[Show abstract][Hide abstract] ABSTRACT: Objective:
We evaluated the effect of endovascular treatment (EVT) for acute ischemic stroke in patients over 80 years of age.
Materials and methods:
The records of 156 acute stroke patients aged over 80 years who were considered as candidates for EVT were analyzed. Fifty-six patients (35.9%, EVT group) underwent EVT and 100 patients (64.1%, non-EVT group) did not. Outcomes, in terms of functional outcomes and rates of symptomatic hemorrhage, in-hospital morbidity and mortality, were compared between groups. Each comparison was adjusted for age, time from onset, initial National Institute of Health Stroke Scale, and pre-stroke modified Rankin Scale (mRS).
More patients in the EVT group achieved good outcomes (mRS score of 0-2) at 3 months (35.7% vs. 11.0%, adjusted odds ratio [OR] 4.779 [95% confidence interval 1.972-11.579], p = 0.001) and 12 months (35.7% vs. 14.0%, adjusted OR 3.705 [1.574-8.722], p = 0.003) after stroke. During admission, rates of hospital-acquired infection including pneumonia (12.5% vs. 29.0%, adjusted OR 0.262 [0.098-0.703], p = 0.008) and urinary tract infection (16.0% vs. 34.0%, adjusted OR 0.256 [0.099-0.657], p = 0.005) were significantly lower in the EVT group. More symptomatic hemorrhages (10.7% vs. 2.0%, adjusted OR 6.859 [1.139-41.317], p = 0.036) occurred in the EVT group, but no significant difference was observed in in-hospital mortality rate (12.5% vs. 8.0%, adjusted OR 1.380 [0.408-4.664], p = 0.604).
EVT improved functional outcome and reduced the risk of hospital-acquired infections in acute stroke patients over 80 years of age without increasing the risk of in-hospital mortality, although symptomatic hemorrhage occurred more frequently after EVT.
[Show abstract][Hide abstract] ABSTRACT: OBJECT Treatment strategies for venous-predominant arteriovenous malformation (vp-AVM) remain unclear due to the limited number of cases and a lack of long-term outcomes. The purpose of this study was to report the authors' experience with treatment outcomes with a review of the pertinent literature in patients with vp-AVM. METHODS Medical and radiological data from 1998 to 2011 were retrospectively evaluated. The degree of the arteriovenous (AV) shunt was categorized into 2 groups, a high- and low-flow AV shunt based on the angiographic findings. RESULTS Sixteen patients with a mean age of 45.3 years (range 16-78 years) and a mean follow-up of 79.9 months (range 25-264 months) were examined. Symptomatic lesions were noted in 13 patients: intracranial hemorrhage (ICH) in 9, seizure in 1, and headache in 3. A high-flow shunt was observed on angiography in 13 patients. Among these 13 patients, 12 patients were symptomatic. Nine patients presenting with ICH underwent hematoma removal with additional Gamma Knife surgery (GKS; n = 4), GKS only (n = 2), or conservative treatment (n = 3). The 3 asymptomatic patients received conservative treatment, and 1 rebleeding episode was observed. Seven of 8 patients who underwent GKS as an initial or secondary treatment modality experienced a marked reduction in the AV shunt on follow-up angiography, but complete obliteration was not observed. CONCLUSIONS Poor lesion localization makes a vp-AVM challenging to treat. Symptomatic patients with a high-flow shunt are supposedly best treated with GKS, despite the fact that only 87.5% of the vp-AVMs treated this way showed a reduction in the malformation volume, and none were cured.
Journal of Neurosurgery 09/2015; DOI:10.3171/2015.4.JNS142475 · 3.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The aim of present study was to assess safety and efficacy of early carotid artery stent (CAS) in patients with symptomatic carotid artery stenosis compared with delayed CAS.
This retrospective study was approved by the institutional review board, and the requirement to obtain written informed consent was waived. Outcomes of 206 patients with symptomatic carotid stenosis who were treated by CAS were analyzed. According to CAS timing from last symptom, patients were divided into early (within 2 weeks, 74 [35.0 %]) and delayed (after 2 weeks, 112 [64.1 %]) group by CAS timing from the last symptom. Procedural complication and early (≤30 days of CAS) event (ipsilateral stroke or any death) for safety, and late (31 days to 1 year of CAS) event for efficacy of CAS preventing further stroke were evaluated. The two groups were compared using Cox proportional hazard analysis.
