Association of Methylenetetrahydrofolate Reductase (MTHFR 677C>T and 1298A>C) Polymorphisms and Haplotypes with Silent Brain Infarction and Homocysteine Levels in a Korean Population

PURPOSE: Methylenetetrahydrofolate reductase (MTHFR) is the main regulatory enzyme for homocysteine metabolism. In the present study, we evaluated whether the MTHFR 677C>T and 1298A>C gene polymorphisms are associated with SBI and plasma homocysteine concentration in a Korean population. MATERIALS AND METHODS: We enrolled 264 patients with SBI and 234 healthy controls in South Korea. Fasting plasma total homocysteine (tHcy) concentrations were measured, and genotype analysis of the MTHFR gene was carried out. RESULTS: The plasma tHcy levels were significantly higher in patients with SBI than in healthy controls. Despite a significant association between the MTHFR 677TT genotype and hyperhomocysteinemia, the MTHFR 677C>T genotypes did not appear to influence susceptibility to SBI. However, odds ratios of the 1298AC and 1298AC + CC genotypes for the 1298AA genotype were significantly different between SBI patients and normal controls. The frequencies of 677C-1298A and 677C-1298C haplotypes were significantly higher in the SBI group than in the control group. CONCLUSION: This study demonstrates that the MTHFR 1298A>C polymorphism is a risk factor for SBI in a Korean population. The genotypes of 677C>T and 1298A>C polymorphisms interact additively, and increase the risk of SBI in Korean subjects.

Isolated Aspergillosis of the Brain in an Immunocompetent Patient: A Case Report

Brain aspergillosis has been increasing remarkably. They are known to occur commonly in immunocompromised individuals by hematogenous spread from other primary sites or by direct extension from adjacent structures to central nervous system. We report a rare case of a 29-year-old male without any known medical history, who had isolated brain lesion and the pathology from stereotactic biopsy confirmed cerebral aspergillosis.

Isolated Aspergillosis of the Brain in an Immunocompetent Patient: A Case Report

Brain aspergillosis has been increasing remarkably. They are known to occur commonly in immunocompromised individuals by hematogenous spread from other primary sites or by direct extension from adjacent structures to central nervous system. We report a rare case of a 29-year-old male without any known medical history, who had isolated brain lesion and the pathology from stereotactic biopsy confirmed cerebral aspergillosis.

Endovascular Treatment Using Multiple Stents for Symptomatic Intracranial Vertebral Artery Dissecting Aneurysm / 대한뇌혈관외과학회지

OBJECTIVE: Endovascular treatment with stent placement or stent-assisted coiling was recently introduced as an alternative to parent artery occlusion for treating intracranial vertebral artery dissections. However, complete aneurysm obliteration after single stent placement is often not accomplished. The aim of the study was to evaluate the safety and efficacy of placing multiple stents in intracranial vertebral dissecting aneurysms. METHODS: We retrospectively reviewed 8 patients who underwent stent angioplasty with placing multiple stents for treating intracranial vertebral dissecting aneurysms. There were 5 male patients and 3 female patients with a mean age of 54 years (age range, 37-71 years). Three patients presented with subarachnoid hemorrhage (SAH), 1 presented with ischemic events and 4 presented with headache. Follow-up angiogram was performed in 8 patients within 6~12 months to determine whether or not the affected segment was occluded. RESULTS: Eight patients with intracranial vertebral artery dissections were treated by placing multiple stents, 6 were treated by double stent placement and the others were treated by triple and quadruple stent placement. Although immediate complete occlusion was not shown in any cases, the follow-up angiogram revealed complete occlusion in 5 cases (62.5%) within 6-12 months. There were 2 complications (25%, temporary vasospasm during the procedure and acute thrombosis). On the modified Rankin scale applied during follow-up, 6 patients were ssessed as functionally improved or of a stable clinical status, 1 patient expired due to cardiopulmonary complications, and 1 was lost to follow-up). CONCLUSION: Intracranial vertebral artery dissections can be treated by the endovascular method with placing multiple stents and the morbidity is acceptable. However, further study is needed since the treatment of patients presenting with SAH using multiple stent placement can be controversial.

