• The Korean Journal of Nuclear Medicine
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• v.27 no.2
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• pp.175-182
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• 1993

We evaluated the usefulness of $^{99m}Tc$-HMPAO SPECT in 21 Patients with subarachnoid hemorrhage due to ruptured intracranial aneurysm and in 3 patients with unruptured intracranial aneurysm. SPECT study could detect the bilaterally hypoperfused cases in 10 patients (48%), but CT/MRI showed the bilateral abnormalities in only 3 patients (14%). The number of abnormal lesions were 56 in SPECT and 25 in CT/MRI. The lesions found in SPECT were well correlated with the neurological signs of the patients such as aphasia or hemiplegia. SPECT study during Matas test was helpful in evaluating the risk for carotid artery occlusion therapy. We thought that $^{99m}Tc$-HMPAO brain SPECT is helpful in evaluating the functional changes in patients with subarachnoid hemorrhage.

• Journal of Korean Neurosurgical Society
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• v.43 no.3
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• pp.162-164
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• 2008

Post-clipping intraparenchymal hemorrhage of the contralateral hemisphere is a very unusual phenomenon in a patient with aneurysmal subarachnoid hemorrhage, unless there is an underlying condition. We report a complicated case of 47-year-old man, who underwent uneventful clipping of ruptured aneurysm and experienced vasospasm two weeks later. Vasospasm was treated by intra-arterial nimodipine and systemic hyperdynamic therapy. One week thereafter, he became unconscious due to intraparenchymal hemorrhage on the anterior border-zone of contalateral hemisphere, but intraoperative and pathologic findings failed to disclose any vascular anomaly. We suggest that the anti-spastic regimens cause local hemodynamic redistribution through the vasodilatory effect and in turn, resulted in such an unexpected bleeding.

• Journal of Korean Neurosurgical Society
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• v.51 no.5
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• pp.268-271
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• 2012

Objective : To propose grading of intracerebral hemorrhage (ICH) in ruptured middle cerebral artery (MCA) aneurysms, which helps to predict the prognosis more accurately. Methods : From August 2005 to December 2010, 27 cases of emergent hematoma evacuation and aneurysm clipping for MCA aneurysms were done in the author's clinic. Three variables were considered in grading the ICH, which were 1) hematoma volume, 2) diffuse subarachnoid hemorrhage (SAH) that extends to the contralateral sylvian cistern, and 3) the presence of midline shifting from computed tomography findings. For hematoma volume of greater than 25 mL, we assigned 2 points whereas 1 point for less than 25 cc. We also assigned 1 point for the presence of diffuse SAH whereas 0 point for the absence of it. Then, 1 point was assigned for midline shifting of greater than 5 mm whereas 0 point for less than 5 mm. Results : According to the grading system, the numbers of patients from grade 1 to 4 were 4, 6, 8 and 9 respectively and 5, 7, 8, 4 and 3 patients belonged to Glasgow Outcome Scale (GOS) 5 to 1 respectively. It was found that the patients with higher GOS had lower ICH grade which were confirmed to be statistically significant (p<0.01). Preoperative Hunt and Hess grade and absence of midline shifting were the factors to predict favorable outcome. Conclusion : The ICH grading system composed of above three variables was helpful in predicting the patient's outcome more accurately.

• Journal of Korean Neurosurgical Society
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• v.58 no.3
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• pp.175-183
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• 2015

Objective : Intracranial ruptured vertebral artery dissecting aneurysms (VADAns) are associated with high morbidity and mortality when left untreated due to the high likelihood of rebleeding. The present study aimed to establish an endovascular therapeutic strategy that focuses specifically on the angioarchitecture of ruptured VADAns. Methods : Twenty-three patients with ruptured VADAn received endovascular treatment (EVT) over 7 years. The patient group included 14 women (60.9%) and 9 men (39.1%) between the ages of 39 and 72 years (mean age 54.2 years). Clinical data and radiologic findings were retrospectively analyzed. Results : Four patients had aneurysms on the dominant vertebral artery. Fourteen (61%) aneurysms were located distal to the posterior inferior cerebellar artery (PICA). Six (26%) patients had an extracranial origin of the PICA on the ruptured VA, and 2 patients (9%) had bilateral VADAns. Eighteen patients (78%) were treated with internal coil trapping. Two patients (9%) required an adjunctive bypass procedure. Seven patients (30%) required stent-supported endovascular procedures. Two patients experienced intra-procedural rupture during EVT, one of which was associated with a focal medullary infarction. Two patients (9%) exhibited recanalization of the VADAn during follow-up, which required additional coiling. No recurrent hemorrhage was observed during the follow-up period. Conclusion : EVT of ruptured VADAns based on angioarchitecture is a feasible and effective armamentarium to prevent fatal hemorrhage recurrence with an acceptable low risk of procedural complications. Clinical outcomes depend mainly on the pre-procedural clinical state of the patient. Radiologic follow-up is necessary to prevent hemorrhage recurrence after EVT.

