Anterior spinal artery aneurysm presenting with spinal subarachnoid hemorrhage in a case of polyarteritis nodosa

Polyarteritis nodosa is characterized by presence of aneurysms in the renal, hepatic and mesenteric vasculature, and less often by vascular abnormalities in the intracranial compartment. Spinal subarachnoid hemorrhage is a rare phenomenon that can be associated with inflammatory vasculopathies such as polyarteritis nodosa, but the link between aneurysm formation and spinal subarachnoid hemorrhage in polyarteritis nodosa is unclear. We describe a case of a patient with polyarteritis nodosa and spinal subarachnoid hemorrhage following rupture of an aneurysm of the anterior spinal artery. Following operative washout and decompression of the subarachnoid hemorrhage, spinal digital subtraction angiography was performed and revealed intimal contour irregularities, stenotic changes, and multiple small aneurysms in renal, hepatic, and bronchial arteries and some proximal spinal arteries, and, most notably, a pseudoaneurysm of the anterior spinal artery supplied directly by the artery of Adamkiewicz. Polyarteritis nodosa was subsequently diagnosed in light of these findings. Though previous cases have noted spinal subarachnoid hemorrhage in of the context of polyarteritis nodosa, we found no previously documented case of a definitive aneurysm of the anterior spinal artery in a case of polyarteritis nodosa documented on angiography. This case highlights the potential importance of monitoring for aneurysms of the spinal vasculature in cases of polyarteritis nodosa and in screening for vasculitides in cases of spinal subarachnoid hemorrhage. Future studies are needed to describe patterns of the specific anatomic localization and incidence of spinal artery aneurysms in polyarteritis nodosa.     

Aneurysms of the vertebrobasilar junction: incidence, clinical presentation, and outcome of endovascular treatment

BACKGROUND AND PURPOSE: The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular treatment of 10 aneurysms of the vertebrobasilar junction. MATERIALS AND METHODS: Between January 1995 and January 2007, 2112 aneurysms were treated in our institution. Ten aneurysms in 10 patients were located on the vertebrobasilar junction and 7 aneurysms (70%) were associated with proximal basilar fenestration. There were 5 men and 5 women, ranging from 29 to 75 years of age. Nine aneurysms presented with subarachnoid hemorrhage, and one was a giant partially thrombosed aneurysm with mass effect on the brain stem. RESULTS: Nine ruptured aneurysms were treated by primary coil occlusion. One giant unruptured aneurysm was initially treated with bilateral vertebral artery occlusion, 2 months later followed by selective coil occlusion of the remaining aneurysm lumen via the posterior communicating artery. At imaging follow-up of 6-30 months in 7 patients, all aneurysms were adequately occluded. In 2 patients, the vertebrobasilar junction and distal vertebral arteries (including the aneurysm) thrombosed completely on follow-up without clinical sequelae. CONCLUSION: Vertebrobasilar junction aneurysms are rare, with an incidence of 0.5% of treated aneurysms at our institution. Vertebrobasilar junction aneurysms are frequently associated with proximal basilar fenestration. Most patients present with subarachnoid hemorrhage. Endovascular treatment is effective and safe in excluding the aneurysms from the circulation.     

Peripheral cerebral aneurysm associated with a glioma

Summary This 42-year-old man with acute subarachnoid, intraventricular and parenchymal hemorrhage from an angiographically and surgically confirmed successfully clipped, right splenial artery aneurysm, subsequently manifested a grade 3 astrocytoma at the site of the aneurysm. Intracranial aneurysms are recognized in association with metastases from cardiac myxoma and choriocarcinoma, but are rarely seen with primary brain tumors. In patients with nontraumatic peripheral aneurysms it would seem prudent to biopsy the aneurysm and/or surrounding necrotic tissue at the time of surgical clipping.     

