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Background Recurrence is one of the concerns even after successful endovascular treatment of intracranial aneurysms. We sought to determine the critical aneurysm volume and risk factors related to aneurysmal stability in patients undergoing coil embolization of intracranial aneurysms. Methods Aneurysm volume and follow-up imaging data were retrieved in 3042 patients with 3530 aneurysms who were treated with endovascular coil embolization from January 2006 to October 2016. We analyzed the anatomic outcome in relation to aneurysm volume and determined the critical aneurysm volume favoring coil embolization. Results Recanalization rates were 2.8%, 6.3%, 19.4%, and 67.4% in each group with aneurysm volume of 1000 mm3, respectively. When we investigated the 100–1000 mm3 group, the recanalization rate remarkably increased at 500 mm3 (16.4% vs. 57.5%, P 500 mm3 (7.2% vs. 62.9%, respectively; P 500 mm3, the location was a significant prognostic factor for long-term stability (posterior circulation vs. anterior circulation; OR, 4.737; 95% CI, 1.275–17.602; P = 0.020). Conclusions In our series of cerebral aneurysms treated with coil embolization, 500 mm3 was found to be the critical volume determining stability after coil embolization. Large volume aneurysms in the posterior circulation were especially prone to recanalization after coiling.

The aim of this study was to investigate the specific thyroid condition and thyroid autoantibodies in adult moyamoya disease (MMD) according to clinical presentation (ischemia vs. hemorrhage stroke). In addition, a meta-analysis was performed to reveal the association between adult MMD and elevated thyroid function, or autoantibodies. Prospectively collected data on 169 consecutive patients with MMD at a single institution were analyzed. Community-based controls matched for age and sex were selected for comparison. Penalized multinomial logistic regression analysis was used for factors affecting stroke. For meta-analysis, heterogeneity was evaluated by using the I2 test. If I2 < 50%, a fixed effect model was used. Fifty-four cases (32.0%) presented with ischemic stroke and 37 cases (21.9%) with hemorrhage stroke. Hyperthyroidism had a marginally increased risk of MMD with ischemic stroke with reference value of MMD without stroke [odds ratio (OR), 2.53; P = 0.055]. Anti-thyroperoxidase antibody (TPOAb) increased the risk of MMD presenting with ischemic stroke significantly (OR, 2.99; P = 0.020). A meta-analysis revealed that adult MMD was significantly associated with elevated autoantibodies (OR, 7.663; P = 0.002) and hyperthyroidism (OR, 10.936; P < 0.001). Elevated TPOAb and hyperthyroidism may play important roles in adult MMD with ischemic stroke. Studies focusing on targeted hyperthyroidism and thyroid autoantibodies are necessary in treating adult MMD patients in the future.

Elastin encoded by elastin gene (ELN) is a crucial extracellular matrix protein responsible for arterial resilience. The objective of this study was to identify single nucleotide polymorphisms (SNPs) of ELN gene susceptible to intracranial aneurysm (IA) in Korean population. Two SNPs of ELN gene, rs2071307 (Gly422Ser) and rs2856728 (intron), were genotyped in 90 patients with IA and 90 age and frequency matched controls. Fisher’s exact test was conducted to evaluate allelic association with IA. Of the two SNPs in ELN gene, T allele of rs2856728 (intron) showed statistically significant association with increased development of IA (odds ratio [OR]: 2.34, 95% confidence interval [CI]: 1.44–3.81, P = 7.6 × 10−4). However, G allele of rs2071307 (Gly422Ser) had no significant association with the development of IA (OR: 1.27, 95% CI: 1.44–3.81, P = 0.607). Interestingly, the odds of having rs2856728 variant was approximately 2-fold higher in males than that in females (OR: 3.46 vs. 1.88, P < 0.05). However, none of SNPs showed difference between single and multiple IA in this study. This preliminary study implies that the rs2856728 variant in ELN gene polymorphisms might play crucial roles in the development and pathogenesis of IA in Korean population.

Background Recurrent hemorrhage is a serious neurosurgical problem in adult moyamoya disease (MMD) patients. Objective To find the natural history and risk factors of recurrent hemorrhage in cases of adult hemorrhagic MMD. Methods One hundred seventy-six adult MMD patients presenting with hemorrhage were enrolled. Patients' medical records and radiological images were retrospectively reviewed. Clinical and radiological features of recurrent hemorrhage, and related risk factors were analyzed. Poor neurological outcome was defined as a score on the modified Rankin Scale of 4 to 6. The hemisphere in which the initial hemorrhage occurred was considered as the affected one. The mean follow-up duration was 83 months. Results The overall estimated rate of recurrent hemorrhage was 16.9%/person (95% confidence interval, 11.3%-24.8%) at 5 years and 26.3%/person (95% confidence interval, 18.5%-36.4%) at 10 years after the initial episode of hemorrhage. The affected hemisphere showed a higher recurrent hemorrhagic rate (11.7% vs 8.3%/hemisphere at 5 years, P = .09) after conservative treatment. As a result of recurrent hemorrhages, the number of patients with poor neurological outcome increased (first episode: 13.8%, second: 37.5%, third: 40.0%, fourth: 100%). The presence of intraventricular hemorrhage ( P = .05, hazard ratio = 3.32) and bilateral MMD ( P = .05, hazard ratio = 4.15) had a marginal significance for recurrent hemorrhage. Eight ischemic strokes (4.5%) including 4 postoperative infarctions were identified, and all ischemic strokes were minor stroke. Conclusion During the follow-up period, recurrent hemorrhagic events continued to increase and deteriorated the patients' neurological conditions. The presence of intraventricular hemorrhage was a significant risk factor of recurrent hemorrhage.

