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Background The treatment protocol for hemifacial spasm (HFS) associated with dissecting vertebral artery aneurysm (DVAA) has not been established. Case Description A-42-year-old man with left HFS underwent endovascular trapping for a DVAA that was identified on brain imaging. Although the dissecting segment was treated successfully, the HFS persisted for 3 months, and subsequently microvascular decompression (MVD) was needed. The posteroinferior cerebellar artery (PICA) was found to be interposed between the root exit zone of the facial nerve and DVAA during surgery. After pulling out the PICA, the HFS ceased immediately. Conclusion HFS associated with DVAA should be considered carefully before formulating a treatment strategy. Moreover, the cause of pulsatile compression may not be visible on brain imaging, and MVD surgery may be indicated in such cases.

Objectives: To investigate the efficacy of acupuncture in preventing cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) and explore its underlying mechanism. Design: A randomized...

Objective Since less invasive endovascular treatment was introduced to South Korea in 1994, a considerable proportion of endovascular treatments have been performed by neuroradiology doctors, and endovascular treatments by vascular neurosurgeons have recently increased. However, few specific statistics are known regarding how many endovascular treatments are performed by neurosurgeons. Thus, authors compared endovascular treatments collaboratively performed by vascular neurosurgeons with all cases throughout South Korea from 2013 to 2017 to elucidate the role of neurosurgeons in the field of endovascular treatment in South Korea. Methods The Society of Korean Endovascular Neurosurgeons (SKEN) has issued annual reports every year since 2014. These reports cover statistics on endovascular treatments collaboratively or individually performed by SKEN members from 2013 to 2017. The data was requested and collected from vascular neurosurgeons in various hospitals. The study involved 77 hospitals in its first year, and 100 in its last. National statistics on endovascular treatment from all over South Korea were obtained from the Healthcare Bigdata Hub website of the Health Insurance Review & Assessment Service based on the Electronic Data Interchange (EDI) codes (in the case of intra-arterial (IA) thrombolysis, however, statistics were based on a combination of the EDI and I63 codes, a cerebral infarction disease code) from 2013 to 2017. These two data sets were directly compared and the ratios were obtained. Results Regionally, during the entire study period, endovascular treatments by SKEN members were most common in Gyeonggido, followed by Seoul and Busan. Among the endovascular treatments, conventional cerebral angiography was the most common, followed by cerebral aneurysmal coiling, endovascular treatments for ischemic stroke, and finally endovascular treatments for vascular malformation and tumor embolization. The number of endovascular treatments performed by SKEN members increased every year. Conclusion The SKEN members have been responsible for the major role of endovascular treatments in South Korea for the recent 5 years. This was achieved through the perseverance of senior members who started out in the midst of hardship, the establishment of standards for the training/certification of endovascular neurosurgery, and the enthusiasm of current SKEN members who followed. To provide better treatment to patients, we will have to make further progress in SKEN.

Purpose Characteristic signs - the susceptibility vessel sign (SVS) and the prominent hypointense vessel sign (PHVS) - on T2*-based magnetic resonance imaging (T2*MRI) can be seen for acute ischemic stroke with large artery occlusion. In this study, we investigated the evidence to support our hypothesis that these findings may help to predict outcomes after reperfusion therapy. Materials and methods We searched for papers describing SVS and PHVS in patients treated with reperfusion therapy for acute ischemic stroke, and their functional/radiologic outcomes were systematically reviewed. Results Nine studies on the SVS and six studies on the PHVS were included. The pooled odds ratio (OR) of recanalization after intravenous thrombolysis or mechanical thrombectomy was not significantly different with the presence of SVS (OR, 0.615; 95% confidence interval [CI], 0.335-1.131 and OR, 0.993; 95% CI, 0.629-1.567). The OR of favorable functional outcome after reperfusion therapy in terms of the presence of PHVS varied (0.083 to 1.831) by study. Conclusion Our meta-analysis of the published data showed that a SVS was not a predictive factor for recanalization after reperfusion therapy for acute ischemic stroke. Currently, the data available on T2*MRI are too limited to warrant reperfusion therapy in routine practice. More data are needed from studies with randomized treatment allocation to determine the role of T2*MRI.

The cerebral aneurysm 'clip scissoring' phenomenon resulting from clip blade twisting is an unpredictable surgical complication. Additionally, incomplete clipping resulting from the presence of an atherosclerotic wall in the neck of the aneurysm can also cause unforeseen problems. Here, the authors present an unusual case of incomplete clipping of a large, atheromatous aneurysm resulting from clip scissoring, which was treated with additional endovascular coiling.

