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Various grading systems and surgical techniques have been developed for the treatment of intraventricular hemorrhage (IVH); however, little attention has been paid to the fourth ventricle hematoma. Nonetheless, hemorrhagic dilation of the fourth ventricle may lead to catastrophic consequences for patients with massive IVH. We present two cases of massive IVH accompanied by massive fourth ventricle hematoma which was successfully removed with combination of suboccipital craniotomy for fourth ventricle hematoma and intraventricular fibrinolysis for supratentorial hematoma.

The incidence of acute subdural hemorrhage (ASDH), which is often caused by head trauma, is steadily increasing due to an increase in the elderly population and the use of anticoagulants. Urgent surgical treatment is recommended if the patient has impaired consciousness, worsening neurological symptoms, or brain midline shift (MLS) due to large hematomas on brain computed tomography (CT). Although large craniotomy is traditionally recommended for ASDH removal, old age, comorbidities, and antiplatelet drugs are considered risk factors for surgical complications, many neurosurgeons hesitate to perform aggressive surgical procedures in these patients. In this study, we introduced a method that can quickly and effectively remove ASDH without general anesthesia. We retrospectively reviewed 11 cases of patients with ASDH who underwent hematoma drainage between June 2019 and December 2020. We measured the maximum subdural hematoma thickness and MLS on brain CT of patients and recorded the Glasgow Coma Scale scores before and after the surgical procedure. All patients had multiple comorbidities, and seven patients received anticoagulant or antiplatelet therapy. On initial brain CT, the median subdural hemorrhage thickness was 21.36 mm, median MLS was 10.09 mm, and mean volume of the subdural hematoma was 163.64 mL. The mean evacuation rate of the subdural hematoma after drainage was 83.57%. There was no rebleeding or operation-related infection during the aspiration procedure, and the median MLS correction after the procedure was 7.0 mm. Our treatment strategies can be a reliable, less invasive, and alternative treatment option for patients at high risk of complications due to general anesthesia or patients who are reluctant to undergo a large craniotomy due to a high bleeding tendency.

Background The unilateral anterior interhemispheric approach has been widely used for distal anterior cerebral artery (DACA) aneurysms. However, there are some drawbacks of this approach because of the narrow operative field, including possible brain traction injury, bridging vein injury, and inadequate exposure of the aneurysm. Here, we report a case of a DACA aneurysm covered by the falx that could not be totally exposed with the unilateral interhemispheric approach. We successfully obtained a wide view with wedge resection of the falx, avoiding excessive brain traction and division of the superior sagittal sinus. Case Description A 76-year-old woman with a 6-mm unruptured DACA aneurysm underwent a unilateral craniotomy with the anterior interhemispheric approach. In the operative field, the aneurysm was found at the midline, just below the falx. The aneurysm was covered by the falx and could not be completely exposed with the usual brain retraction. Therefore, we performed wedge resection of the falx, thus obtaining sufficient surgical field and totally exposing the aneurysm. We were then able to apply the clip successfully. Postoperative brain computed tomography angiography showed no remnant aneurysm sac or complications of falx resection or brain retraction, such as bleeding or vessel injury. Conclusions When an aneurysm is located just below the falx and is exposed inadequately, performing wedge resection of the falx can expose the aneurysms adequately for application of the clip.

Apocrine carcinoma is a rare malignant sweat gland tumor that has been reported in approximately 200 cases. This tumor usually occurs in the axilla, but in rare cases, it can also develop in the scalp. In the present work, we report 2 cases of cutaneous apocrine carcinoma of the scalp.Two men visited our outpatient clinic with recurrence of tumor after undergoing surgery for scalp tumor at another hospital.Brain magnetic resonance imaging of a 56-year old man showed the presence of a 5.0 × 4.5 × 4.4 cm scalp mass in the right parietal region, invading the skull and dura mater and a 2.2 × 2.0 × 0.7 cm bony mass without any skin lesions right next to the scalp mass. Neck magnetic resonance imaging of a 76-year-old man revealed the presence of a well-defined oval mass in the subcutaneous layer of the left occipital scalp and 2 enlarged lymph nodes in the left neck. Definite diagnoses were made postoperatively. The patients were diagnosed with cutaneous apocrine carcinoma. The diagnosis was confirmed through histopathological and immunohistochemical staining tests.The tumors were removed with a wide safety margin and reconstructive surgery was performed.Additional radiotherapy or chemotherapy was performed. Follow-up more than 6 months revealed no recurrence or metastasis.If accurate diagnosis and treatment had taken place at the initial stages of the primary cutaneous apocrine carcinoma, it would have been possible to prevent recurrence and intracranial invasion. As recurrent primary cutaneous apocrine carcinoma can become aggressive and difficult to treat, even a small mass on the scalp must be evaluated carefully and treated properly.

Background In this prospective, multicenter, non-comparative observational study, the effectiveness and safety of the triple single-pill combination (SPC) of olmesartan/amlodipine/hydrochlorothiazide (OM/AML/HCTZ) were evaluated in a real clinical practice setting in Korean patients with essential hypertension. Methods A total of 3752 patients were enrolled and followed for 12 months after administration of OM/AML/HCTZ. Primary endpoint was change from baseline to month 6 in the mean systolic blood pressure (SBP). Secondary endpoints included changes from baseline in the mean SBP at month 3, 9, 12 and the mean diastolic blood pressure (DBP) at month 3, 6, 9, 12; changes in the mean SBP/DBP according to age and underlying risk factors; and blood pressure control rate (%) at different time points. Adherence to and satisfaction with OM/AML/HCTZ treatment among patients and physicians were assessed by medication possession ratio (MPR) and numeric rating scale, respectively, as exploratory endpoints. Safety was evaluated by the incidence and severity of adverse events (AEs) as well as the discontinuation rate due to AEs. Results OM/AML/HCTZ administration led to significant reductions in the mean SBP/DBP by 11.5/6.6, 12.3/7.0, 12.3/7.2, and 12.8/7.4 mmHg from baseline to month 3, 6, 9 and 12, respectively (P Conclusions Treatment with the triple SPC of OM/AML/HCTZ demonstrated significant effectiveness in reducing SBP/DBP and achieving target BP control with high adherence over the 1-year observation period in Korean hypertensive patients and was well-tolerated. Trial registration CRIS, KCT0002196, Registered 3 May 2016.