Background Estimations of the intracranial aneurysm incidence require long-term follow-up of a relatively large at-risk population; as a result, the incidence remains largely unknown. Aims To investigate the national incidence of intracranial aneurysm in a Korean population. Methods After excluding 18,604 potential subjects with a previous history of stroke (I6x.x), 998,216 subjects were included in this observational cohort. The primary endpoint was the earliest date of diagnosis of either unruptured intracranial aneurysm (UIA; I67.1) or subarachnoid hemorrhage (SAH; I60.x). We collected anthropometric data, blood pressure measurements, laboratory data, and smoking, drinking, and physical exercise habits of 132,355 subjects for whom healthcare screening data were available. Factors influencing intracranial aneurysm were evaluated via multivariate Cox regression. Results The overall observation size was 8,792,214 person-years. During follow-up, 4346 subjects were diagnosed with intracranial aneurysm (SAH, 1960; UIA, 2386). The crude incidence of intracranial aneurysm was 49.4/100,000 person-years. The hazard ratio for women was 1.56 ( p Conclusions In this Korean population study, the standardized incidence of intracranial aneurysm was 52.2/100,000 person-years. Older age, female sex, hypertension, history of heart disease, and family history of stroke were independent risk factors for intracranial aneurysm.

OBJECT Treatment strategies for venous-predominant arteriovenous malformation (vp-AVM) remain unclear due to the limited number of cases and a lack of long-term outcomes. The purpose of this study was to report the authors’ experience with treatment outcomes with a review of the pertinent literature in patients with vp-AVM. METHODS Medical and radiological data from 1998 to 2011 were retrospectively evaluated. The degree of the arteriovenous (AV) shunt was categorized into 2 groups, a high- and low-flow AV shunt based on the angiographic findings. RESULTS Sixteen patients with a mean age of 45.3 years (range 16–78 years) and a mean follow-up of 79.9 months (range 25–264 months) were examined. Symptomatic lesions were noted in 13 patients: intracranial hemorrhage (ICH) in 9, seizure in 1, and headache in 3. A high-flow shunt was observed on angiography in 13 patients. Among these 13 patients, 12 patients were symptomatic. Nine patients presenting with ICH underwent hematoma removal with additional Gamma Knife surgery (GKS; n = 4), GKS only (n = 2), or conservative treatment (n = 3). The 3 asymptomatic patients received conservative treatment, and 1 rebleeding episode was observed. Seven of 8 patients who underwent GKS as an initial or secondary treatment modality experienced a marked reduction in the AV shunt on follow-up angiography, but complete obliteration was not observed. CONCLUSIONS Poor lesion localization makes a vp-AVM challenging to treat. Symptomatic patients with a high-flow shunt are supposedly best treated with GKS, despite the fact that only 87.5% of the vp-AVMs treated this way showed a reduction in the malformation volume, and none were cured.

Background: Although there is a standard guideline for performing revascularization surgery in patients with Moyamoya diseases (MMD), more objective and easily obtainable predictors are still needed. Objectives: In this study, we aimed to evaluate the relationship between an ipsilateral ivy sign and ischemic stroke recurrence in adult MMD patients without revascularization surgery. Methods: We included consecutive MMD patients without revascularization surgery between 2006 and 2014. The ivy sign was defined as a linear or focal high-signal intensity on fluid-attenuated inversion recovery images, and the burdens of ivy sign were rated in each hemisphere. The ischemic stroke recurrence was defined as a new clinical event that accompanied a new brain lesion on magnetic resonance imaging. Results: Overall, 84 patients with 154 hemispheres were analyzed. We found recurrent ischemic stroke in 9 (6%) hemispheres within 3 years. In multivariate analysis, an ipsilateral ivy sign remained an independent predictor of 3-year ischemic recurrence (adjusted hazard ratio [aHR] 10.15, 95% CI 2.10–49.14, p = 0.004). An initial presentation as infarction was also significant (aHR 7.15, 95% CI 1.36–36.78, p = 0.019). The burdens of ivy sign showed a dose-response tendency with the 3-year ischemic recurrence rate (p < 0.001). When comparing the ischemic recurrence rate among 4 groups with and without ivy sign and perfusion defect, the “Ivy sign (+) Perfusion defect (+) group” showed a significantly higher risk in both observed (p = 0.005) and estimated (p = 0.003) 3-year ischemic recurrence than did the other group. Additionally, the “Ivy sign (+) Perfusion defect (–) group” showed a higher recurrence rate than did the “Ivy sign (–) Perfusion defect (+) group”. Conclusions: The ivy sign is associated with ischemic recurrence in adult MMD patients in a dose-response manner. It would be helpful for selecting high-risk patients who need revascularization surgery.

Background The purpose of this study was to qualitatively and quantitatively evaluate the effects of a metal artifact reduction for orthopedic implants (O-MAR) for brain computed tomographic angiography (CTA) in patients with aneurysm clips and coils. Methods The study included 36 consecutive patients with 47 intracranial metallic implants (42 aneurysm clips, 5 coils) who underwent brain CTA. The computed tomographic images with and without the O-MAR were independently reviewed both quantitatively and qualitatively by two reviewers. For quantitative analysis, image noises near the metallic implants of non-O-MAR and O-MAR images were compared. For qualitative analysis, image quality improvement and the presence of new streak artifacts were assessed. Results Image noise was significantly reduced near metallic implants (P < 0.01). Improvement of implant-induced streak artifacts was observed in eight objects (17.0%). However, streak artifacts were aggravated in 11 objects (23.4%), and adjacent vessel depiction was worsened in eight objects (17.0%). In addition, new O-MAR-related streak artifacts were observed in 32 objects (68.1%). New streak artifacts were more prevalent in cases with overlapping metallic implants on the same axial plane than in those without (P = 0.018). Qualitative assessment revealed that the overall image quality was not significantly improved in O-MAR images. Conclusion In conclusion, the use of the O-MAR in patients with metallic implants significantly reduces image noise. However, the degree of the streak artifacts and surrounding vessel depiction were not significantly improved on O-MAR images., Graphical Abstract

