• Journal of Korean Neurosurgical Society
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• v.62 no.1
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• pp.35-45
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• 2019

Objective : To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR). Methods : A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation. Results : Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using $XperGuide^{(R)}$ system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications. Conclusion : Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

• Archives of Plastic Surgery
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• v.50 no.3
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• pp.248-253
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• 2023

Metal fixation systems for cranial bone flaps cut by a drill are convenient devices for cranioplasty, but cause several complications. We use modified craniotomy using a fine diamond-coated threadwire saw (diamond T-saw) to reduce the bone defect, and osteoplasty calcium phosphate cement without metal fixation. We report our outcomes and tips of this method. A total of 78 consecutive patients underwent elective frontotemporal craniotomy for clipping of unruptured intracranial aneurysms between 2015 and 2019. The follow-up periods ranged from 13 to 66 months. The bone fixation state was evaluated by bone computed tomography (CT) and three-dimensional CT (3D-CT). The diamond T-saw could minimize the bone defect. Only one wound infection occurred within 1 week postoperatively, and no late infection. No pain, palpable/cosmetically noticeable displacement of the bone flap, fluid accumulations, or other complications were observed. The condition of bone fixation and the cosmetic efficacy were thoroughly satisfactory for all patients, and bone CT and 3D-CT demonstrated that good bone fusion. No complication typical of metal fixation occurred. Our method is technically easy and safety, and achieved good mid-term bone flap fixation in the mid-term course, so has potential for bone fixation without the use of metal plates.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.390-402
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• 2023

Objective: Chronic subdural hematoma (CSDH) is a neurological complication following clipping surgery. However, the natural course and ideal approach for the treatment of clipping-related-CSDH (CR-CSDH) have not been clearly established. We aimed to investigate the course of CR-CSDH using chronological radiological findings. Methods: We performed a retrospective analysis of 28 (3.8%) patients who developed CSDH among 736 patients who underwent surgical clipping using pterional approach for unruptured aneurysms at our institution between December 2010 and December 2018. Patients underwent follow-up CT scan 6-8 weeks after clipping surgery and decision to pursue surgical intervention rests upon the patient's symptom based on the Markwalder's grading scale (MGS) and numeric rating scale (NRS). Results: Of the 28 patients, 3 patients (10.7%) underwent surgery, while 25 (89.2%) showed spontaneous resolution of CR-CSDH. Eighteen patients (64.2%) had mild headache with MGS of 0-1. The mean maximum hematoma volume was 41.9±30.9 ml (5.8-135 ml), and 26 patients (92.8%) had homogeneous hematoma. The mean time to hematoma resolution was 126.7±52.9 days (46-228 days). Comparing group of CR-CSDH volume ≥43 ml or a midline shift ≥5 mm, the difference in presence of linear low-density area (p=0.002) and age (p=0.026) between the conservative and operative groups were found to be statistically significant. Conclusions: Most CR-CSDH cases spontaneously resolved within 4 months. Therefore, we suggest that close observation should be performed if patient's symptoms are mild and special radiologic findings are present, despite its relatively large volume and midline shifting.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.26 no.2
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• pp.187-195
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• 2024

Perianeurysmal cysts are a rare and poorly understood finding in patients both with treated and untreated aneurysms. While the prior literature suggests that a minority of perianeurysmal cysts develop 1-4 years following endovascular aneurysm treatment, this updated review demonstrates that nearly half of perianeurysmal cysts were diagnosed following aneurysm coiling, with the other half diagnosed concurrently with an associated aneurysm prior to treatment. 64% of perianeurysmal cysts were surgically decompressed, with a 39% rate of recurrence requiring re-operation. We report a case of a 71-year-old woman who presented with vertigo and nausea and was found to have a 3.4 cm perianeurysmal cyst 20 years after initial endovascular coiling of a ruptured giant ophthalmic aneurysm. The cyst was treated with endoscopic fenestration followed by open fenestration upon recurrence. The case represents the longest latency from initial aneurysm treatment to cyst diagnosis reported in the literature and indicates that the diagnosis of perianeurysmal cyst should remain on the differential even decades after treatment. Based on a case discussion and updated literature review, this report highlights proposed etiologies of development and management strategies for a challenging lesion.

