Safe and time-saving treatment method for acute cerebellar infarction: Navigation-guided burr-hole aspiration - 6-years single center experience.

OBJECTIVE: While patients with medically intractable acute cerebellar infarction typically undergo suboccipital craniectomy and removal of the infarcted tissue, this procedure is associated with long operating times and postoperative complications. This study aimed to investigate the effectiveness of minimally invasive navigationguided burr hole aspiration surgery for the treatment of acute cerebellar infarction. METHODS: Between January 2015 and December 2021, 14 patients with acute cerebellar infarction, who underwent navigation-guided burr hole aspiration surgery, were enrolled in this study. RESULTS: The preoperative mean Glasgow Coma Scale (GCS) score was 12.7, and the postoperative mean GCS score was 14.3. The mean infarction volume was 34.3 cc at admission and 23.5 cc immediately following surgery. Seven days after surgery, the mean infarction volume was 15.6 cc. There were no surgery-related complications during the 6-month follow-up period and no evidence of clinical deterioration. The mean operation time from skin incision to catheter insertion was 28 min, with approximately an additional 13 min for extra-ventricular drainage. The mean Glasgow Outcome Scale score after 6 months was 4.8. CONCLUSIONS: Navigation-guided burr hole aspiration surgery is less time-consuming and invasive than conventional craniectomy, and is a safe and effective treatment option for acute cerebellar infarction in selected cases, with no surgery-related complication.

Dual antiplatelet treatment associated with reduced risk of symptomatic vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage.

OBJECTIVE: Cerebral vasospasm and delayed cerebral ischemia (DCI) are considered complications after aneurysmal subarachnoid hemorrhage (aSAH). Several hypotheses involving platelet activation have been asserted in the pathophysiology of cerebral vasospasm and DCI. This study aimed to investigate the effect of dual antiplatelet treatment (DAPT) on symptomatic vasospasm and DCI in patients with aSAH. METHODS: A retrospective study was conducted on patients with aSAH from 2009 to 2018. The patients are divided into 2 groups according to the treatment method such as simple or balloon-assisted coil embolization group (SB coiling), and stent-assisted coil embolization group. Patients treated by SB coiling without DAPT were classified as the control group. Patients who required dual antiplatelet treatment due to stent-assisted coil embolization were classified as DAPT group. The incidence of symptomatic vasospasm and DCI was compared between the two groups. RESULTS: Of 743 patients with aSAH, 563 patients were treated with clipping, 115 patients treated with SB coiling, and 65 patients receive stent-assisted coiling. Among 115 patients underwent SB coiling, 14 patients were excluded by the exclusion criteria. Total number of control group (SB coiling) was 101, DAPT group (stent-assisted coiling) was 65. Depending on whether or not taking DAPT, the incidence of symptomatic vasospasm was lower in the DAPT group (p=0.010). DCI incidence was also lower in the DAPT group, which was statistically significant (p=0.029). CONCLUSIONS: DAPT reduces the frequency of symptomatic vasospasm and DCI in patients with aSAH in our single-center study. To warranting this topic, further, larger prospective and randomized studies should be needed.

Endovascular Treatment of Symptomatic Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Three-year Experience.

OBJECTIVE: The cause of severe clinical vasospasm after aneurysmal subarachnoid hemorrhage remains unknown, despite extensive research over the past 30 years. However, the intra-arterial administration of vasodilating agents and balloon angioplasty have been successfully used in severe refractory cerebral vasospasm. MATERIALS AND METHODS: We retrospectively analyzed the data of 233 patients admitted to our institute with aneurysmal subarachnoid hemorrhage (SAH) over the past 3 years. RESULTS: Of these, 27 (10.6%) developed severe symptomatic vasospasm, requiring endovascular therapy. Vasospasm occurred at an average of 5.3 days after SAH. A total of 46 endovascular procedures were performed in 27 patients. Endovascular therapy was performed once in 18 (66.7%) patients, 2 times in 4 (14.8%) patients, 3 or more times in 5 (18.5%) patients. Intra-arterial vasodilating agents were used in 44 procedures (27 with nimodipine infusion, 17 with nicardipine infusion). Balloon angioplasty was performed in only 2 (7.4%) patients. The Average nimodipine infusion volume was 2.47 mg, and nicardipine was 3.78 mg. Most patients recovered after the initial emergency room visit. Two patients (7.4%) worsened, but there were no deaths. CONCLUSION: With advances in endovascular techniques, administration of vasodilating agents and balloon angioplasty reduces the morbidity and mortality of vasospasm after aneurysmal SAH.