BACKGROUND The availability of stents has widened the indications of endovascular intervention for cerebral aneurysms. OBJECTIVE To elucidate the effect of stents on radiologic outcomes and to analyze the risk factors for aneurysmal recanalization via propensity score matching. METHODS From the 735 aneurysms treated with coil embolization with stents (n = 187) and without stents (n = 548) between 2009 and 2011, 157 propensity score-matched case pairs were selected. The recanalization rates and relevant risk factors were analyzed. The mean follow-up interval was 24.1 ± 11.3 months (range, 6-48 months) and 22.9 ± 11.4 months (range, 6-56 months) in the stent and nonstent groups, respectively (P = .388). RESULTS The stent group demonstrated lower recanalization rates than the nonstent group during both the 6-month (1.9% vs 10.2%, P = .004) and the final follow-up periods (8.3% vs 18.5%, P = .005). The multivariate analysis identified the following significant factors for recanalization: the use of stents (hazard ratio, 0.40; 95% confidence interval, 0.21-0.76, P = .005), larger aneurysm size (hazard ratio, 1.21; 95% confidence interval, 1.11-1.31, P < .001), and initially incomplete occlusion (hazard ratio, 2.39; 95% confidence interval, 1.28-4.43, P = .006). The incidence of permanent neurological complication tended to be higher in the stent group than in the nonstent group (3.2% vs 0%, P = .063). CONCLUSION In this propensity score-matched analysis, stent implantation reduced the overall recanalization of the coiled cerebral aneurysms. However, the use of stents should be carefully decided upon.

OBJECT Moyamoya disease (MMD) is a rare cerebrovascular disease and its natural history is still unclear. The authors aimed to investigate the natural course of hemodynamically stable cases of adult MMD, with the analysis of stroke risk factors. METHODS Two hundred forty-one patients were included in this retrospective study. One hundred sixty-six (68.9%) were female, and mean age (± SD) at first visit was 41.3 ± 12.0 years (range 18–69 years). Unilateral involvement was identified in 33 patients, and 19 patients (7.9%) had a family history of MMD. According to the clinical presentations, patients were classified into hemorrhagic (n = 62, 25.7%), ischemic (n = 144, 59.8%), and asymptomatic (n = 35, 14.5%) groups. The mean duration of follow-up was 82.5 ± 62.9 months (range 7.3–347.0 months). RESULTS The annual stroke risk was 4.5%, and the annual risks of rebleeding in the hemorrhagic group and recurrent ischemic events in the ischemic group were 4.3% and 3.0%, respectively. There was no significant difference in cumulative stroke risk between the 3 groups (p = 0.461). Risk factors included thyroid disease for overall strokes (HR 2.56, 95% CI 1.16–5.67), initial hemorrhagic presentation for hemorrhagic strokes (HR 2.53, 95% CI 1.24–5.17), and initial ischemic presentation for ischemic strokes (HR 2.69, 95% CI 1.15–6.27). Familial MMD was a common risk factor for all types of stroke. Among the 3 clinical groups, the hemorrhagic group showed the worst clinical status at discharge and at most recent follow-up. Twenty-three patients (9.5%) eventually underwent revascularization surgery. CONCLUSIONS There was no statistically significant difference in the incidence of stroke in the different clinical groups; clinical status, however, was most severe in patients with hemorrhagic presentation. In patients who experienced stroke during the follow-up period, the stroke type tended to correspond to their initial presentation. Close follow-up is needed in patients with thyroid disease and a family history of MMD.

OBJECTIVEThe purpose of this study was to evaluate treatment outcomes of future stroke prevention, perioperative complications, and angiographic revascularization in adults with symptomatic moyamoya disease (MMD) according to treatment modalities and surgical techniques.METHODSA systemic literature review was performed based on searches of the PubMed, Embase, and Cochrane Central databases. A fixed-effects model was used in cases of heterogeneity less than 50%. Publication bias was determined by Begg’s funnel plot, Egger’s test of the intercept, and the Begg and Mazumdar rank correlation test.RESULTSEleven articles were included in the meta-analysis. Bypass surgery significantly decreased the future stroke events compared with conservative treatments in adult MMD (odds ratio [OR] 0.301, p < 0.001). Direct bypass showed better future stroke prevention than indirect bypass (OR 0.494, p = 0.028). There was no meaningful difference in perioperative complications between direct and indirect bypass (OR 0.665, p = 0.176). Direct bypass was associated with better angiographic outcomes than indirect bypass (OR 6.832, p < 0.001).CONCLUSIONSBypass surgery can be effective in preventing future stoke events in adults with MMD. Direct bypass seems to provide better risk reduction with respect to stroke than indirect bypass in these patients.

HydroSoft (MicroVention, Aliso Viejo, CA), a hydrogel-platinum coil hybrid device, is one of various efforts to overcome recanalization of coiled intracranial aneurysms. The purpose of this study was to evaluate the efficacy and safety of the HydroSoft coils in patients with intracranial aneurysms, and to compare the 12-month outcomes with that of bare platinum coils. Four-hundred one patients harboring 430 intracranial aneurysms underwent endovascular embolization with the HydroSoft coils. In the control group, 221 patients harboring 253 aneurysms underwent coil embolization with bare platinum coils. The authors compared the degree of occlusion of the aneurysms, packing attenuations, procedural-related complications, and 12-month follow-up results between the two groups. There were no significant differences of initial angiographic outcomes and procedure-related complications between the HydroSoft-coil group and the bare-coil group. Mean volumetric packing density of the HydroSoft-coil group was significantly higher than that of the bare platinum coil group (36.0 ± 8.50 % versus 32.1 ± 8.22 %, p

Objective The elevation of cellular retinoic acid-binding protein-I (CRABP-I) has been suggested as a candidate in the pathogenesis of paediatric moyamoya disease (MMD). However, few studies have addressed CRABP-I in adult onset MMD. The aim of this study was to examine the expression of CRABP-I in the cerebrospinal fluid (CSF) of adult onset MMD, and to evaluate its association with clinical presentation and postoperative haemodynamic change. Methods This study examined the CSF from 103 patients: bilateral MMD, n=58 (56.3%); unilateral MMD, n=19 (18.4%); atherosclerotic cerebrovascular disease (ACVD), n=21 (20.4%); and control group, n=5 (4.9%). The intensity of CRABP-I was confirmed by western blotting and expressed as the median (25th–75th percentile). The differences in CRABP-I expression according to disease entity (unilateral MMD vs bilateral MMD vs ACVD), initial presenting symptoms (haemorrhage vs ischaemia) and postoperative haemodynamic change (vascular reserve in single photon emission CT and basal collateral vessels in digital subtraction angiography) were analysed. Results CRABP-I intensities in bilateral MMD (1.45(0.86–2.52)) were significantly higher than in unilateral MMD (0.91(0.78–1.20)) (p=0.044) or ACVD (0.85(0.66–1.11)) (p=0.004). No significant differences were noted based on the initial presenting symptoms (p=0.687). CRABP-I was not associated with improvement in vascular reserve (p=0.327), but with decrease in basal collateral vessels (p=0.023) postoperatively. Conclusions Higher CRABP-I in the CSF can be associated with typical bilateral MMD pathogenesis in adults. Additionally, postoperative basal collateral change may be related to the degree of CRABP-I expression.