Management of a Complicated Cerebral Aneurysm with Distal Migration of a Detachable Coil: A Case Report / 대한뇌혈관외과학회지

We describe our experience in which the migration of a coil into the parent artery occurred during the coil embolization. A feared complication during coil embolization of cerebral aneurysm is parent artery occlusion by migration of a detachable coil. Obstruction with migration of the coil into the parent artery may be especially hard to solve with an endovascular procedure. The patient had an unruptured internal carotid artery trunk aneurysm where endovascular treatment was performed with detachable coils. One of the packed coils escaped from the sac and migrated into the distal middle cerebral artery (MCA). Cerebral angiography demonstrated non-filling of a number of MCA branches. Repeated attempts at endovascular retrieval of the migrated coil were unsuccessful. Only after an emergent arteriotomy the migrated coil could be successfully removed. Subsequently, endovascular intra-arterial thrombolysis was required to dissolve the thrombus formed postoperatively in the distal MCA. The patient fully recovered with no neurological deficit. In our case a combined surgical and endovascular treatment of coil migration were performed.

Coexisting Dissecting Aneurysms of the Internal Carotid and Basilar Arteries Following Flexion Injury: Case Report / 대한뇌혈관외과학회지

Traumatic or sponataneous arterial dissections have been well recognized at the cervical portion of the internal carotid artery and extracranial vertebral artery as an important cause of stroke, especially in young and middle-aged patients. Multiple arterial dissections following craniocervical injury are exceedingly rare. We describe a patient with brain stem infarction caused by basilar occlusion secondary to basilar artery dissection, associated with left ICA dissecting aneurysm after following minor craniocervical trauma without known underlying arteriopathy.

Characteristics and Surgical Outcomes of Distal Anterior Cerebral Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Distal anterior cerebral artery (dACA) aneurysms are uncommon, and they require special treatment because of the narrow exposure in the interhemispheric fissures, the dense adhesions between the cingulate gyri and their association with multiple aneurysms or traumatic pseudoaneurysm. The aim of this study was to assess the characteristics and surgical outcomes of dACA aneurysms. METHODS: Among the 520 cases of cerebral aneurysms that were operated on from 1997 to April 2007, we experienced 31 cases of dACA aneurysms that developed in 30 patients. The medical records and radiological findings were retrospectively reviewed. RESULTS: The clinical characteristics of the patients with dACA aneurysms included the following. (1) The incidence of the dACA aneurysm was 5.9% of the total 520 cases, and the dACA aneurysms displayed a female predominance. (2) The most common location of the dACA aneurysms was the junction of the pericallosal and callosomarginal arteries. (3) Multiple aneurysms were found in 12 patients (40%), and the most concomitantly found aneurysm was MCA aneurysm. (4) The larger aneurysms more than 10 mm size all had thrombus in the sac, and their angiographic findings were underestimated compared with their findings on the operative fields. (5) dACA aneurysms shows frequent intracerebral hemorrhage (ICH) and subdural hemorrhage on the initial brain CT scan (28.5%). They also had a higher rate of intraoperative rupture (12.9%) than the rupture rate for the aneurysm at other locations (7.9%). (6) Traumatic pseudoaneurysms on the dACA were observed in two cases, and one of these cases showed massive ICH shortly after head trauma. (7) Twenty-six out of 30 patients (86.7%) showed a good outcome with a mortality rate of 3.3%. CONCLUSIONS: The dACA aneurysms are uncommon and they have unique characteristics compared to intracerebral aneurysms at other sites. Especially, a very careful surgical approach must be used for dACA aneurysms because they have a higher rate of intraoperative rupture. Yet the surgical outcome for dACA patients was good for the ruptured or unruptured aneurysm cases in our study. Therefore, dACA aneurysms have to be treated with considering their special characteristics.