• Journal of Korean Neurosurgical Society
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• v.30 no.6
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• pp.705-710
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• 2001

Objective : Postoperative seizure is a well documented complication of aneurysm surgery. The purpose of the present study was to analyze risk factors for postoperative seizure. Methods : Between January 1990 and December 1996, we performed craniotomy for ruptured cerebral aneurysms in 321 patients. Among them 206 patients who could be followed up for more than 1 year(range, 1 to 4.6 years) were enrolled to present study. All patients were treated with anticonvulsants for 3 to 18 months postoperatively. We analyze the incidence of postoperative seizure in different sex and age groups, and risk factors associated with postoperative seizures following aneurysm rupture. For statistical processing chi-square test and Fisher's exact test were used. Results : In the follow-up period of 1 to 4.6 years(mean, 1.8 years) postoperative seizure appeared in 18 out of 206 patients(8.7%). Mean latency between the operation and the first seizure was 6 months(range, 3 weeks to 18 months). The age of the patients has significant influence on the risk of seizure, it occurred more often in younger patients(p =0.0014). Aneurysm location in the MCA was associated with a significantly a higher risk of seizure(p = 0.042). Eight patients(19%) out of 42 patients who suffered delayed ischemic neurologic deficit(DID) developed seizure. Delayed ischemic neurologic deficit was associated with significantly a higher risk of seizure(p =0.019). Infarct and hypertension were associated with significantly a higher risk of seizure(p <0.05). pre- or postoperative intracranial hematoma(intracerebral or epidural hematoma) was associated with significantly a higher risk of seizure(p <0.0001). H-H grade, Fisher grade, Glasgow Outcome Scale of patients and timing of operation after subarachnoid hemorrhage had no significant relation with the risk of seizure. Conclusion : Factors associated with the development of postoperative seizure were middle cerebral artery aneurysm, delayed ischemic neurologic deficit, infarct on late postoperative CT scan, hypertension, pre or postoperative intracranial hematoma(intracerebral or epidural hematoma). Identification of the risk factors may be help to focus the antiepileptic drug threapy in cases prone to develop seizures. Prospective evaluation is indicated.

• Journal of Internet Computing and Services
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• v.17 no.1
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• pp.101-107
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• 2016

Due to the recent advancement in digital imaging technology, development of intervention equipment has become generalize. Video arbitration procedure is a process to insert a tiny catheter and a guide wire in the body, so in order to enhance the effectiveness and safety of this treatment, the high-quality of x-ray of image should be used. However, the increasing of radiation has become the problem. Therefore, the studies to improve the performance of x-ray detectors are being actively processed. Moreover, this intervention is based on the reference of the angiographic imaging and 3D medical image processing. In this paper, we propose a guidance system to support this intervention. Through this intervention, it can solve the problem of the existing 2D medical images based vessel that has a formation of cerebrovascular disease, and guide the real-time tracking and optimal route to the target lesion by intervention catheter and guide wire tool. As a result, the system was completely composed for medical image acquisition unit and image processing unit as well as a display device. The experimental environment, guide services which are provided by the proposed system Brain Phantom (complete intracranial model with aneurysms, ref H+N-S-A-010) was taken with x-ray and testing. To generate a reference image based on the Laplacian algorithm for the image processing which derived from the cerebral blood vessel model was applied to DICOM by Volume ray casting technique. $A^*$ algorithm was used to provide the catheter with a guide wire tracking path. Finally, the result does show the location of the catheter and guide wire providing in the proposed system especially, it is expected to provide a useful guide for future intervention service.

• Journal of Korean Neurosurgical Society
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• v.62 no.5
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• pp.536-544
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• 2019