The fate of the contralateral unaffected side of the surgically treated unilateral moyamoya disease (MMD) in adults has not been well described due to the limited number of cases and the heterogeneous ages and treatment methods. The aim of this study was to evaluate the contralateral angiographic progression rate and its risk factors in homogeneous adult MMD patients who underwent surgical revascularization, with a review of pertinent literature.Forty-one surgically treated unilateral MMD patients were retrospectively evaluated. We reviewed medical and radiological records including data on gender, age, hypertension (HTN), smoking, familial MMD, presenting symptom, surgical method, Suzuki stage, and contralateral progression. Then, we conducted univariate and multivariate analyses to determine risk factors.Six of the 41 cases (14.6%) exhibited contralateral progression during the mean follow-up of 34 months. Four of those six patients (66.7%) were asymptomatic. Additional revascularization surgery was performed in the two symptomatic patients. The presence of a contralateral angiographic abnormality on initial angiography was a statistically significant risk factor for progression (OR, 49.00; p = 0.04). Younger age at diagnosis (32.7 ± 7.8 years in progression group vs. 42.5 ± 10.3 years in non-progression group, p = 0.046) was statistically significant in the univariate analysis, but age was not a significant factor in the multivariate analysis (p = 0.82). Other variables, such as gender (p = 0.13), HTN (p = 0.24), smoking (p = 0.47), and familial MMD (p = 0.20), did not show statistical significance.The presence of a contralateral angiographic abnormality on initial angiography was a significant risk factor for progression in surgically treated unilateral adult MMD. Consequently, patients with contralateral abnormalities should be monitored closely.

BACKGROUND Bypass surgery is a treatment option for complex intracranial aneurysms. OBJECTIVE To determine the utility of bypass surgery for the treatment of complex intracranial aneurysms and to review the literature on this topic. METHODS Sixty-two patients were included in this retrospective study. Unruptured aneurysms were dominant (80.6%), and the internal carotid artery was the most common location of the aneurysm (56.4%), followed by the middle cerebral artery (21.0%). The mean maximal diameter of the aneurysms was 20.5 ± 11.4 mm. The clinical and angiographic states were evaluated preoperatively, immediately after surgery (within 3 days) and at the last follow-up. The mean angiographic and clinical follow-up duration was 34.2 ± 38.9 and 46.5 ± 42.5 months, respectively. RESULTS Sixty-one patients (98.3%) underwent extracranial-intracranial bypass, and 1 underwent intracranial-intracranial bypass. At the last follow-up angiography, 58 aneurysms (93.5%) were completely obliterated and 4 were incompletely obliterated, with a graft patency of 90.3%. Surgical mortality was 0 and permanent morbidity was 8.1%. A good clinical outcome (Karnofsky Performance Scale ≥ 70 and modified Rankin Scale score ≤ 2) was achieved in 91.9% of patients (n = 57). CONCLUSION With a proper selection of bypass type, bypass-associated treatment can be a good alternative for patients with complex intracranial aneurysms when conventional microsurgical clipping or endovascular intervention is not feasible.

Delayed cranioplasty after decompressive craniectomy was performed using various reconstruction materials and methods. Bone graft infection is a major concern with cranioplasty. This study identified factors that are related to bone graft infection after cranioplasty.A total of 140 patients underwent reconstructive cranioplasty after decompressive craniectomy between 2000 and 2009. The sample population included 102 male patients and 39 female patients aged 6 years to 76 years, with a mean age of 47.5 years. Autografts were used for cranioplasty when available. Polymethylmethacrylate or customized linear high-density polyethylene was considered when autografts were unavailable. Bone graft infection was defined as the removal of the infected bone graft, and the related factors were evaluated retrospectively.Bone graft infection occurred in 11 patients (7.86%). Bone graft infection after cranioplasty was significantly related to the number of operations (p = 0.002), operation time (p = 0.031), and diabetes (p = 0.004). An increased number of operations increased the infection rate from 4.3% to 33%. Infection rates increased rapidly after three times. The infection rate was less than 10% when cranioplasty was completed within 199 minutes. An infection rate greater than 20% was observed when cranioplasty required more than 200 minutes. Other factors, such as graft material, fixation devices, age, sex, the cause of the operation, the interval between craniectomy and cranioplasty, and underlying nondiabetic diseases, did not significantly alter the infection rate.Short surgical times (200 minutes) and a lower number of previous operations (less than three times) may decrease the risk of bone flap infection. Careful attention is required when performing cranioplasty, particularly in patients with diabetes.Prognostic/therapeutic study, level IV.

Technical report.To present a detailed surgical technique of percutaneous endoscopic interlaminar diskectomy (PEID) for recurrent lumbar disk herniation and present features of postoperative magnetic resonance images that were unavailable in previous studies.Revision lumbar diskectomy is troublesome because of the difficulty in dissecting a surgical scar. Endoscopic diskectomy is regarded as an alternative method with comparable clinical outcome and less complication. Technically, a transforaminal approach is similar to a virgin operation, whereas an interlaminar approach is not, because of the scar tissue. There have been only 2 papers describing a PEID surgical procedure. Sharing details of the surgical technique is important in furthering the adoption of this technique, when it is indicated.We operated on 10 patients (M:F=6:4; mean age, 61.2±11.6 y) with PEID for recurrent lumbar disk herniation after open diskectomy. The level operated was L5-S1 in 5 cases, L4-5 in 4, and L2-3 in 1. During operation, we dissected the scar tissue from the medial facet joint with a working channel and removed the reherniated disk material after retraction of the scar tissue and the neural tissue together. Dissection of the scar tissue from the neural tissue was not attempted. The follow-up period was 14.4±9.9 months.In all 10 patients, the reherniated disk materials were removed successfully. There was no incidence of dural tear. Postoperative magnetic resonance imaging showed good decompression with thecal sac reexpansion irrespective of the attached scar tissue, except in 1 patient. Excellent or good outcome by Macnab criteria was obtained in 6 of 10 patients, fair outcome in 2, and poor in 2 patients. Rerecurrence occurred in 1 patient 1 year after the surgery.PEID with dissection of the scar tissue from the medial facet joint rather than from the neural tissue may be an effective alternative surgical method for recurrent disk herniation.

