Treatment for subarachnoid hemorrhage due to ruptured posterior cerebral arterial dolichoectasia with aortic arch anomaly

Subarachnoid hemorrhage (SAH) due to ruptured posterior cerebral artery (PCA) intracranial arterial dolichoectasia (IADE) is very rare. As these lesions are difficult to treat microsurgically, neurointervention is preferred because the dolichoectatic artery does not have a clear neck, and the surgical field of view was deep seated with the SAH. However, in some cases, neurointervention is difficult due to anatomical variation of the blood vessel to access the lesion. In this case, a 30-year-old male patient presented with a ruptured PCA IADE and an aortic arch anomaly. Aortic arch anomalies render it difficult to reach the ruptured PCA IADE via endovascular treatment. The orifice of the vertebral artery (VA) was different from the usual cases, so it was difficult to find the entrance. After only finding the VA and arriving at the lesion along the VA, trapping was performed. Herein, we report the PCA IADE with aortic arch anomaly endovascular treatment methods and results.

Characteristics of patients with ruptured very small intracranial aneurysm sized less than 3 mm

Objective@#If the size of an intracranial aneurysm is below 3 mm, clinicians rarely treat them because of the low risk of rupture. But subarachnoid hemorrhage (SAH) due to the rupture of very small intracranial aneurysm (VSIA) (saccular aneurysm sized less than 3 mm) may lead to many critical neurological complications. So we analyzed the characteristics and differences between the ruptured VSIA group and the ruptured non-VSIA group. @*Methods@#421 saccular aneurysms from patients with SAH between January 2016 and December 2019 were included. Patient information including age, sex, and medical history and information about the aneurysm including location, size, aspect ratio, inflow angle, and height-width ratio were collected. And we compared the VSIA group with non-VSIA group about these characteristics @*Results@#12.1% (51/421) of the aneurysms were included in the VSIA group, while the non-VSIA group consisted of 87.9% of the aneurysms (370/421). The female predominance was significantly higher in the VSIA group than that in the non-VSIA group (p=0.011). No significant difference was observed in location, medical history, height-width ratio between the groups. The mean value of the inflow angle in the VSIA group was much lower than that in the non-VSIA group, but no statistically significant association between rupture risk and the inflow angle was observed. The average aspect ratio was significantly lower than that in the non-VSIA group. @*Conclusions@#Ruptured VSIA group has higher percentage of females and lower aspect ratio than ruptured non-VSIA group. Further studies regarding the characteristics of ruptured and unruptured VSIA patients is required for assistance in clinical decision related to treatment of VSIA group before the aneurysmal sac rupture.

Characteristics of patients with ruptured very small intracranial aneurysm sized less than 3 mm

Objective@#If the size of an intracranial aneurysm is below 3 mm, clinicians rarely treat them because of the low risk of rupture. But subarachnoid hemorrhage (SAH) due to the rupture of very small intracranial aneurysm (VSIA) (saccular aneurysm sized less than 3 mm) may lead to many critical neurological complications. So we analyzed the characteristics and differences between the ruptured VSIA group and the ruptured non-VSIA group. @*Methods@#421 saccular aneurysms from patients with SAH between January 2016 and December 2019 were included. Patient information including age, sex, and medical history and information about the aneurysm including location, size, aspect ratio, inflow angle, and height-width ratio were collected. And we compared the VSIA group with non-VSIA group about these characteristics @*Results@#12.1% (51/421) of the aneurysms were included in the VSIA group, while the non-VSIA group consisted of 87.9% of the aneurysms (370/421). The female predominance was significantly higher in the VSIA group than that in the non-VSIA group (p=0.011). No significant difference was observed in location, medical history, height-width ratio between the groups. The mean value of the inflow angle in the VSIA group was much lower than that in the non-VSIA group, but no statistically significant association between rupture risk and the inflow angle was observed. The average aspect ratio was significantly lower than that in the non-VSIA group. @*Conclusions@#Ruptured VSIA group has higher percentage of females and lower aspect ratio than ruptured non-VSIA group. Further studies regarding the characteristics of ruptured and unruptured VSIA patients is required for assistance in clinical decision related to treatment of VSIA group before the aneurysmal sac rupture.

