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1.  Sphenoid Ridge Meningioma Presenting as Acute Cerebral Infarction 
A previously healthy 52-year-old man presented to the emergency room with acute onset left hemiparesis and dysarthria. Brain computed tomography and magnetic resonance examinations revealed acute cerebral infarction in the right middle cerebral artery territory and a sphenoid ridge meningioma encasing the right carotid artery terminus. Cerebral angiography demonstrated complete occlusion of the right proximal M1 portion. A computed tomography perfusion study showed a wide area of perfusion-diffusion mismatch. Over the ensuing 48 hours, left sided weakness deteriorated despite medical treatment. Emergency extracranial-intracranial bypass was performed using a double-barrel technique, leaving the tumor as it was, and subsequently his neurological function was improved dramatically. We present a rare case of sphenoid ridge meningioma causing acute cerebral infarction as a result of middle cerebral artery compression.
doi:10.3340/jkns.2014.55.2.99
PMCID: PMC3958582  PMID: 24653805
Acute cerebral infarction; Meningioma; Middle cerebral artery; Occlusion
2.  Endovascular Treatment of Aneurysms Arising from the Proximal Segment of the Anterior Cerebral Artery 
Objective
Aneurysms arising from the proximal segment of the anterior cerebral artery (A1) are rare and challenging to treat. The aim of this study was to report our experience with endovascular treatment of A1 Aneurysms.
Methods
From August 2007 through May 2012, eleven A1 aneurysms in eleven patients were treated endovascularly. Six aneurysms were unruptured and 5 were ruptured. One patient with an unruptured A1 aneurysm presented with subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. Procedural data, clinical and angiographic results were reviewed retrospectively.
Results
All of the aneurysms were successfully treated with coil embolization. Six were treated with a simple technique while the remaining 5 required adjunctive technique : double catheters (n=2), balloon-assisted (n=2), and stent-assisted (n=1). The immediate angiographic control showed a complete occlusion in all cases. Procedure-related complication occurred in only one patient : parent artery occlusion, which was not clinically significant. All patients had excellent clinical outcomes but one patient was discharged with a slight disability. No neurologic deterioration or bleeding was seen during the follow-up period in this cohort of patients. Follow-up angiography (mean, 20 months) was available in ten patients and revealed stable occlusion in all cases.
Conclusion
Endovascular treatment is a feasible and effective therapeutic modality for A1 aneurysms. Tailored microcatheter shaping and/or adjunctive techniques are necessary for successful aneurysm embolization because of the projection and location of A1 aneurysms.
doi:10.3340/jkns.2013.54.2.75
PMCID: PMC3809447  PMID: 24175019
Endovascular treatment; Intracranial aneurysm; Anterior cerebral artery aneurysm
3.  In-Stent Stenosis of Stent-Assisted Coil Embolization of the Supraclinoid Internal Carotid Artery Aneurysm 
The intracranial stent functions primarily to prevent protrusion of coils into the parent vessel during the embolization of wide-necked cerebral aneurysms and might also reduce aneurysm recanalization rate. In spite of these advantages, little is known about the long-term interaction of the stent with the parent vessel wall. We present a rare case of severe in-stent stenosis occurring as a delayed complication of Neuroform stent-assisted coil embolization of an unruptured intracranial aneurysm.
doi:10.3340/jkns.2012.51.6.370
PMCID: PMC3424179  PMID: 22949968
Cerebral aneurysms; In-stent stenosis; Stent
4.  Retained Microcatheter after Onyx Embolization of Intracranial Arteriovenous Malformation 
Endovascular embolization is being increasingly used to treat intracranial arteriovenous malformations (AVMs). However, we experienced two patients with retained microcatheters after AVM embolization using Onyx.
