Risk of Shunt Dependent Hydrocephalus after Treatment of Ruptured Intracranial Aneurysms : Surgical Clipping versus Endovascular Coiling According to Fisher Grading System

OBJECTIVE: The amount of hemorrhage observed on a brain computed tomography scan, or a patient's Fisher grade (FG), is a powerful risk factor for development of shunt dependent hydrocephlaus (SDHC). However, the influence of treatment modality (clipping versus coiling) on the rate of SDHC development has not been thoroughly investigated. Therefore, we compared the risk of SDHC in both treatment groups according to the amount of subarachnoid hemorrhage (SAH). METHODS: We retrospectively reviewed 839 patients with aneurysmal SAH for a 5-year-period. Incidence of chronic SDHC was analyzed using each treatment modality according to the FG system. In addition, other well known risk factors for SDHC were also evaluated. RESULTS: According to our data, Hunt-Hess grade, FG, acute hydrocephalus, and intraventricular hemorrhage were significant risk factors for development of chronic SDHC. Coiling group showed lower incidence of SDHC in FG 2 patients, and clipping groups revealed a significantly lower rate in FG 4 patients. CONCLUSION: Based on our data, treatment modality might have an influence on the incidence of SDHC. In FG 4 patients, the clipping group showed lower incidence of SDHC, and the coiling group showed lower incidence in FG 2 patients. We suggest that these findings could be a considerable factor when deciding on a treatment modality for aneurysmal SAH patients, particularly when the ruptured aneurysm can be occluded by either clipping or coiling.

Remote Cerebellar Hemorrhage Complicated after Supratentorial Surgery: Retrospective Study with Review of Articles

OBJECTIVE: Remote cerebellar hemorrhage (RCH) is one of the rare complications occurring after supratentorial surgery, and its pathomechanism is poorly understood. We report 10 cases of RCH from our institution and review 154 cases from a database in order to delineate incidence, common presentation, risk factors, and outcomes of this complication. In addition, the means of prevention are discussed. METHODS: We reviewed the medical records of 10 patients who experienced RCH after undergoing supratentorial surgery at our institution between 2001 and 2008. A database search in Medline revealed 154 cases of RCH in the English literature. Characteristic features were analyzed and compared. RESULTS: There were 10 cases of RCH among 3307 supratentorial surgery cases, indicating a 0.3% incidence. All patients had characteristic imaging features of RCH, namely a streaky bleeding pattern in the superior folia of the cerebellum. Seven patients had a history of preoperative hypertension. Four cases were related to cerebral aneurysms, and other four developed after the removal of brain tumors. Cerebrospinal fluid (CSF) drainage apparatuses were installed postoperatively in all cases. Outcomes according to modified Rankin scale (mRS) were good in 7 patients, with 1 fatal case. CONCLUSION: RCH is a rare complication after supratentorial surgery, and the exact etiology still remains uncertain. Hypertension and perioperative loss of CSF seem positively correlated with RCH, but no single risk factor is totally responsible. Patients with RCH should be closely observed to improve their prognosis.

Saccular Aneurysm at the Anterior Communicating Artery Complex Associated with an Accessory Middle Cerebral Artery : Report of Two Cases and Review of the Literature

Accessory middle cerebral artery (MCA) is an infrequent vascular anomaly of the brain. Cerebral aneurysms associated with this anomalous artery are also very rare. To our knowledge, there have only been ten previous reports of an aneurysm associated with accessory MCA. The authors present two patients with accessory MCA-related aneurysms. A 38-year-old male and a 59-year-old female both presented with sudden-onset severe headache. In both patients, computed tomography (CT) scan revealed subarachnoid hemorrhage. A subsequent angiogram demonstrated an accessory MCA arising from the anterior cerebral artery (ACA) and a saccular aneurysm at the anterior communicating artery (ACoA) complex associated with an accessory MCA. Surgical clipping allowed for complete exclusion of the aneurysm from the arterial circulation. Based on our review of the ten cases of aneurysms associated with accessory MCA documented in the literature, we suggest that accessory MCA-related aneurysms can be classified according to whether the accessory MCA originates from the proximal A1 segment or from the ACoA complex. We also emphasize the importance of precise interpretation of preoperative angiograms and intraoperative precaution in determining the presence of this anomalous artery prior to temporary clip placement.

