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Neurovascular compression syndrome is generally caused by vascular compression at the root entry or exit zone of the corresponding cranial nerve. Trigeminal neuralgia is the most frequent syndrome, followed by hemifacial spasm. Despite ongoing debate in the literature, pulsatile tinnitus is also known to be a neurovascular compression syndrome resulting from vascular compression of the vestibulocochlear nerve. Combined manifestations of neurovascular compression symptoms are very rare. We report a case with a simultaneous manifestation of trigeminal neuralgia, hemifacial spasm, and pulsatile tinnitus as neurovascular compression syndrome with separate offending vessels. A 53-year-old female presented with lancinating pain in the left face, left hemifacial spasm, and ipsilateral pulsatile tinnitus for 2 years. Trigeminal neuralgia and hemifacial spasm were diagnosed after a neurological examination, imaging study, and electromyography. Microvascular decompression via a retrosigmoid approach for separate offenders, including the superior cerebellar artery, anterior inferior cerebellar artery, and posterior inferior cerebellar artery was performed using Teflon sponges. The patient’s hemifacial spasm, pulsatile tinnitus, and hemifacial pain improved immediately after microvascular decompression.

Objective : Accurate measurement of T1 slope (a component of T1s minus cervical lordosis [CL]) is often constrained by anatomical limitations. In this situation, efforts should be made to find the exact meaning of T1s-CL and whether there are any alternatives to it.Methods : We enrolled 117 patients who received two-level anterior cervical discectomy and fusion (ACDF). Occipital slope, C2 slope (C2s), C7 slope (C7s), T1, O-C2 angle (O-C2A), C2-7 angle (C2-7A), O-C7 angle (O-C7A), T1s-CL, C7-T1 angle (C7-T1A), and C2-7 sagittal vertical axis were measured. We determined 16° (T1s-CL) as the reference point for dividing subjects into the mismatch group and the balance group, and a comparative analysis was performed.Results : The mean value of C7-T1A was constantly maintained within 2.6° peri-operatively. In addition, C2s and T1s-CL showed the same absolute change (Δ|0.8|°). The mean values of T1s-CL of the mismatch and balance groups were 23.0° and 7.6°, respectively. The five factors with the largest differences between the two groups were as follows : C2s (Δ13.3°), T1s-CL (Δ15.4°), O-C2A (Δ8.7°), C2-7A (Δ14.7°), and segmental angle (Δ7.9°) before surgery. Only four factors showed statistically significant change between the two groups after ACDF : T1s-CL (Δ4.0° vs. Δ0.2°), C2s (Δ3.2° vs. Δ0.7°), O-C2A (Δ2.6° vs. Δ1.3°), C2-7A (Δ6.3° vs. Δ1.3°). A very strong correlation between T1s-CL and C2s was also found (r=|0.88–0.96|).Conclusion : C2s itself may be the essential key to represent T1s-CL. The amounts and directions of change of these two factors (T1s-CL and C2s) were also almost identical. The above phenomenon was re-confirmed once again through the correlation analysis.

BACKGROUND Modified orbitozygomatic craniotomy is characterized by simplicity and wide exposure. The purpose of the present study was to describe a modified orbitozygomatic approach without resecting the zygomatic arch for large parasellar tumor surgeries. METHODS Between April 2016 and December 2019, seven patients with parasellar tumor underwent surgiest with a modified orbitozygomatic approach. Surgical procedures, clinical outcomes, and complications were analyzed. RESULTS This study included 3 meningiomas, 2 pituitary adenomas, 1 chondrosarcoma, and 1 schwannoma. Modified orbitozygomatic craniotomy provides a wider surgical freedom in the opticocarotid and prechiasmatic cistern than frontotemporal craniotomy without orbitotomy, Total, subtotal, and partial resections were achieved for 3, 2, and 2 patients, respectively. Reasons for partial resections were tight adhesion to the carotid artery and encasing of the carotid artery. Permanent morbidities developed in one patient with 3rd nerve palsy and one patient with hemiparesis. CONCLUSION Modified orbitozygomatic approach can provide the shortest access to the interpeduncular cistern with a minimum brain retraction. Surgeons who experience surgical challenge during the conventional approach for parasellar tumor resection are recommended to learn the modified orbitozygomatic approach.

Objective: Mechanical thrombectomy (MT) is an effective treatment for patients suffering from acute ischemic stroke secondary to large vessel occlusion. However, recanalization failure rates of interventions were about 20% in literature studies. We report our experience of unsuccessful MT with a focus on technical reasons.Methods: From December 2010 to June 2021, six hundred eight patients with acute ischemic stroke due to large artery occlusion received MT using a stent retriever with or without an aspiration catheter in our institution. We divided the reasons for failure into six categories. We analyzed the reasons for failure by dividing our experience time into 3 periods.Results: A total of 608 cases of thrombectomy for large vessel occlusion were identified in the study period. The successful recanalization rate was 90.4%. In most of the cases (20/57, 35%), the thrombus persisted despite several passes, and the second most common cause was termination of the procedure even after partial recanalization (10/57, 18%). Similar proportions of in-stent occlusion, distal embolization, and termination due to vessel rupture were observed. On analysis of three periods, the successful recanalization rate improved over time.Conclusions: MT fails due to various reasons, and intracranial artery stenosis is the main cause of MT failure. With the development of rescue techniques, the failure rate has gradually decreased. Further development of new devices and techniques could improve the recanalization rates.