Solitary spinal artery aneurysms as a rare source of spinal subarachnoid hemorrhage: potential etiology and treatment strategy

Solitary aneurysms of spinal arteries lacking associated vascular malformations are rare. We report three patients with spinal subarachnoid hemorrhage (SAH) due to rupture of such aneurysms, which regressed spontaneously, as confirmed on conventional angiography. One patient had spinal SAH with presumed spontaneous dissection of a segmental artery. In the other two, SAH resulted from ruptured fusiform aneurysms of the artery of Adamkiewicz immediately proximal to the anterior spinal artery. Solitary aneurysms of the spinal arteries appear to be etiopathologic entities completely different from intracranial aneurysms. Spontaneous occlusion seems to be common, justifying a wait-and-see strategy rather than urgent treatment.     

Distal aneurysms of cerebellar arteries: incidence, clinical presentation, and outcome of endovascular parent vessel occlusion

BACKGROUND AND PURPOSE: The aim of this retrospective study was to report the incidence, clinical presentation, and midterm clinical and imaging results of endovascular parent vessel occlusion of 11 patients with 13 distal cerebellar artery aneurysms. MATERIALS AND METHODS: Between January 1995 and December 2006, 2201 aneurysms were treated in our institution. Thirteen aneurysms in 11 patients were located on distal cerebellar arteries (incidence, 0.6%), 8 of them arising from vessels feeding small arteriovenous malformations. There were 6 men and 5 women, ranging from 44 to 70 years of age. One patient with a superior cerebellar artery aneurysm presented with isolated trochlear nerve palsy. Ten patients presented with subarachnoid and intraventricular hemorrhage, and most patients were in poor clinical condition on admission. Aneurysm location was the superior cerebellar artery in 3, the anterior inferior cerebellar artery in 5, and the posterior inferior cerebellar artery in 5. Two patients had 2 aneurysms each. RESULTS: Eleven aneurysms were treated by simultaneous coil occlusion of the aneurysm and parent artery or occlusion of the parent artery just proximal to the aneurysm. Clinical follow-up was at a mean of 16.5 months (range, 2-40 months). Infarction in the territory of the occluded vessel was apparent on follow-up imaging in 5 of 11 patients, all without functional impairment. CONCLUSION: Distal cerebellar artery aneurysms are rare. Most patients present with poor-grade hemorrhage. Endovascular parent vessel occlusion is effective in excluding the aneurysm from the circulation. In most patients, adequate collateral circulation prevents infarction in the territory of the occluded vessel. In this series, when infarction did occur, the clinical consequences were limited.     

Evaluation of the circle of Willis with three-dimensional CT angiography in patients with suspected intracranial aneurysms.

PURPOSETo determine the usefulness of CT angiography in the setting of suspected acute subarachnoid hemorrhage or intracranial aneurysm.METHODSWe prospectively studied 68 patients suspected of having subarachnoid hemorrhage or an intracranial aneurysm with noncontrast CT of the head followed immediately by contrast-enhanced helical CT of the circle of Willis with three-dimensional reconstruction. Twenty-seven patients with CT findings positive for subarachnoid hemorrhage or intracranial aneurysm were evaluated with digital subtraction angiography or MR angiography within 12 hours of CT angiography. Patients with negative CT/CT angiography findings were followed up with lumbar puncture.RESULTSCT angiography showed 23 of 24 aneurysms and 2 of 2 arteriovenous malformations (sensitivity, 96%; specificity, 100%). Aneurysm size ranged from 2 to 40 mm (mean, 7.9 mm). Interobserver variability was 10%. In the 23 cases of subarachnoid hemorrhage, cisternal blood did not limit the three-dimensional reconstruction. Two patients with aneurysms on CT angiography had normal noncontrast scans.CONCLUSIONSCT angiography of the circle of Willis is a useful technique for evaluation of suspected acute subarachnoid hemorrhage and intracranial aneurysm. It provides anatomic display of intracranial aneurysms, allowing for planning of conventional angiography and surgical approach. In selected cases, CT angiography may eliminate the need for preoperative conventional angiography.     

