Clinical Features of Superficially Located Brain Arteriovenous Malformations with Transdural Arterial Communication.

BACKGROUND: Contrary to deeply located brain arteriovenous malformations (AVMs), superficially located AVMs are more likely to have transdural arterial communications (TACs). However, the clinical and radiologic characteristics of patients presenting with AVMs and TACs are poorly understood. The purpose of this study is to determine whether clinicoradiological features of cerebral AVMs differ according to TAC. METHODS: Between 2002 and 2012, 438 consecutive patients with a brain AVM were treated in our hospital. Among them were 124 patients with superficially located brain AVMs who met the inclusion and exclusion criteria of our study. We retrospectively reviewed the clinicoradiological features of their TACs to explore the variation in characteristics. RESULTS: Thirty-two of the 124 patients with a superficially located AVM (25.8%) had TAC. Radiologic findings of brain AVM images with TAC showed that TAC occurred significantly more frequently among larger AVMs (with vs. without TAC, 11.2 vs. 4.0 ml) and among diffuse AVMs (56.3 vs. 28.3%, p = 0.004). Clinical findings indicate that TAC was associated with chronic headache (43.8 vs. 12.0%, p < 0.001) and older age (43.1 vs. 36.6 years, p = 0.037). CONCLUSIONS: Brain AVM with TAC seems to be accompanied by distinctive clinical features, such as chronic headache and older age. Larger size and diffuseness of the AVM were also associated with TAC. Findings from this study and the prognostic significance of TAC should be further explored in a large prospective study.

Treatment outcomes of surgical clipping for unruptured anterior circulation aneurysm-single institute experiences in the era of neurophysiologic monitoring and endovascular treatment.

Recently, the treatment of intracranial aneurysms entered a new phase due to safe surgical tool such as neurophysiologic monitoring and challenged by endovascular treatment. To determine the safety of clipping surgery in the modern era, we reviewed our experiences of simple unruptured anterior circulation aneurysm surgery which is commonly performed in many places. We retrospectively reviewed 610 consecutive patients who were treated with surgical clipping under motor evoked potential (MEP) monitoring for a tiny to large anterior circulation aneurysm in a single institute between 2008 and 2012. MEP changes were identified in 40 cases (6.6 %). MEP deterioration was associated with remote site epidural hematoma (n = 1), anesthesia (n = 2), temporary clipping (n = 21), and permanent clipping (n = 16). Despite that no persistent MEP deterioration was noted after prompt corrective measures, 56 (9.2 %) patients showed symptomatic (n = 14) and asymptomatic (n = 42) radiologic abnormalities. Anterior cerebral artery (ACA) aneurysm was associated with a higher radiologic complication rate (Fisher's exact test, P < 0.05). Two (0.3 %) patients showed severe morbidity (mRS >2) at latest follow-up. MEP monitoring can be helpful in preventing postoperative motor deterioration but seems to have some limitations. Although the permanent morbidity rate was low, a significant clinical (2.3 %) or radiologic (9.2 %) abnormality rate was identified even in simple aneurysm clipping that should be taken into account when performing interdisciplinary treatment planning and patient counseling. Also, direct vascular monitoring or new neurophysiologic monitoring techniques are needed to reduce surgical complications, especially in ACA aneurysm surgery.

Efficacy of postoperative radiotherapy for high grade meningiomas.