Objective Cerebral edema is the predominant mechanism of secondary inflammation after intracerebral hemorrhage (ICH). Pioglitazone, peroxisome proliferator-activated receptor gamma agonist has been shown to play a role in regulation of central nervous system inflammation. Here, we examined the pharmacological effects of pioglitazone in an ICH mouse model and investigated its regulation on NLRP3 inflammasome and glucose metabolism. Methods The ICH model was established in C57 BL/6 mice by the stereotactical inoculation of blood (30 µL) into the right frontal lobe. The treatment group was administered i.p. pioglitazone (20 mg/kg) for 1, 3, and 6 days. The control group was administered i.p. phosphate-buffered saline for 1, 3, and 6 days. We investigated brain water contents, NLRP3 expression, and changes in the metabolites in the ICH model using liquid chromatography-tandem mass spectrometry. Results On day 3, brain edema in the mice treated with pioglitazone was decreased more than that in the control group. Expression levels of NLRP3 in the ICH model treated with pioglitazone were decreased more than those of the control mice on days 3 and 7. The pioglitazone group showed higher levels of glycolytic metabolites than those in the ICH mice. Lactate production was increased in the ICH mice treated with pioglitazone. Conclusion Our results demonstrated less brain swelling following ICH in mice treated with pioglitazone. Pioglitazone decreased NLRP3-related brain edema and increased anaerobic glycolysis, resulting in the production of lactate in the ICH mice model. NLRP3 might be a therapeutic target for ICH recovery.

Objective The Solitaire Platinum 4×40 mm stent retriever contains radiopaque markers with a long length. We evaluated the effect of Solitaire Platinum 4×40 mm stent retriever in Solumbra technique thrombectomy, and compared it with shorter Solitaire stent retrievers. Methods A total of 70 patients who underwent Solumbra technique thrombectomy with equal diameter (4 mm) and different length (40 vs. 20 mm) Solitaire stent retrievers were divided into two groups : the Solitaire Platinum 4×40 mm stent (4×40) group and the Solitaire FR 4×20 mm stent or Solitaire Platinum 4×20 mm stent (4×20) group. The clinical outcomes, Thrombolysis in Cerebral Infarction score, the first pass reperfusion status, and complications were evaluated and compared between the two groups. Multivariate analysis was performed to evaluate the predictive factors for reperfusion and complete reperfusion from the first pass. Results Higher first-pass reperfusion and complete reperfusion were achieved in the 4×40 group (68.0% and 48.0%) than in the 4×20 group (46.7% and 33.3%; p=0.004 and 0.007, respectively). In multivariate analysis, radiopaque device and longer stent retriever were correlated with first-pass reperfusion (p=0.014 and 0.008, respectively) and first-pass complete reperfusion (p=0.022 and 0.012, respectively). Conclusion Our study demonstrated the usefulness of the Solitaire Platinum 4×40 mm stent retriever, which led to higher firstpass reperfusion and complete reperfusion rates than the Solitaire FR 4×20 mm stent or the Solitaire Platinum 4×20 mm stent, especially in Solumbra technique thrombectomy.

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.

Objective Globus pallidus interna (GPi) is acknowledged as an essential treatment for advanced Parkinson's disease (PD). Nonetheless, the neurotransmitter study about its results is undiscovered. The goal of this research was to examine influences of entopeduncular nucleus (EPN) stimulation, identical to human GPi, in no-lesioned (NL) rat and 6-hydroxydopamine (6-HD)-lesioned rat on glutamate change in the striatum. Methods Extracellular glutamate level changes in striatum of NL category, NL with deep brain stimulation (DBS) category, 6-HD category, and 6-HD with DBS category were examined using microdialysis and high-pressure liquid chromatography. Tyrosine hydroxylase (TH) immunoreactivities in substantia nigra and striatum of the four categories were also analyzed. Results Extracellular glutamate levels in the striatum of NL with DBS category and 6-HD with DBS category were significantly increased by EPN stimulation compared to those in the NL category and 6-HD category. EPN stimulation had no significant effect on the expression of TH in NL or 6-HD category. Conclusion Clinical results of GPi DBS are not only limited to direct inhibitory outflow to thalamus. They also include extensive alteration within basal ganglia.

