• 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.

• 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 Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.2
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• pp.150-159
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• 2023

Objective: The aim of this study was to investigate the efficacy of intraoperative indocyanine green videoangiography (ICG-VA) and intraoperative neuromonitoring (IONM) to prevent postoperative ischemic complications during microsurgical clipping of unruptured anterior choroidal artery (AChA) aneurysms. Methods: We retrospectively reviewed the clinical and radiological records of all patients who had undergone microsurgical clipping for unruptured AChA aneurysms at our institution between April 2001 and December 2019. We compared the postoperative complication rate of the group for which intraoperative ICG-VA and IONM were utilized (group B; n=324) with that of the group for which intraoperative ICG-VA and IONM were not utilized (group A; n=72). Results: There were no statistically significant differences in demographic data between the two groups. Statistically significant differences were observed in the rate of overall complications (p=0.014) and postoperative ischemic complications related to AChA territory (p=0.039). All the cases (n=4) in group B who had postoperative infarctions related to AChA territory showed false-negative results of intraoperative ICG-VA and IONM. Conclusions: Preserving the patency of the AChA is essential to minimize postoperative complications. Intraoperative monitoring tools including ICG-VA and IONM can greatly contribute to lowering complication rates. However, their pitfalls and false-negative results should always be considered.

• Journal of Cerebrovascular and Endovascular Neurosurgery
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• v.25 no.4
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• pp.420-428
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• 2023

Objective: Intraprocedural rupture (IPR) is a fatal complication of endovascular coiling for cerebral aneurysms. We hypothesized that contrast leakage period may be related to poor clinical outcomes. This study aimed to retrospectively evaluate the relationship between clinical outcomes and contrast leakage period. Methods: Data from patients with cerebral aneurysms treated via endovascular coiling between January 2010 and October 2018 were retrospectively assessed. The enrolled patient's demographic data, the aneurysm related findings, endovascular treatment and IPR related findings, rescue treatment, and clinical outcome were analyzed. Results: In total, 2,859 cerebral aneurysms were treated using endovascular coiling during the study period, with IPR occurring in 18 (0.63 %). IPR occurred during initial frame coiling (n=4), coil packing (n=5), stent deployment (n=7), ballooning (n=1), and microcatheter removal after coiling (n=1). Tear sites included the dome (n=14) and neck (n=4). All IPRs were controlled and treated with coil packing, with or without stenting. Flow arrest of the proximal balloon was not observed. Temporary focal neurological deficits developed in two patients (11.1%). At clinical follow-up, 14 patients were classified as modified Rankin Scale (mRS) 0, three as mRS 2, and one as mRS 4. The mean contrast leakage period of IPR was 11.2 min (range: 1-31 min). Cerebral aneurysms with IPR were divided into late (n=9, mean time: 17.11 min) and early (n=9, mean time: 5.22 min) control groups based on the criteria of 10 min of contrast leakage period. No significant between-group differences regarding clinical outcomes were observed after IPR (p=1). Conclusions: In our series, all patients with IPR were controlled with further coil packing or stenting without proximal balloon occlusion within 31 min of contrast leakage. There was no difference in clinical outcomes when the long contrast leakage period group and short contrast leakage period group were compared.

• 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 Korean Neurosurgical Society
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• v.53 no.6
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• pp.342-348
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• 2013

Objective : Several scales are currently used to assess occlusion rates of coiled cerebral aneurysms. This study compared these scales as predictors of recanalization. Methods : Clinical data of 827 patients harboring 901 aneurysms treated by coiling were retrospectively reviewed. Occlusion rates were assessed using angiographic grading scale (AGS), two-dimensional percent occlusion (2DPO), and volumetric packing density (vPD). Every scale had 3 categories. Followed patients were dichotomized into either presence or absence of recanalization. Kaplan-Meier analysis was conducted, and Cox proportional hazards analysis was performed to identify surviving probabilities of recanalization. Lastly, the predictive accuracies of three different scales were measured via Harrell's C index. Results : The cumulative risk of recanalization was 7% at 12-month, 10% at 24-month, and 13% at 36-month of postembolization, and significantly higher for the second and third categories of every scale (p<0.001). Multivariate-adjusted hazard ratios (HRs) of the second and third categories as compared with the first category of AGS (HR : 3.95 and 4.15, p=0.004 and 0.001) and 2DPO (HR : 4.87 and 3.12, p<0.001 and 0.01) were similar. For vPD, there was no association between occlusion rates and recanalization. The validated and optimism-adjusted C-indices were 0.50 [confidence (CI) : -1.09-2.09], 0.47 (CI : -1.10-2.09) and 0.44 (CI : -1.10-2.08) for AGS, 2DPO, and vPD, respectively. Conclusion : Total occlusion should be reasonably tried in coiling to maximize the benefit of the treatment. AGS may be the best to predict recanalization, whereas vPD should not be used alone.

