Fusiform posterior cerebral artery aneurysm treated with excision and end-to-end anastomosis. Case report

A case of a ruptured fusiform aneurysm of the posterior cerebral artery is reported. The aneurysm was excised and end-to-end anastomosis was carried out between the two ends of the posterior cerebral artery. There is no previous report of a posterior cerebral artery aneurysm treated with this technique. The pertinent literature is reviewed and the significance of this technique in the treatment of unclippable cerebral aneurysms is discussed.     

Coil embolization of a ruptured posterior cerebral artery aneurysm via the internal carotid artery and a posterior communicating artery: a case report

A posterior cerebral artery aneurysm is a rare condition. Various surgical approaches have to be considered for operating on these aneurysms because the position of the aneurysm and the surrounding structures restrict the operative field and render the operation difficult. Recently, endovascular treatments for posterior cerebral artery aneurysms have been reported to provide a good outcome. We present a case of a ruptured posterior cerebral artery aneurysm treated with coil embolization. We adopted endovascular treatment because a large vein of Labbé was expected to restrict the operative field. The internal carotid artery and a fetal-type posterior communicating artery (PCoA) were chosen as the access route because of P1 hypoplasty, and a coaxial guiding system was used because of the tortuous access route. The aneurysm was suitably embolized using Guglielmi detachable coils (GDCs). In a case of posterior cerebral artery aneurysm, we report the usefulness of endovascular treatment performed through the internal carotid artery and a fetal-type PCoA.     

Spontaneous thrombosis of a fusiform aneurysm arising from the distal posterior cerebral artery: case report

A 58-year-old woman complaining of a mild headache was admitted to our hospital. MRI 3 months before admission revealed a round lesion at the right quadrigeminal cistern. Cerebral angiograms demonstrated a fusiform aneurysm arising from the parietooccipital artery, which is the distal branch of the right posterior cerebral artery. Repeated MRI and cerebral angiograms performed on admission demonstrated complete thrombosis of an aneurysm and the parent artery without any clinical symptoms. This is the first case of complete spontaneous thrombosis of an aneurysm of the distal posterior cerebral artery. The mechanism of its development and spontaneous thrombosis in a fusiform aneurysm is discussed.     

Fusiform Aneurysm of the Posterior Cerebral Artery: Report of Two Cases

Summary.  Two cases with fusiform aneurysm in the posterior cerebral artery are presented: The first one is a large fusiform aneurysm of the P₂ segment of posterior cerebral artery (PCA) in a 58 years old patient and the second a fusiform aneurysm of the P₃ segment of PCA in a 43 years old patient.  The aneurysms were successfully treated the first by proximal ligation and the second by trapping of the aneurysm. The patients had no additional neurological deficits postoperatively and they are in an good condition, in four years and one year follow up respectively.  The operative approaches and the radiological investigation in relation to the micro-anatomy of the posterior cerebral artery, as well as the outcome in these cases are discussed.     

Confirmation of blood flow in perforating arteries using fluorescein cerebral angiography during aneurysm surgery

OBJECT: The authors performed fluorescein cerebral angiography in patients after aneurysm clip placement to confirm the patency of the parent artery, perforating artery, and other arteries around the aneurysm. METHODS: Twenty-three patients who underwent aneurysm surgery were studied. Aneurysms were located in the internal carotid artery in 12 patients, middle cerebral artery in six, anterior cerebral artery in three, basilar artery bifurcation in one, and junction of the vertebral artery (VA) and posterior inferior cerebellar artery in one. After aneurysm clip placement, the target arteries were illuminated using a beam from a blue light-emitting diode atop a 7-mm diameter pencil-type probe. In all patients, after intravenous administration of 5 ml of 10% fluorescein sodium, fluorescence in the vessels was clearly observed through a microscope and recorded on videotape. RESULTS: The excellent image quality and spatial resolution of the fluorescein angiography procedure facilitated intraoperative real-time assessment of the patency of the perforating arteries and branches near the aneurysm, including: 12 posterior communicating arteries; 12 anterior choroidal arteries; four lenticulostriate arteries; three recurrent arteries of Heubner; three hypothalamic arteries; one ophthalmic artery; one perforating artery arising from the VA; and one posterior thalamoperforating artery. All 23 patients experienced an uneventful postoperative course without clinical symptoms of perforating artery occlusion. CONCLUSIONS: Because the fluorescein angiography procedure described here allows intraoperative confirmation of the patency of perforating arteries located deep inside the surgical field, it can be practically used for preventing unexpected cerebral infarction during aneurysm surgery.     

