Dynamic changes of systemic inflammation response index and systemic immune-inflammation index are associated with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.

OBJECTIVES: Delayed cerebral ischemia (DCI) is a factor contributing to poor outcome of aneurysmal subarachnoid hemorrhage (aSAH). Serial inflammatory response is known to affect the occurrence of DCI. The aim of this study was to evaluate associations of dynamic changes of various inflammatory markers with occurrence of DCI after aSAH. METHODS: A total of 279 patients with interventional treatment for aSAH were enrolled, and dichotomized according to the occurrence of DCI. Various inflammatory markers, including systemic immune-inflammation index (SII), systemic inflammation response index (SIRI), and their dynamic changes were analyzed at four different time points. Receiver operating characteristic (ROC) curve analysis with area under the curve (AUC) and univariate, multivariate Cox regression analyses with hazard ratio (HR) and 95 % confidence interval (CI) were performed to identify predictors for DCI. RESULTS: Differences of SII and SIRI values between DCI (+) and DCI (-) group were significantly higher at 5-7 days than at other time points (P < 0.001 and P < 0.001, respectively). SII and SIRI had higher predicting values for DCI occurrence than other inflammatory markers (AUC: 0.862, 95 % CI: 0.786-0.928; P < 0.001 and AUC: 0.851, 95 % CI: 0.769-0.913; P < 0.001, respectively). SII at 5-7 days (HR: 1.74, 95 % CI: 1.38-3.22, P = 0.020) and SIRI at 5-7 days (HR: 1.62, 95 % CI: 1.28-2.84, P = 0.035) were associated with occurrence of DCI. CONCLUSIONS: Dynamic changes of SII and SII might be predictors of DCI occurrence in patients with aSAH.

Elevated blood viscosity is associated with delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage.

OBJECTIVES: Delayed cerebral ischemia (DCI) is a contributing factor for poor clinical outcome in aneurysmal subarachnoid hemorrhage (aSAH). Blood viscosity can reflect flow resistance and dehydration status. Our study aimed to analyze the association between blood viscosity and DCI in patients with aSAH. METHODS: In this retrospective cohort, systolic blood viscosity (SBV) and diastolic blood viscosity (DBV) were measured at admission in patients with aSAH. Receiver operating characteristic curve analysis was used to assess the predictive values of SBV and DBV for DCI after aSAH. Univariate and multivariate logistic regression was performed to analyze the association between blood viscosity and the development of DCI. RESULTS: A total of 470 patients with aSAH were included in this study, and 184 (39.1%) patients had DCI. Optimal cut-off values of DBV and SBV were presented as 12.05 (cP) and 3.75 (cP), respectively. In addition, DBV has higher predictable value of DCI than SBV (DBV: area under the curve [AUC] 0.793; standard error [SE] 0.026; 95% CI 0.722-0.864; P < 0.001, and SBV: AUC 0.702; SE 0.040; 95% CI 0.624-0.781; P < 0.001). In multivariate logistic regression analysis, elevated DBV was a predicting factor for development of DCI (odds ratio: 1.60; 95% confidence interval: 1.32-2.58; P = 0.037). CONCLUSIONS: Blood viscosity is associated with development of DCI in patients with aSAH. Especially, DBV has a higher predictive value for the occurrence of DCI than SBV. Elevated DBV is a potential predicting factor for the occurrence of DCI.

Intractable hiccups caused by syringobulbia and syringomyelia associated with intramedullary spinal hemangioblastoma.

INTRODUCTION: Hiccups caused by a neoplasm in the spinal cord are rare. MATERIALS AND METHODS: We report a case of intractable hiccups caused by syringobulbia and syringomyelia associated with cervical intramedullary spinal hemangioblastoma, which was successfully treated by surgical excision. A 60-year-old man was referred from the neurology department after presenting with hiccups for 1 year. The hiccups were aggravated 3 months ago and were sustained during eating or sleeping. Several doctors administered a muscle relaxant and an anticonvulsant, but they were ineffective. Spinal MRI revealed a huge syringomyelia from C2 to T2, associated with a highly enhancing intramedullary mass lesion at the C5 level. The hiccups were ceased after removal of the tumor through a right hemilaminectomy. The pathology of the specimen was hemangioblastoma. The size of the syringobulbia and syringomyelia decreased markedly on MRI checked 5 months after surgery. CONCLUSIONS: Intractable hiccups can be caused by syringobulbia associated with an intramedullary cord tumor in the cervical area and possible mechanisms of hiccups were reviewed.

