• 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.

• Journal of Korean Neurosurgical Society
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• v.41 no.2
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• pp.100-104
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• 2007

Objective : Despite the widespread use of preoperative ventriculostomy in aneurysmal subarachnoid hemorrhage [SAH], there is no general consensus regarding the risk of bleeding associated with its use before aneurysm repair. This study was conducted to define the efficacy and rebleeding risk of ventriculostomy in aneurysmal SAH. Methods : The authors reviewed 339 consecutive patients with aneurysmal SAH who were treated at our hospital between January 1998 and December 2004. Results : Preoperative ventriculostomy was performed on 73 patients for acute hydrocephalus after aneurysmal SAH. The Hunt-Hess[H-H] grades of patients who underwent ventriculostomy were higher. Out of the 73 patients who underwent preoperative ventriculostomy, 58 [79%] demonstrated immediate clinical improvement after ventriculostomy. Of those same 73 patients 22 [30%] suffered aneurysmal rebleeding, whereas only 11 [4%] of the 266 patients who did not undergo ventriculostomy showed preoperative aneurysm rebleeding. The causes of rebleeding in the 22 patients who underwent ventriculostomy before surgery were related to the ventriculostomy procedure itself, subsequent cerebrospinal fluid [CSF] drainage, angiography and patient care procedures, such as endotracheal suction and nursing care. The mean time interval between SAH and surgery in the patients who underwent ventriculostomy was not statistically different from those who did not receive preoperative ventriculostomies [44.66 compared with 42.13 hours; p=0.73]. Conclusion : The preoperative ventriculostomy improved patients' clinical condition but increased the risk of rebleeding after aneurysmal SAH. When necessary, however, rapid change in transmural pressure during ventriculostomy must be avoided, careful management during ventricular drainage is needed, and surgery should be performed as soon as possible to prevent or reduce the incidence of rebleeding.

• Journal of Korean Neurosurgical Society
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• v.61 no.1
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• pp.19-27
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• 2018

Objective : The objectives of this study were to evaluate the immediate and long-term efficacy and safety of coil embolization for large or giant aneurysms. Methods : One hundred and fifty large or giant aneurysm cases treated with endovascular coil embolization between January 2005 and February 2014 at a single institute were included in this study. Medical records and imaging findings were reviewed. Statistical analysis was performed to evaluate prognostic factors associated with major recurrence (major recanalization or rupture) and delayed thromboembolism after selective coil embolization. Results : Procedure-related symptomatic complications occurred in five (3.3%) patients. The mean clinical and radiological follow-up periods were 38 months (range, 2-110) and 26 months (range, 6-108), respectively. During the follow-up period, the estimated recurrence rate was 4.6% per year. Multivariate analysis using Cox regression showed the degree of occlusion to be the only factor associated with recurrence (p=0.008, hazard ratio 3.15, 95% confidence interval 1.34-7.41). The patient's history of rupture in addition to the size and location of the aneurysm were not associated with recurrence in this study. Delayed infarction occurred in eight cases, and all were incompletely occluded. Conclusion : Although immediate postprocedural safety profiles were reasonable, longterm results showed recanalization and thromboembolic events to occur continuously, especially in patients with incomplete occlusion. In addition, incomplete occlusion was associated with delayed thromboembolic complications. Patients with incomplete occlusions should be followed carefully for delayed recurrence or delayed thromboembolic events.

• 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.40 no.4
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• pp.227-233
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• 2006

Objective : To determine the rationale for treating pure unruptured intracranial aneurysms[UIAs]. it is mandatory to know the risk of each treatment modality. The purpose of this study is to evaluate the surgical risk for treating UIAs. Methods : Between December 1994 and May 2005, 147 unruptured aneurysms in 135 patients were treated. The majority of these cases [94.6%] were treated with aneurysmal neck clipping. The remainder received aneurysmal wrapping [2.7%], trapping with bypass [20%], or proximal occlusion [0.7%]. The clinical outcomes were evaluated in each patient by the Glasgow Outcome Scale at one month post-surgery. Results : The patient pool consisted of 41 males and 94 females. The mean age was 55.9 years [range : $16{\sim}82$]. The aneurysms were located at middle cerebral artery in 63 [42.9%]. anterior communicating artery 30 [20.4%], posterior communicating artery in 26 [177%]. internal carotid artery[ICA] in 14 [95%], anterior choroidal artery in 4 [2.7%] and others in 10[6.9%]. One hundred fifteen [78.2%] of aneurysms were small [<10mm]. Others were large [10 to 25mm] and giant [>25mm]; 29 [19.7%] and 3 [21%] respectively. More than ninety percent [91.1%] of all patients recovered well. Mild to severe disability was seen in 8.7% of the patients. One patient succumbed to complications following injury to the ICA. Conclusion : The mortality and morbidity associated with UIA surgery at our hospital compared very favorably to the previous reported literature and with the previously established natural history of this disease.

