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Voura EB, Stulb JR, Eller JL, Padalino DJ, Ramaswamy R. Delayed Iatrogenic Direct Carotid Cavernous Fistula Following Flow Diversion for Aneurysm With Spontaneous Healing: A Case Report. Cureus 2024; 16:e58944. [PMID: 38800138 PMCID: PMC11126303 DOI: 10.7759/cureus.58944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2024] [Indexed: 05/29/2024] Open
Abstract
An abnormal connection between the carotid artery and cavernous sinus is referred to as a carotid cavernous fistula (CCF). A direct CCF results when the connection occurs between the intracranial internal carotid artery (ICA) and the cavernous sinus. These events are typically the result of a head injury, but can also be iatrogenic, resulting from various intracranial procedures. Direct CCF occurrences rarely heal spontaneously due to the high flow rate across the fistula. In this report, we present an uncommon case involving a delayed iatrogenic direct CCF, which developed following the placement of a pipeline flow-diverting stent that was used to treat a cerebral aneurysm. Interestingly, this unusual iatrogenic direct CCF subsequently spontaneously resolved within a few months. To our knowledge, this is the only case of a delayed CCF occurring with the use of a flow-diverting sent, which then resolved on its own. This report recounts our experience with the case.
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Affiliation(s)
- Evelyn B Voura
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
- Department of Neuroscience and Physiology, State University of New York Upstate Medical University, Syracuse, USA
| | - John R Stulb
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| | - Jorge L Eller
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| | - David J Padalino
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
| | - Raghu Ramaswamy
- Department of Neurosurgery, Crouse Neuroscience Institute, Crouse Health at Crouse Hospital, Crouse Medical Practice, PLLC, Syracuse, USA
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Qu LZ, Dong GH, Zhu EB, Lin MQ, Liu GL, Guan HJ. Carotid-cavernous fistula following mechanical thrombectomy of the tortuous internal carotid artery: A case report. World J Clin Cases 2023; 11:6005-6011. [PMID: 37727479 PMCID: PMC10506033 DOI: 10.12998/wjcc.v11.i25.6005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 07/26/2023] [Accepted: 07/31/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND A carotid-cavernous fistula (CCF) is an abnormal connection between the internal carotid artery (ICA) and the cavernous sinus. Although direct CCFs typically result from trauma or as an iatrogenic complication of neuroendovascular procedures, they can occur as surgery-related complications after mechanical thrombectomy (MT). With the widespread use of MT in patients with acute ischemic stroke complicated with large vessel occlusion, it is important to document CCF following MT and how to avoid them. In this study, we present a case of a patient who developed a CCF following MT and describe in detail the characteristics of ICA tortuosity in this case. CASE SUMMARY A 60-year-old woman experienced weakness in the left upper and lower limbs as well as difficulty speaking for 4 h. The neurological examination revealed left central facial paralysis and left hemiplegia, with a National Institutes of Health Stroke Scale score of 9. Head magnetic resonance imaging revealed an acute cerebral infarction in the right basal ganglia and radial crown. Magnetic resonance angiography demonstrated an occlusion of the right ICA and middle cerebral artery. Digital subtraction angiography demonstrated distal occlusion of the cervical segment of the right ICA. We performed suction combined with stent thrombectomy. Then, postoperative angiography was performed, which showed a right CCF. One month later, CCF embolization was performed, and the patient's clinical symptoms have significantly improved 5 mo after the operation. CONCLUSION Although a CCF is a rare complication after MT, it should be considered. Understanding the tortuosity of the internal carotid-cavernous sinus may help predict the complexity of MT and avoid this complication.
