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1.  Relationship Between Systemic Thrombogenic or Thrombolytic Indices and Acute Increase of Spontaneous Intracerebral Hemorrhage 
Objective
The objective of this study was to determine the correlations between changes in thrombogenesis or thrombolysis related factors, and the acute increase of a spontaneous intracerebral hemorrhage (sICH).
Materials and Methods
From January 2009 to October 2011, 225 patients with sICH were admitted to our hospital within 24 hours of onset. Among them, 111 patients with hypertensive sICH were enrolled in this study. Thrombogenic or thrombolytic factors were checked at admission. The authors checked computed tomography (CT) scans at admission and followed up the next day (between 12-24 hours) or at any time when neurologic signs were aggravated. Cases in which the hematoma was enlarged more than 33% were defined as Group A and the others were defined as Group B.
Results
Group A included 30 patients (27%) and group B included 81 patients (73%). Factors including activated partial thromboplastin time, prothrombin time, fibrinogen, and D-dimer showed a greater increase in group A than in group B. Factors including antithrombin III, factor V, and factor X showed a greater increase in group A than in group B.
Conclusion
Based on the results of this study, it seems that the risk of increase in hematoma size can be predicted by serum thrombogenic or thrombolytic factors at admission.
doi:10.7461/jcen.2014.16.3.159
PMCID: PMC4205240  PMID: 25340016
Intracerebral hemorrhage; Spontaneous; Correlation; Thrombogen; Thrombolysis
2.  Primary Angioplasty for Symptomatic Atherosclerotic Middle Cerebral Artery Stenosis 
Objective
The objective of this study is to evaluate the clinical and angiographic outcomes after primary balloon angioplasty in patients with symptomatic middle cerebral artery (MCA, M1 segment) stenosis refractory to medical therapy.
Materials and Methods
Eleven patients with intracranial stenosis were treated with primary balloon angioplasty. All patients had MCA stenosis with recurrent transient ischemic attack (TIA). The indication for balloon angioplasty was patients with significant MCA stenosis: 1) age older than 18 years with recurrent or progressive TIA or infarction despite optimal medical therapy, including anti-coagulation, dual anti-platelet, and anti-lipid medication; 2) previous ischemic events or asymptomatic severe stenosis (more than 50%) with poor collateral cerebral circulation, or diminished cerebral perfusion on single photon emission computed tomography before and after administration of the intravenous dosage of acetazolamide.
Results
The median age of patients was 53 years (range 44-79). The technical success rate was 100%. Mean pretreatment stenosis degree was 83.63 ± 9.53% and 29.1 ± 15.4% before and after angioplasty, respectively. Procedural-related complications occurred in four of 11 patients (36%), but none of the patients had permanent neurological deficit. All patients were available for an average follow-up period of 19.4 ± 5.1 months. One patient had a stroke in the territory of angioplasty at two months after angioplasty. The stroke free survival rate at 30 days and 12 months was 100% and 91%, respectively. Restenosis over 50% was observed in three of 11 patients (27%); all were asymptomatic.
Conclusion
Intracranial angioplasty for symptomatic MCA stenosis refractory to medical therapy can be a treatment option to reduce the risk of further TIA or stroke.
doi:10.7461/jcen.2014.16.3.166
PMCID: PMC4205241  PMID: 25340017
Balloon angioplasty; Middle cerebral artery; Intracranial stenosis; Atherosclerosis
3.  Thromboembolic Event Detected by Diffusion Weighted Magnetic Resonance Imaging After Coil Embolization of Cerebral Aneurysms 
Objective
The purpose of this study was to evaluate the occurrence rate of diffusion positive lesions (DPLs), and to assess the peri-procedural risk factors for the occurrence of DPLs in patients who underwent coil embolization of cerebral aneurysms.
Materials and Methods
A total of 304 saccular aneurysms were embolized during a seven-year period from Jan 2007 to Dec 2013. Of these, postoperative diffusion-weighted images were obtained in 186 procedures. There were 100 ruptured aneurysm and 86 unruptured aneurysms. The coiling procedures were as follows: simple coiling in 96, balloon assisted coiling (BAC) in 39, and stent assisted coiling (SAC) in 51 aneurysms. Clinical, angiographic and procedural factors were analyzed in relation to the occurrence of DPLs.