Objective: The surgical method for treating spontaneous intracranial hemorrhage (ICH) is not well established despite ICH’s high prevalence and poor prognosis. Minimally invasive surgery has recently received attention; however, literature on this method is scarce. In particular, the appropriate location of the catheter in the hematoma has not been described. We examined whether the catheter position affects the hematoma reduction in a hematoma ＞50 cc.Methods: We investigated the prognoses of 36 patients with ICH who underwent stereotactic aspiration and hematoma drainage using urokinase from January 2010 to December 2018 and the hematoma reduction rates according to the tube position. Two methods evaluated the position of the catheter. In the first method, the hematoma was an imaginary sphere. The center point was set as the operation target. We evaluated the catheter position by determining whether it was in the deep part or the outer part of the half point from that location to the hematoma margin. In the second method, we evaluated whether the catheter was located 1 cm inside the hematoma margin.Results: In both the first and second evaluations, there were no differences in age, midline shift, intraventricular hemorrhage status, hematoma volume on admission, Glasgow Coma Scale score on admission, time to operation after symptom onset, and systolic blood pressure. The rates of decrease in bleeding and the prognoses were also not significantly different.Conclusions: If the catheter is in the hematoma, the rate of hematoma reduction at any position is similar.

Background In patients with intracerebral hemorrhage (ICH), brain volume loss can occur in the hemisphere ipsilateral to the hematoma. However, contralateral hemispheric volume change after ICH is not well known. The present study aimed to investigate contralateral brain volume changes in patients with ICH who had not undergone surgery. Methods Of the 2213 patients with ICH admitted to our hospital between January 2010 and December 2017, 46 patients without surgical intervention were included in the present study. We measured contralateral hemispheric brain volume in the axial images of brain computed tomography at the time of ICH onset and after 12 months. We analyzed the relationship between various factors and volume changes in the contralateral hemisphere. Results The mean change percentage between the initial and follow-up contralateral parenchyma volume was 96.84%. The average volume decreased by 3.16% (P = 0.001). Univariate and multivariate logistic regression models revealed no significant factors associated with contralateral brain volume loss. Kruskal–Wallis test and Mann–Whitney U test showed no statistical significance (P = 0.824, P = 0.122) between ICH volume groups. Conclusions Contralateral parenchymal volumes were significantly decreased at follow-up brain computed tomography scanning; these changes may provide important clinical information on the remote effect of focal lesion and symptoms in the course of ICH treatment. However, further investigation is required to determine the mechanisms underlying these volume changes.

Background Microsurgical management of blood blister aneurysms of the internal carotid artery is challenging because of the special characteristics of these aneurysms. We reviewed our diverse surgical methods with long-term clinical and radiologic follow-up. Methods We retrospectively reviewed all patients with blood blister aneurysms presenting with subarachnoid hemorrhage that were treated with microsurgical obliteration between 1993 and 2017. Baseline characteristics of patients and aneurysms, surgical methods, and clinical and radiologic outcomes were analyzed. Results This study included 36 patients. The patients were treated using microsurgery with direct clipping (2 patients; 5.6%), cotton-assisted clipping (24 patients; 66.7%), wrapping-clipping (5 patients; 13.9%), or wrapping-clipping with suturing (5 patients; 13.9%). Complete occlusion of aneurysm was achieved in 34 of 36 patients (94.4%). Severe vasospasm developed in 18 of 36 patients (50%). Ischemic events occurred in 8 patients (22.2%), 2 of whom remained with severe disability. Regrowth or recurrence occurred in 1 patient (0.28%), which required additional stent-assisted coil embolization. Mean modified Rankin Scale score was 2.0 (median, 1.0; range, 0–4) at discharge and 1.3 (median, 1.0; range, 0–4) at the last follow-up. Conclusions Direct clipping is ideal if possible; however, direct clipping is challenging in most blood blister aneurysms. Assisted clipping with cotton is mainly used and could be an effective technique for reinforcement of the friable wall, with good clinical outcomes in our series. Moreover, suturing followed by wrapping-clipping is also useful for managing intraoperative rupture.

Anterior cranial base reconstruction is occasionally necessary following severe trauma. Several methods for reconstruction have been described and some authors have described their experiences regarding the use of a pericranial flap for anterior skull base reconstruction after trauma. A 26-year-old woman was admitted to our department with multiple facial bone fractures identified using facial bone computed tomography. Plastic surgeons performed surgery under general anesthesia for the patient's nasal bone fractures. On the seventh day after admission, the patient's brain computed tomography showed an abscess in the frontal lobe. Antibiotic treatment was started, but the lesion deteriorated. Anterior skull base reconstruction was then performed using a pericranial flap with gelfoam compression. No complications, including leakage of cerebrospinal fluid, cerebral hemorrhage, necrosis of the pericranial flap, or frontal lobe herniation, were observed 1 year following surgery. In our case, the authors performed a simple and effective treatment with reconstruction using pericranial flap and gelfoam compression without complications. This technique is useful for reconstructing defects in the base of the frontal bone resulting from various causes, as well as for fracture of the anterior skull base following trauma.

