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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.

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Ki Young Lee, Jung-Hee Lee, Kyung-Chung Kang, Won-Ju Shin, Sang Kyu Im and Seong Jin Cho

OBJECTIVE

The incidence of proximal junctional kyphosis (PJK) after long-segment fixation in patients with adult spinal deformity (ASD) has been reported to range from 17% to 61.7%. Recent studies have reported using “hybrid” techniques in which semirigid fixation is introduced between the fused and flexible segments at the proximal level to allow a more gradual transition. The authors used these hybrid techniques in a clinical setting and analyzed PJK to evaluate the usefulness of the flexible rod (FR) technique.

METHODS

The authors retrospectively selected 77 patients with lumbar degenerative kyphosis (LDK) who underwent sagittal correction and long-segment fixation and had follow-up for > 1 year. An FR was used in 30 of the 77 patients. PJK development and spinal sagittal changes were analyzed in the FR and non-FR groups, and the predictive factors of PJK between a PJK group and a non-PJK group were compared.

RESULTS

The patient population comprised 77 patients (75 females and 2 males) with a mean (± SD) follow-up of 32.0 ± 12.7 months (36.7 ± 9.8 months in the non-FR group and 16.8 ± 4.7 months in the FR group) and mean (± SD) age of 71.7 ± 5.1 years. Sagittal balance was well maintained at final follow-up (10.5 and 1.5 mm) in the non-FR and FR groups, respectively. Thoracic kyphosis (TK) and lumbar lordosis (LL) were improved in both groups, without significant differences between the two (p > 0.05). PJK occurred in 28 cases (36.4%) in total, 3 (10%) in the FR and 25 (53.2%) in the non-FR group (p < 0.001). Postoperatively, PJK was observed at an average of 8.9 months in the non-FR group and 1 month in the FR group. No significant differences in the incidence of PJK regarding patient factors or radiological parameters were found between the PJK group and non-PJK group (p > 0.05). However, FR (vs non-FR) and interbody fusion except L5–S1 using oblique lumbar interbody fusion (vs non–oblique lumbar interbody fusion), demonstrated a significantly lower PJK prevalence (p < 0.001 and p = 0.044) among the surgical factors.

CONCLUSIONS

PJK was reduced after surgical treatment with the FR in the patients with LDK. Solid long-segment fixation and the use of the FR may become another surgical option for spine surgeons who plan and make decisions regarding spine reconstruction surgery for patients with ASD.

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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.

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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.

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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.