Results
Overall, DPLs were observed in 50.5%. In unruptured aneurysms, DPLs occurred in 23.5% of BAC, 41.9% of SAC and 57.7% of simple coiling (p = 0.08). Among ruptured aneurysms, DPLs occurred in 63.6% of BAC, 62.5% of SAC and 54.3% of simple coiling (p = 0.71). DPLs had a tendency to increase in ruptured aneurysms compared with unruptured aneurysms (57% vs. 43%, p = 0.077). Logistic regression analysis revealed that age > 55 years was the only independent risk factor for the occurrence of DPLs.
Conclusion
DPLs occured more frequently in ruptured aneurysm and at an older age. Although most DPLs are asymptomatic, careful manipulation of cerebral or extracerebral arteries using various endovascular devices is important to reducing the occurrence of DPLs. BAC appeared to reduce occurrence of TE events in patient with unruptured aneurysm.
doi:10.7461/jcen.2014.16.3.175
PMCID: PMC4205242  PMID: 25340018
Thromboembolism; Aneurysm; Embolization; Balloon assisted coiling; Diffusion positive lesions
4.  Location and Characteristics of Warfarin Associated Intracranial Hemorrhage 
Objective
In the so-called primary intracerebral hemorrhage (ICH), lobar and deep ICH were mainly due to cerebral amyloid angiopathy and deep perforating arterial disease. Our aim was to identify specifics of warfarin associated ICH (WAICH) and to focus on differences in susceptibility to warfarin according to the underlying vasculopathies, expressed by ICH location.
Materials and Methods
We identified all subjects aged ≥ 18 years who were admitted with primary ICH between January 1, 2007 and September 30, 2012. We retrospectively collected demographic characteristics, the presence of vascular risk factors and pre-ICH medication by chart reviews. We categorized ICH into four types according to location: lobar, deep, posterior fossa, and undetermined. We investigated characteristics (including hematoma volume and expansion) of ICH according to the location of ICH.
Results
WAICH accounted for 35 patients (5.6%) of 622 ICH cases. In WAICH, 13 patients (37.1%) had lobar ICH and 22 patients (60.0%) had non-lobar ICH. Compared to other locations of ICH, lobar ICH showed an excess risk of WAICH (OR 2.53, 95% CI 1.03-6.21, p = 0.042). The predictors of lobar location of ICH were warfarin (OR 2.29, 95% CI 1.05-5.04, p = 0.038) and diabetes mellitus (DM) (OR 0.54, 95% CI 0.29-0.98, p = 0.044). The lobar location of ICH showed significant association with larger hematoma volume (p = 0.001) and high ratio of hematoma expansion (p = 0.037) compared with other locations of ICH.
Conclusion
In our study, warfarin showed significant association with lobar ICH and it caused larger hematoma volume and more expansion of hematoma in lobar ICH.
doi:10.7461/jcen.2014.16.3.184
PMCID: PMC4205243  PMID: 25340019
Warfarin; Cerebral amyloid angiopathy; Intracerebral hemorrhage
5.  Clinical Outcomes of Treatment for Intracranial Aneurysm in Elderly Patients 
Objective
The aim of this study is to evaluate the clinical course of intracranial aneurysm in patients aged 65 years and older and the immediate outcome after its aggressive management.
Materials and Methods
We performed a retrospective analysis using the medical records of 159 elderly patients managed at our institute from September 2008 to December 2013. Obtained clinical information included age, sex, Hunt and Hess grade (HHG), aneurysm location, Fisher grade (FG) and the treatment modality. Concomitant clinical data aside from cerebrovascular condition (hypertension, diabetes, previous medication) were evaluated to determine risk factors that might affect the functional outcomes.
Results
A total of 108 patients (67.9%) presented with subarachnoid hemorrhage (SAH), and 51 (32.1%) with unruptured intracranial aneurysms (UIAs). Coiling was performed in 101 patients and 58 patients underwent clipping. In the SAH population, 62 patients (57.4%) showed favorable outcomes, with a mortality rate of 11.3% (n = 18). In the UIAs population, 50 (98%) patients achieved 'excellent' and one (2%) achieved 'good' outcome. Factors including high-grade HHG (p < 0.001), advanced age (p = 0.014), and the presence of intraventricular hematoma (IVH) (p = 0.017) were significant predictors of poor outcome.
Conclusion
SAH patients with high grade HHG and IVH are associated with poor outcome with statistical significance, all the more prominent the older the patient is. Therefore, the indication for aggressive therapy should be considered more carefully in these patients. However, as the outcomes for elderly patients with UIAs were excellent regardless of the treatment modality, aggressive treatment could always be considered in UIAs cases.
doi:10.7461/jcen.2014.16.3.193
PMCID: PMC4205244  PMID: 25340020
Elderly; Intracranial aneurysm; Subarachnoid hemorrhage; Outcome; Microsurgical clipping; Endovascular coiling
6.  Endovascular Treatment of the Distal Internal Carotid Artery Large Aneurysm 
Objective
According to the development of endovascular technique and devices, larger aneurysms on the distal internal carotid artery (ICA) can be treated using a less invasive method. The authors report on clinical and angiographic outcomes of these aneurysms treated using an endovascular technique.