Objective: Macrophages have been shown to play important roles in various pathophysiological processes of the central nervous system via neuroinflammation, leading to an increased interest in macrophage biology. Circulating blood monocytes are among the first cells to infiltrate the brain after ischemic stroke; however, the role of innate immune cells such as monocytes and macrophages remains to be elucidated. Here, we investigated the association between blood monocytes and infarct size following ischemic stroke.Methods: We induced stroke using a focal ischemia mouse model through middle cerebral artery suture occlusion. To deplete circulating blood monocytes, clodronate was injected intraperitoneally 24 h before the surgery. Animals were sacrificed at specified time points, and the infarct size and mRNA expression were then measured.Results: The clodronate-injected mice showed significantly smaller infarct size than the control mice. Immunohistochemical staining revealed that monocyte depletion significantly blocked the infiltration of macrophages and microglia. The mRNA expression levels of macrophage and microglia markers were higher in the left infarcted brain than in the right non-infarcted brain.Conclusions: In summary, monocyte depletion reduced the infarct size and mitigated neurological deficits in mice following ischemic stroke, likely by blocking the infiltration of inflammatory cells such as macrophages and microglia.

Objective Carotid endarterectomy (CEA) is an effective surgical procedure for treating symptomatic or asymptomatic patients with carotid stenosis. Many neurosurgeons use a shunt to reduce perioperative ischemic complications. However, the use of shunting is still controversial, and the shunt procedure can cause several complications. In our institution, we used two types of modified arteriotomy suture techniques instead of using a shunt. Methods In technique 1, to prevent ischemic complications, we sutured a third of the arteriotomy site from both ends after removing the plaque. Afterward, the unsutured middle third was isolated from the arterial lumen by placing a curved Satinsky clamp. And then, we opened all the clamped carotid arteries before finishing the suture. In technique 2, we sutured the arteriotomy site at the common carotid artery (CCA). We then placed a curved Satinsky clamp crossing from the sutured site to the carotid bifurcation, isolating the unsutured site at the internal carotid artery (ICA). After placing the Satinsky clamp, the CCA and external carotid artery (ECA) were opened to allow blood flow from CCA to ECA. By opening the ECA, ECA collateral flow via ECA-ICA anastomoses could help to reduce cerebral ischemia. Results The modified suture methods can reduce the cerebral ischemia directly (technique 1) or via using collaterals (technique 2). The modified arteriotomy suture techniques are simple, safe, and applicable to almost all cases of CEA. Conclusion Two modified arteriotomy suture techniques could reduce perioperative ischemic complications by reducing the cerebral ischemic time.

Measurement of cortisol in hair is a reliable method for determining long-term cortisol exposure reflecting chronic stress. Research using hair cortisol concentration has been limited to mainly cardiometabolic diseases. The association between hair cortisol concentration and aneurysmal rupture has not yet been studied. We aimed to investigate the relationship between the degree of chronic stress as measured by hair cortisol concentration and aneurysmal rupture. Sixty-eight patients diagnosed with intracranial aneurysms were included in this study (ruptured group, 30; unruptured group, 38). Hair cortisol was measured in 3-cm hair segments, reflecting roughly 3 months of hair growth. For a risk factor analysis, patient-specific factors and aneurysm-specific factors as well as hair cortisol concentration were investigated. Hair cortisol concentrations were significantly higher in the ruptured group than in the unruptured group (55.8 ± 22.0 ng/dL vs. 19.1 ± 6.4 ng/dL; P

Distal peripheral artery aneurysms in moyamoya disease (MMD) remain difficult to treat given their deep location, small size, and fragility. Here, we report two cases of choroidal artery aneurysms associated with MMD who were treated through direct clipping and coil embolization. Timing of aneurysm formation remains unclear, however, annual follow-up DSA for surveillance of hemodynamic status is necessary and prompt treatment of aneurysm should be performed when diagnosed. Moreover, choroidal artery aneurysms may benefit from endovascular coil embolization due to their characteristics.

In patients with intracerebral hematoma (ICH), it is well known that brain atrophy occurs in the hemisphere ipsilateral to the hematoma. The present study aimed to investigate contralateral hemispheric volume changes in patients with ICH as well as related factors.Of 112 patients with ICH who were surgically treated at our hospital between January 2011 and December 2015, 44 were included in the present study. We measured contralateral hemispheric brain areas in 3 planes of axial brain computed tomography images. We obtained the proportion of contralateral hemispheric parenchyma to the hemispheric intracranial area to adjust for individual differences in head size. We analyzed the relationship between various factors and volume changes in the contralateral hemisphere.The average volume percentages of preoperative and follow-up contralateral hemispheric parenchyma were 92.3% versus 88.8%, 90.3% versus 85.3%, and 86.9% versus 82.5% in the level of foramen of Monro, septum pellucidum, and lateral ventricle, respectively. These decreases were all statistically significant (paired t-test; P 0.001). As far as the causes of these decreases, the presence of intraventricular hematoma was the most significant factor for a decrease (P = 0.006). Glasgow coma scale score on arrival, as well as, smoking were independent factors in a multivariate analysis (P = 0.016, 0.039).Contralateral parenchymal volumes were significantly decreased at the 3-month follow-up brain computed tomography scan. These findings may offer important clinical information on the remote brain injury of ICH.

Nonsaccular vertebral artery aneurysms involving the posterior inferior cerebellar artery (PICA) are rare. Treatment is considered a significant challenge because of their angiographic and anatomical features, especially in high-riding PICA. Therefore, meticulous preoperative angiographic and anatomical evaluation is necessary. Moreover, consideration of the distance between the cerebellar skull base and caudal loop of the PICA is important. We present two cases of occipital artery-high-riding PICA bypass and discuss important preoperative technical considerations.

Background Ruptured vertebral artery dissecting aneurysms (VADAs) involving the posterior inferior cerebellar artery (PICA) are the most difficult to treat among variations of VADAs but require prompt treatment. The major challenge is to preserve the PICA while occluding the aneurysm. Despite advances in the management of ruptured VADAs involving the PICA, each treatment, whether it is combined or not, is associated with a significant degree of risk. Case Description This study presents 4 cases of ruptured VADAs involving the PICA that were successfully treated using a staged, combined method. Embolization of the rupture point in the acute stage was followed 3–4 weeks later by occlusion of the proximal vertebral artery (VA) and PICA origin after occipital artery–PICA bypass in the chronic stage. Conclusions Although it is sometimes very difficult to determine the exact rupture point of VADAs, ruptures tend to occur at distal segments of a dissecting aneurysm presenting as bleb. Also, when planning a trapping of the VA, careful examination of angiography is needed to assess the contralateral VA and rupture point. Our staged and combined strategy may provide another valuable treatment option for treating VADAs involving the PICA with special emphasis on the safety and efficacy in our method.

