Jin-Yang Joo

Clinical Risk Factors Affecting Procedure-Related Major Neurological Complications in Unruptured Intracranial Aneurysms

Purpose The operative risk and natural history rupture risk for the treatment of unruptured intracranial aneurysms (UIAs) should be evaluated. The purpose of this study was to report our experience with treating UIAs and to outline clinical risk factors associated with procedure-related major neurological complications. Materials and Methods We treated 1158 UIAs in 998 patients over the last 14 years. All patients underwent operation performed by a single microvascular surgeon and two interventionists at a single institution. Patient factors, aneurysm factors, and clinical outcomes were analyzed in relation to procedure-related complications. Results The total complication rate was 22 (2.2%) out of 998 patients. Among them, complications developed in 14 (2.3%) out of 612 patients who underwent microsurgery and in 8 (2.1%) out of 386 patients who underwent endovascular procedures. One patient died due to intraoperative rupture during an endovascular procedure. The procedure-related complication was highly correlated with age (p=0.004), hypertension (p=0.002), and history of ischemic stroke (p<0.001) in univariate analysis. The multivariate analysis revealed previous history of ischemic stroke (p=0.001) to be strongly correlated with procedure-related complications. Conclusion A history of ischemic stroke was strongly correlated with procedure-related major neurological complications when treating UIAs. Accordingly, patients with UIAs who have a previous history of ischemic stroke might be at risk of procedure-related major neurological complications.

Benefits of Surgical Treatment for Unruptured Intracranial Aneurysms in Elderly Patients

OBJECTIVE Due to longer life spans, patients newly diagnosed with unruptured intracranial aneurysms (UIAs) are increasing in number. This study aimed to evaluate how management of UIAs in patients age 65 years and older affects the clinical outcomes and post-procedural morbidity rates in these patients. METHODS We retrospectively reviewed 109 patients harboring 136 aneurysms across 12 years, between 1997 and 2009, at our institute. We obtained the following data from all patients : age, sex, location and size of the aneurysm(s), presence of symptoms, risk factors for stroke, treatment modality, and postoperative 1-year morbidity and mortality. We classified these patients into three groups : Group A (surgical clipping), Group B (coil embolization), and Group C (observation only). RESULTS Among the 109 patients, 56 (51.4%) underwent clipping treatment, 25 (23%) patients were treated with coiling, and 28 observation only. The overall morbidity and mortality rates were 2.46% and 0%, respectively. The morbidity rate was 1.78% for clipping and 4% for coiling. Factors such as hypertension, diabetes mellitus, hypercholesterolemia, smoking, and family history of stroke were correlated with unfavorable outcomes. Two in the observation group refused follow-up and died of intracranial ruptured aneurysms. The observation group had a 7% mortality rate. CONCLUSION Our results show acceptable favorable outcome of treatment-related morbidity comparing with the natural history of unruptured cerebral aneurysm. Surgical clipping did not lead to inferior outcomes in our study, although coil embolization is generally more popular for treating elderly patients. In the treatment of patients more than 65 years old, age is not the limiting factor.

Borderline basal ganglia hemorrhage volume: patient selection for good clinical outcome after stereotactic catheter drainage

OBJECTIVE The purpose of this study was to determine predisposing factors for good clinical outcome in patients with spontaneous basal ganglia hemorrhage with borderline volumes (defined as a hematoma volume between 20 and 50 cm3) who had undergone treatment by stereotactic catheter drainage. METHODS From the 298 patients whose information had been prospectively collected in the institutional database between January 2010 and December 2013, 93 patients were included in this retrospective study and divided into 2 groups: best medical treatment alone (Group A, n = 44) and best medical treatment plus catheterization (Group B, n = 49). All patients met the following criteria: 1) a diagnosis of spontaneous basal ganglia hemorrhage, and 2) a borderline hematoma volume (20 to 50 cm3). Postoperative modified Rankin Scale (mRS) scores and recovery of motor weakness were compared between the 2 groups, and predisposing factors for good clinical outcome were evaluated. RESULTS Patients in Group B showed earlier recovery of motor weakness and improved mRS scores than patients in Group A. The final mRS score at 12 months was better in Group B than in Group A (p = 0.006). Predisposing factors for a good clinical outcome were a hematoma volume < 30 cm3 (OR 6.158, 95% CI 1.221-31.053, p = 0.028), an initial Glasgow Coma Scale (GCS) score ≥ 13 (OR 6.331, 95% CI 1.129-35.507, p = 0.036), the absence of internal capsule involvement (OR 4.680, 95% CI 1.152-19.010, p = 0.031), and catheterization (OR 13.376, 95% CI 2.423-73.842, p = 0.003) based on logistic regression analysis. CONCLUSIONS Good clinical outcome can be expected after stereotactic catheter drainage in patients with a hematoma volume between 20 and 30 cm3, an initial GCS score ≥ 13, and the absence of internal capsule involvement. Among these patients, stereotactic catheter drainage may have a beneficial effect on early recovery of motor weakness and functional outcome, indicating that lateral-type basal ganglia hematoma compression not involving the internal capsule may be better treated using stereotactic catheter drainage than treated medically.

