Chun Sik Choi

Reconstructive endovascular treatment of ruptured blood blister–like aneurysms of the internal carotid artery

OBJECT Ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are rare but carry a high rate of morbidity and mortality. Furthermore, BBAs are very difficult to treat surgically as well as endovascularly. The authors present their experience in treating BBAs with reconstructive endovascular methods. METHODS Nine ruptured BBAs in 9 consecutive patients (2 men and 7 women; mean age 50 years, range 42-57 years) were treated using reconstructive endovascular methods between January 2006 and November 2007. Treatment methods and angiographic and clinical outcomes were retrospectively evaluated. RESULTS All 9 BBAs were initially treated with stent-assisted coil (SAC) embolization. This was followed by a second stent insertion using the stent-within-a-stent (SWS) technique in 3, covered stent placement in 3, and SAC embolization alone in 3. All 3 patients who underwent SWS placement had excellent outcomes (Glasgow Outcome Scale Score 5) with complete angiographic resolution of the BBAs. There were no treatment-related complications in the SWS group. Two of the 3 patients who received covered stents had excellent outcomes (Glasgow Outcome Scale Score 5) and complete occlusion of the BBA was achieved. The remaining patient who received a covered stent died of ICA rupture during the procedure. Aneurysm regrowth without rebleeding occurred in the 3 patients who underwent SAC embolization. Two of the 3 recurrent BBAs were treated with coil embolization with a second stent insertion, and as a result these belonged to the SWS group. The other recurrent BBA was treated with a covered stent. Of the 8 surviving patients, 5 underwent SWS, and 3 underwent covered stent placement. All surviving patients had excellent outcomes during the clinical follow-up period (mean 11 months, range 4-26 months); complete BBA resolution and smooth reconstruction of the affected ICA segment was shown on follow-up angiography. CONCLUSIONS In the present study, the SWS and covered-stent techniques effectively prevented rebleeding and regrowth of the BBA without sacrifice of the ICA. The SWS and covered-stent techniques can be considered an alternative treatment option for BBAs in selected patients in whom ICA sacrifice is not feasible. Stent-assisted coiling alone seems insufficient to prevent BBA regrowth.

Treatment of blood blister-like aneurysm of the internal carotid artery with stent-assisted coil embolization followed by stent-within-a-stent technique. Case report.

Ruptured blood blister-like aneurysms (BBAs) of the internal carotid artery (ICA) are potentially dangerous lesions because of the high risk of intraoperative bleeding associated with their wide fragile neck. The authors discuss cases in which BBAs were treated endovascularly during the chronic stage and report a case in which a ruptured BBA of the ICA was successfully treated in the acute phase with stent-assisted coil embolization and a subsequent stent-within-a-stent procedure.

Stent-assisted coil embolization followed by a stent-within-a-stent technique for ruptured dissecting aneurysms of the intracranial vertebrobasilar artery. Clinical article.

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

Comparison of Serum CRP and Procalcitonin in Patients after Spine Surgery

OBJECTIVE Classical markers of infection cannot differentiate reliably between inflammation and infection after neurosurgery. This study investigated the dynamics of serum procalcitonin (PCT) in patients who had elective spine surgeries without complications. METHODS Participants were 103 patients (47 women, 56 men) who underwent elective spinal surgery. Clinical variables relevant to the study included age, sex, medical history, body mass index (BMI), site and type of surgery, and surgery duration. Clinical and laboratory data were body temperature, white blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and PCT, all measured preoperatively and postoperatively on days 1, 3, and 5. RESULTS PCT concentrations remained at <0.25 ng/mL during the postoperative course except in 2 patients. PCT concentrations did not correlate with age, sex, DM, hypertension, BMI, operation time, operation site, or use of instrumentation. In contrast, CRP concentrations were significantly higher with older age, male, DM, hypertension, longer operation time, cervical operation, and use of instrumentation. CONCLUSION PCT may be useful in the diagnosing neurosurgical patients with postoperative fever of unknown origin.

Intravascular Papillary Endothelial Hyperplasia (Masson tumor) of the Skull : Case Report and Literature Review

A 10-year-old female patient presented with a rapidly growing nodular mass lesion on her right frontal area. On skull radiography and computed tomography (CT) imaging, this mass had a well-demarcated punch-out lesion with a transdiploic, exophytic soft tissue mass nodule on the frontal scalp. Magnetic resonance (MR) imaging revealed the presence of a 1.5×1.2×1 cm sized calvarial lesion. This lesion was hypointense on T1 and heterogenous hyperintense on T2 weighted MR images, and exhibited heterogeneous enhancement of the soft tissue filling the punch-out lesion after intravenous administration of gadolinium. En block removal of the tumor with resection of the rim of the normal bone was performed. The pathological diagnosis was intravascular papillary endothelial hyperplasia (IPEH). After surgery, no recurrence was found for 8 months. IPEH is a rare and benign reactive lesion usually found in thrombosed subcutaneous blood vessels. Involvement of skull bone is rare. In this article, we present a case of IPEH involving the calvarium, in a 10-year-old woman.

Clinical Analysis of Risk Factors for Recurrence in Patients with Chronic Subdural Hematoma Undergoing Burr Hole Trephination

Objective Chronic subdural hematoma (CSDH) is one of the most common types of intra-cranial hemorrhages usually associated with trauma. Surgical treatment is the treatment of choice and burr hole trephination (BHT) is widely performed. The recurrence rate in the patients with CSDH is 3.7-30%. This study investigated the risk factors associated with the recurrence of patients with CSDH who underwent BHT. Methods One hundred twenty-five patients with CSDH underwent BHT. Eight of 125 patients (6.4%) underwent reoperation for recurrent CSDH. We retrospectively analyzed demographic, clinical and radiological findings, catheter tip location and drainage duration as the risk factors for the recurrence of CSDH. Results Recurrence of CSDH in the high- or mixed-density groups was significantly higher than those in the low- or iso-density groups (p<0.001). Placement of catheter tip at the temporoparietal area was associated with a significantly higher recurrence rate of CSDH than placement at the frontal area (p=0.006) and the brain re-expansion rate (BRR) was much lower than placement at the frontal area (p<0.001). Conclusion The operation may be delayed in high- and mixed-density groups, unless severe symptoms or signs are present. In addition, placing the catheter tip at the frontal area helps to reduce the incidence of postoperative recurrence of CSDH and to increase the BRR.