Background The unilateral interhemispheric approach for distal anterior cerebral artery aneurysms presents several risks, such as postoperative venous infarction due to occasional sacrifice of parasagittal bridging vein and postoperative frontal lobe damage due to retraction force. To overcome these risks, we used a bifrontal craniotomy with straight dural incision and cutting of the superior sagittal sinus. Methods We retrospectively reviewed 61 patients (42 unruptured and 19 ruptured A2 and A3 aneurysms) who under aneurysm clipping through bifrontal interhemispheric approach between March 2007 and December 2017. There were 35 A2 aneurysms and 27 A3 aneurysms, and mean size of aneurysms was 5.45 mm. The modified bifrontal interhemispheric approach involved 3 steps: bifrontal craniotomy of centrobasal portion of the frontal bone, ligation and division of anterior one third of the superior sagittal sinus, and approaching the aneurysm via the interhemispheric space. All patients underwent computed tomography on postoperative days 3 and 7 for evaluation of brain retraction damage or venous infarction. Results Among patients with ruptured aneurysms, 79% had a favorable outcome (Glasgow Outcome Scale score 4 or 5) 6 months after primary subarachnoid hemorrhage; all patients with unruptured aneurysms had favorable outcomes. Surgical outcome was strongly related to preoperative neurologic Hunt and Hess grade. Three patients had poor outcomes due to poor Hunt and Hess grade on admission (grade 3 in 2 patients, grade 4 in 1 patient). Follow-up CT showed that venous infarction did not occur in any of the patients. Conclusions Modified bifrontal interhemispheric approach may be a safe and effective method for treating A2 and A3 aneurysms with relatively good clinical outcome and no surgery-related complications.

Rationale: Patients with long term bed rest in intensive care unit after neurosurgery could experience splanchnic hypoperfusion. These patients have several other medical conditions that exacerbate splanchnic hypoperfusion during treatment and the splanchnic hypoperfusion could result in “stress-induced intestinal necrosis”, which could cause massive hematochezia. We report here the experience of life-threatening hematochezia in 3 patients who underwent brain surgery in our institution. Patients concerns: One female patient (72-year-old) and 2 male patients (58- and 35-year-old) were admitted to our institution because of traumatic intracerebral hemorrhage, subarachnoid hemorrhage due to a ruptured anterior communicating artery, and subarachnoid hemorrhage with unknown cause respectively. All patients underwent emergency brain surgery for diagnosis and treatment. After surgery, they all experienced long-term bed rest in intensive care unit. Hematochezia occurred on postoperative day 15, 17, and 49, respectively. Diagnoses: All of the patients were assessed by abdomen/pelvis computed tomography and underwent a colonoscopy. Interventions: The female patient underwent embolization through pelvic arteriography and epinephrine injection through colonoscopy, but a total colectomy and ileostomy was performed due to refractory hematochezia. 58-year-old male patient had a laparoscopic ileostomy for the bowel rest. The other patient underwent nil per os and conservative treatment for 2 weeks. Outcomes: The female patient was discharged without further treatment plan, 58-year-old male patient survived after laparoscopic ileostomy, while the other patient survived after 2 weeks of nil per os. Lesson: Abdominal symptoms, such as hematochezia, should be actively managed in neurosurgical patients who are undergoing long-term bed rest in an intensive care unit under physiologically stressful medical conditions.

Enophthalmos after a ventriculo-peritoneal (V-P) shunt placement is very rare. Previous defects of the orbital wall with intracranial hypotension can cause enophthalmos after V-P shunting. The authors present 2 patients of enophthalmos with orbital wall defects resulting from anterior clinoidectomy that was performed during previous aneurysmal surgery. Both patients received a V-P shunt for hydrocephalus after subarachnoid hemorrhage. Although the hydrocephalus was improved by V-P shunts in both patients, sunken eyes were observed. The patients received reconstructive surgery of the superior orbital wall using titanium mesh and recovered after surgery without any neurological deficits. Here, the authors present 2 patients of enophthalmos with orbital wall defects treated by orbital wall reconstruction.

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Ischemic postconditioning (IPostC) has been shown to attenuate brain injury in rat stroke models, but a mouse model has not been reported. This study establishes an IPostC model in mice and investigates how IPostC affects infiltration of leukocytes in the ischemic brain and lymphopenia associated with stroke-induced immunodepression.A total of 125 mice were used. IPostC was performed by a repeated series of brief occlusions of the middle cerebral artery (MCA) after reperfusion, in a focal ischemia model in mice. Infarct sizes, neurological scores, inflammatory brain cells and immune cell populations in lymph nodes, spleen and bone marrow were analyzed with fluorescence-activated cell sorting (FACS).IPostC performed immediately, 2 min and 3 h after reperfusion significantly reduced infarct sizes and attenuated neurological scores as measured up to 3 days post-stroke. In the group with strongest protection, infarct sizes were reduced from 49.6±2.8% (n=16) to 27.9±2.9% (n=10, P.001). The spared infarct areas were seen in the ischemic penumbra or ischemic margins, i.e., the border zones between the cortical territories of the anterior cerebral artery and those of the MCA, as well as in the ventromedial and dorsolateral striata. FACS analyses showed that IPostC significantly blocked increases in the numbers of microglia (CD45intCD11b+), macrophages (CD45hiCD68+), CD4 T cells (CD45+CD4+) and CD8 T cells (CD45+CD8+) as well as B lymphocytes (CD45+CD19+) in the ischemic brain (n=5/group). Reduced-immune cell numbers in the peripheral blood and spleen were increased by IPostC while immune cell populations in the bone marrow were not altered by IPostC.IPostC reduced brain infarction and mitigated neurological deficits in mice, likely by blocking infiltration of both innate and adaptive immune cells in the ischemic brain. In addition, IPostC robustly attenuated peripheral lymphopenia and thus improved systemic immunodepression.

