Search Results

You are looking at 1 - 10 of 16 items for

  • Author or Editor: Dong-Hun Kang x
Clear All Modify Search
Restricted access

Jaechan Park and Dong-Hun Kang

Because infundibular widening most commonly appears at the origins of the posterior communicating artery and anterior choroidal artery from the internal carotid artery, its occurrence in association with the anterior communicating artery (ACoA) or the A1-A2 junction can be misinterpreted as an ACoA aneurysm on angiograms.

The authors report on 2 such cases; one in a 73-year-old woman with infundibular widening of the recurrent artery of Heubner, and the other in a 44-year-old woman with infundibular widening of a perforating vessel from the ACoA. The correct diagnosis was established based on surgical exploration. In addition, grayscale modification of 3D reconstruction images of preoperative digital subtraction angiography revealed the cases of the recurrent artery of Heubner and perforating artery of the ACoA arising from the apex of the infundibular widening.

Restricted access

Jaechan Park, Dong-Hun Kang and Bo-Young Chun

Object

For oculomotor nerve palsy (ONP) induced by unruptured posterior communicating artery (PCoA) aneurysms, the authors performed surgical clipping via a superciliary keyhole approach as an optimal treatment modality with high efficiency and low invasiveness. In this study, they then evaluated the technical feasibility, safety, clinical outcomes, including recovery from ONP as well as cosmetic results, and durability of the procedure.

Methods

Thirteen patients presenting with complete (7 patients) or incomplete (6 patients) ONP underwent surgery via a superciliary approach. The operative video record was used to evaluate the technical feasibility, neurological examinations and CT were performed to analyze the safety of the treatment, and neuroophthalmological examinations and 3D CT angiography were undertaken to determine the effectiveness and durability of the treatment.

Results

In all cases, the aneurysms were successfully clipped using a 3.5-cm eyebrow incision and supraorbital minicraniotomy. The mean operative time was 108 ± 24 minutes. Twelve (92.3%) of the 13 patients showed complete resolution of the ONP. All 6 patients (100%) with incomplete ONP recovered completely within 1–2 months after surgery, whereas 6 (85.7%) of the 7 patients with complete ONP recovered completely within 1–6 months after surgery. Cosmetic results for the operative wounds were excellent without frontalis palsy. The durability of the treatment was ascertained based on 3D CT angiograms obtained 1 year after surgery.

Conclusions

Surgical clipping via a superciliary keyhole approach can be an optimal treatment modality for PCoA aneurysms inducing ONP because it is effective, safe, and durable.

Restricted access

Bradley A. Gross, Ashutosh P. Jadhav, Brian T. Jankowitz and Tudor G. Jovin

Restricted access

Jaechan Park, Wonsoo Son, Ki-Su Park, Dong-Hun Kang and Im Hee Shin

OBJECTIVE

This study was an investigation of surgical cases of a ruptured middle cerebral artery (MCA) aneurysm that was conducted to identify the risk factors of an intraoperative premature rupture.

METHODS

Among 927 patients with a ruptured intracranial aneurysm who were treated over an 8-year period, the medical records of 182 consecutive patients with a ruptured MCA aneurysm were examined for cases of a premature rupture, and the risk factors were then investigated. The risk factors considered for an intraoperative premature rupture of an MCA aneurysm included the following: patient age; sex; World Federation of Neurosurgical Societies clinical grade; modified Fisher grade; presence of an intracerebral hemorrhage (ICH); location of the ICH (frontal or temporal); volume of the ICH; maximum diameter of the ruptured MCA aneurysm; length of the preaneurysmal M1 segment between the carotid bifurcation and the MCA aneurysm; and a sign of sphenoid ridge proximation. The sphenoid ridge proximation sign was defined as a spatial proximation < 4 mm between the sphenoid ridge and the rupture point of the MCA aneurysm, such as a daughter sac, irregularity, or dome of the aneurysm, based on the axial source images of the brain CT angiography sequences.

RESULTS

A total of 11 patients (6.0%) suffered a premature rupture of the MCA aneurysm during surgery. The premature rupture occurrences were classified according to the stage of the surgery, as follows: 1) craniotomy and dural opening (n = 1); 2) aspiration or removal of the ICH (n = 1); 3) retraction of the frontal lobe (n = 1); 4) dissection of the sphenoid segment of the sylvian fissure to access the proximal vessel (n = 4); and 5) perianeurysmal dissection (n = 4). The multivariate analysis with a binary logistic regression revealed that presence of a sphenoid ridge proximation sign (p < 0.001), presence of a frontal ICH associated with the ruptured MCA aneurysm (p = 0.019), and a short preaneurysmal M1 segment (p = 0.043) were all statistically significant risk factors for a premature rupture. Plus, a receiver operating characteristic curve analysis revealed that a preaneurysmal M1 segment length ≤ 13.3 mm was the best cutoff value for predicting the occurrence of a premature rupture (area under curve 0.747; sensitivity 63.64%; specificity 81.66%).