doi:10.3340/jkns.2012.51.6.374
PMCID: PMC3424180  PMID: 22949969
Arteriovenous malformation; Onyx; Retained microcatheter
5.  Intramedullary Spinal Cord Metastasis of Choriocarcinoma 
The authors describe a case of choriocarcinoma that metastasized to the cerebral cortex, vertebral body, and intramedullary spinal cord. A 21-year-old woman presented with sudden headache, vomiting and a visual field defect. Brain computed tomography and magnetic resonance examinations revealed an intracranial hemorrhage in the left temporo-parietal lobe and two enhancing nodules in the left temporal and right frontal lobe. After several days, the size of the hemorrhage increased, and a new hemorrhage was identified in the right frontal lobe. The hematoma and enhancing mass in the left temporo-parietal lobe were surgically removed. Choriocarcinoma was diagnosed after histological examination. At 6 days after the operation, her consciousness had worsened and she was in a state of stupor. The size of the hematoma in the right frontal lobe was enlarged. We performed an emergency operation to remove the hematoma and enhancing mass. Her mental status recovered slowly. Two months thereafter, she complained of paraplegia with sensory loss below the nipples. Whole spine magnetic resonance imaging revealed a well-enhancing mass in the thoracic intramedullary spinal cord and L2 vertebral body. Despite chemotherapy and radiotherapy, the patient died 13 months after the diagnosis.
doi:10.3340/jkns.2012.51.3.141
PMCID: PMC3358599  PMID: 22639709
Choriocarcinoma; Intracerebral hematoma; Intramedullary spinal cord metastasis; Spinal metastasis
6.  Massive Intracerebral Hemorrhage Caused by a Cavernous Malformation 
We present a rare case of massive intracerebral hemorrhage resulting from a small, superficially-located supratentorial cavernous malformation, or cavernoma. These lesions rarely lead to massive, life-threatening intracerebral hemorrhages. A 17-year-old female presented with a 3-week history of declining mental status. Brain computed tomography and magnetic resonance imaging revealed a sizable intracranial hemorrhage, within the right occipital region, associated with a small nodule at the hematoma's posterior margin. An emergency operation removed the entire hematoma and nodule. Histological examination of the nodule was compatible with a diagnosis of cavernous malformation. The patient's post-operative course was uneventful.
doi:10.3340/jkns.2012.51.1.37
PMCID: PMC3291704  PMID: 22396841
Cavernous malformation; Intracerebral hemorrhage
7.  Endovascular Treatment Using Graft-Stent for Pseudoaneurysm of the Cavernous Internal Carotid Artery 
A 57-year-old man presented with a 2-day history of left oculomotor palsy. Digital subtraction angiography revealed a pseudoaneurysm of the left cavernous internal carotid artery (ICA) measuring 37×32 mm. The pseudoaneurysm was treated with a balloon expandable graft-stent to occlude the aneurysmal neck and preserve the parent artery. A post-procedure angiogram confirmed normal patency of the ICA and complete sealing of the aneurysmal neck with no opacification of the sac. After the procedure, the oculomotor palsy improved gradually, and had completely resolved 3 months after the procedure. A graft-stent can be an effective treatment for a pseudoaneurysm of the cavernous ICA with preservation of the parent artery.
doi:10.3340/jkns.2011.50.1.48
PMCID: PMC3159881  PMID: 21892405
Internal carotid artery; Pseudoaneurysm; Graft-stent; Oculomotor palsy
8.  Glue Embolization of Ruptured Anterior Thalamoperforating Artery Aneurysm in Patient with Both Internal Carotid Arteries Occlusion 
Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.
doi:10.3340/jkns.2011.49.5.287
PMCID: PMC3115150  PMID: 21716902
Anterior thalamoperforating artery; Aneurysm; Glue embolization
9.  Safety and Efficacy of Transluminal Balloon Angioplasty Using a Compliant Balloon for Severe Cerebral Vasospasm after an Aneurysmal Subarachnoid Hemorrhage 
Objective
Vasospasm of cerebral vessels remains a major source of morbidity and mortality after an aneurysmal subarachnoid hemorrhage (SAH). The purpose of this study was to evaluate the safety and efficacy of transluminal balloon angioplasty (TBA) for SAH-induced vasospasm.