Materials and Methods
Data on 21 patients with large aneurysms at distal ICA treated by endovascular method between January 2005 and December 2012 were included in this retrospective analysis.
Results
Clinical outcome of patients showed strong correlation with the initial neurologic status (p < 0.05). Aneurysm morphology showed saccular, fusiform, and wide-neck in 12, six and three patients. Six patients underwent stent assisted coiling and the other 15 patients underwent simple coiling. Aneurysm occlusion was performed immediately after embolization with near-complete (Raymond class 1-2) in 20 patients (95.2%) and incomplete (Raymond class 3) in one patient (4.8%). Delayed thrombotic occlusion occurred in two patients and their clinical result was fatal. Another five patients died in the hospital, from massive brain edema and/or increased intracranial pressure due to initial subarachnoid hemorrhage. Overall mortality was 30% (seven out of 21). Fatal complication related to the endovascular procedure occurred in two patients with thrombosis at middle cerebral artery (one with stent, the other without it).
Conclusion
Recent developed endovascular device and technique is safe enough and a less invasive method for distal large or giant aneurysms. Based on our analysis of the study, we suspect that coil embolization of large distal ICA aneurysms (with or without stenting) is effective and safe.
doi:10.7461/jcen.2014.16.3.200
PMCID: PMC4205245  PMID: 25340021
Large aneurysm; Internal carotid artery; Endovascular; Stent
7.  Age and Meteorological Factors in the Occurrence of Spontaneous Intracerebral Hemorrhage in a Metropolitan City 
Objective
The aim of this study was to investigate the correlation between meteorological factors and occurrence of spontaneous intracerebral hemorrhage (ICH) according to age.
Materials and Methods
We retrospectively analyzed the records of 735 ICH patients in a metropolitan hospital-based population. Observed and expected numbers of ICH patients were obtained at 5℃ intervals of ambient temperature and a ratio of observed to expected frequency was then calculated. Changes in ambient temperature from the day before ICH onset day were observed. The Wilcoxon-Mann-Whitney test was used to test differences in meteorological variables between the onset and non-onset days. The Kruskal-Wallis test was used for comparison of meteorological variables across gender and age.
Results
ICH was observed more frequently (observed/expected ratio ≥ 1) at lower mean, minimum, and maximum ambient temperature (p = 0.0002, 0.0003, and 0.0002, respectively). Significantly lower mean, minimum, and maximum ambient temperature, dew point temperature, wind speed, and atmospheric pressure (p = 0.0003, 0.0005, 0.0001, 0.0013, 0.0431, and 0.0453, respectively) was observed for days on which spontaneous ICH occurred. In the subgroup analysis, the ICH onset day showed significantly lower mean, minimum, and maximum ambient temperature, dew point temperature, relative humidity, and higher atmospheric pressure in the older (≥ 65 years) female group (p = 0.0093, 0.0077, 0.0165, 0.0028, 0.0055, and 0.0205, respectively).
Conclusion
Occurrence of spontaneous ICH is closely associated with meteorological factors and older females are more susceptible to lower ambient temperature.
doi:10.7461/jcen.2014.16.3.209
PMCID: PMC4205246  PMID: 25340022
Age; Meteorology; Spontaneous intracerebral hemorrhage
8.  Clinico-radiological Characteristics of Spontaneous Basal Ganglia Hemorrhage, According to Regional Classification 
Objective
The clinico-radiologic features of the spontaneous basal ganglia hemorrhage (BGH) may often differ one from another, according to its regional location. Therefore, we attempted to classify the BGH into regional subgroups, and to extrapolate the distinct characteristics of each group of BGH.
Materials and Methods
A total of 103 BGHs were analyzed by retrospective review of medical records. BGH was classified according to four subgroups; anterior BGH; posterior BGH; lateral BGH; massive BGH.