Purpose To evaluate image features and diagnostic performance of susceptibility-weighted image (SWI) in detection of intracranial vertebral artery dissection (VAD) and unruptured intracranial aneurysm (UIA). Materials and methods From January 2015 to December 2021, symptomatic patients who underwent 3.0 T MR SWI were recruited. For study group, transfemoral cerebral angiography-proven lesions were included, while 1:1 matched control group with MR angiography were included. Image features of SWI were evaluated. Diagnostic performance and interobserver agreements were calculated for detecting VAD with stenosis and UIA greater than 7 mm. Results Total of 110 patients (mean age: 60.92 years, female: 60/110) were included. In the study group (N = 55), 21 patients (38.2%) had VAD, while 34 patients (61.8%) had UIA. For SWI-detectable VAD, larger parent artery (PA)-dilatation ratio was observed (1.36 vs. 1.84, p = 0.034). For SWI-detectable UIA, larger PA-dome ratio (1.32 vs. 1.90, p = 0.020) and larger PA-height ratio (1.25 vs. 1.77, p = 0.005) were observed. The diagnostic performance and kappa values for VAD with stenosis were as follow: sensitivity: 91.7 (95% CI: 61.5–99.8); specificity: 93.9 (95% CI: 87.2–97.7); к: 0.80. The diagnostic performance for UIA larger than 7 mm were as follow: sensitivity: 87.5 (95% CI: 47.4–99.7); specificity: 95.1 (95% CI: 88.9–98.4); к: 0.73. Conclusion SWI-detectable lesions were VAD with larger PA-dilatation ratio, and UIA with larger PA-dome ratio, and PA-height ratio. SWI was able to accurately detect VAD with stenosis and UIA larger than 7 mm with substantial interobserver agreements.

Objective The low-profile Neuroform Atlas stent can be deployed directly without an exchange maneuver by navigating into the Gateway balloon. This retrospective study assessed the safety and efficacy of Neuroform Atlas stenting as a rescue treatment after failure of mechanical thrombetomy (MT) for large artery occlusion. Methods Between June 2018 and December 2019, a total of 31 patients underwent Neuroform Atlas stenting with prior Gateway balloon angioplasty after failure of conventional MT caused by residual intracranial atherosclerotic stenosis (ICAS). Primary outcomes were successful recanalization and patency of the vessel 24 hours after intervention. Secondary outcomes were vessel patency after 14 days and 3-month modified Rankin Scale. Peri-procedural complications, intracerebral hemorrhage (ICH), and 3-month mortality were reviewed. Results With a 100% of successful recanalization, median value of stenosis was reduced from 79.0% to 23.5%. Twenty-eight patients (90.3%) showed tolerable vessel patency after 14 days. New infarctions occurred in three patients (9.7%) over a period of 14 days; two patient (6.5%) underwent stent occlusion at 24 hours, and the other patient (3.2%) with delayed stent occlusion had a non-symptomatic dot infarct. There were no peri-procedural complications. Two patients (6.5%) developed an ICH immediately after the procedure with one of them is symptomatic. Conclusion Neuroform Atlas stenting seems to be an effective and safe rescue treatment modality for failed MT with residual ICAS, by its high successful recanalization rate with tolerable patency, and low peri-procedural complication rate. Further multicenter and randomized controlled trials are needed to confirm our findings.

The present study reports on the usefulness of FlowGate(2) (FG2) as a novel balloon guide catheter (BGC) for mechanical thrombectomy (MT) treatment. MT using a BGC device was performed on 255 patients at the authors' institution (St. Vincent's hospital, Suwon, Korea and Hangang Sacred Heart Hospital, Seoul, Korea) between January 2014 and September 2018. A total of 235 patients underwent successful application of BGCs and were divided into two groups; an FG2 and a Merci group, and a comparative analysis was performed. The failure rate in the FG2 group (2.5%) was significantly lower than that in the Merci group (10.8%; P=0.016). Occurrence of distal emboli was significantly lower in the FG2 group (4.7%) than in the Merci group (7.3%; P=0.012). According to subgroup analysis of the BGC and the intermediate catheter, the incidence rate of the distal emboli in the FG2 with an intermediate catheter (2.3%) was significantly lower than that of the Merci with an intermediate catheter (6.6%; P=0.038). The ratio of thrombolysis in cerebral infarction (TICI) 3 recanalization in the first pass was higher in the FG2 group than in the Merci group, in both total (44.7 vs. 34.7%; P=0.033) and subgroup patients (46.5 vs. 34.4%; P=0.029). In the multivariate analysis, use of an intermediate catheter [odds ratio (OR), 0.75; 95% confidence interval (CI), 0.66-0.94; P=0.029] and FG2 application (OR, 0.59; 95% CI, 0.25-0.93; P=0.020) were the predictive factors for fewer distal emboli. In summary, FG2 BGC enables an effective MT with less application failures and occurrence of distal emboli, and higher TICI 3 recanalization at the first stent passage, compared with Merci BGC.

Objective Chronic subdural hematoma is a common and relatively benign disease. However, recurrence is common after surgical treatment, and the recurrence rate varies from 5% to 33%. The aim of this study was to investigate the predictive factors for recurrence of chronic subdural hematoma. Methods We analyzed data from 248 patients with chronic subdural hematoma who were treated by burr-hole craniostomy with a closed drainage system for hematoma evacuation in this five-year retrospective study. Results Thirty-one (12.6%) patients underwent re-operation for recurrence of chronic subdural hematoma. Univariate analysis revealed that anticoagulation (p=0.0279), headache (p=0.0323), and preoperative midline shifting (p=0.0321) showed significant differences with respect to recurrent chronic subdural hematoma. We performed a multivariate logistic regression analysis and found that diabetes mellitus (odds ratio [OR], 2.618; 95% confidence interval [CI], 1.0899-6.2898; p=0.0314), anticoagulation (OR, 6.739; 95% CI, 1.1287-40.2369; p=0.0364), headache (OR, 2.951; 95% CI, 1.1464-7.5964; p=0.0249), and preoperative midline shifting (OR, 1.0838; 95% CI, 1.0040-1.1699; p=0.0391) were independent predictive factors for recurrence of chronic subdural hematoma. Conclusion We showed that diabetes mellitus, anticoagulation, headache, and preoperative midline shifting were independent predictors of recurrence of chronic subdural hematoma.

