Initial misdiagnosis of aneurysmal subarachnoid hemorrhage: associating factors and its prognosis.

BACKGROUND: Predicting the fate of patients who are given a misdiagnosis of aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. The purpose was to examine factors associated with initial misdiagnosis of aSAH and to investigate the impact of initial misdiagnosis of aSAH on clinical outcomes. METHODS: Between January 2007 and December 2015, medical records and radiographic data for 3118 consecutive patients with aSAH were reviewed. There were 33 patients who had been documented with an initial misdiagnosis of aSAH, and all met the following criteria: (1) failure to correctly identify aSAH upon initial presentation to health care professionals; and 2) subsequently documented aSAH after the initial misdiagnosis. After applying exclusion criteria, remaining 2898 patients were included in the control group. RESULTS: The most common cause of the misdiagnosis is failure to detect aSAH on the initial radiographic imaging. Misdiagnosis group showed lower initial Glasgow Coma Scale, better Hunt-Hess grade, and lower Fisher's grade. Logistic regression analysis showed that initial HH grade (OR, 0.216; p = 0.014), initial Fisher's grade (OR, 0.732; p = 0.036), and hospital type during initial contact (OR, 2.266; p = 0.042) were independently associated with misdiagnosis of aSAH. CONCLUSIONS: Patients with initially good HH grade, lower Fisher's grade, and visiting non-teaching hospital for initial contact were at risk of being misdiagnosed. Misdiagnosis of aSAH in patients with initial good HH grade did affect clinical outcomes negatively. The rebleeding rate was not significantly different between two groups. However, the mortality rate due to rebleeding was higher in MisDx group than in non-MisDx group.

The course of headache in patients with moderate-to-severe headache due to mild traumatic brain injury: a retrospective cross-sectional study.

BACKGROUND: Little is known about the long-term course of headache in patients with moderate-to-severe headache due to traumatic brain injury (TBI). We evaluated the course of headache in patients with moderate-to-severe headache due to mild TBI. METHODS: Since September 2009, patients with TBI prospectively rated their headache using a numeric rating scale (NRS). From the database containing 935 patients with TBI between September 2009 and December 2013, 259 patients were included according to following criteria: (1) newly onset moderate-to-severe headache (NRS ≥ 4) due to head trauma; (2) age ≥ 15 years; (3) Glasgow Coma Scale ≥ 13; (4) transient loss of consciousness ≤ 30 min; and (5) radiographic evaluation, such as computed tomography or magnetic resonance image. We evaluated initial and follow-up NRS scores to determine the significance of NRS changes and identified risk factors for moderate-to-severe headache at 36-month follow-up. RESULTS: At 36-month follow-up, 225 patients (86.9%) reported improved headache (NRS ≤ 3) while 34 (13.1%) reported no improvement. The NRS scores were significantly decreased within a month (P < 0.001). The follow-up NRS scores at 12-, 24-, and 36-months were lower than those at one month (P < 0.001). Multiple logistic regression analysis showed that post-traumatic seizure (odds ratio, 2.162; 95% CI, 1.095-6.542; P = 0.041) and traumatic intracranial hemorrhage (odds ratio, 2.854; 95% CI, 1.241-10.372; P = 0.024) were independent risk factors for moderate-to-severe headache at 36-month follow-up. CONCLUSIONS: The course of headache in patients with mild TBI continuously improved until 36-month follow-up. However, 13.1% of patients still suffered from moderate-to-severe headache at 36-month follow-up, for whom post-traumatic seizure and traumatic intracranial hemorrhage might be risk factors.

Post-traumatic headache in patients with minimal traumatic intracranial hemorrhage after traumatic brain injury: a retrospective matched case-control study.