The necessity of postoperative radiotherapy (PORT) for meningiomas remains contentious. Here, the role of PORT in patients who underwent surgical resection for WHO grade II and III meningiomas was assessed. The record of 114 patients with WHO grade II (n = 72) and III (n = 42) meningiomas treated at Samsung Medical Center between March 1995 and April 2013 were reviewed and classified according to the extent of surgical resection and implementation of PORT. Median follow-up was 55.9 months. Simpson grade (SG) I, II, III, and IV resections were achieved in 29, 56, 9 and 20 patients, respectively. The 5-year local control (LC) and overall survival rate was 65.8 and 84.2 %, respectively. Thirty patients (26.3 %) developed local failure and five patients (4.4 %) developed distant metastases. The extent of surgical resection (SG I-II vs. III-IV) was influenced by tumor location (orbital and skull base lesions vs. others, p = 0.001) and the surgeons' experience (>10 operations, p = 0.044). Extent of surgical resection was also associated with local failure, overall progression, and overall survival (p = 0.001, p < 0.001, and p < 0.001, respectively). PORT improved LC in patients with incomplete surgical resection (SG III-IV, p = 0.049). Complete resection (SG I-II) is an important prognostic factor for LC and survival, and the extent of surgical resection (SG I-II vs. III-IV) is influenced by tumor location. PORT could improve the LC in WHO grade II-III meningioma patients who underwent incomplete surgical resection (SG III-IV).

Clinical course of asymptomatic adult moyamoya disease.

BACKGROUND: As regular medical check-ups are becoming more common, the prevalence of asymptomatic moyamoya disease (MMD) is increasing. However, the definition and clinical features are still unclear. The lack of precision has hampered the establishment of guidelines for the management of asymptomatic MMD. The purpose of this study was to define and clarify the clinical characteristics of asymptomatic MMD in adults. METHODS: We identified all adults (aged ≥18 years) with MMD who underwent digital subtraction angiography or magnetic resonance angiography at our institution from 1995 through 2010. The authors defined asymptomatic MMD as asymptomatic or nonspecific symptom without any infarction or ischemia on magnetic resonance imaging. In our MMD registry, 40 patients (74 hemispheres) were identified and enrolled in this retrospective cohort study. Their demographic, radiological and clinical findings were evaluated. The log-rank test was used to assess prognostic factors. Pearson's correlation test and the Mann-Whitney U test were used to identify correlation angiographic staging and age or perfusion status. RESULTS: Overall, 6 patients underwent indirect bypass surgery and 36 received antiplatelet medication. On initial single positron emission tomography (35 patients, 67 affected hemispheres), basal and acetazolamide stress brain perfusion were decreased in 19 (28.4%) and 22 (32.8%) hemispheres, respectively. Among 70 angiographically evaluated hemispheres, 6 were unilateral MMD; 27 of 64 affected hemispheres (42.2%) had transdural collateral at evaluation. Age (p = 0.309, Pearson's correlation test) and hemodynamic impairment (p = 0.614, Mann-Whitney U test) did not correlate with angiographic staging. During a median 32-month (range 6-203) clinical follow-up, 3 nonsurgically treated patients had a transient ischemic attack, which was associated with decreased vascular reserve (p < 0.001, log-rank test) and smoking (p = 0.017). Other variables did not show a significant association with clinical progression. During a median 24-month (range 12-108) radiological follow-up, 3 patients displayed angiographic progression and 3 displayed new hemodynamic abnormalities. Radiological progressions were related to hypertension only (p = 0.022). In this case series, there was no case of ischemic or hemorrhagic stroke. CONCLUSION: The findings suggest that asymptomatic MMD in adults is not a stable disease in our definition. However, stroke rate (0%) was lower than previous reports. Lifestyle modification, stroke risk factor control and/or antiplatelet medication seem to be appropriate initial treatments for patients with normal cerebrovascular reserve. A clear definition of asymptomatic MMD and further clarification of its clinical course are needed to set precise treatment guidelines.

Radiosurgery to palliate symptoms in brain metastases from uterine cervix cancer.