Role of Three-dimensional Computed Tomography Angiography in the Follow-up of Patients with Aneurysm Clips

OBJECTIVE: The purpose of this study is to assess the usefulness of three-dimensional computed tomography angiography (3D-CTA) as a postoperative follow-up examination after intracranial aneurysms have been clipped. METHODS: Between January 2002 and June 2005, 522 consecutive patients received treatment for intracranial aneurysms. A retrospective analysis of 310 patients with postoperative 3D-CTAs was performed to evaluate aneurysmal remnants and de novo aneurysms. This study was conducted in 271 patients with at least immediate and 6-month routine 3D-CTAs for postoperative clipped aneurysm and 39 patients with 3D-CTAs for clipped aneurysm before 2002 when there was no 3D-CTA in our hospital. RESULTS: Eight patients had abnormal CT angiographic findings. Aneurysm remnants were revealed in 4 patients and de novo aneurysms were discovered in 5 patients. Two patients were found at the postoperative 6-month 3D-CTA performed routinely. In 1 patient, the aneurysm was demonstrated on the way to the examination of syncope. In 2 patients, the author recommended 3D-CTA although there was no symptom because the patients had visited our institute long time ago (5.1, 4.5 years). Of the 8 patients, 2 remnants and 1 de novo aneurysm were treated by endovascular treatment. Three de novo aneurysms at the middle cerebral artery and 1 pericallosal artery aneurysm were treated by direct clipping because these aneurysms were not suitable for the endovascular treatment in point of anatomical configuration. One patient with both remnant and de novo aneurysm was treated conservatively. CONCLUSION: 3D-CTA is an available, non-invasive diagnostic tool for the postoperative follow-up examination of aneurysmal state in patients after clipping.

A Subcortical Anaplastic Meningioma

Meningioma without dural attachment usually occurs in the intraventricular region, the pineal region, and the sylvian fissure. However, subcortical meningioma located far from such locations is extremely rare. The authors report a case of subcortical anaplastic meningioma without any dural attachment in a 41-year-old woman.

Role of Transcranial Doppler to Detect Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage / 대한뇌혈관외과학회지

OBJECTIVE: The authors investigated the role of transcranial Doppler ultrasound (TCD) in clinical decision making about vasospasm due to subarachnoid hemorrhage (SAH). METHODS: In this retrospective study, a total of 383 patients, admitted to our hospital between January 2001 to December 2004 and treated surgically with the diagnosis of aneurysmal SAH, were examined by TCD. RESULTS: Blood flow velocity (BFV) was significantly lower in older patients than in younger patients (p<0.01). BFV in the hypertensive patients were not significantly lower than in the normotensive individuals (p=0.93). The amount of blood clots in the computed tomography after SAH was significantly correlated with BFV (p<0.01). However, there was no statistically significant difference between Hunt-Hess Grade and BFV (p=0.54). The maximum mean flow velocity was greater in 54 patients who developed a delayed ischemic neurological deficit(DIND, 144.1 cm/sec) than in 221 patients who did not develop DIND (94.3 cm/sec, p=0.04). A maximum velocity increase of 40.6 cm/sec/24hr was recorded higher in patients with DIND, compared to that of 22.6 cm/sec/24 hr in patients without DIND (p<0.01). Lindegaard's index (LI) was higher in patients with DIND (4.6) than in those without DIND (2.8, p<0.01). Peak velocity, maximum velocity increase, and LI can thus assist in diagnosis of DIND, however, when those readings made before onset of DIND were considered, there was only significant difference in LI between the groups. CONCLUSION: Serial TCD studies after SAH are of value to detect cerebral vasospasm, especially, LI is significantly correlated with identifying patients who later develop DIND.

Surgical Resuscitation of a Patient with Cerebral Herniation Secondary to Massive Hemorrhage in the Basal Ganglia: Ultrasound-monitored Aspiration

The authors report a case of hyperacute, massive hemorrhage in the left basal ganglia with severe midline shift that was treated successfully by the ultrasound-monitored free hand aspiration technique. Every effort was made to shorten time until removal of considerable amount of the hematoma and minimize duration of cerebral herniation, avoiding additional irreVersible neurological deficit. A burr hole aspiration technique was preferred to standard craniotomy procedure, and any time-consuming procedures such as stereotactic frame application were abandoned. A burr hole was localized on the basis of computed tomography images simply and quickly with a ruler, and safety of the aspiration procedure was augmented by real-time ultrasound monitoring. Such minimally invasive technique relieved cerebral herniation successfully while avoiding time consumption and the morbidity of major craniotomy procedure. Early resuscitation of the patient with cerebral herniation in this case resulted in excellent recovery of the patient's neurological deficit. The patient's mentality started to improve rapidly and was clear six months after the surgery.