Aneurysm originating from the fenestration of the posterior cerebral artery: case report

OBJECTIVE AND IMPORTANCE: A rare case of an aneurysm arising at the fenestration of the P2 segment of the posterior cerebral artery is reported. CLINICAL PRESENTATION: A 37-year-old man presented with severe headache and disturbance of consciousness. Computed tomographic scanning showed diffuse subarachnoid hemorrhage. Cerebral angiography revealed an aneurysm at the fenestration of the P2 segment of the right posterior cerebral artery. The aneurysm was located at the middle portion of the lower trunk of the fenestration. An unruptured arteriovenous malformation was incidentally found in the right thalamus. INTERVENTION: A right frontotemporal craniotomy with orbitozygomatic osteotomy was made, and the aneurysm was successfully clipped. One year after the operation, gamma knife surgery was performed for the right thalamic arteriovenous malformation. CONCLUSION: This is the first reported case of an aneurysm originating from the middle portion of a fenestrated posterior cerebral artery.     

Spontaneous middle cerebral artery occlusion leading to moyamoya phenomenon and aneurysm formation on collateral arteries

BACKGROUND: Spontaneous middle cerebral artery occlusion associated with moyamoya phenomenon is distinct from moyamoya disease. The hemodynamic stress on the collateral channel occasionally leads to aneurysm formation, which may manifest as hemorrhage. The etiology of this disease has not been fully understood. CASE DESCRIPTION: A 63-year-old woman presented with left putaminal hemorrhage. The cerebral angiogram revealed a significant stenosis in the proximal segment of the left middle cerebral artery. Collateral arteries originating from the horizontal segment of the ipsilateral anterior cerebral artery and the ambient segment of the ipsilateral posterior cerebral artery supplied the middle cerebral artery distal to the stenosis. Both of the collateral channels had associated aneurysms that were surgically obliterated. The aneurysm on the collateral artery from the posterior cerebral artery was responsible for the putaminal hemorrhage. CONCLUSIONS: Spontaneous middle cerebral artery occlusion may lead to focal moyamoya phenomenon and aneurysmal intracerebral, intraventricular, or subarachnoid hemorrhage. The presence of a co-existing anomalous collateral artery in the present case suggests a congenital etiology of the focal middle cerebral artery occlusion.     

Proximal migration and compaction of an Enterprise stent into a coiled basilar apex aneurysm: a posterior circulation phenomenon?

A patient with a giant partially thrombosed basilar apex aneurysm was treated with balloon-assisted coil embolization. At the conclusion of the embolization, an Enterprise stent was placed from the upper basilar artery to the left P1 segment. Follow-up angiography 4 months later showed that the distal stent had pulled out of the posterior cerebral artery and was in the coil mass within the aneurysm. Angiography clearly showed that the stent had migrated down the basilar artery and that the artery was now kinked proximal to the stent. Nonetheless, the left posterior cerebral artery and the basilar artery were still widely patent. This is the first documented case in which a stent 'compacted' into a completed coiled aneurysm in a delayed fashion.     

Anterior subtemporal approach for posteriorly projecting posterior communicating artery aneurysms

We report our experience with the anterior subtemporal approach for the posterior communicating artery aneurysm protruding posteriorly. Between 2000 and 2005, seven patients with posterior communicating artery aneurysm were operated on through the anterior subtemporal approach. The approach provided a better view than the pterional approach. This approach seems to be suitable for posteriorly projecting posterior communicating artery aneurysms. The advantages of the anterior subtemporal approach are as follows: (1) It provides a short and a direct trajectory to the aneurysm. (2) Aneurysmal neck and surrounding structures can be easily identified and secured compared with the pterional approach. (3) A previously placed clip for a middle cerebral artery or internal carotid artery aneurysm through the pterional route does not interfere with the clipping surgery for regrown or de novo posterior communicating artery aneurysms.     

