The Endovascular Management of Saccular Posterior Inferior Cerebellar Artery Aneurysms

송하헌,원유동,김영주,김범수 대한영상의학회 2008 Korean Journal of Radiology Vol.9 No.5

Objective: The purpose of this retrospective study was to report the outcome of the endovascular treatment of eight patients with eight saccular posterior inferior cerebellar artery (PICA) aneurysms. Materials and Methods: Over the last seven years (1999-2006), eight consecutive patients with saccular PICA aneurysms were treated by endovascular methods. Five of the aneurysms were presented with subarachnoid hemorrhaging, whereas three were discovered incidentally. Four of the aneurysms (3 ruptured and 1 incidental) were treated by intrasaccular coiling, whereas the remaining four (1 ruptured and 3 incidental) were treated by vertebral artery (VA) occlusion. Results: Of the four aneurysms treated by intrasaccular coiling, three were completely packed with coils and one was partially packed. In three of four patients who underwent vertebral artery occlusions, follow-up digital subtraction angiographies demonstrated thrombosed aneurysms and PICA. No procedurerelated morbidity occurred and no re-bleed was encountered during a follow-up examination (mean; 31 months). Conclusion: As a result of this study, we found that the endovascular management of saccular PICA aneurysms should be considered as safe and effective. Objective: The purpose of this retrospective study was to report the outcome of the endovascular treatment of eight patients with eight saccular posterior inferior cerebellar artery (PICA) aneurysms. Materials and Methods: Over the last seven years (1999-2006), eight consecutive patients with saccular PICA aneurysms were treated by endovascular methods. Five of the aneurysms were presented with subarachnoid hemorrhaging, whereas three were discovered incidentally. Four of the aneurysms (3 ruptured and 1 incidental) were treated by intrasaccular coiling, whereas the remaining four (1 ruptured and 3 incidental) were treated by vertebral artery (VA) occlusion. Results: Of the four aneurysms treated by intrasaccular coiling, three were completely packed with coils and one was partially packed. In three of four patients who underwent vertebral artery occlusions, follow-up digital subtraction angiographies demonstrated thrombosed aneurysms and PICA. No procedurerelated morbidity occurred and no re-bleed was encountered during a follow-up examination (mean; 31 months). Conclusion: As a result of this study, we found that the endovascular management of saccular PICA aneurysms should be considered as safe and effective.