Chronic subdural hematoma (SDH) is a well-known disease entity and is traditionally managed with surgery. However, when associated with spontaneous intracranial hypotension (SIH), the treatment strategy ought to be modified, as classical treatment could lead to unwanted consequences. A 59-year-old man presented with a case of SIH that manifested as a bilateral chronic SDH. He developed fatal extensive pneumocephalus and SDH re-accumulation as a complication of burr-hole drainage. Despite application of an epidural blood patch, the spinal cerebrospinal fluid leak continued, which required open spinal surgery. Chronic SDH management should not be overlooked, especially if the exact cause has not been determined. When chronic SDH assumed to be associated with SIH, the neurosurgeon should determine the exact cause of SIH in order to effectively correct the cause.

Background It is important to manage inflammation after craniotomy. It may be prudent to reduce the excessive usage of antibiotics and to add supplementary treatments like acupuncture, which would be effective and safe. However, there are only a few studies available to date on the effects of acupuncture on anti-inflammatory response after craniotomy. The aim of this study was to explore the anti-inflammatory effects of acupuncture in patients after a craniotomy. Methods This study was a single-center, prospective, open-label, controlled trial. Forty-four subjects who underwent craniotomy for an unruptured aneurysm, facial spasm, or brain tumor were allocated to either an acupuncture group or a control group. Both groups received postoperative routine care in the Department of Neurosurgery. The subjects in the acupuncture group also received a total of 6 acupuncture treatments sessions within 8 days after craniotomy. Acupuncture treatments included acupuncture, electroacupuncture, and intradermal acupuncture. The serum interleukin (IL)-1β and IL-6, tumor necrosis factor-α (TNF-α), C-reactive protein (CRP), and erythrocyte sedimentation rate levels were assessed four times within 7 days after surgery. The presence of fever, use of additional antibiotics, presence of infection including pneumonia or urinary tract infection, and safety were also reviewed. Results The IL-1β levels of subjects who underwent aneurysmal clipping were significantly lower in the acupuncture group (P = .02). TNF-α levels of subjects who underwent aneurysmal clipping at the seventh postoperative day were also significantly lower in the acupuncture group (P = .03). Six cases of fever of unknown origin were observed in the control group, while none were seen in the acupuncture group, revealing that the incidence of fever was significantly lower in the acupuncture group (P = .02). No adverse events occurred during the trial. Conclusion Acupuncture showed a possibility of alleviating inflammation by attenuating the levels of proinflammatory cytokines and significantly reduced the incidence of fever of unknown origin in patients after craniotomy. Acupuncture would be suitable as an adjunctive therapy to alleviate inflammation after craniotomy.

Background Traumatic injury of the posterior communicating artery or the basilar artery causing arteriovenous fistulae is rare. Case Description Here we report an unusual case of the coincidence of a posterior communicating artery-cavernous sinus fistula and a basilar artery-cavernous sinus fistula associated with traumatic pseudoaneurysms of the posterior communicating and basilar arteries. The fistulas and pseudoaneurysms were obliterated completely after staged endovascular surgery via a transarterial and transvenous route. Conclusions To our knowledge, this is the first such report worldwide.

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.

Retrograde stenting via the contralateral vertebral artery (VA) is a safe and effective treatment for posterior inferior cerebellar artery (PICA) aneurysm. Many methods, including tip shaping and the looping technique, have been attempted as ways to cross the vertebrobasilar (VB) junction. Here, we introduce an alternative method using a Snare system to overcome the acute-angled VB junction after repeated failures using other techniques. The Snare system was navigated to the proximal basilar artery via the ipsilateral VA. A guide-wire was introduced in the contralateral VA and gently advanced to the basilar artery in order to pass through the loop of the Snare system. Following this, the Snare system caught the guide-wire and it was very carefully pulled down to the ipsilateral VA crossing the VB junction. We suggest this technique as a method to cross the acute-angled VB junction after failure of all other attempts to overcome this challenge.

Background Even although microvascular decompression is the standard treatment for hemifacial spasm (HFS), the treatment is not always 100% successful. Some patients experience the reappearance of HFS after temporary relief after surgery. We analyzed our data to elucidate the reasons for and prognosis of HFS reappearance, specifically focusing on exact compressive location of the facial nerve. Methods The patients were divided into 2 groups: group A, the patients whose symptoms of spasm disappeared immediately after surgery but recurred within a month, and group B, the patients whose symptoms of spasm completely disappeared and never recurred. We adopted the terms of subdivision in the facial nerve root exit zone: RExP, root exit point; AS, attached segment; RDP, root detachment point; TZ, transition zone; and CP, distal cisternal portion. Results Among 115 patients, 56 (48.7%) belonged to group A and 59 (51.3%) to group B. In 54 of the 56 patients in group A (96.4%), the reappearing HFS disappeared gradually over several weeks. The precise location of compression in group A was at the RExP in 46.4% of the patients, AS in 33.9%, RDP in 16.1%, and TZ in 3.6%, and the RExP compression was significantly more frequent compared with in group B. Conclusions After microvascular decompression for HFS, almost half of the patients experienced transient HFS recurrence despite sufficient decompression of the facial nerve. However, in most cases, recurrent HFS gradually resolved over a period. Based on the compression location, the surgeon could anticipate recurrence of transient HFS.