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Affiliation(s)
- Lin-Zhuo Qu
- Department of Medicine, Yanbian University, Yanji 133000, Jilin Province, China
| | - Guang-Hui Dong
- Department of Neurology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - En-Bo Zhu
- Department of Neurology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Ming-Quan Lin
- Department of Neurology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Guang-Lin Liu
- Department of Neurology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Hong-Jian Guan
- Department of Neurology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
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Tan R, van den Berg R, Brandsen RP, Saeed P. Likelihood of spontaneous closure of cavernous sinus dural arteriovenous fistulas based on clinical and radiological findings. Interv Neuroradiol 2023:15910199231164833. [PMID: 36945855 DOI: 10.1177/15910199231164833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Cavernous sinus dural arteriovenous fistula (CSDAVF) is a rare condition that radiologists would encounter in their careers. We aim to describe the clinical and radiological characteristics of this condition, and to provide a management workflow. METHODS In our retrospective study, we studied 27 patients with CSDAVF from January 2007 to August 2020. Patients with direct cavernous sinus AVFs and patients with incomplete date were excluded. Clinical and radiological data were collected and analyzed. RESULTS Fourteen patients were conservatively treated with spontaneous resolution while 13 patients had endovascular intervention performed. In the intervention group, seven patients had intra-cranial reflux seen on radiological imaging and six patients had clinical deterioration, hence requiring intervention. Clinically, among our patients, 21 had proptosis, 20 had conjunctiva hyperaemia, 18 had extraocular movement limitation, 13 had raised intraocular pressure, 11 had chemosis, ten had ocular pain, nine had ocular bruit, eight had headache and six had worsening visual acuity. Radiologically, a concurrence was seen between superior ophthalmic vein thrombosis and spontaneous resolution of the CSDAVF, as compared to those who underwent intervention. A paradoxical increase of ocular symptoms was seen despite a decrease of flow or stagnation of contrast in radiological imaging of CSDAVF. CONCLUSIONS In our study, 52% of CSDAVF closed spontaneously. As deterioration of ocular symptoms in patients with CSDAVF might also reflect spontaneous progressive occlusion, it warrants dynamic vascular imaging to check the status of venous outflow. Patients with CSDAVF with corticovenous reflux or deterioration of visual acuity need more urgent (endovascular) treatment.
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Affiliation(s)
- Roy Tan
- Department of Ophthalmology, Orbital Centre, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Rajani P Brandsen
- Department of Ophthalmology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Peerooz Saeed
- Department of Ophthalmology, Orbital Centre, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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Miyamoto S, Kato N, Yamazaki T, Yamano A, Akutsu Y, Yasuda S, Matsumaru Y, Ishikawa E. Direct Carotid-Cavernous Fistula Caused by Internal Carotid Artery Perforation by a Microcatheter Body during Mechanical Thrombectomy. Asian J Neurosurg 2022; 17:638-641. [PMID: 36570747 PMCID: PMC9771614 DOI: 10.1055/s-0042-1757629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rapid advances in emergent mechanical thrombectomy have resulted in a higher occurrence of arterial perforations during neurointerventions. Here, we report a case of internal carotid artery (ICA) perforation during mechanical thrombectomy in a 78-year-old man with a left middle cerebral artery occlusion. The ICA was perforated by a microcatheter during thrombectomy, forming a direct carotid-cavernous fistula. A two-stage drainer occlusion was conducted because of cortical venous reflex aggravation and ocular symptoms. Here, we report the perforation details and treatment, adding to evidence that ICA perforation with the microcatheter body is a concern during mechanical thrombectomy.
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Affiliation(s)
- Satoshi Miyamoto
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan,Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Tomosato Yamazaki
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Akinari Yamano
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Yoshimitsu Akutsu
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Susumu Yasuda
- Department of Neurosurgery, Mito Medical Center, Mito, Ibaraki, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan,Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Eiichi Ishikawa
- Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan,Address for correspondence Eiichi Ishikawa, MD, PhD Department of Neurosurgery, Faculty of Medicine, University of TsukubaTsukuba, Ibaraki, 305-8575Japan
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Iatrogenic carotid-cavernous fistula secondary to endovascular rescue of a left M1 occlusion in the presence of a cavernous carotid aneurysm utilizing a stentriever. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Iampreechakul P, Tirakotai W, Tanpun A, Wattanasen Y, Lertbusayanukul P, Siriwimonmas S. Spontaneous resolution of direct carotid-cavernous fistulas: case series and literature review. Interv Neuroradiol 2018; 25:71-89. [PMID: 30244626 DOI: 10.1177/1591019918800220] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Spontaneous regression of direct carotid-cavernous fistulas (CCFs) is extremely rare. Most of the patients with direct CCFs are usually treated using endovascular techniques. Spontaneous obliteration of the direct fistulas probably results from thrombosis of the venous drainage and/or cavernous sinus. We report spontaneous closure of nine direct CCFs in nine patients. From literature review, we found another 37 patients with 43 fistulas due to spontaneous obliteration of bilateral lesions in six cases. There was no spontaneous closure in large-sized fistula. The factors associated with spontaneous thrombosis of the fistulas may be low-flow and small-sized fistula, hypotension, severe ocular manifestations, dissections or spasm of carotid artery, and increased intracranial pressure. Spontaneous healing of direct traumatic CCFs should be confirmed with cerebral angiography. Conservative treatment of direct CCFs should be carefully restricted in patients with normal vision or minimal visual impairment, and the patients must be monitored closely for any changes in visual function. Prompt endovascular treatment for complete obliteration of the fistula should be performed in patients with rapidly progressive visual loss. Venous thrombosis can still effect vision and rerouting towards cortical veins remains a concern. Because spontaneous resolution cannot be reliably predicted, the fistula then should be treated rather than waiting for spontaneous thrombosis.