Management of Unruptured Intracranial Aneurysms in Patients with Ischemic Cerebrovascular Disease / 대한뇌혈관외과학회지

OBJECTIVE: Unruptured intracranial aneurysms (UIA) accompanied by ischemic cerebrovascular disease (CVD), will be an increasing problem for neurosurgeons in the future, as the population ages. These patients are a high-risk group of treatment. UIA associated with ischemic CVD in seventeen patients were analyzed and their managements are discussed. METHODS: In the past four years, one hundred seventy seven cases of UIAs were treated in our hospital. Among them, seventeen patients suffered from ischemic CVD before treatment of aneurysm. The age of patients varied from 40 to 78 (mean 63.2) years old. The associated ischemic CVD was that transient ischemic attack (TIA) was nine, minor completed stroke in eight patients. There was permanent neurological deficit in two patients. Microsurgical treatment underwent for ten patients and seven patients were treated with endovascular technique. RESULTS: Fourteen patients were fully recovered from surgical and endovascular management. In clipping group, hemiparesis event occurred in one patient after the surgery. The patient suffered from ischemia-related permanent neurological worsening. There were two patients who developed neurological deficit following endovascular treatment for UIA in seven patients of coiling group. One patient was recovered after rehabilitation but the other patient didn't improve left hemiparesis until discharge. This patient had bilateral paraclinoid aneurysms. We treated these lesions simultaneously and coil embolization for the aneurysm was uneventful. However, left side weakness developed after the procedure. Angiography revealed occlusion of cortical branches of middle cerebral artery and MRI scan showed hyperintense areas in the right motor cortex. CONCLUSION: Our results suggest that surgical treatment of unruptured cerebral aneurysm is not contraindicated in patients with CVD. However, the treatment of UIA accompanied by CVD should be performed only after careful examination of the factors involved in the particular ischemic episodes. Careful case selection and perioperative management are mandatory for preventing surgical complications.

Clinical Characteristics and Surgical Treatment of Patients with Distal Middle Cerebral Artery Aneurysms / 대한뇌혈관외과학회지

OBJECTIVE: Middle cerebral artery (MCA) aneurysm is a common source of aneurysmal subarachnoid hemorrhage, but distal MCA aneurysms are rare. This present study was conducted to evaluate the clinical characteristics of the distal MCA aneurysms and the optimal treatment for a good outcome. METHODS: Among 3323 patients underwent aneurysmal surgery from 1975 to 2007, 21 patients with distal MCA aneurysm was identified. The clinical, radiological and operative records of 21 patients with distal MCA aneurysms who underwent surgical management were reviewed retrospectively. The clinical outcomes were evaluated according to the Glasgow Outcome Scale. RESULTS: The clinical analyses of 21 patients with distal MCA aneurysms has following characteristics. (1) Mean aneurysm size of 5.3mm (range 2~8mm). (2) All lesions were considered to be saccular except one case. (3) The location being M2 in one patient, M2-3 junction in 12, M3 in 3, and M4 in 5 patients. (4) In 7 of 21 patients, initial CT scan revealed intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). (5) All patients underwent surgical treatment for aneurysm; the procedures were clipping in 17 patients, trapping in 2 patients, trapping and end-to-end anastomosis in 1 patient, and direct vessel suture in 1 patient. (6) All patients without ICH had a good recovery. However, the patient with ICH had a different prognosis. Of the 7 patients with ICH, 4 patients had a good recovery and 2 patients had a moderate disability. 1 patient died due to severe brain swelling. CONCLUSION: The patients with distal MCA aneurysm were relatively young, and there was no female predominance. The aneurysms have high rates of cardiac problems such as infective endocarditis or mitral valve prolapse, attributing to be developed infectious aneurysm. Ruptured distal MCA aneurysms are rare and can cause life-threatening ICH with SAH. However, the appropriate surgical treatments can obtain a favorable outcome.