Purpose The Alberta Stroke Program Early CT Score (ASPECTS) was devised to quantify the extent of early ischemic changes in the middle cerebral artery territory on brain CT. We performed a systematic review and meta-analysis of studies that presented clinical outcomes and baseline ASPECTS in ischemic stroke patients managed with endovascular methods to validate the use of ASPECTS for risk prognostication. Materials and methods We searched the MEDLINE, EMBASE, and Cochran databases for observational or interventional studies that reported clinical outcomes and baseline ASPECTS in ischemic stroke patients treated with endovascular methods. Data were pooled to perform a meta-analysis for comparisons of clinical outcomes between high and low ASPECTS patients. Results A meta-analysis of 13 studies (six observational and seven interventional) revealed favorable outcomes (mRS sore 0-2 at 90 days) for high baseline ASPECTS (odds ratio=2.22; 95% CI: 1.74-2.86). Conclusion High ASPECTS is a predictor of favorable outcome after endovascular therapy for ischemic stroke.

Intracranial hemorrhage (ICH) is the most serious bleeding event that occurs in patients with hemophilia; its estimated mortality rate is approximately 20 %, accounting for the largest number of deaths from bleeding. We conducted this single-center, retrospective study to examine the characteristics of and prognostic factors in patients with hemophilia. A comprehensive review of 12 cases of intracranial hemorrhage (ICH) among 10 patients. All 12 cases of ICH in the 10 patients were treated with clotting factor concentrates. Three patients had intracerebral hemorrhage that required neurosurgical intervention. After presenting with ICH, two pediatric patients developed antibodies to clotting factors. Two adult patients with intracerebral hemorrhage died, and the mortality rate was thus 20.0 % (2/10) in our clinical series. Prompt and intensive treatment with clotting factor concentrates may significantly lower the mortality rate among patients with hemophilia presenting with ICH. Our results showed a better prognosis in pediatric patients with intracerebral hemorrhage. Clinicians should pay special attention to the possible development of inhibitors after intensive treatment in pediatric patients. Further studies are needed to examine methods for administering clotting factor concentrates and to determine whether neurosurgical intervention is essential in each case.

Early spontaneous recanalization of the middle cerebral artery in acute ischemic phase artery is not uncommon, whereas the late spontaneous recanalization of chronic occluded artery is a very rare phenomenon and exact incidence and the timing of this event have not been quantified. We present a case in which late spontaneous recanalization of long-lasting middle cerebral artery occlusion occurred in the absence of surgical, endovascular and thrombolytic treatments.

Background Optimal management of bilateral vertebral artery dissecting aneurysms (bi-VDAs) causing subarachnoid hemorrhage (SAH) remains unclear. Objective To investigate the treatment methods and outcomes of bi-VDA causing SAH. Methods Seven patients were treated endovascularly for bi-VDA causing SAH. Treatment methods and outcomes were evaluated retrospectively. Results Two patients were treated with 2 overlapping stents for both ruptured and unruptured VDAs, 2 with 2 overlapping stents and coiling for ruptured VDA and with conservative treatment for unruptured VDA, 1 with internal trapping (IT) for ruptured VDA and stent-assisted coiling for unruptured VDA, 1 with IT for ruptured VDA and 2 overlapping stents for unruptured VDA, and 1 with IT for ruptured VDA and a single stent for unruptured VDA. None had rebleeding during follow-up (range, 15-48 months). All patients had favorable outcomes (modified Rankin Scale score, 0-2). On follow-up angiography at 6 to 36 months, 9 treated and 2 untreated VDAs revealed stable or improved state, whereas 3 VDAs in 2 patients showed regrowth. Of the 3 recurring VDAs, 1 was initially treated with IT but recurred owing to retrograde flow to the ipsilateral posterior inferior cerebellar artery (PICA), the second was treated with single stent but enlarged, and the last was treated with 2 overlapping stents and coiling but recurred from the remnant sac harboring the PICA origin. All 3 recurred VDAs were retreated with coiling with or without stent insertion. Conclusion Bilateral VDAs presenting with SAH were safely treated with endovascular methods. However, endovascular treatment may be limited for VDAs with PICA origin involvement.

Two cases of the posterior fossa dissecting aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA) causing subarachnoid hemorrhage are presented. After observing a relationship between the aneurysm and DOPICA on a three dimensional rotational angiogram (3DRA), the dissecting aneurysms were successfully obliterated by surgical trapping and endovascular internal trapping, respectively. This report warrants suspecting DOPICA of an associating anomaly predisposing to dissecting aneurysm in the vertebral artery-posterior inferior cerebellar artery territory and highlights the role of 3DRA in pretreatment evaluation of unusual aneurysms accompanying a particular anatomical variation.