Endovascular occlusion of intracranial vessels for curative treatment of unclippable aneurysms: report of 16 cases

Among 121 intracerebral aneurysms presenting at one institution between 1984 and 1989, 16 were treated by endovascular means. All 16 lesions were intradural and intracranial, and had failed either surgical or endovascular attempts at selective exclusion with parent vessel preservation. The lesions included four giant middle cerebral artery (MCA) aneurysms, one giant anterior communicating artery aneurysm, six giant posterior cerebral artery aneurysms, one posterior inferior cerebellar artery aneurysm, one giant mid-basilar artery aneurysm, two giant fusiform basilar artery aneurysms, and one dissecting vertebral artery aneurysm. One of the 16 patients failed an MCA test occlusion and was approached surgically after attempted endovascular selective occlusion. Treatment involved pretreatment evaluation of cerebral blood flow followed by a preliminary parent vessel test occlusion under neuroleptic analgesia with vigilant neurological monitoring. If the test occlusion was tolerated, it was immediately followed by permanent occlusion of the parent vessel with either detachable or nondetachable balloon or coils. The follow-up period ranged from 1 to 8 years. Excellent outcomes were obtained in 12 cases with complete angiographic obliteration of the aneurysm and no new neurological deficits and/or improvement of the preembolization symptoms. Four patients died: two related to the procedure, one secondary to rupture of another untreated aneurysm, and the fourth from a postoperative MCA thrombosis after having failed endovascular test occlusion. The angiographic, clinical, and cerebral blood flow criteria for occlusion tolerance are discussed.     

Rupture of previously documented small asymptomatic saccular intracranial aneurysms. Report of three cases.

In a recent study from the Mayo Clinic on the natural history of intact saccular intracranial aneurysms, none of the aneurysms smaller than 10 mm in diameter ruptured. It was concluded that these aneurysms carry a negligible risk for future hemorrhage and that surgery for their repair could not be recommended. These findings and recommendations have been the subject of much controversy. The authors report three patients with previously documented asymptomatic intact saccular intracranial aneurysms smaller than 5 mm in diameter that subsequently ruptured. In Case 1, a 70-year-old man bled from a 4-mm middle cerebral artery aneurysm that had been discovered incidentally 2 1/2 years previously during evaluation of cerebral ischemic symptoms. A 10-mm internal carotid artery aneurysm and a contralateral 4-mm middle cerebral artery aneurysm had not ruptured. Case 2 was that of a 66-year-old woman who bled from a 4-mm pericallosal aneurysm that had been present 9 1/2 years previously when she suffered subarachnoid hemorrhage (SAH) from a 7 x 9-mm posterior inferior cerebellar artery aneurysm. Although the pericallosal aneurysm had not enlarged in the intervening years, a daughter aneurysm had developed. The third patient was a 45-year-old woman who bled from a 4- to 5-mm posterior inferior cerebellar artery aneurysm that had measured approximately 2 mm on an angiogram obtained 4 years previously; at that time she had suffered SAH due to rupture of a 5 x 12-mm posterior communicating artery aneurysm. These cases show that small asymptomatic intact saccular intracranial aneurysms are not innocuous and that careful consideration must be given to their surgical repair and long-term follow-up study.     

The limitations of three-dimensional CT angiography (3D-CTA) in the diagnosis of cerebral aneurysms

OBJECT: The purpose of this study is to show some limitations of 3D-CTA to diagnose cerebral aneurysms. METHODS: Sixteen saccular aneurysms less than 10 mm in diameter were included. Large and complicated aneurysms were excluded. RESULTS: Although information about perforating arteries from the posterior cerebral artery is very important for surgery of basilar bifurcation aneurysms, 3D-CTA could not delineate the perforating arteries. A small posterior communicating artery (Pcom.A.) was not detected, and it was very difficult to differentiate infundibular dilatation of the Pcom. A. from an aneurysm. A small aneurysm of the distal middle cerebral artery could not be detected. Flow direction can not be determined by 3D-CTA, and nor could the side of the neck of the anterior communicating artery aneurysm be determined. Fenestration of the anterior communicating artery and the origin of the triple anterior cerebral artery were both misdiagnosed as anterior communicating artery aneurysms. CONCLUSION: It is premature to consider 3D-CTA as a replacement for conventional angiography.     