Predictors of Emboli in Mechanical Thrombectomy for Anterior Circulation Stroke.

OBJECTIVE: Emboli commonly occurs in mechanical thrombectomy (MT). The objective of this study was to analyze predicting factors of emboli after MT. METHODS: Patients who underwent MT with successful reperfusion for anterior circulation occlusion were enrolled. Emboli included distal emboli at digital subtraction angiography (DSA) and unexpected embolic infarct on diffusion-weighted image (DWI) without distal emboli at DSA. Baseline characteristics, procedural details, angiographic outcomes, and clinical outcomes were reviewed. Multivariable analyses were performed to evaluate predictive factors for the occurrence of emboli. RESULTS: Of 601 patients, 149 (24.8%) patients had distal emboli at DSA, and 169 (28.1%) patients had unexpected embolic infarction on DWI even without distal emboli at DSA. A total of 318 (52.9%) patients were enrolled in the embolic group, and 283 (47.1%) patients were assigned to the non-embolic group. In multivariate analysis, larger microcatheter (OR 1.26, 95% CI 1.12-1.94; p = 0.047), clot passage (OR 1.33, 95% CI 1.07-1.87; p = 0.041), use of balloon guide catheter (BGC) (OR 0.70, 95% CI 0.52-0.92; p = 0.014), early ballooning of BGC (OR 0.68, 95% CI 0.50-0.90; p = 0.009), and longer stent retriever (OR 0.72, 95% CI 0.54-0.90; p = 0.029) were associated with occurrence of emboli. CONCLUSION: MT with only a stent retriever, use of a larger microcatheter, and clot passage might increase the risk of emboli. In contrast, contact aspiration thrombectomy, use of BGC, early ballooning of BGC, and use of longer stent retrievers could reduce the chance of emboli.

Comparison of 4 mm-sized and 3 mm-sized Stent Retrievers in Mechanical Thrombectomy for M2 Occlusion.

INTRODUCTION: A stent retriever (SR) is widely used in mechanical thrombectomy (MT) for M2 segment occlusion. However, the suitable size of SR in M2 occlusion remains unclear. Therefore, we aimed to compare 4 mm-sized SR with 3 mm-sized SR in M2 occlusion. METHODS: Patients who underwent MT with SR for M2 occlusion were dichotomized into 4×20 mm SR and 3×20 mm SR groups. Then, 1:1 propensity score matching was performed. The M2 segment was divided into proximal and distal segments according to the occlusion site. Subgroup analysis was then performed for each cohort. RESULTS: A total of 111 patients were enrolled, with 4×20 mm SR and 3×20 mm SR applied in 72 (64.9%) and 39 (35.1%) cases, respectively. In propensity score matching, mean number of stent passages for reperfusion was significantly lower in the 4×20 mm SR group than in the 3×20 mm SR group (1.5 ± 0.8 vs. 2.1 ± 1.1; p = 0.004). First-pass reperfusion (FPR) was more highly achieved in the 4×20 mm SR group than in the 3×20 mm SR group (52.6% vs. 42.1%; p = 0.007). In both proximal and distal occlusion cohorts, the 4 mm SR group showed lower mean number of SR passage (p = 0.004 and p =0.003, respectively) and higher FPR rate than the 3 mm SR group (p = 0.003 and p = 0.007, respectively). CONCLUSION: In MT for M2 occlusion, 4×20 mm SR enables an effective procedure with lesser SR passage for reperfusion and a higher rate of FPR than 3×20 mm SR.

Pan-immune-inflammation value predict delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage.