Effects of Head Lift Exercise on Oropharyngeal Swallowing Function and Dropout Rate According to Reclining Angle in Patients with Dysphagia after Stroke: A Randomized Trial / 대한연하장애학회지

Objective@#Although the effects of head lift exercise (HLE) in the reclining position have been reported, there is insufficient clinical evidence of the effects. This study compared the effects of HLE in the 0° supine position and 45° reclining position on the swallowing function and the compliance of patients with dysphagia after stroke after both exercises. @*Methods@#This was a randomized, assessor-blinded clinical trial. Thirty-five patients with stroke and dysphagia were assigned randomly to HLE in the 0° supine group (n=18) or HLE in the 45° reclining group (n=17). Patients in both groups performed HLE five days a week for four weeks and received the same conventional dysphagia therapy. The videofluoroscopic dy sphagia scale (VDS) was used to evaluate the swallowing function. The dropout rate and subjective feedback related to compliance with the two exercises were monitored. @*Results@#No significant differences in the baseline characteristics were observed between the two groups. Patients in both groups showed significant improvement in the oral and pharyngeal phases of VDS (P＜0.05). After the intervention, no significant differences were observed between the groups (P＞0.05). Dropout rates of 22% and 6% owing to neck discomfort or fatigue were observed in the HLE in 0° supine group and the HLE in 45° reclining group, respectively. @*Conclusion@#HLE in the 45° reclining position has a similar effect on the swallowing function in patients with dysphagia after stroke to that of HLE in the 0° supine position and is associated with better exercise compliance.

Efficacy of dual antiplatelet therapy as premedication before diagnostic cerebral digital subtraction angiography

OBJECTIVE: Several studies have reported that periprocedural dual antiplatelet therapy lowers the incidence of thromboembolic complications (TEC) associated with coiling of unruptured aneurysms. We hypothesized that preprocedural administration of dual antiplatelet agents (aspirin and cilostazol) for 7days may reduce the risk of complications associated with diagnostic cerebral digital subtraction angiography (DSA).METHODS: We retrospectively reviewed the records of patients who underwent diagnostic cerebral DSA between September 2015 and April 2018. Of the 419 patients included (149 men, 270 women, mean age 58.5 years), 221 (72 men, 149 women, mean age 57.8 years) who underwent cerebral DSA between September 2015 and June 2016 were not premedicated with antiplatelet therapy. The remaining 198 (77 men, 121 women, mean age 59.4 years) who underwent cerebral DSA between July 2016 and April 2018 were premedicated with dual antiplatelet therapy (aspirin and cilostazol). We defined ischemic stroke as a cerebral DSA-induced complication identified on magnetic resonance imaging (MRI) among patients with neurological symptoms.RESULTS: Of the 221 patients who did not receive antiplatelet therapy, 210 (95.0%) showed no neurological symptoms; however, 11 (5.0%) developed neurological symptoms with MRI-proven ischemic stroke, which represents a TEC. Of the 198 patients who received dual antiplatelet therapy, 196 patients (99.0%) showed no evidence of TEC. The remaining 2 (1.0%) developed diplopia and motor weakness each, and MRI confirmed acute ischemic stroke (p=0.019).CONCLUSIONS: The use of dual antiplatelet agents (aspirin and cilostazol) for 7 days before DSA may reduce the risk of cerebral DSA-induced TEC.

Antiepileptic and anti-neuroinflammatory effects of red ginseng in an intrahippocampal kainic acid model of temporal lobe epilepsy demonstrated by electroencephalography / 영남의대학술지