Currently, endovascular coiling is a popular treatment for basilar tip aneurysms, which usually involve a wide neck. Serious complications can occur when the posterior cerebral artery (PCA) originating from a wide neck is not properly preserved. Accordingly, various adjunctive procedures using stents or a balloon have been introduced. Herein we report two cases of basilar tip aneurysms in which retrograde horizontal (from one PCA to the other PCA) stent-assisted coiling was successful, and we provide a summary of the important technical points.

Objective High frequency stimulation (HFS) of the subthalamic nucleus (STN) is recognized as an effective treatment of advanced Parkinson's disease. However, the neurochemical basis of its effects remains unknown. The aim of this study is to investigate the effects of STN HFS in intact and 6-hydroxydopamine (6-OHDA)-lesioned hemiparkinsonian rat model on changes of principal neurotransmitters, glutamate, and gamma-aminobutyric acid (GABA) in the striatum. Methods The authors examined extracellular glutamate and GABA change in the striatum on sham group, 6-OHDA group, and 6-OHDA plus deep brain stimulation (DBS) group using microdialysis methods. Results High-pressure liquid chromatography was used to quantify glutamate and GABA. The results show that HFS-STN induces a significant increase of extracellular glutamate and GABA in the striatum of 6-OHDA plus DBS group compared with sham and 6-OHDA group. Conclusion Therefore, the clinical results of STN-HFS are not restricted to the direct STN targets but involve widespread adaptive changes within the basal ganglia.

Introduction Mechanical thrombectomy (MT) after intravenous thrombolysis (IVT) is recommended in acute ischemic stroke (AIS) patients with large artery occlusion (LAO). But in cases of ineligible for IVT, MT is the only option. The aim of this study is to evaluate the efficacy and outcome of MT in case of ineligible for IVT. Method Retrospective analysis was performed in consecutive patients treated between January 2016 and November 2018 for AIS with LAO. Patient demographic data were collected and clinical outcome, procedure details and complication rate were compared. Results During the period, 80 patients were visited within 4.5 hours from onset, but only 31 underwent MT alone due to contraindication (MT group). And 49 underwent MT combined IVT (MTIVT group). There was no significant difference in demographics and complication (distal emboli, mortality rate, symptomatic intracranial hemorrhage). The mean time from onset to groin puncture, successful reperfusion rate (defined thrombolysis in cerebral infarction 2b/3) and favorable functional outcome (determined by modified Rankin Scale score 0–2 at 90 days) also showed no significant statistically difference. But MT group had a significantly shorter mean procedure time (45.84 vs. 76.06 min; p = 0.001) and hospital stay (11.53 vs. 15.0 day; p = 0.042), and a lower 1-day NIHSS score (6.35 vs 10.88; p = 0.012). Conclusion In ineligible patient for IVT, MT alone isn’t inferior to MT combined with IVT. Disclosures J. Sung: None. M. Lee: None. D. Lee: None. H. Lee: None. S. Yang: None.

Background and Objectives: Endovascular thrombectomy (EVT is an emerging gold standard treatment for acute cerebral infarction and may allow functional improvement after subacute cerebral infarction. However, the long-term functional benefits of EVT in patients with moderate to severe disability remain unclear. We investigated the effects of EVT on the activities of daily living (ADL), handicap, gait, and eating in patients with middle cerebral artery (MCA) occlusion who exhibited moderate to severe disability (score of 3–5 on the modified Rankin scale (mRS)) due to stroke, up to six months after onset. Materials and Methods: This retrospective longitudinal case–control study assessed 45 patients with MCA occlusion who exhibited moderate to severe disability (mRS score ≥ 3): 15 underwent EVT and 30 served as controls. Clinical assessments were conducted at two weeks (12–16 days), four weeks (26–30 days), and six months (180–210 days) after stroke onset. Functional assessments comprised the Korean version of the modified Barthel index (MBI), mRS, functional ambulation category (FAC), and dysphagia outcome severity scale (DOSS) to assess disability, handicap, gait, and eating. Results: The MBI, mRS, FAC, and DOSS scores all improved significantly (all p &lt, 0.05) in the EVT group, compared to the controls. Conclusions: EVT has favorable effects on performing routine ADL, the handicap itself, walking, and eating. Therefore, EVT is recommended for patients with acute MCA occlusion, including those with severe disability at the initial assessment.

