Publications by authors named "Won-Sang Cho"

112 Publications

Endovascular Treatment of Intracranial Kissing Aneurysms: Technical Feasibility and Clinical Outcomes.

World Neurosurg 2021 Aug 28. Epub 2021 Aug 28.

Department of Neurosurgery and Radiology, Veterans Health Service Medical Center, Seoul, Korea.

Background: Kissing aneurysms are situated on the same artery but have separate points of origin. Open surgical strategies for access from opposing directions may be technically problematic. Recent advances in protective devices and coiling techniques have compelled the present study, aimed at technical aspects and procedural outcomes of coil embolization in this setting.

Methods: Data prospectively accruing between May 2001 and May 2020 were systematically reviewed, assessing clinical and morphologic outcomes of coil embolization in 36 patients with 72 kissing aneurysms.

Results: Lesions most often involved paraclinoid internal carotid artery (n = 22), followed by anterior communicating artery (n = 7). Single-stage coil embolization of both aneurysms took place in nearly all patients (n = 35). Microcatheter tips for selecting paired aneurysms were usually directed opposite to one another (32 of 36, 88.9%), applying protective devices (i.e., balloons or stents) to 1 or both aneurysms in 21 patients (58.3%). Balloons were placed in 9 patients, often when treating first aneurysms and largely for second aneurysms as well (7 of 9, 77.8%). Stents deployed in 14 patients involved first and second aneurysms equally. Two patients required balloon of stent combinations. No procedure-related morbidity or mortality resulted. In follow-up of 68 aneurysms (mean: 40.2 ± 28.1 months) after coiling, 86.8% (59 of 68) showed sustained complete saccular occlusion.

Conclusions: Strategies for endovascular treatment of kissing aneurysms rely heavily on characteristics that the paired aneurysms display. Properly conducted single-stage coil embolization is a safe and effective method of treating such lesions.
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http://dx.doi.org/10.1016/j.wneu.2021.08.095DOI Listing
August 2021

Endovascular treatment of medullary bridging vein-draining dural arteriovenous fistulas: foramen magnum vs. craniocervical junction lesions.

Neuroradiology 2021 Aug 25. Epub 2021 Aug 25.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehangno, Jongno-Gu Seoul, Korea.

Purpose: Dural arteriovenous fistulas (AVFs) draining to medullary bridging vein (MBV) are located at foramen magnum (FM) and craniocervical junction (CCJ). Such fistulas are rare but pose a challenge to endovascular management. This study was undertaken to assess clinical manifestations, angiographic features, and outcomes of endovascular treatment in patients with MBV dural AVFs.

Methods: A number of our patients (N = 22) were diagnosed with MBV dural AVF and treated by endovascular means. There were 9 FM lesions and 13 CCJ lesions. We reviewed clinical records and imaging studies to define clinical characteristics, vascular anatomic details, and treatment outcomes, comparing FM- and CCJ-level subsets.

Results: Subjects ranged from 37 to 74 years of age (mean, 57.7 years) with male predominance (2.7:1). They presented with intracranial hemorrhage (11/22, 50%), myelopathy (8/22, 36%), or nonspecific symptoms (3/22, 14%). In 17 patients (77.3%), the shunts showed complete or near-complete occlusion following endovascular treatment (FM, 100%; CCJ, 61.5%). However, seven patients experienced ischemic events (FM, 11.1%; CCJ, 46.2%) and one patient sustained a hemorrhagic complication. No hemorrhages recurred during follow-up monitoring, and myelopathic symptoms abated.

Conclusion: MBV dural AVFs are highly aggressive lesions for which proper diagnosis and treatment are of utmost importance. Although transarterial embolization proved highly successful in FM lesions, shunt occlusion was less frequent in the CCJ subset, with greater risk of ischemic complications.
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http://dx.doi.org/10.1007/s00234-021-02790-zDOI Listing
August 2021

Treatment outcomes of 1-stage clipping of multiple unruptured intracranial aneurysms via keyhole approaches.

J Neurosurg 2021 Aug 13:1-10. Epub 2021 Aug 13.

Objective: Complete exclusion of multiple unruptured intracranial aneurysms (UIAs) in one session of intervention may be ideal. However, such situations are not always feasible in terms of treatment modalities and outcomes. The authors aimed to analyze their experience with 1-stage clipping of multiple UIAs.

Methods: Medical records between March 2013 and December 2018 were retrospectively reviewed, and 111 1-stage keyhole approaches in 110 patients with 261 multiple UIAs were ultimately included in this study. Clinical and radiological outcomes were analyzed, as well as postoperative complications up to 1 month after the surgery and their risk factors.

Results: Keyhole approaches included unilateral supraorbital in 87 operations (78.4%), bilateral supraorbital in 12 (10.8%), and others in 12. The mean operative duration was 169.6 minutes (range 80-490 minutes). The highest numbers of aneurysms clipped at once were 2 (73.9%) and 3 (18.9%). Complete exclusion and residual neck of the clipped aneurysms were achieved in 89.3% and 7.3%, respectively. There was no significant difference between pre- and postoperative 1-month neurological states (p = 0.14). The permanent morbidity rate was 1.8% (n = 2), and there were no deaths. Postoperative transient neurological deterioration (TND) with no radiological and electrophysiological abnormalities occurred in 8 operations (7.2%). Hypertension was the only significant risk factor for postoperative TND (adjusted odds ratio 17.03, 95% confidence interval 1.99-2232.24, p = 0.01).

Conclusions: One-stage clipping of multiple UIAs via keyhole approaches showed satisfactory treatment outcomes with a low permanent morbidity. Patients with chronic hypertension had a high risk of postoperative TND.
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http://dx.doi.org/10.3171/2021.1.JNS204078DOI Listing
August 2021

Midterm Outcomes After Low-Profile Visualization Endoluminal Support or Atlas Stent-Assisted Coiling of Intracranial Aneurysms: A Propensity Score Matching Analysis.

Neurosurgery 2021 Aug 12. Epub 2021 Aug 12.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Background: The interplay of various commercially available stents during coil embolization of intracranial aneurysms and their ultimate impact are subject to debate.

Objective: To compare midterm outcomes of Low-Profile Visualization Endoluminal Support (LVIS) (MicroVention Inc) and Atlas (Stryker) stent-assisted coiling procedures.

Methods: A total of 459 intracranial aneurysms subjected to coil embolization using LVIS (n = 318) or Atlas stents (n = 141) between April 2015 and December 2019 were eligible for study. To assess occlusive status postembolization, magnetic resonance angiography and/or conventional angiography were used. The Raymond classification was applied to categorize recanalization. Our analysis was propensity score matched according to probability of stent type deployed.