This study evaluated the efficacy of intra-arterial nimodipine infusion for symptomatic vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH). Clinical data collected from 42 consecutive patients with symptomatic vasospasm after aSAH were retrospectively reviewed. Forty-two patients underwent 101 sessions of intra-arterial nimodipine infusion. Angiographic response, immediate clinical response, and clinical outcome were evaluated at discharge and six months later. Angiographic improvement was achieved in 82.2% of patients. The immediate clinical improvement rate was 68.3%, while the deterioration rate was 5.0%. A favorable clinical outcome was achieved in 76.2% at discharge and 84.6% six months. Vasospasm-related infarction occurred in 21.4%. There was no drug-related complication. The nimodipine group showed satisfactory outcomes. Nimodipine can be recommended as an effective and safe intra-arterial agent for the treatment of symptomatic vasospasm after aSAH.

The recanalization rate after coil embolization of unruptured aneurysms was compared between young and old age groups. From May 2003 to December 2010, 636 patients with 715 saccular unruptured intracranial aneurysms (UIA) underwent endovascular coiling and were followed for at least 6 months. For comparative analysis, patients were categorized into two groups according to age 40: 42 patients with 46 aneurysms who were 40 years or younger (young age group) and 594 patients with 669 aneurysms who were older than 40 years (old age group). Angiographic and clinical outcomes including recanalization rates were compared. Angiographically, class 1 or 2 occlusion according to the Raymond–Roy Occlusion Classification system was achieved in 89.2 % of the patients (91.3 % in the young age group and 89.1 % in the old age group, p = 0.74). Procedure-related complication rate was 2.2 % and 3.4 % in the young and the old age group (p = 0.16), respectively. The mean follow-up duration was 30.51 ± 18.59 months. Major recanalization occurred in seven aneurysms (15.2 %) in the young age group and in 44 aneurysms (6.6 %) in the old age group (p = 0.03). Retreatment was performed in seven patients (15.2 %) in the young age group and in 35 patients (5.2 %) in the old age group (p = 0.01). The present study showed that the technical feasibility and safety of endovascular coiling for UIA did not differ between the two age groups. However, the major recanalization rate was higher in the young age group.

Supplemental Digital Content is available in the text, Although metabolomics has been increasingly used to observe metabolic pattern and disease-specific metabolic markers, metabolite profiling for moyamoya disease (MMD) has not yet been done in adults. This study investigated cerebrospinal fluid (CSF) metabolites specific to bilateral MMD (B-MMD) and compared them to those of unilateral MMD (U-MMD) or atherosclerotic stenosis with hydrogen-1 nuclear magnetic resonance spectroscopy to identify metabolic biomarkers associated with MMD in adults. CSF samples of B-MMD (n = 29), U-MMD (n = 11), and atherosclerotic cerebrovascular disease (ACVD) (n = 8) were recruited. Principal component analysis, partial least square discriminant analysis, and orthogonal projections to latent structure discriminant analysis (OPLS-DA) were done for the comparisons. Diagnostic performance was acquired by prediction of 1 left-out sample from the distinction model constructed with the rest of the samples. B-MMD showed an increase in glutamine (P

Background. The natural history of vertebrobasilar artery dissection (VAD) is not fully known. The purpose of this study was to review the clinical outcome of the patients with VAD, then to propose an appropriate management strategy for VAD. Method. From 1992 to 2004, 35 VAD patients admitted to our institutes were retrospectively reviewed. There were 28 men and 7 women, whose age ranged from 4 to 67 years with a mean age of 44 years. Angiography was assessed to document the shape, and location of the dissecting aneurysm with respect to the posterior inferior cerebellar artery (PICA). A modified Rankin score was assigned for functional outcome. The functional outcome scores were analyzed according to the patient’s age, gender, hypertension history, the pattern of initial manifestation, angiographic shape of VAD, angiographic location of VAD, treatment modality. Findings. There was no statistically significant difference between the functional outcome with age, gender, trauma history and past medical history of hypertension. Of 35 patients, 22 presented with SAH, 11 with ischemic symptoms and 2 were incidentally detected. The patients without SAH had a better functional outcome than those with SAH (p = 0.029). There was statistical significance between Hunt–Hess (H–H) grade and clinical outcome (p = 0.032). The shape and location of VAD was not significantly related to the functional outcome (p = 0.294, 0.840). But all the cases of rebleeding and mortality (except one case with initially poor H–H grade) developed exclusively in patients with aneurysms. There was no statistically significant correlation between the treatment modality and the outcome (p = 0.691). Conclusion. The VAD patients with SAH would be recommended to be managed by either surgical or endovascular treatment, but those without SAH, could be managed conservatively with antiplatelet therapy and/or anticoagulation.

Background and Purpose— The surgical outcomes of adult moyamoya disease are rarely reported. We aimed to evaluate the long-term outcomes of combined revascularization surgery in patients with adult moyamoya disease. Methods— Combined revascularization surgery consisting of superficial temporal artery–middle cerebral artery anastomosis with encephalodurogaleosynangiosis was performed on 77 hemispheres in 60 patients. Clinical, angiographic, and hemodynamic states were evaluated retrospectively using quantitative methods preoperatively and postoperatively in the short-term (≈6 months) and long-term (≈5 years) periods. The mean clinical follow-up duration was 71.0±10.1 months (range, 60–104 months). Results— Clinical status improved until 6 months after surgery and remained stable thereafter, as assessed by the Karnofsky Performance Scale and modified Rankin Scale. The revascularization area relative to supratentorial area significantly increased in the long-term period compared with that in the short-term period (54.8% versus 44.2%; P P P =0.219). The annual risks of symptomatic hemorrhage and infarction were 0.4% and 0.2%, respectively, in the operated hemispheres. Conclusions— Combined revascularization surgery resulted in satisfactory long-term improvement in clinical, angiographic, and hemodynamic states and prevention of recurrent stroke.

