Simultaneous Endovascular Treatment of Ruptured Cerebral Aneurysms and Vasospasm

OBJECTIVE: The management of patients with ruptured cerebral aneurysms and severe vasospasm is subject to considerable controversy. We intended to describe herein an endovascular technique for the simultaneous treatment of aneurysms and vasospasm. MATERIALS AND METHODS: A series of 11 patients undergoing simultaneous endovascular treatment of ruptured aneurysms and vasospasm were reviewed. After placement of a guiding catheter within the proximal internal carotid artery for coil embolization, an infusion line of nimodipine was wired to one hub, and of a microcatheter was advanced through another hub (to select and deliver detachable coils). Nimodipine was then infused continuously during the coil embolization. RESULTS: This technique was applied to 11 ruptured aneurysms accompanied by vasospasm (anterior communicating artery, 6 patients; internal carotid artery, 2 patients; posterior communicating and middle cerebral arteries, 1 patient each). Aneurysmal occlusion by coils and nimodipine-induced angioplasty were simultaneously achieved, resulting in excellent outcomes for all patients, and there were no procedure-related complications. Eight patients required repeated nimodipine infusions. CONCLUSION: Our small series of patients suggests that the simultaneous endovascular management of ruptured cerebral aneurysms and vasospasm is a viable approach in patients presenting with subarachnoid hemorrhage and severe vasospasm.

Concurrent Hypertensive Intracerebral Hemorrhage and Rupture of a Previously Clipped Intracranial Aneurysm / 대한뇌혈관외과학회지

Simultaneous occurrence of remote intracerebral hemorrhage (ICH) and intracranial aneurysmal subarachnoid hemorrhage is very rare. We report on a case of concurrent hypertensive ICH at the left thalamus and rupture of an intracranial aneurysm at the bifurcation of the single A2 segment of the anterior cerebral artery in a 64-year-old woman, which was clipped previously, with review of the literature. To our knowledge, this is the first case report demonstrating bleeding of previously clipped aneurysm with simultaneous hypertensive ICH. Hypertensive crisis following ICH seems to have provoked rupture of the residual aneurysm.

Sclerotherapy for Craniofacial Venous Malformation / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Venous malformations are one of the most common vascular anomalies, and are more frequently found in head and neck region. Various treatment options are available, and intralesional injection of sclerosant is the commonest primary treatment modality. We reviewed 20 cases of venous malformation treated with sclerotherapy at Seoul National University Hospital. MATERIALS AND METHODS: Twenty cases of venous malformation in head and neck were reviewed retrospectively, which had been managed with sclerotherapy from January 1991 to July 2001. The patients were treated at the department of otolaryngology-Head and Neck Surgery or plastic surgery of Seoul National University Hospital. Emulsion of Ethamolin and Lipiodol was used as a sclerosing agent. Some patients received surgical treatment after sclerotherapy. All of the patients received direct-puncture venography(Digital subtraction angiography) before sclerotherapy. Treatment results were evaluated by using MRI, angiography, or CT. If the reduction of volume of mass was more than 50 percent after sclerotherapy, we regarded the result as effective, if less than 50 percents, non-effective. Statistical analysis was done using SPSS10.0 for windows. RESULTS: Among twenty patients, there were eight males(40%), and twelve females(60%). Ages at the beginning of treatment ranged from six to thirty-eight years(mean age:20.6 years). The most common site of lesions was cheek(in 12 cases). Mass sizes(largest diameter) ranged from 2 cm to 20 cm. Nine cases were managed with both sclerotherapy and surgical excision, and eleven cases, only with sclerotherapy. Thirteen cases(65%) responded well to sclerotherapy(volume reduction>or=50%). There was no major complication. Tenderness, induration, swelling, and pain were reported as post-sclerotherapy complaints. Mild dyspnea occurred in one case, and the patient was managed at ICU shortly without fatal event. CONCLUSION: Sclerotherapy with or without surgical excision was an effective treatment modality for venous malformation, with minimal risk of major complications. There were no significant differences in the treatment results according to the initial size of the lesions.