Results: Eventually, 41 aneurysms (8.9%) displayed recanalization (minor, 28; major, 13) 6 mo after coiling. Patient age (P = .018), sex (P = .015), aneurysmal location (P < .001), and type of aneurysm (P < .001) differed significantly by group. Overall and major recanalization rates at midterm were similar in both groups (9.1% and 8.5% vs 3.1% and 2.1%, respectively), and there was no significant difference even after 1:1 propensity score matching (odds ratio [OR] = 0.75 [P = .514] and OR = 0.75 [P = .706], respectively).

Conclusion: In stent-assisted coil embolization of intracranial aneurysms, midterm outcomes of LVIS and Atlas device groups were similar, despite theoretic LVIS superiority. Further randomized comparative studies are needed to confirm our findings.
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http://dx.doi.org/10.1093/neuros/nyab302DOI Listing
August 2021

Rescue Strategy for Troublesome Situations Related to Recipient and Donor Arteries During Low-Flow Bypass Surgery.

World Neurosurg 2021 Aug 2;154:83-90. Epub 2021 Aug 2.

Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.

Objective: Although technically demanding, bypass surgery is a vital part of the neurosurgical armamentarium. The aim of this article was to present representative troublesome cases related to the manipulation of donor arteries (DAs) and recipient arteries during low-flow extracranial-intracranial bypass.

Methods: In the past 5 years, 507 low-flow bypass surgeries were performed in patients with cerebral aneurysms, moyamoya disease, and intracranial atherosclerotic stenosis. Frustrating perioperative situations were retrospectively reviewed, and 6 representative cases were described.

Results: Case 1 involved repeat microanastomosis owing to occlusion of the anastomotic segment by thrombus formation. Case 2 involved repair of the DA injured by thermal energy. Case 3 involved direct repair of the DA damaged by a sharp knife. Case 4 involved repeat microanastomosis owing to avulsion of the anastomotic segment. Case 5 involved lengthening of the short DA with a nearby interposition graft. Case 6 involved use of retrograde flow via the distal segment of the DA secondary to the injury of the proximal segment of the DA. In all patients, rescue procedures were successful, and bypass flow was patent with no relevant complications.

Conclusions: The intraoperative accidents reported here were frustrating; however, all patients were safely rescued without significant sequelae. It is hoped that our experiences will help young neurosurgeons handle troublesome situations.
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http://dx.doi.org/10.1016/j.wneu.2021.07.117DOI Listing
August 2021

Endovascular Treatment of Fenestration-related Aneurysms : Morphological Features, Operative Techniques and Therapeutic Outcomes.

Clin Neuroradiol 2021 Jun 16. Epub 2021 Jun 16.

Department of Neurosurgery and Radiology, Veterans Health Service Medical Center, Seoul, Korea (Republic of).

Purpose: Endovascular treatment of fenestration-related aneurysms (FAs) is prone to technical challenges, given the inherent complexities. Herein, we have analyzed FAs in terms of angioarchitectural characteristics and outcomes achieved through endovascular intervention.

Methods: Data accrued prospectively between January 2002 and July 2020 were productive of 105 FAs in 103 patients, each classifiable by the nature of incorporated vasculature as proximal portion, fenestrated limb, or distal end. Our investigation focused on clinical and morphological outcomes, with emphasis on technical aspects of treatment.

Results: The FAs selected for study originated primarily in anterior communicating artery (AcomA: 88/105, 83.8%), followed by basilar (7/105, 6.7%), anterior cerebral (4/105, 3.8%), and internal carotid (3/105, 2.8%) arteries. In nearly all locations, proximally situated aneurysms (43/105, 41%) were more frequent than aneurysms arising at distal ends (3/105, 2.8%), but the majority of AcomA lesions involved fenestrated segments (58/88, 65.9%); and most fenestrated channels (90/105, 85.7%) were asymmetric in size. Orifices of smaller fenestrated limbs were intentionally compromised during coil embolization in 23 aneurysms (21.9%), achieving complete (n = 19) or incomplete (n = 4) compromise, without resultant symptomatic ischemia. Saccular occlusion proved satisfactory in 77 lesions (73.3%). In follow-up monitoring of 100 patients for a mean period of 35.3 ± 26.5 months, 17 instances of recanalization (17.0%) occurred (minor, 9; major, 8). There was no recanalization of aneurysms with compromised limbs.

Conclusion: Coil embolization of FAs is safe and effective, enabling tailored procedures that accommodate aberrant angioanatomic configurations. Compromise of a single limb during coiling also appears safe, conferring long-term protection from recanalization.
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http://dx.doi.org/10.1007/s00062-021-01043-zDOI Listing
June 2021

Clinical application of 3D virtual and printed models for cerebrovascular diseases.

Clin Neurol Neurosurg 2021 Jul 29;206:106719. Epub 2021 May 29.

Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea. Electronic address:

Objective: Three-dimensional (3D) printing techniques are rapidly advancing in the medical industry and in clinical practice. We aimed to evaluate the usefulness of 3D virtual and printed models of 6 representative cerebrovascular diseases using the software we developed.

Methods: Six cases consisted of 4 intracranial aneurysms (IAs) including complex ones with intrasaccular thrombosis, large size and a skull base location; 1 cavernous malformation in the pons; and 1 arteriovenous malformation in the parietal lobe. The 3D modeling process was performed retrospectively in 3 cases and prospectively in 1 IA. Segmentation of raw data and rendering and modification for 3D virtual models were processed mostly automatically.

Results: Most intracranial structures were satisfactorily made, including the skull, brain, vessels, thrombus, tentorium and major cranial nerves. Based on 3D modeling, surgical plan was changed in 1 prospective IA case. However, it was still difficult to discriminate small vessels and cranial nerves, to feel a realistic tactile sense and to directly perform presurgical simulations, such as dissection, removal, clipping and microanastomosis.

Conclusions: The 3D modeling was thought to be very helpful in experiencing the operative views from various directions in advance, in selecting an appropriate surgical approach, and in educating physicians and patients. With advancements in radiological resolution, processing techniques and material properties, 3D modeling is expected to simulate real brain tissues more closely.
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http://dx.doi.org/10.1016/j.clineuro.2021.106719DOI Listing
July 2021

Clinical application of patient-specific 3D printing brain tumor model production system for neurosurgery.

Sci Rep 2021 Mar 26;11(1):7005. Epub 2021 Mar 26.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro 101, Jongno-gu, Seoul, 03080, Republic of Korea.

