Indocyanine Green Videoangiography for Confirmation of Bypass Graft Patency

Schuette, Albert J.,Dannenbaum, Mark J.,Cawley, Charles M.,Barrow, Daniel L. The Korean Neurosurgical Society 2011 Journal of Korean neurosurgical society Vol.50 No.1

Objective : The aim of the study is to determine the efficacy of indocyanine green (ICG) videoangiography for confirmation of vascular anastomosis patency in both extracranial-intracranial and intracranial-intracranial bypasses. Methods : Intraoperative ICG videoangiography was used as a surgical adjunct for 56 bypasses in 47 patients to assay the patency of intracranial vascular anastomosis. These patients underwent a bypass for cerebral ischemia in 31 instances and as an adjunct to intracranial aneurysm surgery in 25. After completion of the bypass, ICG was administered to assess the patency of the graft. The findings on ICG videoangiography were then compared to intraoperative and/or postoperative imaging. Results : ICG provided an excellent visualization of all cerebral arteries and grafts at the time of surgery. Four grafts were determined to be suboptimal and were revised at the time of surgery. Findings on ICG videoangiography correlated with intraoperative and/or postoperative imaging. Conclusion : ICG videoangiography is rapid, effective, and reliable in determining the intraoperative patency of bypass grafts. It provides intraoperative information allowing revision to reduce the incidence of technical errors that may lead to early graft thrombosis.

Intracranial Dissemination from Spinal Cord Anaplastic Astrocytoma

Jeong, Seong-Man,Chung, Yong-Gu,Lee, Jang-Bo,Shin, Il-Young The Korean Neurosurgical Society 2010 Journal of Korean neurosurgical society Vol.47 No.1

We report a case of intracranial dissemination developing approximately 4 months after partial removal of a spinal cord anplastic astrocytoma in a 22-year-old male. He presented with paraplegia on initial admission at a local hospital. Spinal magnetic resonance (MR) images disclosed multiple intramedullary lesions at the T3-11. The tumor was partially removed. The final histologic diagnosis was anaplastic astrocytoma. Four months after the operation, he was admitted with the symptoms of headache and deterioration of consciousness. MR images showed enhanced lesions in the anterior horn of the left lateral ventricle, and septum pellucidum. He underwent computed tomography-guided stereotactic biopsy and histological appearance was consistent with anaplastic astrocytoma. The clinical course indicates that the tumor originated in the spinal cord and extended into the subarachnoid space, first the spinal canal and later intracranial.

Plasma total homocysteine and the methylenetetrahydrofolate reductase 677C>T polymorphism do not contribute to the distribution of cervico‐cerebral atherosclerosis in ischaemic stroke patients

Oh, S‐,H.,Kim, N‐,K.,Kim, H‐,S.,Kim, W‐,C.,Kim, O‐,J. Blackwell Publishing Ltd 2011 European Journal of Neurology Vol.18 No.3

<P><B>Objective: </B> To evaluate the effects of plasma total homocysteine (tHcyt) and the MTHFR 677C>T polymorphism on determining the intracranial‐ (IC) and extracranial (EC) locations of atherosclerosis.</P><P><B>Methods: </B> Brain MR angiography was performed on 463 patients with symptomatic ischaemic stroke to detect significant atherosclerosis (more than 50% stenosis of vessel diameter) in the IC‐ and EC arteries. Relationships between IC‐ or EC atherosclerosis and plasma tHcyt level and/or MTHFR 677C>T genotypes were analyzed after adjusting for vascular risk factors.</P><P><B>Results: </B> The odd ratios (ORs) of plasma tHcyt were not significantly higher in patients with either IC‐ or EC atherosclerosis than in patients with no atherosclerosis. When the study subjects were stratified into three subgroups according to their plasma tHcyt levels, neither the crude ORs nor adjusted ORs of each IC‐ and EC atherosclerosis in highest and middle plasma tHcyt tertile were significantly different from those in lowest plasma tHcyt tertile. The ORs of the MTHFR 677TT genotype in IC‐ and EC atherosclerosis were not significantly different from those in no atherosclerosis. There was no dose‐dependent effect of MTHFR 677T allele on either IC‐ or EC atherosclerosis.</P><P><B>Conclusion: </B> Plasma tHcyt level and the MTHFR 677C>T polymorphism do not contribute to the distribution of cervico‐cerebral atherosclerosis in ischaemic stroke patients.</P>