Objective Low back pain, caused intervertebral disc degeneration has been treated by thermal annuloplasty procedure, which is a non-surgical treatement. The theoretical backgrounds of the annuloplasty are thermal destruct of nociceptor and denaturization of collagen fiber to induce contraction, to shrink annulus and thus enhancing stability. This study is about temperature and its distribution during thermal annuloplasty using 1414 nm Nd : YAG laser. Methods Thermal annuloplasty was performed on fresh human cadaveric lumbar spine with 20 intact intervertebral discs in a 37℃ circulating water bath using newly developed 1414 nm Nd : YAG laser. Five thermocouples were attached to different locations on the disc, and at the same time, temperature during annuloplasty was measured and analyzed. Results Thermal probe's temperature was higher in locations closer to laser fiber tip and on lateral locations, rather than the in depth locations. In accordance with the laser fiber tip and the depth, temperatures above 45.0℃ was measured in 3.0 mm depth which trigger nociceptive ablation in 16 levels (80%), in accordance with the laser fiber end tip and laterality, every measurement had above 45.0℃, and also was measured temperature over 60.0℃, which can trigger collagen denaturation at 16 levels (80%). Conclusion When thermal annuloplasty is needed in a selective lesion, annuloplasty using a 1414 nm Nd : YAG laser can be one of the treatment options.

Objective The spot sign on computed tomography angiography is little known about the relationship between the spot sign and the results of cerebral angiography We retrospectively analyzed the spot sign, digital subtraction angiography results, and other factors. Material and methods From December 2009 to May 2014, DSA was performed in 52 ICH patients with non-specific location or abnormalities on CTA findings. 26 of those patients, whose initial CTA showed the spot sign, were analyzed. Two groups, one with the spot sign in the ventricle (Group A) and others with the spot sign in another location (Group B) were statistically compared. Results The mean age of the study subjects was 46.9 years (range, 15 to 80 years) and the percentage of males was 53.8%. Thirteen of 26 patients had ICH without intraventricular hemorrhage, and 6 patients had co-existing IVH. In 17 cases, the DSA results were negative. Seven patients were diagnosed with pseudoaneurysms, and two cases showed developmental venous anomalies. Group A consisted of the 8 patients (30.8%) who showed the spot sign in a ventricle. The number of pseudoaneurysms was statistically significantly higher in Group A than in Group B (71.4% versus 28.6%; OR, 13.3; 95% CI, 1.7-103.8 P = 0.014). All three patients who underwent endovascular treatment were members of Group A (P = 0.022), whereas most (92.3%) of those in Group B underwent surgical evacuation. (P = 0.030). Conclusion When CTA shows the spot sign in a ventricle, it is a clue that an existing underlying vascular lesion requires endovascular treatment.

Background Although C1 screw fixation is becoming popular, only a few studies have discussed about the risk factors and the patterns of C1 screw complications. Objective To investigate the incidence of C1 screw complications and analyze the risk factors of the C1 screw complications. Methods A total of 358 C1 screws in 180 consecutive patients were analyzed for C1 screw complications. Screw malposition, occipital neuralgia, major complications, and total C1 screw complications were analyzed. Results The distribution of C1 screw entry point is as follows: inferior lateral mass, 317 screws (88.5 %); posterior arch (PA), 38 screws (10.7 %); and superior lateral mass, 3 screws (0.8 %). We sacrificed the C2 root for 127 screws (35.5 %). C1 instrumentation induced 3.1 % screw malposition, 6.4 % occipital neuralgia, 0.6 % vascular injury, and 3.4 % major complications. In multivariate analysis, deformity (odds ratio [OR]: 2.10, P = .003), traumatic pathology (OR: 4.97, P = .001), and PA entry point (OR: 3.38, P = .001) are independent factors of C1 screw malposition. C2 root resection can decrease the incidence of C1 screw malposition (OR: 0.38, P = .012), but it is a risk factor of occipital neuralgia (OR: 2.62, P = .034). Advanced surgical experience (OR: 0.09, P = .020) correlated with less major complication. Conclusion The incidence of C1 screw complications might not be uncommon, and deformity or traumatic pathology and PA entry point could be the risk factors to total C1 screw complications. The PA screw induces more malposition, but less occipital neuralgia. C2 root resection can reduce screw malposition, but increases occipital neuralgia.

Basilar artery fenestration is infrequent and even rarer in association with a large aneurysm. With proximity to brain stem and vital perforators, endovascular coiling can be considered first. If the large ruptured aneurysm with a wide neck originated from fenestra of the proximal basilar artery and the fenestration loop has branches of posterior circulation, therapeutic consideration should be thorough and fractionized. We report endovascular therapeutic details for a case of a ruptured large saccular aneurysm in proximal basilar artery fenestration.

Objective Acute basilar artery occlusion (BAO) is associated with severe neurological dysfunction and high mortality rates. The benefits of mechanical thrombectomy in BAO have not been explored in recent clinical trials. Therefore, we analyzed outcomes of stent retriever mechanical thrombectomy for BAO, and compared with anterior circulation occlusions (ACO). Methods In total, 161 consecutive patients (24 BAO, 137 ACO) who underwent mechanical thrombectomy with the stent retriever between January 2013 and August 2016 enrolled in our study. All patients underwent clinical assessment with the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS). Radiological results were used to evaluate thrombolysis in cerebral infarction (TICI) scores and successful recanalization was defined by TICI 2b or 3. Results Mean NIHSS scores at 24 hours and 30 days were significantly higher in the BAO group than the ACO group (p=0.021, p=0.001). mRS at 90 days was significantly higher in the BAO group (4.2) compared with the ACO group (3.0) (p=0.003). The BAO group (2.0) performed fewer stent retriever passages than the ACO group (2.7) (p=0.049). There were no significant differences between the two groups in terms of complications, but the BAO patients experienced a higher mortality (16.6%) rate than ACO patients (5.8%) (p=0.001). In subgroup analysis of BAO, patients with short procedure times achieved successful recanalization (p=0.001) and successfully recanalized patients exhibited more favorable mRS at 90 days (p=0.027). Conclusion In our study, mechanical thrombectomy of BAO patients showed worse clinical outcome and higher mortality rate than ACO patients. However, mechanical thrombectomy with a stent retriever in BAO is an effective treatment, because successfully recanalized patients showed good clinical outcome in BAO patients.