BACKGROUND: No evidence is available on the risks of neurologically asymptomatic minimal traumatic intracranial hemorrhage (mTIH) in patients with traumatic brain injury (TBI) for post-traumatic headache (PTH). The purpose of this study was to investigate whether mTIH in patients with TBI was associated with PTH and to evaluate its risk factors. METHODS: Between September 2009 and December 2014, 1484 patients with TBI were treated at our institution, 57 of whom had mTIH after TBI and were include in this study. We performed propensity score matching to establish a control group among the 823 patients with TBI treated during the same period. Patients with TBI rated their headaches prospectively using a numeric rating scale (NRS). We compared NRS scores between mTIH group (n = 57) and non-mTIH group (n = 57) and evaluated risk factors of moderate-to-severe PTH (NRS ≥ 4) at the 12-month follow-up. RESULTS: Moderate-to-severe PTH was reported by 21.9% of patients (29.8% in mTIH group and 14.0% in non-mTIH group B, p = 0.012) at the 12-month follow-up. The mean NRS was higher in mTIH group than in non-mTIH group throughout the follow-up period (95% confidence interval [CI], 0.11 to 1.14; p < 0.05, ANCOVA). Logistic regression analysis showed that post-traumatic seizure (odds ratio, 1.520; 95% CI, 1.128-6.785; p = 0.047) and mTIH (odds ratio, 2.194; 95% CI, 1.285-8.475; p = 0.039) were independently associated with moderate-to-severe PTH at the 12-month follow-up. CONCLUSIONS: Moderate-to-severe PTH can be expected after TBI in patients with mTIH and post-traumatic seizure. PTH occurs more frequently in patients with mTIH than in those without mTIH.

Three-year follow-up of blood pressure after treating hypertensive patients with symptomatic carotid artery stenosis.

BACKGROUND: Blood pressure (BP) was reported to decrease significantly after carotid endarterectomy (CEA) or carotid stenting (CAS) up to the 1-year follow-up. We evaluated changes in BP for 3 years after treating hypertensive patients with symptomatic carotid artery stenosis by either CEA or CAS and determined predisposing factors for normotensive BP at the 3-year follow-up. METHODS: A total of 123 hypertensive patients with at least 3 years of clinical and radiographic follow-up after treatment were included in this study and placed in the CEA (n = 65) or CAS group (n = 58). BP changes for 3 years, the number of patients with a normotensive BP (≤120/80 mmHg), and the percentage decrease in BP were evaluated and compared between groups. RESULTS: Compared to pretreatment BP, the CEA group had significantly decreased BP at the 1- and 2-year follow-up (p < 0.05), but not the 3-year follow-up. The CAS group had significantly decreased BP at the 1-, 2-, and 3-year follow-up (p < 0.05). Stenosis location (body lesions over apical lesions; OR = 1.526, 95 % CI, 1.341 to 6.224; p = 0.034) was an independent predisposing factor for normotensive BP at the 3-year follow-up. CONCLUSIONS: For hypertensive patients with symptomatic carotid artery stenosis, BP was lowered at 3 years after both CEA and CAS compared to pretreatment BP. CAS might lower BP better over the long term than did CEA, and hypertensive patients with stenosis at body lesions might be normotensive at 3 years after CEA or CAS.

The Course of Headache in Patients With Moderate-to-Severe Headache Due to Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cross-Sectional Study.

OBJECTIVES: The purpose of this study was to evaluate the course of headache in patients with moderate-to-severe headache due to aneurysmal subarachnoid hemorrhage (aSAH) and to identify its predisposing factors. BACKGROUND: Little is known about the long-term course of headache in patients with aSAH. METHODS: Since September 2009, patients with aSAH have had their headaches prospectively rated using a numeric rating scale (NRS). From this database containing 838 patients, 217 were included and all included patients met the following criteria: (1) presence of ruptured intracranial aneurysms on computed tomography angiography or magnetic resonance angiography; (2) alert consciousness (Glasgow Coma Scale 15); (3) newly onset moderate-to-severe headache (NRS ≥ 4) due to ruptured intracranial aneurysms; and (4) good clinical outcome at discharge (modified Rankin Scale 0, 1, or 2). We observed the changes in NRS scores from initial to 12-month follow-up and identified the predisposing factors of NRS changes. RESULTS: Of the 217 patients, 182 (83.9%) experienced improvement in NRS score ≤ 3 upon discharge. The NRS scores at discharge were significantly lower than those on admission (P < .001). The independent predisposing factors for headache improvement included previous stroke (odds ratio [OR] = 0.141; 95% CI 0.051-0.381; P < .001), previous headache treated with medication (OR = 0.079; 95% CI 0.010-0.518; P = .008), and endovascular treatment (EVT; OR = 2.531; 95% CI 1.141-5.912; P = .026). The NRS scores tended to decrease continuously until the 12-month follow-up. EVT and symptomatic vasospasm were independently associated with a decrease of NRS in the follow-up periods. CONCLUSIONS: The course of headache in patients with aSAH continuously improved during the 12 months of follow-up. Headache improvement might be expected in patients who were treated with EVT and in those who did not have previous stroke or headache.