Usefulness of Plaque Magnetic Resonance Imaging in Identifying High-Risk Carotid Plaques Irrespective of the Degree of Stenosis.

OBJECTIVE: Measurement of the degree of stenosis is not enough to decide on the treatment strategy for patients with carotid stenosis. Plaque morphology examination is needed for such a decision-making. Thus, we evaluated the usefulness of plaque magnetic resonance imaging (MRI) to decide on the modality of treatment for patients with carotid atherosclerotic plaques. MATERIALS AND METHODS: Fifteen patients presenting with carotid stenosis between 2014 and 2016 were included. They underwent angiography for measurement of the degree of stenosis. Carotid plaques were visualized using MRI. RESULTS: There were six (40%) stable and nine (60%) unstable plaques. Seven symptomatic patients (77.7%) had unstable lesions and two symptomatic patients (33.3%) had stable lesions (p = 0.096). There were six (40%) intraplaque hemorrhage (IPH) cases. There were six symptomatic patients (100%) in the IPH group and three symptomatic patients (33.3%) in the non-IPH group (p = 0.013). The mean stenosis degree was 58.9% in the IPH group and 70.4% in the non-IPH group (p = 0.094). Symptoms occurred irrespective of the degree of the stenosis in the IPH groups. In the IPH group, the recurrent ischemic cerebrovascular event rate was 33.3%. Particularly, the recurrent ischemic cerebrovascular event rate was 66.7% in the IPH group with mild stenosis treated with medications. CONCLUSION: IPH in plaque MRI is significantly associated with ischemic symptoms and has a high risk for subsequent ischemic cerebrovascular events irrespective of the degree of stenosis. Plaque MRI is a useful tool in predicting symptomatic risks for carotid stenosis irrespective of the degree of such stenosis.

Delayed Rebleeding of Cerebral Aneurysm Misdiagnosed as Traumatic Subarachnoid Hemorrhage.

An intracranial saccular aneurysm is uncommonly diagnosed in a patient with closed head trauma. We herein present a patient with delayed rebleeding of a cerebral aneurysm misdiagnosed as traumatic subarachnoid hemorrhage (SAH). A 26-year-old female visited our emergency department because of headache after a motorcycle accident. Brain computed tomography (CT) showed a right-side dominant SAH in Sylvian fissure. Although traumatic SAH was strongly suggested because of the history of head trauma, we performed a CT angiogram to exclude any vascular abnormalities. The CT angiogram showed no vascular abnormality. She was discharged after conservative treatment. One day after discharge, she returned to the emergency department because of mental deterioration. Brain CT showed diffuse SAH, which was dominant in the right Sylvian fissure. The CT angiogram revealed a right middle cerebral artery bifurcation aneurysm. During operation, a non-traumatic true saccular aneurysm was found. The patient recovered fully after successful clipping of the aneurysm and was discharged without neurologic deficit. Normal findings on a CT angiogram do not always exclude aneurysmal SAH. Follow-up vascular study should be considered in trauma patients who are highly suspicious of aneurysmal rupture.

Characteristics of Patients With Aneurysmal Subarachnoid Hemorrhage and Risk Factors Related to Dysphagia.