Cost-effectiveness of treatment of unruptured intracranial aneurysms in patients with a history of subarachnoid hemorrhage

RATIONALE AND OBJECTIVES: The study goal was to evaluate the cost-effectiveness of surgery and endovascular treatment of unruptured intracranial aneurysms in patients with a history of subarachnoid hemorrhage from a previous aneurysm, incorporating the results of the prospective International Study of Unruptured Intracranial Aneurysms. MATERIALS AND METHODS: Using a Markov model, we performed a decision and cost-effectiveness analysis comparing surgery or endovascular treatment with no treatment. Twelve clinical scenarios were defined based on aneurysm size and location. Probabilistic sensitivity analyses were performed for 50- and 40-year-old cohorts. Treatment was considered to be cost-effective at an incremental cost-effectiveness ratio less than $100,000 per quality-adjusted life-year. RESULTS: In 50-year-old patients, no treatment was the most cost-effective strategy for aneurysms located in the cavernous carotid artery. For aneurysms less than 7 mm located in the anterior circulation, no treatment was the most cost-effective strategy. Endovascular treatment was the most cost-effective option for 7- to 24-mm aneurysms, whereas surgery was the most cost-effective option for aneurysms of 25 mm or larger. For aneurysms less than 7 mm and located in the posterior circulation, endovascular treatment was the most cost-effective option, whereas surgery was the most cost-effective option for 7- to 12-mm aneurysms. No treatment was the most cost-effective strategy for aneurysms of 13 mm or larger. CONCLUSION: For 50-year-old patients with a history of aneurysmal subarachnoid hemorrhage, treatment of unruptured aneurysms that are located in the cavernous carotid artery, or small (<7 mm) and located in the anterior circulation, or large (>or=13 mm) and located in the posterior circulation is ineffective or not cost-effective.     

CT detection of intracranial aneurysms in subarachnoid hemorrhage.

Contrast enhanced computed tomography (CT) scans of 59 patients with subarachnoid hemorrhage were evaluated for intracranial aneurysms. After prospective study, the CT results were compared with angiography. Depending on the location, the CT detection rate varied from a low of 36% for the internal carotid artery complex to a high of 76% for anterior and middle cerebral artery aneurysms. It was concluded that angiography may be deferred if the causative aneurysm is demonstrated by CT.     

Active bleeding from ruptured cerebral aneurysms during diagnostic angiography: emergency treatment

Despite new developments in the treatment of cerebral aneurysms, recurrent hemorrhage of an aneurysm is the most feared complication of subarachnoid bleeding. The prognosis of patients with early reruptured aneurysms is discouraging. A rerupture of an aneurysm with active bleeding is extremely rare, and the mechanisms involved remain unclear. We report the management of active bleeding of reruptured aneurysms during diagnostic angiography. In two patients, emergency treatment of the active hemorrhage was performed by means of neurosurgical intervention and by an endovascular approach in one other case. The causes and management of reruptured aneurysms with active bleeding are also discussed within the context of a review of the literature.     

Endovascular treatment of peripheral cerebellar artery aneurysms

BACKGROUND AND PURPOSE: Peripheral cerebellar artery aneurysms are rare and difficult to treat surgically. We report the angiographic results and the clinical outcomes for eight patients treated by embolization for peripheral cerebellar artery aneurysms. METHODS: Between 1994 and 2001, eight patients with peripheral cerebellar artery aneurysms were referred from the neurosurgery department for endovascular treatment. The patients consisted of four women and four men with a mean age of 43 years (range, 16-68 years). Seven patients presented with subarachnoid hemorrhage. In one patient, the aneurysm was incidental. In five cases, selective embolization of the aneurysmal sac was performed using GDCs. Two large peripheral cerebellar artery aneurysms and one small aneurysm with a wide neck were treated by parent vessel occlusion. Mean clinical and imaging follow-up duration was 18.5 months (range, 12-36 months). RESULTS: Endovascular treatment resulted in five complete occlusions, two neck remnants, and one residual aneurysmal flow. Clinical evaluation showed that good or excellent recovery was achieved by all patients. Imaging follow-up revealed seven complete occlusions and one residual aneurysmal flow. CONCLUSION: Our study showed that the endovascular approach to treat peripheral cerebellar artery aneurysms by selective embolization or parent vessel occlusion was feasible, safe, and effective. Imaging follow-up showed excellent anatomic results in accordance with clinical recovery.     