뇌동맥류에서 용적묘사 기법을 이용한 3차원 전산화단층혈관조영술: 3차원 디지털감산혈관조영술과 비교

신옥란,서정진,이은주,윤웅,정용연,정태웅,김재규,박진균,강형근 대한영상의학회 2004 대한영상의학회지 Vol.50 No.6

Purpose: The author compared three-dimensional computed tomographic angiography with combined volume rendering technique (3D-CTA VR) with three-dimensional digital subtraction angiography (3D-DSA) in the detection and characterization of intracranial aneurysms, in order to assess the diagnostic capability of 3DCTA VR. Materials and Methods: This study included 50 patients with suspected intracranial aneurysm who underwent both 3D-CTA VR and 3D-DSA, and who were subsequently confirmed as having aneurysms by intracranial operation or other neurointerventional procedures. The detectability and the characteristics of the aneurysms, such as their aneurysmal neck, direction, and vasospasm of the adjacent vessels, were evaluated retrospectively. Results: Sixty-five intracranial aneurysms were detected through surgery or other interventional procedures. 3D-DSA was more sensitive (96.92%) than 3D-CTA VR in the detection of the aneurysms. All of the aneurysms that were more than 3mm in size were detected with both techniques. 3D-DSA failed to reveal one posterior communicating artery aneurysm, while 3D-CTA VR missed three aneurysms. The aneurysmal necks were clearly visualized in 58 of 61 aneurysms (95.1%) on 3D-CTA VR, but all of the aneurysmal necks(100%) were clearly identified on 3D-DSA. Conclusion: 3D-CTA combined with VR technique showed good sensitivity for the depiction of intracranial aneurysms greater than 3 mm in size, and its usefulness in characterizing the aneurysms for surgical or endovascular treatment planning was equal to or less than that of 3D-DSA. 목적: 뇌동맥류가 의심된 환자의 뇌동맥류의 평가에서 용적묘사(volume rendering, VR) 기법 을 이용한 3차원 전산화단층혈관조영술(three-dimensional Computed Tomographic angiography, 3D-CTA)의 유용성을 3차원 디지털감산혈관조영시술(three dimensional subtraction angiography, 3D-DSA)과 수술 및 신경 중재적 시술소견과의 비교를 통해 평가하고자 하였 다. 대상과 방법: 뇌동맥류가 의심되어 3D-CTA의 VR기법과 고식적 혈관조영술과 3D-DSA를 함 께 시행하여 중재적 시술 혹은 수술소견을 통해 뇌동맥류로 확진된 50명의 환자를 대상으로 하였다. 두 명의 방사선과 의사가 각각의 영상에서 뇌동맥류를 진단하였고, 뇌동맥류를 발견한 경우 뇌동맥류의 위치, 크기, 경부, 방향을 판단하여 두 가지 기법과 수술및 신경 중재적 시술 소견과의 일치정도를 후향적으로 비교 분석하였다. 결과: 수술 혹은 중재적 시술에서 모두 65예의 뇌동맥류를 발견할 수 있었고 3D-CTA의 VR 기법상 총 61예(93.85%)의 뇌동맥류를 발견할 수 있었으며 3D-DSA에서 65예 중 63예 (96.92%)를 발견할 수 있었다. 3D-CTA의 VR기법과 3D-DSA에서 발견 못했던 2개의 뇌동 맥류는 후교통동맥과 중대뇌동맥의 2 mm의 뇌동맥류였다. 경부모양 확인이 가능하였던 경우 는 3D-CTA의 VR기법에서 61예중 58예(95.1%), 3D-DSA상 전부(63예중 63예, 100%)로 3D-DSA가 약간 더 우수하였으며, 뇌동맥류의 방향은 3D-CTA의 VR 기법이나 3D-DSA에 서 각각 발견된 경우는 의무 기록지의 수술 및 중재적 시술소견과 일치하였다. 결론: 3D-CTA의 VR기법은 뇌동맥류의 치료전 진단에 있어서 3D-DSA의 역할을 완전히 대 체 할 수 없지만 비침습적인 방법으로 뇌동맥류의 발견, 크기 및 경부의 모양, 방향에 대하여 정확하게 파악할 수 있으며 뇌동맥류 주위 혈관상태를 평가할 수 있어 수술 및 중재적 혈관치 료를 위한 계획 수립에 중요한 정보를 제공할 수 있는 유용한 방법이라고 생각한다.

Characteristics and Treatment Outcome of Intracranial Aneurysms in Children and Adolescents

Nam, Sun Mo,Jang, Donghwan,Wang, Kyu-Chang,Kim, Seung-Ki,Phi, Ji Hoon,Lee, Ji Yeoun,Cho, Won-Sang,Kim, Jeong Eun,Kang, Hyun-Seung The Korean Neurosurgical Society 2019 Journal of Korean neurosurgical society Vol.62 No.5

Objective : Intracranial aneurysms are not common in young age patients. We sought to find the characteristics of the intracranial aneurysms in patients under 20 years of age. Methods : We reviewed 23 consecutive patients ${\leq}20$ years of age treated for their intracranial aneurysms during the period from 1995 to 2017. From medical records and imaging studies, we gathered data on age, sex, presentation, associated medical condition, location and characteristics of aneurysms, treatment and clinical outcomes. Results : The patients' ages ranged from 13 months to 20 years (median, 14 years). There were 16 males and seven females (male to female ratio, 2.3 : 1) with 31 aneurysms. Clinical presentations included sudden severe headache in 61%, followed by altered mentality in 17% and seizure in 17%. More than one-fourth patients had specific medical conditions related to the development of the cerebral aneurysms. The majority of aneurysms occurred in the anterior circulation (71%), and were saccular (71%). There were each three patients with false aneurysms (13%) and giant aneurysms (13%), and only one patient with multiple aneurysms (4%). We treated 22 patients : 21 aneurysms with the endovascular methods, three with open surgery, and one with combined treatment. Good functional outcome could be achieved in 86% during the follow-up period. Conclusion : In this series, the young-age patients with intracranial aneurysms were characterized by male predominance, related specific medical conditions, low incidence of multiple aneurysms, high incidence of giant aneurysms and good functional outcome after treatment.