Results
The most common BGH was the posterior BGH (56, 54.4%), followed by the lateral BGH (26, 25.2%), the massive BGH (12, 11.7%), and the anterior BGH (9, 8.7%). The shape of hemorrhage tended to be round in anterior, irregular in posterior, and ovoid in lateral BGH. A layered density of hematoma on initial computed tomography showed correlation with hematoma expansion (p = 0.016), which was observed more often in the postero-lateral group of BGH than in the anterior BGH group. Relatively better recovery from the initial insult was observed in the lateral BGH group than in the other regional BGH groups. The proportion of poor outcome (modified Rankin scale 4, 5, 6) was 100% in the massive, 41.1% in the posterior, 34.6% in the lateral, and 0% in the anterior BGH group.
Conclusion
We observed that BGH can be grouped according to its regional location and each group may have distinct characteristics. Thus, a more sophisticated clinical strategy tailored to each group of BGHs can be implemented.
doi:10.7461/jcen.2014.16.3.216
PMCID: PMC4205247  PMID: 25340023
Basal Ganglia; Hemorrhage; Outcome; Classification
9.  Clinical Outcome of Paraclinoid Internal Carotid Artery Aneurysms After Microsurgical Neck Clipping in Comparison with Endovascular Embolization 
Objective
Because of the complex anatomical association among vascular, dural, and bony structures, paraclinoid internal carotid artery (ICA) aneurysms remain a major challenge for vascular neurosurgeons. We studied the clinical outcomes of 61 paraclinoid ICA aneurysms after microsurgical clipping in comparison with endovascular coiling.
Materials and Methods
Between January 2008 and December 2012, we treated 61 paraclinoid ICA aneurysms created by surgical clipping or endovascular coiling. Preoperative neurologic status and postoperative outcome were evaluated using the Glasgow coma scale (GCS) and the modified Rankin scale (mRS). Postoperative hydrocephalus and vasospasm were reviewed using the patients' medical charts.
Results
Most patients were in good clinical condition before the operations and had good treatment outcomes. Clinical vasospasm was observed after the operation in five patients, and hydrocephalus occurred in six patients. No statistically significant difference regarding aneurysm size, sex, GCS score, H-H grade, and mRS was observed between the surgical clipping group and the endovascular coiling group. In addition, the treatment results and complications did not show statistically significant difference in either group.
Conclusion
Surgical occlusion of paraclinoid ICA aneurysms is difficult; however, no significant differences were observed in the treatment results or complications when compared with coil embolization. In particular, use of an adequate surgical technique may lead to better outcomes than those for coil embolization in the treatment of large and/or wide-neck paraclinoid ICA aneurysms.
doi:10.7461/jcen.2014.16.3.225
PMCID: PMC4205248  PMID: 25340024
Paraclinoid aneurysms; Microsurgical clipping; Endovascular coiling; Outcome
10.  The Usefulness of the Frontolateral Approach as a Minimally Invasive Corridor for Clipping of Anterior Circulation Aneurysm 
Objective
Several studies have reported on the effectiveness of fronto-lateral craniotomy in reducing the operating time and post-operative complications. However, no study has practically evaluated this method from the cosmetic point of view.
Materials and Methods
We designed this study for comparison of the clinical differences and cosmetic outcomes between the frontolateral craniotomy and the conventional pterional craniotomy for clipping of unruptured intracranial aneurysms. We performed a retrospective analysis of the two groups based on their medical records and radiologic findings juxtaposed with their length of hospital stay, intensive care unit day and operation time, and the emergence of postoperative complication, mean size of aneurysm, and temporal depression.
Results
After careful comparison of the thickness of temporalis muscle between the craniotomy side and the contralateral side, the results clearly showed that the conventional pterional craniotomy group was asymmetric by a p value of 0.152 and the frontolateral craniotomy group was symmetric by a p value of 0.002.
Conclusion
Frontolateral craniotomy could be a practical alternative for patients with an unruptured intracranial aneurysm in the anterior circulation including the posterior communicating artery, particularly those who are in a medically poor state or who highly demand minimal aesthetic mutilation.
doi:10.7461/jcen.2014.16.3.235
PMCID: PMC4205249  PMID: 25340025
Frontolateral craniotomy; Temporal depression; Conventional pterional craniotomy; Unruptured intracranial aneurysm; Clipping; Minimal aesthetic mutilation
11.  Clinicoepidemiological Features of Asymptomatic Moyamoya Disease in Adult Patients 
Objective
The aim of this study was to document the natural course of asymptomatic adult moyamoya disease (MMD) and the factors related to disease progression to aid in treatment decisions.
Materials and Methods
Among 459 adult MMD patients (aged ≥ 20 years), 42 patients were included in this retrospective cohort study. Clinical records of adult asymptomatic MMD patients (n = 42) and follow-up data from September 2013 were reviewed to determine the factors related to disease progression.