Intracranial Aneurysms in the 3rd and 4th Decades in Comparison with Those in the 8th and 9th Decades

OBJECTIVE: This study is performed to compare older with younger groups about clinical characteristics and overall outcome of treatments for the intracranial aneurysms. METHODS: We retrospectively investigated 633 patients with cerebral aneurysms who were admitted to our institute from January 2000 to May 2004. The authors divided the patients of cerebral aneurysm into two groups, one the third, fourth decades and the other eighth, ninth decades, analyzed clinical characteristics and overall outcome of treatments. RESULTS: There were 57 patients (9.0%) under 39years old and 58 patients (9.2%) over 70. The female to male sex ratio was 0.5:1 in the younger group(YG) and 7.3:1 in the older group(OG), showing a female predominance with increasing age. In the YG, aneurysms were found in anterior communicating artery(A-com) (44.8%), middle cerebral artery (31.0%). In the OG, aneurysm of posterior communicating artery (30.1%) was most common followed by that of A-com (26.9%). More smokers and alcoholics were found in the YG. Older age was related to poor Hunt-Hess grade, Fisher's grade on admission, high incidence of unruptured aneurysms, and endovascular surgery. There was a higher prevalence of hypertension, intraventricular hematoma, hydrocephalus, and rebleeding in the preoperative state in the OG and postoperative complications including hydrocephalus, subdural fluid collection, and systemic complications. Overall outcome was poorer with advancing age (p=0.01). CONCLUSION: The patients with aneurysms in the YG have distinct characteristics compared to those in the OG. Because of a good clinical grade on admission, a thin subarachnoid clot, and low incidence of perioperative complications, the overall outcomes of the young patients were better than those of the old patients.

Six-year Experience of Endovascular Embolization for Intracranial Aneurysms

OBJECTIVE: This study is performed to evaluate the procedural complications, aneurysm occlusion rate, and mid-term outcome of endovascular treatments in intracranial aneurysms. METHODS: We retrospectively investigated 135patients with 161 cerebral aneurysms who were treated by endovascular means at our institute from March 1999 to December 2004. We statistically analyzed overall outcome, occlusion rate, and occurrence of complications according to the location, size, rupture history, and neck size of aneurysms. RESULTS: Forty-nine patients (36.3%) had experienced acute intracranial or extracranial complications related to the procedure. Among these, there were 13cases of perforation of the aneurysm, 9 of local vasospasm, 8 of thromboembolism, 4 of coil migration, 3 of occlusion of parent vessels due to coil protrusion, and 1 of seizure. Extracranial complications occurred in 14cases including alopecia (9cases), femoral artery thrombosis (2cases), acute renal failure (2cases), and hypovolemic shock (1case). One hundred twenty-six aneurysms (78.3%) had complete occlusion of the aneurysm and 35 (21.7%) incomplete occlusion at 6months angiographic follow-up. Postembolization clinical follow-up ranged from 1 to 60months (mean, 14.2months). Seven of the 161 aneurysms underwent additional embolization and 2 incomplete embolized aneurysms required subsequent surgery. CONCLUSION: The procedural complications and incomplete occlusion rates are substantial. Therefore, endovascular treatment needs close and continued neurosurgical and neuroradiological concerns for the therapy of intracranial aneurysms.

Intubation Difficulty in Patient with Pseudoankylosis of Temporo-mandibular Joint after Pterional Craniotomy

The authors report on a severe case of pseudoankylosis of the temporo-mandibular(TM) joint following a pterional craniotomy and the intubation difficulty encountered in the second surgery. Preventive and therapeutic aspects in addition to the clinical pitfalls of the case are discussed.