OBJECTIVE: To investigate the characteristics and risk factors of dysphagia with the Videofluoroscopic Dysphagia Scale (VDS) using a videofluoroscopic swallowing study (VFSS) in patients with ruptured aneurysmal subarachnoid hemorrhage (aSAH). METHODS: Data of 64 patients presenting with first-ever ruptured aSAH were analyzed. Characteristics of dysphagia were evaluated using VFSS and all subjects were divided into a high (>47) and low risk group (≤47) by the VDS score. Clinical and functional parameters were assessed by medical records including demographics, hypertension and diabetes mellitus (DM), the Glasgow Coma Scale (GCS), the Hunt and Hess scale, endotracheal intubation, acute management modalities, as well as Korean version of the Mini-Mental Status Examination (K-MMSE) and Korean version of Modified Barthel Index (K-MBI). Radiologic factors identified the amount of hemorrhage, ventricular rupture, and aneurysmal location. RESULTS: About a half of the subjects showed oral phase abnormalities and the oral transit time was delayed in 46.8% of the patients. The pharyngeal transit time was also prolonged in 39.0% of the subjects and the proportion of penetration and aspiration observed was 46.8%. The parameters-GCS score (p=0.048), hemorrhagic volume (p=0.028), presence of intraventricular hemorrhage (p=0.038), and K-MMSE (p=0.007)-were predisposing factors for dysphagia in patients with aSAH. CONCLUSION: Abnormalities in the oral phase were more prominent in patients with aSAH than in those with other types of stroke. The risk factors associated with dysphagia persisting over 6 months after stroke onset were the initial GCS, hemorrhage volume, presence of intraventricular hemorrhage, and cognitive status as measured by the K-MMSE.

Rupture of Very Small Intracranial Aneurysms: Incidence and Clinical Characteristics.

OBJECTIVE: Unruptured intracranial aneurysms are now being detected with increasing frequency in clinical practice. Results of the largest studies, including those of the International Study of Unruptured Intracranial Aneurysms, indicate that surgical and endovascular treatments are rarely justified in small aneurysms. However, we have encountered several cases of rupture of small and very small aneurysms in our clinical practice. This retrospective study analyzed the incidence and clinical characteristics of very small ruptured aneurysms. MATERIALS AND METHODS: A total of 200 patients with aneurysmal subarachnoid hemorrhage between January 2012 and December 2014 were reviewed. Various factors were analyzed, including the aneurysm location and size as well as the associated risk factors. RESULTS: The mean age of patients was 56.31 ± 13.78 (range, 25-89) years, and the male to female ratio was 1:2.1. There were 94 (47%) small-sized (< 5 mm), 91 (45.5%) medium-sized (5-9.9 mm), and 15 large-sized (> 10 mm) aneurysms. Of these, 30 (15%) aneurysms were very small-sized (< 3 mm). The most frequent site of aneurysms was the anterior communicating artery (ACoA). However, the proportion of aneurysms at the ACoA was significantly high in very small aneurysms (53.3%, p = 0.013). Hypertension was a significant risk factor for rupture of very small aneurysms (p < 0.001). CONCLUSION: About half of our cases of ruptured aneurysms involved the rupture of small and very small aneurysms. The most common site of rupture of very small aneurysm was the ACoA. Rupture of small and very small aneurysms is unpredictable, and treatment may be considered in selected high-risk patients according to factors such as young age, ACoA location, and hypertension.

Clinical practice guidelines for the medical and surgical management of primary intracerebral hemorrhage in Korea.

The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.

Spontaneous recanalization of an occluded middle cerebral artery in a patient with moyamoya.

Moyamoya disease is a rare cerebrovascular disorder that is characterized by progressive stenosis of the distal portion of the internal carotid artery and its main branches. Here the authors present the first case of spontaneous recanalization of an occluded middle cerebral artery in a woman with moyamoya who had not undergone surgical or endovascular treatment. Although the exact mechanisms remain unclear, spontaneous recanalization in moyamoya could be considered a possible phenomenon. Thus, the neurosurgeons should always pay attention to the pathological variety of dynamic changes in the cerebrovascular structure in moyamoya.

Wharton's jelly-derived mesenchymal stem cells: phenotypic characterization and optimizing their therapeutic potential for clinical applications.