Intracranial Atherosclerosis: Incidence, Diagnosis and Treatment

Kim, Jong S.,Kang, Dong-Wha,Kwon, Sun U. Korean Neurological Association 2005 Journal of Clinical Neurology Vol.1 No.1

<P>Intracranial atherosclerosis is considered a cause of approximately 8% of all strokes in the western society. However, its frequency is much higher in Asian countries. In our hospital-based study, among the patients who had angiographic abnormalities, the frequency of intracranial atherosclerosis was approximately 70% far exceeding that of extratracranial atherosclerosis. Symptomatic atherosclerotic diseases were most often found in the middle cerebral artery. Generally, it has been shown that obesity and hyperlipidemia are related to extracranial diseases while advance hypertension is associated with intracranial diseases. However, these results have not always been replicated, and certain genetic factors may be related with the ethnic differences in the location of atherosclerosis. Recent studies using diffusion weighted MRI showed that the main mechanisms of stroke in patients with intracranial atherosclerosis are the branch occlusion, artery to artery embolism and both. The intracranial stenosis, especially symptomatic one, is not a static condition and may progress or regress in a relatively short period of time. Progressive stenosis of intracranial arteries is clearly related to the development of ischemic events. The annual risk of stroke relevant to the stenosed intracranial vessel is approximately 8%. In retrospective studies including ASID, anticoagulation was found to be superior to aspirin in reducing the stroke events. However, a recent prospective study failed to confirm the superiority of anticoagulation over aspirin in patients with intracranial stenosis. Moreover, anticoagulation resulted in excessive central nervous system bleeding as compared to aspirin. Because aspirin alone seems to be insufficient in the prevention of progression of intracranial stenosis, a combination of antiplatelets has been tried. Recently, we found that a combination of aspirin + cilostazol was superior to aspirin monotherapy in the prevention of progression of symptomatic intracranial stenosis. However, further studies are required to find out the best combination of antiplatelets for symptomatic intracranial stenosis. The effect of other atheroma stabilizers such as statins should also be properly evaluated. Angioplasty/stent is another important option for the relatively severe intracranial stenosis. According to previous studies, immediate success rate has reached up to 90%. If patients are carefully selected, and procedures done by experienced hand, angioplasty/stent can be of benefit especially in relatively young patients with proximal, short-segment, severe symptomatic stenosis. However, this procedure is not without complications or long-term re-stenosis. Further studies are required to elucidate the best therapeutic strategy in patients with intracranial atherosclerosis.</P>

두개내 저혈압에서 두개내 고혈압으로의 진행을 안과적으로 진단한 증례

이지영(Jiyoung Lee),정연웅(Yeon Woong Chung) 대한검안학회 2021 Annals of optometry and contact lens Vol.20 No.3