OBJECTIVE Recently, microscope-integrated near infrared indocyanine green videoangiography (ICG-VA) has been widely used in cerebrovascular surgery because it provides real-time high resolution images. In our study, we evaluate the efficacy of intraoperative ICG-VA during cerebrovascular surgery. METHODS Between August 2011 and April 2012, 188 patients with cerebrovascular disease were surgically treated in our institution. We used ICG-VA in that operations with half of recommended dose (0.2 to 0.3 mg/kg). Postoperative digital subtraction angiography and computed tomography angiography was used to confirm anatomical results. RESULTS Intraoperative ICG-VA demonstrated fully occluded aneurysm sack, no neck remnant, and without vessel compromise in 119 cases (93.7%) of 127 aneurysms. Eight clipping (6.3%) of 127 operations were identified as an incomplete aneurysm occlusion or compromising vessel after ICG-VA. In 41 (97.6%) of 42 patients after carotid endarterectomy, the results were the same as that of postoperative angiography with good patency. One case (5.9%) of 17 bypass surgeries was identified as a nonfunctioning anastomosis after ICG-VA, which could be revised successfully. In the two patients of arteriovenous malformation, ICG-VA was useful for find the superficial nature of the feeding arteries and draining veins. CONCLUSION ICG-VA is simple and provides real-time information of the patency of vessels including very small perforators within the field of the microscope and has a lower rate of adverse reactions. However, ICG-VA is not a perfect method, and so a combination of monitoring tools assures the quality of cerebrovascular surgery.

Objective Traumatic intracranial aneurysm (tIA) is rare and is associated with high rates of morbidity and mortality. We describe our experiences with tIA at our institution. Methods We retrospectively reviewed records from patients who underwent treatment for tIA between January 1986 and December 2015. Results Data from 5532 patients with cerebral aneurysms between January 1986 and December 2015 were reviewed. Of these, 13 cases (0.23%) were tIA. Most occurred after blunt brain trauma (12/13; 92%). The most common location was the distal anterior cerebral artery (7/13; 53%) followed by the internal carotid artery (5/13; 38%). One patient had a tIA in the distal middle cerebral artery. Delayed intracerebral hemorrhage was the major presentation at the time of aneurysmal rupture (70%). Most patients underwent surgical treatment (10/12; 83.3%), which included clipping (5/10), trapping (3/10), aneurysmal excision and bypass (1/10), and aneurysmal excision and coagulation (1/10). In 2 cases, tIA located in the internal carotid artery was treated with coil embolization and detachable balloon occlusion, respectively. Most patients had good recovery (5/12; 41.7%); 3 patients and 1 patient had moderate and severe disability, respectively; 1 patient was in a vegetative state; and 2 patients died. Conclusions tIA is an uncommon complication of head trauma. tIA should be considered when unexpected new symptoms develop in patients with head trauma. Early diagnosis and prompt treatment could help to improve final clinical outcomes.

Background Preservation of the superficial Sylvian veins (SSVs) is essential to prevent neurologic deficits during Sylvian dissection. We describe an appropriate surgical approach for unruptured middle cerebral artery (MCA) aneurysms to preserve these veins by using indocyanine green videoangiography (ICG-VA). Methods Between August 2014 and August 2015, we performed microsurgical clipping for 37 unruptured MCA aneurysms in 36 patients. We classified all of the cases into 3 types according to the location between the Sylvian fissure and the SSV. We defined 3 surgical approaches (frontosylvian, intersylvian, and temporo-sylvian) based on the SSV and investigated the proper surgical approach according to the type of case. Results In our study, most SSVs were located above the Sylvian fissure (fissure type, 64.9%). The SSV was located on the temporal lobe in 10 cases (temporal type) and on the frontal lobe in 3 cases (frontal type). The frontosylvian approach (splitting between the SSV and frontal lobe) was performed in all of the patients with temporal type; the temporo-sylvian approach (splitting between the SSV and temporal lobe) was performed in all of the patients with frontal type and single SSV of fissure type. The intersylvian approach (splitting between the frontal and temporal SSV, or among multiple SSVs) was successfully performed in the patients with double or multiple SSVs of fissure type. No venous complications occurred that were related to the surgical approach. Conclusions Correct dissection strategy using intraoperative ICG-VA is greatly useful to define the optimal surgical approach without vein injury.

Intracranial aneurysm rupture usually manifests with subarachnoid hemorrhage, often combined with intracerebral hemorrhage with intraventricular hemorrhage extension. In rare cases, however, these aneurysms present only as subdural hematomas. Recently, we treated a 48-years-old female patient who presented only with subdural hematoma. Interestingly, she did not have a history of trauma. Computed tomography angiography and digital subtraction angiography revealed a 5 × 3 mm sized aneurysm at the A3-A4 junction of the left anterior cerebral artery. On admission, emergency operation (clipping and hematoma evacuation) was performed to protect against re-bleeding. Along with postoperative intensive care, the patient returned to normal daily life with only a mild headache. Given that patients may present with atraumatic acute subdural hematoma, the clinician must bear in mind the possibility of intracranial vascular pathology and obtain angiographic scans to evaluate for any underlying conditions to prevent patient deaths.

We report here one case of rapid and aggressive course of cerebral metastatic angiosarcoma from the heart. A 36-year-old man presented with 10-days history of headache. Magnetic resonance imaging demonstrated subacute hemorrhage with a small region of enhancement in right parietal region and the pathological diagnosis was angiosarcoma. Transthoracic echocardiography demonstrated 3.2×3 cm sized mass on right atrial wall. Newly developed lesion was reoperated, three and four weeks later respectively, and whole brain radiotherapy of total 30 Gy was done. With the interval of two months, gamma knife surgery was done for new lesions two times, which were well controlled. Newly developed lesions rapidly happened even in the adjuvant treatment. He died 9 months after the diagnosis because of the aggravation of primary cancer. The cerebral metastatic angiosarcoma from the heart showed the rapid aggressive behavior and the closed follow-up could be needed for the adjuvant treatment.