The usefulness of 3-dimensional (3D)-printed disease models has been recognized in various medical fields. This study aims to introduce a production platform for patient-specific 3D-printed brain tumor model in clinical practice and evaluate its effectiveness. A full-cycle platform was created for the clinical application of a 3D-printed brain tumor model (3D-printed model) production system. Essential elements included automated segmentation software, cloud-based interactive communication tools, customized brain models with exquisite expression of brain anatomy in transparent material, adjunctive devices for surgical simulation, and swift process cycles to meet practical needs. A simulated clinical usefulness validation was conducted in which neurosurgeons assessed the usefulness of the 3D-printed models in 10 cases. We successfully produced clinically applicable patient-specific models within 4 days using the established platform. The simulated clinical usefulness validation results revealed the significant superiority of the 3D-printed models in surgical planning regarding surgical posture (p = 0.0147) and craniotomy design (p = 0.0072) compared to conventional magnetic resonance images. The benefit was more noticeable for neurosurgeons with less experience. We established a 3D-printed brain tumor model production system that is ready to use in daily clinical practice for neurosurgery.
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http://dx.doi.org/10.1038/s41598-021-86546-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7998007PMC
March 2021

The Fate of Partially Thrombosed Intracranial Aneurysms Treated with Endovascular Intervention.

J Korean Neurosurg Soc 2021 May 26;64(3):427-436. Epub 2021 Feb 26.

Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.

Objective: The fate of partially thrombosed intracranial aneurysms (PTIAs) is not well known after endovascular treatment. The authors aimed to analyze the treatment outcomes of PTIAs.

Methods: We retrospectively reviewed the medical records of 27 PTIAs treated with endovascular intervention between January 1999 and March 2018. Twenty-one aneurysms were treated with intraluminal embolization (ILE), and six were treated with parent artery occlusion (PAO) with or without bypass surgery. Radiological results, clinical outcomes and risk factors for major recurrence were assessed.

Results: The initial clinical status was similar in both groups; however, the last status was better in the ILE group than in the PAO group (p=0.049). Neurological deterioration resulted from mass effect in one case and rupture in one after ILE, and mass effect in two and perforator infarction in one after PAO. Twenty cases (94.2%) in the ILE group initially achieved complete occlusion or residual neck status. However, 13 cases (61.9%) showed major recurrence, the major causes of which included coil migration or compaction. Seven cases (33.3%) ultimately achieved residual sac status after repeat treatment. In the PAO group, all initially showed complete occlusion or a residual neck, and just one case ultimately had a residual sac. Two cases showed major recurrence, the cause of which was incomplete PAO. Aneurysm wall calcification was the only significantly protective factor against major recurrence (odds ratio, 36.12; 95% confidence interval, 1.85 to 705.18; p=0.018).

Conclusion: Complete PAO of PTIAs is the best option if treatment-related complications can be minimized. Simple fluoroscopy is a useful imaging modality because of the recurrence pattern.
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http://dx.doi.org/10.3340/jkns.2020.0195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8128530PMC
May 2021

Optimizing Nitrogen Balance Is Associated with Better Outcomes in Neurocritically Ill Patients.

Nutrients 2020 Oct 14;12(10). Epub 2020 Oct 14.

Department of Neurology, Seoul National University Hospital, Seoul 03080, Korea.

Marked protein catabolism is common in critically ill patients. We hypothesized that optimal protein supplementation using nitrogen balance might be associated with better outcomes in the neurointensive care unit (NICU) patients. A total of 175 patients admitted to the NICU between July 2017 and December 2018 were included. Nitrogen balance was measured after NICU admission and measurements were repeated in 77 patients. The outcomes were compared according to initial nitrogen balance results and improvement of nitrogen balance on follow-up measurements. A total of 140 (80.0%) patients had a negative nitrogen balance on initial assessments. The negative balance group had more events of in-hospital mortality and poor functional outcome at three months. In follow-up measurement patients, 39 (50.6%) showed an improvement in nitrogen balance. The improvement group had fewer events of in-hospital mortality ( = 0.047) and poor functional outcomes ( = 0.046). Moreover, improvement of nitrogen balance was associated with a lower risk of poor functional outcomes (Odds ratio, 0.247; 95% confidence interval, 0.066-0.925, = 0.038). This study demonstrated that a significant proportion of patients in the NICU were under protein hypercatabolism. Moreover, an improvement in protein balance was related to improved outcomes in neurocritically ill patients. Further studies are needed to confirm the relationship between protein balance and outcomes.
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http://dx.doi.org/10.3390/nu12103137DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7602201PMC
October 2020

Preoperative platelet count may predict postoperative symptomatic cerebral hyperperfusion syndrome after superficial temporal artery-middle cerebral artery anastomosis in moyamoya patients.

Clin Neurol Neurosurg 2020 12 2;199:106260. Epub 2020 Oct 2.

Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, South Korea. Electronic address:

Objective: Platelets play a critical role in the inflammatory response, accompanied by microvascular endothelial dysfunction, underlying postoperative symptomatic cerebral hyperperfusion syndrome (PSCHS) after superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis in moyamoya patients. We examined whether the preoperative platelet count can predict PSCHS after STA-MCA anastomosis in such patients.

Methods: In 160 adult moyamoya patients undergoing 186 STA-MCA anastomoses, preoperative (demographics, initial clinical manifestation, and Suzuki grade), intraoperative (surgical time, operative side, fluid balance, and maximum and minimum mean blood pressure before and after vessel anastomosis), immediate postoperative (APACHE 2 score), and laboratory (hemoglobin and C-reactive protein levels and white blood cell and platelet counts) data were collected retrospectively.

Results: 84 patients (90 sides, 48.4 %) developed PSCHS with a median(IQR) onset of postoperative day 1(0-3) and duration of 4(3-7) days. The preoperative (25.2[22.8-28.0] vs. 23.1[19.7-26.2] ×10/μL, p = 0.009) platelet count was significantly higher in patients with PSCHS than in those without. The preoperative platelet count (odds ratio[95 % confidence interval], 1.14[1.03-1.27], p = 0.011), operation on the dominant hemisphere (6.84 [3.26-14.36], p < 0.001), and negative fluid balance (2.41[1.04-5.59], p = 0.040) were significant independent predictors of PSCHS. The optimal cut-off value for preoperative platelet count was 22.7 ×10/μL, and PSCHS developed more frequently in cases with a preoperative platelet count ≥ 22.7 × 10/μL (2.90[1.54-5.45]; p = 0.001).