Coil Embolization of Traumatic Ophthalmic Artery Aneurysm: Case Report.

We describe the case of a 57-year-old man who had traumatic subarachnoid hemorrhage (SAH) with a delayed growth of an ophthalmic artery aneurysm. Initially, computed tomography angiography did not show any evidence of aneurysmal dilatation, but digital subtraction angiography (DSA) after 3 days showed small aneurysmal dilatation or dissection of a presumed lesion. Early intervention or surgery was difficult because of the patient's unstable condition. The SAH was completely resolved within 7 days. Follow-up DSA was performed 2 weeks later and it revealed an increasing size and shape change. We treated the patient with coil embolization, partially filling the aneurysm to save the ophthalmic artery. DSA performed 6 months later indicated that the aneurysm was completely embolized, sparing the ophthalmic artery. In traumatic SAH, delayed growth of the aneurysm should always be considered, and follow-up imaging should be performed. Partial embolization to save the ophthalmic artery can be one of the treatment modalities for selected patients.

Incidentally Detected Intracranial Sewing Needle in an Adult: Case Report.

The author presents a 48-year-old man who showed an intracranial sewing needle incidentally detected on a skull radiograph. He had no history of cranial surgery or a penetrating head injury. On radiography, the sewing needle was found to be located close to the frontal bone in the midline, with a trajectory to the right anterior skull base. Computed tomography angiography revealed that the needle head was located at an approximately 3.57 mm depth from the inner table and attached to the cortical vein. The distal end of the needle was surrounded by the right distal pericallosal artery. No cortical injury or vascular injury was observed. The needle may have penetrated during the early period before the closure of the anterior fontanelle.

The effect of hematoma evacuation with decompressive craniectomy on clinical outcomes in patients with parenchymal hematoma type 2 of hemorrhagic transformation after middle cerebral artery infarction.

OBJECTIVES: The purpose of this study was to investigate the feasibility of hematoma evacuation (HE) with decompressive craniectomy (DC) and to evaluate whether HE with DC is associated with improvement of clinical outcomes in patients with parenchymal hematoma type 2 (PH2) after middle cerebral artery (MCA) infarction. METHODS: Between March 2007 and August 2020, 73 patients with PH2 after MCA infarction underwent DC. The HE group (n = 28) consisted of subjects who underwent HE with DC and the non-HE group (n = 45) consisted of subjects who underwent only DC without HE. The clinical outcomes were analyzed and compared between groups. RESULTS: Significant differences in clinical outcomes were not observed between the groups at discharge (P = 0.648) and 12-month follow-up (P = 0.346). Mortality rate within 12 months was not significantly different between the groups (log-rank, P = 0.685). There were 12 reoperations in the HE group (42.9%) and three reoperations in the non-HE group (6.7%; P = 0.037). Logistic regression analysis showed the initial National Institutes of Health Stroke Scale score (OR, 2.320; 95% CI, 1.128-5.965; P = 0.046) and the infarction volume (OR, 1.876; 95% CI, 1.935-11.892; P = 0.041) were independently associated with mortality (modified Rankin Scale, 6) within the 12 months. CONCLUSIONS: In patients with PH2 of hemorrhagic transformation after MCA infarction, HE with DC does not change the clinical outcomes or mortality but might increase the reoperation risk.

