• Journal of the Korean Society of Radiology
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• v.81 no.3
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• pp.665-675
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• 2020

Purpose This study aimed to identify independent predictors of favorable outcomes associated with emergent carotid artery stenting (CAS) in patients with acute anterior circulation stroke. Materials and Methods This study included 93 patients with acute stroke who underwent emergent CAS to treat stenoocclusive lesions in the cervical internal carotid artery (ICA) within 6 hours of the onset of the associated symptoms. Data were compared between patients with and without favorable outcomes. The independent predictors of a favorable outcome were determined via logistic regression analysis (modified Rankin Scale 0-2 at 90 days). Results Intracranial tandem occlusion was noted in 81.7% of patients (76/93) among which (76/93), 55 of whom underwent intracranial recanalization therapy. Intracranial reperfusion was successful in 74.2% (69/93) and favorable outcomes were noted in 51.6% of patients (48/93). The mortality rate was 6.5% (6/93). In logistic regression analysis, diffusion-weighted imaging-Alberta Stroke Program Early CT Score [odds ratio (OR), 1.487; 95% confidence interval (CI), 1.018-2.173, p = 0.04], successful reperfusion (OR, 5.199; 95% CI, 1.566-17.265, p = 0.007), and parenchymal hemorrhage (OR, 0.042; 95% CI, 0.003-0.522, p = 0.014) were independently associated with a favorable outcome. Conclusion Baseline infarct size, reperfusion status, and parenchymal hemorrhage were independent predictors of favorable outcomes after emergent CAS to treat stenoocclusive lesions in the cervical ICA in patients with acute anterior circulation stroke.

• Investigative Magnetic Resonance Imaging
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• v.1 no.1
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• pp.94-102
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• 1997

Purpose: There have been some efforts to diagnose intracranial aneurysm through a non-invasive method using MRA, although the process may be difficult when the lesion is less than 3mm. The present study prospectively compares the results of high resolution, fast speed slice interpolation MRA and DSA thereby examing the potentiality of primary non-invasive screening test. Materials and Methods: A total of 26 cerebral aneurysm lesions from 14 patients with subarachnoid hemorrhage from ruptured aneurysm (RA) and 5 patients with unruptured aneurysm(UA). In all subjects, MRA was taken to confirm the vessel of origin, definition of aneurysm neck and the relationship of the aneurysm to nearby small vessels, and the results were compared with the results of DSA. The images were obtained with 1.5T superconductive machine (Vision, Siemens, Erlangen, Germany) on 4 slabs of MRA using slice interpolation. The settings include TR/TE/FA=30/6.4/25, matrix $160{\times}512$, FOV $150{\times}200$, 7minutes 42 seconds of scan time, effective thickness of 0.7 mm and an entire thickness of 102. 2mm. The images included structures from foramen magnum to A3 portion of anterior cerebral artery. MIP was used for the image analysis, and multiplanar reconstruction (MPR) technique was used in cases of intracranial aneurysm. Results: A total of 26 intracranial aneurysm lesions from 19 patients with 2 patients having 3 lesion, 3 patients having 2 lesions and the rest of 14 patients having 1 lesion each were examined. Among those, 14 were RA and 12 were UA. Eight lesions were less than 2mm in size, 9 lesions were 3-5mm, 7 were 6-9mm and 2 were larger than IOmm. On initial exams, 25 out of 26 aneurysm lesions were detected in either MRA or DSA showing 96% sensitivity. Specificity cannot be estimated since there was no true negative of false positive findings. When MRA and MPR were used concurrently for the confirmation of size and shape, the results were equivalent to those of DSA, while in the confirmation of aneurysm neck and parent vessels, the concurrent use of MRA and MPR was far superior to the sole use of either MRA or DSA. Conclusion: High resolution MRA using slice interpolation technique showed equal results as those of DSA for the detection of intracranial aneurysm, and may be used as a primary non-invasive screening test in the future.