Aneurysm formation after carotid occlusion.

We present two cases of subarachnoid hemorrhage caused by aneurysm development and enlargement in the anterior communicating artery complex. The cases occurred in a series of 58 balloon occlusions for unclippable giant aneurysms of the internal carotid artery.     

Endovascular treatment of peripheral intracranial aneurysms

BACKGROUND AND PURPOSE: Distally located cerebral aneurysms are difficult to treat with preservation of the parent vessel. We report the angiographic results and clinical outcome for 27 patients with peripheral cerebral aneurysms. METHODS: From January 2000 to June 2005, 27 patients, 13 female and 14 male, presented to our institution with peripheral intracranial aneurysms and were treated endovascularly. None of these aneurysms were mycotic in origin. The age of our patients ranged from 23 to 76 years with a mean age of 53. Twenty of the 27 patients had subarachnoid and/or intracerebral hemorrhage upon presentation. In 5 patients, the aneurysm was an incidental finding. One patient with a fusiform P2 aneurysm presented with cranial nerve III palsy, and another patient with P4 aneurysm had visual disturbances. Locations of the aneurysms were as follows: posterior cerebral artery in 9 patients, superior cerebellar artery in 5 patients, anterior inferior cerebellar artery in 1 patient, posterior inferior cerebellar artery in 5 patients, middle cerebral artery (MCA) in 5 patients, and anterior cerebral artery in 2 patients. RESULTS: Seven patients were treated with selective embolization with Guglielmi detachable coils (GDCs). Nineteen patients with fusiform aneurysms underwent parent artery occlusion (PAO). Fifteen PAOs were performed with coils and 4 with glue. One patient with a MCA aneurysm was found at the time of planned embolization to have spontaneously thrombosed the aneurysm and the distal branch of the MCA, 1 day after the initial diagnostic angiogram. Five patients (5/18 or 27.7%) who underwent PAO developed neurologic deficits. Two patients (2/18 or 11.1%) had permanent neurologic deficits (a visual field defect). CONCLUSION: Our results support that distally located aneurysms can be treated with endovascular PAO in the cases in which selective occlusion of the aneurysmal sac with GDC or surgical clipping cannot be achieved.     

Dissecting aneurysms of all four cervicocranial arteries in fibromuscular dysplasia: treatment with self-expanding endovascular stents,coil embolization,and surgical ligation.

A patient with cervicocranial fibromuscular dysplasia (FMD) presented with subarachnoid hemorrhage. A ruptured dissecting distal vertebral artery aneurysm required clip ligation of the parent artery; a contralateral dissecting proximal vertebral aneurysm was occluded with detachable coils. Progressive dissecting, extracranial aneurysms of the internal carotid artery were treated with self-expanding stents. Subsequent angiography and intravascular sonography revealed patent stents, a smooth luminal surface, and total occlusion of the aneurysm. Clinical outcome was excellent.     

CT of subarachnoid hemorrhage due to ruptured aneurysm

Computed tomographic scans in 81 consecutive patients wih subarachnoid hemorrhage due to ruptured aneurysm were analyzed for patterns of hemorrhage and lucency and correlated with the development of spasm and hydrocephalus. The circulation time was measured angiographically in representative cases of spasm. Hemorrhage corresponded in a general way to the fossa of aneurysm origin and, when there was parenchymal or ventricular hemorrhage, in more specific ways to anterior communicating, middle cerebral, and posterior inferior cerebellar artery aneurysms. Basal ganglionic hemorrhages due to aneurysm ruptures occurred in two cases and could not be distinguished by appearance from hypertensive hemorrhage. Regions of low attenuation (lucencies) were often persistent and had lateralizing value; they showed a high correlation with arterial spasm. Conversely, spasm, particularly of a distal type, showed a significant correlation with increased circulation time and the occurrence of brain lucency. In cases of multiple aneurysms arising from different vessels in which there was hemorrhage or lucency, CT scans correctly predicted the site of aneurysm in 77% of cases. Periventricular lucency was a weak predictor of progressive hydrocephalus, while an intraventricular hemorrhage was a strong predictor of moderate to severe hydrocephalus.     