Neurosurgical Approaches to and through the Frontal Sinus using Osteoplastic Frontal Sinusotomy

OBJECTIVE: The frontal sinus is frequently a troublesome anatomical obstacle to gain access to the medial anterior cranial base. Surgical approaches to and through the frontal sinus using osteoplastic frontal sinusotomy provide significant advantages to the treatment of lesions of the medial anterior cranial base in addition to the frontal sinus itself. However, appropriate management is necessary to avoid postoperative complications such as cerebrospinal fluid leakage, infection, mucocele formation, and deformity of the forehead. METHODS: The advantages and shortcomings of the approach along with the surgical technique are reported based on our clinical experience with pertinent literature review. The approach using the osteoplastic frontal sinusotomy was applied to two cases of osteoma in the frontal sinus, seven cases of craniofacial tumors, a case of chordoma in the sphenoid and clivus, and two cases of intradural lesions in the anterior cranial fossa. The frontal sinus was managed in such a way as to prevent the postoperative complications. RESULTS: All patients underwent gross total resection of the tumors. With a mean follow-up of 26 months, there were no postoperative complications related to frontal sinus violation. CONCLUSION: The neurosurgical approaches via the frontal sinus using osteoplastic frontal sinusotomy are versatile for various lesions of the anterior cranial base in patients with large frontal sinuses. In situations that the frontal sinus have to be violated to approach medial anterior cranial base, the osteoplastic frontal sinusotomy provides such advantages as optimal frontal sinus control to prevent postoperative complications; increases viewing angle with superior trajectory from nasofrontal suture; lower incidence of pnemocephalus due to minimal dural exposure; and excellent cosmesis without frontal burr holes.

A Case of the Redundant Nerve Root Syndrome Mimicking Intradural Spinal Tumor

The redundant nerve root syndrome is not common and demonstrates a large, elongated, and tortuous nerve roots of cauda equina. Usually, the diagnosis of this syndrome is not difficult with the radiological finding and clinical symptom. The authors report a case of the redundant nerve root syndrome mimicking intradural spinal tumor in view of the symptom and radiological findings. Magnetic resonance imaging revealed a globular intradural mass just above canal stenosis. Decompressive laminectomy and durotomy improved back pain and radicular pain. From the experience of this case, the relief of nerve root compression is recommended as early as possible in the redundant nerve root syndrome.

Cerebral Fat Embolism with Multiple Rib and Thoracic Spinal Fractures

Cerebral fat embolism(CFE) is a rarely reported and usually underestimated disease entity. It is important to consider the possibility of CFE when intracranial lesions on brain magnetic resonance(MR) imaging without direct relation to the trauma are seen in patients with multiple bone fractures. The authors report a case of CFE caused by trauma with multiple enhancing lesions on the enhanced T1-weighted MR images and high signal intensity on T2-weighted images in a 24-year-old-man with multiple bone fractures.

Hemichorea-Hemiballism with Non-ketotic Hyperglycemia in a Chronic Renal Failure Patient

Multiple metabolic complications of uremia are believed to cause neurologic manifestations in chronic renal failure. It is important to consider the possibility of non-ketotic hyperglycemia when hemichorea-hemiballism(HCHB) occurs in patients with end stage renal disease due to diabetes mellitus nephropathy. HCHB that accompanies hyperglycemia exhibits characteristic findings on the T1-weighted magnetic resonance(MR) imaging. The authors report a case of HCHB associated with non-ketotic hyperglycemia and basal ganglia hyperintensity on the T1-weighted brain MR imaging in a 64-year-old-woman with non-insulin dependent diabetes mellitus nephropathy.

A Rupture of Distal Anterior Cerebral Artery Aneurysm Invaded by Anaplastic Oligodendroglioma

The authors report a very unusual case of ruptured aneurysm by direct vessel invasion of anaplastic oligodendroglioma (WHO grade III) confirmed by histopathological examinations. As local invasion is the hallmark of malignant gliomas, malignant glial tumors invade neighboring structure and often cause microscopic endothelial proliferation, telangiectasias in small arteriols, but direct arterial invasion by glioma is very rare. Possible mechanisms of intracranial aneurysm development by glioma are thought to be related to the close proximity to the tumor, perivascular basement membrane breakage due to high tumor pressure and increased regional blood flow through the feeding artery of tumor. The aneurysm and tumor were treated in a single operation simultaneously.

Strategy & Pitfalls of Internal Carotid Artery Aneurysm Surgery / 대한뇌혈관외과학회지

Saccular aneurysms of the subarachnoid segment of the internal carotid artery(ICA) are among the most common aneurysms encountered by neurosurgeons. Surgical strategy and techniques to deal with such aneurysms arising from the ophthalmic artery to the ICA bifurcation are described. Intimate understanding of the anatomy and proper surgical technique improve surgical result.