목적: 양안 복시로 안과 내원한 환자에서 두개내 고혈압을 진단하고 그 선행 원인이 역설적으로 두개내 저혈압으로 인한 경막하혈종이었던 환자를 보고하고자 한다. 증례요약: 기저질환 고혈압이 있으며, 2개월 전 특발성 두개내 저혈압 진단 받은 29세 남자가 4일 전부터 시작된 양안 복시로 내원하였다. 양안 시력은 정상, 상대적 구심동공운동장애는 없었고, 시신경유두부종, 우측 제육뇌신경마비 소견, 좌안 시야검사에서 맹점확장 소견이 보여 두개내 고혈압을 생각할 수 있었다. 그러나 원인 감별을 위해 시행한 뇌컴퓨터단층촬영에서 최소 2-3주 지난 경막하혈종이 발견되어 두개내 저혈압의 합병증으로 발생한 경막하혈종이 순차적으로 두개내 고혈압을 일으켰을 가능성이 제기되었다. 결론: 두통을 동반한 두개내 고혈압으로 입원한 환자에서 뇌척수압이 감소되어 두개내 저혈압 발생으로 기존 두통이 지속된 증례는 있으나, 이와 반대로 두통이 지속된 두개내 저혈압 환자에서 두개내 고혈압으로 진행한 상황과 이를 안과적으로 처음 진단한 경우는 아직까지 보고된 바가 없어 본 증례를 보고하는 바이다. Purpose: To report a case of a 29-year-old binocular-diplopia patient diagnosed with intracranial hypertension, caused by a subdural hematoma due to intracranial hypotension. Case summary: A 29-year-old male hypertensive patient, diagnosed 2 months previously with idiopathic intracranial hypotension, presented to an ophthalmologist with a 4-day history of binocular diplopia. Visual acuity was 1.0/0.63 (1.0) without relative afferent pupillary defects. There was bilateral papilledema, right 6th cranial nerve palsy, and blind spot enlargement in visual field examinations, suggestive of intracranial hypertension. Computer tomography of the brain identified a 2- to 3-week-old subdural hematoma, a complication of intracranial hypotension, which may have led to intracranial hypertension. Conclusion: While persistent headaches in intracranial hypertension patients progress to intracranial hypotension due to lowered cerebrospinal fluid pressures, this is the first report of intracranial hypotension progressing to intracranial hypertension.

두개 내압 감시 장치를 이용한 두개강 내압 측정에 대한 임상적 연구

구환회,김윤 대한신경외과학회 1986 Journal of Korean neurosurgical society Vol.15 No.1

Continous monitoring of intracranial pressure can be one of the most important physical parameters in assesing patients who have or might develop intracranial hypertension. The author has measured an intracranial epidural pressure by use of a Fiberoptic pressure monitor on 20 cases among brain damaged patients and evaluated it's effect by an epidural pressure change and Glasgow coma scale change after craniectomy and hypertonic solution infusion. Intracranial pressure was compared with signs of increased ICP on brain computed tomography. Also, complications were evaluated. The results are as follows ; 1) Average intracranial pressure was significantly decreased 48㎝ H₂O during the first day after craniectomy. 2) Average intracranial pressure was significantly decreased 33㎝ H₂O after infusion of 10 % glycerol. 3) Improvement of the clinical states after craniectomy was not found in the cases above 20㎝H₂O in spite of decreasing intracranial pressure. 4) Sixteen of seventeen patients showing signs of increased intracranial pressure on brain computed tomography on admission developed elevated intracranial pressure. 5) The infection and intracranial hemorrhage were not found at the monitoring implement site three weeks after removing the intracranial pressure monitor.

두개강내 병소와 동반되는 급성 고혈압의 치료 : 이상적인 항고혈압 치료제의 선택을 중심으로 Focus on Selecting Ideal Antibypertensive Agents

박정율,이자규,이일옥,공명훈,송우혁,정흥섭,이기찬,이훈갑 고려대학교 의과대학 1997 고려대 의대 잡지 Vol.34 No.2

Patients with acute hypertension associated with intracranial pathology often require prompt reduction of elevated blood pressure. But the principal goal here is to ameliorate systemic hypertension while maintaining adequate cerebral perfusion pressure to provide required cerebral blood flow and thereby preventing secondary ischemic brain damage. Although many new antihypertensive agents are now available, the ideal agent along with optimal guidelines for blood pressure reduction still remain controversial in acute hypertensive patients with different types of intracranial pathologies. Object of this study was to first review briefly the cerebrovascular pathophysiology of hypertension in conjunction with management of these patients. Pertinent literature is searched, indexed, and referenced from MEDLINE for this purpose. From this information, along with clinical experiences, authors tried to provide some of basic guidelines for managing these patients in various clinical situations, focusing mainly on selecting ideal antihypertensive agents available at present time. From the present standpoint it is generally agreed that 1- or 1-adrenergic receptor antagonists provide arterial pressure reduction with little or no adverse effect on intracranial pressure within regulatory range. Although many promising calcium-channel blocking agents are now available, their use are often limited by their action to cause cerebral vasodilation and thus increased intracranial pressure. Angiotensin converting enzyme inhibitors can be used for moderate hypertension but have potential to further increase intracranial pressure in patients who already have intracranial hypertension. It has long been known that barbiturates can be adjuvant method in case of resistant or malignant hypertension with intractablly increased intracranial pressure since it decreases both the blood pressure and cerebral blood flow with reduction of oxygen metabolism. The proper management of acute hypertension in the patients with intracranial pathology should be based on sufficient understanding of the pathophysiology of hypertension and cerebral perfusion pressure. Ideal agents would be individually based on their ability to promptly and reliably ameliorate the hypertension and at the same time maintain adequate cerebral blood flow and intracranial pressure.