Inflammatory reaction and immune dysregulation are known as components contributing to delayed cerebral ischemia (DCI) in patients with following aneurysmal subarachnoid hemorrhage (aSAH). The objective of this study was to investigate the role of pan-immune-inflammation value (PIV) as a novel comprehensive inflammatory marker in predicting the DCI development following aSAH. A total of 1028 participants with aSAH were enrolled. There were 296 patients with DCI and 732 patients without DCI. Various inflammatory markers were analyzed using peripheral blood sample obtained at admission. Receiver operating characteristic (ROC) analysis was performed to identify the optimal cutoff value of PIV for distinguishing DCI. Multivariate analysis was used to determine independent predictors for DCI. Mean PIV was significantly higher in the DCI (+) group than in the DCI (-) group (437.6 ± 214.7 vs 242.1 ± 154.7, P = 0.007). In ROC analysis, the optimal cutoff value of PIV was 356.7 for predicting DCI (area under the curve [AUC] 0.772, 95 % confidence interval [CI] 0.718-0.816; P < 0.001). Multivariate analysis showed that high Hunt-Hess grade (odds ratio [OR] 1.70, 95 % CI 1.38-2.22; P = 0.007), thick SAH (OR 1.82, 95 % CI 1.44-2.32; P = 0.005), and elevated PIV (≥356.7) (OR 1.42, 95 % CI 1.10-1.74; P = 0.013) were independent predictors of DCI after aSAH. PIV is a potent predictor of DCI in patients with aSAH. Elevated PIV is associated with more DCI development. Thus, PIV has predictive value for DCI development.

Effect of Early Balloon Inflation of Balloon Guide Catheter in Mechanical Thrombectomy for Large Vessel Occlusion.

OBJECTIVE: A balloon guide catheter (BGC) is widely used in mechanical thrombectomy (MT). However, the balloon inflation timing of BGC has not been clearly established. We evaluated whether balloon inflation timing of BGC affects the results of MT. METHODS: Patients who underwent MT with BGC for anterior circulation occlusion were enrolled. Patients were dichotomized into early and late balloon inflation groups, according to the timing of BGC inflation. Angiographic and clinical outcomes were compared between the two groups. Multivariable analyses were performed to evaluate the predictive factors for first-pass reperfusion (FPR) and successful reperfusion (SR). RESULTS: Of 436 patients, the early balloon inflation group showed a shorter procedure time (21 min (11-37) vs. 29 min (14-46), p = 0.014), a higher rate of SR with aspiration only (64.0% vs. 55.4%, p = 0.016), a lower aspiration catheter delivery failure rate (11.1% vs. 19.4%, p = 0.005), less frequent technique conversion (36.0% vs. 44.5%, p = 0.009), higher rate of FPR (58.2% vs. 50.2%, p = 0.011), and a lower rate of distal embolization (7.9% vs. 11.7%, P = 0.006), compared to the late balloon inflation group. In multivariate analysis, early balloon inflation was an independent predictor for FPR (odds ratio, OR 1.53, 95% confidence interval, CI 1.37-2.57; p = 0.011) and SR (OR 1.26, 95% CI 1.18-1.64; p = 0.018). CONCLUSION: Early balloon inflation of BGC enables an effective procedure than late balloon inflation. Early balloon inflation was associated with higher rates of FPR and SR.

Comparison of Neuroform Atlas Stent-Assisted Coiling and Coiling Alone in Ruptured Intracranial Aneurysms: A Propensity Score Matching Analysis.

BACKGROUND: Although Neuroform Atlas stent is commonly used in stent-assisted coiling (SAC) to treat ruptured intracranial aneurysms (RIA), its safety and efficacy remain controversial. OBJECTIVE: To assess the safety and efficacy of SAC using Neuroform Atlas for treating RIA compared with coiling alone by performing a propensity score matching analysis. METHODS: RIA treated with coiling alone and SAC between January 2017 and May 2021 were retrospectively reviewed. Demographics, periprocedural complication rates, angiographic outcomes, and clinical outcomes of the SAC using Neuroform Atlas group and the coiling-alone group were analyzed with 1:1 propensity score matching. RESULTS: A total of 375 aneurysms were enrolled, and 274 (63.1%) aneurysms were treated with coiling alone. In total, 101 (26.9%) aneurysms were treated with SAC, and Neuroform Atlas stent was used in 71 aneurysms. In propensity score matching, the SAC using Neuroform Atlas group showed higher incidence of complete occlusion (69.0% vs 56.3%, P = .029), lower rate of recanalization (11.3% vs 25.4%, P = .011), and lesser need for retreatment (7.0% vs 16.9%, P = .016) compared with the coiling-alone group. However, there were no significant differences in periprocedural complications such as intraprocedural thrombosis or postprocedural cerebral infarct between the 2 groups. CONCLUSION: The use of Neuroform Atlas is safe and effective for SAC in RIA with comparable procedure-related complication rates but better angiographic outcome in comparison with coiling alone.

The impact of collateral status on cerebral vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage.