Severe Symptomatic Vasospasm following Intraventricular Hemorrhage from Arteriovenous Fistula

The authors present a rare case of severe vasospasm following the rupture of arteriovenous fistula. On initial CT scan, hematoma in the corpus callosum and left inferior frontal region with surrounding cerebromalacia and all ventricles without apparent subarachnoid hemorrhage were seen. Angiograms showed arterivenous fistula but did not show cerebral vasospasm. Thirteen days after admission the neurological state of patient suddenly deteriorated and bilateral motor weaknesses developed. Following angiograms revealed severe narrowing on the supraclinoid portion of bilateral internal carotid arteries, bilateral anterior cerebral arteries and bilateral middle cerebral arteries. Transluminal angioplasty and intra-arterial papaverine infusion were performed. The patient remained stable with moderate neurologic deficits.

Initial Troponin Level as a Predictor of Prognosis in Patients with Intracerebral Hemorrhage

OBJECTIVE It has been suggested that elevated cardiac troponin T (cTnT) level is a marker of increased risk of mortality in acute ischemic stroke and subarachnoid hemorrhage (SAH). However, the association of serum cTnT level and prognosis of intracerebral hemorrhage (ICH) has been sparsely investigated. The aim of this study was to identify the relationship between cTnT level and the outcome in patients with spontaneous ICH. METHODS We retrospectively investigated 253 patients identified by a database search from records of patients admitted in our department for ICH between January 1, 2003 and December 31, 2007. The patients were divided into 2 groups; the patients in group 1 (n=225) with serum cTnT values of 0.01 ng/mL or less, and those in group 2 (n=28) with serum cTnT values greater than 0.01 ng/mL. RESULTS The serum cTnT level was elevated in 28 patients. There were significant differences in sex, hypertension, creatine kinase-myocardial band, midline shift, side of hematoma, and presence of intraventricular hemorrhage between the 2 groups. Logistic regression analysis identified the level of consciousness on admission, cTnT and midline shift as independent predictors of hospital mortality. CONCLUSION Theses results suggest that increased serum cTnT level at admission is associated with in-hospital mortality and the addition of a serum cTnT assay to routine admission testing should be considered in patients with ICH.

A Comparative Coagulopathic Study for Treatment of Vasospasm by Using Low- and High-molecular Weight Hydroxyethyl Starches.

OBJECTIVE High-molecular-weight hydroxyethyl starch (HES) compromises blood coagulation more than does low-molecular-weight HES. We compared the effects of low- and high-molecular-weight HES for the treatment of vasospasm and investigated the dose relationship with each other. METHODS Retrospectively, in a series of consecutive 102 patients with subarachnoid hemorrhage (SAH), 35 patients developed clinical symptoms of vasospasm of these fourteen patients were treated with low-molecular-weight HES for volume expansion while the other 21 received high-molecular-weight HES as continuous intravenous infusion. Prothrombin time (PT), partial thromboplastin time (PTT), fibrinogen level, and platelet count were all measured prior to initiation, during treatment and after termination of therapy for symptomatic vasospasm. The total dose of HES ranged from 5 L to 14 L and median infusion duration was 10 days. RESULTS A more pronounced PTT prolongation was observed in high-molecular-weight HES group compared with low-molecular-weight HES group. No other coagulation parameters were altered. Dosage (=duration) shows a positive correlation with PTT. Clinically, significant bleeding episodes were noted in four patients who received high-molecular-weight HES. CONCLUSION Coagulopathy was developed in direct proportion to molecular weight of starch and dosages. We propose the extreme caution in the administration of HES solution for the vasospasm treatment.

Effect of cisternal drainage on the shunt dependency following aneurysmal subarachnoid hemorrhage.

Objective Shunt-dependent chronic hydrocephalus (SDCH) is known to be a major complication associated with aneurysmal subarachnoid hemorrhage (aSAH). Old age is known to be one of numerous factors related to the development of SDCH. This study investigated whether postoperative cisternal drainage affects the incidence of SDCH and clinical outcome in elderly patients with aSAH. Methods Fifty-nine patients participated in this study. All patients underwent aneurysmal clipping with cisternal cerebrospinal fluid (CSF) drainage. Clinical variables relevant to the study included age, sex, location of ruptured aneurysm, CT finding and clinical state on admission, clinical outcome, and CSF drainage. We first divided patients into two groups according to age (<70 years of age and ≥70 years of age) and compared the two groups. Secondly, we analyzed variables to find factors associated with SDCH in both groups (<70 years of age and ≥70 years of age). Results Of 59 patients, SDCH was observed in 20 patients (33.9 %), who underwent shunt placement for treatment of hydrocephalus. Forty seven percent of cases of acute hydrocephalus developed SDCH. In the elderly group (≥70 years of age), the duration and amount of CSF drainage did not affect the development of chronic hydrocephalus. Conclusion In elderly patients, although the incidence of SDCH was significantly higher, clinical outcome was acceptable. The duration and the amount of cisternal drainage did not seem to be related to subsequent development of chronic hydrocephalus within elderly patients aged 70 or older.