Peripheral branch (P4 segment) aneurysm of the posterior cerebral artery: a case report

Four to fifteen percent of all intracranial aneurysms reported are peripheral aneurysms of the posterior fossa. Peripheral branch aneurysm of the posterior cerebral artery has only rarely been described. A 69-year-old woman had sudden onset of severe headache and vomiting and was transferred to our hospital. On admission the patient showed mild mental impairment. She had signs of meningeal irritation and right homonymous hemianopsia. CT scan showed intracerebral hematoma in the left occipital lobe, large hematoma in the left lateral ventricle and subdural hematoma in the interhemispheric region. The left carotid angiogram showed an aneurysm on the parieto-occipital artery of the left posterior cerebral artery. On the 13th day from onset left occipital craniotomy was performed. When the dura was opened, subdural hematoma was seen and removed by suction. A saccular aneurysm measuring 4 X 8 mm in diameter was seen on the parieto-occipital artery. Neck clipping for the aneurysm was successfully performed and the aneurysm disappeared completely in the postoperative angiographical study. Postoperative course was uneventful and the patient was discharged.     

Giant aneurysm arising from the anterior cerebral artery and causing an isolated homonymous hemianopsia

A case of a giant aneurysm arising from the anterior cerebral artery and producing a left homonymous hemianopsia is presented. The aneurysm caused lateral compression of the posterior part of the optic chiasm. After preoperative dynamic assessment of the circle of Willis by angiography and by electroencephalographic recording during carotid artery compression, the aneurysm was trapped with microclips on the anterior cerebral artery proximal and distal to it. Visual field examination 6 months postoperatively showed complete visual field recovery. This is the first case of homonymous hemianopsia caused by an angiographically proven giant aneurysm of the ACA.     

Enlargement and rupture of distal basilar artery aneurysm after iatrogenic carotid occlusion

A case of angiographic enlargement and fatal rupture of a previously asymptomatic distal basilar aneurysm in a 12-year-old girl is reported. She had been treated by carotid sacrifice for a giant intracavernous carotid aneurysm. After superficial temporal-middle cerebral artery bypass, this patient underwent a trapping procedure and decompression of her symptomatic giant aneurysm. Despite postoperative patency of her bypass graft, the involved middle cerebral circulation was irrigated substantially by retrograde flow through her posterior communicating artery. An incidental distal basilar aneurysm involving the origin of her superior cerebellar arteries, posterior cerebral arteries, and multiple perforators was treated by a wrapping procedure. Eleven days after carotid ligation, she suffered a fatal subarachnoid hemorrhage from her basilar aneurysm. This catastrophe was undoubtedly produced by our failure to consider the additional hemodynamic stress placed upon the distal basilar artery by carotid sacrifice and may have been preventable by a more aggressive attack on this previously asymptomatic lesion.     

Familial cerebral aneurysms in three families, with two sibling pairs

The authors describe two pairs of siblings and a mother-son with cerebral aneurysms and the characteristics of familial intracranial aneurysms are briefly discussed. Family 1: A 54-year-old hypertensive woman (case 1) developed subarachnoid hemorrhage and a saccular aneurysm at the proximal portion of the left anterior cerebral artery was demonstrated on the angiogram. An azygos anterior cerebral artery was found as an associated anomaly. A 53-year-old hypertensive woman (case 2), a younger sister of case 1, suffered from subarachnoid hemorrhage and a saccular aneurysm at the distal portion of the right anterior cerebral artery was found on the angiogram. Vertebral angiogram showed bilateral fenestration of the extracranial vertebral arteries as a coincidental anomalies. Neck clipping for the aneurysms were successfully done in these two cases. Family 2: A 52-year-old hypertensive woman (case 3) suffered from subarachnoid hemorrhage and vertebral angiogram demonstrated a saccular aneurysm at the distal portion of the right posterior inferior cerebellar artery. The aneurysm was re-bled before surgical intervention and she died five days after admission. A 65-year-old hypertensive woman (case 4), an elder sister of case 3, was admitted with subarachnoid hemorrhage. Vertebral angiogram showed a saccular aneurysm on the proximal portion of the left posterior inferior cerebellar artery at the junction of the vertebral artery and a massive extravasation of the contrast medium from the aneurysm. The patient died three days after the onset before surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Basilar bifurcation aneurysm associated with internal carotid artery occlusion. Report of two cases