Intracranial Aneurysm Is Associated with High Intracranial Artery Tortuosity

Kim, Bum Joon,Lee, Sung Ho,Kwun, Byung Duk,Kang, Hyun Goo,Hong, Keun-Sik,Kang, Dong-Wha,Kim, Jong S.,Kwon, Sun U. Elsevier 2018 World neurosurgery Vol.112 No.-

<P><B>Background</B></P> <P>Although intracranial aneurysms (IAs) are focal bulges of arterial walls, an uncharacterized predisposing factor that affects cerebral arteries may increase tortuosity of intracranial arteries in patients with IAs.</P> <P><B>Methods</B></P> <P>Subjects who underwent routine health examinations and magnetic resonance angiography at a university hospital health promotion center were enrolled. Age- and sex-matched control subjects were selected from among individuals who did not have IAs. Tortuosity of right and left middle cerebral arteries and basilar artery (BA) was measured. Distant factor [(arc/chord ratio × 100) − 100] was used to estimate tortuosity. Vascular risk factors and intracranial arterial tortuosities were compared between subjects with IAs and control subjects. Independent factors associated with intracranial artery tortuosity were also investigated.</P> <P><B>Results</B></P> <P>Of 18,954 (1.9%) subjects, 367 exhibited IAs. The prevalence of hypertension (<I>P</I> = 0.01) and current smoking (<I>P</I> = 0.01) were higher in subjects with IAs than in control subjects. The BA tortuosity was greater in subjects with IAs compared with control subjects (9.0 ± 8.1 vs. 5.5 ± 7.2; <I>P</I> < 0.001). In addition to hypertension, smoking, and absence of coronary artery disease, BA tortuosity (<I>P</I> < 0.001) was independently associated with presence of IAs. The presence of IA (<I>P</I> < 0.001) and absence of coronary artery disease (<I>P</I> = 0.002) were independently associated with high BA tortuosity.</P> <P><B>Conclusions</B></P> <P>Patients with IAs exhibit a more tortuous BA. A predisposing factor weakening the cerebrovasculature in patients with IAs may exist and may manifest as high tortuosity of intracranial arteries.</P> <P><B>Highlights</B></P> <P> <UL> <LI> Basilar artery tortuosity is greater in patients with intracranial aneurysm. </LI> <LI> Intracranial aneurysm is independently associated with high arterial tortuosity. </LI> <LI> A predisposing factor weakening the vasculature may exist in patients with aneurysm. </LI> </UL> </P>