BACKGROUND@#Chronic inflammation can lower the seizure threshold and have influence on epileptogenesis. The components of red ginseng (RG) have anti-inflammatory effects. The abundance of peripherally derived immune cells in resected epileptic tissue suggests that the immune system is a potential target for anti-epileptogenic therapies. The present study used continuous electroencephalography (EEG) to evaluate the therapeutic efficacy of RG in intrahippocampal kainic acid (IHKA) animal model of temporal lobe epilepsy.@*METHODS@#Prolonged status epilepticus (SE) was induced in 7-week-old C57BL/6J mice via stereotaxic injection of kainic acid (KA, 150 nL; 1 mg/mL) into the right CA3/dorsal hippocampus. The animals were implanted electrodes and monitored for spontaneous seizures. Following the IHKA injections, one group received treatments of RG (250 mg/kg/day) for 4 weeks (RG group, n=7) while another group received valproic acid (VPA, 30 mg/kg/day) (VPA group, n=7). Laboratory findings and pathological results were assessed at D29 and continuous (24 h/week) EEG monitoring was used to evaluate high-voltage sharp waves on D7, D14, D21, and D28.@*RESULTS@#At D29, there were no differences between the groups in liver function test but RG group had higher blood urea nitrogen levels. Immunohistochemistry analyses revealed that RG reduced the infiltration of immune cells into the brain and EEG analyses showed that it had anticonvulsant effects.@*CONCLUSION@#Repeated treatments with RG after IHKA-induced SE decreased immune cell infiltration into the brain and resulted in a marked decrease in electrographic seizures. RG had anticonvulsant effects that were similar to those of VPA without serious side effects.

Technical Consideration for Coiling of Ruptured Proximal Posterior Inferior Cerebellar Artery Aneurysm

OBJECTIVE: Surgical obliteration of ruptured aneurysm of the proximal posterior inferior cerebellar artery (PICA) is challenging because of limited surgical accessibility. In recent years, coil embolization is the first-choice treatment for these lesions. However, coil embolization is not always easy in ruptured PICA aneurysm owing to the variable anatomical diversity of its shapes, its relationship to the parent artery, its low incidence, and accordingly, lesser neurointerventionist experience.METHODS: The parent artery and microcatheter for easier navigation and the embolization technique for stable coiling were identified.RESULTS: This study aimed to identify the more appropriate approach route, microcatheter, and strategies for an easier and safer, and more durable coil embolization in the treatment of lesions in the proximal PICA.CONCLUSION: Coil embolization for aneurysmal subarachnoid hemorrhage due to a ruptured proximal PICA remains a challenge, but with the appropriate coiling plan, it can be treated successfully.

Evaluation of the Accuracy in Maximum Intensity Projection Images of Cerebral Computed Tomographic Angiography for the Diagnosis of Cerebral Vasospasm Following Subarachnoid Hemorrhage, in Comparison to Digital Subtraction Angiography

OBJECTIVE: The purpose of this retrospective study is to determine the accuracy of maximum intensity projection (MIP) images of computed tomographic angiography (CTA) for diagnosis of cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) compared with that of digital subtraction angiography (DSA). MATERIALS AND METHODS: For patients admitted to our hospital for SAH, MIP images of CTA and DSA were checked at admission, and images were taken again 1 week later. This protocol was used in 39 cases. MIP images of CTA and DSA examinations were reviewed by two independent readers. RESULTS: Accuracy of MIP images of CTA in various arterial segments, using DSA as the gold standard: the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for different segments varied from 84 to 97, 33–100, 84–100%, 25–85, and 79–97%, respectively, for readers. Accuracy of CTA in various vasospasm severity, using DSA as the gold standard: the sensitivity, specificity, PPV, NPV, and accuracy for different vasospasm severity varied from 44 to 100, 69–100, 36–100%, 61–100, and 88–100%, respectively, for readers. Accuracy of CTA in central segments versus peripheral segments, using DSA as the gold standard: the sensitivity, specificity, PPV, NPV, and accuracy for central segments and peripheral segments varied from 90 to 94, 68–83, 93–97%, 56–69, and 87–93%, respectively, for readers. CONCLUSION: MIP imaging of CTA is a useful modality when diagnosing CV after SAH.

A Pseudoaneurysm Associated with a Ruptured Cerebral Aneurysm: Hypothesis on the Formation of the PA and Feasibility of Endovascular Treatment

An intracranial pseudoaneurysm (PA) is a very rare disease and is known to occur in less than 1% of intracranial aneurysms. The pathophysiology and the modality of the proper treatment of PA have not yet been clearly established. We report a case of PA associated with ruptured cerebral aneurysms which was successfully treated by coil embolization, and also discuss the possible hypothesis on the formation of the PA and feasibility of endovascular treatments.