Central pontine myelinolysis occurs inconsistently as a complication of severe and prolonged hyponatremia, particularly when corrected too rapidly. This condition is a concentrated, frequently symmetric, noninflammatory demyelination within the central basis pontis. We describe a head injury patient who developed central pontine and extrapontine myelinolysis following a gradual correction of hyponatremia. More attention should be paid to correcting hyponatremia combined with hypokalemia in patients who have a history of alcoholism.

Objective Mechanical thrombectomy is increasingly being used for the treatment of acute ischemic stroke. The population over 80 years of age is growing, and many of these patients have acute infarction; however, these patients are often excluded from clinical trials, so the aim of this study was to compare the functional outcomes and complication rates in very elderly patients (age ≥80 years) and aged patients (60-79 years) treated with mechanical thrombectomy. Methods Between January 2010 and June 2015, we retrospectively reviewed 113 senior patients (over 60 years old) treated at our institution for acute ischemic stroke with mechanical thrombectomy. They were divided into a very elderly (≥80 years) and aged (60-79 years) group, with comparisons in recanalization rates, complications, death and disability on discharge be reported. Results The mean age was 70.3 years in the aged group and 83.4 years in the very elderly group. Elderly patients had higher rates of mechanical thrombectomy failure than the younger group (40% vs. 14%; odds ratio [OR] 4.1; 95% confidence interval [CI] 1.4-11.9; p=0.012). Results from thrombolysis in cerebral ischemia and modified Rankin scale at discharge were worse in the older group (p=0.005 and 0.023 respectively). There were no differences in mortality rate or other complications, but infarction progression rates were significantly higher in the very elderly group. (15% vs. 2.2%; OR 8.0; 95% CI 1.2-51.7; p=0.038). The majority (92.3%) of the patients who failed in aged group were not successful after several trials. However, in half (4 of 8) of the very elderly group, the occlusion site could not be accessed. Conclusion Patients older than 80 years of age undergoing mechanical thrombectomy for acute infarction were more difficult to recanalize due to inaccessible occlusion sites and had a higher rate of infarction progression, However, mortality and other complications were similar to those in younger patients.

OBJECTIVEIn this study the authors evaluated whether extracranial-intracranial bypass surgery can prevent stroke occurrence and decrease mortality in adult patients with symptomatic moyamoya disease (MMD).METHODSThe medical records of 249 consecutive adult patients with symptomatic MMD that was confirmed by digital subtraction angiography between 2002 and 2011 at 8 institutions were retrospectively reviewed. The study outcomes of stroke recurrence as a primary event and death during the 6-year follow-up and perioperative complications within 30 days as secondary events were compared between the bypass and medical treatment groups.RESULTSThe bypass group comprised 158 (63.5%) patients, and the medical treatment group comprised 91 (36.5%) patients. For 249 adult patients with MMD, bypass surgery showed an HR of 0.48 (95% CI 0.27–0.86, p = 0.014) for stroke recurrence calculated by Cox regression analysis. However, for the 153 patients with ischemic MMD, the HR of bypass surgery for stroke recurrence was 1.07 (95% CI 0.43–2.66, p = 0.887). For the 96 patients with hemorrhagic MMD, the multivariable adjusted HR of bypass surgery for stroke recurrence was 0.18 (95% CI 0.06–0.49, p = 0.001). For the treatment modality, indirect bypass and direct bypass (or combined bypass) did not show any significant difference for stroke recurrence, perioperative stroke, or mortality (log rank; p = 0.524, p = 0.828, and p = 0.616, respectively).CONCLUSIONSDuring the treatment of symptomatic MMD in adults, bypass surgery reduces stroke recurrence for the hemorrhagic type, but it does not do so for the ischemic type. The best choice of bypass methods in adult patients with MMD is uncertain. In adult ischemic MMD, a prospective randomized study to evaluate the effectiveness and safety of bypass surgery to prevent recurrent stroke is necessary.

OBJECTIVE To compare the clinical and radiological outcome of both sides using the unilateral approach. METHODS Unilateral laminotomy was performed to achieve bilateral decompression. Thirty-nine patients who underwent this procedure were analyzed prospectively using the Oswestry Disability Index (ODI), the visual analog scale (VAS) pain score to evaluate symptoms in both legs, and the radiological morphometric index to calculate the anteriorposterior diameter and midcanal width. The incidence of complications from this approach was then evaluated. RESULTS The mean follow-up time was 12.2 months. The mean ODI was 48.4 preoperatively and 14.2 postoperatively. The mean dural sac widening of the ipsilateral side (187.0%) was significantly larger (p