Incidence and Risk Factors for Rebleeding during Cerebral Angiography for Ruptured Intracranial Aneurysms

Purpose The purpose was to evaluate the incidence and risk factors for rebleeding during cerebral angiography in ruptured intracranial aneurysms. Materials and Methods Among 1896 patients with ruptured intracranial aneurysms between September 2006 and December 2013, a total of 11 patients who experienced rebleeding of the ruptured aneurysms during digital subtraction angiography (DSA) were recruited in this study. Results There were 184 patients (9.7%) who had suffered rebleeding prior to the securing procedure. Among them, 11 patients experienced rebleeding during DSA and other 173 patients at a time other than DSA. Eight (72.7%) of the 11 patients experienced rebleeding during three-dimensional rotational angiography (3DRA). The incidence of rebleeding during DSA was 0.6% in patients with ruptured intracranial aneurysms. Multivariate logistic regression analysis showed that aneurysm location in anterior circulation [odds ratio=14.286; 95% confidence interval (CI), 1.877 to 250.0; p=0.048] and higher aspect ratio (odds ratio=3.040; 95% CI, 1.896 to 10.309; p=0.041) remained independent risk factors for rebleeding during DSA. Conclusion Ruptured aneurysms located in anterior circulation with a high aspect ratio might have the risk of rebleeding during DSA, especially during 3DRA.

The Course of Headache in Patients With Moderate-to-Severe Headache Due to Aneurysmal Subarachnoid Hemorrhage: A Retrospective Cross-Sectional Study

The purpose of this study was to evaluate the course of headache in patients with moderate‐to‐severe headache due to aneurysmal subarachnoid hemorrhage (aSAH) and to identify its predisposing factors.

Headache After Cerebral Angiography: Frequency, Predisposing Factors, and Predictors of Recovery

Headache after cerebral angiography is frequent but has received little attention. The purpose of this study was to evaluate the incidence and risk factors of headache after cerebral angiography. This study also addressed the predisposing factors that facilitate headache recovery.

Characteristics and Management of Residual or Slowly Recurred Intracranial Aneurysms

OBJECTIVE Residual aneurysm from incomplete clipping or slowly recurrent aneurysm is associated with high risk of subarachnoid hemorrhage. We describe complete treatment of the lesions by surgical clipping or endovascular treatment. METHODS We analyzed 11 patients of residual or recurrent aneurysms who had undergone surgical clipping from 1998 to 2009. Among them, 5 cases were initially clipped at our hospital. The others were referred from other hospitals after clipping. The radiologic and medical records were retrospectively analyzed. RESULTS All patients presented with subarachnoid hemorrhage at first time, and the most frequent location of the ruptured residual or recurrent aneurysm was in the anterior communicating artery to posterior-superior direction. Distal anterior cerebral artery, posterior communicating artery, and middle cerebral artery was followed. Repositioning of clipping in eleven cases, and one endovascular treatment were performed. No residual aneurysm was found in postoperative angiography, and no complication was noted in related to the operations. CONCLUSION These results indicate the importance of postoperative or follow up angiography and that reoperation of residual or slowly recurrent aneurysm should be tried if such lesions being found. Precise evaluation and appropriate planning including endovascular treatment should be performed for complete obliteration of the residual or recurrent aneurysm.