Methods
Eleven patients with an angiographically confirmed significant vasospasm (>50% vessel narrowing and clinical deterioration) were studied. A total of 54 vessel segments with significant vasospasm were treated by TBA. Digital subtraction angiography was used to confirm the presence of vasospasm, and TBA was performed to dilate vasospastic arteries. Medical and angiographic reports were reviewed to determine technical efficacy and for procedural complications.
Results
TBA using Hyper-Glide or Hyper-Form balloons (MicroTherapeutics, Irvine, CA) was successfully accomplished in 88.9% vasospastic segments (48 of 54), namely, in the distal internal carotid artery (100%, n=7), the middle cerebral artery (100%), including the M1 (n=10), M2 (n=10), and M3 segments (n=4), in the vertebral artery (100%, n=2), basilar artery (100%, n=1), and in the anterior cerebral artery (ACA), including the A1 (66%), A2 (66%), and A3 segments (100%). Vessel diameters significantly increased after TBA. There were no cases of vessel rupture or thromboembolic complications. GCS at one day after TBA showed an improvement in all patients except one.
Conclusion
This study suggests that TBA using Hyper-Glide or Hyper-Form balloons is a safe and effective treatment for subarachnoid hemorrhage-induced cerebral vasospasm.
doi:10.3340/jkns.2011.49.3.157
PMCID: PMC3085811  PMID: 21556235
Transluminal balloon angioplasty; Vasospasm; Subarachnoid hemorrhage; Endovascular procedure
10.  Non-Dura Based Intaspinal Clear Cell Meningioma 
A 34-year-old female patient was presented with leg and hip pain for 6 months as well as voiding difficulty for 1 year. Magnetic resonance imaging revealed a well-demarcated mass lesion at L2-3. The mass was hypo-intense on T1- and T2-weighted images with homogeneous gadolinium enhancement. Surgery was performed with the presumptive diagnosis of intradural extramedullary meningioma. Complete tumor removal was possible due to lack of dural adhesion of the tumor. Histologic diagnosis was clear cell meningioma, a rare and newly included World Health Organization classification of meningioma usually affecting younger patients. During postoperative 2 years, the patient has shown no evidence of recurrence. We report a rare case of cauda equina clear cell meningioma without any dural attachment.
doi:10.3340/jkns.2011.49.1.71
PMCID: PMC3070901  PMID: 21494369
Clear cell meningioma; Spinal meningioma; World Health Organization classification; Younger patients; Cauda equina
11.  Transient Global Aphasia with Hemiparesis Following Cerebral Angiography : Relationship to Blood Brain Barrier Disruption 
Temporary disruption of the blood-brain barrier (BBB) after cerebral angiography is presumably caused by nonionic radiographic contrast medium (CM). We hereby report a case of 58-year-old woman who developed decreased mentality, global aphasia and aggravated right hemiparesis after cerebral angiography. Brain CT examination demonstrated gyriform enhancement throughout the left cerebral cortex and thalamus. MR diffusion did not reveal acute infarction. MR angiography did not show any stenosis, spasm or occlusion at the major cerebral vessels. Follow-up CT scan after 1 day did not show any gyriform enhancement. Worsened neurologic signs and symptoms were improved completely after 7 days. In the present study, disruption of the BBB with contrast medium after angiography seems to be the causative factor of transient neurologic deterioration.