Wharton's jelly (WJ) is a gelatinous tissue within the umbilical cord that contains myofibroblast-like stromal cells. A unique cell population of WJ that has been suggested as displaying the stemness phenotype is the mesenchymal stromal cells (MSCs). Because MSCs' stemness and immune properties appear to be more robustly expressed and functional which are more comparable with fetal than adult-derived MSCs, MSCs harvested from the "young" WJ are considered much more proliferative, immunosuppressive, and even therapeutically active stem cells than those isolated from older, adult tissue sources such as the bone marrow or adipose. The present review discusses the phenotypic characteristics, therapeutic applications, and optimization of experimental protocols for WJ-derived stem cells. MSCs derived from WJ display promising transplantable features, including ease of sourcing, in vitro expandability, differentiation abilities, immune-evasion and immune-regulation capacities. Accumulating evidence demonstrates that WJ-derived stem cells possess many potential advantages as transplantable cells for treatment of various diseases (e.g., cancer, chronic liver disease, cardiovascular diseases, nerve, cartilage and tendon injury). Additional studies are warranted to translate the use of WJ-derived stem cells for clinical applications.

Effects of art therapy using color on purpose in life in patients with stroke and their caregivers.

PURPOSE: Patients with stroke suffer from physical disabilities, followed by mental instability. Their caregivers also suffer from mental instability. The present study attempted to address the degree and the change of the level of Purpose in Life (PIL) in patients with stroke and caregivers by applying art therapy using colors. MATERIALS AND METHODS: Twenty-eight stroke patients with a good functional recovery or a moderate disability and their 28 caregivers were selected and evaluated. The period of the study between the stroke and color therapy was more than 6 months. Patients and caregivers were divided into the color therapy (28) and control groups (28). A questionnaire, which measures the level of PIL was conducted separately for patients and caregivers prior to the first session of color therapy (2 hours per week, total 16 sessions). The final examination was performed 5 months after the last color therapy session. RESULTS: There was significant difference between before and after color therapy when the level of PIL was measured both in patients and caregivers (p<0.01). These were the same between the color therapy group, compared with the control group (p<0.01). As color therapy progressed to the late phase, patients and caregivers applied increasing number of colors and color intensity. CONCLUSION: These results prove that color therapy will improve PIL of the patients with post-stroke disability and caregivers. Furthermore, color therapy would be a useful adjuvant for improving the quality of life of the patients with stroke and their caregivers.

Ophthalmic artery occlusion after carotid revascularization.

Distal embolization resulting from carotid angioplasty and stenting (CAS) occurs mainly in the cerebral hemisphere. We report a case of ophthalmic artery occlusion after carotid revascularization. A 75-year old man received emergency CAS for cervical internal carotid artery occlusion. Two months later, the patient was readmitted for decreased visual acuity. We found ophthalmic artery occlusion that was not noticed soon after CAS. Although ophthalmic artery occlusion after CAS is rare, endovascular neurosurgeons should be aware of this potential complication.

Clinical and angiographic outcomes of wingspan stent placement for treatment of symptomatic intracranial stenosis: single center experience with 19 cases.

OBJECTIVE: The limitations of medical management of symptomatic intracranial arterial stenosis (ICS) have prompted development of new strategies, including endovascular treatment. However, stenting of symptomatic ICS remains investigational. Here, we have reported and analyzed a series of 19 endovascular procedures involving placement of a Wingspan stent. METHODS: We conducted a retrospective review of a series of ICS in which patients were treated with percutaneous transarterial balloon angioplasty and stent placement (PTAS). Patients included in the study were diagnosed as symptomatic ICS between May 2010 and September 2011. RESULTS: Nineteen patients (median age, 65 years; 12 males, seven women) were treated with the Wingspan stent system for symptomatic ICS ranging from 50% to 99%. The technical success rate was 100%. The location of ICS included the internal carotid (n = 5; 1 petrous, 3 cavernous, and 1 clinoid segments), vertebral (n = 1; V4 segment), basilar (n = 1), and middle cerebral (n = 12; 9 M1, 3 M2) arteries. There was no occurrence of procedure-related mortality. Periprocedural morbidity occurred in two cases (10.5%), including carotid-cavernous fistula (n = 1) and subarachnoid hemorrhage (n = 1). No ipsilateral stroke was recorded beyond 30 days during a mean follow-up period of 13.2 months (range 9-19 months). Restenosis (> 50%) was observed in one patient (6.3%), who was asymptomatic, on follow-up imaging. CONCLUSION: Wingspan stent for symptomatic ICS can be performed with a high rate of technical success and acceptable periprocedural morbidity rates. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.

