Journal of Neurosurgery
Min A. Yoon, Eunhee Kim, Bae-Ju Kwon, Jeong Eun Kim, Hyun-Seung Kang, Jae Hyo Park, Chul-Ho Sohn, Ji-Hoon Kim and Dong Hoon Lee
Reinforcement of aneurysms with additional wrapping is an alternative procedure if the aneurysm cannot be completely clipped. Wrapping with muslin (cotton gauze) rarely incites foreign body inflammatory reactions. In this study, the authors describe the clinical and radiological features of muslinomas or muslin-induced foreign body reactions that can develop after treatment of intracranial aneurysms.
Over a 3-year period, 5 patients with muslinomas underwent treatment at the authors' institution. All patients underwent aneursym clipping and wrapping, and were subsequently readmitted with acute or subacute neurological symptoms. Clinical and imaging features on diffusion weighted MR images and cerebral angiography images were retrospectively reviewed. The patients' clinical course and follow-up imaging studies were also evaluated.
In all 5 cases, muslinomas were seen as rim-enhancing inflammatory masses around the clipped aneurysms with perilesional edema visible on MR images at the time of clinical deterioration. The MR images also demonstrated adhesive arachnoiditis with a sterile intracranial abscess in 3 patients, optic neuropathy in 2, parent artery narrowing in 2, and a resultant acute ischemic infarction in 1 patient. Follow-up imaging revealed resolution of both the perilesional edema and adhesive arachnoiditis but no significant changes in the muslinomas. All patients underwent conservative management and fully recovered, but during the follow-up period, 2 patients experienced clinical and radiological relapses.
When a patient with a history of wrapping of an aneurysm presents with acute neurological symptoms and an enhancing intracranial mass in the region of the surgical site on MR imaging, a muslin-induced foreign body inflammatory reaction should be considered in the differential diagnosis, and careful clinical and radiological follow-up is advised.
Eun Ju Lee, Hyun Joo Lee, Min Kyung Hyun, Ji Eun Choi, Jong Hee Kim, Na Rae Lee, Jin Seub Hwang and Jin-Won Kwon
The authors investigated the rupture rate among patients with untreated unruptured intracranial aneurysms (UIAs) in South Korea during 2006–2009.
A longitudinal study using national representative health-claim data, including all hospital records for every Korean citizen, was used. Patients with a UIA who were 18–80 years old in 2006 were identified using the I67.1 ICD-10 code. To select eligible patients, a historical period of 1 year prior to the first diagnosis of a UIA in 2006 was utilized. Patients with a previous UIA diagnosis, subarachnoid hemorrhage (SAH), or treatments, such as clipping or coiling, during the historical period were excluded from analysis. Patients with head trauma or a brain tumor during the historical period were also excluded. Eligible patients were followed up for at least 3 years from the index date. Rupture was defined as SAH events with at least 14 days of hospitalization, using the I60 ICD-10 code and excluding the I60.8 code, or death within 14 days of hospitalization.
Seven thousand four hundred four patients with UIAs were identified, including 1441 treated patients (20%) and 5963 untreated patients (80%), with a median follow-up of 3.3 years. Rupture events occurred in 163 (0.9 cases/100 person-years) of the 5963 untreated patients. The rupture rate was highest in the 1st year after UIA diagnosis. An older age was a risk factor for rupture among patients with UIAs.
The overview of the incidence of rupture indicates the need for a preventive strategy and future studies to prevent rupture in Asian patients with UIAs.
Hyunwook Kwon, Dae Hyuk Moon, Youngjin Han, Jong-Young Lee, Sun U Kwon, Dong-Wha Kang, Suk Jung Choo, Tae-Won Kwon, Min-Ju Kim and Yong-Pil Cho
Controversy persists regarding the optimal management of subclinical coronary artery disease (CAD) prior to carotid endarterectomy (CEA) and the impact of CAD on clinical outcomes after CEA. This study aimed to evaluate the short-term surgical risks and long-term outcomes of patients with subclinical CAD who underwent CEA.
The authors performed a retrospective study of data from a prospective CEA registry. They analyzed a total of 702 cases involving patients without a history of CAD who received preoperative cardiac risk assessment by radionuclide myocardial perfusion imaging (MPI) and underwent CEA over a 10-year period. The management strategy (the necessity, sequence, and treatment modality of coronary revascularization and optimal perioperative medical treatment) was determined according to the presence, severity, and extent of CAD as determined by preoperative MPI and additional coronary computed tomography angiography and/or coronary angiography. Perioperative cardiac damage was defined on the basis of postoperative elevation of the blood level of cardiac troponin I (0.05–0.5 ng/ml) in the absence of myocardial ischemia. The primary endpoint was the composite of any stroke, myocardial infarction, or death during the perioperative period and all-cause mortality within 4 years of CEA. The associations between clinical outcomes after CEA and subclinical CAD were analyzed.
Concomitant subclinical CAD was observed in 81 patients (11.5%). These patients did have a higher incidence of perioperative cardiac damage (13.6% vs 0.5%, p < 0.01), but they had similar primary endpoint incidences during the perioperative period (2.5% vs.1.8%, p = 0.65) and similar estimated 4-year primary endpoint rates (13.6% vs 12.4%, p = 0.76) as the patients without subclinical CAD. Kaplan-Meier survival analysis showed that the 2 groups had similar rates of overall survival (p = 0.75).
Patients with subclinical CAD can undergo CEA with acceptable short- and long-term outcomes provided they receive selective coronary revascularization and optimal perioperative medical treatment.