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Affiliation(s)
| | - Wuttipong Tirakotai
- 1 Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | - Adisak Tanpun
- 1 Department of Neurosurgery, Prasat Neurological Institute, Bangkok, Thailand
| | - Yodkhwan Wattanasen
- 2 Department of Neuroradiology, Prasat Neurological Institute, Bangkok, Thailand
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Yeh CF, Chen YH, Lin MS, Huang CC, Hung CS, Meng SW, Lee CK, Kao HL. Carotid-cavernous fistula after endovascular intervention for chronic carotid artery total occlusion. Catheter Cardiovasc Interv 2017; 91:735-741. [DOI: 10.1002/ccd.27392] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/23/2017] [Accepted: 10/09/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Chih-Fan Yeh
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Yin-Hsien Chen
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Mao-Shin Lin
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Ching-Chang Huang
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Chi-Sheng Hung
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital; Taipei Taiwan
| | - Shih-Wei Meng
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital Hsinchu Branch; Hsinchu Taiwan
| | - Chih-Kuo Lee
- Division of Cardiology, Department of Internal Medicine; National Taiwan University Hospital Hsinchu Branch; Hsinchu Taiwan
| | - Hsien-Li Kao
- Department of Internal Medicine; National Taiwan University College of Medicine; Taipei Taiwan
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Aguiar GBDE, Silva JM, Paiva AL, Jory M, Conti ML, Veiga JC. Endovascular treatment of carotid-cavernous vascular lesions. Rev Col Bras Cir 2017; 44:46-53. [PMID: 28489211 DOI: 10.1590/0100-69912017001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 09/22/2016] [Indexed: 11/22/2022] Open
Abstract
Objective: to evaluate the endovascular treatment of vascular lesions of the cavernous segment of the internal carotidartery (ICA) performed at our institution. Methods: we conducted a descriptive, retrospective and prospective study of patients with aneurysms of the cavernous portion of the ICA or with direct carotid-cavernous fistulas (dCCF) undergoing endovascular treatment. Results: we included 26 patients with intracavernous aneurysms and ten with dCCF. All aneurysms were treated with ICA occlusion. Those with dCCF were treated with occlusion in seven cases and with selective fistula occlusion in the remaining three. There was improvement of pain and ocular proptosis in all patients with dCCF. In patients with intracavernous aneurysms, the incidence of retro-orbital pain fell from 84.6% to 30.8% after treatment. The endovascular treatment decreased the dysfunction of affected cranial nerves in both groups, especially the oculomotor one. Conclusion: the endovascular treatment significantly improved the symptoms in the patients studied, especially those related to pain and oculomotor nerve dysfunction. Objetivo: avaliar o tratamento endovascular de lesões vasculares da artéria carótida interna (ACI), segmento cavernoso, realizado na Santa Casa de São Paulo. Métodos: estudo descritivo, retrospectivo e prospectivo, de pacientes com aneurisma da porção cavernosa da ACI ou com fístulas carótido-cavernosas diretas (FCCd) submetidos a tratamento endovascular. Resultados: foram incluídos 26 pacientes com aneurismas intracavernosos e dez com FCCd. Todos os aneurismas foram tratados com oclusão da ACI. Os com FCCd foram tratados com oclusão, em sete casos, e com oclusão seletiva da fístula nos outros três. Houve melhora da dor e proptose ocular em todos os pacientes com FCCd. Nos pacientes com aneurisma intracavernoso, a incidência de dor retro-orbitária caiu de 84,6% para 30,8% após o tratamento. Após o tratamento endovascular houve uma melhora importante da disfunção de nervos cranianos afetados em ambos os grupos, sobretudo no nervo oculomotor. Conclusão: o tratamento endovascular trouxe melhora para os pacientes deste estudo, especialmente nos critérios dor e acometimento do nervo oculomotor.