No difference was found in procedural complication between the groups (early 2 [2.7 %] vs. delayed group 7 [5.3 %], hazard ratio [HR] 0.61, 95 % confidence interval [CI] 0.123-2.979, p = 0.537). In the early group, however, early event developed more frequently than in the late group (9 [12.2 %] vs. 1 [0.8 %], HR 16.05, 95 % CI 1.991-129.438, p = 0.009). The late event rate showed no difference between the two groups (4 [5.4 %] vs. 4 [3.0 %], HR 2.09, 95 % CI 0.484-8.989, p = 0.324).
Early CAS is not safe during periprocedural period, compared with late CAS. In CAS for symptomatic carotid stenosis, delayed CAS should be considered.
[Show abstract][Hide abstract] ABSTRACT: Early neurological deterioration (END) is a common condition associated with poor outcome after acute ischemic stroke. We studied association between blood pressure (BP) variability and development of END.
In this retrospective observational study, we studied a consecutive series of patients hospitalized for acute ischemic stroke within 24 h of onset. The primary outcome of interest was the development of END according to predefined criteria within the first 72 h of stroke onset. During this period, the mean, maximum (max), and minimum (min) values for the SBP and DBP were measured. The following parameters of BP variability were calculated for the SBP and DBP: the difference between the maximum and minimum (max-min), the SD, and the coefficient of variation.
Of the 1161 patients enrolled in the study (mean age, 67.5 ± 13.3 years; 59.6% men), 210 (18.1%) developed END. All of the BP variability parameters were linearly associated with END independent of mean BP and potential clinical variables (P values < 0.05 on likelihood ratio tests for trend), except for SBPmax-min. Among the other BP parameters, SBPmean, SBPmax, DBPmax, and DBPmin were independently associated with END. After adjustments for potential confounders, the odds for END increased 14-21% with each increase of one standard deviation in the BP variability parameter.
BP variability is independently and linearly associated with the development of neurologic deterioration in acute stage of ischemic stroke.
Journal of Hypertension 07/2015; DOI:10.1097/HJH.0000000000000675 · 4.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: There have been a few studies reporting the epidemiology of moyamoya disease in Korea. Previous studies revealed relatively high prevalence and incidence of moyamoya disease in Korea and Japan. This study was designed to provide the latest epidemiologic information of moyamoya disease in Korea. We analyzed a database comprising of 50 million people covered in Korea by the National Health Insurance Service to calculate the prevalence. The incidence was estimated by eliminating the duplicated records of previous 3 years. We summarized the prevalence and incidence according to age, sex, and local distribution. In addition, the chronological changes were demonstrated with direct standardization using the 2010 population structure information. The standardized prevalence was 6.5 per 100000 persons in 2005, which was increased to 18.1 in 2013. In the same period, standardized incidence was increased from 2.7 to 4.3 per 100000 persons. The prevalence for men was 4.9 and 8.3 for women in 2005. In 2013, the prevalence had increased for men and women to 13.8 and 25.3, respectively. The incidence for men and women was 2.2 and 3.2, respectively, in 2005. It had increased to 3.5 and 5.7, respectively. The mean age of patients was 33.5 in 2005 and increased to 42.5 in 2013. The peak prevalent age group had shifted slightly to the older age groups, with chronologically consistent female predominance. The prevalence was highest in Jeollabuk province and lowest in Ulsan city.
Journal of Korean Neurosurgical Society 06/2015; 57(6):390-5. DOI:10.3340/jkns.2015.57.6.390 · 0.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Although metabolomics has been increasingly used to observe metabolic pattern and disease-specific metabolic markers, metabolite profiling for moyamoya disease (MMD) has not yet been done in adults. This study investigated cerebrospinal fluid (CSF) metabolites specific to bilateral MMD (B-MMD) and compared them to those of unilateral MMD (U-MMD) or atherosclerotic stenosis with hydrogen-1 nuclear magnetic resonance spectroscopy to identify metabolic biomarkers associated with MMD in adults.CSF samples of B-MMD (n = 29), U-MMD (n = 11), and atherosclerotic cerebrovascular disease (ACVD) (n = 8) were recruited. Principal component analysis, partial least square discriminant analysis, and orthogonal projections to latent structure discriminant analysis (OPLS-DA) were done for the comparisons. Diagnostic performance was acquired by prediction of 1 left-out sample from the distinction model constructed with the rest of the samples.B-MMD showed an increase in glutamine (P < 0.001) and taurine (P = 0.004), and a decrease in glucose (P < 0.001), citrate (P = 0.002), and myo-inositol (P = 0.006) than those in ACVD. U-MMD showed a higher level of glutamine (P = 0.005) and taurine (P = 0.034), and a lower level of glutamate (P < 0.004) than those in ACVD. No difference at the metabolite level was observed between B-MMD and U-MMD. Cross-validation with the OPLS-DA model showed a high accuracy for the prediction of MMD.The results of the study suggest that a metabolomics approach may be helpful in confirming MMD and providing a better understanding of MMD pathogenesis. Elevated glutamine in the CSF may be associated with MMD pathogenesis, which was different from ACVD.