Isolated Distal Leg Weakness due to a Small Cerebral Infarction Masquerading as a Spinal Lesion

Acute stroke with isolated monoparesis manifesting as distal weakness of a single lower extremity has rarely been described. We report two patients with small cortical infarction who had distal weakness of a single lower extremity. In both cases, diffusion-weighted image (DWI) was used to detect small lesions in the contralateral cortex. These cases illustrate that small cortical infarction can cause isolated monoparesis limited to distal part of the leg and it may be misdiagnosed as spinal lesions, especially when lower back pain and transient sensory symptoms are accompanied. In case of the abrupt onset of weakness limited to one lower limb, the possibility of stroke should be considered and careful attention to identify cortical lesions using magnetic resonance imaging, especially DWI is required.

Isolated Dissecting Posterior Inferior Cerebellar Artery Aneurysm

Dissecting aneurysms frequently involve the vertebral arteries and their branches, but those involving the posterior inferior cerebellar artery (PICA) and not vertebral artery at all are extremely rare. We present a case of an isolated dissecting aneurysm of the PICA without involvement of vertebral artery. A 54-year-old man presented with dizziness and headache. MR imaging of the brain showed a cerebellar infarction of the left PICA territory. MR angiographic and cerebral angiographic studies revealed a dissecting fusiform aneurysm involving the left proximal PICA. Subsequently, the patient underwent GDC embolization. A postembolization angiogram demonstrated complete obliteration of the aneurysm. In this report, the treatment modalities for this rare condition is described with review of the literature.

Influence of Combined Methionine Synthase (MTR 2756A > G) and Methylenetetrahydrofolate Reductase (MTHFR 677C > T) Polymorphisms to Plasma Homocysteine Levels in Korean Patients with Ischemic Stroke

PURPOSE: Methionine synthase (MTR) and 5,10-methylenetetrahydrofolate reductase (MTHFR) are the main regulatory enzymes for homocysteine metabolism. The present case- control study was conducted to determine whether there is an association between the MTR 2756A > G or MTHFR 677C > T polymorphism and plasma homocysteine concentration in Korean subjects with ischemic stroke. MATERIALS AND METHODS: DNA samples of 237 patients who had an ischemic stroke and 223 age and sex-matched controls were studied. MTR 2756A > G and MTHFR 677C > T genotypes were determined by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). RESULTS: Frequencies of mutant alleles for MTR and MTHFR polymorphisms were not significantly different between the controls and cases. The patient group, however, had significantly higher homocysteine concentrations of the MTR 2756AA and MTHFR 677TT genotypes than the control group (p=0.04 for MTR, p=0.01 for MTHFR). The combined MTR 2756AA and MTHFR 677TT genotype (p= 0.04) and the homocysteine concentrations of the patient group were also higher than those of the controls. In addition, the genotype distribution was significant in the MTHFR 677TT genotype (p=0.008) and combined MTR 2756AA and MTHFR 677TT genotype (p=0.03), which divided the groups into the top 20% and bottom 20% based on their homocysteine levels. CONCLUSION: The results of the present study demonstrate that the MTR 2756A > G and MTHFR 677C > T polymorphisms interact with elevated total homocysteine (tHcy) levels, leading to an increased risk of ischemic stroke.

Navigation-assisted Aspiration and Thrombolysis of Deep Intracerebral Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: Frame-based stereotatic catheter placement and subsequent thrombolysis is one treatment option for the management of a deep intracerebral hemorrhage. Recently, frameless stereotactic surgery with a navigation system has been introduced to reduce the hematoma volume. This study was designed to evaluate the effectiveness of frameless stereotactic ICH catheterization using a navigation system. METHODS: From January 2006 to November 2006, we identified 27 patients who were diagnosed with deep ICH and underwent navigationassisted frameless stereotactic catheter insertion with/without thrombolysis by urokinase irrigation. RESULTS: The mean length between the center of the hematoma and the tip of the catheter was 6.8 mm (range between 0 and 15 mm). The catheter tip and target matched in 8 patients (29.6%). In cases of an inappropriately located catheter tip (70.4%), most of the hematomas were thalamic in location due to the long trajectory (9 of 10 thalamic locations). The preoperative hematoma volume showed a statistically significant correlation with the final hematoma volume. There was no mortality reported. Multiple regression analysis showed a statistically significant correlation between the initial Glasgow coma scale score and the outcome. CONCLUSIONS: Navigation-assisted frameless stereotactic ICH catheterization has limited accuracy but is effective in reducing the ICH volume reduction.