A 61-year-old woman presented with typical trigeminal neuralgia (TN), caused by an aberrant posterior inferior cerebellar artery (PICA) associated with the primitive trigeminal artery (PTA). Magnetic resonance angiography and digital subtraction angiography clearly showed an anomalous artery directly originating from the PTA and coursing into the PICA territory at the cerebellum. During microvascular decompression (MVD), we confirmed and decompressed vascular compression of the trigeminal nerve by this anomalous, PICA-variant type of PTA. The PTA did not conflict with the trigeminal nerve, and the anomalous PICA only compressed the caudolateral part of the trigeminal nerve, without the more common compression at its root entry zone. This case is informative due not only to its very unusual angioanatomical variation but also to its helpfulness for surgeons preparing a MVD for a TN associated with such a rare vascular anomaly.

A 70-year-old woman presented with headaches and recurrent stroke symptoms. During five years, the patient has been treated for cerebral infarction associated with severe atherosclerotic stenosis of the internal carotid artery. Three-year follow-up magnetic resonance angiography showed a tiny de novo aneurysm arising from the distal part of atherosclerotic internal carotid artery. And 5-year follow-up three-dimensional CT angiogram demonstrated a definite aneurysm enlargement as large as requiring treatment. During dissection of aneurysm, the oculomotor nerve was found to be penetrated with the growing de novo aneurysm. The authors report a case of a de novo aneurysm, which resulted from atherosclerotic stenosis of the internal carotid artery at the supraclinoid portion, that was found to be penetrating the oculomotor nerve with no ocular palsy.

Although hemifacial spasm is usually caused by vascular compression around the root exit zone of the facial nerve, it is sometimes brought on by a cerebellopontine angle tumor. We reviewed and analyzed data from past experience with hemifacial spasm induced by cerebellopontine angle tumors. Nine patients of a total 2,050, who had presented with hemifacial spasms associated with cerebellopontine angle tumors between 1986 and 2009, were reviewed. Two vestibular schwannomas, five meningiomas, and two epidermoid tumors were included in this study. Hemifacial spasm occurred on the same side of the lesion in eight patients whereas it occurred on the opposite side of the lesion in one patient. With respect to the pathogenesis of hemifacial spasms, offending vessels were found in six patients, tumor encasement of the facial nerve in one patient, hypervascular tumor compression of the facial nerve without offending vessels in one patient, and a huge tumor compressing the brain stem and, thus, contralateral facial nerve compression in one patient. Hemifacial spasm was resolved in seven patients, whereas in two patients with a vestibular schwannoma and an epidermoid tumor, it improved transiently and then recurred in a month. Each type of tumor had different characteristics with respect to the induction of hemifacial spasm; therefore, it is suggested that neurosurgeons, who are planning surgeries both for the purposes of relieving hemifacial spasm and removal of cerebellopontine angle tumor, should thoroughly prepare appropriate approaches and specific dissecting strategies according to each causative lesion.

Endovascular trapping is the preferred treatment method for a vertebral dissecting aneurysm. We describe a case of ruptured dissecting aneurysms located just proximal to the vertebrobasilar junction treated by trapping the dissecting segment and barricading the basilar artery with a stent to protect against coil protrusion. Modified parent artery trapping with a stent barricade allows preservation of the adjoining confluent zone or side branch during endovascular trapping of the vertebral dissection.

Object A ruptured dissecting aneurysm of the vertebrobasilar artery (VBA-DA) is a well-known cause of acute subarachnoid hemorrhage (SAH) with a high rate of early rebleeding. Internal trapping of the parent artery, including the dissected segment, is one of the most reliable techniques to prevent rebleeding. However, for a ruptured VBA-DA not suitable for internal trapping, the optimal treatment method has not been well established. The authors describe their experience in treating ruptured VBA-DAs not amenable to internal trapping of the parent artery with stent-assisted coil embolization (SAC) followed by a stent-within-a-stent (SWS) technique. Methods Eleven patients—6 men and 5 women with a mean age of 48 years and each with a ruptured VBA-DA not amenable to internal trapping of the parent artery—underwent an SAC-SWS between November 2005 and October 2007. The feasibility and clinical and angiographic outcomes of this combined procedure were retrospectively evaluated. Results The SAC-SWS was successful without any treatment-related complications in all 11 patients. Immediate posttreatment angiograms revealed complete obliteration of the DA sac in 3 patients, near-complete obliteration in 7, and partial obliteration in 1. One patient died as a direct consequence of the initial SAH. All 10 surviving patients had excellent clinical outcomes (Glasgow Outcome Scale Score 5) without posttreatment rebleeding during a follow-up period of 8–24 months (mean follow-up 15 months). Angiographic follow-up at 6–12 months after treatment was possible at least once in all surviving patients. Nine VBA-DAs showed complete obliteration; the other aneurysm, which had appeared partially obliterated immediately after treatment, demonstrated progressive obliteration on 2 consecutive follow-up angiography studies. There was no in-stent stenosis or occlusion of the branch or perforating vessels. Conclusions The SAC-SWS technique seems to be a feasible and effective reconstructive treatment option for a ruptured VBA-DA. The technique may be considered as an alternative therapeutic option in selected patients with ruptured VBA-DAs unsuitable for internal trapping of the parent artery.