CONCLUSIONS

Patients exhibiting a sphenoid ridge proximation sign, the presence of a frontal ICH, and/or a short preaneurysmal M1 segment are at high risk for an intraoperative premature rupture of a MCA aneurysm. Such high-risk MCA aneurysms have a superficial location close to the arachnoid in the sphenoidal compartment of the sylvian fissure and have a rupture point directed anteriorly.

Restricted access

Jaechan Park, Tae-du Jung, Dong-Hun Kang and So-Hyun Lee

Object

Although a supraorbital keyhole approach utilizing an eyebrow incision and supraorbital minicraniotomy is one of the most commonly used keyhole approaches for treating cerebral aneurysms, the risk of frontalis muscle palsy due to an injury of the frontal branch of the facial nerve remains a serious drawback to a supraorbital keyhole approach as a minimally invasive surgical technique. Therefore, the authors attempted to evaluate the risk of frontalis muscle palsy by mapping the frontal nerve branch in the lower forehead using a nerve conduction study in individual patients.

Methods

Percutaneous mapping of the frontal nerve branch was performed preoperatively on 52 patients who underwent supraorbital keyhole approaches for aneurysmal clipping. The maximal compound muscle action potentials (CMAPs) in the lower forehead were observed at 5 points along a laterally inclined line angled 30° from the midpupillary line, in which the points were 1.0, 1.5, 2.0, 2.5, and 3.0 cm as measured from the supraorbital margin.

Results

Severe frontalis muscle palsy was observed in 11 patients (21.2%), yet recovery occurred 2–5 months after surgery. No patients experienced permanent palsy. The incidence of severe palsy was 7.4% in those patients showing clear CMAPs with a high location (exclusively at 2.0, 2.5, or 3.0 cm), 14.3% in those with a bimodal distribution, 40.0% in those with a low location (exclusively at 1.5 cm), and 83.3% in those with an extremely low location (exclusively at 1.0 cm).

Conclusions

Percutaneous mapping of the frontal branch of the facial nerve using a nerve conduction study can be used to assess the risk of postoperative frontalis muscle palsy following a supraorbital keyhole approach. The patients with the highest risk of postoperative palsy showed a clear CMAP exclusively at 1.0 cm along the inclined line measured from the supraorbital margin.

Free access

Jaechan Park, Hyunjin Woo, Dong-Hun Kang, Yong-Sun Kim, Min Young Kim, Im Hee Shin and Sang Gyu Kwak

OBJECT

While the incidence of a recurrent hemorrhage is highest within 24 hours of subarachnoid hemorrhage (SAH) and increases with the severity of the clinical grade, a recurrent hemorrhage can occur anytime after the initial SAH in patients with both good and poor clinical grades. Therefore, the authors adopted a 24-hour-a-day, formal protocol, emergency treatment strategy for patients with ruptured aneurysms to secure the aneurysms as early as possible. The incidences of in-hospital rebleeding and clinical outcomes were investigated and compared with those from previous years when broadly defined early treatment was used (< 3 days of SAH).

METHODS

During an 11-year period, a total of 1224 patients with a ruptured aneurysm were managed using a strategy of broadly defined early treatment between 2001 and 2004 (Period B, n = 423), a mixture of early or emergency treatment between 2005 and 2007, and a formal emergency treatment protocol between 2008 and 2011 (Period A, n = 442). Propensity score matching was used to adjust the differences in age, sex, modified Fisher grade, World Federation of Neurosurgical Societies (WFNS) clinical grade at admission, size and location of a ruptured aneurysm, treatment modality (clip placement vs coil embolization), and time interval from SAH to admission between the two time periods. The matched cases were allotted to Group A (n = 280) in Period A and Group B (n = 296) in Period B and then compared.

RESULTS

During Period A under the formal emergency treatment protocol strategy, the catheter angiogram, endovascular coiling, and surgical clip placement were started at a median time from admission of 2.0 hours, 2.9 hours, and 3.1 hours, respectively. After propensity score matching, Group A showed a significantly reduced incidence of in-hospital rebleeding (2.1% vs 7.4%, p = 0.003) and a higher proportion of patients with a favorable clinical outcome (modified Rankin Scale score 0–3) at 1 month (87.9% vs 79.7%, respectively; p = 0.008). In particular, the patients with good WFNS grades in Group A experienced significantly less in-hospital rebleeding (1.7% vs 5.7%, respectively; p = 0.018) and better clinical outcomes (1-month mRS score of 0–3: 93.8% vs 87.7%, respectively; p = 0.021) than the patients with good WFNS grades in Group B.