Stent Angioplasty for Intracranial Vertebral Dissections: Single Stent versus Double Stent Placement / 대한뇌혈관외과학회지

OBJECTIVE: The reduced stent porosity caused by a double stent may accelerate the intraaneurysmal thrombosis and be helpful in achieving a more rapid complete occlusion compared with that achieved by single stent placement. This study examined the safety and efficacy of stent angioplasty according to two different stent techniques (single versus double stent placement). METHODS: Twenty two patients who underwent stent angioplasty for vertebral dissections were reviewed retrospectively. RESULTS: In the 22 patients, 23 intracranial vertebral artery dissections were treated using stent placement. Among them, 12 dissections were treated with single stent placement. The immediate and follow-up angiography showed a complete occlusion in only one case(8.3%). Eleven dissections were treated using a double stent method. Although an immediate complete occlusion was performed in only one case, the follow-up angiography revealed a complete occlusion in six cases(54.6%). Complications were encountered in only one case (4.3%, acute thrombosis) in the double stent placement group. On the modified Rankin scale applied in the follow-up, all the patients were assessed as being functionally improved or of a stable clinical status in both groups except for one patient with a severe subarachnoid hemorrhage who underwent a double stent placement. CONCLUSIONS: Intracranial vertebral artery dissections can be treated alternatively using an endovascular method with a stent. Double stent placement is superior to the single stent method. However, there are some limitations and complications associated with stent angioplasty.

Cerebellar Ganglioglioma in an Old Patient

Gangliogliomas could be found anywhere throughout the central nervous system and mainly affect children and young adults during the first three decades of life. Cerebellar gangliogliomas may be rarely found, especially in old ages. Here, we present a case of ganglioglioma of the cerebellum in an old patient. The cystic cerebellar mass was associated with calcifications, intratumoral hemorrhage without ng edema. When a cystic cerebellar mass is associated with calcifications and intratumoral hemorrhage, ganglioglioma should be included in differential diagnosis. Gangliogliomas usually have good prognoses. Radiation therapy should be deferred even in subtotally removed cases.

Progressively Enlarged Intracerebral Ependymal Cyst Presenting with Movement Disorder

Ependymal cysts are neuroepithelial cysts, typically found in the central white matter of the temporoparietal and frontal lobes. Clinical symptoms usually result from neurological deficits referable to these regions, from seizures, and chronic headaches associated with increased intracranial pressure. We describe here a case of ependymal cyst on the right fronto-parietal lobe, presenting with tremor and weakness. The cyst was resected surgically and presurgical neurological abnormalities were improved. An exploratory surgery with establishment of an adequate route of drainage and histological examination of the cyst wall are mandatory in the management of patients with a progressive and symptomatic intraparenchymal cyst.

G-CSF Mobilized Peripheral Blood Human Hematopoietic CD34+ Stem Cells Therapy for Acute Stroke: Preliminary Results / 대한뇌혈관외과학회지

OBJECTIVE: Acute stroke caused by cerebral artery occlusion or rupture is the most important vascular central nervous system disorder in Korea and remains a leading cause of death and disability despite significant clinical benefits after current treatment modalities. Therefore, it is crucial to develop new alternative therapeutic strategies. The most encouraging approach is directed towards cell transplantation into damaged regions. We discuss the ideal candidate for cell transplantation in current status and preliminary results of peripheral blood stem cells transplantation for acute stroke. METHODS: Five patients with acute stroke (three patients with deep intracerebral hemorrhage and two patients with middle cerebral artery occlusion) underwent peripheral blood stem cells transplantation stereotactically. RESULTS: Cell transplantation of three patients did not improve motor function recovery, as evidenced by NIHSS. However, interestingly, cell transplantation significantly increased CSF levels of vascular endothelial growth factor (VEGF). CONCLUSION: Cell transplantation did correlate positively with elevated growth factor levels in CSF, but not with improved motor function.