Stereotactic burr hole aspiration surgery for spontaneous hypertensive cerebellar hemorrhage.

OBJECTIVE: Patients with severe spontaneous cerebellar hemorrhage typically undergo treatment with suboccipital craniectomy and hematoma evacuation. However, this is a stressful procedure for patients due to the long operating time and operation-induced tissue damage. In addition, the durotomy can result in pseudomeningocele. We investigated the efficacy of stereotactic or navigation-guided burr hole aspiration surgery as a treatment for spontaneous hypertensive cerebellar hemorrhage (SHCH). METHODS: Between January 2002 and December 2011, 26 patients with SHCH underwent surgery using the stereotactic or navigation-guided burr hole aspiration and catheter insertion technique in our institution. RESULTS: Mean hematoma volume was 21.8 ± 5.8 cc at admission and 13.1 ± 5.4 cc immediately following surgery. Preoperative Glasgow Coma Scale (GCS) score was 12.5 ± 1.3 and postoperative GCS score was 13.1 ± 1.2. Seven days after surgery, the mean hematoma volume was 4.3 ± 5.6 cc, and there was no occurrence of surgery-related complications during the six-month follow-up period. The mean operation time for catheter insertion was 43.1 ± 8.9 min, and a mean 31.3 ± 6.0 min was also added for extra-ventricular drainage. The mean Glasgow Outcome Scale (GOS) score after six months was 4.6 ± 1.0. CONCLUSION: Stereotactic burr hole aspiration surgery for treatment of SHCH is less time-consuming and invasive than other interventions, and resulted in no surgery-related complications. Therefore, we suggest that this surgical method could be a safe and effective treatment option for selected patients with SHCH.

Effects of Resveratrol and trans-3,5,4'-Trimethoxystilbene on Glutamate-Induced Cytotoxicity, Heme Oxygenase-1, and Sirtuin 1 in HT22 Neuronal Cells.

Resveratrol (trans-3,5,4'-trihydroxystilbene) has received considerable attention recently for the potential neuroprotective effects in neurodegenerative disorders where heme oxygenase-1 (HO-1) and sirtuin 1 (SIRT1) represent promising therapeutic targets. Resveratrol has been known to increase HO-1 expression and SIRT1 activity. In this study, the effects of resveratrol and trans-3,5,4'-trimethoxystilbene (TMS), a resveratrol derivative, on cytotoxicity caused by glutamate-induced oxidative stress, HO-1 expression, and SIRT1 activation have been investigated by using murine hippocampal HT22 cells, which have been widely used as an in vitro model for investigating glutamate-induced neurotoxicity. Resveratrol protected HT22 neuronal cells from glutamateinduced cytotoxicity and increased HO-1 expression as well as SIRT1 activity in a concentration-dependent manner. Cytoprotec-tion afforded by resveratrol was partially reversed by the specific inhibition of HO-1 expression by HO-1 small interfering RNA and the nonspecific blockage of HO-1 activity by tin protoporphyrin IX, but not by SIRT1 inhibitors. Surprisingly, TMS, a resveratrol derivative with methoxyl groups in lieu of the hydroxyl groups, and trans-stilbene, a non-hydroxylated analog, failed to protect HT22 cells from glutamate-induced cytotoxicity and to increase HO-1 expression and SIRT1 activity. Taken together, our findings suggest that the cytoprotective effect of resveratrol was at least in part associated with HO-1 expression but not with SIRT1 activation and, importantly, that the presence of hydroxyl groups on the benzene rings of resveratrol appears to be necessary for cytoprotection against glutamate-induced oxidative stress, HO-1 expression, and SIRT1 activation in HT22 neuronal cells.