• Journal of Korean Neurosurgical Society
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• v.63 no.5
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• pp.559-565
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• 2020

Objective : Conflicting results regarding SOX17 genes and the risk of intracranial aneurysms (IA) exist in the Korean population, although significant positive correlations were noted in genome-wide association studies in European and Japanese populations. Therefore, we aimed to investigate an association between SOX17 gene variants and IA using exome sequencing data. Methods : This study included 26 age-gender matched IA patients and 26 control subjects. The SOX17 gene variants identified from whole-exome sequencing data were examined. Genetic associations to estimate odds ratio (OR) and 95% confidence interval (CI) were performed using the software EPACTS. Results : The mean age of the IA and control groups were 51.0±9.3 years and 49.4±14.3 years, respectively (p=0.623). Seven variants of SOX17, including six single nucleotide polymorphisms and one insertion and deletion, were observed. Among these variants, rs12544958 (A>G) showed the most association with IA, but the association was not statistically significant (OR, 1.97; 95% CI, 0.81-4.74; p=0.125). Minor allele frequencies of the IA patients and controls were 0.788 and 0.653, respectively. None of the remaining variants were significantly associated with IA formation. Conclusion : No significant association between SOX17 gene variants and IA were noted in the Korean population. A large-scale exome sequencing study is necessary to investigate any Korean-specific genetic susceptibility to IA.

• Journal of Korean Neurosurgical Society
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• v.50 no.3
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• pp.185-190
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• 2011

Objective : To investigate the efficacy of extracranial-intracranial (EC-IC) bypass surgery using a radial artery interposition graft (RAIG) for surgical management of cerebrovascular diseases. Methods : The study involved a retrospective analysis of 13 patients who underwent EC-IC bypass surgery using RAIG at a single neurosurgical institute between 2003 and 2009. The diseases comprised intracranial aneurysm (n=10), carotid artery occlusive disease (n=2), and delayed stenosis in the donor superficial temporal artery (STA) following previous STA-middle cerebral artery bypass surgery (n=1). Patients were followed clinically and radiographically. Results : Bypass surgery was successful in all patients. At a mean follow-up of 53.4 months, the short-term patency rate was 100%, and the long-term rate was 92.3%. Twelve patients had an excellent clinical outcome of Glasgow Outcome Scale (GOS) 5, and one case had GOS 3. Procedure-related complications were a temporary dysthesia on the graft harvest hand (n=1) and a hematoma at the graft harvest site (n=1), and these were treated successfully with no permanent sequelae. In one case, spasm occurred which was relieved with the introduction of mechanical dilators. Conclusion : EC-IC bypass using a RAIG appears to be an effective treatment for a variety of cerebrovascular diseases requiring proximal occlusion or trapping of the parent artery.

• Journal of Korean Neurosurgical Society
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• v.29 no.3
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• pp.345-352
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• 2000

Objective : The purpose of this study was to compare computed tomographic angiography(CTA) with conventional cerebral angiography(CCA) and to assess usefulness of CTA in detection and anatomic definition of intracranial aneurysms of the circle of Willis in subarachnoid hemorrhage. Patients and Methods : Fifty consecutive patients with known or suspected intracranial saccular aneurysms underwent CTA with preoperative CCA from 1997 to 1999. Using surface shaded display post-processing technique, CTA was interpreted for the presence, location of aneurysms and anatomic features. The image obtained with CTA was then compared with CCA image. Results : In 47 patients, CCA revealed 57 cerebral aneurysms and CTA revealed 54 aneurysms. Two of the 57 cerebral aneurysms were located outside of the imaging volume of CTA and one case was misdiagnosed. The sensitivity of CTA was 94.7% and the specificity was 100%. The results obtained with CTA were, compared with the results obtained with CCA, equal in determining dome shape, direction and lobularity. However, CTA provided a 3-dimensional representation of aneurysmal lesion very useful for surgical planning. Moreover, CTA was useful for rapid and relatively noninvasive detection of aneurysms in the circle of Willis. Conclusion : CTA can be a diagnostic tool for the patients with acute subarachnoid hemorrhage due to a ruptured aneurysm of the circle of Willis and provides adequate anatomic detail for surgical planning, especially to complex cerebral aneurysms. However, we think CCA is necessary because of CTA limitations including its difficulty in detecting unusually located aneurysms(including those in cavernous sinus or distal artery) and combined vascular lesion (including arteriovenous malformation) and acquiring dynamic flow information.