Comparison of Long-Term Angiographic Results of Wide-Necked Intracranial Aneurysms : Endovascular Treatment with Single-Microcatheter Coiling, Double-Microcatheter Coiling, and Stent-Assisted Coiling.

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.

Preliminary experience of stent salvage using Neuroform Atlas stent for procedure-related complication during coil embolization of intracranial aneurysms.

OBJECTIVES: Although stent-salvage technique has been well-known to rescue the situation of coil protrusion into the parent artery aggravating to make thromboembolism, the smallest profiled Neuroform Atlas stent can be expected to handle those situations easily compared to previously used intracranial stents. Thus, the purpose of this study was to report our series of stent salvage using the Neuroform Atlas stent for procedure-related complications during coil embolization of intracranial aneurysms. PATIENTS AND METHODS: In March 2018, the Neuroform Atlas was approved for use in our country. Since then, we have treated 541 aneurysms in 502 patients with coil embolization. There were 15 consecutive cases (14 unruptured and 1 ruptured) with procedure-related complications, such as coil protrusion or parent artery thrombosis, rescued by the Neuroform Atlas stent. Follow-up angiography was performed in 14 of the 15 patients between 6-12 months (mean 8.2 months) after the procedure, and clinical follow-up was performed from 2 to 18 months (mean 11.2 months) after the procedure. RESULTS: Procedure-related complications included parent artery thrombosis due to coil herniation (n = 5) and coil protrusion floating in the parent artery (n = 10). There was no complication related to delivery or deploy of Neuroform Atlas stents. In 12 (80.0 %) of the 15 cases, the stent was deployed via the same microcatheter for coil delivery. In 3 cases of wide neck aneurysms, the stent was deployed via another microcatheter per the scheduled stent-assisted or double microcatheter techniques. Initial angiographic results showed 11 (73.3 %, 11/15) cases of complete occlusion, and 12 (85.7 %, 12/14) cases achieved complete occlusion in follow-up angiographies. CONCLUSIONS: Facing with procedure-related complications during coil embolization of intracranial aneurysms, the smallest profiled Neuroform Atlas stent might be a time-saving and feasible option for the salvage technique by using the same microcatheter to deliver coils.

External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications.

PURPOSE: The purpose of this study was to report the authors' experience with external ventricular drainage (EVD) before endovascular treatment (EVT) in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to investigate its relation to hemorrhagic complications. MATERIALS AND METHODS: Between March 2010 and December 2017, a total of 122 patients were recruited who had an aSAH, underwent EVT to secure the ruptured aneurysm, and had EVD performed within 72 hours of rupture. The pre-embo EVD group (n=67) comprised patients who underwent EVD before EVT, and the post-embo EVD group (n=55) comprised those who underwent EVD after EVT. RESULTS: Overall, EVD-related hemorrhage occurred in 18 patients (14.8%): six (8.9%) in the pre-embo EVD group and 12 (21.8%) in the post-embo EVD group (P=0.065). No rebleeding occurred between EVD and EVT in the pre-embo EVD group. Clinical outcomes at discharge did not differ significantly between groups (P=0.384). At discharge, the final modified Rankin Scale score in patients who experienced pre-embo rebleeding was better in the pre-embo EVD group than in the post-embo EVD group (P=0.041). Current use of an antiplatelet agent or anticoagulant on admission (odds ratio [OR], 2.928; 95% confidence interval [CI], 1.234-7.439; P=0.042) and stent use (OR, 2.430; 95% CI, 1.524-7.613; P=0.047) remained independent risk factors for EVD-related hemorrhagic complications. CONCLUSION: EVD before EVT in patients with aSAH in acute period did not increase the rate of rebleeding as well as EVD-related hemorrhagic complications. Thus, performing EVD before EVT may be beneficial by normalizing increased intracranial pressure. Especially in patients with rebleeding before the ruptured aneurysm is secured, pre-embo EVD may improve clinical outcomes at discharge.