CONCLUSIONS

Patients with ruptured aneurysms may benefit from a strategy of emergency application of surgical clip placement or endovascular coiling due to the reduced incidence of recurrent bleeding and improved clinical outcomes.

Full access

Jaechan Park, Jae-Hoon Cho, Duck-Ho Goh, Dong-Hun Kang, Im Hee Shin and In-Suk Hamm

OBJECT

This study investigated the incidence and risk factors for the postoperative occurrence of subdural complications, such as a subdural hygroma and resultant chronic subdural hematoma (CSDH), following surgical clipping of an unruptured aneurysm. The critical age affecting such occurrences and follow-up results were also examined.

METHODS

The case series included 364 consecutive patients who underwent aneurysm clipping via a pterional or superciliary keyhole approach for an unruptured saccular aneurysm in the anterior cerebral circulation between 2007 and 2013. The subdural hygromas were identified based on CT scans 6–9 weeks after surgery, and the volumes were measured using volumetry studies. Until their complete resolution, all the subdural hygromas were followed using CT scans every 1–2 months. Meanwhile, the CSDHs were classified as nonoperative or operative lesions that were treated by bur-hole drainage. The age and sex of the patients, aneurysm location, history of a subarachnoid hemorrhage (SAH), and surgical approach (pterional vs superciliary) were all analyzed regarding the postoperative occurrence of a subdural hygroma or CSDH. The follow-up results of the subdural complications were also investigated.

RESULTS

Seventy patients (19.2%) developed a subdural hygroma or CSDH. The results of a multivariate analysis showed that advanced age (p = 0.003), male sex (p < 0.001), middle cerebral artery (MCA) aneurysm (p = 0.045), and multiple concomitant aneurysms at the MCA and anterior communicating artery (ACoA) (p < 0.001) were all significant risk factors of a subdural hygroma and CSDH. In addition, a receiver operating characteristic (ROC) curve analysis revealed a cut-off age of > 60 years, which achieved a 70% sensitivity and 69% specificity with regard to predicting such subdural complications. The female patients ≤ 60 years of age showed a negligible incidence of subdural complications for all aneurysm groups, whereas the male patients > 60 years of age showed the highest incidence of subdural complications at 50%–100%, according to the aneurysm location. The subdural hygromas detected 6–9 weeks postoperatively showed different follow-up results, according to the severity. The subdural hygromas that converted to a CSDH were larger in volume than the subdural hygromas that resolved spontaneously (28.4 ± 16.8 ml vs 59.6 ± 38.4 ml, p = 0.003). Conversion to a CSDH was observed in 31.3% (5 of 16), 64.3% (9 of 14), and 83.3% (5 of 6) of the patients with mild, moderate, and severe subdural hygromas, respectively.

CONCLUSIONS

Advanced age, male sex, and an aneurysm location requiring extensive arachnoid dissection (MCA aneurysms and multiple concomitant aneurysms at the MCA and ACoA) are all correlated with the occurrence of a subdural hygroma and CSDH after unruptured aneurysm surgery. The critical age affecting such an occurrence is 60 years.

Full access

Dong-Hun Kang, Duck-Ho Goh, Seung-Kug Baik, Jaechan Park and Yong-Sun Kim

Object

This study aimed to investigate morphological predictors of intraprocedural rupture (IPR) during coil embolization of ruptured cerebral aneurysms.

Methods

A retrospective analysis was conducted in 322 consecutive patients with ruptured cerebral aneurysms who were treated with coil embolization over an 8-year period from January 2005 to December 2012. The authors analyzed all available data with emphasis on morphological characteristics of the aneurysm as shown on baseline angiography in relation to IPR. Regarding aneurysm morphology, the authors classified patients according to multilobulation, presence of a daughter sac, and presence of a small basal outpouching (SBO).

Results

The incidence of IPR was 4.8% (16 of 332). In terms of aneurysm configuration, the presence of multilobulation (100.0% [16 of 16] in the IPR group vs 89.2% [282 of 316] in the non-IPR group, p = 0.388) and daughter sac (75.0% [12 of 16] in the IPR group vs 59.2% [187 of 316] in the non-IPR group, p = 0.208) were not significantly associated with IPR. However, SBO, found in 9% (30 of 332) of the study population, was significantly associated with IPR (56.3% [9 of 16] in the IPR group vs 6.7% [21 of 316] in the non-IPR group, OR 18.06, p < 0.0001).