Two cases of subarachnoid hemorrhage caused by rupture of a basilar bifurcation aneurysm associated with occlusion of the internal carotid artery (ICA) at the neck are presented. Case 1, a 71-year-old female, was hospitalized in a coma. Angiography demonstrated occlusion of the bilateral ICA, collateral blood supply through the branches of the foramen rotundum or vidian artery from the maxillary arteries and right posterior communicating artery, and a saccular aneurysm at the basilar bifurcation. The patient died 1 month later following rerupture of the aneurysm. Case 2, a 64-year-old male, was hospitalized for drowsiness. Angiography showed occlusion of the right ICA, collateral blood supply through a tortuous artery (a vidian artery), and a large aneurysm at the basilar bifurcation. Posterior circulation supplied anteriorly through the right posterior communicating artery. The patient died 1 month later because of rerupture of the aneurysm. Laminar thrombosis of the right ICA and an anastomotic vessel, seemingly a branch of the foramen rotundum or a vidian artery, were demonstrated by autopsy. The combination of cerebral aneurysm and collateral circulation is extremely rare in cases of occlusion of the ICA. The two cases described here suggest that hemodynamic stress is an important factor in the formation of cerebral aneurysms.     

Anesthesia with controlled hypotension for treatment of intracranial arterial aneurysm in an infant

A case is reported of a ruptured intracranial aneurysm of the posterior cerebral artery in a 21/2 month old infant. The clinical picture of subarachnoid haemorrhage included coma, seizures and left hemiparesis. The aneurysm was detected by two dimensional ultrasonography and CT scan. The carotid and vertebral arteriogram showed an aneurysm located on the posterior cerebral artery. Surgery was performed after neurological improvement, 25 days after admission. The operation was conducted under controlled systemic hypotension using sodium nitroprusside. The mean blood pressure was decreased from 70 mmHg to 40 mmHg during 20 min. This technique established good haemostatic conditions during removal of the aneurysm. Postoperative recovery was uneventful with full neurological recovery. The interest of sodium nitroprusside as a hypotensive agent is discussed. The difficulties of monitoring haemodynamic variables in infants are stressed.     

A case of distal posterior cerebral artery aneurysm associated with occlusion of the internal carotid artery

Hemodynamic stress is considered one of the most important factors in the growth of cerebral aneurysms. The authors report a rare case of cerebral aneurysm located at the distal posterior cerebral artery (PCA) in which collateral circulation developed due to occlusion of the internal carotid artery (ICA). A 73-year-old male was admitted to our hospital with a sudden headache and nausea. Computerized tomography (CT) revealed an intracerebral hematoma in the right parieto-occipital lobe and the acute subdural hematoma in both the cerebral interhemispheric fissure and the convexity. Moreover, angiography revealed a saccular aneurysm at the P4 portion of the PCA. The right ICA was occluded at the cervical portion and collateral circulation which had developed in the PCA was extended to the region of the right middle cerebral artery. The aneurysm was clipped 15 days after admission without new neurological complications. This case demonstrates that increased hemodynamic stress plays a role in the growth and rupture of cerebral aneurysm.     

A case of multiple mycotic intracranial aneurysms

A patient with multiple mycotic aneurysms associated with infective endocarditis is reported. A 45-year-old man was admitted on February 16, 2001 under the diagnosis of infective endocarditis. After alpha-streptococcus was identified by a blood culture, he was treated with high doses of antibiotics. However, 2 weeks after admission, he suddenly suffered from headache and mild left hemiparesis. A CT showed a parenchymal hematoma in the right parietal lobe. Cerebral angiography demonstrated aneurysms of the bilateral middle cerebral artery and the left posterior cerebral artery. At first, we trapped and resected the ruptured right middle cerebral aneurysm. After the surgery, we tried to treat two unruptured aneurysms by endovascular treatment. During the provocation test for the posterior cerebral artery, the arterial wall was perforated by a guide wire. The parent artery was occluded by coils at this site. Although the aneurysm was still filled by retrograde blood flow, it finally disappeared six months after treatment. The left middle cerebral artery aneurysm could not be treated because the provocation test showed cognitive deficits. The patient recovered from infective endocarditis after four-months of antibiotic therapy; and the unruptured aneurysm had not changed in size for 11 months. Recently, the outcome of patients with intracranial mycotic aneurysm is improved by development of multimodality management. Especially, endovascular therapy may become an effective treatment for unruptured aneurysms, but it is necessary to take risks, such as arterial perforation into consideration.