• Journal of Chest Surgery
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• 제23권4호
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• pp.758-763
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• 1990

A congenital fistulous communication between the coronary artery and the cardiac chamber or the pulmonary artery is a rare condition, but increasing cases with this anomaly are being recognized with wide spread use of cardiac catheterization and coronary arteriography. Recently we experienced one case of right coronary artery fistula which was associated with atrial septal defect. The patient was a 24 year old female who was admitted because of cardiac murmur, palpitation and dyspnea on exertion after pregnancy. Cardiac catheterization and selective coronary arteriography revealed that a fistulous communication, forming a large aneurysm, was noted from the right coronary artery emptied into the right ventricle. On the operation field, the right coronary artery was curved and markedly dilated from the aorta to the middle segment at acute margin of the right ventricle. The egg-sized aneurysm of dilated right coronary artery was noticed on right ventricle. The aneurysm was incised longitudinally and both the proximal opening and the termination site of the fistula were closed directly with aneurysmectomy. The right atrium was also opened to evaluate the fistulous termination site and repaired only small interatrial septal defect. Postoperative course was uneventful and she was discharged without problems

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• 제25권4호
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• pp.475-484
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• 2023

Objective: This study aimed to develop microsurgical strategies based on the anatomical relationship between dorsal internal carotid artery (ICA) aneurysms, the falciform ligament (FL), and the anterior clinoid process (ACP). Methods: Between 2017 and 2022, 25 patients with unruptured dorsal ICA aneurysms (less than 4 mm in diameter) underwent microsurgical direct clipping. These cases involved the left ICA (n=17) and the right ICA (n=8), with a mean aneurysm size of 3.3 mm (range, 2.5 to 4 mm). We used computed tomography angiography (CTA) and digital subtraction angiography to elucidate the anatomical relationship between dorsal ICA aneurysms and other structures. All procedures involved an ipsilateral pterional approach with securement of the ipsilateral cervical ICA for proximal control. Results: Among the 25 dorsal ICA aneurysms, 8 (32%) were clipped without the FL being incised. Another 5 (20%) were clipped solely after the FL was cut. For the remaining 12 cases, the aneurysms were successfully clipped following FL incision and partial ACP removal. Patients exhibited favorable postoperative recoveries with good outcomes, and postoperative CTA revealed complete aneurysm clipping without any residual remnants. Conclusions: We were able to perform clipping without removing the ACP in 13 patients (52%), and in 8 of these (32%), the clipping was carried out directly without cutting the FL. Microsurgery, coupled with proximal control of the cervical ICA, can serve as a viable alternative for patients with small dorsal ICA aneurysms, especially when endovascular treatment options are limited, and 3D CTA confirms a clear anatomical relationship with the ACP.

• Journal of Korean Neurosurgical Society
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• 제59권5호
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• pp.521-524
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• 2016

Use of the Pipeline embolization device (PED) has increased based on studies about its safety and effectiveness, and new reports that describe perior postprocedural complications are now emerging. We report a rare periprocedural device-related complication that occurred during endovascular treatment with the pipeline embolization device for a dissecting aneurysm on the vertebral artery. A 55-year old woman was admitted due to left medullary infarction, and angiography showed a fusiform dilatation in the left vertebral artery that was suspicious for dissecting aneurysm. Endovascular treatment with PED was planned. Under general anesthesia, the procedure was performed without significant problems and a PED was deployed in an appropriate position. However, in the final step of the procedure, the distal tip of the PED delivery wire became engaged within a small branch of the posterior cerebral artery and fractured. Fortunately, imaging studies after the procedure revealed neither hemorrhagic nor ischemic stroke, and the patient recovered without neurological morbidities except initial symptoms.

• Journal of Korean Neurosurgical Society
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• 제30권12호
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• pp.1361-1368
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• 2001