BACKGROUND AND PURPOSE: There have been inconsistencies on the prognosis and controversies as to the proper management of acute basilar artery dissection. The aim of this study was to evaluate acute basilar artery dissection and its outcome after management. MATERIALS AND METHODS: A total of 21 patients (mean age, 53 years; range, 24–78 years) with acute basilar artery dissection were identified between January 2001 and October 2007. Clinical presentation, management, and outcomes were retrospectively evaluated. RESULTS: The patients presented with subarachnoid hemorrhage (n = 10), brain stem ischemia (n = 10), or stem compression sign (n = 1). Ruptured basilar artery dissections were treated by stent placement with coiling (n = 4), single stent placement (n = 3), or conservatively (n = 3). Of the patients treated with endovascular technique, 6 had favorable outcome (modified Rankin scale [mRS], 0–2) and the remaining patient, who was treated by single stent placement, died from rebleeding. All 3 conservatively managed patients experienced rebleeding, of whom 2 died and the other was moderately disabled. Unruptured basilar artery dissections were treated conservatively (n = 7) or by stent placement (n = 4). Of the patients with unruptured basilar artery dissection, 9 had favorable outcome and the remaining 2 patients, both of whom were conservatively managed, had poor outcome because of infarct progression. The group with the ruptured basilar artery dissection revealed a higher mortality rate than the group with the unruptured dissection (30% vs 0%). The group treated with endovascular means revealed more favorable outcome than the group that was treated with conservative measures (90.9% vs 50%). CONCLUSION: The ruptured basilar artery dissections were at high risk for rebleeding, resulting in a grave outcome. Stent placement with or without coiling may be considered to prevent rebleeding in ruptured basilar dissections and judiciously considered in unruptured dissections with signs of progressive brain stem ischemia.

Objective: The presence of an intracerebral hematoma from a ruptured aneurysm is a negative predictive factor and it is associated with high morbidity and mortality rates even though clot evacuation followed by the neck clipping is performed. Endovascular coil embolization is a useful alternative procedure to reduce the surgical morbidity and mortality rates. We report here on our experiences with the alternative option of endovascular coil placement followed by craniotomy for clot evacuation. Materials and Methods: Among 312 patients who were admitted with intracerebral subarachnoid hemorrhage during the recent three years, 119 cases were treated via the endovascular approach. Nine cases were suspected to show aneurysmal intracerebral hemorrhage (ICH) on CT scan and they underwent emergency cerebral angiograms. We performed immediate coil embolization at the same session of angiographic examination, and this was followed by clot evacuation. Results: Seven cases showed to have ruptured middle cerebral artery (MCA) aneurysms and two cases had internal carotid artery aneurysms. The clinical status on admission was Hunt-Hess grade (HHG) IV in seven patients and HHG III in two. Surgical evacuation of the clot was done immediately after the endovascular coil placement. The treatment results were a Glasgow Outcome Scale score of good recovery and moderate disability in six patients (66.7%). No mortality was recorded and no procedural morbidity was incurred by both the endovascular and direct craniotomy procedures. Conclusion: The results indicate that the coil embolization followed by clot evacuation for the patients with aneurysmal ICH may be a less invasive and quite a valuable alternative treatment for this patient group, and this warrants further investigation.

Objective Early rebleeding after coil embolization of ruptured intracranial aneurysms is rare, however serious and fatal results of rebleeding have been reported. We studied the incidence and angiographic and clinical characteristics of rebleeding of ruptured aneurysms occurring in the immediate postoperative period after coil embolization. Materials and Methods We analyzed patients who had aneurysmal subarachnoid hemorrhage and underwent coil embolization. Patients with dissecting aneurysms, blood blister-like aneurysms, fusiform aneurysms, and pseudoaneurysms were excluded. This study included 330 consecutive patients. The clinical and radiological data of 7 of these patients with acute rebleeding after coil embolization were reviewed. Results The incidence of rebleeding of ruptured aneurysms after coil embolization was 2.1% (7/330), and all cases of rebleeding occurred in the immediate postoperative period within 3 days after coiling. The radiological characteristics were as follows: anterior communicating artery (ACoA) aneurysm (71.4%, 5/7); presence of intracerebral hemorrhage (ICH, 71.4%, 5/7); dome-to-neck ratio < 2 (42.9%, 3/7); presence of bleb (42.9%, 3/7); and subtotal occlusion of aneurysm after coiling (14.3%, 1/7). A thrombolytic agent was administered in 1 patient and continued anticoagulation was performed in 2 patients. Rebleeding patients showed a very poor outcome (Glasgow Outcome Scale 1, 85.7%, 6/7). Conclusion The prognosis of early rebleeding was very poor. Location of aneurysms on ACoA, the unilateral hypoplasia of A1 segment, presence of ICH and bleb, and adverse events during the procedure were probably associated with early rebleeding of ruptured intracranial aneurysms in the immediate postoperative period after coil embolization.