Results
The mean age of patients at the time of diagnosis was 41.2 years (range, 23-64 years), and the mean follow-up period was 37.3 months (range, 7.4-108.7 months). Of the 42 patients and 75 hemispheres, there were 12 patients (28.6%) and 13 hemispheres (17.3%) with disease progression. There were four hemispheres (5.3%) with symptomatic progression (three hemorrhage, one transient ischemic attack) and nine hemispheres (12.0%) with asymptomatic radiographic progression. There were no relationships with sex, diabetes, hypertension, thyroid disease, family history of MMD, or family history of stroke. However, reduced initial cerebrovascular reserve capacity was observed in seven hemispheres (9.3%) in patients with disease progression. A relationship was found between disease progression and initial cerebrovascular reserve capacity (p = 0.05). None of the patients underwent bypass surgery during the follow-up period.
Conclusion
It appears that asymptomatic adult MMD is not a permanent stable disease. In particular, reduced cerebrovascular reserve capacity is an indication of MMD progression, so close regular observation is needed.
doi:10.7461/jcen.2014.16.3.241
PMCID: PMC4205250  PMID: 25340026
Asymptomatic disease; Cerebrovascular insufficiency; Moyamoya disease
12.  Clinical Analysis and Surgical Considerations of Atherosclerotic Cerebral Aneurysms: Experience of a Single Center 
Objective
Atherosclerotic cerebral aneurysms are known to increase occurrence of thromboembolic events and occlusion of perforator vessels intraoperatively due to pathological changes in the vessels themselves. In the current study, we analyzed the points to be considered during surgery for atherosclerotic cerebral aneurysms and the postoperative results.
Materials and Methods
We retrospectively reviewed the medical records, radiological results, and surgical records, including intraoperative video recordings and photographs, of 262 patients who underwent cerebral aneurysm surgery. We then performed a detailed analysis of aneurysm features, surgical methods, and clinical outcomes.
Results
Among 278 aneurysms in 262 patients, 73 aneurysms in 67 patients showed atherosclerotic features (atherosclerotic group, AG), and 205 aneurysms in 195 patients showed no evidence of atherosclerosis (non-atherosclerotic group, NAG). In the AG, clipping with multiple permanent clips was performed in 14 aneurysms, and clip slippage was found in four cases. Six AG cases had a remnant neck after clipping, which was significantly more frequent than in the NAG (p < 0.05). Clinical outcomes and surgery-related complications did not differ significantly between the two groups.
Conclusion
In the surgical repair of aneurysms, the incidence of ischemia, which is irreversible or severe, might be greater in atherosclerotic than in non-atherosclerotic aneurysms. In addition, multiple clips might be applied to atherosclerotic aneurysms for effective obliteration and an aneurysm neck might be left to avoid a region of atheroma.
doi:10.7461/jcen.2014.16.3.247
PMCID: PMC4205251  PMID: 25340027
Intracranial aneurysm; atherosclerosis; surgical procedure
13.  Decompressive Surgery in Patients with Poor-grade Aneurysmal Subarachnoid Hemorrhage: Clipping with Simultaneous Decompression Versus Coil Embolization Followed by Decompression 
Objective
In addition to obliterating the aneurysm using clipping or coiling, decompressive surgery for control of rising intracranial pressure (ICP) is thought to be crucial to prevention of adverse outcomes in patients with poor grade aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the clinical characteristics of patients with poor-grade aSAH, and compared outcomes of aneurysmal clipping with simultaneous decompressive surgery to those of coil embolization followed by decompression.
Materials and Methods
In 591 patients with aSAH, 70 patients with H-H grade IV and V underwent decompressive surgery including craniectomy, lobectomy, and hematoma removal. We divided the patients into two groups according to clipping vs. coil embolization (clip group vs. coil group), and analyzed outcomes and mortality.
Results
Aneurysmal clipping was performed in 40 patients and coil embolization was performed in 30 patients. No significant differences in demographics were observed between the two groups. Middle cerebral artery and posterior circulation aneurysms were more frequent in the clip group. Among 70 patients, mortality occurred in 29 patients (41.4%) and 61 patients (87.1%) had a poor score on the Glasgow outcome scale (scores I-III). No significant difference in mortality was observed between the two groups, but a favorable outcome was more frequent in the coil group (p < 0.05).