Objective : "Paraclinoid" aneurysms include those aneurysms arising from the internal carotid artery between the site of emergence of the carotid artery from the roof of the cavernous sinus and the origin of the posterior communicating artery. The authors reviewed and analysed the results of surgical approaches to paraclinoid aneurysms treated with transcranial surgery and endovascular surgery. Methods : Between January 1998 and May 1999, 14 patients were treated surgically through ipsilateral and contralateral pterional approaches, and anterior interhemispheric approach, and endovascular surgery for paraclinoid aneurysms. All transcranial approaches were performed by same surgeon. The medical records, neuroimaging studies and videotapes which had been recorded operations were reviewed retrospectively. Results : Twelve patients presented with subarachnoid hemorrhage and ICH. Nine of fourteen patients had multiple aneurysms. Thirteen cases were small and one was a large aneurysm. Six patients were treated through ipsilateral approaches, six contralateral pterional approaches, one anterior interhemispheric approach and one primarily by GDC embolization. All aneurysms treated through contralateral approaches were multiple aneurysms. Neck clipping was performed in 9(69.2%) of the thirteen aneurysms, wrapping in four cases, among them three cases were followed by GDC embolization. The surgical outcomes were : Glasgow Outcome Scale(GOS) I 71.4%, GOS II 21.4% and GOS V 7.1%. Conclusion : The surgical approaches to paraclinoid aneurysms should be chosen after careful anatomical evaluation of aneurysm and its neighboring structures. 3D-CT angiography and/or the raw data of MR angiography were useful. This study supports the usefulness of the contralateral approach to paraclinoid aneurysm associated with multiple aneurysms, unruptured and small aneurysms whose dome projecting medially, superiorly and dorsally. The determination of contralateral approach to small and medially projecting paraclinoid aneurysm may be stressful to operator, thus we believe anterior interhemispheric approach is better alternated. Also we recommend the endovascular surgery after reinforcement of aneurym neck and dome in the case with difficulty in clipping.

• Journal of Korean Neurosurgical Society
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• 제62권6호
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• pp.649-660
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• 2019

Objective : To analyze the angiographic features and clinical course, including treatment outcomes and the natural course, of fusiform middle cerebral artery aneurysms (FMCAAs) according to their location, size, and configuration. Methods : We reviewed the literature on adult cases of FMCAAs published from 1980 to 2018; from 25 papers, 112 FMCAA cases, for which the location, size, and configuration could be identified, were included in this study. Additionally, 33 FMCAA cases in our hospital were included, from which 16 were assigned to the observation group. Thus, a total of 145 adult FMCAA cases were included. We classified the FMCAAs according to their location (l-type 1, beginning from prebifurcation; l-type 2, beginning from bifurcation; l-type 3, beginning from postbifurcation), size (small, <10 mm; large, ${\geq}10mm$; giant, ${\geq}25mm$), and configuration (c-type 1, classic dissecting aneurysm; c-type 2, segmental ectasia; c-type 3, dolichoectatic dissecting aneurysm). Results : The c-type 3 was more commonly diagnosed with ischemic symptoms (31.8%) than hemorrhage (13.6%), while 40.9% were found accidentally. In contrast, c-type 2 was more commonly diagnosed with hemorrhagic symptoms (14.9%) than ischemic symptoms (10.6%), and 72.3% were accidentally discovered. According to location, ischemic symptoms and hemorrhage were the most frequent symptoms in l-type 1 (28.6%) and l-type 3 (34.6%), respectively. Most of l-type 2 FMCAAs were found incidentally (68.4%). Based on the size of FMCAAs, only 11.1% of small aneurysms were found to be hemorrhagic, while 18.9% and 26.0% of large and giant aneurysms were hemorrhagic, respectively. Although four aneurysms of the 16 FMCAAs in the observation group increased in size and one aneurysm decreased in size during the observation period, no rupture was seen in any case and there were no significant predictors of aneurysm enlargement. Of 104 FMCAAs treated, 14 cases (13.5%) were aggravated than before surgery and all the aggravated cases were l-type 1. Conclusion : While ischemic symptoms occurred more frequently in l-type 1 and c-type 3, hemorrhagic rather than ischemic symptoms occurred more frequently in l-type 3 and c-type 2. In case of l-type 1 FMCAAs, more caution is required in determining the treatment due to the relatively high complication rate.

• Journal of Korean Neurosurgical Society
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• 제46권3호
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• pp.232-238
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• 2009