Objective To report a series of 20 consecutive patients with aneurysms of the proximal segment (A1) of the anterior cerebral artery (ACA. Methods The medical records of patients who had undergone surgery for intracranial aneurysms at two institutions between January 1, 1989, and February 1, 2009, were reviewed. Mean patient age was 52.15 years (range 39–69 years). All 20 patients underwent direct surgery, with clipping or trapping, via standard pterional craniotomy. Results The incidence of A1 segment aneurysm was 0.59%. There were 16 women and 4 men, showing a strong predominance of this lesion in women. Mean aneurysm size was 6.95 mm (range 3–10 mm). Four patients (20%) had multiple aneurysms, and three patients (15%) had associated vascular anomalies. Among patients whose aneurysms originated from perforating arteries, dissection sacrificed the perforating arteries in two patients, and the perforating arteries occluded postoperatively in three patients. In the patients whose aneurysms did not originate from perforating arteries, no perforating arteries were sacrificed during dissection, and perforating arteries became occluded in two patients postoperatively. There was no statistically significant difference between the two groups of patients regarding the incidence of injury or occlusion. Clinical outcomes were as follows: good recovery in 15 (75%) patients, moderate disability in 2 (10%) patients, severe disability in 2 (10%) patients, and death in 1 (5%) patient. Conclusions The important consideration in surgery for intracranial aneurysms is preservation of the perforating arteries, through cautious dissection around the neck or dome and avoidance of direct clip compression, even after releasing the retracted frontal lobe.

RATIONALE A subdural empyema (SDE) following burr hole drainage of a chronic subdural hematoma (CSDH) can be difficult to distinguish from a recurrence of the CSDH, especially when imaging data is limited to a computed tomography (CT) scan. PATIENTS CONCERNS All patients underwent burr hole drainage of the CSDH at first, and the appearance of the SDE occurred within one month. DIAGNOSES A contrast-enhanced magnetic resonance imaging (MRI) scan, with diffusion-weighted imaging (DWI), revealed both the SDE and diffuse meningitis in all patients. INTERVENTIONS In Case 1, because the patient was very young, burr hole drainage of the SDE, rather than craniotomy, was performed. However, subsequent craniotomy was required due to recurrence of the SDE. In Cases 2 and 3, an initial craniotomy was performed without burr hole drainage. OUTCOMES Symptoms improved for all patients, and each was discharged without any neurologic deficits or subsequent recurrence. LESSONS Neurosurgeons should consider the possibility of infection if recurrence of CSDH occurs within 1 month following drainage of a subdural hematoma. A contrast-enhanced MRI with DWI should be performed to differentiate SDE from CSDH. In addition, surgical evacuation of the empyema via wide craniotomy is preferred to burr hole drainage.

The purpose of this study was to evaluate the effect of endovascular treatment of ruptured dissecting aneurysms of the vertebral artery, the benefits of early embolization, and the predictors of outcomes. Between September, 2001 and May, 2009, 25 patients with ruptured vertebral dissecting aneurysms were treated by internal coil trapping (n = 23) or stents (n = 2) in our hospital. There were 14 males and 11 females with a mean age of 45 years (age range, 22–66 years). Dissecting aneurysms were supra-posterior inferior cerebellar artery lesions (n = 16), infra-posterior inferior cerebellar artery lesions (n = 6), or involved the posterior inferior cerebellar artery (n = 3). Complete occlusion of dissected arterial and aneurysm segments (internal trapping) was achieved in 21 (91.3%) of 23 patients. The two patients with posterior inferior cerebellar artery involvement underwent double stent only placement. Clinical outcomes were favorable in 17 (68%) of 25 patients, 2 (8%) had severe disability, and 6 (24%) patients died. Risk factors that varied with favorable versus unfavorable outcomes were: preoperative Hunt–Hess, World Federation of Neurological Surgeons scale, presence of hydrocephalus, presence of lateral medullary syndrome, presence of low cranial nerve palsy, rebleeding, time of endovascular procedures, and time from admission to procedure. However, univariate Cox analysis confirmed that only low preoperative Hunt–Hess grade predicted favorable clinical outcome. Early embolization did not affect clinical outcome, but reduced the risk of rebleeding and inpatient stay. In our experience, internal trapping of the dissected segment with a coil was straightforward, applicable to most patients, prevented rebleeding safely and effectively without significant procedural complications, and had a good follow-up outcome. The low Hunt–Hess grade remained predictors of favorable clinical outcomes. The timing of embolization did not significantly affect clinical outcome but early embolization reduces inpatient stay.

Objective Ischemic postconditioning (IPostC), consisted of transient brain ischemia/reperfusion cycles, is considered to have neuroprotective effect. However, there is no best single protocol of IPostC, because varied factors like species tested and characteristics of the tissue may affect the efficacy of IPostC. Thus, we investgated whether different protocols of IPostC affect neuroprotective effects in experimental animal models. Materials and methods Through occlusion of middle cerebral artery (MCA) with intraluminal suture, stroke was induced in a transient focal ischemia model in mice. We conducted IPostC via brief and repeated MCA occlusion, 2 minutes after reperfusion, followed by different ischemia and reperfusion protocols. After procedure, functional neurological score and histological examination were evaluated. Results IPostC with different protocols resulted in diverse effects. Among them, a protocol that consists of 3 cycle of IPostC significantly reduced the infarction size 3 days after stroke. Conclusion IPostC was confirmed to reduce infarction size. The effects of IPostC are definitely affected by differences in the protocol used, including the number of cycles, the duration of individual ischemia/reperfusion episode and the entire duration of the IPostC stimuli.