doi:10.3340/jkns.2010.48.6.524
PMCID: PMC3053547  PMID: 21430979
Blood brain barrier (BBB) disruption; Contrast medium; Transient global aphasia; Transient hemiparesis; Cerebral angiography
12.  Fusiform Aneurysm Presenting with Cervical Radiculopathy in Ehlers-Danlos Syndrome 
Ehlers-Danlos syndrome (EDS) type IV is characterized by its clinical manifestations, which are easy bruising, thin skin with visible veins, and rupture of arteries, uterus, or intestines. Arterial complications are the leading cause of death in vascular EDS because they are unpredictable and surgical repair is difficult due to tissue fragility. The authors report a case presented with cervical radiculopathy due to a segmental fusiform aneurysm of the cervical vertebral artery. Transfemoral cerebral angiography (TFCA) was done to verify the aneurysmal dilatation. However, during TFCA, bleeding at the puncture site was not controlled, skin and underlying muscle was disrupted and profound bleeding occurred during manual compression after femoral catheter removal. Accordingly, surgical repair of the injured femoral artery was performed. At this time it was possible to diagnose it as an EDS with fusiform aneurysm on cervical vertebral artery. Particularly, cervical fusiform aneurysm is rare condition, and therefore, connective tissue disorder must be considered in such cases. If connective tissue disorder is suspected, the authors suggest that a noninvasive imaging modality, such as, high quality computed tomography angiography, be used to evaluate the vascular lesion to avoid potential arterial complications.
doi:10.3340/jkns.2010.48.6.528
PMCID: PMC3053548  PMID: 21430980
Ehlers-Danlos syndrome; Cervical radiculopathy; Fusiform aneurysm; Vascular reconstruction
13.  Hypopharyngeal Wall Exposure within the Surgical Field : The Role of Axial Rotation of the Thyroid Cartilage during Anterior Cervical Surgery 
Objective
Esophageal/hypopharyngeal injury can be a disastrous complication of anterior cervical surgery. The amount of hypopharyngeal wall exposure within the surgical field has not been studied. The objective of this study is to evaluate the chance of hypopharyngeal wall exposure by measuring the amount of axial rotation of the thyroid cartilage (ARTC) and posterior projection of the hypopharynx (PPH).
Methods
The study was prospectively designed using intraoperative ultrasonography. We measured the amount of ARTC in 27 cases. The amount of posterior projection of the hypopharynx (PPH) also was measured on pre-operative CT and compared at three different levels; the superior border of the thyroid cartilage (SBTC), cricoarytenoid joint and tip of inferior horn of the thyroid cartilage (TIHTC). The presence of air density was also checked on the same levels.
Results
The angle of ARTC ranged from -6.9° to 29.7°, with no statistical difference between the upper and lower cervical group. The amount of PPH was increased caudally. Air densities were observed in 26 cases at the SBTC, but none at the TIHTC.
Conclusion
Within the confines of the thyroid cartilage, surgeons are required to pay more attention to the status of hypopharynx/esophagus near the inferior horn of the thyroid cartilage. The hypopharynx/esophagus at the TIHTC is more likely to be exposed than at the upper and middle part of the thyroid cartilage, which may increase the risk of injury by pressure. Surgeons should be aware of the fact that the visceral component at C6-T1 surgeries also rotates as much as when the thyroid cartilage is engaged with a retractor. The esophagus at lower cervical levels warrants more careful retraction because it is not protected by the thyroid cartilage.
doi:10.3340/jkns.2010.48.5.406
PMCID: PMC3030079  PMID: 21286476
Anterior cervical surgery; Thyroid cartilage; Hypopharynx; Esophageal injury
14.  Endovascular Treatment of Wide-Necked Intracranial Aneurysms Using Balloon-Assisted Technique with HyperForm Balloon 
Objective
To assess the feasibility, safety, and effectiveness of the balloon-assisted technique with HyperForm balloon in the endovascular treatment of wide-necked intracranial aneurysms.