Emergency microsurgical embolectomy for the treatment of acute intracranial artery occlusion: report of two cases.

BACKGROUND: The main treatment for acute arterial ischemic stroke is intravenous or intra-arterial thrombolysis within a particular time window. Endovascular mechanical embolectomy is another treatment option in the case of major artery occlusion. Endovascular mechanical embolectomy is a useful technique for restoring blood flow in patients with large-vessel occlusion, and especially in those who are contraindicated for thrombolytics or in whom thrombolytic therapy has failed. CASE REPORT: We report herein two cases of emergency microsurgical embolectomy for the treatment of acute middle cerebral artery and internal carotid artery occlusion as an alternative treatment for major artery occlusion. CONCLUSIONS: Emergency microsurgical mechanical embolectomy may be an alternative treatment option for restoring blood flow in selected patients with large-vessel acute ischemic stroke.

Recanalization of completely thrombosed non-giant saccular aneurysm mimicking as de novo aneurysm.

Partial thrombosis of giant aneurysms is not uncommon however, complete angiographic occlusion occurs less frequently. In the case of non-giant aneurysms, complete thrombosis and recanalization has been rarely reported. A 31-year-old man presented to the emergency department with sudden bursting headache. Brain computed tomography (CT) revealed diffuse subarachnoid hemorrhage on the left side. Both CT angiography (CTA) and digital subtraction angiography showed suspicion of small left anterior choroidal artery aneurysm. We performed surgical exploration. In the operation field, anterior choroidal artery aneurysm of 2 × 2 mm with broad neck and friable appearance was observed. Because we could not clip without sacrificing the anterior choroidal artery, we performed wrapping only. Follow up CTA after 7 months demonstrated 4 mm right internal carotid artery bifurcation aneurysm. The patient underwent aneurismal neck clipping. During the operation, 9 × 13 mm sized thrombosed aneurysm was detected and completely clipped. We initially thought this aneurysm to be a de novo aneurysm however, it was an aneurysm that had recanalized from a completely thrombosed aneurysm. This case report provides an insight into the potential for complete thrombosis and recanalization of non-giant aneurysms.

Intracerebral hemorrhage caused by rupture of a giant aneurysm complicating superficial temporal artery-middle cerebral artery anastomosis for moyamoya disease.

INTRODUCTION: Aneurysm formation at the anastomosis site after extracranial-intracranial (EC-IC) bypass surgery for major arterial occlusion or stenosis due to atherosclerosis has only been reported a few times previously. However, no case describing the formation of a giant aneurysm after EC-IC bypass surgery has been reported to date. Additionally, this complication associated with moyamoya disease is extremely rare, and only one case has been reported so far. CLINICAL REPORT: We report a case of a 51-year-old woman having a rare complication of intracerebral hemorrhage due to rupture of a giant aneurysm that developed after superficial temporal artery-middle cerebral artery anastomosis for the treatment of moyamoya disease. CONCLUSION: To the best of our knowledge, this is the first reported case of a giant aneurysm, also the largest so far occurring after EC-IC bypass surgery and the second reported case of a rupture of an aneurysm formed after bypass surgery for moyamoya disease.

Bilateral diffuse intracerebral hemorrhagic infarction after cranioplasty with autologous bone graft.

We present the first case of a bilateral diffuse intracerebral hemorrhagic infarction following cranioplasty using an autologous bone graft. The case is that of a 63-year-old man who had undergone previous decompressive craniectomy due to right middle cerebral artery and posterior cerebral artery territory infarction. In order to avoid this extremely rare complication, the possible pathogenic mechanism underlying the deleterious cascade following cranioplasty is discussed.