후순환계 뇌동맥류의 수술적 치료

허원,이동열 대한신경외과학회 1996 Journal of Korean neurosurgical society Vol.25 No.1

Aneurysms arising from the posterior circulation are·5-10% of total intracranial aneurysms. Although many neurosurgeons have challended with various innovations but the confined surgical space, complicated anatomical structure and many small perforators to vital organ of brain were remained the barrier that we have to overcome. From July 1987 to December 1994, we have been operated on 23 cases of posterior circulation aneurysms among 409 cases of surgically treated all intracranial aneurysms. The present 5.6% of all intracranial aneurysm, the average age of these patients was 49 years old. The ratio of male to female was 1 : 1.8. The number of basilar bifurcation artery aneurysms(BBAA) were 14(61%), the posterior cerebral artery(PCA) aneurysms3(13%), the upper basilar trunk aneurysm 1, posterior inferior cerebellar artery (PICA) aneurysm 3(13%), anterior inferior cerebellar artery(AICA) aneurysm 1 and vertebral artery aneurysm 1. Five patients had accompanined with anterior circulation aneurysm and one patient had concomitant arteriovenous malformation. We have successfully clipped 12 cases and wrapped 2 cases of BBAA aneurysms through modified pterional approach and subtemporal approach according to the hight of basilar bifurcation and the other posterior circulation aneurysms are all clipped through most available approaches including lateral, far-lateral suboccipital and interhemispheric approach. Surgical outcome was good in 15 cases, fair in 4 cases, poor in 3 cases and one patient expired.

Management of Aneurysms of the Proximal (A1) Segment of the Anterior Cerebral Artery

박현석,최재형,강명진,허재택 대한뇌혈관외과학회 2013 Journal of Cerebrovascular and Endovascular Neuros Vol.15 No.1

Objective:Aneurysms originating from the proximal segment (A1) of the anterior cerebral artery are rare; however, because of their small size, the risk of injury of perforating arteries, and the location of the aneurysm in the surgical field, they are challenging to treat. We report on 15 patients with A1 aneurysms and review surgical views according to the direction of aneurysms. Methods:Fifteen patients were diagnosed with A1 aneurysms and underwent surgical clipping or endovascular coiling at our institution between January 2006 and March 2012. We conducted a retrospective review of clinical and radiological features of all patients with A1 aneurysms. Results:Nine patients underwent surgical clipping, and six patients received endovascular coiling. Six patients (40%) had multiple aneurysms. A1 aneurysms ranged in size from 1.5 to 8.2 mm, with an average size of 3.26 mm. Most A1 aneurysms (73%) had a posterior direction. In the surgical view, A1 aneurysms projecting posteriorly were located behind the A1 trunk. The A1 aneurysm projecting posteroinferiorly was completely eclipsed by the parent artery. In A1 aneurysms with a posterosuperior or superior direction, finding and clipping the aneurysm neck was relatively easy. Thirteen patients (87%) had an excellent outcome, one had moderate disability, and one died. Conclusion:A1 aneurysms have certain characteristics; small size, multiple aneurysms, and, usually, a posterior direction. A1 aneurysms with a posterosuperior or superior direction are relatively easy to assess, however, clipping of A1 aneurysms with a posterior or posteroinferior direction is more difficult. Endovascular coiling is an alternative therapeutic option when surgical clipping is expected to be difficult.