Solitary skull metastasis as initial manifestation of hepatocellular carcinoma.

BACKGROUND: A solitary skull metastasis from hepatocellular carcinoma (HCC) prior to diagnosis of the primary tumor without liver dysfunction is a very rare event. CASE PRESENTATION: A 71-year-old male, without known liver disease, presented to our institution with a palpable occipital scalp mass. On brain magnetic resonance imaging (MRI), a highly enhanced and osteolytic skull tumor was observed. The histological diagnosis obtained from the percutaneous needle biopsy was a cranial metastasis from HCC. The metastatic tumor was removed via occipital craniectomy, and the two primary liver mass lesions were subsequently treated by transarterial chemoembolization. CONCLUSION: An isolated skull metastasis may be the sole initial presentation of HCC. Early diagnosis is essential in order to treat the primary disease. A skull metastasis from HCC should be considered in the differential diagnosis in patients with subcutaneous scalp mass and osteolytic defects on X-ray.

Vision Outcomes of Endovascular Treatment for Unruptured Ophthalmic Artery Aneurysms.

OBJECTIVE: The purpose of this study was to report the authors' experience with endovascular treatment (EVT) of ophthalmic artery (OA) aneurysms and to investigate risk factors for visual complications of EVT for unruptured OA aneurysms. METHODS: Fifty-four patients with unruptured OA aneurysms subjected to EVT were recruited for this study from March 2010 to December 2017. The clinical and angiographic outcomes of all 54 patients were investigated and analyzed retrospectively. RESULTS: Of the 54 patients included in this study, 5 patients (9.3%) had visual complications, including asymptomatic unintended OA occlusion in 2 patients (3.7%) and symptomatic complications in 3 patients (5.6%); 2 patients (3.7%) had transient visual complications, and 1 (1.9%) had a permanent complication. No subacute or delayed visual complications occurred during the 20.8-month follow-up period. OA incorporation by the aneurysm (odds ratio [OR], 3.471; 95% confidence interval [CI], 1.115-9.184; P = 0.038) and intentional OA occlusion (OR, 1.820; 95% CI, 1.248-6.221; P = 0.044) were independent risk factors for visual complications in a multivariate logistic regression analysis. CONCLUSIONS: The visual complication rate was 9.3% when performing EVT for unruptured OA aneurysms. OA aneurysms with OA incorporation by the aneurysm might be at higher risk of visual complications when performing EVT. Intentional OA occlusion should be performed with caution, even though a patient may have favorable collaterals during balloon test occlusion.

What are the causative factors for a slow, progressive enlargement of a chronic subdural hematoma?

PURPOSE: To test the hypothesis that chronic subdural hematoma (CSDH) enlarges by the causative factors, this study has performed. MATERIALS AND METHODS: In 10 patients with CSDH, coagulation factors in venous blood taken at the time of surgery and hematomic contents aspirated from the CSDH were studied, using both laboratory assays and microscopy. RESULTS: When compared to the range of normal plasma, the hematoma fluids demonstrated a marked reduction in factor II, V, VII, VIII, and X, moderate reduction of factors IX and XI, and slight reduction of factor XII. Activated protein C and antithrombin III levels were decreased. The FDP (Fibrinogen Degradation Product) levels in chronic subdural hematoma were extremely high. The endothelial cells of the macrocapillaries (also called ''sinusoid'') showed numerous gap junctions between adjacent endothelial cells and a thinness or absence of the basement membrane, suggesting that the macrocapillaries are very fragile and susceptible to bleeding. CONCLUSION: Excessive coagulation in the hematoma, predominantly via the extrinsic clotting pathway, local hyperfibrinolysis, transmitted pulsations, and characteristics of the macrocapillaries play an important role in the leakage of blood and the enlargement of CSDH.

Importance of Hematoma Removal Ratio in Ruptured Middle Cerebral Artery Aneurysm Surgery with Intrasylvian Hematoma.