Conclusion
In this study, despite aggressive surgical and endovascular management for elevated ICP, there were high rates of adverse outcomes and mortality in poor-grade aSAH. Despite poor outcomes overall, early coil embolization followed by decompression surgery could lead to more favorable outcomes in patients with poor-grade aSAH.
doi:10.7461/jcen.2014.16.3.254
PMCID: PMC4205252  PMID: 25340028
Subarachnoid hemorrhage; Intracranial aneurysm; Decompressive craniectomy; Endovascular; Microsurgery; Intracranial hypertension
14.  Endovascular Coil Embolization After Clipping: Endovascular Treatment of Incompletely Clipped or Recurred Cerebral Aneurysms 
Objective
The presence of a cerebral aneurysm remnant after surgical clipping is associated with a risk of regrowth or rupture. For these recurred aneurysms, coil embolization can be considered as a treatment option. We retrospectively reviewed cases of ruptured or regrown aneurysms after clipping treated by endovascular coil embolization.
Materials and Methods
We conducted a retrospective review of patients with ruptured or recurred aneurysm after clipping, who underwent coil embolization between January 1995 and December 2013. We evaluated clinical information and the outcomes of these cases.
Results
Eight patients were treated by endovascular coil embolization after surgical clipping. Six aneurysms were located in the anterior communicating artery, one in the posterior communicating artery, and one in the middle cerebral artery bifurcation. All patients were initially treated by surgical clipping because of a ruptured aneurysm. Aneurysm recurrence at the initial clipping site was detected in all cases. The median interval from initial to second presentation was 42 months. In four patients, aneurysms were detected before rupture and the four remaining patients presented with recurrent subarachnoid hemorrhage. All patients were treated by coil embolization and showed successful occlusion of aneurysms without complications.
Conclusion
Endovascular coil embolization can be a safe and successful treatment option for recurred aneurysms after clipping.
doi:10.7461/jcen.2014.16.3.262
PMCID: PMC4205253  PMID: 25340029
Intracranial aneurysm; Recurrence; Coil embolization; Clipping
15.  Retrieval of Unintended Migrated Detached Coil: Case Report 
Owing to the rapid development of intervention techniques and devices, endovascular coil embolization of cerebral arteries has become standardized. It is particularly preferred when a patient presents with an unruptured intracranial aneurysm of the posterior communicating artery (PcomA). However, the risk of thrombogenic complications of the coil migration may also result in a large cerebral infarction.
When coil migration occurs during embolization, a procedure for removal of the embolic coil should be performed immediately. We experienced a clinically rare case of migration of a framing coil to the distal middle cerebral artery aneurysm during endovascular embolization of an unruptured PcomA aneurysm. The migrated coil was barely retrieved using snare techniques.
doi:10.7461/jcen.2014.16.3.268
PMCID: PMC4205254  PMID: 25340030
Aneurysm; Coil distal migration; Coil retrieval; Frame
16.  Delayed Vascular Claudication Following Diagnostic Cerebral Angiography: A Rare Complication of the AngioSeal Arteriotomy Closure Device 
With rapidly increasing numbers of neuroendovascular procedures performed annually in recent years, use of arterial closure devices after femoral artery access has been exceedingly common secondary to reduced time to hemostasis, decreased patient discomfort, earlier mobilization, and shortened hospital stay. Although uncommon, use of these devices can lead to a different spectrum of complications, as compared to manual compression. Ischemic symptoms following the use of these devices can have unexpected clinical sequelae and can occur in a delayed fashion. Awareness and recognition of such complications is important with the dramatically increased use of these devices in recent years. We report on a case of delayed vascular complication manifesting as vascular claudication following use of the AngioSeal closure device.
doi:10.7461/jcen.2014.16.3.275
PMCID: PMC4205255  PMID: 25340031
AngioSeal; Cerebral angiography; Closure device; Complication; Manual compression; Vascular
17.  Spontaneous Thrombolysis of Multiple Thrombi at Distal Region of Hypoplastic Vertebral Artery After Stent-assisted Angioplasty on Vertebral Artery Origin Stenosis: Angiographic Follow-up 
Vertebral artery hypoplasia (VAH) can be easily overlooked if the contralateral side vertebral artery is intact, because of compensation by the contralateral artery or cerebral collateral network. The clinical relevance and hemodynamic impact of VAH is still controversial. However, VAH has recently been considered a risk factor for posterior circulation ischemia. Ischemic stroke is seldom caused by free floating thrombi (FFT) in the artery. Pathophysiology of FFT has not yet been clarified. The state of reduced blood flow such as a vertebral artery origin stenosis may cause FFT. Their instability may make them sources of recurrent artery to artery embolism. Patients with FFT will require appropriate medical and endovascular treatment.