Fatal rebleeding following coil embolization of cerebral aneurysms: the role of long-term systemic anticoagulation

Embolization of cerebral aneurysms has become a common technique. Its impact on subsequent medical management of the patient is not well known. We report two patients who presented in a poor neurological grade after subarachnoid hemorrhage from posterior communicating artery aneurysms. Both were treated by coil embolization and both developed subclavian vein thrombosis, requiring systemic anticoagulation, initiated 11 and 21 days after embolization, respectively. Both developed a large, fatal intracranial hemorrhage adjacent to the embolized aneurysm in the fourth week of anticoagulation. Systemic anticoagulation of patients who have had a ruptured aneurysm treated by coil embolization may carry a significant risk of rebleeding. Alternate management strategies should be considered in these patients. Received: 21 January 2000 Accepted: 3 October 2000     

Combined use of endovascular coils and surgical clipping for intracranial aneurysms.

We report two cases in which combined surgical clipping and endovascular coils have been used to treat intracranial aneurysms. In one case, a 59-year-old woman with multiple episodes of subarachnoid hemorrhage had an anterior communicating artery aneurysm, which was initially treated with coils and then clipped to occlude the aneurysm securely. In the second case, a broad-based cavernous aneurysm could not be completely surgically occluded, but surgical clipping did decrease the aneurysm neck size, allowing it to be successfully treated with coils.     

Endovascular treatment of wide-necked aneurysms by using two microcatheters: techniques and outcomes in 25 patients

BACKGROUND AND PURPOSE: The endovascular occlusion of aneurysms with unfavorable configurations such as a broad neck and an important branch from the fundus remains a technical challenge. The purpose of this study was to evaluate the radiologic and clinical results of complicated aneurysm treatment by using two microcatheters. METHODS: Twenty-five aneurysms in 25 patients were treated by using two microcatheters, from August 2001 to February 2004. Fourteen patients presented with a subarachnoid hemorrhage (SAH) and 11 had unruptured aneurysms. The aneurysms were of the basilar top (7), middle cerebral artery bifurcation (4), posterior communicating artery (4), anterior communicating artery (3), superior cerebellar artery (2), ophthalmic artery (2), and one aneurysm of each of cavernous internal carotid artery (ICA), dorsal ICA, and midbasilar artery. In 16 aneurysms (64%), the width of the aneurysm was the same or longer than the height. In 19 (76%), important branches arose from the aneurysm base, and some were even incorporated with the aneurysm fundus. The mean dome (height)-to-neck ratio was 1.23 +/- 0.37 (range, 0.65-2.33), and this was greater than or equal to 1.0 in 19 aneurysms (76%). RESULTS: All aneurysms were successfully embolized. Immediate postembolization angiography showed no residual contrast filling in eight aneurysms (32%), and some residual contrast filling in 16. The aneurysm remnants, however, were intentionally left to preserve important branches in 12 of the 16 aneurysms with incomplete occlusion. Two complications occurred, including one thromboembolic and one coil protrusion, but they were successfully resolved and produced no clinical symptoms. All patients except one showed excellent clinical outcomes. One patient revealed moderate cognitive dysfunction. During the follow-up period, no new bleeding occurred. CONCLUSION: Our experience with 25 cerebral aneurysm patients shows that the technique of using two microcatheters is feasible and safe for coil embolization of aneurysms with unfavorable configurations. Although the lack of angiographic follow-up prevents us from drawing conclusions about its effectiveness as compared with other techniques such as stent placement and balloon-neck protection, we believe that this technique offers a reliable alternative for endovascular therapy of complicated aneurysms.     