Unusual Acute Encephalitis Involving the Thalamus: Imaging Features

OBJECTIVE: To describe the brain CT and MR imaging findings of unusual acute encephalitis involving the thalamus. MATERIALS AND METHODS: We retrospectively reviewed the medical records and CT and/or MR imaging findings of six patients with acute encephalitis involving the thalamus. CT (n=6) and MR imaging (n=6) were performed during the acute and/or convalescent stage of the illness. RESULTS: Brain CT showed brain swelling (n=2), low attenuation of both thalami (n=1) or normal findings (n=3). Initial MR imaging indicated that in all patients the thalamus was involved either bilaterally (n=5) or unilaterally (n=1). Lesions were also present in the midbrain (n=5), medial temporal lobe (n=4), pons (n=3), both hippocampi (n=3) the insular cortex (n=2), medulla (n=2), lateral temporal lobe cortex (n=1), both cingulate gyri (n=1), both basal ganglia (n=1), and the left hemispheric cortex (n=1). CONCLUSION: These CT or MR imaging findings of acute encephalitis of unknown etiology were similar to a combination of those of Japanese encephalitis and herpes simplex encephalitis. In order to document the specific causative agents which lead to the appearance of these imaging features, further investigation is required.

MR Findings of Neuro-Behcet's Disease: Initial and Follow-up Changes

PURPOSE: To evaluate the MR findings of neuro-Behcet's disease, and changes occurring during follow up. MATERIALS AND METHODS: Brain MR imaging was performed in 19 patients in whom neuro-Behcet's disease had been clinically diagnosed. After treatment with corticosteroids and immunosuppressive agents, 23 follow-up MR images were obtained in 12 patients, and a total of 42 MR images were retrospectively reviewed by two radiologists. RESULTS: Of the 19 patients, 17 (89%) had parenchymal lesions, and the other two had dural venous sinus thrombosis. Among the 17 patients with parenchymal lesions, three showed leptomeningeal enhancement. A total of 72 parenchymal lesions were detected on initial MR images; 55 (76%) were patchy or nodular in shape and the lesion of the internal capsule appeared linear. Seventeen lesions (24%) in 12 patients were confluent. In order of frequency, the involved sites were the pons, midbrain, thalamus, basal ganglia, internal capsule, and frontal lobe. Thirteen lesions of 39 lesions detected on postcontrast images were enhanced, and a mass effect was seen in the area of 16 parenchymal lesions. Associated findings were microhemorrhage of the brain in two patients and spinal cord involvement in one. On short-term follow-up images obtained 1 week to 2 months after intensive treatment during the acute stage of the illness, the leptomeningeal enhancement seen in three patients had decreased and most parenchymal lesions showed improvement. Long-term follow-up images obtained 3 months to 3 years later showed that parenchymal lesions had relapsed in five patients, and brainstem atrophy had developed or progressed in five others. CONCLUSION: The most characteristic MR finding of neuro-Behcet 's disease is multiple non-hemorrhagic lesions involving the brainstem. Leptomeningeal enhancement and dural venous sinus thrombosis may also be noted. On follow-up MR, the lesions may show either improvement or aggravation, and brainstem atrophy is not uncommon.

Nonsurgical Treatment of Congenital Vascular Malformations of the Trunk and Limb by Transcatheter Embolization

PURPOSE: We evaluated the effectiveness of embolization in the management of congenital vascular malformations(CVMs). METHODS AND MATERIALS: A retrospective analysis was performed in 10 patients who underwent embolotherapy for their soft tissue CVMs(eight arteriovenous malformations, one hemangioma, one venous malformation) involving the extremity or back. In nine patients, intraarterial embolization was performed with multiple embolic agents including Gelfoam, Ivalon, IBCA, ethanol mixed with Lipiodol, and micro-coils. In one patient with venous malformation, direct puncture and embolization of the lesion were performed with absolute ethanol mixed with Lipiodol. RESULTS: In four patients, who subsequently underwent surgery, preoperative embolization decreased operative morbidity and facilitated a thorough extirpation. Five of six patients with inoperable CVMs experienced dramatic reduction of symptoms by single or repeated embolization, with a mean follow-up period of four months. CONCLUSION: We believe that preoperative embolization may decrease operative morbidity and facilitate a thorough extirpation in the patients with extensive but resectable CVMs and repeated embolizations are effective for symptom control in the patients with inoperable CVMs.