두개강내 동맥류 환자의 신경안과적 분석

윤한결(Han Gyul Yoon),김대현(Dae Hyun Kim) 대한안과학회 2017 대한안과학회지 Vol.58 No.11

목적: 두개강내 동맥류 환자에서 발생한 신경안과 진단 및 임상양상에 대해서 알아보고자 하였다. 대상과 방법: 2008년 4월부터 2016년 12월까지 두개강내 동맥류로 진단 받은 환자 중에서 신경안과 검사가 시행된 환자 33명을 대상 으로 후향적인 분석을 시행하였다. 영상검사 및 신경외과, 신경안과 의무기록을 통해 안과에서 동맥류를 발견한 빈도, 신경안과 진단및 예후, 동맥류의 위치, 동맥류 파열 여부 등을 알아보았고 터슨증후군이 동반된 환자의 신경학적 예후도 조사하였다. 결과: 전체 환자 33명에서 2명만이 안과에서 두개강내 동맥류를 먼저 발견하였고, 대부분의 환자 31명(94%)은 신경외과에서 동맥류를 발견하였다. 신경안과 진단으로는 3번뇌신경마비가 10명(30%)으로 가장 많았고 핵간안근마비, 시야결손, 시신경위축, 6번뇌신경마비, 안구진탕 등이 발생하였다. 동맥류 위치는 전교통동맥이 13예(39%)로 가장 많았고 12예, 후교통동맥 5예 순이었다. 전체 33명 중 10명 에서 터슨증후군이 동반되었고, 최종 관찰 시 6명(60%)에서 인지장애, 보행장애 등의 영구적인 신경학적 장애가 발생하였다. 결론: 두개강내 동맥류 환자에서 가장 많이 발생하는 신경안과 질환은 3번뇌신경마비였다. 신경안과 질환의 예후는 비교적 양호하였 으나, 터슨증후군이 동반된 환자의 신경학적 예후는 좋지 않았다. Purpose: To investigate the neuro-ophthalmic diagnosis and clinical manifestations of intracranial aneurysm. Methods: A retrospective survey of 33 patients who were diagnosed with intracranial aneurysm and underwent neuro-ophthalmic examination from April 2008 to December 2016. Frequency of the first diagnosis of intracranial aneurysm in ophthalmology, neuro-ophthalmic diagnosis, location of intracranial aneurysm, examination of intracranial aneurysm rupture, and neurologic prognosis of Terson’s syndrome patients were analyzed by image examination, neurosurgery, and ophthalmology chart review. Results: Of the 33 patients, most patients (n = 31, 94%) were diagnosed with intracranial aneurysm at the neurosurgical department and only 2 patients were diagnosed initially at the ophthalmology department. Causes and association were: Terson’s syndrome (n = 10, 30%), third cranial nerve palsy (n = 10, 30%), internclear ophthalmoplegia (n = 4, 12%), visual field defect (n = 3, 9%), optic atrophy (n = 3, 9%), sixth cranial nerve palsy (n = 2, 6%), and nystagmus (n = 1, 3%). The location of intracranial aneurysms were: anterior communicating artery (n = 13, 39%), medial communicating artery (n = 12, 36%), and posterior communicating artery (n = 5, 15%). Ten of 33 patients had Terson’s syndrome, and 6 patients (60%) with Terson’s syndrome had a permanent neurological disorder such as agnosia, gait disorder and conduct disorder. Conclusions: Third cranial nerve palsy was the most common neuro-ophthalmic disease in patients presenting with intracranial aneurysm. The neuro-ophthalmic prognoses for those diseases were relatively good, but, if Terson’s syndrome was present, neurological disorders (agnosia, gait disorder, conduct disorder) were more likely to remain after treatment. J Korean Ophthalmol Soc 2017;58(11):1276-1281

두개내압저하의 신경계 증상

강규식,김병건 대한신경과학회 2019 대한신경과학회지 Vol.37 No.2

Intracranial hypotension usually arises in the context of known or suspected leak of cerebrospinal fluid (CSF). This leakage leads to a fall in intracranial CSF pressure and CSF volume. The most common clinical manifestation of intracranial hypotension is orthostatic headache. Post-dural puncture headache and CSF fistula headache are classified along with headache attributed to spontaneous intracranial hypotension as headache attributed to low CSF pressure by the International Classification of Headache Disorders. Headache attributed to low CSF pressure is usually but not always orthostatic. The orthostatic features at its onset can become less prominent over time. Other manifestations of intracranial hypotension are nausea, spine pain, neck stiffness, photophobia, hearing abnormalities, tinnitus, dizziness, gait unsteadiness, cognitive and mental status changes, movement disorders and upper extremity radicular symptoms. There are two presumed pathophysiologic mechanisms behind the development of various manifestations of intracranial hypotension. Firstly, CSF loss leads to downward shift of the brain causing traction on the anchoring and supporting structures of the brain. Secondly, CSF loss results in compensatory meningeal venodilation. Headaches presenting acutely after an intervention or trauma that is known to cause CSF leakage are easy to diagnose. However, a high degree of suspicion is required to make the diagnosis of spontaneous intracranial hypotension and understanding various neurological symptoms of intracranial hypotension may help clinicians.