OBJECTIVE: Cerebral collateral circulation may affect subarachnoid hemorrhage (SAH) induced cerebral vasospasm and delayed cerebral ischemia. In this study our aim was to investigate the relationship between collateral status, vasospasm and delayed cerebral ischemia (DCI) in both aneurysmal and nonaneurysmal SAH. METHODS: Patients diagnosed as SAH with and without aneurysm were included and their data investigated retrospectively. After the patients diagnosed as SAH according to cerebral computed tomography (CT)/magnetic resonance imaging (MRI), they underwent cerebral angiography to check for cerebral aneurysm. The diagnosis of DCI was made according to the neurological examination and control CT/MRI. All the patients had their control cerebral angiography on days 7 to 10 in order to assess vasospasm and also collateral circulation. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System was modified to measure collateral circulation. RESULTS: A total of 59 patients data were analyzed. Patients with aneurysmal SAH had higher Fisher scores and DCI was more common. Although there was no statistically significant difference between the patients with and without DCI in terms of demographics and mortality, patients with DCI had worse collateral circulation and more severe vasospasm. These patients had higher Fisher scores and more cerebral aneurysm overall. CONCLUSIONS: According to our data, patients with higher Fisher scores, more severe vasospasm, and poor cerebral collateral circulation may experience DCI more frequently. Additionally aneurysmal SAH had higher Fisher scores and DCI was seen more common. To improve the clinical results for SAH patients, we believe that physicians should be aware of the DCI risk factors.

Painful eccrine spiradenoma containing nerve fibers: a case report.

An eccrine spiradenoma is a rare benign tumor most often seen in the head, neck and upper trunk of young adults. Although spontaneous pain or tenderness is a typical symptom of eccrine spiradenomas, the underlying mechanism has not been fully elucidated. Here, we report the case of a 47- year-old woman who had a spiradenoma in the subcutaneous tissue of her posterior neck accompanied by agonizing pain which was triggered by pressure. Multiple nodular lesions were excised and the typical histopathological findings of spiradenoma were seen. The histopathological architecture of a disorganized nerve fiber encasing the tumor nodules appeared to correlate with the unique clinical symptom of pain.

Prognostic significance of platelet-to-lymphocyte and platelet-to-neutrophil ratios in patients with mechanical thrombectomy for acute ischemic stroke.

OBJECTIVE: The present study aimed to analyze the correlation between platelet-to-lymphocyte ratio (PLR) and platelet-to-neutrophil ratio (PNR) with prognosis of patients who underwent mechanical thrombectomy (MT). METHODS: A total of 432 patients was included, PLR and PNR were calculated from laboratory data on admission. Prognosis was evaluated with a modified Rankin Scale at 3 months after MT. Using receiver operating characteristic (ROC) analysis, optimal cutoff values of PLR and PNR were identified to predict the prognosis after MT. Multivariate analyses were performed to identify the relationship of PLR and PLR with prognosis of MT. RESULTS: Patients with favorable outcomes had a lower mean PLR (135.0, standard deviation [SD] 120.3) with a higher mean PNR (47.1 [SD] 24.6) compared with patients with unfavorable outcomes (167.6 [SD] 139.3 and 35.4 [SD] 22.4) (p<0.001 and <0.001, respectively). In ROC analyses, the optimal cutoff value of PLR and PNR to predict the 3 months prognosis were 145 and 41, respectively (p=<0.001 and p=0.006). In multivariate analysis, PLR less than 145 (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.06-2.06; p=0.016) and PNR greater than 41 (OR 1.22, 95% CI 1.10-1.62; p=0.022) were predictors of favorable outcome at 3 months. CONCLUSIONS: In patients with MT, PLR and PNR on admission could be predictive factors of prognosis and mortality at 3 months. Decreased PLR and increased PNR were associated with favorable clinical outcome 3 months after MT.

Clinical relevance of serum procalcitonin in patients with aneurysmal subarachnoid hemorrhage.