Technical Consideration for Coiling of Ruptured Proximal Posterior Inferior Cerebellar Artery Aneurysm

OBJECTIVE: Surgical obliteration of ruptured aneurysm of the proximal posterior inferior cerebellar artery (PICA) is challenging because of limited surgical accessibility. In recent years, coil embolization is the first-choice treatment for these lesions. However, coil embolization is not always easy in ruptured PICA aneurysm owing to the variable anatomical diversity of its shapes, its relationship to the parent artery, its low incidence, and accordingly, lesser neurointerventionist experience. METHODS: The parent artery and microcatheter for easier navigation and the embolization technique for stable coiling were identified. RESULTS: This study aimed to identify the more appropriate approach route, microcatheter, and strategies for an easier and safer, and more durable coil embolization in the treatment of lesions in the proximal PICA. CONCLUSION: Coil embolization for aneurysmal subarachnoid hemorrhage due to a ruptured proximal PICA remains a challenge, but with the appropriate coiling plan, it can be treated successfully.

Antiepileptic and anti-neuroinflammatory effects of red ginseng in an intrahippocampal kainic acid model of temporal lobe epilepsy demonstrated by electroencephalography / 영남의대학술지

BACKGROUND: Chronic inflammation can lower the seizure threshold and have influence on epileptogenesis. The components of red ginseng (RG) have anti-inflammatory effects. The abundance of peripherally derived immune cells in resected epileptic tissue suggests that the immune system is a potential target for anti-epileptogenic therapies. The present study used continuous electroencephalography (EEG) to evaluate the therapeutic efficacy of RG in intrahippocampal kainic acid (IHKA) animal model of temporal lobe epilepsy.METHODS: Prolonged status epilepticus (SE) was induced in 7-week-old C57BL/6J mice via stereotaxic injection of kainic acid (KA, 150 nL; 1 mg/mL) into the right CA3/dorsal hippocampus. The animals were implanted electrodes and monitored for spontaneous seizures. Following the IHKA injections, one group received treatments of RG (250 mg/kg/day) for 4 weeks (RG group, n=7) while another group received valproic acid (VPA, 30 mg/kg/day) (VPA group, n=7). Laboratory findings and pathological results were assessed at D29 and continuous (24 h/week) EEG monitoring was used to evaluate high-voltage sharp waves on D7, D14, D21, and D28.RESULTS: At D29, there were no differences between the groups in liver function test but RG group had higher blood urea nitrogen levels. Immunohistochemistry analyses revealed that RG reduced the infiltration of immune cells into the brain and EEG analyses showed that it had anticonvulsant effects.CONCLUSION: Repeated treatments with RG after IHKA-induced SE decreased immune cell infiltration into the brain and resulted in a marked decrease in electrographic seizures. RG had anticonvulsant effects that were similar to those of VPA without serious side effects.

Simultaneous Onset of Ischemic and Hemorrhagic Stroke Due To Intracranial Artery Dissection

Intracranial dissections commonly present as ischemic stroke and as hemorrhagic stroke. In general, while either ischemic stroke or hemorrhagic stroke may develop, the simultaneous onset of both may also occasionally occur. In this report, we present a case of simultaneous development of ischemic stroke and hemorrhagic stroke due to an intracranial artery dissection.

Fluoroscopy-guided Combined (Surgical/Endovascular) Treatment of Dural Arteriovenous Fistula

For dural arteriovenous fistula (DAVF), when the usual endovascular or neurosurgical approaches are difficult to treat, multi-modal treatment can be helpful. We present a case of a 71-year-old woman with DAVF, who presented with an intracerebral haemorrhage. Digital subtraction angiography revealed a DAVF of the transverse sinus, with cortical venous reflux. Transvenous and transarterial approaches for coil embolization failed. In the operating room, a small craniotomy was performed, and coil embolization was done under fluoroscopy. Transcranial venous embolization might be a useful method to occlude DAVF in a case that is difficult to access by usual surgical or endovascular approaches.

