A case of giant renal artery aneurysm

A 72-year-old woman consulted our hospital for a cystic mass in the right kidney. Ultrasonography and drip infusion pyelography revealed a right renal cystic mass 10 cm in diameter and right hydronephrosis. Computed tomography (CT) and magnetic resonance imaging revealed a giant mass with partial calcification in the right renal hilus. The mass was diagnosed the fusiform aneurysm 10 cm in diameter occurring in the main stem of right renal artery by selective abdominal angiography and 3-dimensional CT. We performed total nephrectomy and the histological finding was atherosclerosis. A total of 485 cases of renal artery aneurysm have been reported in Japan. These cases and 15 cases of renal artery aneurysm more than 5.0 cm in diameter are herein reviewed.     

Ruptured Distal Anterior Choroidal Artery Aneurysm Presenting with Casting Intraventricular Haemorrhage

Summary This report describes a rare case of a distal anterior choroidal artery aneurysm which developed intraventricular haemorrhage without subarachnoid haemorrhage as shown on computerized tomographic (CT) scan. A 69-year-old hypertensive man suddenly became unconscious. An emergency CT scan showed a severe intraventricular haemorrhage and a small round low-dense lesion within the haematoma at the right trigone. The haematoma with obstructive hydrocephalus made the lateral ventricles larger on the right than on the left. CT scan could not detect any subarachnoid haemorrhage. Right interal carotid angiography revealed a saccular aneurysm at the plexal point of the right anterior choroidal artery. We approached the aneurysm and the small round lesion through the trigone via a right temporo-occipital corticotomy. We could clip the aneurysmal neck and remove the intraventricular haematoma and the papillary cystic mass (corresponding to the small round lesion on CT scan) totally in one sitting. Histological examination revealed the aneurysm to be a true one and the papillary cystic mass to be a choroid plexus cyst.     

Vertebrobasilar junction aneurysms associated with fenestration: experience of five cases treated with Guglielmi detachable coils

BACKGROUND: Fenestration of vertebrobasilar junction is a rare congenital anomaly and often associated with aneurysm formation. We describe five cases of vertebrobasilar junction aneurysms in four patients associated with fenestration, which were treated with endovascular coil occlusion using Guglielmi detachable coils (GDCs). The importance of preoperative computed tomography (CT) angiography to understand the complex anatomy of fenestration and aneurysm is emphasized. CASE REPORTS: Three patients presented with subarachnoid hemorrhage and one patient presented with headache only. Among 3 patients with subarachnoid hemorrhage, 1 patient was referred for endovascular coil occlusion after clipping of ruptured distal ACA aneurysm. A six-French guiding catheter was placed in the left vertebral artery via right femoral artery, except for 1 patient who had two vertebrobasilar junction aneurysms with complex anatomic relationship, accessed bilaterally. Five vertebrobasilar junction aneurysms with fenestration were treated with endovascular coil occlusion using GDCs. Postoperative angiography demonstrated successful occlusion of aneurysmal sac with preservation of basilar artery. CONCLUSIONS: Vertebrobasilar junction aneurysms are frequently associated with fenestrations. In addition to vertebral angiography on both sides, CT angiography may be a valuable tool for better understanding of complex anatomy of aneurysms associated with fenestration. The surgically difficult aneurysms such as vertebrobasilar junction aneurysm with fenestration can be successfully treated with GDCs.     

Ruptured aneurysm arising from the proximal end of an azygos anterior cerebral artery--case report

A 59-year-old woman presented with subarachnoid hemorrhage. Conventional angiography and three-dimensional computed tomography (3-D CT) angiography showed a saccular aneurysm at the junction of the azygos anterior cerebral artery (ACA) and the left A1 segment. This aneurysm was associated with a fenestration of the right hypoplastic A1 segment. The aneurysm neck was completely clipped, preserving the azygos ACA and other perforators. Aneurysm of the azygos ACA is almost always located at the distal bifurcation, and rarely at the proximal end. Proximal azygos ACA aneurysm can mimic anterior communicating artery aneurysm. Therefore, accurate preoperative diagnosis is critical using 3-D CT angiography as well as conventional angiography, and close follow up of patient is necessary to monitor for development of a de novo aneurysm at the distal bifurcation of the azygos ACA.     