The current case illustrates a short-term angiographic change of spontaneous thrombolysis of VAH and multiple thrombi at the distal region of the stenosed lesion after stent-assisted angioplasty for a vertebral artery origin stenosis.
doi:10.7461/jcen.2014.16.3.281
PMCID: PMC4205256  PMID: 25340032
Vertebral artery hypoplasia; Free floating thrombi; Endovascular treatment; Vertebral artery origin stenosis
18.  Surgical Recanalization of Distal Middle Cerebral Artery Occlusion Due to a Coil Migration During Endovascular Coil Embolization: A Case Report 
Coil migration into the parent artery during endovascular coil embolization is a rare, but life-threatening complication, which can induce thromboembolism and result in poor outcome. A 63-year-old man was referred to Chonbuk National University Hospital emergency center due to migration of a coil for a left middle cerebral artery bifurcation unruptured aneurysm. We performed an emergency craniectomy to remove the coil migrated to the distal M2 branch and thrombus, and aneurysmal neck clipping for his aneurysm. Fortunately, at the six month follow-up, the patient did not show any noticeable neurological sequela. In case of parent artery occlusion due to coil migration an immediate recanalization should be performed by a neurovascular specialist who can provide both surgical treatment and endovascular management in order to prevent severe sequela or even death.
doi:10.7461/jcen.2014.16.3.287
PMCID: PMC4205257  PMID: 25340033
Endovascular coil embolization; Cerebrovascular complication; Neurosurgical procedure
19.  Aneurysm of the Posterior Meningeal Artery Embedded Within a Dorsal Exophytic Medullary Hemangioblastoma: Surgical Management and Review of Literature 
Hemangioblastomas are World Health Organization (WHO) Grade I neoplasms of the hindbrain and spinal cord, whose management can be complicated by preoperative hemorrhage. We report on a case of a young female in extremis with posterior fossa hemorrhage following rupture of a fusiform posterior meningeal artery aneurysm embedded within a medullary hemangioblastoma. We discuss management options, including operative staging and embolization, and review similar cases of hemangioblastoma associated with aneurysm.
doi:10.7461/jcen.2014.16.3.293
PMCID: PMC4205258  PMID: 25340034
Aneurysm; Hemangioblastoma; Embolization; Posterior fossa hemorrhage
20.  Holmes' Tremor Associated with Bilateral Hypertrophic Olivary Degeneration Following Brain Stem Hemorrhage: A Case Report 
Holmes' tremor is a condition characterized by a mixture of postural, rest, and action tremors due to midbrain lesions in the vicinity of the red nucleus. Hypertrophic olivary degeneration (HOD) is a rare type of neuronal degeneration involving the dento-rubro-olivary pathway and may present clinically as Holmes tremor. We report on a 59-year-old female patient who developed Holmes tremor in association with bilateral HOD, following brain stem hemorrhage.
doi:10.7461/jcen.2014.16.3.299
PMCID: PMC4205259  PMID: 25340035
Tremor; Red nucleus; Olivary Nucleus; Midbrain
21.  Combination Treatment for Rapid Growth of a Saccular Aneurysm on the Internal Carotid Artery Dorsal Wall: Case Report 
Aneurysms arising from non-branching sites of the supraclinoid internal carotid artery (ICA) are considered rare, accounting for only 0.9-6.5% of all ICA aneurysms. They are thin-walled, broad-based, can easily rupture during surgery, and are referred to as dorsal, superior, anterior, or ventral wall ICA aneurysms, as well as blister-like aneurysms. Various treatment modalities are available for blister-like aneurysms, but with varying success. Here, we report on two cases of saccular shaped dorsal wall aneurysms. Both patients were transferred to the emergency department with subarachnoid hemorrhage because of an aneurysmal rupture. Computed tomography angiography and transfemoral cerebral angiography (TFCA) showed a dorsal wall aneurysm in the distal ICA. We performed clipping on the wrapping material (Lyodura®, temporal fascia). Follow-up TFCA showed rapid configuration changes of the right distal ICA. Coil embolization was also performed as a booster treatment to prevent aneurysm regrowth. Both patients were discharged without neurologic deficit. No evidence of aneurysm regrowth was observed on follow-up TFCA at two years. Dorsal wall ICA aneurysms can change in size over a short period; therefore, follow-up angiography should be performed within the short-term. In cases of regrowth, coil embolization should be considered as a booster treatment.