Medicine 05/2015; 94(17):e629. DOI:10.1097/MD.0000000000000629 · 5.72 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECT The authors aimed to assess whether the prevalence of intracranial aneurysms in patients with intracranial meningiomas was higher than that in a healthy population. METHODS The authors performed a hospital-based case-control study of 300 patients with newly diagnosed intracranial meningiomas and 900 age- and sex-matched controls without a history of brain tumors to evaluate any associations between intracranial aneurysms and intracranial meningiomas. Unconditional multivariate logistic regression models were used for case-control comparisons. RESULTS Intracranial aneurysms were identified in 23 patients (7.7%) and 24 controls (2.7%; p < 0.001). There was a significant association between intracranial aneurysms and intracranial meningiomas (OR 2.913, 95% CI 1.613-5.261) and hypertension (OR 1.905, 95% CI 1.053-3.446). In a subgroup analysis of the patients with newly diagnosed intracranial meningiomas, there was a significant association between intracranial aneurysms and hypertension (OR 2.876, 95% CI 1.125-7.352) and tumor volume (OR 1.012, 95% CI 1.001-1.024). These patients were also more likely than controls to have other intracranial vascular diseases (p < 0.001), such as isolated occlusion of the intracranial vessels, excluding intracranial aneurysms. CONCLUSIONS The prevalence of intracranial aneurysms was higher in patients with intracranial meningiomas. Hypertension and tumor volume appear to be associated with the formation of intracranial aneurysms in these patients.
Journal of Neurosurgery 04/2015; 123(2):1-5. DOI:10.3171/2014.10.JNS14710 · 3.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The availability of stents has widened the indications of endovascular intervention for cerebral aneurysms.
To elucidate the effect of stents on radiologic outcomes and to analyze the risk factors for aneurysmal recanalization via propensity score matching.
From the 735 aneurysms treated with coil embolization with stents (n = 187) and without stents (n = 548) between 2009 and 2011, 157 propensity score-matched case pairs were selected. The recanalization rates and relevant risk factors were analyzed. The mean follow-up interval was 24.1 ± 11.3 months (range, 6-48 months) and 22.9 ± 11.4 months (range, 6-56 months) in the stent and nonstent groups, respectively (P = .388).
The stent group demonstrated lower recanalization rates than the nonstent group during both the 6-month (1.9% vs 10.2%, P = .004) and the final follow-up periods (8.3% vs 18.5%, P = .005). The multivariate analysis identified the following significant factors for recanalization: the use of stents (hazard ratio, 0.40; 95% confidence interval, 0.21-0.76, P = .005), larger aneurysm size (hazard ratio, 1.21; 95% confidence interval, 1.11-1.31, P < .001), and initially incomplete occlusion (hazard ratio, 2.39; 95% confidence interval, 1.28-4.43, P = .006). The incidence of permanent neurological complication tended to be higher in the stent group than in the nonstent group (3.2% vs 0%, P = .063).
In this propensity score-matched analysis, stent implantation reduced the overall recanalization of the coiled cerebral aneurysms. However, the use of stents should be carefully decided upon.
DSA, digital subtraction angiographymRS, modified Rankin Scale.
[Show abstract][Hide abstract] ABSTRACT: The authors evaluated the feasibility and targeting accuracy of CT fluoroscopy (CTF)-guided catheter placement and aspiration of intracerebral hematoma (ICH)s.
Nine patients (mean age, 63.3 ± 15.3 years) were treated by CTF-guided hematoma aspiration under local anesthesia. The targeting errors in the lesion center, volume of the aspirated hematoma, accuracy of the final catheter position, procedure time, and clinical outcomes were evaluated.