BACKGROUND: The optimal management of brain metastases from uterine cervix cancer (UCC) is not well defined because of the rarity of the condition and the scarcity of published reports. Here we report our experience with stereotactic radiosurgery for the management of brain metastases from UCC. METHODS: Thirteen consecutive patients with brain metastases from UCC were managed with a Leksell gamma-knife at our institution between January 2003 and December 2010. Clinical features and radiosurgical outcomes of patients were analyzed retrospectively. RESULTS: Gamma-knife radiosurgery (GKRS) was chosen as the only treatment in four patients and performed in combination with whole-brain radiotherapy (WBRT) in nine patients. GKRS was conducted simultaneously with WBRT within a 1-month interval in six patients and was chosen as the salvage treatment after WBRT in three patients. The mean number of metastatic brain lesions per patient was 5.7 (range, 1-16). The median cumulative tumor volume was 23.7 cm(3) (range, 2.7-40.2 cm(3)), and the median marginal dose covering the tumors was 14 Gy of a 50 % isodose line (range, 8-25 Gy). Nine patients showed relief of main neurologic symptoms after GKRS. The median length of time that the patients spent in an improved neurologic state was 11.1 weeks (range, 2-39.6 weeks). The local and distant control rates were 66.7 % and 77.8 %, respectively. The median survival from the date of GKRS until death was 4.6 months (range, 1.0-15.9 months). The 6-month and 12-month survival rates after GKRS were 38 and 15 %, respectively. CONCLUSIONS: GKRS could be an efficient palliative measure to relieve neurologic symptoms caused by brain metastasis from UCC.

Effects of Recycled Polymer on Melt Viscosity and Crystallization Temperature of Polyester Elastomer Blends.

As the world is paying attention to the seriousness of environmental pollution, the need for a resource circulation economy is emerging due to the development of eco-friendly industrial groups. In particular, the recycling of thermoplastic elastomers without cross-link has been highlighted in the plastics field, which has rapidly developed the industry. Growing interests have been directed towards the advancement of thermoplastic polyether-ester elastomer (TPEE) as a material suitable for the circular economy owing to its remarkable recyclability, both in terms of mechanical and chemical processes. Due to its excellent processability, simple mechanical recycling is easy, which is a driving force towards achieving price competitiveness in the process. In molding TPEE resin, it is essential to check the thermal properties of the resin itself because the thermal properties, including the melting and crystallization temperatures of the resin, depend on the design of the polymer. In this study, the thermal and mechanical performances of TPEE blends were evaluated by manufacturing compounds by changing the amount of recycled resin and additives. When the recycled resin was added, the melt flow index (MFI) changed rapidly as the temperature of the melt flow index measurement increased. Rapid changes in MFI make the fiber spinning process uncontrollable and must be controlled by optimizing the addition of compatibilizers. Based on the thermal property results, compatibilizers such as Lotader and Elvaloy series exhibited minimal change in glass transition temperature, even with greater amounts added. This makes them well-suited as compatibilizers for fiber spinning.

Leptomeningeal seeding in patients with brain metastases treated by gamma knife radiosurgery.

To characterize the development of leptomeningeal seeding (LMS) in patients with brain metastases after gamma knife radiosurgery (GKRS). Eight hundred and twenty-seven patients that underwent GKRS as a part of an initial treatment plan for brain metastases between January 2002 and December 2010 were included in the study. Six hundred and fifty patients were treated with GKRS alone and 177 patients received GKRS combined with upfront whole brain radiation therapy (WBRT). Actuarial curves for overall survival (OS) and the development of LMS were plotted using the Kaplan-Meier method. Median overall survival for all patients was 55 weeks (95 % CI, 47.8-62.2), and the overall incidence of LMS was 5.3 %. The actuarial rates for LMS at 6 and 12 months were 3.1 and 5.8, respectively. Uni- and multivariate analysis suggested that breast cancer and a large number of metastases (n ≥ 4) are significant risk factors of LMS (P < 0.05). Regarding treatment modalities, the addition of WBRT was found to have a significant impact on lowering the risk of LMS by multivariate analysis (P = 0.045). LMS is an important pattern of CNS failure. The risk of LMS following GKRS may be associated with multiple lesions, breast cancer, and the omission of WBRT. Additional data from large-scale, randomized controlled trials are required to identify risk factors associated with the LMS more accurately.