Renal artery aneurysm causing hydronephrosis

A 42-year-old man presented with left hydronephrosis incidentally discovered on abdominal echogram during a routine health examination. Color Doppler ultrasonography, intravenous pyelography and angiography revealed a non-calcified renal artery aneurysm of 30 mm in size compressing the pyeroureteral junction and causing hydronephrosis. Three-dimensional computed tomography (3-D CT) using spiral CT clearly displayed the aneurysm located at the first bifurcation of the left renal artery and involving the anterior segmental artery. Decompression was successfully obtained via in situ revascularization of the renal artery after aneurysmectomy. A literature search revealed 12 cases of renal artery aneurysm causing hydronephrosis reported in Japan, although only three cases were documented in other countries, and these reports are reviewed. Use of 3-D CT for evaluation of renal artery aneurysm is advocated.     

Stent-assisted Gugliemi detachable coil repair of wide-necked renal artery aneurysm using 3-D angiography

PURPOSE: To report a wide-necked renal artery aneurysm treated successfully with stent-assisted Gugliemi detachable coil occlusion, assisted by three-dimensional (3-D) angiography. CASE REPORT: A 56-year-old woman with history of hypertension presented with a 2.5-cm wide-necked saccular aneurysm involving her distal right renal artery. A balloon-expandable stent was positioned across the neck of the aneurysm and multiple Gugliemi detachable coils were deployed through a microcatheter inserted through the interstices of the stent into the aneurysm sac, guided by 3-D angiography. Follow-up 3-D angiography at 6 months revealed a patent renal artery with continued exclusion of the aneurysm and preservation of renal blood flow. CONCLUSION: Stent-assisted coil occlusion assisted by 3-D angiography is a potential renal-sparing endovascular approach to treating wide-necked renal artery aneurysms with complex vascular anatomy.     

Saccular aneurysm of the distal anterior choroidal artery--case report.

The authors report a case of a distal anterior choroidal artery aneurysm in a 75-year-old female who presented with nausea, vomiting, and severe headache. Computed tomographic (CT) scans revealed a hematoma in the right lateral ventricle and a subarachnoid hemorrhage in the right parasellar-Sylvian cistern. Cerebral angiography showed a saccular aneurysm at the right distal anterior choroidal artery. The authors intended to operate at the chronic stage, and carried out conservative management. After 1 month her condition suddenly worsened and she died, although a CT scan showed no remarkable changes. At autopsy, a pulmonary artery thrombosis was considered the cause of death. The aneurysm was identified in the temporal horn of the right lateral ventricle, and was a true aneurysm.     

Bilateral distal anterior cerebral artery aneurysms associated with polycystic kidney and liver disease; a case report]

A patient who had bilateral distal anterior cerebral artery aneurysms and a right middle cerebral artery aneurysm in association with polycystic kidney and liver disease is reported. A 57-year-old woman was referred to our center with headache and disturbance of consciousness. On admission, her level of consciousness as evaluated by the Japan Coma Scale was 10. CT revealed subarachnoid hemorrhage, especially in the interhemispheric fissures. Right carotid angiography demonstrated bilateral distal anterior cerebral artery aneurysms and a right middle cerebral artery aneurysm. All three aneurysms were clipped in a one-stage procedure. The patient was discharged without any neurological deficits two weeks after the operation. Bilateral distal anterior cerebral artery aneurysms are extremely rare. This is the first report of such aneurysms and a right middle cerebral artery aneurysm in association with polycystic kidney and liver disease. The etiology of these aneurysms is discussed.     

Thrombosed giant aneurysm of the pericallosal artery with inconclusive findings of multiple neuroimaging studies

A 65-year-old woman presented with a thrombosed giant pericallosal artery aneurysm manifesting as headache and memory loss that developed over a 2-year period. Computed tomography (CT), magnetic resonance (MR) imaging, and conventional and CT angiography could not establish the differential diagnosis. Open craniotomy revealed the mass as thrombosed giant aneurysm from the pericallosal artery. Direct clipping with thrombectomy was performed successfully with an uneventful postoperative course. Thrombosed giant aneurysm of the distal anterior cerebral artery should be considered in the differential diagnosis of an unusual mass in the mid-frontal area, particularly in the presence of inconclusive angiographic and MR imaging findings.     