Methods
A total of 34 patients with 34 wide-necked intracranial aneurysms were treated with endovascular coil embolization using balloon-assisted technique with Hyperform balloon. Twenty-nine aneurysms (85.3%) were located in the anterior circulation. The group of patients was comprised of 16 men and 18 women, aged 33 to 72 years (mean : 60.6 years). The size of aneurysms was in the range of 2.0 to 22.0 mm (mean 5.5 mm) and one of neck was 2.0 to 11.9 mm (mean 3.8 mm). The dome to neck ratio was ranged from 0.83 to 1.43 (1.15). Sixteen patients were treated for unruptured aneurysms and the remaining 18 presented with a subarachnoid hemorrhage.
Results
In the 34 aneurysms treated by the remodeling technique with HyperForm balloon, immediate angiographic results consisted of total occlusion in 31 cases (91.2%) and partial occlusion in three cases (8.8%). There were five procedure-related complications (14.7%), including two coil protrusions and three thromboembolisms; Except one patient, all were successfully resolved without permanent neurologic deficit. No new bleeding occurred during the follow-up. Twenty patients (59%) underwent angiographic follow-up from 2 to 33 months (mean 9.2 months) after treatment. Focal recanalization with coil compaction of the neck portion was observed in 5 cases (25%). Only one case showed major recanalization and underwent stent-assisted coil embolization.
Conclusion
The balloon-assisted technique with Hyperform balloon is a feasible, safe, and effective endovascular treatment of wide-necked cerebral aneurysms.
doi:10.3340/jkns.2010.48.3.207
PMCID: PMC2966720  PMID: 21082046
Intracranial aneurysms; Wide-necked aneurysms; Endovascular treatment; Balloon-assisted technique
15.  Spinal Epidural Hematoma after Pain Control Procedure 
Spinal epidural hematoma is a rare complication associated with pain control procedures such as facet block, acupuncture, epidural injection, etc. Although it is an uncommon cause of acute myelopathy, and it may require surgical evacuation. We report four patients with epidural hematoma developed after pain control procedures. Two procedures were facet joint blocks and the others were epidural blocks. Pain was the predominant initial symptom in these patients while two patients presented with post-procedural neurological deficits. Surgical evacuation of the hematoma was performed in two patients while in remaining two patients, surgery was initially recommended but not performed since symptoms were progressively improved. Three patients showed near complete recovery except for one patient who recovered with residual deficits. Although, spinal epidural hematoma is a rare condition, it can lead to serious complications like spinal cord compression. Therefore, it is important to be cautious while performing spinal pain control procedure to avoid such complications. Surgical treatment is an effective option to resolve the spinal epidural hematoma.
doi:10.3340/jkns.2010.48.3.281
PMCID: PMC2966734  PMID: 21082060
Spinal epidural hematoma; Pain control procedure; Surgical evacuation
16.  Unruptured Intracranial Aneurysms with Oculomotor Nerve Palsy : Clinical Outcome between Surgical Clipping and Coil Embolization 
Objective
To evaluate the clinical outcome of coil embolization for unruptured intracranial aneurysm (UIA) with oculomotor nerve palsy (ONP) compared with surgical clipping.
Methods
A total of 19 patients presented with ONP caused by UIAs between Jan 2004 and June 2008. Ten patients underwent coil embolization and nine patients surgical clipping. The following parameters were retrospectively analyzed to evaluate the differences in clinical outcome observed in both coil embolization and surgical clipping : 1) gender, 2) age, 3) location of the aneurysm, 4) duration of the symptom, and 5) degree of ONP.
Results
Following treatment, complete symptomatic recovery or partial relief from ONP was observed in 15 patients. Seven of the ten patients were treated by coil embolization, compared to eight of the nine patients treated by surgical clipping (p = 0.582). Patient's gender, age, location of the aneurysm, size of the aneurysm, duration of symptom, and degree of the ONP did not statistically correlate with recovery of symptoms between the two groups. No significant differences were observed in mean improvement time in either group (55 days in coil embolization and 60 days in surgical clipping).