Microsurgical resection of deep-seated lesions using transparent tubular retractor: pediatric case series.

BACKGROUND: To facilitate effective resection of deep-seated brain lesions without causing significant trauma to the overlying cortex, the authors used a transparent plastic tubular retractor to approach these lesions. METHODS: Between July 2009 and January 2011, we used an 11-mm diameter transparent plastic tubular retractor in combination with a frameless stereotactic navigation system to remove 18 deep lesions. RESULTS: Gross total resection of the lesions was achieved in 14 of 18 patients, and subtotal removal occurred in four patients. Effective resection of lesions was achieved in all patients through small size craniotomy window and small cortical incision. The histopathologic diagnosis was established in all 18 patients: 3 hematomas, 3 cavernous angioma, 7 low-grade glioma, 2 dysembryoplastic neuroepithelial tumor, 1 choroid plexus papilloma, 1 abscess, and 1 meningioma. CONCLUSION: Microsurgery using a transparent tubular retractor guided by a neuronavigation system facilitated accurate and effective removal of these deep-seated brain lesions.

Modified Arachnoid Plasty Reduces Chronic Subdural Hematoma after Unruptured Aneurysm Clipping : Technical Note.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a rare complication of unruptured intracranial aneurysm (UIA) clipping surgery. To prevent postoperative CSDH by reducing subdural fluid collection, we applied the modified arachnoid plasty (MAP) during the UIA clipping surgery to seal the dissected arachnoid plane. METHODS: This retrospective study included 286 patients enrolled from July 2012 to May 2015. We performed arachnoid plasty in all patients, with MAP used after June 17, 2014. Patients were divided into two groups (non-MAP vs. MAP), and by using uni- and multivariate analyses, baseline characteristics, and relationships with postoperative CSDH between the two groups were analyzed. The degree of preoperative brain atrophy was estimated using the bicaudate ratio (BCR) index. RESULTS: Ten patients (3.5%) among 286 patients had postoperative CSDH after clipping. Nine (3.1%) were in the non-MAP group, and one (0.9%) was in the MAP group. The higher BCR index showed statistical significance with occurrence of postoperative CSDH in both uni- (p=0.018) and multivariate (p=0.012, odds ratio [OR] 8.547, 95% confidence interval [CI] 1.616-45.455) analyses. MAP was associated with a lower risk of postoperative CSDH (p=0.022, OR 0.068, 95% CI 0.007-0.683). CONCLUSION: This study shows that the degree of preoperative brain atrophy is associated with an increased occurrence of CSDH after clipping and that MAP could help reduce the risk of postoperative CSDH after unruptured aneurysm clipping via a lateral supraorbital approach.

Prognostic Value of Ki-67 Labeling Index and Postoperative Radiotherapy in WHO Grade II Meningioma.

OBJECTIVE: This study was performed to determine the clinical significance of the Ki-67 labeling index (LI) for local control (LC) in patients with World Health Organization (WHO) grade II meningioma. We also tried to discern the effect of postoperative radiotherapy (PORT) on LC depending upon the Ki-67 LI value. MATERIALS AND METHODS: The medical records and values of Ki-67 LIs were retrospectively reviewed for 50 patients who underwent surgical resection of intracranial WHO grade II meningiomas at Samsung Medical Center from May 2001 to December 2012. Forty-three patients (86%) were treated with immediate PORT. The median total radiation dose was 60 Gy (range, 54 to 60 Gy). RESULTS: The median follow-up was 47.4 months. The mean Ki-67 LI was 13% (range, 1% to 47%). Twelve patients (24.0%) showed local failure, and 8 patients (16.0%) experienced local failure even after PORT. The mean Ki-67 LI was 15% in patients with local failure (n=12) and 12% in patients without local failure (n=38). The 3-year actuarial LC was 80.5%. The 3-year overall survival was 89.5%. Ki-67 LI>13% and PORT were significant prognostic factors for LC (P=0.015 and 0.009, respectively). In patients with Ki-67 LI>13% (n=17), PORT (n=14) improved LC (P<0.001). However, PORT (n=29) did not affect LC (P=0.412) for patients with Ki-67 LI≤13% (n=33). CONCLUSIONS: Ki-67 LI can be a useful prognostic factor for LC in WHO grade II meningioma. In patients with Ki-67 LI>13%, PORT should be recommended to improve LC.