Objective : Intracranial aneurysms are sometimes presented with visual symptoms by their rupture or direct compression of the optic nerve. It is because their prevalent sites are anatomically located close to the optic pathway. Anterior communicating artery is especially located in close proximity to optic nerve. Aneurysm arising in this area can produce visual symptoms according to their direction while the size is small. Clinical importance of visual symptoms presented by aneurysmal optic nerve compression is stressed in this study. Methods : Retrospective analysis of ruptured anterior communicating artery aneurysms compressing optic apparatus were carried out. Total 33 cases were enrolled in this study. Optic nerve compression of the aneurysms was confirmed by the surgical fields. Results : In 33 cases among 351 cases of ruptured anterior communicating artery aneurysms treated surgically, from 1991 to 2000, the dome of aneurysm was compressed in optic pathway. In some cases, aneurysm impacted into the optic nerve that deep hollowness was found when the aneurysm sac was removed during operation. Among 33 cases, 10 cases presented with preoperative visual symptoms, such as visual dimness (5), unilateral visual field defect (2) or unilateral visual loss (3), 20 cases had no visual symptoms. Visual symptoms could not be checked in 3 cases due to the poor mental state. In 6 cases among 20 cases having no visual symptoms, optic nerve was deeply compressed by the dome of aneurysm which was seen in the surgical field. Of 10 patients who had visual symptoms, 8 showed improvement in visual symptoms within 6 months after clipping of aneurysms. In 2 cases, the visual symptoms did not recover. Conclusion : Anterior communicating artery aneurysm can cause visual symptoms by compressing the optic nerve or direct rupture to the optic nerve with focal hematoma formation. We emphasize that cerebral vascular study is highly recommended to detect intracranial aneurysm before its rupture in the case of normal CT findings with visual symptoms and frequent headache.

• Journal of Korean Neurosurgical Society
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• 제54권2호
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• pp.86-92
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• 2013

Objective : Surgical results for anterior choroidal artery (AChA) aneurysms have previously been reported as unsatisfactory due to inadvertent occlusion of the AChA, while the low incidence of AChA aneurysms hampers the accumulation of surgical experience. The authors reviewed their related surgical experience to document the ischemic complications and surgical outcomes. Methods : Identification of the AChA at its origin by rigorous visual scrutiny, careful microdissection, and meticulous clip placement to avoid the AChA origin are all crucial surgical maneuvers. A retrospective review of a surgical series of 62 consecutive cases of an AChA aneurysm between 2004 and 2012 was performed. Results : All patients, except for five (8.1%) with a small residual neck, showed complete aneurysm obliteration in postoperative angiographic evaluations. There was no incidence of procedure-related permanent AChA syndrome or oculomotor nerve palsy, while three (4.8%) patients suffered from transient AChA syndrome. The clinical outcomes [the 3-month modified Rankin Scale (mRS)] of the patients were related to their preoperative World Federation of Neurologic Surgeons (WFNS) grade. As regards the 3-month mRS, significant differences were found between patients with an unruptured aneurysm (WFNS grade 0; n=20), good-grade subarachnoid hemorrhage (WFNS grade 1-3; n=30), and poor-grade subarachnoid hemorrhage (WFNS grade 4-5; n=4). Conclusion : In surgical treatment of AChA aneurysms, a risk of AChA insufficiency can be minimized by taking every precaution to preserve the AChA patency and intraoperative monitoring. In addition, the surgical outcome is primarily determined by the preoperative clinical state.

• Journal of Korean Neurosurgical Society
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• 제65권5호
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• pp.710-718
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• 2022

Objective : Although endovascular treatment for intracranial aneurysms is considered effective and safe, its durability is still debated. Also, few studies have described angiographic follow-up plan after endovascular treatment of intracranial aneurysm, especially in ruptured cases. Hence, we report the long-term results of follow-up angiography protocol. Methods : Radiological records of 639 cases of coil embolization with ruptured aneurysms from March 2003 to December 2016 were retrospectively reviewed. Patients who received treatment of a saccular aneurysm less than 7 mm resulted with near complete occlusion were included. Two hundred thirty-eight aneuryms which received the follow-up angiography at least once were enrolled. We classified four periods of follow-up as follows : post-treatment 1 year (defined as the first period), from 1 to 2 years (the second period), 2 to 5 years (the third period), and over 5 years (long-term). Results : We identified 14 cases (6.4%) of recurrence from 218 aneurysms in follow-up angiography in the first period. Among 143 aneurysms in the second period, five cases (3.5%) of recurrence were identified. There were no findings suspicious of recanalization in 97 patients in the third period. Of the total 238 cases, there were 19 recurrences, for a recurrence rate of 8.0%. Six (31.6%) out of 19 recurrences showed a tendency toward repeat recurrences even after additional treatment. Twenty-eight received long-term follow-up over 5 years and there was no recurrence. Conclusion : Most of the recurrence were found during the first and the second year. We suggest that at least one digital subtraction angiography examination may be necessary around post-treatment 2 years, especially in ruptured cases. If the angiographic results are favorable at 2 years post-treatment, long-term result should be favorable.