Conclusion
This study indicates that no significant differences were observed in the clinical outcome between coil embolization and surgical clipping techniques in the treatment of aneurysms causing ONP. Coil embolization seems to be more feasible and safe treatment modality for the relief and recovery of oculomotor nerve palsy.
doi:10.3340/jkns.2010.48.2.109
PMCID: PMC2941851  PMID: 20856657
Oculomotor nerve palsy; Intracranial aneurysm; Surgical clipping; Coil embolization
17.  Epidermoid Tumors in the Cerebellopontine Angle Presenting with Trigeminal Neuralgia 
Objective
The purpose of this study is to evaluate the clinical characteristics and surgical outcome of cerebellopontine angle (CPA) epidermoids presenting with trigeminal neuralgia.
Methods
Between 1996 and 2004, 10 patients with typical symptoms of trigeminal neuralgia were found to have cerebellopontine angle epidermoids and treated surgically at our hospital. We retrospectively analyzed the clinico-radiological records of the patients.
Results
Total resection was done in 6 patients (60%). Surgical removal of tumor and microvascular decompression of the trigeminal nerve were performed simultaneously in one case. One patient died due to postoperative aseptic meningitis. The others showed total relief from pain. During follow-up, no patients experienced recurrence of their trigeminal neuralgia (TN).
Conclusion
The clinical features of TN from CPA epidermoids are characterized by symptom onset at a younger age compared to TN from vascular causes. In addition to removal of the tumor, the possibility of vascular compression at the root entry zone of the trigeminal nerve should be kept in mind. If it exists, a microvascular decompression (MVD) should be performed. Recurrence of tumor is rare in both total and subtotal removal cases, but long-term follow-up is required.
doi:10.3340/jkns.2010.47.4.271
PMCID: PMC2864819  PMID: 20461167
Epidermoid; Cerebellopontine angle; Trigeminal neuralgia; Microvascular vascular decompression
18.  The Variable Ellipsoid Modeling Technique as a Verification Method for the Treatment Planning System of Gamma Knife Radiosurgery 
Objective
The secondary verification of Leksell Gamma Knife treatment planning system (LGP) (which is the primary verification system) is extremely important in order to minimize the risk of treatment errors. Although prior methods have been developed to verify maximum dose and treatment time, none have studied maximum dose coordinates and treatment volume.
Methods
We simulated the skull shape as an ellipsoid with its center at the junction between the mammillary bodies and the brain stem. The radiation depths of the beamlets emitted from 201 collimators were calculated based on the relationship between this ellipsoid and a single beamlet expressed as a straight line. A computer program was coded to execute the algorithm. A database system was adopted to log the doses for 31×31×31 or 29,791 matrix points allowing for future queries to be made of the matrix of interest.
Results
When we compared the parameters in seven patients, all parameters showed good correlation. The number of matrix points with a dose higher than 30% of the maximal dose was within ± 2% of LGP. The 50% dose volume, which is generally the target volume, differs maximally by 4.2%. The difference of the maximal dose ranges from 0.7% to 7%.
Conclusion
Based on the results, the variable ellipsoid modeling technique or variable ellipsoid modeling technique (VEMT) can be a useful and independent tool to verify the important parameters of LGP and make up for LGP.
doi:10.3340/jkns.2010.47.2.128
PMCID: PMC2836448  PMID: 20224712
Gamma knife radiosurgery; Treatment planning system; Quality assurance
19.  Endovascular Graft-Stent Placement for Treatment of Traumatic Carotid Cavernous Fistulas 
Detachable balloon-based endovascular fistula occlusion is a widely accepted treatment for traumatic carotid cavernous fistulas (CCF). However, more recently coils have been used to obliterate the lesion, especially in case detachable balloon is not available. We failed balloon-assisted coil embolization for CCF because of large fistulas and herniation of coil loops into the parent artery. The authors describe our experiences of balloonexpandable graft-stents to treat CCF, and place emphasis on arterial wall reconstruction. Three traumatic CCF patients were treated using a graft-stent with/without coils, and underwent angiographic follow-up to evaluate the patency of the internal carotid artery (ICA). In all cases, symptoms related to CCF regressed after stent deployment and did not recur during follow-up. Follow-up angiography revealed good patency of the ICA in all patients. Graft-stents should be considered as an alternative means of treating CCF and preserving the parent artery by arterial wall reconstruction especially in patients with a fistula that cannot be successfully occluded with detachable balloons or coils.