Clinical features of high-degree centrum semiovale-perivascular spaces in cerebral amyloid angiopathy.

BACKGROUND: There is no doubt that cerebral amyloid angiopathy (CAA) is a key risk factor for recurrent lobar ICH, however, the exact mechanism and interaction with MRI markers of disease severity are less well known. Centrum semiovale-perivascular spaces (CSO-PVS) have been suggested as adjunctive diagnostic criteria in order to enhance diagnostic power. The purposes of this study were to investigate the prevalence of CSO-PVS and its association with other imaging signatures {lobar microbleeds (CMB), cortical superficial siderosis (CSS), white matter hyperintensity (WMH)} in lobar ICH patients as well as recurrent lobar ICH risk, especially in patients taking antithrombotic agents. METHODS: This retrospective study included 85 patients who visited our institute between 2005 and 2013 with lobar ICH on magnetic resonance imaging(MRI). CSO-PVS were rated on axial T2-weighted sequences using a validated 2-point visual rating scale (high degree >20, low degree ≤20). The CSS, CMB and WMH were also evaluated. The relationship between CSO-PVS, CSS, CMB, antithrombotic usage and recurrent bleeding were explored. RESULTS: A high degree of CSO-PVS was present in 71.8% of patients. The prevalence of CSS and CMB was higher in patients with a high degree of CSO-PVS (CSS, 49.2% vs. 16.7%, P=0.006; CMB count, 7.3% vs. 2.1%, P=0.002). A high degree of CSO-PVS and antithrombotic usage following lobar ICH was not associated with recurrent hemorrhage. In multivariate logistic regression analysis of predictors of recurrent lobar ICH in lobar ICH patients, post-ICH antithrombotics use and disseminated CSS are independently associated with increased risk of recurrent lobar ICH. CONCLUSIONS: High-degree CSO-PVS is highly prevalent in probable cerebral amyloid angiopathy and is related to CSS and CMB. Disseminated CSS was associated with recurrent ICH in CAA. Our study might help physicians decide whether or not to use antithrombotic agents in hemorrhagic stroke patients with a high risk of ischemic stroke. A large prospective study is warranted to validate these findings.

Recurrent Bleeding in Hemorrhagic Moyamoya Disease : Prognostic Implications of the Perfusion Status.

OBJECTIVE: Hemorrhagic moyamoya disease (hMMD) is associated with a poor clinical course. Furthermore, poorer clinical outcomes occur in cases of recurrent bleeding. However, the effect of hemodynamic insufficiency on rebleeding risk has not been investigated yet. This study evaluated the prognostic implications of the perfusion status during the clinical course of adult hMMD. METHODS: This retrospective study enrolled 52 adult hMMD patients between April 1995 and October 2010 from a single institute. Demographic data, clinical and radiologic characteristics, including hemodynamic status using single photon emission computed tomography (SPECT), and follow up data were obtained via a retrospective review of medical charts and imaging. Statistical analyses were performed to explore potential prognostic factors. RESULTS: Hemodynamic abnormality was identified in 44 (84.6%) patients. Subsequent revascularization surgery was performed in 22 (42.3%) patients. During a 58-month (median, range 3-160) follow-up assessment period, 17 showed subsequent stroke (hemorrhagic n=12, ischemic n=5, Actuarial stroke rate 5.8±1.4%/year). Recurrent hemorrhage was associated with decreased basal perfusion (HR 19.872; 95% CI=1.196-294.117) and omission of revascularization (10.218; 95%; CI=1.532-68.136). CONCLUSION: Decreased basal perfusion seems to be associated with recurrent bleeding. Revascularization might prevent recurrent stroke in hMMD by rectifying the perfusion abnormality. A larger-sized, controlled study is required to address this issue.