Efficacy of Pre-procedural Rehydration against Thromboembolic Complications for Ruptured Aneurysm Embolization

OBJECTIVE: To report effects of the pre-procedural rehydration for reduce thromboembolic complications in acute phase aneurysmal subarachnoid hemorrhage coil embolization. MATERIALS AND METHODS: From January 2009 to December 2013, 190 patients with ruptured aneurysmal subarachnoid hemorrhage (aSAH) treated by coil embolization at our institution were consecutively enrolled in this study. In period 1 (from January 2009 to June 2012, n = 122), pre-procedural fluid was not supplied. In period 2 (from July 2012 to December 2013, n = 68), depending on the state of the patient's body weight and degree of dehydration, intravenous fluid was started with infusion of approximately 7 mL/kg of 0.9 percent saline (minimum 300 to maximum 500 mL) over 30 minutes. RESULTS: A total of 190 patients were hospitalized due to aSAH and underwent coil embolization for five years between January 2009 and December 2013. Of these, 122 patients underwent coil embolization based on the old protocol before June 2012 (period 1) and 68 underwent the procedure based on the new protocol after the period 2. Neck size, width, maximum diameter of the aneurysm and procedure time were associated with procedure related thromboembolic complications in entire periods (multivariate analysis, p < 0.05, in respectively). The frequency of thromboembolism showed a drastic decrease in period 2 (re-hydration period), from 18.0% (22/123) to 4.4% (3/67), which was also statistically significant (p = 0.007, Chi-square test). CONCLUSION: Pre-procedural administration of a sufficient dose of fluid considering the patient's dehydration reduced the frequency of thromboembolism in cases of emergency coil embolization for ruptured aneurysm, without increasing additional specific complications.

Procedure-related Complication Rate for the Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage under Local Anesthesia

OBJECTIVE: To report the procedure related complication rate of endovascular treatments (EVTs) performed on patients with aneurysmal subarachnoid hemorrhage (aSAH) under local anesthesia (LA). MATERIALS AND METHODS: This study enrolled 186 patients who underwent EVT for ruptured aneurysm under LA from January 2009 to December 2013. Procedure-related complications rate and factors associated with it were analyzed depending on the patients' factors, aneurysm factors and physician factors. RESULTS: Among the 186 patients who underwent EVT under LA, the respective rates of thromboembolic complication (TEC) and intraoperative rupture (IOR) were 12.8% (23 cases) and 12.9% (24 cases), respectively. Aneurysm size (≥ 7 mm) was the only risk factor for TEC (p = 0.048). CONCLUSION: Compared to previous result with under general anesthesia (GA), the rate of TEC was similar in patients treated under LA, but the IOR rate was significantly higher. The main reason for increasing IOR is considered as the unexpected patients' motion and in accordance with the unexpected movement of the microinstruments. Therefore, another methods to stabilize the patients or switching from LA to GA may be necessary when performing EVT, to reduce complications.

Superficial Temporal Artery Pseudoaneurysm Treated with Manual Compression Alone

Traumatic pseudoaneurysm of the superficial temporal artery (STA) is an uncommon lesion and resection of the lesion is the treatment of choice. Three patients with traumatic pseudoaneurysm of the STA treated with only manual compression of the lesions were examined for this study. We report on an effective and safe minimally invasive technique for treatment of traumatic pseudoaneurysm of the STA.