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Affiliation(s)
| | - João Miguel Silva
- - Faculty of Medical Sciences, São Paulo Holy Home, Department of Surgery, Sao Paulo, Sao Paulo State, Brazil
| | - Aline Lariessy Paiva
- - Faculty of Medical Sciences, São Paulo Holy Home, Department of Surgery, Sao Paulo, Sao Paulo State, Brazil
| | - Maurício Jory
- - Faculty of Medical Sciences, São Paulo Holy Home, Department of Surgery, Sao Paulo, Sao Paulo State, Brazil
| | - Mario Luiz Conti
- - Faculty of Medical Sciences, São Paulo Holy Home, Department of Surgery, Sao Paulo, Sao Paulo State, Brazil
| | - José Carlos Veiga
- - Faculty of Medical Sciences, São Paulo Holy Home, Department of Surgery, Sao Paulo, Sao Paulo State, Brazil
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Aguiar GBD, Jory M, Silva JMDA, Conti MLM, Veiga JCE. Advances in the endovascular treatment of direct carotid-cavernous fistulas. Rev Assoc Med Bras (1992) 2016; 62:78-84. [DOI: 10.1590/1806-9282.62.01.78] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 06/08/2015] [Indexed: 11/22/2022] Open
Abstract
SUMMARY Carotid cavernous fistulas (CCFs) are abnormal connections between the carotid artery and the cavernous sinus. They are considered direct when there is a direct connection between the internal carotid artery and the cavernous sinus. These cases are generally traumatic. Direct CCFs are high-flow lesions, possibly related to intracranial bleeding, visual loss, corneal exposure or even fatal epistaxis. Treatment of such lesions is, thus, always recommended. The ideal treatment for direct CCF is to exclude the fistula from circulation, preserving the carotid flow. This can be attained using diverse endovascular techniques. The objective of the present article is to review the current techniques for treatment of direct CCFs, with special attention to the currently available endovascular treatment options.
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Ono K, Oishi H, Tanoue S, Hasegawa H, Yoshida K, Yamamoto M, Arai H. Direct carotid-cavernous fistulas occurring during neurointerventional procedures. Interv Neuroradiol 2015; 22:91-6. [PMID: 26628454 DOI: 10.1177/1591019915617321] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 10/03/2015] [Indexed: 11/15/2022] Open
Abstract
This study shows the frequency and types of carotid-cavernous fistula (CCF) complications that occurred during endovascular treatment. Transarterial endovascular surgeries involving the anterior circulation were performed for 1071 cases at our hospitals during four years. CCFs occurred in nine of 1071 cases (0.8%). CCF risk factors were female sex (p=0.032), aneurysmal location in the paraclinoid portion (p<0.001), and use of a distal access catheter (DAC) (p<0.001). There were no significant correlations between CCF risk and procedure type (p=0.411-1.0) and balloon use or nonuse (p=0.492). Eighty-nine percent (eight of nine) of the CCFs occurred at the genu of a cavernous internal carotid artery (ICA). Two cases of CCF disappeared spontaneously. The shunt was decreased by balloon expansion in one case, no additional treatment was required in one case, and five cases required transarterial fistula coil embolization. It is necessary to remember that a CCF may occur especially in aneurysmal treatment using a DAC in a female patient. The DAC and the 0.035-inch guidewire should be kept proximal to the carotid siphon and not go beyond it. When we cannot avoid navigating beyond it, we should consider using a softer DAC. In the case of a CCF caused by a DAC, it may be cured spontaneously or is treatable by transarterial coil embolization.
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Affiliation(s)
- Kenichiro Ono
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Hidenori Oishi
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Shunsuke Tanoue
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Hiroshi Hasegawa
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Kensaku Yoshida
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Munetaka Yamamoto
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
| | - Hajime Arai
- Department of Neurosurgery, Juntendo University School of Medicine, Japan
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Park HR, Yoon SM, Shim JJ, Bae HG, Yun IG. Iatrogenic carotid-cavernous fistula after stent assisted coil embolization of posterior communicating artery aneurysm. J Cerebrovasc Endovasc Neurosurg 2015; 17:43-8. [PMID: 25874185 PMCID: PMC4394119 DOI: 10.7461/jcen.2015.17.1.43] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Revised: 02/20/2015] [Accepted: 02/24/2015] [Indexed: 11/23/2022] Open
Abstract
Stent assisted coiling (SAC) is a useful technique for the treatment of wide necked complex aneurysm. As the frequency of SAC increases, stent-related complications such as thromboembolism, aneurysm rupture, and vessel rupture have been reported. However, to the best of our knowledge, carotid-cavernous fistula (CCF) after SAC has never been reported. The authors experienced a case of direct CCF after a SAC procedure for treatment of a complex posterior communicating artery (PCoA) aneurysm regrowth, which was treated by clip ligation 12 years before. The patient was managed conservatively and angiograms performed three months after the procedure showed the complete obliteration of the left PcoA aneurysm and the spontaneous disappearance of CCF. Navigation of Solitaire stent lumen with microcatheter can cause unexpected arterial injury, especially when the proximal tip is placed in the curved portion. It seems to be desirable to place the proximal tip of Solitaire stent in the straight portion whenever possible to reduce the risk of inadvertent arterial injury which might be caused by future navigation of stent lumen.
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Affiliation(s)
- Hye-Ran Park
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Seok-Mann Yoon
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Jai-Joon Shim
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Hack-Gun Bae
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
| | - Il-Gyu Yun
- Department of Neurosurgery, Soonchunhyang University Cheonan Hospital, Cheonan, Korea
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