Prevalence and clinical implications of renal artery stenosis in pediatric moyamoya disease.

PURPOSE: Until recently, extracranial involvement of moyamoya disease (MMD) had not been fully elucidated. The purpose of this study was to determine the prevalence and clinical implications of renal artery stenosis in pediatric MMD patients. MATERIALS & METHODS: This retrospective study included 101 pediatric (<18 years old) MMD patients who visited our hospital from July 2008 to May 2013. All patients had legible abdominal or renal angiography. Baseline characteristics, including hypertension (HT) and angiographic findings, were retrospectively evaluated. RESULT: The median age was 8 (range 2-16) years. Six patients (5.9%) had HT. Renal artery stenosis was identified in 8 patients (7.9%). Five of 8 renal artery stenosis patients had HT. Statistical analysis showed that advanced stages of MMD and HT were associated with renal artery stenosis (p < 0.05). CONCLUSION: Renal artery stenosis was not uncommon in pediatric MMD. Renal artery evaluation could help determine the cause of HT in advanced pediatric MMD cases. Further prospective and large-scale studies may be helpful in elucidating the extracranial manifestation of MMD.

Predictive Factors for Response of Intracranial Dural Arteriovenous Fistulas to Transarterial Onyx Embolization: Angiographic Subgroup Analysis of Treatment Outcomes.

OBJECTIVE: Endovascular treatment using Onyx has been increasingly used to treat intracranial dural arteriovenous fistulas (DAVFs). This study evaluated predictive factors for favorable treatment outcome in patients with intracranial noncavernous DAVFs treated by transarterial Onyx embolization. METHODS: Between August 2008 and August 2014, 55 patients who underwent transarterial Onyx embolization for noncavernous DAVFs were retrospectively reviewed. Patients' demographic, clinical, and procedural data were analyzed to find statistically significant predictive factors for favorable treatment outcomes after Onyx embolization. Fistulas were classified angiographically according to the relationship between fistulas and dural venous sinuses and the presence of leptomeningeal venous reflux. RESULTS: Sixty-eight Onyx embolizations were performed in 55 patients. Immediate angiographic cure was achieved in 28 patients, and 14 of 27 patients with residual shunts showed progressive occlusion at follow-up imaging studies. Therefore, the overall favorable treatment outcome was 76.4% (42/55). The remaining 13 patients (23.6%) showed persistent residual shunts, and 3 (5.5%) of them showed aggravation of residual lesion on follow-up studies. Of 25 patients with non-sinus fistulas, 23 patients (92%) showed favorable treatment outcomes, and 19 of 30 patients (63.3%) with sinus fistulas showed favorable outcomes. Among the evaluated variables, non-sinus DAVFs was a statistically significant predictive factor for favorable response to transarterial Onyx embolization (P < 0.05). CONCLUSIONS: Transarterial Onyx embolization is a highly effective treatment method for non-sinus DAVFs. Careful consideration of angiographic features and multimodal embolization strategies are required for treatment of sinus DAVFs.

Endovascular treatment of unruptured ophthalmic artery aneurysms: clinical usefulness of the balloon occlusion test in predicting vision outcomes after coil embolization.