The purpose of this study was to assess the risk factors of prospective symptomatic haemorrhage in a large series of adult patients with cerebral cavernous malformation (CM).Three hundred twenty-six patients18 years of age with 410 CMs were evaluated retrospectively. Symptomatic haemorrhage was defined as new clinical symptoms with radiographic features of haemorrhage. Clinical data and the characteristics of CM were analysed. MR appearance was divided into three groups according to Zabramski's classification.The overall haemorrhage rate of CM was 4.46% per lesion-year. The overall annual haemorrhage rate according to MR appearance was as follows: type I, 9.47%; type II, 4.74%; and type III, 1.43%. A multivariate analysis revealed that prior symptomatic haemorrhage (p0.001) and MR appearance (p0.001) were statistically significant. After multiple comparisons, type I (p0.001) and type II (p=0.016) showed higher haemorrhage risk than type III. However, no significant difference in haemorrhage rate was observed between type I and type II (p=0.105). Other variables including female gender, age, location, multiplicity, hypertension, size and associated venous angioma were not significant. The haemorrhage rates based on risk factors were estimated at 3 years as follows: 33.77% in patients with prior haemorrhage versus 7.54% in patients without prior haemorrhage (p0.001); type I, 27.62% vs type II, 15.44% vs type III, 5.38% (p0.001).Prior symptomatic haemorrhage and MR appearance could be related to prospective symptomatic CM haemorrhage in adults. A prospective multicentre observational study is necessary to confirm our results.

Precommunicating (A1) segment aneurysms of the anterior cerebral artery are rare and often pose technical challenges for coil embolization due to their distinctive configurations. Clinical and radiologic outcomes of treating such aneurysms through endovascular coil embolization are presented herein. Data accruing prospectively from May 2002 to August 2013 yielded 48 patients harboring 50 A1 segment aneurysms, each classified as proximal, middle, or distal by location. Clinical outcome of the patients and morphological outcome of the aneurysms were assessed, with emphasis on technical aspects of treatment. The aneurysms studied occupied either proximal (n = 39), middle (n = 6), or distal (n = 5). Proximal aneurysms were largely directed posteriorly (80 %), and most (97 %) were devoid of branches. Middle and distal aneurysms were associated with the medial lenticulostriate artery, cortical branches, or fenestrations. The preshaped “S” and steam-shaped “S” microcatheters facilitated aneurysm selection in 60 % of lesions. Single-microcatheter technique was most commonly applied for coil embolization (62 %), followed by balloon protection (16 %). Successful aneurysmal occlusion could be achieved in 76 % of the patients, with no procedure-related morbidity and mortality. At final follow-up (mean interval, 29.9 months), stable aneurysmal occlusion was sustained in 93 % of the patients (40/43). A1 segment aneurysms are amenable to safe and efficacious endovascular coil embolization by adjusting procedural strategy to accommodate distinctive anatomic configurations.

Objective The optimal consensus concerning treatment of incidental small paraclinoid unruptured intracranial aneurysms (UIAs) remains controversial. The aim of this retrospective study was to reveal the natural history of small paraclinoid UIAs with the goal of informing the treatment plan. Methods 524 patients harbouring 568 paraclinoid UIAs (≤5 mm) were retrospectively evaluated during the mean follow-up of 35.4 months. The aneurysms were divided into two groups with respect to arterial branch: related (ophthalmic and superior hypophyseal artery), and non-related. Medical records were reviewed concerning multiple variables, such as sex, age, hypertension (HTN), diabetes mellitus, smoking and aneurysmal factors (size, arterial relationship, multiplicity and the occurrence of rupture and growth). The cumulative risk and the risk factors of aneurysmal rupture and growth were analysed. Results Two aneurysmal (0.35%) ruptures and 17 growths (3.0%) were observed during the follow-up of 1675.5 aneurysm-years with an annual rupture of 0.12% and an annual growth of 1.01%. The cumulative survival without aneurysmal growth reached a significant difference in aneurysms ≥4 mm (p=0.001), HTN (p=0.002), and arterial branch-related location (p=0.001). Multivariate analysis disclosed that aneurysm ≥4 mm (HR, 4.41; p=0.003), HTN (HR, 5.74; p=0.003), arterial branch-related location (HR, 6.04; p=0.002), and multiplicity (HR, 0.27; p=0.042) were significant predictive factors for aneurysm growth. Conclusions Although incidental small paraclinoid UIAs have a relatively lower rupture and growth risk, patients with high-risk factors, including aneurysm ≥4 mm, HTN, arterial branch-related aneurysms, and multiple aneurysms must be monitored closely. The limitation of the retrospective nature of this study should be taken into consideration.

BACKGROUND: Although endovascular technique and related devices continue to improve, recanalization of embolized aneurysm remains a pitfall of this approach. The problem of how to treat the recanalized aneurysm needs to be addressed. OBJECTIVE: To determine the outcomes of patients undergoing repeat embolization for recanalized intracranial aneurysms and to evaluate the impact of stent implantation on subsequent recanalization. METHODS: Between September 2001 and September 2011, we performed endovascular retreatment in 162 patients with a total of 197 recanalized intracranial aneurysms. Stent implantation was performed in 68 aneurysms during the retreatment. Clinical and morphological outcomes were assessed at 6 months or more after repeat embolization. RESULTS: Procedure-related complications, including asymptomatic thromboembolism, occurred with 15 aneurysms (7.6%) without permanent neurological sequelae. Follow-up imaging of 172 aneurysms documented stable occlusion in 96 of the lesions (55.8%), minor recanalization in 17 (9.9%), and major recanalization in 59 (34.3%) during the mean follow-up period of 26.0 ± 18.0 months. In multiple logistic regression analysis, stent implantation was shown to reduce the major recanalization rate at 6 months after retreatment (odds ratio: 0.161; 95% confidence interval:, 0.038-0.670; P = .012) and thereafter (odds ratio: 0.226; 95% confidence interval: 0.088-0.581; P = .002). CONCLUSION: Stent implantation, as well as compact coil packing, at the time of repeat embolization seems beneficial in reducing rates of further recanalization.