Feasibility & Limitations of Endovascular Coil Embolization of Anterior Communicating Artery Aneurysms

Hwang, Sung-Kyun,Benitez, Ronald,Veznedaroglu, Erol,Rosenwasser, Robert H. The Korean Neurosurgical Society 2005 Journal of Korean neurosurgical society Vol.38 No.2

Objective : The purpose of this study is to analyze aneurysm morphology and define limitations and feasibility in endovascular Gugliemi detachable coil[GDC] embolization for anterior communicating artery [ACoA] aneurysms. Methods : From January 2000 through October 2003, 123patients were treated with endovascular coil embolization for ACoA aneurysms. There were 75women and 48men, with a mean age of 63years. All ruptured aneurysms were treated within 15days of rupture. Aneurysm morphology was classified according to neck size and projection of aneurysm dome as follows-A : neck of aneurysm <4mm & anterior projection, B : neck of aneurysm [4mm & anterior projection, C : neck of aneurysm<4mm & posterior [superior] projection, D : neck of aneurysm [4mm & posterior [superior] projection, E : neck of aneurysm<4mm & inferior projection, and F : neck of aneurysm [4mm & inferior projection. Endovascular procedures were categorized as either "successful" or "unsuccessful". Clinical follow-up was estimated at discharge and at 6months, post treatment results were classified according to Glasgow Outcome Scale[GOS]. Results : Successful embolization for ACoA was performed in 86patients of 123patients [69.9%]. Complete or near complete aneurysm occlusion was observed in 102patients [82.9%]; a neck remnant was observed in 6patients [4.9%]; partial embolization was done in 3patients [2.4%]; and embolization was attempted in 12patients [9.8%]. Among 55patients with follow-up angiographic results, 18patients [32.7%] were defined as recanalization of the aneurysm sac. Morphological analysis demonstrated that anterior projecting aneurysms and morphological classifications [morphological classifications worsens [A - D] chances of successful coil occlusion significantly decrease] were major factors in successful embolization, and, inferiorly projecting and wide neck [${\ge}4mm$] aneurysms are highly related to recanalization of aneurysms. Conclusion : Endovascular coil embolization of ACoA aneurysms shows good outcome in our study. Nevertheless, there is a limitation in the endovascular approach to ACoA, even though advanced modern techniques evolve rapidly. Compensatory surgical approach with the endovascular approach is required for successful treatment of ACoA aneurysms.

뇌동맥류에서 혈관형성 인자와 혈관벽 기질 단백에 대한 면역조직화학적 연구

김재홍,임만빈,이창영,김상표,Kim, Jae Hong,Yim, Man Bin,Lee, Chang Young,Kim, Sang Pyo 대한신경외과학회 2000 Journal of Korean neurosurgical society Vol.29 No.12

Objective : Until now, it has been little known about the biological mechanisms associated with the genesis, growth, and rupture of intracranial aneurysm. This study was performed to investigate and understand a part of these mechanisms. Materials and Methods : Immunohistochemical stains for angiogenesis growth factors(basic fibroblast growth factor (bFGF) and vascular endothelial growth factor(VEGF)) and selected vascular wall matrix proteins(alpha smooth muscle actin(${\alpha}SMA$) and collagen Type IV) were performed in fixed sections from a normal circle of Willis artery which was taken from the autopsy specimen as a control vessel and 17 aneurysmal wall specimens which was taken during surgical clipping of aneurysms. The staining intensity and distribution of immunoreactivity to angiogenesis growth factors and selected wall matrix proteins in control vessel and aneurysmal wall were examined and compared with each other. The difference of staining intensity according to the size of aneurysm was also investigated. Results : There was no immunoreactivity to bFGF and VEGF in the control vessel. bFGF immunoreactivity was exhibited in 15 of 17 aneurysm specimens around smooth muscle cells within the media of aneurysm. VEGF immunoreactivity was also exhibited in all aneurysm specimens in patches or diffusely affecting all layers of the aneurysmal wall. The degrees of intensity of bFGF and VEGF immunoexpression were proportionate roughly to the size of aneurysm. Strong immunoexpression of both factors were noticed in large aneurysm. A regularly arranged and defined band of immunoreactivity of ${\alpha}SMA$ was noticed in the media of the control vessel, whereas diffuse, faint, irregularly arranged ${\alpha}SMA$ was noticed in the aneurysmal wall. A regularly defined band of collagen Type IV immunoreactivity was also noticed in the subendothelium of the control vessel, whereas diffuse disorganized immunoreactivity of collagen Type IV was noticed in the entire wall of the aneurysm. Conclusion : These results indicate substantial evidences of abnormal expression of angiogenesis factors and changes of selected vascular wall matrix proteins in the wall of intracranial aneurysm. The unbalanced changes of angiogenesis factors and vascular wall matrix proteins in the wall of aneurysm may be one of the biological mechanisms for the growth and rupture of aneurysm.