• Journal of Chest Surgery
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• v.36 no.10
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• pp.772-775
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• 2003

Moyamoya disease is an unusual cerebrovascular disorder characterized by occlusive intimal dysplasia of the distal internal carotid and proximal cerebral arteries, but the etiology remains unclear. Angiographic characteristics include bilateral stenosis or occlusion of the terminal portions of the intracranial internal carotid arteries and bilateral development of fine collateral vessels at the base of the brain known as ‘Moyamoya vessels’. Cardiac surgery using cardiopulmonary bypass due to coronary artery disease and others among patients with moyamoya disease is very rare, and cardiac surgery for such patients has a potential risk of intraoperative and perioperative brain ischemia. We successfully treated a patient who underwent artrial septal defect closure and coronary artery bypass graft using the cardiopulmonary bypass, so we report this case with a brief literature review.

• Journal of Korean Neurosurgical Society
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• v.58 no.3
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• pp.197-204
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• 2015

Objective : Aneurysms arising from the pericallosal artery (PA) are uncommon and challenging to treat. The aim of this study was to report our experiences of the endovascular treatment of ruptured PA aneurysms. Methods : From September 2003 to December 2013, 30 ruptured PA aneurysms in 30 patients were treated at our institution via an endovascular approach. Procedural data, clinical and angiographic results were retrospectively reviewed. Results : Regarding immediate angiographic control, complete occlusion was achieved in 21 (70.0%) patients and near-complete occlusion in 9 (30.0%). Eight procedure-related complications occurred, including intraprocedural rupture and early rebleeding in three each, and thromboembolic event in two. At last follow-up, 18 patients were independent with a modified Rankin Scale (mRS) score of 0-2, and the other 12 were either dependent or had expired (mRS score, 3-6). Adjacent hematoma was found to be associated with an increased risk of poor clinical outcome. Seventeen of 23 surviving patients underwent follow-up conventional angiography (mean, 16.5 months). Results showed stable occlusion in 14 (82.4%), minor recanalization in two (11.8%), and major recanalization, which required recoiling, in one (5.9%). Conclusion : Our experiences demonstrate that endovascular treatment for a ruptured PA aneurysms is both feasible and effective. However, periprocedural rebleedings were found to occur far more often (20.0%) than is generally suspected and to be associated with preoperative contrast retention. Analysis showed existing adjacent hematoma is predictive of a poor clinical outcome.

• Journal of Korean Neurosurgical Society
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• v.59 no.3
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• pp.269-275
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• 2016

Objective : Although middle cerebral artery (MCA) aneurysms are less amenable to coil embolization, an increasing number of studies support favorable endovascular treatment for them. The purpose of this study is to compare the outcomes of two different treatments (surgery versus coiling) and evaluate the benefits of surgical clipping for MCA aneurysms. Methods : Here we retrospectively analyzed the outcomes of 178 ruptured and unruptured MCA aneurysms treated in patients between September 2008 and April 2012. Parameters assessing treatment outcomes include degree of aneurysm occlusion, presence of regrowth, clinical status, and complications. Results : Among 178 MCA aneurysms, 153 were treated surgically. After a mean follow-up of 12 months, the surgery group showed a clinically significant complete occlusion rate (98%) compared with the coiling group (56%) (p<0.001). Follow-up radiologic evaluation showed a higher regrowth rate (four of 16 cases) in the coiling group than in the surgery group (one of 49 cases) (p=0.003). There was no statistically significant difference in favorable clinical outcome rate between the two groups. The procedure-related permanent morbidity and mortality rates were 2% (three of 153 cases) in the surgery group and 0% (0 of 25 cases) in the coiling group. Conclusion : Compared to endovascular treatment, surgical neck clipping for both ruptured and unruptured MCA aneurysms results in a significantly higher complete obliteration rate and less regrowth. Therefore, even in this endovascular era, we still recommend surgical clipping as the primary treatment option for MCA aneurysms rather than coil embolization.