Background The COL1A2 is located on chromosome 7q22.1, and mutations in this gene have been associated with the development of IAs. In this study, we investigated whether the rs42524 and rs2621215 polymorphisms of the COL1A2 gene are associated with the development of cerebral aneurysms in the Korean population. Methods This was a hospital-based case control study conducted at Chonnam University Hospital, Gwangju, Korea. The study population consisted of 320 patients who had been treated for IA and 189 healthy hospital-based controls (angiographically negative for an IA). Two polymorphic loci were amplified by polymerase chain reaction, namely, rs42524 in exon 28 and rs2621215 in intron 46 of the COL1A2 gene, and analyzed by RFLP using Hha I or Bfa I restriction enzymes, respectively. Results The genotype frequencies of rs42524 in cases were 88.0%, 11.4%, and 0.6% for the GG, GC, and CC genotypes, respectively, and in controls were 88.9%, 10.0%, and 1.1%, respectively. Similarly, the genotype frequencies of rs2621515 in cases were 88.0%, 10.1%, and 0.2% for the TT, TG, and GG genotypes, respectively, and among controls were 92.1%, 7.9%, and 0%, respectively. Conclusion The rs2621215 SNP in intron 46 of the COL1A2 gene was found to be marginally associated with an increased risk of IA development in the Korean population examined. In contrast, rs42524 showed no association with an increased risk of IA development.

Purpose Yasagil temporary clips have been widely used in extracranial-intracranial (EC-IC) arterial bypass surgery. However, the extremely delicate vessels involved often require the application of finer clips. We report on the use of the Kopitnik arteriovenous malformation (AVM) microclip system for superficial temporal artery-middle cerebral artery (STA-MCA) bypass. Methods Kopitnik AVM microclips are new mechanical devices that are used during AVM surgery. They exert a pre-defined closing force of 50–70 g, and also feature a special, pyramid-shaped structure stamped on inner surfaces of the blades. These characteristics avoid vascular intimal injury and provide a secure grip. We prospectively studied their use in 15 patients requiring STA-MCA anastomosis. Results Clinical results were excellent and there were no new ischemic events during 6-months’ follow-up. Conclusions Kopitnik AVM microclips have several advantages; they have small and variously sized clip blades (2, 3, 4 and 5 mm), and the small clip head allows the operator an excellent view of the pathology and clip status. The Kopitnik AVM microclip appears to be clinically effective and safe for EC-IC bypass surgery, especially when smaller vessels are involved.

Abstract Moyamoya disease is a rare, progressive cerebrovascular disorder that is characterized by a stenosis or occlusion of the bilateral internal carotid arteries and the development of collateral vessels. Transient ischemic attacks or seizures are the usual presentation of moyamoya disease in children, whereas cerebral hemorrhage is the most common symptom in adults. We report an 18-year-old female patient with active lupus nephritis who presented with the sudden onset of left hemiparesis. Brain magnetic resonance imaging showed acute infarctions in the right basal ganglia and subcortical white matter of the right frontal lobe. Cerebral angiography showed the stenosis of the bilateral internal carotid arteries with rich basal collateral vessels (moyamoya vessels). There was no evidence of atherosclerosis or antiphospholipid syndrome. Glucocorticoid therapy was used to control the systemic lupus erythematosus. Prophylactic bypass surgery was performed to prevent recurrent ischemic attacks. This case report shows that an underlying cerebrovascular lesion of moyamoya vessels in a patient with systemic lupus erythematosus is susceptible to cerebrovascular accidents.

Background Intracranial infectious aneurysms (IAs) are rare cerebrovascular lesions that represent only 1%–6% of all intracranial aneurysms. IAs are rare cerebrovascular lesions and pose a significant therapeutic challenge because of their angiographic and pathophysiologic features. We describe a patient with an intracranial IA treated by the use of reconstructive endovascular methods using a balloon-expandable covered stent and discuss the pathophysiologic characteristics of IA based on serial brain imaging findings. Case Description A 21-year-old man was admitted to our emergency department with headache and vomiting. Neurologic examination, hematologic workup, and cerebrospinal fluid examination confirmed a diagnosis of bacterial meningitis. Initial brain magnetic resonance angiography revealed no significant stenosis lesions or aneurysm. After 4 weeks of antibiotic treatment, follow-up brain magnetic resonance imaging revealed an 8-mm sized aneurysm on the petrous portion of the right internal carotid artery, and 3 months later, follow-up brain magnetic resonance angiography revealed that the aneurysm had increased in size from 8 to 15 mm. Conventional 4-vessel angiography confirmed the presence of a pseudoaneurysm. Endovascular treatment was then planned via the use of a balloon-expandable covered stent. Postoperatively, the patient was discharged without specific neurologic deficit. Conclusions IAs are rare cerebrovascular lesions and pose a significant therapeutic challenge because of their angiographic and pathophysiologic features. Although endovascular treatment is not performed routinely for infectious aneurysms, the covered stent may represent a safe and effective treatment that achieves complete endoluminal reconstruction of the damaged vessel wall.

Blood blister-like aneurysms (BBAs) account for 0.5–2.0 % of ruptured intracranial aneurysms. Because of their rarity, the natural history and pathophysiology of such aneurysms are not fully understood. We present two patients with BBAs treated with Bemsheets-covered clipping and discuss their pathophysiological characteristics, through the intraoperative and specific indocyanine green (ICG) video angiography (VA) findings. A 34-year-old male and a 53-year-old female were admitted to our emergency room with suddenly reduced levels of consciousness. Brain imaging studies demonstrated a blood blister-like aneurysm of the supraclinoid segment of the right ICA. Craniotomy and an attempt of surgical clipping were performed. ICG-VA showed the filling defect of dye in aneurysm in the operative field. The BBAs were clipped after being covered by Bemsheets (Kawamoto Corporation, Osaka, Japan) and then confirmed by the ICG-VA. Postoperatively, both patients showed transient neurological deficit due to vasospasms and recovered to their normal statuses within a few months after their respective operations. ICG-VA showed the filling defect of dye in BBAs, which supported that BBAs have been a pseudoaneurysm. In addition, although not routinely recommended in the treatment of BBAs, we believe that Bemsheet-covered clipping is a safe and effective treatment option for BBAs.