Conclusion: A high preoperative platelet count may be associated with the development of PSCHS after STA-MCA anastomosis in adult moyamoya patients.
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http://dx.doi.org/10.1016/j.clineuro.2020.106260DOI Listing
December 2020

Surgical strategy for patients with supratentorial spontaneous intracerebral hemorrhage: minimally invasive surgery and conventional surgery.

J Cerebrovasc Endovasc Neurosurg 2020 Sep 21;22(3):156-164. Epub 2020 Sep 21.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

Objective: The role of surgery in spontaneous intracerebral hemorrhage (sICH) is still controversial. We aimed to investigate the effectiveness of minimally invasive surgery (MIS) compared to conventional surgery (CS) for supratentorial sICH.

Methods: The medical data of 70 patients with surgically treated supratentorial sICH were retrospectively reviewed. MIS was performed in 35 patients, and CS was performed in 35 patients. The surgical technique was selected based on the neurological status and radiological findings, such as hematoma volume, neurological status and spot signs on computed tomographic angiography. Treatment outcomes, prognostic factors and the usefulness of the spot sign were analyzed.

Results: Clinical states in both groups were statistically similar, preoperatively, and in 1 and 3 months after surgery. Both groups showed significant progressive improvement till 3 months after surgery. Better preoperative neurological status, more hematoma removal and intensive care unit (ICU) stay ≤7 days were the significant prognostic factors for favorable 3-month clinical outcomes (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.10-0.96, p=0.04; OR 1.04, 95% CI 1.01-1.08, p=0.02; OR 26.31, 95% CI 2.46-280.95, p=0.01, respectively). Initial hematoma volume and MIS were significant prognostic factors for a short ICU stay (≤7 days; OR 0.95; 95% CI 0.91-0.99; p=0.01; OR 3.91, 95% CI 1.03-14.82, p=0.045, respectively). No patients in the MIS group experienced hematoma expansion before surgery or postoperative rebleeding.

Conclusions: MIS was not inferior to CS in terms of clinical outcomes. The spot sign seems to be an effective radiological marker for predicting hematoma expansion and determining the surgical technique.
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http://dx.doi.org/10.7461/jcen.2020.22.3.156DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522387PMC
September 2020

Revascularization Evaluation in Adult-Onset Moyamoya Disease after Bypass Surgery: Superselective Arterial Spin Labeling Perfusion MRI Compared with Digital Subtraction Angiography.

Radiology 2020 12 22;297(3):630-637. Epub 2020 Sep 22.

From the Departments of Radiology (I.H., R.E.Y., K.M.K., D.H.Y., T.J.Y., S.H.C., J..K., C.H.S.) and Neurosurgery (W.S.C., J.E.K.), Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea; and Department of Radiology, Seoul National University College of Medicine, Seoul, Korea (S.H.C., J..K., C.H.S.).

Background A superselective (SS) arterial spin labeling (ASL) MRI technique can be used to monitor the revascularization area as a supplementary or alternative modality to digital subtraction angiography (DSA), with the advantage of being noninvasive. Purpose To evaluate whether SS-ASL perfusion MRI could be used to visualize the revascularization area after combined direct and indirect bypass surgery in adults with moyamoya disease compared with DSA. Materials and Methods Patients diagnosed with moyamoya disease who underwent DSA and SS-ASL 6 months after surgery between June 2017 and November 2019 in a single institution were retrospectively evaluated. Subjective grading of the revascularization area and collateral grading in 10 Alberta Stroke Program Early CT Score (ASPECTS) locations were performed. The change in perfusion status in a subgroup that underwent both preoperative and postoperative SS-ASL studies was evaluated. Intermodality agreement was analyzed by using weighted κ statistics. Results Thirty-seven hemispheres from 33 patients (mean age, 39 years ± 12 [standard deviation]; 20 women) were evaluated. The intermodality agreement of the revascularization area grading was substantial (weighted κ = 0.70; 95% confidence interval [CI]: 0.37, 1.00). The overall intermodality agreement of the postoperative collateral grading in the 10 ASPECTS locations for all vessels was substantial (weighted κ = 0.77; 95% CI: 0.74, 0.80). For the presence of postoperative collateral supplied by the ipsilateral external carotid artery in 10 ASPECTS locations (a total of 370 locations) using DSA as a reference test, the SS-ASL showed a sensitivity of 92% (183 of 199 locations; 95% CI: 87%, 95%) and a specificity of 83% (142 of 171 locations; 95% CI: 77%, 88%). The overall intermodality agreement of the changes in perfusion status was moderate (weighted κ = 0.59; 95% CI: 0.54, 0.65). Conclusion Superselective arterial spin labeling imaging precisely depicted the revascularization territory in patients with moyamoya disease who underwent bypass surgery, and it showed the changes in the vascular supplying territories before and after bypass surgery. © RSNA, 2020 See also the editorial by Hendrikse in this issue.
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http://dx.doi.org/10.1148/radiol.2020201448DOI Listing
December 2020

Reduced Brainstem Volume After Mild Traumatic Brain Injury.

Am J Phys Med Rehabil 2021 05;100(5):473-482

From the Department of Rehabilitation Medicine (EK, HGS, HHL, SHL, SJY, M-GK, B-MO), Biomedical Research Institute (EK), Department of Radiology (SHC, R-EY), and Department of Neurosurgery (W-SC), Seoul National University Hospital, Seoul, Korea; Department of Rehabilitation Medicine, Konkuk University School of Medicine and Konkuk University Medical Center, Seoul, Korea (HHL); Department of Rehabilitation Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (SHL); Department of Radiology (SHC, R-EY), Department of Rehabilitation Medicine (B-MO), and Neuroscience Research Institute (B-MO), Seoul National University College of Medicine, Seoul, Korea; Institute on Aging, Seoul National University, Seoul, Korea (B-MO); and National Traffic Injury Rehabilitation Hospital, Yangpyeong, Korea (B-MO).

Objective: The aims of this study were to investigate changes in regional brain volume after concussion (mild traumatic brain injury) and to examine the relationship between change in brain volume and cognitive deficits.

Design: Twenty-eight patients with mild traumatic brain injury and 27 age-matched controls were included in this study. Magnetic resonance imaging (3 T) data were obtained from the participants. Structural brain volume changes were examined using tensor-based morphometry, which identifies regional structural differences in the whole brain, including cerebrospinal fluid, gray matter, and white matter. Volume contraction and expansion were compared between groups using a two-sample t test. The association between time post-injury or neurocognitive function and volumetric changes was examined using regression analysis.

Results: Individuals with mild traumatic brain injury exhibited volume reduction in the brainstem, including the pontine reticular formation. Regional cerebral volume changes were not associated with time post-injury but were significantly associated with neurocognitive function, especially with executive card sorting test, forward digit span test, and performance on verbal learning test. The greater regional cerebral volume was associated with better cognitive performance after mild traumatic brain injury.