doi:10.3340/jkns.2009.46.6.572
PMCID: PMC2803275  PMID: 20062575
Carotid cavernous fistulas; Graft-stent; Endovascular treatment
20.  External Carotid Artery Angioplasty and Stenting Followed by Superficial Temporal Artery to Middle Cerebral Artery Anastomosis 
A 31-year-old man presented with right hemiparesis, and magnetic resonance imaging revealed a small infarct at left basal ganglia. Digital subtraction angiography showed left cervical internal carotid artery (ICA) occlusion and severe stenosis of the ipsilateral external carotid artery (ECA) with collateral cerebral circulation fed by ECAs. Based on the results of a functional evaluation of cerebral blood flow, we performed preventive ECA angioplasty and stenting for advanced ECA stenosis to ensure sufficient blood flow to the superficial temporal artery. Eight weeks later, superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis was performed. His postoperative course was uneventful and no additional transient ischemic attacks have occurred. To our knowledge, this is the first report of preventive angioplasty and stenting for advanced narrowing of an ECA before STA-MCA anastomosis for ipsilateral ICA occlusion.
doi:10.3340/jkns.2009.46.5.488
PMCID: PMC2796357  PMID: 20041061
Angioplasty; External carotid artery; Internal carotid artery; Middle cerebral artery
21.  A Case of Calvarial Hemangioma in Cranioplasty Site 
It is not uncommon for hemangiomas to occur in the calvarium, accounting for about 10% of the benign skull tumors. A 46-year-old man was presented with a palpable scalp mass on the left parietal region. Past medical history indicated that he had undergone cranioplasty 25 years prior due to a depressed skull fracture suffered from a traffic accident. Magnetic resonance imaging revealed mixed signal intensity mass on T1 -and T2-weighted images pushing a linear signal void lesion outward in the left parietal region. After total surgical removal along with cranioplasty, he was discharged without neurological deficits. Histological examination of the surgical specimen revealed a cavernous hemangioma. A skull hemangioma occurring at the site of a cranioplasty has not yet been reported. Therefore, authors report this case in combination with a pertinent literature review.
doi:10.3340/jkns.2009.46.5.484
PMCID: PMC2796356  PMID: 20041060
Cavernous hemangioma; Calvarium; Cranioplasty
22.  Assessment of the Intracranial Stents Patency and Re-Stenosis by 16-Slice CT Angiography with Optimized Sharp Kernel : Preliminary Study 
Objective
Our retrospective study aimed to determine whether 16-slice computerized tomography (CT) angiography optimized sharp kernel is suitable for the evaluation of visibility, luminal patency and re-stenosis of intracranial stents in comparison with conventional angiography.
Methods
Fifteen patients with symptomatic intracranial stenotic lesions underwent balloon expandable stent deployment of these lesions (10 middle cerebral arteries, 2 intracranial vertebral arteries, and 3 intracranial internal carotid arteries). CT angiography follow-up ranged from 6 to 15 months (mean follow-up, 8 months) after implantation of intracranial stents and conventional angiography was confirmed within 2 days. Curved multiplanar reformations with maximal intensity projection (MIP) with optimal window settings for assessment of lumen of intracranial stents were evaluated for visible lumen diameter, stent patency (contrast distal to the stent as an indirect sign), and re-stenosis by two experienced radiologists who blinded to the reports from the conventional angiography.