Digital subtraction angiography (DSA) has been used as the standard method for detecting cerebral vasospasm after subarachnoid hemorrhage (SAH). Multislice computed tomographic angiography (CTA) is a relatively recent method used for evaluating the vasculature of the intracranial arteries. The purpose of this study was to compare multislice CTA and DSA for the detection and quantification of cerebral vasospasm after SAH, and to analyze the usefulness of multislice CTA. Eight patients with SAH underwent initial CTA with DSA within 72 hours after the onset of symptoms and follow-up multislice CTA and DSA 8 to 48 days after SAH. Five arterial locations were established in the Al and A2 segments of the anterior cerebral artery, the M1 and M2 segments of the middle cerebral artery and the posterior cerebral artery (PCA) on both multislice CTA and DSA images. Vasospasm was classified as none, mild (up to 30% reduction in luminal diameter), moderate (31-60% reduction), and marked (at least 60 % reduction) using the scale of Schneck and Kricheff. The multislice CT system used the following parameters: 1.25 mm collimation and 3.75 pitch with a 4-channel system. The degree of vasospasm revealed by the multislice CTA was significantly correlated with the degree of vasospasm revealed by DSA. In general, most discrepancies between CTA and DSA were in the detection of mild and moderate vasospasm. We found that the consistency between multislice CTA and DSA was greater for mild (100%, n=3) or moderate (100%, n=3) vasospasm than none (n = 1) or marked vasospasm (n = 1). However, it was unclear whether multislice CTA was more specific for a proximal location (Al, Ml, PCA) or distal location (A2, M2) for evaluation of cerebral arteries. Multislice CTA can detect angiographic vasospasm after SAH with an accuracy similar to that of DSA. Multislice CTA is highly sensitive, specific and accurate in detecting mild and moderate cerebral vasospasm. It is less accurate for detecting no vasospasm and marked vasospasm. Therefore, the authors propose that multislice CTA be considered as a useful tool for the detection and management of intracranial vasospasm after SAH.

A 32-year-old woman with Behcet's disease suffered repeated transient ischemic attacks (TIA) consisting of left hemiparesis. Cerebral angiography revealed the typical findings of moyamoya disease, with occlusion of the supraclinoid portion of both internal carotid arteries, coupled with abnormal collateral vessels. She underwent right superficial temporal artery to middle cerebral artery (STA-MCA) anastomosis and encephalomyosynangiosis, due to decreased reserve capacity demonstrated on acetazolamide single positron emission computed tomography (SPECT). Postoperatively, the TIA symptoms subsided. This is the first report of moyamoya disease associated with Behcet's disease, and moyamoya disease should be considered in the differential diagnosis of cerebrovascular events in patients with Behcet's disease. Revascularization surgery is recommended for the prevention of ischemic insults resulting in permanent deficits.

Iatrogenic spinal epidermoid tumors are extremely rare and may be caused by skin fragments which were implanted in the spine as a result of a trauma or lumbar puncture. Due to the time lag between the lumbar puncture and the development of a symptomatic tumor, this relationship is often overlooked and can cause a delay in the proper diagnosis. Here, we report a rare case of an intraspinal epidermoid tumor, which developed 7 years after a lumbar puncture in a 12-year-old boy, who presented with back pain and radiating pain to the posterior of both thighs. A total excision of the tumor via L3–L4 hemilaminectomy yielded a good functional recovery.

Involvement of the cervical spinal cord by a solitary osteochondroma is rare. We describe a case of cervical osteochondroma extending from C5 to C7 in a 16-year-old male. The tumor, arising from the inner aspect of the C6 spinous process, projected longitudinally into the spinal canal and compressed the spinal cord; this caused clinical symptoms associated with myelopathy and radiculopathy. Total excision of the tumor by C5–C7 hemilaminectomy resulted in a good functional recovery.

Clipping for intracranial aneurysms is done to achieve complete occlusion of the aneurysm without a remnant sac. Despite modern advancements of neurosurgical techniques, morbidity related to the clipping of intracranial aneurysms still exists. Clip occlusion of a parent artery or small hidden perforators commonly leads to permanent neurological deficits, and is a serious and unwanted complication. Thus, preserving blood flow in the branches and perforators of a parent artery is very important for successful surgery without postoperative morbidity and mortality. The aim of this review article is to discuss the consequences of perforator injury and how to avoid this phenomenon in aneurysm surgeries using intraoperative monitoring devices.

Objectives To clarify the characteristics of brain magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) at symptom onset in patients with childhood moyamoya disease (MD) according to developmental stage. Methods In 26 childhood MD patients who underwent brain MRI and MRA within 3 months from symptom onset, MRA scores and grades and MRI findings from symptomatic hemispheres were summarized according to developmental stage: infancy (0–1 years, three patients), toddlerhood/preschool age (2–5 years, nine patients), school age (6–10 years, seven patients), and adolescence (11–18 years, seven patients). Results Mean MRA score was 5.6, which was higher in adolescents (6.9). The most common MRA grade was grade 3, particularly in those under 10 years. Acute ischemic infarction presented in 17 patients (65%), was more common in patients below 5 years (83%) and was mainly in a gyral pattern (47%). Most hemorrhagic infarctions occurred in adolescents. Moyamoya vessels in the Sylvian valleys were apparent in 22 patients (85%), which were the most sensitive non-ischemic findings on T2 weighted images. The signal void in the distal internal carotid artery was diminished in 73% and apparent signal voids in basal ganglia were seen in three patients. The ivy sign was positive in 81% on fluid attenuated inversion recovery images and 69% on contrast-enhanced T1-weighted images in 21 and 16 patients, respectively. Conclusions Brain MRIs and MRAs at symptom onset in childhood MD have characteristic findings, which differ in different developmental stage.