Cerebral vasospasm (CV), which is closely related to the prognosis of aneurysmal subarachnoid hemorrhage (aSAH), is known to be related to an inflammatory reaction. The aim of the present study was to investigate predictable values of procalcitonin (PCT) for systemic infection and the development of CV in patients with aSAH. Patients who underwent endovascular treatment for aSAH were retrospectively enrolled. Receiver operating characteristic curve analysis was performed to evaluate the predicable value of PCT for systemic infection and CV in patients with aSAH. To clarify the association of PCT and CV, additional subgroup analysis was performed for patients without systemic infection. Multivariate logistic regression was used to explore the associations of PCT and the development of CV. A total of 374 patients with aSAH were enrolled. Of them, 164 (43.9%) had systemic infection. Optimal cutoff value of PCT for systemic infection was 0.21 ng/ml (P<0.001). In subgroup analysis of 210 patients without infection, 0.09 ng/ml of PCT level was defined as the optimal cutoff value for predicting CV after aSAH (P<0.001). In multivariate logistic regression analysis, PCT was a significant predicting factor for CV (odds ratio, 1.82; 95% confidence interval, 1.42-2.96; P=0.015). Overall, PCT had predictable value for systemic infection and the development of CV in patients who underwent endovascular treatment for aSAH. Further studies are needed to validate our results and establish its clinical applicability.

Factors Related to Mechanical Thrombectomy Failure in Large Vessel Occlusion: A Propensity Score Matching Analysis.

OBJECTIVE: Mechanical thrombectomy (MT) is an effective treatment for large vessel occlusion (LVO) with a high successful recanalization (SR) rate. However, MT fails in a proportion of patients, leading to poor clinical outcomes. We analyzed the factors associated with the failure of MT. METHODS: A total of 648 consecutive patients with MT were enrolled. MT failure was defined as 0,1, or 2a of modified Thrombolysis in Cerebral Infarction (mTICI) grade. Failed MTs were divided into 3 categories, reaching failure, passage failure, and recanalization failure (RF). Various factors in RF and SR groups were analyzed with 1: 1 propensity score matching. RESULTS: Failed MT was observed in 97 patients (14.3%). Among them, 69 patients (10.2% of the entire cohort, 71.1% of the failed MT group) were included in the RF group. Propensity matching analysis with 69 patients in each group showed that the RF group had a higher rate of residual intracranial atherosclerotic stenosis (ICAS) than the SR group (30.4% vs. 14.5% P = 0.003). The rates of 4 or more passages and no change of method were significantly higher in the RF group than in the SR group (34.8% vs. 13.0%; P = 0.001 and 28.9% vs. 8.7%; P = 0.001). CONCLUSION: The failure rate for all of the MT was approximately 15%, and RF accounted for more than 70% of the failed MT. RF was associated with residual ICAS. In cases with RF, even in repeated attempts for recanalization, an alteration of the thrombectomy method should be considered.

Sudden bilateral foot drop due to dorsally unilateral migration of the herniated lumbar disc: A case report.

BACKGROUND: Due to the anatomical characteristics of the anterior epidural space, dorsal migration of material from herniated lumbar disc is quite rare. Also, bilateral foot drop due to unilateral dorsal migration of disc herniation is extremely rare. This report presents a case of sudden bilateral foot drop caused by the unilateral dorsal migration of material from a herniated lumbar disc. CASE DESCRIPTION: A 51-year-old male presented with sudden onset severe leg pain with bilateral foot drop. The patient was referred to our emergency department by a local clinic. Neurological examination showed bilateral ankle and big toe dorsiflexion weakness grade 1. There was no perianal anesthesia, anal sphincter weaknesses, or voiding difficulty. Apart from essential hypertension, this patient's medical history was unremarkable. Magnetic resonance imaging showed that intervertebral disc material in the dorsal extradural space at the L3-4 level had compressed the dural sac from the left side to the center. We performed an emergency operation. The pathologic result revealed fibrous cartilaginous materials. After the operation, the leg pain was markedly resolved. At postoperative three months, the patient showed improvement of foot drop. CONCLUSION: We recommended emergent mass removal, which produced a favorable outcome.

Clinical Outcomes after Spinal Cord Stimulation According to Pain Characteristics.