We report here on a rare case of carotid artery angioplasty and stenting in a patient with spontaneous recanalization after complete occlusion of the proximal internal carotid artery (ICA). The patient initially showed severe stenosis at the left proximal ICA on MR angiography (MRA). Digital subtraction angiography (DSA) performed three days after MRA showed complete occlusion of the proximal ICA. The follow-up DSA after four weeks showed recanalization of the ICA, and then carotid artery stenting was successfully performed. There has been no neurologic complication during more than one year follow-up.

BACKGROUND AND PURPOSE: Despite the increasing use of stent-assisted coiling for ruptured intracranial aneurysms, there is little consensus regarding the appropriate antiplatelet administration for this. The objectives of this systematic review were to provide an overview of complications and their association with the method of antiplatelet administration in stent-assisted coiling for ruptured intracranial aneurysms. MATERIALS AND METHODS: A comprehensive search of the literature in the data bases was conducted to identify studies reporting complications of stent-assisted coiling for ruptured intracranial aneurysms. The pooled event rate of preprocedural thromboembolisms, hemorrhages, and mortality was estimated from the selected studies. Subgroup analyses were performed by the method of antiplatelet administration (pre-, postprocedural, and modified). Meta-analysis was conducted to compare periprocedural complications and mortality between ruptured intracranial aneurysms and unruptured intracranial aneurysms. RESULTS: Of the 8476 studies identified, 33 with 1090 patients were included. The event rates of thromboembolism and intra- and postprocedural hemorrhage were 11.2% (95% CI, 9.2%–13.6%), 5.4% (95% CI, 4.1%–7.2%), and 3.6% (95% CI, 2.6%–5.1%), respectively. Subgroup analyses of thromboembolism showed a statistically significant difference between groups (P < .05). In the preprocedural and modified antiplatelet groups, the risk for thromboembolism in stent-assisted coiling for ruptured intracranial aneurysm was not significantly different from that for unruptured intracranial aneurysm, though this risk of the postprocedural antiplatelet group was significantly higher in ruptured intracranial aneurysms than in unruptured intracranial aneurysms. CONCLUSIONS: On the basis of current evidence, complications of stent-assisted coiling for ruptured intracranial aneurysm may be affected by the method of antiplatelet administration.

Subarachnoid hemorrhage (SAH) is a neurological disease with a high mortality rate. Several serious complications frequently arise after successful surgery for this condition. Cerebral vasospasm, one such complication, occurs in 50 to 70% of SAH patients. These patients suffer neurological symptoms known as delayed ischemic neurological deficit (DIND); however, the effect of treatment of vasospasm is limited. The major pathogenesis of cerebral vasospasm is the reduction of nitric oxide (NO) and activation of vasoconstrictors. Acupuncture is known to increase the production and activity of vascular endothelial cell-derived NO and improve endothelium-dependent vasodilatation. A preliminary retrospective case study to investigate the ability of acupuncture to prevent the occurrence of cerebral vasospasm has been conducted. However, no randomized, controlled clinical trials have been carried out to evaluate the efficacy of acupuncture for cerebral vasospasm. This trial will be a single-center, randomized, placebo-controlled, parallel group, patient-assessor-blinded clinical trial. A total of 80 patients with SAH will be randomized into two groups: a study group given acupuncture, electroacupuncture, and intradermal acupuncture, and a control group given mock transcutaneous electrical nerve stimulation and sham intradermal acupuncture. Intervention will start within 96 h after SAH, and a total of 12 sessions will be performed during a 2-week period. The primary outcome measure will be the occurrence of DIND, and the secondary outcomes will be vasospasm as measured by cerebral angiography, transcranial Doppler, clinical symptoms, vasospasm-related infarcts, NO and endothelin-1 plasma levels, mortality, and modified Rankin Scale scores. This trial will examine the efficacy and safety of acupuncture for cerebral vasospasm after SAH. The placebo effect will be excluded and the mechanism of action of the treatments will be evaluated through blood testing. ClinicalTrials.gov NCT02275949 , Registration date: 26 October 2014.

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.