• Journal of Korean Neurosurgical Society
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• v.64 no.5
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• pp.740-750
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• 2021

Objective : Retrograde suction decompression (RSD) is an adjuvant technique used for the microsurgical treatment of large and giant internal carotid artery (ICA) aneurysms. In this study, we analyzed the efficacy and safety of the RSD technique for the treatment of large and giant ICA aneurysms relative to other conventional microsurgical techniques. Methods : The aneurysms were classified into two groups depending on whether the RSD method was used (21 in the RSD group vs. 43 in the non-RSD group). Baseline characteristics, details of the surgical procedure, angiographic outcomes, clinical outcomes, and procedure-related complications of each group were reviewed retrospectively. Results : There was no significant difference in the rates of complete neck-clipping between the RSD (57.1%) and non-RSD (67.4%) groups. Similarly, there was no difference in the rates of good clinical outcomes (modified Rankin Scale score, 0-2) between the RSD (85.7%) and non-RSD (81.4%) groups. Considering the initial functional status, 19 of 21 (90.5%) patients in the RSD group and 35 of 43 (81.4%) patients in the non-RSD group showed an improvement or no change in functional status, which did not reach statistical significance. Conclusion : In this study, the microsurgical treatment of large and giant intracranial ICA aneurysms using the RSD technique obtained competitive angiographic and clinical outcomes without increasing the risk of procedure-related complications. The RSD technique might be a useful technical option for the microsurgical treatment of large and giant intracranial ICA aneurysms.

• Journal of Korean Neurosurgical Society
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• v.30 no.1
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• pp.33-40
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• 2001

Objective : Aneurysms of vertebral artery and its branches make up approximately 3% of all intracranial aneurysms. As the aneurysm have an intimate relationship with lower cranial nerves and medulla, surgical management of the aneurysms are one of the challenging neurosurgical problems. The authors analyzed the management outcomes for aneurysms arising from vertebral artery and its branches. Methods : At the authors' institution between May 1989 and Jan. 2000, 42 patients were treated with transcranial and endovascular surgery for aneurysms of vertebral artery and its branches. The medical records and neuroimaging studies of the patients were reviewed retrospectively. Results : Forty two patients were comprised of 28 female and 14 male patients aged from 26-80 year old(mean : 51.8). Of the 42 patients, 37 patients(88%) had subarachnoid hemorrhage. Of the 37 patients with subarachnoid hemorrahge, 35 patients(95%) were in good neurological status(Hunt Hess grade I-III), 2 patients(5%) in poor grade(H-H grade IV-V) before operation. Location of the aneurysm were 16 in vertebral artery, 12 in vertebro-PICA junction, and 14 in the peripheral PICA. Twenty nine patients were treated with transcranial surgery and 13 patients with endovascular surgery. The management outcome of the transcranial surgery was : Glasgow outcome scale(GOS) I and II ; 24, GOS III ; 2, GOS IV ; 1 and GOS V(death) ; 2. The causes of mortality related to transcranial surgery were rebleeding after failure in clipping in one and suspected brainstem infarct in one. Morbidity was attributed to vasospasm(3), lower CN palsy(7, including temporary dysfunction) and pseudomeningocele(1). The management outcome of the endovascular surgery was : Glasgow outcome scale(GOS) I-II ; 9, GOS III ; 1, GOS IV ; 1, and GOS V(death) ; 2. The causes of mortality related to endovascular surgery were sepsis from pneumonia(1) and vasospasm(1). There were one cerebellar infarct and one lateral medullary syndrome. Conclusion : Excellent and good surgical results can be expected in 80% of the patients with aneurysms of vertebral arery and its branches. The outcomes of endovascular surgery in treating vertebral artery aneurysm were satisfactory and endovascular surgery may offer a therapeutic alternative especially in vertebral dissecting aneurysm.