OBJECTIVE: Spinal cord stimulation (SCS) is an effective treatment for chronic neuropathic pain. However, its clinical efficacy in regard to specific types of pain has not been well studied. The primary objective of this study was to retrospectively analyze the clinical outcomes of paddle-type SCS according to the type of neuropathic pain. METHODS: Seventeen patients who underwent paddle-lead SCS at our hospital were examined. Clinical outcomes were evaluated pre- and postoperatively (3 months, 1 year, and last follow-up) using the Neuropathic Pain Symptom Inventory (NPSI). The NPSI categorizes pain as superficial, deep, paroxysmal, evoked, or dysesthesia and assess the duration of the pain (pain time score). Changes in NPSI scores were compared with change in Visual analogue scale (VAS) scores. RESULTS: After SCS, the pain time score improved by 45% (independent t-test, p=0.0002) and the deep pain score improved by 58% (independent t-test, p=0.001). Improvements in the pain time score significantly correlated with improvements in the VAS score (r=0.667, p=0.003, Spearman correlation). Additionally, the morphine milligram equivalent value was markedly lower after vs. before surgery (~49 mg, pared t-test, p=0.002). No preoperative value was associated with clinical outcome. CONCLUSION: The NPSI is a useful tool for evaluating the therapeutic effects of SCS. Chronic use of a paddle-type spinal cord stimulation improved the deep pain and the pain time scores.

Clinical Implications of Preinterventional Thrombus Migration in Patients with Emergent Large Vessel Occlusion.

BACKGROUND: In patients treated with thrombectomy, thrombus migration (TM) to distal arterial segments is occasionally observed. We investigated the incidence of TM, factors associated with TM, and association between TM and clinical outcomes. METHODS: The study population consisted of 164 patients with anterior circulation stroke who underwent pretreatment brain computed tomography angiography and digital subtraction angiography before undergoing thrombectomy. TM was defined as a thrombus shift to a more distal arterial segment observed on digital subtraction angiography than that on computed tomography angiography. Successful and complete recanalization was defined as cerebral infarction perfusion scale scores of 2b-3 and 3, respectively. Good functional outcomes were defined as scores of ≤2 on the modified Rankin Scale at 3 months. The results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Thirty-two patients (19.5%) had TM. Intravenous thrombolysis (IVT) (OR, 5.238; 95% CI, 1.653-16.603) and female sex (OR, 2.874; 95% CI, 1.135-7.277) were associated with TM. IVT-related TM was not significantly associated with thrombus inaccessibility (P = 0.304). In addition, TM was not associated with successful (P = 0.960) or complete (P = 0.612) recanalization. However, TM (OR, 2.777; 95% CI, 1.019-7.569), together with IVT (OR, 2.982; 95% CI, 1.332-6.676), a low National Institutes of Health Stroke Scale score (OR, 0.906; 95% CI, 0.845-0.972), and successful recanalization (OR, 4.878; 95% CI, 1.940-12.266), were independently associated with good functional outcomes. CONCLUSIONS: TM is common, particularly after IVT. In addition, TM is associated with better functional outcomes, irrespective of the angiographic outcomes.

Neurocritical Management of Traumatic Acute Subdural Hematomas.

Acute subdural hematoma (ASDH) has been a major part of traumatic brain injury. Intracranial hypertension may be followed by ASDH and brain edema. Regardless of the complicated pathophysiology of ASDH, the extent of primary brain injury underlying the ASDH is the most important factor affecting outcome. Ongoing intracranial pressure (ICP) increasing lead to cerebral perfusion pressure (CPP) decrease and cerebral blood flow (CBF) decreasing occurred by CPP decrease. In additionally, disruption of cerebral autoregulation, vasospasm, decreasing of metabolic demand may lead to CBF decreasing. Various protocols for ICP lowering were introduced in neuro-trauma field. Usage of anti-epileptic drugs (AEDs) for ASDH patients have controversy. AEDs may reduce the risk of early seizure (<7 days), but, does not for late-onset epilepsy. Usage of anticoagulants/antiplatelets is increasing due to life-long medical disease conditions in aging populations. It makes a difficulty to decide the proper management. Tranexamic acid may use to reducing bleeding and reduce ASDH related death rate. Decompressive craniectomy for ASDH can reduce patient's death rate. However, it may be accompanied with surgical risks due to big operation and additional cranioplasty afterwards. If the craniotomy is a sufficient management for the ASDH, endoscopic surgery will be good alternative to a conventional larger craniotomy to evacuate the hematoma. The management plan for the ASDH should be individualized based on age, neurologic status, radiologic findings, and the patient's conditions.

Endoscopic Treatment of Acute Subdural Hematoma with a Normal Small Craniotomy.