Background and Purpose Although endovascular therapy for intracranial aneurysms has recently started to replace surgical treatment and literature regarding endovascular therapy's advantages and disadvantages is being published, literature concerning the endovascular treatment of distal posterior inferior cerebellar artery (PICA) aneurysms specifically limited to rupture are lacking. We describe the clinical characteristics of ruptured distal PICA aneurysms, their clinical outcomes, and the strategies in which endovascular treatment are used. Patients and Methods Eleven consecutive patients with ruptured distal PICA aneurysm with at least 1 year of follow-up were retrospectively reviewed. Clinical profiles and radiologic and interventional methods were analyzed. Results The mean age at the time of treatment was 56.3 years (range: 30–86 years). The 11 patients consisted of 8 women (72.7%) and 3 men (27.3%). Six patients had a saccular aneurysm; 5 had a dissecting aneurysm. The aneurysms were located at the lateral medullary segment ( n = 5), telovelotonsillar segment ( n = 4), and tonsillomedullary segment ( n = 2). The mean maximal aneurysm diameter was 6.5 ± 3.1 mm (range: 3.4–12.7 mm). Of the 11 aneurysms, 6 were treated with pure aneurysm coiling, 4 were treated with coil trapping, and 1 was treated with stent-assisted coiling. Complete aneurysm obliteration was achieved in nine patients (pure coiling: five, coil trapping: three, stent-assisted coiling: one), and a residual neck was found in two patients (pure coiling: two). Good outcomes (Glasgow Outcome Scale [GOS] of 4 or 5) were achieved in nine patients (pure coiling: five, coil trapping: four), a GOS of 3 was recorded in one patient (stent-assisted coiling), and one patient (pure coiling) had a GOS of 1. Conclusion The present data suggest that endovascular treatment for ruptured distal PICA aneurysms is a safe and effective treatment modality under an elaborate treatment plan.

Cerebrovascular anomalies resulting from the persistence of unfused embryonic twig-like vessels are associated with intracranial aneurysms. All records of patients with ruptured intracranial aneurysms who were treated at our institution were retrospectively reviewed for the presence of aneurysm-associated, unfused, twig-like vessels in the middle cerebral artery (MCA). Such vessels were recorded as twig-like MCA (T-MCA) or twig-like networks of an anomalous collateral artery (T-NACA). Additionally, we sought to characterize vulnerable intracranial aneurysms associated with those vascular anomalies. A total of 442 ruptured aneurysms were treated from June 2006 to November 2013; of these, 4 ruptured aneurysms exhibited the presence of ipsilateral, unfused, twig-like vessels. Computed tomography (CT) scans, three-dimensional CT angiography, and digital subtraction angiography (DSA) were performed immediately after the initial ictus. Data analysis included age, sex, Hunt and Hess grade (HHG), Fisher grade (FG), medical risk factors, angiographic architecture, operative methods and findings, radiologic outcomes, and Glasgow outcome scale (GOS). The average follow-up period was 26 months. Patient ages ranged from 26 to 49 years with a mean age of 41; there were two females and two males. All four patients showed FG IV, and three patients had unfavorable HHG (IV in 2 and V in one) at admission. An M1 segmental occlusion and an adjacent small aneurysmal pouch were detected with three-dimensional CT angiography in three patients. Hypertension was recorded in all patients. The initial DSA revealed T-MCA in one patient and T-NACA in three patients. Six aneurysms in all, including two unruptured aneurysms, were found; three ruptured aneurysms existed inside of the twigs. All but one patient required diverse treatment modalities, and four of the five aneurysms were completely occluded after treatment. The remaining aneurysm, treated only with gluing, disappeared during follow-up. In two of the three patients with T-NACA, atresia of the M1 segment was confirmed intraoperatively. The GOS during follow-up was recorded as favorable (good recovery) in two patients and unfavorable (severe disability and permanent vegetative state) in two patients. These unique vascular anomalies, T-MCA and T-NACA, which are caused by heterogeneous maldevelopment of the primitive cerebral vessels, are not benign because of their frequent association with flow-related aneurysms, which are vulnerable to rupture. Microsurgical or endovascular treatments for this type of flow-related aneurysm associated with twigs are mandatory to prevent fatal rebleeding, and more attention has to be given when physicians encounter steno-occlusive MCA lesions in patients with subarachnoid hemorrhage to detect any vulnerable aneurysms associated with twig-like vessels.