Effects of Prophylactic Antiepileptic Drugs on Clinical Outcomes in Patients with a Good Clinical Grade Suffering from Aneurysmal Subarachnoid Hemorrhage

Objective Routine use of prophylactic antiepileptic drugs (AED) has been debated. We retrospectively evaluated the effects of prophylactic AED on clinical outcomes in patients with a good clinical grade suffering from aneurysmal subarachnoid hemorrhage (aSAH). Materials and Methods Between September 2012 and December 2014, 84 patients who met the following criteria were included: (1) presence of a ruptured aneurysm; (2) Hunt-Hess grade 1, 2, or 3; and (3) without seizure presentation. Patients were divided into two groups; the AED group (n = 44) and the no AED group (n = 40). Clinical data and outcomes were compared between the two groups. Results Prophylactic AEDs were used more frequently in patients who underwent microsurgery (84.1%) compared to those who underwent endovascular surgery (15.9%, p < 0.001). Regardless of prophylactic AED use, seizure episodes were not observed during the six-month follow-up period. No statistical difference in clinical outcomes at discharge (p = 0.607) and after six months of follow-up (p = 0.178) were between the two groups. After six months, however, favorable outcomes in the no AED group tended to increase and poor outcomes tended to decrease. Conclusion No difference in the clinical outcomes and systemic complications at discharge and after six months of follow-up was observed between the two groups. However, favorable outcomes in the no AED group showed a slight increase after six months. These findings suggest that discontinuation of the current practice of using prophylactic AED might be recommended in patients with a good clinical grade.

Radiographic and microsurgical characteristics of proximal (A1) segment aneurysms of the anterior cerebral artery

BackgroundProximal A1 segment aneurysms of the anterior cerebral artery (ACA) radiologically resemble internal carotid artery bifurcation (ICBIF) aneurysms because of their anatomical proximity. However, proximal A1 aneurysms exhibit distinguishing features, relative to ICBIF aneurysms. We report our experience of managing proximal A1 aneurysms, then compare them to ICBIF aneurysms.MethodsAmong 2191 aneurysms treated between 2000 and 2016 in a single institution, we retrospectively reviewed 100 cases categorized as ICBIF or A1 aneurysms. We included aneurysms originating from the ICBIF and ACA, proximal to the anterior communicating artery (A1 segment) and divided them into two groups: proximal A1 (n = 32) and ICBIF (n = 50). If any portion of the aneurysm involved the ICBIF, it was classified as ICBIF. Aneurysms wholly located in the A1 segment were classified as proximal A1. Patient factors and angiographic factors were evaluated and compared.ResultsThe proximal A1 group exhibited differences in aneurysm size (p = 0.013), posterior aneurysm direction (p = 0.001), and A1 perforators as incorporating vessels (p = 0.001). The proximal A1 group tended to rupture more frequently when the aneurysm was smaller (p = 0.046). One case of morbidity occurred in the proximal A1 group.ConclusionCompared to ICBIF aneurysms, proximal A1 aneurysms were smaller and directed posteriorly, with incorporating perforators. Because of these characteristics, it may be difficult to perform clipping with 360° view in microsurgical field. Therefore, when planning to treat proximal A1 aneurysms, different treatment strategies may be necessary, relative to those used for ICBIF aneurysms.

Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage After Clipping of an Unruptured Aneurysm

BACKGROUND Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage with an excellent clinical outcome. The cause of PNSAH remains unknown. We report a case of PNSAH in a patient with a history of clipping of an unruptured aneurysm. PNSAH after clipping of an unruptured aneurysm is extremely rare. CASE DESCRIPTION A 56-year-old man with a history of clipping surgery for an unruptured aneurysm 10 months previously presented with severe headache. No precipitating causes were shown; however, the patient had been engaged in an exertional activity before the event. After conservative treatment, he was discharged home without any complication from the hemorrhage. CONCLUSIONS On the basis of this case report, clinicians should consider the possibility of PNSAH in a patient who had an unruptured aneurysm previously treated with clipping. Nevertheless, diagnostic workup can be more important than keeping in mind that a subarachnoid hemorrhage might be a PNSAH.