Conclusion: Decreased brainstem volume may indicate its vulnerability to traumatic injury, and cerebral volume in specific regions was positively associated with patients' cognitive function after injury.
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http://dx.doi.org/10.1097/PHM.0000000000001580DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8032213PMC
May 2021

Decreasing Incidence and Mortality in Traumatic Brain Injury in Korea, 2008-2017: A Population-Based Longitudinal Study.

Int J Environ Res Public Health 2020 08 26;17(17). Epub 2020 Aug 26.

Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul 03080, Korea.

Traumatic brain injury (TBI), a global public health concern, may lead to death and major disability. While various short-term, small-sample, and cross-sectional studies on TBI have been conducted in South Korea, there is a lack of clarity on the nationwide longitudinal TBI trends in the country. This retrospective study investigated the epidemiological TBI trends in South Korea, using a population-based dataset of the National Health Insurance (2008-2017). The crude and age adjusted TBI incidence and mortality values were calculated and stratified by age, sex, and TBI diagnosis. The age-adjusted incidence per 100,000 people increased until 2010 and showed a decreasing trend (475.8 cases in 2017) thereafter; however, a continuously decreasing age-adjusted mortality trend was observed (42.9 cases in 2008, 11.3 in 2017). The crude incidence rate increased continually in those aged >70 years across all the TBI diagnostic categories. The mortality per 100,000 people was significantly higher among participants aged ≥70 years than in the other age groups. We observed changing trends in the TBI incidence, with a continuously decreasing overall incidence and a rapidly increasing incidence and high mortality values in older adults. Our findings highlight the importance of active TBI prevention in elderly people.
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http://dx.doi.org/10.3390/ijerph17176197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7504501PMC
August 2020

Outbreak investigation of Serratia marcescens neurosurgical site infections associated with a contaminated shaving razors.

Antimicrob Resist Infect Control 2020 05 12;9(1):64. Epub 2020 May 12.

Center for Infection Control and Prevention, Seoul National University Hospital, Seoul, South Korea.

Background: Surgical site infection (SSI) is the most common healthcare-associated infection. We report an outbreak of neurosurgical site infections caused by Serratia marcescens after craniotomy in a tertiary care hospital.

Methods: Between August 6 and 21, 2018, five cases of early-onset SSI caused by S. marcescens after craniotomy were recorded in a 1786-bed tertiary care hospital. Cultures were collected from potential environmental sources and healthcare workers. Whole-genome sequencing (WGS) was used to investigate the genetic relationships among S. marcescens isolates.

Results: The outbreak involved five patients; S. marcescens was isolated from the cerebrospinal fluid, pus, tissue, and blood samples from these patients. S. marcescens was also isolated from shaving razors and brushes. All S. marcescens isolates from the infected patients and razors showed the same resistance patterns on antibiotic-susceptibility tests. WGS revealed close clustering among four of five isolates from the patients and among three of four isolates from the razors. No additional patient developed S. marcescens infection after we stopped using the razors for scalp shaving.

Conclusions: We report an outbreak of neurosurgical site infections after craniotomy, which was associated with shaving razors contaminated by S. marcescens. Shaving scalps with razors should be avoided to prevent SSI.
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http://dx.doi.org/10.1186/s13756-020-00725-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7216399PMC
May 2020

Delayed Progression to Major Recanalization in Coiled Aneurysms with Minor Recanalization at 36-Month Follow-up : Incidence and Related Risk Factors.

Clin Neuroradiol 2021 Jun 6;31(2):401-408. Epub 2020 Mar 6.

Department of Radiology and Neurosurgery, Veterans Health Service Medical Center, Seoul, Korea (Republic of).

Purpose: The aim was to monitor aneurysms that show imaging evidence of minor recanalization 36 months after coil embolization and to determine the rate and related risk factors of major recanalization during more prolonged observation.

Methods: A total of 54 patients with 55 aneurysms showing minor recanalization at 36-month follow-up imaging between 2011 and 2013 were retrospectively reviewed. Medical records and radiological data accumulating in the course of extended monitoring (mean 83.9 ± 21.5 months) were assessed. Incidence and average annual risk of progression to major recanalization were then calculated. Univariate and multivariate regression analyses were applied to determine possible risk factors for progression to major recanalization.

Results: In the 55 aneurysms studied 26 showed sustained minor recanalization since month 6 of follow-up, whereas minor recanalization of 29 completely occluded coiled lesions appeared in follow-up images after 6-24 months. Only 8 coiled aneurysms (14.5%) with minor recanalization at 36 months progressed to major recanalization during 219.3 aneurysm-years of observation (3.6% per aneurysm-year), 2 surfacing within 72 months and 6 developing thereafter. Additional embolization was performed in six of these patients. By multivariate analysis, no clinical or anatomic factors were statistically linked to such progression, but younger age showed marginal significance (hazard ratio, HR = 1.076; p = 0.099).

Conclusion: Most coiled aneurysms (85.5%) showing minor recanalization at 36 months postembolization proved to be stable in extended observation. Given the low probability but seriousness of delayed major recanalization, careful monitoring is still warranted in this setting but at less frequent intervals (every 2-3 years) beyond 36 months.
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http://dx.doi.org/10.1007/s00062-020-00887-1DOI Listing
June 2021

Neurological Pupil Index as an Indicator of Neurological Worsening in Large Hemispheric Strokes.

Neurocrit Care 2020 10;33(2):575-581

Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.

Background/objective: Cerebral herniation due to brain edema is the major cause of neurological worsening in patients suffering large hemispheric strokes. In this study, we investigated whether quantitative pupillary response could help identify the neurological worsening due to brain swelling in patients with large hemispheric strokes.

Methods: Quantitative pupillary assessment using an automated pupillometer (NPi-100) was performed between April 2017 and August 2019 for patients suffering large hemispheric strokes. Consecutive pupillary responses were measured every 2 or 4 h as a part of routine clinical care. We compared the mean neurological pupil index (NPi) values, NPi value at the time of neurological deterioration, and percentage change in NPi from the immediate previous value between patients with and without neurological worsening.

Results: In this study, 2442 quantitative pupillary assessments were performed (n = 30; mean age, 67.9 years; males, 60.0%). Among the included patients, 10 (33.3%) experienced neurological worsening. Patients with neurological worsening had a significantly lower mean value of NPi and a sudden decrease in the NPi value as compared to those without neurological worsening during the whole monitoring period (3.88 ± 0.65 vs. 4.45 ± 0.46, P < 0.001; and 29.5% vs. 11.1%, P = 0.006, respectively). All patients with NPi values below 2.8 showed neurological deterioration.