All catheters were successfully placed in the center of the hematoma. The mean volume of the aspirated hematoma was 20.6 ± 8.8 mL (pre-treatment, 44.7 ± 20.1 mL; post-treatment, 24.1 ± 13.8 mL). The average procedure time was 25.1 minutes (range, 18-32 minutes). In one case with a scanty residual hematoma, the catheter was removed at the end of the procedure. In the remaining eight cases, the catheter was left in the residual hematoma for drainage and all catheter tips were accurately located in the final position. There were no procedure-related complications, including rebleeding and infection.
CTF-guided ICH aspiration is a feasible, quick, and accurate procedure which could substitute for stereotactic methods. The accurate catheter position provided by real-time observation enables an effective aspiration and drainage of hematomas.
[Show abstract][Hide abstract] ABSTRACT: .
Morphological studies investigating the intracranial-extradural internal carotid artery with moyamoya disease have not been reported. We designed this case–control study to investigate the morphological differences of the internal carotid artery with moyamoya disease, and to clarify the contributions of these differences to the resultant fluid dynamics.
Patients with moyamoya disease and normal controls were assigned to each group. The vascular tortuosity of internal carotid artery was measured with three-dimensional rendering using magnetic resonance angiography. By computational fluid dynamics, hemodynamic characteristics were simulated and compared between two groups.
Distances were measured from the carotid canal to the siphon. A shorter actual distance was observed in the moyamoya group (p = 0.0170). Vascular tortuosity was significantly low in moyamoya patients showing lower curvature angles in the petrous and intra-cavernous segments (p = 0.0012). Less blood flowed (p < 0.0001) through the narrower internal carotid artery (p < 0.0001) in the moyamoya group at the carotid canal level. The blood flow velocities were not significantly different (p = 0.2332). Faster blood flow and higher wall shear stress in the internal carotid artery bifurcation were verified with computational fluid dynamics.
Significant morphological differences were confirmed to exist in the intracranial-extradural internal carotid artery of moyamoya patients. These differences might influence the hemodynamics around the bifurcation of the internal carotid artery
[Show abstract][Hide abstract] ABSTRACT: Elevated cellular retinoic acid binding protein-I (CRABP-I) is thought to be related to the abnormal proliferation and migration of smooth muscle cells (SMCs). Accordingly, a higher CRABP-I level could cause disorganized vessel walls by causing immature SMC phenotypes and altering extracellular matrix proteins which could result in vulnerable arterial walls with inadequate responses to hemodynamic stress. We hypothesized that elevated CRABP-I level in the cerebrospinal fluid (CSF) could be related to subarachnoid hemorrhage (SAH). Moreover, we also extended this hypothesis in patients with vascular malformation according to the presence of hemorrhage.
We investigated the CSF of 26 patients : SAH, n=7; unruptured intracranial aneurysm (UIA), n=7; arteriovenous malformation (AVM), n=4; cavernous malformation (CM), n=3; control group, n=5. The optical density of CRABP-I was confirmed by Western blotting and presented as mean±standard error of the measurement.
CRABP-I in SAH (0.33±0.09) was significantly higher than that in the UIA (0.12±0.01, p=0.033) or control group (0.10±0.01, p=0.012). Hemorrhage presenting AVM (mean 0.45, ranged 0.30-0.59) had a higher CRABP-I level than that in AVM without hemorrhage presentation (mean 0.16, ranged 0.14-0.17). The CRABP-I intensity in CM with hemorrhage was 0.21 and 0.31, and for CM without hemorrhage 0.14. Overall, the hemorrhage presenting group (n=11, 0.34±0.06) showed a significantly higher CRABP-I intensity than that of the non-hemorrhage presenting group (n=10, 0.13±0.01, p=0.001).
The results suggest that elevated CRABP-I in the CSF could be related with aneurysm rupture. Additionally, a higher CRABP-I level seems to be associated with hemorrhage development in vascular malformation.
Journal of Korean Neurosurgical Society 02/2015; 57(2):88-93. DOI:10.3340/jkns.2015.57.2.88 · 0.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Object:
Moyamoya disease (MMD) is a rare cerebrovascular disease and its natural history is still unclear. The authors aimed to investigate the natural course of hemodynamically stable cases of adult MMD, with the analysis of stroke risk factors.