• Investigative Magnetic Resonance Imaging
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• v.19 no.2
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• pp.107-113
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• 2015

Purpose: Susceptibility weighted imaging (SWI) is a new magnetic resonance technique that can exploit the magnetic susceptibility differences of various tissues. Intracranial hemorrhage (ICH) looks a dark blooming on the magnitude images of SWI. However, the pattern of ICH on phase images is not well known. The purpose of this study is to characterize hemorrhagic lesions on the phase images of SWI. Materials and Methods: We retrospectively enrolled patients with ICH, who underwent both SWI and precontrast CT, between 2012 and 2013 (n = 95). An SWI was taken, using the 3-tesla system. A phase map was generated after postprocessing. Cases with an intracranial hemorrhage were reviewed by an experienced neuroradiologist and a trainee radiologist, with 10 years and 3 years of experience, respectively. The types and stages of the hemorrhages were determined in correlation with the precontrast CT, the T1- and T2-weighted images, and the FLAIR images. The size of the hemorrhage was measured by a one- directional axis on a magnitude image of SWI. The phase values of the ICH were qualitatively evaluated: hypo-, iso-, and hyper-intensity. We summarized the imaging features of the intracranial hemorrhage on the phase map of the SWI. Results: Four types of hemorrhage are observed: subdural and epidural; subarachnoid; parenchymal hemorrhage; and microbleed. The stages of the ICH were classified into 4 groups: acute (n = 34); early subacute (n = 11); late subacute (n = 15); chronic (n = 8); stage-unknown microbleeds (n = 27). The acute and early subacute hemorrhage showed heterogeneous mixed hyper-, iso-, and hypo-signal intensity; the late subacute hemorrhage showed homogeneous hyper-intensity, and the chronic hemorrhage showed a shrunken iso-signal intensity with the hyper-signal rim. All acute subarachnoid hemorrhages showed a homogeneous hyper-signal intensity. All parenchymal hemorrhages (> 3 mm) showed a dipole artifact on the phase images; however, microbleeds of less than 3 mm showed no dipole artifact. Larger hematomas showed a heterogeneous mixture of hyper-, iso-, and hypo-signal intensities. Conclusion: The pattern of the phase value of the SWI showed difference, according to the type, stage, and size.

• Journal of Korean Neurosurgical Society
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• v.56 no.6
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• pp.527-530
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• 2014

Spinal subarachnoid hemorrhages (SAH) can extend into the intracranial subarachnoid space, but, severe cerebral vasospasm is rare complication of the extension of intracranial SAH from a spinal subarachnoid hematoma. A 67-year-old woman started anticoagulant therapy for unstable angina. The next day, she developed severe back pain and paraplegia. MRI showed intradural and extramedullar low signal intensity at the T2-3, consistent with intradural hematoma. High signal intensity was also noted in the spinal cord from C5 to T4. We removed subarachnoid hematoma compressing the spinal cord. The following day, the patient complained of severe headache. Brain CT revealed SAH around both parietal lobes. Three days later, her consciousness decreased and left hemiplegia also developed. Brain MRI demonstrated multiple cerebral infarctions, mainly in the right posterior cerebral artery territory, left parietal lobe and right watershed area. Conventional cerebral angiography confirmed diffuse severe vasospasm of the cerebral arteries. After intensive care for a month, the patient was transferred to the rehabilitation department. After 6 months, neurologic deterioration improved partially. We speculate that surgeons should anticipate possible delayed neurological complications due to cerebral vasospasm if intracranial SAH is detected after spinal subarachnoid hematoma.

• Journal of Korean Neurosurgical Society
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• v.49 no.6
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• pp.373-376
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• 2011

We report a case of a non traumatic spinal subdural hematoma or subarachnoid hematoma manifesting as lumbago, leg pain and bladder dysfunction that showed angiographically occult vascular malformation (AOVM). Although the spinal angiogram did not reveal any vascular abnormality, the follow-up magnetic resonance image showed AOVM. Complete surgical removal was performed due to the aggravated bladder dysfunction. This case highlights the need to consider bleeding due to spinal AOVM, even when angiography is negative.