Conclusions: Quantitative monitoring of the pupillary response using an automated pupillometer could be a useful and noninvasive tool for detecting neurological deterioration due to cerebral edema in large hemispheric stroke patients.
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http://dx.doi.org/10.1007/s12028-020-00936-0DOI Listing
October 2020

Impact of fetal-type posterior cerebral artery on recanalization of posterior communicating artery aneurysms after coil embolization: matched-pair case-control study.

J Neurointerv Surg 2020 Aug 8;12(8):783-787. Epub 2020 Jan 8.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea.

Background: It is well known that hemodynamic stress may impact the recanalization of coiled aneurysms. One of the most common sites for aneurysms to develop is the posterior communicating artery (PcoA), the variants of which are defined by diameter ratios (PcoA/P1 segment).

Objective: This study was undertaken to investigate the impact of a fetal-type posterior cerebral artery (PCA) on recanalization of PcoA aneurysms after coil embolization based on matched-pair (fetal vs non-fetal PCA) analysis.

Methods: A total of 480 consecutive PcoA aneurysms (PCA: fetal, n=156; non-fetal, n=324) subjected to coil embolization between January 2007 and June 2017 were selected for study. All lesions were followed for ≥6 months via radiologic imaging, grouped by adjacent PCAs as fetal (PcoA/P1 >1) or non-fetal (PcoA/P1 ≤1) type. Paired subjects were matched (1:1) for several relevant variables.

Results: Of the 480 coiled aneurysms, 159 (33.1%) showed recanalization (minor, 76; major, 83) in the course of follow-up (mean 33.8±21.9 months), developing significantly more often in fetal (37.8%) than in non-fetal (26.9%; p=0.020) PCA types. Once matched, however, 6-month and cumulative recanalization rates did not differ significantly by group (p=0.531 and p=0.568, respectively). Complications (hemorrhage, p=0.97; thromboembolism, p=0.94) during endovascular coil embolization also showed similar rates in these groups.

Conclusions: The chances of recanalization after coil embolization seem to be greater in PcoA aneurysms than in intracranial aneurysms overall, thus calling for careful follow-up monitoring. Surprisingly, PcoA type appeared unrelated in this regard.
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http://dx.doi.org/10.1136/neurintsurg-2019-015531DOI Listing
August 2020

Effect of Sevoflurane Postconditioning on the Incidence of Symptomatic Cerebral Hyperperfusion After Revascularization Surgery in Adult Patients with Moyamoya Disease.

World Neurosurg 2020 Feb 14;134:e991-e1000. Epub 2019 Nov 14.

Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea. Electronic address:

Objective: Various experimental studies have reported neuroprotective effects of sevoflurane postconditioning against cerebral ischemia-reperfusion injury. We therefore investigated its neuroprotective effects on hyperperfusion-related transient neurologic deterioration, called symptomatic cerebral hyperperfusion (SCH), and also identified predictive factors for SCH in patients with moyamoya disease after revascularization surgery.

Methods: A total of 152 adult patients with moyamoya disease undergoing anastomosis of the superficial temporal artery to middle cerebral artery were randomly allocated into 2 groups. The postconditioning group (group S, n = 76) inhaled sevoflurane of 1 minimum alveolar concentration for 15 minutes immediately after reperfusion and then washed it out slowly for 15 minutes. The control group (group C, n = 76) received no intervention. The incidence of SCH was compared between the 2 groups.

Results: The incidence of SCH was not significantly different between groups S and C (53.3% vs. 43.4%, respectively; P = 0.291). The incidence of postoperative complications and the Glasgow Outcome Scale score at hospital discharge also did not differ significantly. Predictive factors for SCH included a decreased vascular reserve in preoperative single-photon emission computed tomography scan (odds ratio [OR], 7.18; 95% confidence interval [CI], 1.78-29.02; P = 0.006), an operation performed on the dominant hemisphere (OR, 3.32; 95% CI, 1.57-6.98; P = 0.002), temporal occlusion time (OR, 1.06; 95% CI, 1.01-1.11; P = 0.017), and intraoperative minimum partial pressure of carbon dioxide (PCO) (OR, 0.86; 95% CI, 0.78-0.94; P = 0.001).

Conclusions: Sevoflurane postconditioning did not reduce the incidence of SCH after revascularization surgery in patients with moyamoya disease. Rather, a decreased vascular reserve, operation on the dominant hemisphere, increased temporal occlusion time, and decreased intraoperative minimum PCO were associated with SCH in these patients.
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http://dx.doi.org/10.1016/j.wneu.2019.11.055DOI Listing
February 2020

Characteristics and Treatment Outcome of Intracranial Aneurysms in Children and Adolescents.

J Korean Neurosurg Soc 2019 Sep 30;62(5):551-560. Epub 2019 Aug 30.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.

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 ≤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.
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http://dx.doi.org/10.3340/jkns.2019.0140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732356PMC
September 2019

Does Systemic Hypertension Impact Recanalization of Coiled Aneurysms?

Clin Neuroradiol 2021 Mar 29;31(1):117-124. Epub 2019 Aug 29.

Department of Radiology, Veterans Health Service Medical Center, Seoul, Korea (Republic of).

Purpose: It is well known that hypertension is a significant factor in the formation, growth, and rupture of aneurysms and recanalization of coiled aneurysms is affected by hemodynamic stress. At present, however, the impact of hypertension on recanalization of coiled aneurysms has not been adequately investigated. This study examined the relation between hypertension and subsequent outcomes of coiled aneurysms, using a matched patient analysis.

Methods: A total of 715 subjects undergoing coil embolization of intracranial aneurysms between 2011 and 2013 were selected for study. Time-of-flight magnetic resonance or conventional angiography was used (singly or together) to gauge degrees of occlusion after coiling, applying the Raymond classification in grading recanalization. Patients with hypertension were grouped as controlled or uncontrolled, based on blood pressure readings at outpatient clinics. Hypertensive and non-hypertensive subjects were matched (1:1) for several relevant variables.

Results: Overall, 484 patients (67.7%) were hypertensive (controlled 338; uncontrolled 146). During the follow-up period (28.6 ± 9.7 months), 129 aneurysms (18.0%) displayed recanalization (minor 58; major 71). Patient age, concomitant diabetes, hyperlipidemia, aneurysm size, neck size, depth-to-neck ratio, and aneurysm type differed significantly in hypertensive and non-hypertensive groups; however, group incidences of cumulative recanalization were similar (p = 0.297). After 1:1 matching the cumulative recanalization rate (13.5%) in hypertensive and non-hypertensive counterparts (14.3%) again proved similar (p = 0.578). In the hypertensive group, in addition, recanalization showed no relation to controlled and uncontrolled subgroup (odds ratio, OR = 1.000, p > 0.999).