OBJECTIVE: Ruptured middle cerebral artery (MCA) aneurysm with intrasylvian hematoma usually accompanied by progressive cerebral swelling with poorer outcomes. The authors present characteristics and importance of intrasylvian hematoma removal in the aneurysm surgery. MATERIALS AND METHODS: From 2012 February to 2014 March, 24 aneurysm surgeries for ruptured MCA aneurysms with intrasylvian hematoma were performed in the authors' clinic. The patients were classified according to three groups. Group A included patients who underwent decompressive craniectomy within a few days after aneurysm surgery due to progressive cerebral swelling, group B included patients for whom decompression was not necessary, and group C included patients who showed severe cerebral swelling on admission and decompressive craniectomy and aneurysm surgery in one stage. RESULTS: The mean hematoma volume on admission was 28.56 mL, 24.96 mL, and 66.78 mL for groups A, B and C, respectively. Removal of a larger amount of hematoma was observed on postoperative computerized tomography scan in groups B and C (63.2% and 59.0%) compared with group A (33.4%). Although no statistical difference was found between group A and group B (p = 0.115), it tends to show the lesser amount of hematoma removed, the more likely cerebral swelling will progress. CONCLUSION: The lesser amount of hematoma in ruptured MCA aneurysm with intrasylvian hematoma tends to show benign clinical course than larger amounts. But, even if the hematoma is not easily removed in the operation, we suggest the other procedures such as continuous external catheter drainage of hematoma to avoid unnecessary coagulation or brain retraction.

Endovascular Treatment of a Fusiform Aneurysm Involving a Premammillary Artery Originating from the Internal Carotid Artery: A Case Report.

The premammillary artery (PMA) is a branch of the posterior communicating artery (PCoA). While the PMA is known to originate from the PCoA as demonstrated by most anatomical studies, it originates directly from the internal carotid artery in approximately 1% of patients. Cerebral aneurysms associated with the PMA have rarely been reported. We report an extremely rare case of a ruptured PMA aneurysm that was managed using endovascular treatment.

Pelvic Incidence Can Be Changed not only by Age and Sex, but also by Posture Used during Imaging.

OBJECTIVE: Computed tomography (CT), rather than conventional 2-dimensional radiography, was used to scan and measure pelvic parameters. The results were compared with measurements using X-ray. METHODS: Pelvic parameters were measured using both CT and X-ray in 254 patients who underwent both abdomino-pelvic CT and X-ray at the pelvic site. We assessed the similarity of the pelvic parameters between the 2 exams, as well as the correlations of pelvic parameters with sex and age. RESULTS: The mean values of the subjects' pelvic parameters measured on X-ray were: sacral slope (SS), 31.6°; pelvic tilt (PT), 18.6°; and pelvic incidence (PI), 50.2°. The mean values measured on CT were: SS, 35.1°; PT, 11.9°; and PI, 47.0°. PT was found to be 4.07° higher on X-ray and 2.98° higher on CT in women, with these differences being statistically significant (p<0.001, p<0.001). PI was 4.10° higher on X-ray and 2.78° higher on CT in women, with these differences also being statistically significant (p<0.001, p=0.009). We also observed a correlation between age and PI. For men, this correlation coefficient was 0.199 measured using X-ray and 0.184 measured using CT. For women, this correlation coefficient was 0.423 measured using X-ray and 0.372 measured using CT. CONCLUSION: When measured using CT compared to X-ray, SS increased by 3.5°, PT decreased by 6.7°, and PI decreased by 3.2°. There were also statistically significant differences in PT and PI between male and female subjects, while PI was found to increase with age.

Endovascular Treatment to Stop Life-threatening Bleeding from Branches of the External Carotid Artery in Patients with Traumatic Maxillofacial Fracture.