BACKGROUND: Endovascular coil embolization for ophthalmic artery (OphA) aneurysms has the latent risk of occlusion of the OphA during the procedure, which can lead to loss of vision. We report clinical and angiographic results of endovascular treatment of OphA aneurysms together with the efficacy of the balloon occlusion test (BOT). METHODS: From August 2005 to December 2013, 31 consecutive patients with 33 OphA aneurysms were treated in our institution. The patients were classified into two groups according to the location of the OphA within the aneurysmal sac. The BOT was performed in 28 patients using a hypercompliant balloon before endovascular coiling. Collateral circulation between the external carotid artery and the OphA was examined and visual function tests were performed before and after treatment. Patient demographics, angiographic and clinical outcomes were reviewed. RESULTS: Among the 28 patients who underwent the BOT, intact collateral circulation was demonstrated in 26 (92.9%) patients and complete occlusion of the OphA was obtained in three patients after coiling. Retrograde filling of the OphA with choroidoretinal blush was observed on post-procedural angiography and no specific visual symptoms were reported during the follow-up period. Complete embolization was achieved in 30 lesions (96.8%) and only five patients (16.1%) had minor recanalization. CONCLUSIONS: Endovascular treatment of OphA aneurysms can be performed safely and effectively in conjunction with BOT. The BOT may give useful information to predict visual outcome in patients whose OphA is likely to be threatened by the coiling procedure and to determine the optimal treatment strategy.

Transvenous Coil Embolization for Dural Arteriovenous Fistulas of the Ophthalmic Sheath: Report of Two Cases and Review of the Literature.

We present two patients with a dural arteriovenous fistula (dAVF) of the ophthalmic sheath who developed progressive exophthalmos, conjunctival chemosis, and visual loss. These symptoms mimic those of cavernous sinus dAVFs. Dural AVFs of the ophthalmic sheath are extremely rare and their clinical management is controversial. We successfully treated these two patients by transvenous coil embolization. Transvenous embolization appears to be a safe and effective method to treat dAVFs of the ophthalmic sheath.

Usefulness of Early Stenting for Symptomatic Extracranial Carotid Stenosis.

BACKGROUND: While carotid angioplasty and stenting (CAS) have become an established procedure, outcomes of early CAS for symptomatic extracranial carotid stenosis (SECS) remain poorly understood. The present study aimed at determining the effectiveness of early CAS in SECS. METHODS: Herein, 224 SECS patients underwent elective CAS between January 2008 and June 2015. The study population was stratified based on the time from symptom onset to the procedure (early CAS group: within 14 days; delayed CAS group: later than 14 days). Subgroup analysis (chi-square test, Mantel-Haenszel chi-square test, and analysis of covariance) evaluated the demographics, incidence of periprocedural thromboembolic complications, cerebral hyperperfusion syndrome (CHS), intracranial bleeding, and treatment outcomes on the modified Rankin Scale (mRS). RESULTS: Symptomatic thromboembolic complications and CHS were noted in 2.68% and 0.89% of patients, respectively. The initial National Institutes of Health Stroke Scale (NIHSS) score was significantly higher in patients who underwent early CAS than in those who underwent delayed CAS (2.50 ± 3.97 vs. 0.97 ± 2.08, P = 0.001). After adjusting for age, duration of preprocedural dual antiplatelet therapy, initial NIHSS score, and preprocedural NIHSS score, the groups did not differ significantly regarding the incidence of symptomatic thromboembolic complications (P = 0.195), incidence of CHS (P = 0.950), incidence of intracranial bleeding (P = 0.970), 30-day mRS score (P = 0.124), and mRS score at final follow-up (P = 0.132). CONCLUSIONS: For SECS patients who cannot undergo early carotid endarterectomy, early CAS is effective and safe if selectively indicated considering disease severity. Early and delayed CAS provide comparable mRS scores, incidence of symptomatic thromboembolic complications, CHS, and intracranial bleeding.

Pipeline Embolization Device for Large/Giant or Fusiform Aneurysms: An Initial Multi-Center Experience in Korea.