Multiple Primary Brain Tumors: Association of Intraventricular Meningioma and Callosal Astrocytoma: Report of Two Cases

Two patients presenting with intraventricular meningioma and callosal astrocytoma are described. The first case is a 51 year old female presented with headache and paraparesis. Magnetic resonance imaging revealed meningioma in the left occipital horn of lateral ventricle and astrocytoma in the corpus callosum, which were confirmed by operative removal and biopsy respectively. The second patient had been removed the meningioma in the left lateral ventricle. Seven years later poorly marginated enhancing lesion was found on the corpus callusum which was confirmed as astrocytoma by computed tomography guided biopsy.

The Clipping on Supraclinoid Internal Carotid Artery Aneurysms

OBJECTIVE: We present a clinical analysis to envision the difficulties in supraclinoid internal carotid artery(ICA) aneurysmal neck clippings to improve the postoperative outcome. METHODS: Two hundred and fifty aneurysm surgeries were undertaken at our hospital from 1997 to 1998. There were 52 patients(20.4% of the total) of supraclinoid ICA saccular aneurysmal patients. Eighteen cases(34.6%) were found with diverse difficulties in direct neck clippings. The authors analyzed the causes of surgical difficulties in the clipping on supraclinoid ICA aneurysms, in a clinical perspective. RESULTS: Perfect aneurysmal clippings were performed in 45 patients(86.5%) of the total 52 cases of supraclinoid ICA aneurysms. The clipping and wrapping were needed in five cases(9.6%), trapping in one(1.9%) with one case(1.9%) needed only for wrapping. The causes of difficulties in direct neck clipings were : aneurysm sac involving perforator in six cases(11.5%), too short an ICA proximal to posterior communicating artery for temporary clipping in 5(9.6%), posterior communicating artery aneurysm directed to the ventral side in three(5.8%), dorsal wall aneurysm in one, severe atheromatous ICA in one, a larger sac than in angiographic finding with partial thrombosis in one, severe adhesion of aneurysm to 3rd cranial nerve in one patient. CONCLUSION: For supraclinoid ICA aneurysm surgery, sufficient preoperative plans and careful inspection including angiographic findings to foresee the various difficulties of neck clippings are needed.

Posttraumatic Seizures in Children: Risk Factors and Prophylactic Antiepileptic Drugs

OBJECTIVE: Identification of risk factors and prevention of the seizures are very important in the management of the pediatric traumatic brain injury(TBI). The authors conduct a study to find the risk factors of the pediatric posttraumatic seizures(PTS) and effectiveness of the prophylactic antiepileptic drugs(AED). METHODS: We respectively analyzed 82 pediatric patients below the age of 15 who visited our hospital with TBI from August 1995 to May 2001. Mean age at arrival was 6.1 years, ranging from 2 months to 15 years. Male to female ratio was 1.9 : 1. Mean follow-up period was 3.9 months ranging from 0.5 to 42 months. RESULTS: Among the 82 patients, 13(15.8%) experienced PTS. In eight of the 13 seizure patients, the seizures developed within 24 hours after trauma. Patients with Glascow coma scale score less than 8 had higher rate of seizure attack. Forty-seven patients(58%) used AED within 24 hours after trauma. Among them, two patients experienced seizure attacks. Among the other 35 patients who had not received prophylactic AED, 11 patients(31%) had seizures with significantly higher rate of PTS. CONCLUSION: PTS are common complication in pediatric TBI. Use of prophylactic AED in the early stage of TBI can reduce the development of early seizures.

Management of Spontaneous Intracerebral Hematoma / 대한뇌혈관학회지

There are many intracranial lesions causing spontaneous intracerebral hemorrhage, including hypertension, aneurysm, arteriovenous malformation, bleeding tumor, coagulopathy, amyloid angiopathy. In fact, the management of spontaneous intracerebral hemorrhage remains still a complex problem. The patient's age and consciousness, general condition, the hematoma location, as well as the cause combine to affect the management outcome. In general, mortality and morbidity is increasing with greater patient's age and hematoma size, deeper hematoma location. The emergent care and management usually are needed in almost all the patients with medical and surgical treatments. Acute medical management is required to control increased intracranial pressure, to stablize cardiorespiratory system, and prevent further compication such as brain edema, hematoma expansion, seizure. Emergent surgical treatment should be considered when surgical removal of hematoma would be benefit the patient's condition by decreasing mass effect and protecting the secondary injury to the surrounding normal brain.