Guglielmi 분리코일을 이용한 뇌동맥류의 혈관내 치료

정해웅,은충기,심재홍 인제대학교 백병원 2002 仁濟醫學 Vol.23 No.5

Purpose : To analyze the result in the treatment of intracranial aneurysms by using Gughelmi detachable coils(GDCs). Materials and methods : We reviewed 29 intracranial aneurysms in 27 patients attempted by GDCs embolization between March 2002 to February 2003. There were 8 males and 19 females, who ranged in age from 18 to 71 years(mean age 52.5 years). 15 patients(55.6%) presented with hemorrhage, 8 patients(29.6%) with incidental finding, and 4 patients(14.8%) with nonhemorrhagic symptom. This series consisted of small(<12mm), and three large(12∼25mm) aneurysms. Aneurysm neck size divided into narrow-(8 cases) and wide-necked(>4mm or neck/aneurysm ratio>0.5, 21cases) aneurysms. Of the 15 patients in whom hemorrhage occurred, 3(20%) presented with Hunt and Hess Grade Ⅱ, 11(73.3%) with Grades Ⅲ and 1(6.7%) with Grades Ⅵ. The locations of the aneurysms were basilar bifurcation(9 cases), parachinoid internal carotid artery(4 cases), posterior communicating artery(4 cases), superior cerebellar artery, posterior inferior cerebellar artery, P2 segment of posterior cerebral artery, cavernous internal carotid artery(2 cases), vertebrobasilar junction, vertebral artery dissection, M1 segment of middle cerebral artery, anterior communicating artery, internal carotid artery bifurcation, and supraclinoid internal carotid artery(1case). Indications for use of the GDCs were location and surgical difficulty(15, 51.7%), surgeon's preference(4, 13.8%) and unruptured condition(10, 34.5%). Results : Of the 29 aneurysms attempted by GDC embolization, 25 aneurysms were successfully treated. The technical success rate was 86.2% (25/29). The causes of technical failure were aneurysm with wide neck in 3 cases and parent vessel tortuousity in 1 case. The length of clinical follow up ranged from 0 to 11 months(average, 4.9 months). In 19(76%) patients, good clinical outcomes were achieved. There were 4 fair outcomes (16%) and 1 poor outcome(4%) due to initial severe hemorrhage. One death(3.7%) were recorded due to ventriculitis and other medical problems. The mortality and morbidity rates directly related to the intervention were 0% and 6.9%, respectively. Angiographic studies were obtained immediately after intervention. Complete or almost complete(99∼100%) occlusion were observed in 19 cases(76%), a greater than 90% occlusion was seen in 4 cases(16%) and a less than 90% occlusion was seen in 2 cases(8%). Technical complications were observed in 5 cases(17.2%) including aneurysm perforation in 1 case, unintentional parent artery occlusion in 1 case, and coil protrusion in 3 cases. Follow-up angiograms were obtained in 4 patients between 6 to 7 months(average 6.8 months) after coil placement. Angiographic recanalization was not seen in all cases and there was no significant interval change compared with immediate postintervention angiography. Conclusion : Endovascular treatment of incranial aneurysms by using GDCs led to excellent clinical and angiographic results in majority of patients. Long-term follow-up studies are necessary to assess effectively the value of GDCs as definitive treatment for intracranial aneurysms.