OBJECTIVE: The purpose of this study was to report our preliminary experience with endovascular treatment (EVT) for life-threatening bleeding from branches of the external carotid artery (ECA) in patients with traumatic maxillofacial fractures. MATERIALS AND METHODS: A total of 12 patients seen between March 2010 and December 2014 were included in this study. All subjects met the following criteria: 1) presence of maxillofacial fracture; 2) continuous blood loss from oronasal bleeding; and 3) EVT to stop bleeding. Various clinical factors were recorded for each patient and the correlations between those factors and clinical outcome (Glasgow Outcome Scale, GOS) were evaluated. RESULTS: Four patients were injured in traffic accidents, five in falls, and three by assaults. Mean initial Glasgow Coma Scale (GCS) was 6.9 ± 2.1 and the lowest hemoglobin measured was mean 6.3 ± 0.9 g/dL. GOS at discharge was 4 in five patients, 3 in three patients, and 1 (death) in four patients. GOS on follow-up (mean 13.7 months) was 5 in two patients, 4 in three patients, and 3 in three patients. Initial GCS (p = 0.016), lowest systolic blood pressure (p = 0.011), and lowest body temperature (p = 0.012) showed a significant positive correlation with good clinical outcomes. The number of units of red blood cells transfused (p = 0.030), the number of units of fresh frozen plasma transfused (p = 0.013), and the time from arrival to groin puncture (p < 0.001) showed significant negative correlation with good clinical outcomes. CONCLUSION: It might be suggested that rapid transition to EVT could be preferable to struggling with other rescue strategies to stop life-threatening bleeding from branches of the ECA in patients with traumatic maxillofacial fractures.

Fusiform Superior Cerebellar Artery Aneurysm Treated with Endovascular Treatment.

An aneurysm of the distal superior cerebellar artery (SCA) is a highly rare disease. Fusiform aneurysms of the distal SCA are particularly challenging to treat. Clipping, trapping with or without bypass using microsurgery or endovascular treatment (EVT) were used to treat this condition. We describe the case of fusiform distal SCA aneurysms treated successfully with endovascular coiling with a 3-month follow-up. A 39 year-old male was presented with subarachnoid hemorrhage (SAH) and a 15 mm fusiform aneurysm of the ambient segment of the left distal SCA. EVT for parent artery occlusion and packing of the aneurysm was done. Left sixth nerve palsy appeared after 1 day of EVT. The symptom completely recovered within 1 week of the post-procedural period. No neurological deficit was seen during the clinical 3-month follow-up. EVT of fusiform distal SCA aneurysms with coils is a safe and feasible option to manage this rare condition. However, the treatment options must be carefully selected depending on the neurologic condition, development of collateral circulation, and configuration of the dissection.

A Faster and Wider Skin Incision Technique for Decompressive Craniectomy: n-Shaped Incision for Decompressive Craniectomy.

OBJECTIVE: Decompressive craniectomy (DC) is a useful surgical method to achieve adequate decompression in hypertensive intracranial patients. This study suggested a new skin incision for DC, and analyzed its efficacy and safety. METHODS: In the retrograde reviews, 15 patients underwent a newly suggested surgical approach using n-shape skin incision technique (Group A) and 23 patients were treated with conventional question mark skin incision technique (Group B). Two groups were compared in the terms of the decompressed area of the craniectomy, protruded brain volume out of the skull layer, the operation time from skin incision to bone flap removal, and modified Rankin Scale (mRS) which was evaluated for 3 months after surgery. RESULTS: The decompressed area of craniectomy (389.1 cm2 vs. 318.7 cm2, p=0.041) and the protruded brain volume (151.8 cm3 vs. 116.2 cm3, p=0.045) were significantly larger in Group A compared to the area and the volume in Group B. The time interval between skin incision and bone flap removal was much shorter in Group A (23.3 minutes vs. 29.5 minutes, p=0.013). But, the clinical results were similar between 2 groups. Group A showed more favorable outcome proportion (mRS 0-3, 6/15 patients vs. 5/23 patients, p=0.225) and lesser mortality cases proportion 1/15 patients vs. 4/23 patients, but these differences were not significantly observed (p=0.225 and 0.339). CONCLUSION: DC using n-shaped skin incision was a feasible and safe surgical technique. It may be an easier and faster method for the purpose of training neurosurgeons.