BACKGROUND Protection techniques using stents or microcatheters allow treatment of aneurysms with complex configurations by coil embolization. However, the application of these techniques is occasionally limited in wide-neck middle cerebral artery (MCA) aneurysms with acute angularity of the efferent branch vessel. OBJECTIVE We describe a looping technique for passage of a microcatheter and microwire into the acutely angled efferent branch vessel without navigating the system through the aneurysm lumen. METHODS To select the acutely angulated branch, a looped microcatheter was advanced near the orifice of the distal acutely angled branch vessel, followed by microwire passage through the looped microcatheter into the efferent vessel. The microcatheter loop was straightened after the microwire had been sufficiently advanced. The microcatheter was then navigated into the distal branch vessel over the advanced microwire. RESULTS A total of 36 wide-neck MCA aneurysms were successfully treated using this looping method. This technique was used to pass the microcatheter for stent protection in 13 patients and for microcatheter protection in 23. The method was most commonly used for aneurysms located at the M1 trunk (n = 21), followed by the MCA bifurcation (n = 15). Complete or near-complete endosaccular occlusion was achieved in 31 aneurysms. There were no complications related to looping the microcatheter. CONCLUSION This microcatheter looping technique facilitates safe entry into the distal branch during coil embolization of wide-neck MCA aneurysms incorporating the origins of acutely angulated branches.

BACKGROUND AND PURPOSE: A number of remodeling or protective techniques available to treat wide-neck intracranial aneurysms are increasingly being used, provided that the shape/type of aneurysm, vessel diameter, and inherent course of the vessel are conducive to their use. The purpose of this study was to describe a novel method using coil protection for treatment of wide-neck aneurysms. MATERIALS AND METHODS: This technique involves sequential maneuvers to the aneurysm and affected branch artery. A microcatheter is first introduced into the aneurysmal sac, and another microcatheter is introduced into the entrance of the branch artery, followed by partial deployment of a small helical coil into the branch artery. A framing coil is then placed within the aneurysmal sac, under the protection of the helical coil. After completion of the first coil insertion, the helical coil should be retrieved to confirm the stability of the framing coil. The helical coil can also serve as a filler. RESULTS: This technique was successfully applied to 12 intracranial saccular aneurysms of the MCA bifurcation (5 patients); anterior communicating artery (3 patients); and A1 and M1 segments, distal ACA, and basilar tip (1 patient each). Selective endovascular treatment was successfully performed and resulted in excellent outcomes in all patients. There were no complications directly related to coil protection. CONCLUSIONS: Our small study suggests that coil protection can be a safe alternative to traditional remodeling or protective techniques when those techniques have failed or are not possible due to vascular geometry. It is particularly suited for the treatment of wide-neck aneurysms arising from small and acutely angulated branching vessels.

Fifteen years of experience with adult moyamoya disease (MMD) in a single department were analyzed to describe the clinical features and to clarify the existence of the disease entity of adult MMD with special reference to its diagnosis. This study included 348 patients treated between 1996 and 2010. Male to female ratio was 128 to 220 with mean age of 39 years. The presence of neurological symptoms and signs during childhood and mean Suzuki stage according to the age were evaluated. Adult MMD was differentiated from other diseases, such as vasculitis, by comparing the laboratory data including common markers and specific markers for such diseases between 22 adult MMD and 21 atherosclerotic disease (ASD) patients. Conventional angiographic data were analyzed to detect progression in 52 unilateral adult MMD patients over a mean follow-up duration of 4.8 years. Only one of 128 patients (0.8%) aged over 40 years showed childhood symptoms and signs. The distribution of the mean Suzuki stage between patients aged 40 years and under and over 40 years was similar. Laboratory tests differentiating the other diseases with the same phenotype with MMD revealed no difference between adult MMD and ASD. The progression of unilateral MMD to bilateral MMD occurred in 6 of 52 patients (11.5%). Adult MMD is not a syndrome, but a distinct disease entity with significant progression of unilateral MMD to bilateral MMD. Diagnostic and therapeutic strategies should be different from pediatric cases when considering adult MMD.

Carotid endarterectomy (CEA) is the most effective treatment method of carotid stenosis or occlusion. Surgeons typically check the blood flow in each vessel using Duplex Doppler ultrasonography or radiocontrast angiography in order to prevent postoperative complications. Embolic cerebral infarction on the ipsilateral side has been reported in 4-7% of patients undergoing CEA despite a tolerable blood flow reported by Duplex ultrasonography. This study was designed to evaluate a new intraoperative method for detecting technical errors during CEA using indocyanine green (ICG) angiography.Six consecutive patients with severe carotid stenosis or occlusion underwent CEA. Both ICG angiography and Doppler ultrasonography were performed before the carotid arterial incision and after the carotid arterial suture. After injecting ICG dye via an intravenous route, the internal surface, atheroma, and flow defect were visualized with a microscope.In ICG angiography, stenotic lesions could be identified as regions of relatively dark signal intensity. Magnified real-time images could be created using a microscope with an infrared filter, including three-dimensional images and detailed images of the inner lumen. These images could then be compared with the results of Doppler ultrasonography. In the six cases assessed by both ICG angiography and Doppler ultrasonography, all Doppler results were acceptable. However, one patient underwent revision surgery because a fluttering atheroma was detected by ICG angiography. ICG angiography could assume the extent of severe stenotic area. ICG angiography could also detect mobile lesions such as a fluttering atheroma.Intraoperative ICG angiography before arteriotomy is useful to determine the precise stenotic area and the shape of the associated plaque. ICG angiography after an arteriotomy site is sutured is also useful for detecting residual stenosis or fluttering atheroma. ICG angiography could be an alternative method to Doppler ultrasonography for ensuring a complete and successful operation and preventing complications.