Conclusion: Unlike other aspects of evolving aneurysms (e.g. formation, growth, or rupture), recanalization of coiled aneurysms seems to be unaffected by systemic hypertension.
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http://dx.doi.org/10.1007/s00062-019-00830-zDOI Listing
March 2021

Intracranial Aneurysms Detected on Imaging Follow-Up of Coiled Aneurysms in a Korean Population.

Korean J Radiol 2019 09;20(9):1390-1398

Department of Radiology, Veterans Health Service Medical Center, Seoul, Korea.

Objective: Coiled aneurysms are known to recanalize over time, making follow-up evaluations mandatory. Although de novo intracranial aneurysms (DNIAs) are occasionally detected during routine patient monitoring, such events have not been thoroughly investigated to date. Herein, we generated estimates of DNIA development during long-term observation of coiled cerebral aneurysms, focusing on incidence and the risk factors involved.

Materials And Methods: In total, 773 patients undergoing coil embolization of intracranial aneurysms between 2008 and 2010 were reviewed retrospectively. Their medical records and radiologic data accrued over the extended period (mean, 52.7 ± 29.7 months) were analyzed. For the detection of DNIA, follow-up magnetic resonance angiography and/or conventional angiography were used. The incidence of DNIAs and related risk factors were analyzed using Cox proportional hazards regression and Kaplan-Meier product-limit estimator.

Results: In 19 (2.5%) of the 773 patients with coiled aneurysms, DNIAs (0.56% per patient-year) developed during continued long-term monitoring (3395.3 patient-years). Of these, 9 DNIAs (47.4%) were detected within 60 months, with 10 (52.6%) emerging thereafter. The most common site involved was the posterior communicating artery (n = 6), followed by the middle cerebral artery (n = 5) and the basilar top (n = 4). Multivariate analysis indicated that younger age (< 50 years) (hazard ratio [HR] = 1.045; = 0.010) and recanalization of coiled aneurysms (HR = 2.560; = 0.047) were significant factors in DNIA formation, whereas female sex, smoking, and hypertension fell short of statistical significance. Cumulative survival rates without DNIA were significantly higher in older subjects (> 60 years; < 0.001) and in the absence of post-coiling aneurysm recurrence ( = 0.006).

Conclusion: In most patients with coiled aneurysms, development of DNIAs during long-term monitoring is rare. However, younger patients (< 50 years) or patients with recurring aneurysms appear to be predisposed to DNIAs.
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http://dx.doi.org/10.3348/kjr.2018.0914DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6715560PMC
September 2019

Altered White Matter Integrity after Mild to Moderate Traumatic Brain Injury.

J Clin Med 2019 Aug 27;8(9). Epub 2019 Aug 27.

Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul 03080, Korea.

(1) Background: White matter changes among individuals with mild-to-moderate traumatic brain injury (TBI) may be sensitive imaging markers reflecting functional impairment, particularly in the context of post-concussion syndrome. The objective of this study was to examine the altered white matter integrity in mild-to-moderate TBI patients compared with age-matched normal controls. (2) Methods: Diffusion tensor imaging data from 15 individuals with TBI and 15 control subjects were retrospectively obtained. We investigated and compared white matter integrity in both groups, with regard to fractional anisotropy (FA), radial diffusivity (RD), and axial diffusivity (AD) and examined the relationship with cognitive dysfunction and impaired balance in patients. (3) Results: In comparison with controls, the TBI patients had significantly decreased FA as well as increased RD, in the right corticospinal tract. Decreased RD was observed in the left cerebellar area near the middle cerebellar peduncle. Decreased AD was observed in the left inferior cerebellar peduncle, showing positive correlation with poor balance control. We observed decreased FA and increased AD in the left superior longitudinal fasciculus showing positive and negative correlation, respectively, with cognitive function in the TBI group. (4) Conclusions: Altered white matter integrity in mild-to-moderate TBI cases may be indicative of cognitive dysfunction and impaired balance.
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http://dx.doi.org/10.3390/jcm8091318DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780936PMC
August 2019

Is 3 years adequate for tracking completely occluded coiled aneurysms?

J Neurosurg 2019 Aug 16:1-7. Epub 2019 Aug 16.

6Department of Radiology, Veterans Health Service Medical Center, Seoul, Korea.

Objective: The authors conducted a study to ascertain the long-term durability of coiled aneurysms completely occluded at 36 months' follow-up given the potential for delayed recanalization.

Methods: In this retrospective review, the authors examined 299 patients with 339 aneurysms, all shown to be completely occluded at 36 months on follow-up images obtained between 2011 and 2013. Medical records and radiological data acquired during the extended monitoring period (mean 74.3 ± 22.5 months) were retrieved, and the authors analyzed the incidence of (including mean annual risk) and risk factors for delayed recanalization.

Results: A total of 5 coiled aneurysms (1.5%) occluded completely at 36 months showed recanalization (0.46% per aneurysm-year) during the long-term surveillance period (1081.9 aneurysm-years), 2 surfacing within 60 months and 3 developing thereafter. Four showed minor recanalization, with only one instance of major recanalization. The latter involved the posterior communicating artery as an apparent de novo lesion, arising at the neck of a firmly coiled sac, and was unrelated to coil compaction or growth. Additional embolization was undertaken. In a multivariate analysis, a second embolization for a recurrent aneurysm (HR = 22.088, p = 0.003) independently correlated with delayed recanalization.

Conclusions: Almost all coiled aneurysms (98.5%) showing complete occlusion at 36 months postembolization proved to be stable during extended observation. However, recurrent aneurysms were predisposed to delayed recanalization. Given the low probability yet seriousness of delayed recanalization and the possibility of de novo aneurysm formation, careful monitoring may be still considered in this setting but at less frequent intervals beyond 36 months.
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http://dx.doi.org/10.3171/2019.5.JNS183651DOI Listing
August 2019

Determination of Aneurysm Volume Critical for Stability After Coil Embolization: A Retrospective Study of 3530 Aneurysms.

World Neurosurg 2019 Dec 12;132:e766-e774. Epub 2019 Aug 12.

Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea. Electronic address:

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 <10, 10-100, 100-1000, and >1000 mm, respectively. When we investigated the 100-1000 mm group, the recanalization rate remarkably increased at 500 mm (16.4% vs. 57.5%, P < 0.0001; odds ratio [OR], 6.968; 95% confidence interval [CI], 3.562-13.631). In the entire cohort, recanalization rates were significantly different between aneurysm volume of <500 and >500 mm (7.2% vs. 62.9%, respectively; P < 0.0001; OR, 21.848; 95% CI, 13.944-34.235). In aneurysm volumes of >500 mm, 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 mm 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.
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http://dx.doi.org/10.1016/j.wneu.2019.08.020DOI Listing
December 2019

Surgical Obliteration of Anterior Cranial Fossa Dural Arteriovenous Fistulas via Unilateral High Frontal Craniotomy.

World Neurosurg 2019 Oct 5;130:89-94. Epub 2019 Jul 5.

Department of Neurosurgery, Seoul National University Hospital, Seoul, Korea.

Background: Surgical obliteration is generally recommended for anterior cranial fossa dural arteriovenous fistulas (ACF DAVFs) because of a high risk of bleeding and the difficulty of endovascular approaches. Surgical obliteration is generally performed via a frontobasal craniotomy; however, it is slightly excessive over the target fistula. Here, we present 2 cases of ACF DAVFs treated with small craniotomy without frontal sinus involvement and a review of the related literature.

Methods: We present 2 cases including a 63-year-old woman who presented with a right-sided ACF DAVF that was fed by both ethmoidal arteries and drained into the right cortical veins (case 1) and a 59-year-old man with right-sided unruptured multiple aneurysms and a left-sided ACF DAVF that was fed by the right ethmoidal artery and drained into the left cortical veins (case 2).

Results: Case 1 underwent surgical obliteration via a right high frontal craniotomy. Case 2 was simultaneously treated with surgical clipping of the multiple aneurysms via a right lateral supraorbital craniotomy and surgical obliteration of the ACF DAVF via a left high frontal craniotomy. These 2 patients had no neurologic deficits, and complete obliteration of all the lesions was confirmed on cerebral angiography.

Conclusions: Constructing a small corridor and a deep working distance in unilateral small high frontal craniotomy may be a slightly unusual approach; however, it is thought to provide sufficient space and a range of microscopic views that facilitate surgical manipulation without requiring extensive bone work.
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http://dx.doi.org/10.1016/j.wneu.2019.06.206DOI Listing
October 2019

Ivy Sign Predicts Ischemic Stroke Recurrence in Adult Moyamoya Patients without Revascularization Surgery.

Cerebrovasc Dis 2019 18;47(5-6):223-230. Epub 2019 Jun 18.

Department of Neurosurgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul, Republic of Korea.

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.
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http://dx.doi.org/10.1159/000500610DOI Listing
May 2020

Newly occurring cranial nerve palsy after endovascular treatment of cavernous sinus dural arteriovenous fistulas.

J Neurointerv Surg 2019 Nov 2;11(11):1168-1172. Epub 2019 May 2.

Radiology, Seoul National University Hospital, Seoul, Republic of Korea.

Objective: Cranial nerve palsy (CNP) is rarely reported after endovascular intervention for cavernous sinus dural arteriovenous fistulas (CS DAVFs). Our aim was to evaluate the treatment outcomes of CS DAVFs, and the clinical course and risk factors of newly occurring CNPs, with a review of the literature.

Methods: 121 patients with 134 lesions treated in our institution were selected. They were retrospectively analyzed in terms of baseline characteristics, radiologic results, clinical outcome, and newly occurring CNPs after treatment. Angiographic and clinical follow-up data were available for 104 lesions (77.6%) and 130 lesions (97.0%), respectively.

Results: The angiographic results showed partial:complete obliterations in 13:91 (87.5%) at the final follow-up. Clinical outcomes were deteriorated or no change:improved or completely recovered (3:126 (96.9%)) at the final follow-up. New CNPs occurred in 24 patients (19.8%), including the sixth CNP alone or mixed in 23 patients (95.8%). 23 cases were completely recovered or improved (21 and 2 cases, respectively), and 19 (90.4%) of 21 were completely recovered within 6 months after treatment. In the multivariate analysis, pretreatment cranial nerve symptoms (OR=0.33; 95% CI 0.14 to 0.76; P=0.010) and complete obliteration immediately after treatment (OR=0.32; 95% CI 0.12 to 0.85; P=0.021) were significant preventive factors for new CNPs. Embolization in the posterior compartments of the CS (OR=5.15; 95% CI 1.71 to 15.47; P=0.004) was a significant risk factor.

Conclusions: Endovascular intervention was satisfactory in patients with CS DAVFs. The prognosis of newly occurring CNPs was favorable.
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http://dx.doi.org/10.1136/neurintsurg-2018-014704DOI Listing
November 2019

Safety and efficacy of anterior communicating artery compromise during endovascular coil embolization of adjoining aneurysms.

J Neurosurg 2019 Mar 1;132(4):1068-1076. Epub 2019 Mar 1.

2Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul; and.

Objective: In the presence of symmetric A1 flow, the safety and efficacy of compromising the anterior communicating artery (ACoA) during coil embolization of ACoA aneurysms has yet to be evaluated. Herein, the authors describe their experience, focusing on procedural safety.

Methods: Between October 2012 and July 2017, 285 ACoA aneurysms with symmetric A1 flows were treated at the authors' institution by endovascular coil embolization. Clinical and angiographic outcome data were subjected to binary logistic regression analysis.

Results: ACoA compromise was chosen in the treatment of 71 aneurysms (24.9%), which were completely (n = 15) or incompletely (n = 56) compromised. In the remaining 214 lesions, the ACoA was preserved. Although 9 patients (3.2%) experienced procedure-related thromboembolisms (compromised, 4; preserved, 5), all but 1 patient (with ACoA compromise) were asymptomatic. In multivariate analysis, subarachnoid hemorrhage at presentation was the sole independent risk factor for thromboembolism (OR 15.98, p < 0.01), with ACoA compromise being statistically unrelated. In 276 aneurysms (96.8%) with follow-up of > 6 months (mean 20.9 ± 13.1 months, range 6-54 months), recanalization was confirmed in 21 (minor, 15; major, 6). A narrow (≤ 4 mm) saccular neck (p < 0.01) and ACoA compromise (p = 0.04) were independently linked to prevention of recanalization.

Conclusions: During coil embolization of ACoA aneurysms, the ACoA may be compromised without serious complications if A1 flows are symmetric. This approach may also confer some long-term protection from recanalization, serving as a valid treatment option for such lesions.
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http://dx.doi.org/10.3171/2018.11.JNS181929DOI Listing
March 2019
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