PURPOSE: The purpose of this study was to assess the safety and early outcomes of the Pipeline device for large/giant or fusiform aneurysms. MATERIALS AND METHODS: The Pipeline was implanted in a total of 45 patients (mean age, 58 years; M:F=10:35) with 47 large/giant or fusiform aneurysms. We retrospectively evaluated the characteristics of the treated aneurysms, the periprocedural events, morbidity and mortality, and the early outcomes after Pipeline implantation. RESULTS: The aneurysms were located in the internal carotid artery (ICA) cavernous segment (n=25), ICA intradural segment (n=11), vertebrobasilar trunk (n=8), and middle cerebral artery (n=3). Procedure-related events occurred in 18 cases, consisting of incomplete expansion (n=8), shortening-migration (n=5), transient occlusion of a jailed branch (n=3), and in-stent thrombosis (n=2). Treatment-related morbidity occurred in two patients, but without mortality. Both patients had modified Rankin scale (mRS) scores of 2, but had an improved mRS score of 0 at 1-month follow-up. Of the 19 patients presenting with mass effect, 16 improved but three showed no changes in their presenting symptoms. All patients had excellent outcomes (mRS, 0 or 1) during the follow-up period (median, 6 months; range, 2-30 months). Vascular imaging follow-up (n=31, 65.9%; median, 3 months, range, 1-25 months) showed complete or near occlusion of the aneurysm in 24 patients (77.4%) and decreased sac size in seven patients (22.6%). CONCLUSION: In this initial multicenter study in Korea, the Pipeline seemed to be safe and effective for large/giant or fusiform aneurysms. However, a learning period may be required to alleviate device-related events.

Reversible Cerebral Vasoconstriction Syndrome and Posterior Reversible Encephalopathy Syndrome Presenting with Deep Intracerebral Hemorrhage in Young Women.

Reversible cerebral vasoconstriction syndrome (RCVS) is a group of syndromes characterized by reversible segmental constriction of cerebral arteries. Posterior reversible encephalopathy syndrome (PRES) is another clinical-radiologic syndrome characterized by reversible, posterior-predominant brain edema. Although the exact causes of these reversible syndromes are poorly understood, these entities may share some common pathophysiologic elements leading to hemorrhagic strokes and rarely, deep intracerebral hemorrhage (ICH). Recent studies have suggested that endothelial dysfunction is a common pathophysiologic factor associated with these syndromes. We report on two young female patients who presented with deep ICH and were later diagnosed as RCVS and PRES. Both patients suffered from vasoconstriction and delayed ischemic stroke. Early detection of distinguishing clinical-radiologic features associated with these reversible syndromes and removing triggers would facilitate successful treatment with no complications.

Feasibility and Efficacy of Olfactory Protection Using Gelfoam and Fibrin Glue during Anterior Communicating Artery Aneurysm Surgery.

OBJECTIVE: Patients treated with surgical clipping for anterior communicating artery (A-com) aneurysm often complain of anosmia, which can markedly impede their quality of life. We introduce a simple and useful technique to reduce postoperative olfactory dysfunction in A-com aneurysm surgery. METHODS: We retrospectively reviewed the medical records of patients who underwent surgical clipping for unruptured aneurysm from 2011-2013 by the same senior attending physician. Since March 2012, olfactory protection using gelfoam and fibrin glue was applied in A-com aneurysm surgery. Therefore we categorized patients in two groups from this time-protected group and unprotected group. RESULTS: Of the 63 enrolled patients, 16 patients showed postoperative olfactory dysfunction-including 8 anosmia patients (protected group : unprotected group=1 : 7) and 8 hyposmia patients (protected group : unprotected group=2 : 6). Thirty five patients who received olfactory protection during surgery showed a lower rate of anosmia (p=0.037, OR 10.516, 95% CI 1.159-95.449) and olfactory dysfunction (p=0.003, OR 8.693, 95% CI 2.138-35.356). Superior direction of the aneurysm was also associated with a risk of olfactory dysfunction (p=0.015, OR 5.535, 95% CI 1.390-22.039). CONCLUSION: Superior direction of aneurysm appears associated with postoperative olfactory dysfunction. Olfactory protection using gelfoam and fibrin glue could be a simple, safe, and useful method to preserve olfactory function during A-com aneurysm surgery.