• Journal of Korean Neurosurgical Society
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• v.53 no.5
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• pp.274-280
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• 2013

Objective : To evaluate the feasibility and clinical and angiographic outcomes of stent-assisted embolization for complex middle cerebral artery (MCA) aneurysms. Methods : The records of 23 consecutive patients with 24 MCA aneurysms, who underwent stent-assisted embolization of the aneurysm, were retrospectively evaluated. Results : Fifteen aneurysms were treated with one stent and 8 were treated using more than two stents (5 a stent-within-a-stent, 1 triple stents, and two Y-stent). Angiographically, complete or near complete occlusion was achieved in 15 aneurysms (65.2%), residual neck in five (21.7%), and residual aneurysm in three (13.1%). Five aneurysms demonstrated thrombosis within the stent during the procedure and hospitalization, and were resolved by intraarterial and intravenous Tirofiban injection. Symptomatic thromboembolic complications were developed in five patients and permanent deficits demonstrated in two patients with modified Rankin Scale 1 and 2, respectively. Treatment-related permanent morbidity and mortality rates were 8.3% and 0% with relatively high complication rate. Angiographic follow-up was available in 17 aneurysms at 6-31 months (mean, 13.2 months) and showed stable or improved in 15 (88.2%) and major and minor recurrence in one, respectively. Conclusion : Complex MCA aneurysms could be treated by stent-assisted coiling and showed lower recanalization rate during mid-term follow-up by effective flow diversion due to various stent-assisted techniques. Our results warrant further study with a longer follow-up period in a larger sample.

• Journal of Korean Neurosurgical Society
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• v.62 no.2
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• pp.193-200
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• 2019

Objective : Endovascular treatment (EVT) outcomes for acute M2 segment of middle cerebral artery occlusion remains unclear because most results are obtained from patients with large artery occlusion in the anterior circulation. The objective of this study was to assess procedural outcomes for acute M2 occlusion and compare outcomes according to thrombus location (M1 vs. M2). Methods : A systematic review was performed for online literature published from January 2004 to December 2016. Primary outcome was successful recanalization rate and symptomatic intracranial hemorrhage (S-ICH) after the procedure. A fixed effect model was used if heterogeneity was less than 50%. Results : Eight articles were included. EVT showed successful recanalization rate of 69.1% (95% confidence interval [CI], 54.9-80.4%) and S-ICH rate of 6.1% (95% CI, 4.5-8.3%). The rates of good clinical outcome at 3 months and mortality were 59.4% (95% CI, 49.9-68.2%) and 14.9% (95% CI, 11.4-19.3%), respectively. According to thrombus location (M1 vs. M2), successful recanalization (odds ratio [OR], 1.539; 95% CI, 0.293-8.092; p=0.610) and S-ICH (OR, 1.313; 95% CI, 0.603-2.861; p=0.493) did not differ significantly. Good clinical outcome was more evident in M2 occlusion after EVT than that in M1 occlusion (OR, 1.639; 95% CI, 1.135-2.368; p=0.008). However, mortality did not differ significantly according to thrombus location (OR, 0.788; 95% CI, 0.486-1.276; p=0.332). Conclusion : EVT seems to be technically feasible for acute M2 occlusion. Direct comparative studies between EVT and medical treatment are needed further to find specific beneficiary group after EVT in patient with M2 occlusion.

• Journal of Yeungnam Medical Science
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• v.36 no.3
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• pp.208-218
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• 2019