BACKGROUND: Endoscopic surgery is helpful in evacuating intracranial hematomas. However, the indication and the craniotomy location are still unclear in the endoscopic evacuation of acute subdural hematomas (SDHs). This study evaluated the feasibility and efficacy of endoscopic treatment of acute SDH via a normal small craniotomy. METHODS: A normal small craniotomy (∼ 3 × 4 cm) as a surgical window was made at the superior temporal line around the coronal suture on the lesion side. A 4-mm rigid endoscope with a 0-degree lens was introduced into the subdural space, and the hematoma was evacuated using irrigation and suction devices with various angles. Endoscopic surgery was performed in 13 older adult patients with acute SDH. Adequacy of the hematoma evacuation, bleeding control, and clinical outcomes were analyzed. RESULTS: The mean age of the patient was 78.6 years (range: 65-89 years). Four cases of cortical arterial bleeding were encountered and controlled with bipolar cauterization. No re-bleeding was observed postoperatively in any patient. Near-total hematoma removal was achieved. Remnant hematoma was scanty and located in the parietal area. No further craniectomy was required after the endoscopic surgery. The outcome at discharge was closely related to the patient's level of consciousness before the operation. CONCLUSION: A small craniotomy around the superior temporal line provides an optimal window to evacuate an acute SDH and achieve hemostasis using an endoscope. Endoscopic evacuation of acute SDHs could be effective in selected cases.

The Evolution of Flow-Diverting Stents for Cerebral Aneurysms; Historical Review, Modern Application, Complications, and Future Direction.

In spite of the developing endovascular era, large (15-25 mm) and giant (>25 mm) wide-neck cerebral aneurysms remained technically challenging. Intracranial flow-diverting stents (FDS) were developed to address these challenges by targeting aneurysm hemodynamics to promote aneurysm occlusion. In 2011, the first FDS approved for use in the United States market. Shortly thereafter, the Pipeline of Uncoilable or Failed Aneurysms (PUFS) study was published demonstrating high efficacy and a similar complication profile to other intracranial stents. The initial FDA instructions for use (IFU) limited its use to patients 22 years old or older with wide-necked large or giant aneurysms of the internal carotid artery (ICA) from the petrous segment to superior hypophyseal artery/ophthalmic segment. Expanded IFU was tested in the Prospective Study on Embolization of Intracranial Aneurysms with PipelineTM Embolization Device (PREMIER) trial. With further post-approval clinical data, the United States FDA expanded the IFU to include patients with small or medium, wide-necked saccular or fusiform aneurysms from the petrous ICA to the ICA terminus. However, IFU is more restrictive in South Korea than in United States. Several systematic reviews and meta-analyses have sought to evaluate the overall efficacy of FDS for the treatment of cerebral aneurysms and consistently identify FDS as an effective technique for the treatment of aneurysms broadly with complication rates similar to other traditional techniques. A growing body of literature has demonstrated high efficacy of FDS for small aneurysms; distal artery aneurysms; non-saccular aneurysms posterior circulation aneurysms and complication rates similar to traditional techniques. In the short interval since the Pipeline Embolization Device was first introduced, FDS has been firmly entrenched as a powerful tool in the endovascular armamentarium. As new FDS are developed, established FDS are refined, and delivery systems are improved the uses for FDS will only expand further. Researchers continue to work to optimize the mechanical characteristics of the FDS themselves, aiming to optimize deploy ability and efficacy. With expanded use for small to medium aneurysms and posterior circulation aneurysms, FDS technology is firmly entrenched as a powerful tool to treat challenging aneurysms, both primarily and as an adjunct to coil embolization. With the aforementioned advances, the ease of FDS deployment will improve and complication rates will be further minimized. This will only further establish FDS deployment as a key strategy in the treatment of cerebral aneurysms.

Rotational vertebral artery syndrome treated via an anterior approach and selective decompression only.

We present the case of a 38-year-old male who complained of repeated dizziness and syncope. Rotational vertebral artery syndrome (RVAS) was diagnosed via videonystagmoraphy (VNG), computed tomography angiography (CTA) and three-position digital subtraction angiography (DSA). In the neutral position, CTA and DSA revealed left vertebral artery (VA) stenosis at the C2 transverse foramen and right VA hypoplasia. When the head was turned to the right, the blood flow stopped at the C2 level. The bony structure around the VA at the C2 transverse foramen was decompressed via an anterior surgical approach, and the symptoms resolved. This case present the precise stenotic point evaluation by three-position DSA is crucial for the planning of surgical treatment.