Wall Shear Stress and Flow Patterns in Unruptured and Ruptured Anterior Communicating Artery Aneurysms Using Computational Fluid Dynamics

Lee, Ui Yun,Jung, Jinmu,Kwak, Hyo Sung,Lee, Dong Hwan,Chung, Gyung Ho,Park, Jung Soo,Koh, Eun Jeong The Korean Neurosurgical Society 2018 Journal of Korean neurosurgical society Vol.61 No.6

Objective : The goal of this study was to compare several parameters, including wall shear stress (WSS) and flow pattern, between unruptured and ruptured anterior communicating artery (ACoA) aneurysms using patient-specific aneurysm geometry. Methods : In total, 18 unruptured and 24 ruptured aneurysms were analyzed using computational fluid dynamics (CFD) models. Minimal, average, and maximal wall shear stress were calculated based on CFD simulations. Aneurysm height, ostium diameter, aspect ratio, and area of aneurysm were measured. Aneurysms were classified according to flow complexity (simple or complex) and inflow jet (concentrated or diffused). Statistical analyses were performed to ascertain differences between the aneurysm groups. Results : Average wall shear stress of the ruptured group was greater than that of the unruptured group (9.42% for aneurysm and 10.38% for ostium). The average area of ruptured aneurysms was 31.22% larger than unruptured aneurysms. Simple flow was observed in 14 of 18 (78%) unruptured aneurysms, while all ruptured aneurysms had complex flow (p<0.001). Ruptured aneurysms were more likely to have a concentrated inflow jet (63%), while unruptured aneurysms predominantly had a diffused inflow jet (83%, p=0.004). Conclusion : Ruptured aneurysms tended to have a larger geometric size and greater WSS compared to unruptured aneurysms, but the difference was not statistically significant. Flow complexity and inflow jet were significantly different between unruptured and ruptured ACoA aneurysms.

Endovascular treatment of residual or recurrent intracranial aneurysms after surgical clipping

da Silva Júnior Nilton Rocha,Trivelato Felipe Padovani,Nakiri Guilherme Seizem,Rezende Marco Túlio Salles,de Castro-Afonso Luís Henrique,Abud Thiago Giansante,Vanzin José Ricardo,Manzato Luciano Bambi 대한뇌혈관외과학회 2021 Journal of Cerebrovascular and Endovascular Neuros Vol.23 No.3

Objective Total aneurysm occlusion is crucial for the prevention of rebleeding of a ruptured aneurysm or to avoid rupture of an unruptured lesion. Both surgical and endovascular embolization fail to achieve complete aneurysm occlusion in all the cases. The objective of the study was to establish the safety and efficacy of endovascular treatment for previously clipped residual or recurrent aneurysms. Methods This was an observational, retrospective study of patients harboring incompletely occluded intracranial aneurysms after clipping who underwent endovascular treatment. Patients were treated using 4 different techniques: (1) simple coiling, (2) balloon remodeling, (3) stent-assisted coiling, and (4) flow diversion. Analyses were performed to identify predictors of total aneurysm occlusion, recanalization and complications. Results Between May 2010 and September 2018, 70 patients harboring incompletely occluded intracranial aneurysms after clipping met the inclusion criteria in 5 centers. The mean residual aneurysm size was 7.5 mm. Fifty-nine aneurysms were unruptured. Total aneurysm occlusion was achieved in 75.3% of the aneurysms after 1 year. All aneurysms treated with flow diversion revealed complete occlusion according to control angiography. Recanalization was observed in 14.5%. Permanent morbidity and mortality occurred in 2.9% and 1.4% of the patients, respectively. Conclusions Endovascular treatment of recurrent or residual aneurysms after surgical clipping was safe and efficacious. Flow diversion seems to be associated with better anatomical results. A more rigid study, a larger group of patients, and long-term follow-up are required to provide stronger conclusions about the best approach for residual clipped aneurysms.