Pediatric infratentorial ependymomas are difficult to cure. Despite the availability of advanced therapeutic modalities for brain tumors, total surgical resection remains the most important prognostic factor. Recently, histological grade emerged as an independent prognostic factor for intracranial ependymoma. We retrospectively reviewed the treatment outcome of 33 pediatric patients with infratentorial ependymoma. Progression-free survival (PFS) and overall survival (OS) rates were calculated and relevant prognostic factors were analyzed. Fourteen patients (42%) were under the age of 3 at diagnosis. Gross total resection was achieved in 16 patients (49%). Anaplastic histology was found in 13 patients (39%). Adjuvant therapies were delayed until progression in 12 patients (36%). Actuarial PFS rates were 64% in the first year and 29% in the fifth year. Actuarial OS rates were 91% in the first year and 71% in the fifth year. On univariate analysis, brainstem invasion (P = 0.047), anaplastic histology (P = 0.004), higher mitotic count (P = 0.001), and higher Ki-67 index (P = 0.004) were significantly related to a shorter PFS. Gross total resection (P = 0.029) and a greater age at diagnosis (P = 0.033) were significantly related to a longer PFS. On multivariate analysis, anaplastic histology alone was significantly related to a shorter PFS (P = 0.023). Gross total resection (P = 0.039) was significantly related to a longer overall survival (OS) on multivariate analysis. Anaplastic histology and gross total resection were the most important clinical factors affecting PFS and OS, respectively. Anaplastic histology, mitotic count, and Ki-67 index can be used as universal and easily available prognostic parameters in infratentorial ependymomas.

We retrospectively evaluated the effect of brain atrophy on the outcome of patients after a large cerebral infarct.Between June 2003 and Oct 2008, 134 of 2975 patients with stroke were diagnosed as having a large cerebral infarct. The mean age of the patients was 70 (21-95) y. The mean infarct volume was 223.6±95.2 cm(3) (46.0-491.0). The inter-caudate distance (ICD) was calculated as an indicator of brain atrophy by measuring the hemi-ICD of the intact side and then multiplying by two to account for brain swelling at the infarct site. The mean ICD was 18.0±4.8 mm (9.6-37.6).Forty-nine (36.6%) patients experienced a malignant clinical outcome (MCO) during management in the hospital. Thirty-one (23.1%) patients had a favourable functional outcome (FO) (modified Rankin scale (mRS) ≤3) and 49 (36.6%) had an acceptable functional outcome (AO) (mRS≤4) at 6 months after stroke onset. In the multivariate analysis, brain atrophy (ICD≥20 mm) had a significant and independent protective effect on MCO (p=0.003; OR=0.137; 95% CI 0.037 to 0.503). With respect to FO, the age and infarct volume reached statistical significance (p0.001, OR=0.844, 95% CI 0.781 to 0.913; p=0.006, OR=0.987, 95% CI 0.977 to 0.996, respectively). Brain atrophy (ICD≥20 mm) was negatively associated only with AO (p=0.022; OR=0.164; 95% CI 0.035 to 0.767).Brain atrophy may have an association with clinical outcome after a large stroke by a trend of saving patients from an MCO but also by interfering with their functional recovery.

Management of large vestibular schwannoma (VS) remains a difficult problem for which the extent of tumor resection and the role of radiosurgery continue to be the subject of debate. To develop an optimal therapeutic strategy for large VS, various treatment options within the avenues of microsurgery and radiosurgery were evaluated and compared. The authors carefully reviewed the clinical data of 50 surgical cases of large VS, defined as tumors with an average diameter over 3 cm in magnetic resonance imaging (MRI). All patients underwent microsurgery as the primary treatment. Gross total removal (GTR) was achieved in nine patients (18%), near total removal (NTR) in 8 (16%), radical subtotal removal (R-STR) in 31 (62%), and subtotal removal (STR) in 2 (4%). Among the 33 patients with R-STR and STR, eight had undergone adjuvant radiosurgery for the residual mass. Average tumor volume and diameter were 26.8 cm(3) (13.5-55.1) and 36.4 mm (30.0-47.2), respectively. The mean follow-up duration was 113 months (58-167). The tumor control rate and facial nerve function according to the extent of removal were analyzed. The overall tumor control rate was 82%. Perfect tumor control was achieved after NTR and R-STR with adjuvant radiosurgery. However, 11% (1 of 9) of GTR patients and 32% (8 of 25) of R-STR-only and STR patients showed recurrence or regrowth. Overall favorable outcome of facial nerve function (H-B grade 1 or 2) was achieved in 78% of the patients. The facial nerve preservation rate was inversely proportional to the extent of tumor removal. NTR or R-STR with adjuvant radiosurgery might be acceptable therapeutic options for large VS in terms of achieving good tumor control and functional preservation of facial nerve.

Though the surgical treatment for medial temporal lobe epilepsy yields a high success rate, more studies are needed in order to determine the most efficacious pre-operative algorithm. The authors studied the relationship between surgical outcome and the localization results of various pre-operative diagnostic tests to assess the predictive value. Seventy-one consecutive patients who had undergone anterior temporal lobectomy with amygdalohippocampectomy with the diagnosis of non-lesional medial temporal lobe epilepsy, who had been followed up more than 24 months, were analyzed retrospectively. Electroencephalogy (EEG), magnetic resonance imaging (MRI), proton emission tomography (PET), single photon emission computed tomography (SPECT), the Wada test, and neuropsychological testing were analyzed. There was no diagnostic test that was found to have a statistically significant relationship between Engel Class I outcome and localization results (P& 0.05). SPECT, neuropsychological testing, and the Wada test all had less predictive values (P< 0.01). EEG and PET had comparable predictive values for Engel Class I with MRI (P& 0.05). No single diagnostic test alone is sufficient to make a diagnosis of non-lesional medial temporal lobe epilepsy. MRI, EEG and PET had comparable predictive values for Engel Class I. SPECT, neuropsychological testing, and the Wada test had less predictive values.