Magnetic resonance imaging of renal ischemia experimentally induced by renal artery ligation

This study was designed to evaluate the potential applications of magnetic resonance imaging for the diagnosis of early and sequential changes of acute renal ischemia. Renal isehmia was induced in seventeen rabbits by surgical ligation of the left renal artery. Magnetic resonance imaging(MRI) was performed with a 2.0T super conductive MR system and s pin-echo technique was used with echo times(TE) of 30 and 80 msec and repetition times(TR) or 0.5 and 2.5 seconds. Kidneys were evaluated before and up to 48 hours after left renal artery ligation, and the spin echo images were analyzed for intensity difference and T1, T2 relaxation times between the cortex and the medulla of both kidneys. After one, and one and half hour following ligation of the left renal artery, the kidneys showed a 4-20% decrease in the left cortex compared to the right cortex contrast uptake(CCC) (P<01). There was a 14-29% decrease in left medulla to right medulla contrast uptake(MMC) (P<01). A 29-147% increase in contrast uptake was noted when the left cortex was compared to the left medulla(P<05). There was a 51-68% decrease in CMC of the right kidney (P<05) on three different spin echo images. In the cortex of the left kidney, T2 relaxation time decreased 14% (P<01). CCC and MMC showed more prominent changes than CMC, and sequential changes of CCC and MMC were most prominent on T2 weighted images with TR = 2.5sec and TE=80msec when compared with T1 weighted and proton density weighted images. Twelve hours after renal arterial ligation. T2 relaxation time, CMC, CCC, and MMC returned to normal values and these findings were believed to be due to congestion and collateral blood supply. In renal ischemia, the most useful MRI findings for diagnosis were fund to be changes of CCC and MMC on T2 weighted image, and T2 relaxation time of the cortex in the ischemic kidney.

Magnetic resonance imaging of renal ischemia experimentally induced by renal artery ligation

This study was designed to evaluate the potential applications of magnetic resonance imaging for the diagnosis of early and sequential changes of acute renal ischemia. Renal isehmia was induced in seventeen rabbits by surgical ligation of the left renal artery. Magnetic resonance imaging(MRI) was performed with a 2.0T super conductive MR system and s pin-echo technique was used with echo times(TE) of 30 and 80 msec and repetition times(TR) or 0.5 and 2.5 seconds. Kidneys were evaluated before and up to 48 hours after left renal artery ligation, and the spin echo images were analyzed for intensity difference and T1, T2 relaxation times between the cortex and the medulla of both kidneys. After one, and one and half hour following ligation of the left renal artery, the kidneys showed a 4-20% decrease in the left cortex compared to the right cortex contrast uptake(CCC) (P<01). There was a 14-29% decrease in left medulla to right medulla contrast uptake(MMC) (P<01). A 29-147% increase in contrast uptake was noted when the left cortex was compared to the left medulla(P<05). There was a 51-68% decrease in CMC of the right kidney (P<05) on three different spin echo images. In the cortex of the left kidney, T2 relaxation time decreased 14% (P<01). CCC and MMC showed more prominent changes than CMC, and sequential changes of CCC and MMC were most prominent on T2 weighted images with TR = 2.5sec and TE=80msec when compared with T1 weighted and proton density weighted images. Twelve hours after renal arterial ligation. T2 relaxation time, CMC, CCC, and MMC returned to normal values and these findings were believed to be due to congestion and collateral blood supply. In renal ischemia, the most useful MRI findings for diagnosis were fund to be changes of CCC and MMC on T2 weighted image, and T2 relaxation time of the cortex in the ischemic kidney.