Autosomal dominant polycystic kidney disease presenting as subarachnoid hemorrhage

Intracranial aneurysms occur in patients with autosomal dominant polycystic kidney disease (ADPKD) approximately five times more often than in the general population, and in the same patient group, subarachnoid hemorrhage from rupture of aneurysms occurs about a decade earlier than in the general population. We present a case of unsuspected ADPKD presenting as spontaneous subarachnoid hemorrhage from a ruptured intracranial aneurysm.     

Stent-assisted coil embolization of intracranial wide-necked aneurysms

The endovascular treatment of cerebral aneurysms with coils poses significant technical challenges, particularly with respect to wide-necked aneurysms. We present the results of our initial experiences in using a stent for endovascular treatment of aneurysms, with an emphasis on potential applications, technical aspects, and associated complications. Twenty-three wide-necked aneurysms from 22 patients were treated during the 13-month study period. Seven patients presented with subarachnoid hemorrhage. Aneurysms were located at the internal carotid artery (n=14), the vertebral artery (n=3), the basilar artery (n=5), and the middle cerebral artery (n=1). A Neuroform stent² was used for stent-assisted procedures. Premedication with antithrombotic agents was available for unruptured cases. Postprocedural antithrombotic medication was prescribed for all patients. Nineteen aneurysms were primarily stented, followed by coil placement. For five of these aneurysms, stenting was performed subsequent to failure of an attempt to frame with an initial coil. Stenting for the remaining four aneurysms was performed as a rescue procedure to prevent the migration of previously placed coils. Complete occlusion was obtained in ten aneurysms, nearly complete occlusion (95% or more occluded) in 11 aneurysms, and partial occlusion (less than 95% occluded) in one aneurysm. In one aneurysm, we failed to navigate the microcatheter into the aneurysmal sac through the interstices of the stent. Stent thrombosis was noted during the procedure in one patient. Hemorrhagic complication on the 25th day after the procedure was noted in one patient. No procedure-related complications were observed during the procedure or during follow-up in the remaining 20 patients, including seven patients who did not receive antithrombotic agents prior to endovascular treatment owing to recent subarachnoid hemorrhage. To overcome the technical limitation in the coiling of wide-necked aneurysms, stent-assisted coil embolization may be a technically feasible and relatively safe method, even though longer periods of follow-up are required.     

Endovascular coil embolization for anterior choroidal artery aneurysms

Introduction We retrospectively evaluated the ischemic complications related to the anterior choroidal artery (AChA) and clinical outcome after coiling of AChA aneurysms. Methods We included 37 patients (27 with subarachnoid hemorrhage, 10 without) harboring 38 AChA aneurysms (23 ruptured, 15 unruptured) who were treated by coiling at four institutions. Ischemic complications related to the AChA and clinical outcomes were retrospectively evaluated. Results Intraprocedural transient AChA occlusion occurred in five aneurysms, all of which had AChA incorporated into the aneurysm neck. Two of the five patients suffered postprocedural transient contralateral hemiparesis, but recovered completely. The remaining three patients had no postprocedural symptoms. Incidence of transient AChA occlusion was significantly higher in those aneurysms in which the AChA was incorporated into aneurysm neck (group 2) than in those in which the AChA was not incorporated (group 1). Of the 37 patients, 31 (83.8%) had good recoveries (modified Rankin scale score 0–2). Two patients died from the consequences of subarachnoid hemorrhage. During follow-up for a mean of 27 months (range 4–72 months), none of the 35 living patients re-bled. A total of 29 aneurysms in 28 patients were followed-up angiographically. Recurrences were found in 5 of the 29 aneurysms during follow-up (mean 18 months, range 6–45 months). Re-embolization achieved near complete occlusion of two recurrent aneurysms, both of which were still stable at the time of the next two follow-up angiographies. The other three recurrent aneurysms were not retreated due to the small size of the recurrences. Conclusion Coiling of AChA aneurysms resulted in good outcomes without AChA-related permanent ischemic complications. Transient AChA occlusion, potentially associated with ischemic complications, was significantly more frequent in the aneurysm in which the AChA was incorporated into the aneurysm neck.