Objective Meralgia paresthetica (MP) is a syndrome of pain and/or dysesthesia in the anterolateral thigh that is caused by an entrapment of the lateral femoral cutaneous nerve (LFCN) at its pelvic exit. Despite early accounts of MP, there is still no consensus concerning the effectiveness of neurolysis or transaction treatments in the long-term relief for medically refractory patients with MP. We retrospectively analyzed available long-term results of LFCN neurolysis for medically refractory MP in an effort to clarify this issue. Methods During the last 7 years, 11 patients who had neurolysis for MP were enrolled in this study. Nerve entrapment was confirmed preoperatively by electrophysiological studies or a positive response to local anesthetic injection. Decompression of the LFCN was performed at the level of the iliac fascia, inguinal ligament, and fascia of the thigh distally. The outcome of surgery was assessed 8 weeks after the procedure followed at regular intervals if symptoms persisted. Results Twelve decompression procedures were performed in 11 patients over a 7-year period. The average duration of symptoms was 8.5 months (range, 4-15 months). The average follow-up period was 33 months (range, 12-60 months). Complete and partial symptom improvement were noted in nine (81.8%) and two (18.2%) cases, respectively. No recurrence was reported. Conclusion Neurolysis of the LFCN can provide adequate pain relief with minimal complications for medically refractory MP. To achieve a good outcome in neurolysis for MP, an accurate diagnosis with careful examination and repeated blocks of the LFCN, along with electrodiagnosis seems to be essential. Possible variation in the course of the LFCN and thorough decompression along the course of the LFCN should be kept in mind in planning decompression surgery for MP.

The authors reviewed the surgical experience and operative technique in a series of 11 patients with middle fossa tumors who underwent surgery using the transzygomatic approach and intraoperative neuromonitoring (IOM) at a single institution. This approach was applied to trigeminal schwannomas (n = 3), cavernous angiomas (n = 3), sphenoid wing meningiomas (n = 3), a petroclival meningioma (n = 1), and a hemangiopericytoma (n = 1). An osteotomy of the zygoma, a low-positioned frontotemporal craniotomy, removal of the remaining squamous temporal bone, and extradural drilling of the sphenoid wing made a flat trajectory to the skull base. Total resection was achieved in 9 of 11 patients. Significant motor pathway damage can be avoided using a change in motor-evoked potentials as an early warning sign. Four patients experienced cranial nerve palsies postoperatively, even though free-running electromyography of cranial nerves showed normal responses during the surgical procedure. A simple transzygomatic approach provides a wide surgical corridor for accessing the cavernous sinus, petrous apex, and subtemporal regions. Knowledge of the middle fossa structures is essential for anatomic orientation and avoiding injuries to neurovascular structures, although a neuronavigation system and IOM helps orient neurosurgeons.

Apoptosis, a predominant cause of neuronal death after stroke, can be executed in a caspase-dependent or apoptosis inducing factor (AIF)–dependent manner. Herpes simplex virus (HSV) vectors expressing caspase inhibitors p35 and crmA have been shown to be neuroprotective against various excitotoxic insults. Here we further evaluated the possible neuroprotective role of p35 and crmA in a rat stroke model. Overexpression of p35, but not crmA, significantly increased neuronal survival. Results of double immunofluorescence staining indicate that compared with neurons infected with crmA or control vectors, p35-infected neurons had less active caspase-3 expression, cytosolic cytochrome c and nuclear AIF translocation.

Mild hypothermia is a robust neuroprotective treatment for stroke. Understanding the mechanisms underlying hypothermia's benefits will lead to more effective treatments to prevent stroke damage. Delta protein kinase C (deltaPKC) is a kinase that has been strongly implicated in executing ischemic damage. We investigated the effects of hypothermia on deltaPKC activation, as determined by its subcellular translocation, proteolytic cleavage, and phosphorylation in a focal cerebral ischemia model. The amount of constitutively activated C-terminal catalytic fragment of deltaPKC (CF-deltaPKC) increased after stroke. Both hypothermia (30 degrees C) and the caspase-3-specific inhibitor, Z-DQMD-FMK, blocked the accumulation of activated deltaPKC in the penumbra. Other hallmarks of deltaPKC activation, its translocation to the mitochondria, and nucleus were observed in the penumbra as early as 10 mins after reperfusion. These events were blocked by hypothermia. Hypothermia also blocked CF-deltaPKC increases in the mitochondria and nuclei. Conversely, a specific deltaPKC activator, psideltaRACK, decreased the neuroprotective effect of hypothermia. Finally, deltaPKC activity may lead to mitochondrial injury and cytochrome c release, as the timing of cytochrome c release corresponded to the time course of deltaPKC translocation. Both cytochrome c release and deltaPKC translocation were blocked by hypothermia. In conclusion, hypothermia protects against ischemic damage in part by suppressing deltaPKC activation after stroke.