• Journal of Korean Neurosurgical Society
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• v.45 no.4
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• pp.253-255
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• 2009

Spontaneous spinal subarachnoid hematoma (SSH) is a rare entity to cause spinal cord or nerve root compression and is usually managed as surgical emergencies. We report a case of spontaneous SSH manifesting as severe lumbago, which demonstrated nearly complete clinical resolution with conservative treatment A 58-year-old female patient developed a large SSH, which was not related to blood dyscrasia, anticoagulation, lumbar puncture. or trauma. Patient had severe lumbago but no neurologic deficits. Because of absence of neurologic deficits, she was treated conservatively. Follow-up magnetic resonance (MR) image showed complete resolution. Conservative treatment of SSH may be considered if the patient with spontaneous SSH has no neurologic deficits.

• Journal of Korean Neurosurgical Society
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• v.44 no.5
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• pp.308-313
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• 2008

Objective: The serum S100 protein has been known to reflect the severity of neuronal damage. The purpose of this study was to assess the prognostic value of the serum S100 protein by Elecsys S100 immunoassay in patients with subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) and to establish reference value for this new method. Methods: Serum S100 protein value was measured at admission, day 3 and 7 after bleeding in 42 consecutive patients (SAH : 20, ICH : 22) and 74 healthy controls, prospectively. Admission Glasgow coma scale (GCS) score, Hunt & Hess grade and Fisher grade for SAH, presence of intraventricular hemorrhage, ICH volume, and outcome at discharge were evaluated. Degrees of serum S100 elevation and their effect on outcomes were compared between two groups. Results: Median S100 levels in SAH and ICH groups were elevated at admission (0.092 versus $0.283{\mu}g/L$) and at day 3 (0.110 versus $0.099{\mu}g/L$) compared to healthy controls ($0.05{\mu}g/L;$ p<0001). At day 7, however, these levels were normalized in both groups. Time course of S100 level in SAH patient was relatively steady at least during the first 3 days, whereas in ICH patient it showed abrupt S100 surge on admission and then decreased rapidly during the next 7 days, suggesting severe brain damage at the time of bleeding. In ICH patient, S100 level on admission correlated well with GCS score (r=-0.859; p=0.0001) and ICH volume (r=0.663; p=0.001). A baseline S100 level more than $0.199{\mu}g/L$ predicted poor outcome with 92% sensitivity and 90% specificity. Logistic regression analyses showed Ln (S100) on admission as the only independent predictor of poor outcome (odd ratio 36.1; 95% CI, 1.98 to 656.3) Conclusion: Brain damage in ICH patient seems to develop immediately after bleeding, whereas in SAH patients it seems to be sustained for few days. Degree of brain damage is more severe in ICH compared to SAH group based on the S100 level. S100 level is considered an independent predictor of poor outcome in patient with spontaneous ICH, but not in SAH. Further study with large population is required to confirm this result.

• Journal of Korean Neurosurgical Society
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• v.48 no.4
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• pp.313-318
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• 2010

Objective : The amount of hemorrhage observed on a brain computed tomography scan, or a patient's Fisher grade (FG), is a powerful risk factor for development of shunt dependent hydrocephlaus (SDHC). However, the influence of treatment modality (clipping versus coiling) on the rate of SDHC development has not been thoroughly investigated. Therefore, we compared the risk of SDHC in both treatment groups according to the amount of subarachnoid hemorrhage (SAH). Methods : We retrospectively reviewed 839 patients with aneurysmal SAH for a 5-year-period. Incidence of chronic SDHC was analyzed using each treatment modality according to the FG system. In addition, other well known risk factors for SDHC were also evaluated. Results : According to our data, Hunt-Hess grade, FG, acute hydrocephalus, and intraventricular hemorrhage were significant risk factors for development of chronic SDHC. Coiling group showed lower incidence of SDHC in FG 2 patients, and clipping groups revealed a significantly lower rate in FG 4 patients. Conclusion : Based on our data, treatment modality might have an influence on the incidence of SDHC. In FG 4 patients, the clipping group showed lower incidence of SDHC, and the coiling group showed lower incidence in FG 2 patients. We suggest that these findings could be a considerable factor when deciding on a treatment modality for aneurysmal SAH patients, particularly when the ruptured aneurysm can be occluded by either clipping or coiling.