Objective The timing of cranioplasty and method of bone flap storage are known risk factors of non-union and resorption of bone flaps. In this animal experimental study, we evaluated the efficacy of cranioplasty using frozen autologous bone flap, and examined whether the timing of cranioplasty after craniectomy affects bone fusion and new bone formation. Methods Total 8 rabbits (male, older than 16 weeks) were divided into two groups of early cranioplasty group (EG, 4 rabbits) and delayed cranioplasty group (DG, 4 rabbits). The rabbits of each group were performed cranioplasty via frozen autologous bone flaps 4 weeks (EG) and 8 weeks (DG) after craniectomy. In order to obtain control data, the cranioplasty immediate after craniectomy were made on the contralateral cranial bone of the rabbits (control group, CG).The bone fusion and new bone formation were evaluated by micro-CT scan and histological examination 8 weeks after cranioplasty on both groups. Results In the micro-CT scans, the mean values of the volume and the surface of new bone were 50.13±7.18 mm3 and 706.23±77.26 mm2 in EG, 53.78±10.86 mm3 and 726.60±170.99 mm2 in DG, and 31.51±12.84 mm3 and 436.65±132.24 mm2 in CG. In the statistical results, significant differences were shown between EG and CG and between DG and CG (volume : p=0.028 and surface : p=0.008). The histological results confirmed new bone formation in all rabbits. Conclusion We observed new bone formation on all the frozen autologous bone flaps that was stored within 8 weeks. The timing of cranioplasty may showed no difference of degree of new bone formation. Not only the healing period after cranioplasty but the time interval from craniectomy to cranioplasty could affect the new bone formation.

Intrathoracic meningoceles are relatively rare entities found in patients with neurofibromatosis type I (NF1). Given that both the BRCA1 and NF-1 genes are located on the same long arm of chromosome 17, one would expect concurrence of neurofibromatosis and breast cancer. However, incidence of such co-disorders is very rare in the literature. Here, the authors report a case of a 50-year-old female patient with NF-1 and concurrent cancer of the left breast, who had a huge bilobulated intrathoracic meningocele with thoracic dystrophic scoliosis, treated surgically via a posterior-only approach for the meningocele and spinal deformity in the same setting.

To examine the possibility of acupuncture as a new promising treatment to prevent delayed cerebral vasospasm, retrospective comparison was done of patient outcomes in patients with subarachnoid hemorrhage (SAH) treated with and without acupuncture.Twenty (20) patients with SAH were treated after their ruptured aneurysms had been secured. Acupuncture treatments were applied to the bilateral Zusanli (ST36) and Neiguan (PC6) once a day for 2 weeks, starting within 3 days of the aneurysm rupture. The incidence of angiographic vasospasm and delayed ischemic neurological deficit (DIND), the patient's functional status at discharge, and mortality rate were analyzed. Patient outcomes were compared with those of an age- and severity-matched comparison group composed of patients treated in the hospital without acupuncture.None of the patients who received acupuncture died. Angiographic vasospasms occurred in 5 patients (25.0%) and DIND in 2 (10%). In terms of functional impairment, the modified Rankin score at discharge was ≤2 in 7 patients (35%). In the control group, angiographic vasospasms occurred in 10 patients (55.6%) and DIND in 7 (38.9%), similar to the reported incidence in conventionally treated patients.Patients with SAH who received acupuncture had a significantly lower incidence of DIND and significantly improved function at discharge, suggesting that acupuncture is effective in preventing cerebral vasospasm. In light of these promising results, a randomized controlled trial is warranted to determine the efficacy of acupuncture in a clinical setting.

The distal anterior inferior cerebellar artery (AICA) aneurysms located inside the internal auditory canal are rare. The association of the distal AICA aneurysms and an arteriovenous malformation (AVM) on the same arterial trunk is exceptional. Eight reports of a total of ten cases have been published and all of the reported aneurysms were located in the meatal or postmeatal segment of the AICA. Herein, we report a case of ruptured aneurysm in the intrameatal portion of the AICA accompanying an AVM fed by the same artery. A 55-year-old man suffering from subarachnoid hemorrhage due to a ruptured intrameatal aneurysm with a small AVM underwent surgical trapping of the meatal loop, resulting in uneventful recovery. Follow-up angiography demonstrated neither aneurysm nor residual AVM nidus. We propose that trapping of the meatal loop could be a safe and feasible alternative to unroofing followed by neck clipping in selected patients with an intrameatal aneurysm of the AICA. We also review here the relevant literature.

Therapeutic strategies for unruptured aneurysms in elective procedures must be carefully planned with respect to safety. We describe the case of a patient who presented with an unruptured aneurysm associated with a double origin of the posterior inferior cerebellar artery (DOPICA), a rare variant of aberrant origin. A three-dimensional rotational angiogram clearly showed that the aneurysm incorporated the origin of the DOPICA caudal channel, which was more dominant than the cranial one. The aneurysm was completely obliterated using detachable coils after a balloon occlusion test (BOT) of the caudal channel was conducted to confirm the tolerance of the patient following sudden interruption of the more prominent flow coming from the caudal channel of the DOPICA. This report affirms the need to suspect anomalies associated with a DOPICA that predispose to intracranial aneurysms and highlights the potential role of a BOT in pretreatment hemodynamic evaluations of unusual aneurysms accompanying a particular developmental anomaly.