Objective : The objective of this study was to evaluatelong-term radiologic prognosis and characteristics of in-stent stenosis (ISS) after stent assisted coiling (SAC) for cerebral aneurysm and analyze its risk factors. Methods : Radiological records of 362 cases of SAC during 10 years were retrospectively reviewed. Patients were included in this study if they had follow-up angiogram using catheter selected angiography at least twice. All subjected were followed up from 12 months to over 30 months. Of 120 patients, 123 aneurysms were enrolled. Patient data including age, sex, aneurysm size, neck size, procedural complication, kinds of stent, ISS associated symptom, ruptured state, location of ISS, degree of ISS, radiologic prognosis of ISS, follow-up period of time, and medical comorbidities such as hypertension, diabetes mellitus (DM), dyslipidemia, and smoking were collected.Statistical comparisons of group clinical characteristics were conducted for the total population. Results : Among 123 casesof aneurysm, 22 cases (17.9%) of ISS were revealed on follow-up angiography. Multiple stenting was performed in three cases and intra-procedural rupture occurred in two cases. Most cases were asymptomatic and symptomatic stenosis was identified in only one case. Sixteen cases were ruptured aneurysm. Mild stenosis was observed in 11 cases. Moderate stenosis was found in eight cases and severe stenosis was identified in three cases. Mean timing of identification of ISS was 8.90 months. The most common type was proximal type. Most cases were improved or not changed on follow-up angiography. Only one case was aggravated from mild stenosis to occlusion of parent artery. Mean follow-up period was 44.3 months. We compared risk factors and characteristic between ISS group and non-ISS group using univariate analysis. Multiple stenting was performed for three cases (13.6%) of the ISS group and four cases (4.0%) of the non-ISS group, showing no statistical difference between the two groups (p=0.108). Additionally, the proportion of patients who had more than two risk factors among four medical risk factors (hypertension, DM, dyslipidemia, and smoking) was higher in the ISS group than that in the non-ISS group, the difference between the two was not statistically significant either (31.8% vs. 12.9%, p=0.05). Conclusion : Clinical course and long-term prognosis of ISS might be benign. Most cases of ISS could be improved or not aggravated. Control of medical co-morbidity might be important. To the best of our knowledge, our study had more cases with longer follow-up period of time than other reports.

• Korean Journal of Radiology
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• v.24 no.7
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• pp.681-689
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• 2023

Objective: Three-dimensional rotational angiography (3D-RA) is increasingly used for the evaluation of intracranial aneurysms (IAs); however, radiation exposure to the lens is a concern. We investigated the effect of head off-centering by adjusting table height on the lens dose during 3D-RA and its feasibility in patient examination. Materials and Methods: The effect of head off-centering during 3D-RA on the lens radiation dose at various table heights was investigated using a RANDO head phantom (Alderson Research Labs). We prospectively enrolled 20 patients (58.0 ± 9.4 years) with IAs who were scheduled to undergo bilateral 3D-RA. In all patients' 3D-RA, the lens dose-reduction protocol involving elevation of the examination table was applied to one internal carotid artery, and the conventional protocol was applied to the other. The lens dose was measured using photoluminescent glass dosimeters (GD-352M, AGC Techno Glass Co., LTD), and radiation dose metrics were compared between the two protocols. Image quality was quantitatively analyzed using source images for image noise, signal-to-noise ratio, and contrast-to-noise ratio. Additionally, three reviewers qualitatively assessed the image quality using a five-point Likert scale. Results: The phantom study showed that the lens dose was reduced by an average of 38% per 1 cm increase in table height. In the patient study, the dose-reduction protocol (elevating the table height by an average of 2.3 cm) led to an 83% reduction in the median dose from 4.65 mGy to 0.79 mGy (P < 0.001). There were no significant differences between dose-reduction and conventional protocols in the kerma area product (7.34 vs. 7.40 Gy·cm², P = 0.892), air kerma (75.7 vs. 75.1 mGy, P = 0.872), and image quality. Conclusion: The lens radiation dose was significantly affected by table height adjustment during 3D-RA. Intentional head off-centering by elevation of the table is a simple and effective way to reduce the lens dose in clinical practice.

• Journal of the Korean Society of Radiology
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• v.84 no.6
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• pp.1361-1366
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• 2023

The persistent primitive olfactory artery (PPOA) is a rare variant of the anterior cerebral artery, first reported in 1979. It reportedly has a high correlation with the development of aneurysms, owing to the hemodynamic stress induced by the structural characteristics of the hairpin turn. Herein, we present a rare case of PPOA type 4 with a fusiform aneurysm at the hairpin turn segment in a 46-year-old female with occasional headaches. Time-of-flight MR angiography and transfemoral cerebral angiography revealed an unusual branch arising from the left A1 segment, running anteromedially along the ipsilateral olfactory tract, and turning the hairpin posterior to the olfactory bulb. This branch continued into the left accessory middle cerebral artery, and a fusiform aneurysm was observed at the hairpin segment. No further treatment was performed, and follow-up imaging was recommended. Nevertheless, it is essential to recognize and diagnose these rare variations.