Conclusions

Based on the authors' data, the more general groups of multilobulation and daughter sac were not significantly associated with IPR, although the more specific subgroup with an SBO was. More confirmation studies on these results are required, but they point to the possibility that SBO (with its possible connection to basal rupture) is an important morphological risk factor for IPR during coiling. In addition, future comparison of coiling and clipping treatment for ruptured aneurysms associated with an SBO seems necessary.

Restricted access

Jaechan Park, Wonsoo Son, Duck-Ho Goh, Dong-Hun Kang, Joomi Lee and Im Hee Shin

OBJECT

The highest incidence of olfactory dysfunction following a pterional approach and its modifications for an intracranial aneurysm has been reported in cases of anterior communicating artery (ACoA) aneurysms. The radiological characteristics of unruptured ACoA aneurysms affecting the extent of retraction of the frontal lobe and olfactory nerve were investigated as risk factors for postoperative olfactory dysfunction.

METHODS

A total of 102 patients who underwent a pterional or superciliary keyhole approach to clip an unruptured ACoA aneurysm from 2006 to 2013 were included in this study. Those patients who complained of permanent olfactory dysfunction after their aneurysm surgery, during a postoperative office visit or a telephone interview, were invited to undergo an olfactory test, the Korean version of the Sniffin’ Sticks test. In addition, the angiographic characteristics of ACoA aneurysms, including the maximum diameter, the projecting direction of the aneurysm, and the height of the neck of the aneurysm, were all recorded based on digital subtraction angiography and sagittal brain images reconstructed using CT angiography. Furthermore, the extent of the brain retraction was estimated based on the height of the ACoA aneurysm neck.

RESULTS

Eleven patients (10.8%) exhibited objective olfactory dysfunction in the Sniffin’ Sticks test, among whom 9 were anosmic and 2 were hyposmic. Univariate and multivariate analyses revealed that the direction of the ACoA aneurysm, ACoA aneurysm neck height, and estimated extent of brain retraction were statistically significant risk factors for postoperative olfactory dysfunction. Based on a receiver operating characteristic (ROC) analysis, an ACoA aneurysm neck height > 9 mm and estimated brain retraction > 12 mm were chosen as the optimal cutoff values for differentiating anosmic/hyposmic from normosmic patients. The values for the area under the ROC curves were 0.939 and 0.961, respectively.

CONCLUSIONS

In cases of unruptured ACoA aneurysm surgery, the height of the aneurysm neck and the estimated extent of brain retraction were both found to be powerful predictors of the occurrence of postoperative olfactory dysfunction.

Restricted access

Dong-Hun Kang, Woong Yoon, Seul Kee Kim, Byung Hyun Baek, Yun Young Lee, Yong-Won Kim, Yong-Sun Kim, Yang-Ha Hwang, Joon-Tae Kim and Man Seok Park

OBJECTIVE

The optimal treatment strategy for patients with emergent large vessel occlusion (ELVO) due to underlying severe intracranial atherosclerotic stenosis (ICAS) is unclear. The purpose of this study was to compare treatment outcomes from intracranial angioplasty with or without stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor in patients with ELVO due to severe ICAS, and to investigate predictors of outcome after endovascular therapy in such patients.

METHODS

A total of 140 consecutive patients with ELVO attributable to severe ICAS underwent endovascular therapy at two stroke centers (A and B). Intracranial angioplasty/stenting was primarily performed at center A and intraarterial infusion of glycoprotein IIb/IIIa inhibitor (tirofiban) at center B. Data from both centers were prospectively collected into a database and retrospectively analyzed.

RESULTS

Overall, successful reperfusion was achieved in 95% (133/140) of patients and a good outcome in 60% (84/140). The mortality rate was 7.9%. Symptomatic hemorrhage occurred in 1 patient. There were no significant differences in the rates of successful reperfusion, symptomatic hemorrhage, 3-month modified Rankin scale score 0–2, and mortality between the two centers. Multivariate logistic regression analysis revealed the only independent predictor of good outcome was a history of previous stroke or transient ischemic attack (TIA) (odds ratio 0.254, 95% confidence interval 0.094–0.689, p = 0.007).

CONCLUSIONS

Both intracranial angioplasty/stenting and intraarterial infusion of a glycoprotein IIb/IIIa inhibitor are effective and safe in the treatment of underlying severe ICAS in acute stroke patients with ELVO. In addition, a lack of a history of stroke/TIA was the only independent predictor of good outcome after endovascular therapy in such patients.