doi:10.7461/jcen.2014.16.3.303
PMCID: PMC4205260  PMID: 25340036
Dorsal wall aneurysm; Subarachnoid hemorrhage; Wrapping; Coiling
22.  Multiple Spontaneous Simultaneous Intracerebral Hemorrhages 
Simultaneous occurrence of intracerebral hemorrhage (ICH) in different arterial territories is an uncommon event. We report on two cases of multiple spontaneous simultaneous ICH for which we could find no specific cause. A 73-year-old man, with no related medical history, was admitted to the hospital with simultaneous bithalamic ICH, and subsequently died of recurrent pneumonia. Second patient was a 60-year-old man who presented with simultaneous ICH in the pons and thalamus; he died of recurrent bleeding. We review the possible pathological mechanisms, clinical and radiologic features of simultaneous multiple ICH.
doi:10.7461/jcen.2014.16.2.104
PMCID: PMC4102749  PMID: 25045650
Simultaneous; Intracerebral hemorrhage; Hypertension; Multiple
23.  Pipeline Embolization Device for Giant Internal Carotid Artery Aneurysms: 9-Month Follow-Up Results of Two Cases 
The pipeline™ embolization device (PED) is a braided, tubular, bimetallic endoluminal implant used for occlusion of intracranial aneurysms through flow disruption along the aneurysm neck. The authors report on two cases of giant internal carotid artery aneurysm treated with the PED. In the first case, an aneurysm measuring 26.4 mm was observed at the C3-C4 portion of the left internal carotid artery in a 64-year-old woman who underwent magnetic resonance imaging (MRI) for dizziness and diplopia. In the second case, MRI showed an aneurysm measuring 25 mm at the C4-C5 portion of the right internal carotid artery in a 39-year-old woman with right ptosis and diplopia. Each giant aneurysm was treated with deployment of a PED (3.75 mm diameter/20 mm length and 4.5 mm diameter/25 mm length, respectively). Nine months later, both cases showed complete radiological occlusion of the giant intracranial aneurysm and sac shrinkage. We suggest that use of the PED can be a therapeutic option for giant intracranial aneurysms.
doi:10.7461/jcen.2014.16.2.112
PMCID: PMC4102750  PMID: 25045651
Flow diverter; Pipeline embolization device; Embolization; Giant intracranial aneurysm
24.  Two Cases of Subarachnoid Hemorrhage from Spontaneous Anterior Cerebral Artery Dissection : A Case of Simultaneous Hemorrhage and Ischemia Without Aneurysmal Formation and Another Case of Hemorrhage with Aneurysmal Formation 
Spontaneous anterior cerebral artery (ACA) dissection, although extremely rare, is often associated with severe morbidity and mortality. It could lead to cerebral hemorrhage, ischemic stroke, or, rarely, combination of hemorrhage and ischemia due to hemodynamic changes. Prompt and accurate diagnosis is essential for determining the appropriate management. However, the optimal treatment for ACA dissection remains controversial. Herein, we report on two rare cases of subarachnoid hemorrhage (SAH) caused by ACA dissection; a case presenting with simultaneous SAH and infarction without aneurysmal formation and another case presenting with SAH with fusiform aneurysmal formation. A review of the related literature is provided, and optimal treatments for each type of dissection are suggested.
doi:10.7461/jcen.2014.16.2.119
PMCID: PMC4102751  PMID: 25045652
Anterior cerebral artery; Dissection; Infarction; Subarachnoid hemorrhage
25.  Balloon Anchor Technique for Pipeline Embolization Device Deployment Across the Neck of a Giant Intracranial Aneurysm 
Treatment of giant intracranial aneurysms, via either surgical or endovascular approaches, is associated with a high level of technical difficulty as well as a high rate of treatment-related morbidity and mortality. Flow-diverting stents, such as the Pipeline embolization device (PED), have drastically altered the therapeutic strategies for the treatment of giant aneurysms. Gaining endovascular access using a microcatheter to the portion of the parent artery distal to the aneurysm neck is requisite for safe and effective stent deployment. Giant aneurysms are often associated with vascular tortuosity, which necessitates significant catheter support systems to enable maneuvering of PEDs across the aneurysm neck. This is also required in order to reduce the probability of stent herniation within giant aneurysms. We report on a case of a giant supraclinoid internal carotid artery (ICA) aneurysm which was treated successfully with a PED utilizing a balloon anchor technique to facilitate direct microcatheter access across the aneurysm neck.
doi:10.7461/jcen.2014.16.2.125
PMCID: PMC4102752  PMID: 25045653
Endovascular procedures; Endovascular techniques; Intracranial aneurysm; Stent; Stroke; Subarachnoid hemorrhage

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