Results
All of stents deployed into symptomatic stenotic lesions. All stents were classified as patent and no re-stenosis, which was correlated with results of conventional angiography. Parts of the stent lumen could be visualized in all cases. On average, 57% of the stent lumen diameter was visible using optimized sharp kernel. Significant improvement of lumen visualization (22%, p<0.01) was observed using the optimized sharp kernel compared with the standard sharp kernel. Inter-observer agreements on the measurement of lumen diameter and density were judged as good, respectively (p<0.05).
Conclusion
Sixteen-slice CT using the optimized sharp kernel may provide a useful information for evaluation of lumen diameter patency, and re-stenosis of intracranial stents.
doi:10.3340/jkns.2009.45.5.284
PMCID: PMC2693787  PMID: 19516945
Intracranial atherosclerosis; Stents; Multislice CT; CT angiography; Cerebral angiography
23.  Moyamoya-Like Vasculopathy in Neurosarcoidosis 
A 31-year-old man presented with dull headache and memory disturbance lasting for one week. Computed tomographic scans revealed acute hydrocephalus. The cerebrospinal fluid contained 53 leukocytes/mm3, with a mononuclear preponderance and no erythrocytes. Magnetic resonance imaging revealed hydrocephalus and leptomeningeal enhancement. Magnetic resonance angiography and digital subtraction angiography showed supraclinoid occlusion of the right internal carotid artery, which resembled unilateral moyamoya disease. Neuroendoscopic biopsy of a lesion in the septum pellucidum revealed noncaseating granulomas, which was consistent with sarcoidosis. The patient was successfully managed with intravenous methylprednisolone and ventriculoperitoneal shunting. To our knowledge, this is the first case of moyamoya-like vasculopathy associated with neurosarcoidosis.
doi:10.3340/jkns.2009.45.1.50
PMCID: PMC2640829  PMID: 19242573
Moyamoya disease; Neurosarcoidosis; Hydrocephalus
24.  Cavernous Malformation of the Optic Chiasm : Case Report 
Cavernous malformations (CMs) arising from the optic nerve and chiasm are extremely rare. The authors present a case of 39-year-old woman with CMs of the optic chiasm. She was referred due to sudden onset of bitemporal hemianopsia and headache, the so-called 'chiasmal apoplexy'. MRI findings suggested a diagnosis of hemorrhage and vascular malformation of the optic chiasm. Pterional craniotomy revealed an intrachiasmatic cavernous malformation with hemorrhage. The malformation was totally excised, but field deficits remained unchanged after surgery.
doi:10.3340/jkns.2008.44.2.88
PMCID: PMC2588336  PMID: 19096699
Cavernous malformation; Optic chiasm; Apoplexy
25.  Fusiform Intracanalicular Ophthalmic Artery Aneurysm; Case Report and Review of Literature 
A 35-year-old man's vision had progressively deteriorated over a 3-month period. His left visual acuity was 5/20. Enhanced orbital computed tomographic (CT) scans revealed a fusiform dilatation of the ophthalmic artery in the left optic canal. Cerebral Angiography revealed a fusiform aneurysm on the left ophthalmic artery in the optic canal, measuring 6.2 × 4.6 mm in size. Four days after admission, visual acuity dropped to hand-motion. Endovascular treatment was chosen and a microcatheter was guided into the proximal segment of the ophthalmic artery. Using 4 detachable coils, parent artery occlusion was done. Three months after the intervention, the visual acuity in his left eye improved to 20/20. Dramatic recovery of visual acuity is exceptional with an ophthalmic artery trunk aneurysm. When an occlusion of the proximal ophthalmic artery is the only treatment option in such a situation, the endovascular occlusion of the proximal ophthalmic artery is quite feasible in the sense that it does not require any optic nerve manipulation.
doi:10.3340/jkns.2008.44.1.43
PMCID: PMC2588290  PMID: 19096656
Detachable coil; Fusiform aneurysm; Intracanalicular portion; Ophthalmic artery trunk aneurysm

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