Toxicity of antioxidative extract collected from Styela clava tunics in ICR mice / 한국실험동물학회지

Some polymers and bioactive compounds derived from Styela clava tunic (SCT) have been reported as traditional medicine for the treatment of inflammation, oxidative stress and surgical wounds although there is little scientific evidence of their liver and kidney toxicity. To investigate the toxicity of ethanol extracts of SCT (EtSCT) in the liver and kidney of ICR mice, alterations in related markers including body weight, organ weight, urine composition, liver pathology and kidney pathology were analyzed following oral administration of 50 and 100 mg/kg body weight/day of EtSCT for 14 days. EtSCT showed a high level of free radical scavenging activity for DPPH (93.1%) and NO (16.2%) as well as the presence of 14.8 mg/mL of flavonoids and 36.2 mg/mL of phenolics, while EtSCT treated groups did not show any significant alterations in the body and organ weight, clinical phenotypes, urine parameters or mice mortality when compared with the vehicle treated group. In addition, constant levels of serum biochemical markers including alanine phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), blood urea nitrogen (BUN) and serum creatinine (CRE) were maintained. Moreover, no specific histopathological features induced by most toxic compounds were observed in liver and kidney sections stained with hematoxilin and eosin. Therefore, the present results indicate that EtSCT with strong antioxidant activity cannot induce any specific toxicity in liver and kidney organs of ICR at doses of 100 mg/kg body weight/day.

Delayed Traumatic Diaphragm Hernia after Thoracolumbar Fracture in a Patient with Ankylosing Spondylitis

Traumatic diaphragm hernia can occur in rare cases and generally accompanies thoracic or abdominal injuries. When suffering from ankylosing spondylitis, a small force can develop into vertebral fracture and an adjacent structural injury, and lead to diaphragm hernia without accompanying concomitant thoracoabdominal injury. A high level of suspicion may be a most reliable diagnostic tool in the detection of a diaphragm injury, and we need to keep in mind a possibility in a patient with ankylosing spondylitis and a thoracolumbar fracture, even in the case of minor trauma.

Endovascular Treatment of a Ruptured Posterior Inferior Cerebellar Artery Aneurysm during Pregnancy

Aneurysmal subarachnoid hemorrhage (SAH) during pregnancy is quite rare, however it has a high maternal mortality rate. A pregnant woman in the 16th gestational week was admitted to our hospital with a drowsy level of consciousness. A brain magnetic resonance (MR) image showed hemorrhage on the prepontine cistern, and both sylvian fissures, and MR angiography and cerebral digital subtraction angiography demonstrated an aneurysm at the left posterior inferior cerebellar artery (PICA). We performed endovascular coil embolization attempting to minimize radiation exposure. She was discharged with no neurologic deficit and delivered a healthy baby by cesarean section at the 38th week of gestation. This case study reported the shortest gestational period and this is the first report on an aneurysmal rupture arising from PICA which was treated using an endovascular method. Using an appropriate technique for reduced radiation exposure to the fetus and limited alterations in maternal-fetal physiology, endovascular coil embolization could guarantee good results in treatment of aneurysmal SAH in pregnant women.

Mortality and Real Cause of Death from the Nonlesional Intracerebral Hemorrhage

OBJECTIVE: The case fatality rate of nonlesional intracerebral hemorrhage (n-ICH) was high and not changed. Knowing the causes is important to their prevention; however, the reasons have not been studied. The aims of this study were to determine the cause of death, to improve the clinical outcomes. METHODS: We retrospectively analyzed consecutive cases of nonlesional intracerebral hemorrhage in a prospective stroke registry from January 2010 to December 2010. RESULTS: Among 174 patients (61.83+/-13.36, 28-90 years), 29 patients (16.7%) died during hospitalization. Most common cause of death was initial neurological damage (41.4%, 12/29). Seventeen patients who survived the initial damage may then develop various potentially fatal complications. Except for death due to the initial neurological sequelae, death associated with immobilization (such as pneumonia or thromboembolic complication) was the most common in eight cases (8/17, 47.1%). However, death due to early rebleeding was not common and occurred in only 2 cases (2/17, 11.8%). Age, initial Glasgow Coma Scale, and diabetes mellitus were statistically significant factors influencing mortality (p<0.05). CONCLUSION: Mortality of n-ICH is still high. Initial neurological damage is the most important factor; however, non-neurological medical complications are a large part of case fatality. Most cases of death of patients who survived from the first bleeding were due to complications of immobilization. These findings have implications for clinical practice and planning of clinical trials. In addition, future conduct of a randomized study will be necessary in order to evaluate the benefits of early mobilization for prevention of immobilization related complications.