Two hundred forty-one patients were included in this retrospective study. One hundred sixty-six (68.9%) were female, and mean age (± SD) at first visit was 41.3 ± 12.0 years (range 18-69 years). Unilateral involvement was identified in 33 patients, and 19 patients (7.9%) had a family history of MMD. According to the clinical presentations, patients were classified into hemorrhagic (n = 62, 25.7%), ischemic (n = 144, 59.8%), and asymptomatic (n = 35, 14.5%) groups. The mean duration of follow-up was 82.5 ± 62.9 months (range 7.3-347.0 months).
The annual stroke risk was 4.5%, and the annual risks of rebleeding in the hemorrhagic group and recurrent ischemic events in the ischemic group were 4.3% and 3.0%, respectively. There was no significant difference in cumulative stroke risk between the 3 groups (p = 0.461). Risk factors included thyroid disease for overall strokes (HR 2.56, 95% CI 1.16-5.67), initial hemorrhagic presentation for hemorrhagic strokes (HR 2.53, 95% CI 1.24-5.17), and initial ischemic presentation for ischemic strokes (HR 2.69, 95% CI 1.15-6.27). Familial MMD was a common risk factor for all types of stroke. Among the 3 clinical groups, the hemorrhagic group showed the worst clinical status at discharge and at most recent follow-up. Twenty-three patients (9.5%) eventually underwent revascularization surgery.
There was no statistically significant difference in the incidence of stroke in the different clinical groups; clinical status, however, was most severe in patients with hemorrhagic presentation. In patients who experienced stroke during the follow-up period, the stroke type tended to correspond to their initial presentation. Close follow-up is needed in patients with thyroid disease and a family history of MMD.
Journal of Neurosurgery 10/2014; 9(1):1-8. DOI:10.3171/2014.9.JNS132281 · 3.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background and purpose:
The surgical outcomes of adult moyamoya disease are rarely reported. We aimed to evaluate the long-term outcomes of combined revascularization surgery in patients with adult moyamoya disease.
Combined revascularization surgery consisting of superficial temporal artery-middle cerebral artery anastomosis with encephalodurogaleosynangiosis was performed on 77 hemispheres in 60 patients. Clinical, angiographic, and hemodynamic states were evaluated retrospectively using quantitative methods preoperatively and postoperatively in the short-term (≈6 months) and long-term (≈5 years) periods. The mean clinical follow-up duration was 71.0±10.1 months (range, 60-104 months).
Clinical status improved until 6 months after surgery and remained stable thereafter, as assessed by the Karnofsky Performance Scale and modified Rankin Scale. The revascularization area relative to supratentorial area significantly increased in the long-term period compared with that in the short-term period (54.8% versus 44.2%; P<0.001). Cerebral blood flow in the territory of the middle cerebral artery improved in the short-term period compared with that in the preoperative period (68.7 versus 59.1; considering blood flow of the pons as 50; P<0.001) and thereafter became stable (65.5 in the long term; P=0.219). The annual risks of symptomatic hemorrhage and infarction were 0.4% and 0.2%, respectively, in the operated hemispheres.
Combined revascularization surgery resulted in satisfactory long-term improvement in clinical, angiographic, and hemodynamic states and prevention of recurrent stroke.
[Show abstract][Hide abstract] ABSTRACT: The purpose of this clinical practice guideline (CPG) is to provide current and comprehensive recommendations for the medical and surgical management of primary intracerebral hemorrhage (ICH). Since the release of the first Korean CPGs for stroke, evidence has been accumulated in the management of ICH, such as intracranial pressure control and minimally invasive surgery, and it needs to be reflected in the updated version. The Quality Control Committee at the Korean Society of cerebrovascular Surgeons and the Writing Group at the Clinical Research Center for Stroke (CRCS) systematically reviewed relevant literature and major published guidelines between June 2007 and June 2013. Based on the published evidence, recommendations were synthesized, and the level of evidence and the grade of the recommendation were determined using the methods adapted from CRCS. A draft guideline was scrutinized by expert peer reviewers and also discussed at an expert consensus meeting until final agreement was achieved. CPGs based on scientific evidence are presented for the medical and surgical management of patients presenting with primary ICH. This CPG describes the current pertinent recommendations and suggests Korean recommendations for the medical and surgical management of a patient with primary ICH.
Journal of Korean Neurosurgical Society 09/2014; 56(3):175-87. DOI:10.3340/jkns.2014.56.3.175 · 0.64 Impact Factor