BACKGROUND AND PURPOSE: This study was conducted to elucidate the association between clinical and angiographic characteristics and stroke types in adult Moyamoya disease that has been rarely evaluated. MATERIALS AND METHODS: We analyzed the clinical and radiologic data obtained from a retrospective adult Moyamoya disease cohort with acute strokes, which were classified into 7 categories: large-artery infarct, hemodynamic infarct, perforator infarct, deep intracerebral hemorrhage, lobar intracerebral hemorrhage, intraventricular hemorrhage, and SAH. With conventional angiography, which was performed in the hemispheres with acute strokes, the Suzuki angiographic stage, intracranial aneurysm, major artery occlusion, and collateral vessel development were confirmed within 1 month of stroke onset. RESULTS: This study included 79 patients with acute ischemic stroke and 96 patients with acute hemorrhagic stroke. The angiographic stage had a strong tendency to be more advanced in the hemorrhagic than the ischemic patients (P = .061). Intracranial aneurysms were more frequently found in the hemorrhagic than ischemic or control hemispheres (P = .002). Occlusions of the anterior cerebral artery and development of fetal-type posterior cerebral artery were more frequently observed in the hemorrhagic than the ischemic (P = .001 and .01, respectively) or control hemispheres (P = .011 and .013, respectively). MCA occlusion (P = .039) and collateral flow development, including the ethmoidal Moyamoya vessels (P = .036) and transdural anastomosis of the external carotid artery (P = .022), occurred more often in the hemorrhagic than the ischemic hemispheres. Anterior cerebral artery occlusion occurred more frequently in patients with deep intracerebral hemorrhage or intraventricular hemorrhage than with lobar intracerebral hemorrhage (P = .009). CONCLUSIONS: In adult Moyamoya disease, major artery occlusion and collateral compensation occurred more often in the hemorrhagic than in the ischemic hemispheres. Thus, anterior cerebral artery occlusion with or without MCA occlusion and intracranial aneurysms may be the main contributing factors to hemorrhagic stroke in adult patients with Moyamoya disease.

OBJECTIVE To evaluate the anatomical feasibility of 3.5 mm screw into the cervical spine in the pediatric population and to establish useful guidelines for their placement. METHODS A total of 37 cervical spine computerized tomography scans (24 boys and 13 girls) were included in this study. All patients were younger than 10 years of age at the time of evaluation for the period of 2007-2011. RESULTS For the C1 screw placement, entry point height (EPH) was the most restrictive factor (47.3% patients were larger than 3.5 mm). All C2 lamina had a height larger than 3.5 mm and 68.8% (51/74) of C2 lamina had a width thicker than 3.5 mm. For C2 pedicle width, 55.4% (41/74) of cases were larger than 3.5 mm, while 58.1% (43/74) of pedicle heights were larger than 3.5 mm. For pedicle width of subaxial spine, 75.7% (C3), 73% (C4), 82.4% (C5), 89.2% (C6), and 98.1% (C7, 1/54) were greater than 3.5 mm. Mean lamina width of subaxial cervical spine was 3.1 (C3), 2.7 (C4), 2.9 (C5), 3.8 (C6), and 4.0 mm (C7), respectively. Only 34.6% (127/370) of subaxial (C3-7) lamina thickness were greater than 3.5 mm. Mean length of lateral mass for the lateral mass screw placement was 9.28 (C3), 9.08 (C4), 8.81 (C5), 8.98 (C6), and 10.38 mm (C7). CONCLUSION C1 lateral mass fixation could be limited by the morphometrics of lateral mass height. C2 trans-lamina approach is preferable to C2 pedicle screw fixation. In subaxial spines, pedicle screw placement was preferable to trans-lamina screw placement, except at C7.

Background and Purpose: This study was aimed to investigate treatment results and outcome predictors in adult patients with moyamoya disease. Methods: During the period from 2000 to 2011, a clinical database of adult patients with definite moyamoya disease were collected retrospectively from 8 participating centers in Korea during the period from 2000 to 2011. Among total 399 elligible patients, 355 cases were evaluated about clinical and radiological outcomes through medical records. Stroke-free survival rate and prognostic factors for stroke recurrence were measured by Kaplan-Meier and Cox regression methods. Neurologic outcome was assessed according to surgical revascularization and conservative observation. Results: The mean age of symptom onset was 39.4 ( ± 13.8) years. Male to female ratio was 1 to 2.16. Presenting symptoms were ischemia in 197 (55.5%), hemorrhage in 118 (33.2%), and asymptomatic in 40 (11.3%) patients. The median follow-up was 34.3 months (range 0.4 to 284.8). One hundred thirty seven (38.6%) of the 355 patients received observational conservative management. The remaining 218 (61.4%) patients underwent one of direct, indirect or combined revascularization. In the total adult moyamoya patients, 5 year stroke-free survival rate of surgery and observation group was 82.8% vs 73.4%, respectively. In the ischemic moyamoya cases, 5 year stroke-free survival rate of surgery and observation group was 80.9% vs 76.2%, respectively. In the hemorrhagic moyamoya cases, 5 year stroke-free survival rate of surgery and observation group was 83.7% vs 70.1%, respectively. In the asymptomatic cases, 5 year stroke-free survival rate of surgery and observation group was 95.3% vs 83.1%. There was no significant difference between surgical and observation group in Kaplan Meier Survival analysis. Angiographic stage was only a significant factor for stroke recurrence (HR 3.275, 95% CI; 1.251-8.575, P=0.016). Neurologic outcome tended to be better in the surgical group than the observation group (88.5% vs 81.8%, P=0.074) Conclusions: In adult moyamoya patients, the long-term prognosis of surgical treatment may be better than that of conservative observation under real-world setting. Angiographic stage is a predictor of future stroke