Stent-Assisted Recanalization for Acute Ischemic Stroke / 대한뇌혈관외과학회지

OBJECTIVE: Acute ischemic stroke attributable to major cerebral arteries occlusion is frequently associated with severe disability or death. Pharmacological or mechanical thrombolysis may achieve better results if the treatment can be performed within 3 hours of stroke onset. If failed thrombolysis, stent-assisted recanalization may improve recanalization rates. METHODS: We reviewed retrospectively 9 patients with acute ischemic stroke resistant to standard thromolytic therapy, who received stent-assisted recanalization from January 2002 to December 2005. Dermographics, clinical, and radiographic presentation and outcomes were studied. RESULTS: Five men and four women with a median baseline National Institutes of Health Stroke Scale (NIHSS) score of 15 (range, 12-20) were included. Five lesions were located in the extracranial internal carotid artery, two in the middle cerebral artery, one in the common carotid artery, and one in the mid-basilar artery. Mean time to treatment was 9.8+/-14.6 hours from symptom onset. All occlusions were successfully recanalized with thrombolysis and stent placement, and the stenotic ratio was reduced from 91% (pre-stenting) to 5% (post-stenting) on average. Procedure-related complications occurred in two patients (22%): distal embolism in one and subacute thrombotic occlusion in the other. NIHSS score at discharge showed significant improvement (P<0.05, Wilcoxon rank sum test). CONCLUSION: Emergency stent angioplasty for acute ischemic stroke with failed thrombolysis appears to have a high recanalization rate and to improve outcome in our retrospective study. This study reveals that emergency stent angioplasty could be considered as an optimal treatment for recalcitrant arterial occlusions.

Diffusion Tensor Magnetic Resonance Imaging as a Prognostic Indicator in the Deep Intracerebral Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: Diffusion tensor MR imaging (DTI) provides a means to visualize the course of the corticospinal tract within the white matter. The purpose of this study was to investigate the corticospinal tract in patients with deep intracerebral hemorrhage (ICH) involving the posterior limb of the internal capsule, to correlate with the motor impairment of the extremities, and to predict with motor improvement after stereotactic evacuation of the ICH. METHODS: Ten patients with deep intracerebral hemorrhage (ICH) on the basal ganglia or thalamic region were included to this study. All patients underwent the stereotactic catheter insertion. The DTI was obtained within 5 days after the hemorrhagic attack, focusing on the posterior limb of the internal capsule (PIC). The patients were evaluated using the motor grading system (grade 0 to 5) initially and 2 months later. The Mann-Whitney U test was used for the statistical analysis. RESULTS: The motor scales improved only in the patients with the partially or non-involved PIC. The p value was 0.007 for upper extremities and 0.008 for lower extremities. In patients with the totally preserved PIC, follow-up motor scales improved in comparison with the preoperative state. In patients with the partially preserved PIC, follow-up motor scales improved according to the hierarchical organization principles. CONCLUSION: The DTI can show the degree and locations of the involvement by the hemorrhages to PIC and the DTI may be used as a good indicator to the motor function outcome in the patients with hemorrhagic stroke at basal ganglia or thalamic region.

Recombinant Factor VIIa Treatment for Acute Intracerebral Hemorrhage / 대한뇌혈관외과학회지

Intracerebral hemorrhage is a lethal stroke type with a high morbidity and mortality. Hematoma growth is one of the independent determinants of neurological and functional outcomes after intracerebral hemorrhage. Attenuation of growth is an important therapeutic strategy. Hemostatic therapeutic intervention, given ultra-early in the course of intracerebral hemorrhage, may thus improve clinical outcomes by arresting ongoing bleeding and limiting in turn the size of the hematoma. Recombinant factor VIIa is a hemostatic drug approved to treat bleeding in hemophilia or other coagulopathy; it has also been reported to arrest bleeding in nonhemophilic cases. We reviewed of the published articles specifically addressing clinical trials of recombinant factor VIIa treatment for acute intracerebral hemorrhage and evaluate the safety and feasibility of it.