Background: The anatomy of middle cerebral artery (MCA) aneurysms has been noted to be unfavorable for endovascular treatment. The purpose of this study was to assess the feasibility and efficacy of coiling for MCA aneurysms. Methods: From January 2004 to December 2015, 72 MCA aneurysms (38 unruptured and 34 ruptured) in 67 patients were treated with coils. Treatment-related complications, clinical outcomes, and immediate and follow-up angiographic outcomes were retrospectively analyzed. Results: Aneurysms were located at the MCA bifurcation (n=60), 1st segment (M1, n=8), and 2nd segment (M2, n=4). Sixty-nine aneurysms (95.8%) were treated by neck remodeling techniques using multi-catheter (n=44), balloon (n=14), stent (n=8), or combination of these (n=3). Only 3 aneurysms were treated by single-catheter technique. Angiographic results were 66 (91.7%) complete, 5 (6.9%) remnant neck, and 1 (1.4%) incomplete occlusion. Procedural complications included aneurysm rupture (n=1), asymptomatic coil migration to the distal vessel (n=1), and acute thromboembolism (n=10) consisting of 8 asymptomatic and 2 symptomatic events. Treatment-related permanent morbidity and mortality rates were 4.5% and 3.0%, respectively. There was no bleeding on clinical follow-up (mean, 29 months; range, 6-108 months). Follow-up angiographic results (mean, 26 months; range, 6-96 months) in patients included 1 major and 3 minor recanalizations. Conclusion: Coiling of MCA aneurysms could be a technically feasible and clinically effective treatment strategy with acceptable angiographic and clinical outcomes. However, the safety and efficacy of this technique as compared to surgical clipping remains to be ascertained.

• Journal of Genetic Medicine
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• v.18 no.2
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• pp.142-146
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• 2021

Alagille syndrome (AGS) is a rare autosomal dominant inherited disorder, with major clinical manifestations of bile duct paucity, cholestasis, cardiovascular anomaly, ophthalmic abnormalities, butterfly vertebrae, and dysmorphic facial appearance. It is caused by heterozygous mutations in JAG1 or NOTCH of the Notch signaling pathway presenting with variable phenotypic penetrance and involving multiple organ systems. The following case report describes a unique case of a 16-year-old female with AGS who presented with the primary complaint of renovascular hypertension. She had a medical history of ventricular septal defect and polycystic ovary syndrome. The patient had a dysmorphic facial appearance including frontal bossing, bulbous tip of the nose, a pointed chin with prognathism, and deeply set eyes with mild hypertelorism. Stenoocclusive changes of both renal arteries, celiac artery, lower part of the abdominal aorta, and left intracranial artery, along with absence of the left internal carotid artery were found on examination. Whole exome sequencing was performed and revealed a pathologic mutation of JAG1, leading to the diagnosis of AGS. Reverse phenotyping detected butterfly vertebrae and normal structure and function of the liver and gallbladder. While the representative symptom of AGS in most scenarios is a hepatic problem, in this case, the presenting clinical features were the vascular anomalies. Clinical manifestations of AGS are diverse, and this case demonstrates that renovascular hypertension might be in some cases a presenting symptom of AGS.

• Journal of Korean Neurosurgical Society
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• v.65 no.4
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• pp.523-530
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• 2022

Objective : To evaluate the safety and efficacy of an overlapped stenting-assisted coiling technique in treating vertebral artery dissecting aneurysm (VADA) via Low-profile Visualized Intraluminal Support (LVIS) stent-within-Neuroform EZ stent. Methods : From January 2017 to June 2019, 18 consecutive patients with VADAs (ruptured : unruptured=5 : 13) were treated with the overlapping stents assisted-coiling technique in our center. The overlapping manner was a Neuroform EZ stent being deployed first, followed by LVIS stents placement using the 'shelf' technique. The patients' clinical characteristics, technical feasibility and safety, and immediate and follow-up angiographic results were retrospectively reviewed. Results : Seventeen (94.4%) procedures were technically successful with an exact deployment of the stents and patent parent or perforator arteries. The immediate angiographies after procedure confirmed Raymond class I, II, and III occlusion of VADAs were in 12 (66.7%), two (11.1%), and four cases (22.2%), respectively. Post-procedural complications developed in one patient (5.6%) with minor brainstem infarctions, which resulted from an in-stent thrombosis during the procedure. Angiographic follow-up at 5.7 months (range 3 to 9 months) demonstrated Raymond class I and II occlusion were in all cases (100%). The modified Rankin Scale scores at 21.3 months (range 15 to 42 months) 0-2 in 17 cases (94.4%) and three in one case (5.6%). Conclusion : Overlapping stents via LVIS stent-within-Neuroform EZ stent combined with coiling is safe and effective for patients with VADA in the midterm results.