• Investigative Magnetic Resonance Imaging
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• 제1권1호
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• pp.94-102
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• 1997

목적: 자기공명혈관조영술(magnetic resonance angiography: MRA)을 이용하여 뇌동맥류를 비침습적 방법으로 진단하고자 하는 시도가 있었지만 크기가 3mm 이하인 경우 진단에 애로가 많았다. 뇌동맥류의 진단에 있어 최근 개발된 고해상도, 고속의 slice interpolation 자기 공명혈관조영술과 디지탈 감산 혈관조영술(digital subtraction angiography: DSA)의 결과를 전향적으로 비교하여 보편적인 선별 검사법으로 가능성을 확인하고자 하였다. 대상 및 방법: 총 19명의 환자에서 26개의 뇌동맥류를 대상으로 하였다. 모두 자기공명혈관조영술을 먼저 촬영하여 기원혈관, 동맥류경부의 확인, 인근 작은 혈관과의 연관관계등을 확인한 후 디지탈 감산 혈관조영술을 시행하여 비교하였다. 영상은 1.5T 초전도형기계(Vision, Siemens, erlangen, Germany)를 이용하여 slice interpolation 을 이용한 자기공명혈관조영술로 촬영하였다. 촬영은 TR / TE / FA = 30 / 6.4 / 25, matrix $512{\times}160$, 관찰면 $200{\times}150$, 촬영시간 7분 42초, 유효 두께 0.7mm, 총 두께가 102.2mm로 하여 대공(foramen magnum)에서 전뇌동맥(anterior cerebral artery)의 A3 부위까지 충분히 포함되도록 하였다. 영상분석은 최대강도투사(maximum intensity projection: MIP)를 사용하였으며 두개강내 동맥류가 있는 경우 다면재구성(multiplanar reconstruction: MPR) 기법을 사용하였다. 결과: 19명의 환자중 2명이 3개, 3명이 2개, 나머지 14명이 각각 1개씩의 두개강내 동맥류를 가져 모두 26개 였으며 파열된 동맥류가 14개였고 파열되지 않은 동맥류가 12 개이었다. 크기가 2mm 이하가 8개, 3-5mm가 9개, 6-9mm가 7개이며 10mm이상이 2개가 있었다. 처음 검사에서 자기공명혈관조영술과 디지탈 감산 혈관조영술에서 23개의 동맥류중 내경동맥에 1mm 크기의 동맥류 1개를 제외한 25개를 각각 발견할 수 있어 96%의 예민도를 보였으나 진음성과 위음성은 없어 특이도를 측정할 수 없었다. 크기와 모양을 확인하는데 자기공명혈과조영술과 다면재구성을 동시에 사용한 경우 디지탈 감산 혈관조영술과 같은 성적을 보인 반면 동맥류 경부와 기원혈관을 확인하는데도 자기공명혈관조영술의 다면재구성을 동시에 사용한 경우가 자기공명혈관조영술 또는 디지탈 감산 혈관조영술만 사용한 경우 보다 월등히 좋았다. 결론: Slice interpolation 기법을 이용한 고해상 자기공명혈관조영술은 두개강내 동맥류를 검사하는데 디지탈 감산 혈관조영술과 동일한 성적을 보여 앞으로 비침습적 일차 선별 검사법으로 가능할 것으로 생각된다.

• Journal of Korean Neurosurgical Society
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• 제51권3호
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• pp.160-163
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• 2012

We report an unusual case of lateral medullary infarction after successful embolization of the vertebral artery dissecting aneurysm (VADA). A 49-year-old man who had no noteworthy previous medical history was admitted to our hospital with a severe headache. Computed tomography (CT) revealed a subarachnoid hemorrhage, located in the basal cistern and posterior fossa. Cerebral angiography showed a VADA, that did not involve the origin of the posterior inferior cerebellar artery (PICA). We treated this aneurysm via endovascular trapping of the vertebral artery distal to the PICA. After operation, CT revealed post-hemorrhagic hydrocephalus, which we resolved with a permanent ventriculoperitoneal shunt procedure. Postoperatively, the patient experienced transient mild hoarsness and dysphagia. Magnetic resonance image (MRI) showed a small infarction in the right side of the medulla. The patient recovered well, though he still had some residual symptom of dysphagia at discharge. Such an event is uncommon but can be a major clinical concern. Further investigation to reveal risk factors and/or causative mechanisms for the medullary infarction after successful endovascular trapping of the VADA are sorely needed, to minimize such a complication.