. Methods: A committee comprising members of the Korean Neuroendovascular Society and other relevant societies was formed. A literature review and analyses of the major published guidelines were conducted to gather evidence. A panel of 40 experts convened to achieve a consensus on the recommendations using the modified Delphi method. Results: The panel members reached the following consensus: 1. Schedule the initial follow-up imaging within 3-6 months of treatment. 2. Noninvasive imaging modalities, such as three-dimensional time-of-flight magnetic resonance angiography (MRA) or contrast-enhanced MRA, are alternatives to digital subtraction angiography (DSA) during the first follow-up. 3. Schedule mid-term follow-up imaging at 1, 2, 4, and 6 years after the initial treatment. 4. If noninvasive imaging reveals unstable changes in the treated aneurysms, DSA should be considered. 5. Consider late-term follow-up imaging every 3-5 years for lifelong monitoring of patients with unstable changes or at high risk of recurrence. Conclusions: The guidelines aim to provide physicians with the information to make informed decisions and provide patients with high-quality care. However, owing to a lack of specific recommendations and scientific data, these guidelines are based on expert consensus and should be considered in conjunction with individual patient characteristics and circumstances.

• Journal of Korean Neurosurgical Society
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• v.58 no.3
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• pp.184-191
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• 2015

Objective : Anterior communicating artery (AcomA) aneurysms represent the most common intracranial aneurysms and challenging to treat due to complex vascularity. The purpose of this study was to report our experience of endovascular treatment of AcomA aneurysms. Methods : Between January 2003 and December 2013, we retrospectively reviewed the medical records of 134 AcomA aneurysm patients available more than 6 months conventional angiographic and clinical follow-up results. We focused on aneurismal or AcomA vascular characters, angiographic and clinical follow-up results, and retreatment. Results : The rate of ruptured cases was 75.4%, and the small (<10 mm) aneurysms were 96.3%. Based on the subtypes defined by dominance of A1, 79 patients (59%) had contralateral A1 hypoplasia or agenesis. The immediate post-procedural angiography confirmed complete occlusion in 75.4%, partial occlusion in 24.6%. Procedure related complications were observed in 25 (18.6%) patients. Most of the adverse events were asymptomatic. Follow-up conventional angiography at ${\geq}6$ months was performed in all patients (mean 16.3 months) and major recanalization was noted in 6.7% and regrowth in one case. The aneurysm size (p=0.016), and initial treatment results (p=0.00) were statistically significant risk factors related to aneurysm recurrence. An overall improvement in mRS was observed during the clinical follow-up period and no rebleeding episode occurred. Conclusion : This study demonstrated that endovascular treatment is an effective treatment modality for AcomA aneurysms with low morbidity. Patients should take long term clinical and angiographic follow-up in order to assess the recurrence and warrant retreatment, especially ruptured, large, and initially incomplete occluded aneurysms.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.468-472
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• 2023

Bilateral posterior communicating (pComm) artery aneurysms represent only 2% of mirror intracranial aneurysms. Usually, these are surgically approached through bilateral craniotomies for clipping. We present the case of a 50-year-old female presenting with headache and horizontal diplopia. Neurological examination revealed a left oculomotor palsy, with no other neurological deficits. Imaging studies revealed bilateral aneurysmatic lesions in both internal carotid arteries (ICA). A conventional left pterional approach was planned in order to treat the symptomatic aneurysm, and, if deemed feasible, a contralateral clipping through the same approach. The procedure was performed in a hybrid operating room (HOR), performing an intraoperative digital subtraction angiography (DSA) and roadmapping assistance during dissection and clipping. Transoperatively, a post-fixed optic chiasm was identified, with a wide interoptic space, which allowed us to perform the contralateral clipping through a unilateral approach. This technique for clipping bilateral pComm aneurysms can be performed when the proper anatomical features are met.

• Journal of Korean Neurosurgical Society
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• v.65 no.6
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• pp.816-824
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• 2022

Objective : Emergency superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis in patients with large vessel occlusion who fails mechanical thrombectomy or does not become an indication due to over the time window can be done as an alternative for blood flow restoration. The authors planned this study to quantitatively measure the degree of improvement in cerebral perfusion flow using perfusion magnetic resonance imaging (MRI) after bypass surgery and to find out what factors are related to the outcome of the bypass surgery. Methods : For a total of 107 patients who underwent emergent STA-MCA bypass surgery with large vessel occlusion, the National Institute of Health stroke scale (NIHSS), modified Rankin score (mRS), infarction volume, and hypoperfusion area volume was calculated, the duration between symptom onset and reperfusion time, occlusion site and infarction type were analyzed. After emergency STA-MCA bypass, hypoperfusion area volume at post-operative 7 days was calculated and analyzed compared with pre-operative hypoperfusion area volume. The factors affecting the improvement of mRS were analyzed. The clinical status of patients who underwent emergency bypass was investigated by mRS and NIHSS before and after surgery, and changes in infarct volume, extent, degree of collateral circulation, and hypoperfusion area volume were measured using MRI and digital subtraction angiography (DSA). Results : The preoperative infarction volume was median 10 mL and the hypoperfusion area volume was median 101 mL. NIHSS was a median of 8 points, and the last normal to operation time was a median of 60.7 hours. STA patency was fair in 97.1% of patients at 6 months follow-up DSA and recanalization of the occluded vessel was confirmed at 26.5% of patients. Infarction volume significantly influenced the improvement of mRS (p=0.010) but preoperative hypoperfusion volume was not significantly influenced (p=0.192), and the infarction type showed marginal significance (p=0.0508). Preoperative NIHSS, initial mRS, occlusion vessel type, and last normal to operation time did not influence the improvement of mRS (p=0.272, 0.941, 0.354, and 0.391). Conclusion : In a patient who had an acute cerebral infarction due to large vessel occlusion with large ischemic penumbra but was unable to perform mechanical thrombectomy, STA-MCA bypass could be performed. By using time-to-peak images of perfusion MRI, it is possible to quickly and easily confirm that the brain tissue at risk is preserved and that the ischemic penumbra is recovered to a normal blood flow state.