• Journal of Korean Neurosurgical Society
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• v.64 no.5
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• pp.751-762
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• 2021

Objective : Endovascular treatment of intracranial aneurysms is challenging in case of wide-necked aneurysms because coils are prone to herniate into the parent artery, causing thromboembolic events or vessel occlusion. This study aims to compare long-term angiographic results of wide-necked aneurysms treated by stent-assisted, double-microcatheter, or single-microcatheter groups. Methods : Between January 2003 and October 2016, 108 aneurysms that were treated with endovascular coil embolization with a neck size wider than 4 mm and a follow-up period of more than 3 years were selected. We performed coil embolization with single-microcatheter, double-microcatheter, and stent-assisted techniques. Angiographic results were evaluated using the Raymond-Roy occlusion classification (RROC). All medical and angiographic records were reviewed retrospectively. Results : Clinical and angiographic analyses were conducted in 108 wide-necked aneurysms. The immediate post-procedural results revealed RROC class I (complete occlusion) in 66 cases (61.1%), class II (residual neck) in 36 cases (33.3%), and class III (residual sac) in six cases (5.6%). The final follow-up results revealed class I in 48 cases (44.4%), class II in 49 cases (45.4%), and class III in 11 cases (10.2%). Of a total of 45 (41.6%) radiologic recurrences, there were 21 cases (19.4%) of major recurrence that required additional treatment, and 24 cases (22.2%) of minor recurrence. The final follow-up angiographic results showed statistically significant differences between the stent-assisted group and the others (p<0.01). Conclusion : Long-term follow-up angiography demonstrated that the stent-assisted technique had a better complete occlusion rate than the other two techniques.

• Journal of Korean Neurosurgical Society
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• v.66 no.6
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• pp.652-663
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• 2023

Objective : This study compared the quality of recovery (QoR) after minicraniotomy for clipping of unruptured intracranial aneurysms (UIAs) between patients with and without scalp nerve block (SNB). Methods : Patients were randomly assigned to the SNB (SNB using ropivacaine with epinephrine, n=27) and control (SNB using normal saline, n=25) groups. SNB was performed at the end of surgery. To assess postoperative QoR, the QoR-40, a patient-reported questionnaire, was used. The QoR-40 scores were measured preoperatively, 1-3 days postoperatively, at hospital discharge, and 1 month postoperatively. Pain and intravenous patient-controlled analgesia (IV-PCA) consumption were evaluated 3, 6, 9, and 12 hours and 1-3 days postoperatively. Results : All QoR-40 scores, including those measured 1 day postoperatively (primary outcome measure; 155.0 [141.0-176.0] vs. 161.0 [140.5-179.5], p=0.464), did not significantly differ between the SNB and control groups. The SNB group had significantly less severe pain 3 (numeric rating scale [NRS]; 3.0 [2.0-4.0] vs. 5.0 [3.5-5.5], p=0.029), 9 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.048), and 12 (NRS; 3.0 [2.0-4.0] vs. 4.0 [3.0-5.0], p=0.035) hours postoperatively. The total amount of IV-PCA consumed was significantly less 3 hours postoperatively in the SNB group (2.0 [1.0-4.0] vs. 4.0 [2.0-5.0] mL, p=0.044). Conclusion : After minicraniotomy for clipping of UIAs, SNB reduced pain and IV-PCA consumption in the early postoperative period but did not improve the QoR-40 scores.

• Journal of Chest Surgery
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• v.25 no.12
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• pp.1550-1555
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• 1992

From June 1989 to July 1992, we used centrifugal Biomedicus pump[CBP] in 20 patients In 9 cases, CBP was used as ventricular assistance after heart surgery for those who could not be weaned off bypass even with intra-aortic balloon counter-pulsation and with maximal inotropic support In 8 patients, CBP was used as partial left heart bypass during repair of aortic aneurysms or congenital aortic anomalies. And in 3 patients, CBP was used as vena caval bypass during resection of renal cell carcinoma with tumor extension into the inferior vena cava. In 2 of 9 patients with ventricular assistance, they were weaned off the device successfully after 16 hours and 7 days respectively. But the patients died of intracranial hemorrhage and sepsis, 7 and 29 days after weaning from cardiac support, respectively. In all the patients who underwent aortic of vena caval surgery using CBP as shunt, there were no complications such as postoperative bleeding necessitating reoperation, renal failure or neurologic sequelae. In conclusion, the centrifugal type of ventricular assistance may be potentially life saving treatment modality in patients with severe postoperative low cardiac output syndrome. The CBP can be safely employed for resection of renal cell carcinoma with vena caval tumor extension and for repair of aortic aneurysms.

• Journal of Korean Neurosurgical Society
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• v.66 no.2
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• pp.205-210
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• 2023

Delayed cerebral ischemia (DCI) remains a devastating complication in subarachnoid hemorrhage (SAH), however, there were no present reports that is associated with a ruptured spinal arteriovenous fistula (sAVF). We would like to present a rare case of DCI following embolization of a ruptured perimedullary sAVF. Initially, the patient clinical symptoms mimic a SAH caused by a ruptured intracranial aneurysm. Further evaluation revealed that the SAH was caused by a ruptured perimedullary sAVF and the patient's condition improved following the embolization procedure. Three days later, the patient developed an acute left-sided facial and motor weakness, which persisted until the patient was discharged on the day-15 onset. A magnetic resonance imaging and angiography is performed 1.5 years after discharge and revealed no signs of cerebral infarction and hemorrhage. In this paper, we reported DCI after embolization in a ruptured sAVF with SAH, supported by evidence from the current literature. We would like to also stress the importance of complete spinal and cerebral vessel imaging to reveal the underlying abnormalities and determine the most appropriate intervention.