Subarachnoid hemorrhage in a case of segmental arterial mediolysis with coexisting intracranial and intraabdominal aneurysms

The authors report the rare case of a 58-year-old man with segmental arterial mediolysis (SAM) with associated intracranial and intraabdominal aneurysms, who suffered subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm. This disease primarily involves the intraabdominal arterial system, resulting in intraabdominal and retroperitoneal hemorrhage in most cases. The patient presented with severe headache and vomiting. The CT scans of the head revealed SAH. Cerebral angiography revealed 3 aneurysms: 1 in the right distal anterior cerebral artery (ACA), 1 in the distal portion of the A(1) segment of the right ACA, and 1 in the left vertebral artery. The patient had a history of multiple intraabdominal aneurysms involving the splenic, gastroepiploic, gastroduodenal, and bilateral renal arteries. He underwent a right frontotemporal craniotomy and fibrin coating of the dissecting aneurysm in the distal portion of the A(1) segment of the right ACA, which was the cause of the hemorrhage. Follow-up revealed no significant changes in the residual intracranial and intraabdominal aneurysms. An SAH due to SAM with associated multiple intraabdominal aneurysms is extremely rare. The authors describe their particular case and review the literature pertaining to SAM with associated intracranial and intraabdominal aneurysms.     

Subarachnoid hemorrhage caused by ruptured intracranial fusiform aneurysm associated with microscopic polyangiitis

A 44-year-old woman with microscopic polyangiitis (MPA) presented with a ruptured cerebral aneurysm. She was admitted to our hospital for further examination of progressive renal failure. She was found lying on the ward floor. Computed tomography showed subarachnoid hemorrhage, and digital subtraction angiography revealed a saccular-like aneurysm arising from the right distal posterior inferior cerebellar artery (PICA) at the non-branching site. We performed neck clipping of the right distal PICA aneurysm, which recurred 5 days after the operation. Second angiography demonstrated a right distal PICA aneurysm just above the site of the clip. Therefore, we performed trapping of the affected lesion with emergent bypass of the contralateral occipital artery to the ipsilateral PICA. Her postoperative course was uneventful until she coughed up blood and had gross hematuria 3 days after the second surgery. Histological examination of a renal biopsy specimen revealed crescentic glomerulonephritis. MPA was diagnosed on the basis of the cardinal symptoms, including progressive glomerular nephritis and the lung abnormality, as well as the presence of myeloperoxidase-antineutrophil cytoplasmic antibodies. After intensive treatment, she was discharged for rehabilitation without neurological deficit. MPA commonly affects small-sized vessels mainly in the kidneys and lungs and may lead to crescentic glomerulonephritis and pulmonary hemorrhage. MPA is rarely associated with aneurysms of medium-sized muscular vessels. Cerebral aneurysm is extremely rare in patients with MPA, but rupture of an intracranial fusiform aneurysm can be lethal, so screening of the intracranial vessels should be performed by magnetic resonance imaging in patients with MPA.     

MISSED ANTERIOR CROSSING VESSELS DURING OPEN RETROPERITONEAL PYELOPLASTY: LAPAROSCOPIC TRANSPERITONEAL DISCOVERY AND REPAIR

PURPOSE: Extrinsic ureteropelvic junction obstruction due to anterior crossing segmental renal vessels is present in more than 50% of patients in adulthood. In this situation the ureter must usually be dismembered and transposed anterior to the crossing vascular structures, where it is anastomosed to the renal pelvis. Via the open retroperitoneal approach there may be a limited view of the anterior surface of the ureteropelvic junction and, hence, anterior crossing vessels may possibly be missed. We describe 2 patients with ureteropelvic junction obstruction in whom anterior vessels were missed during open retroperitoneal repair. Laparoscopic transperitoneal secondary pyeloplasty with posterior displacement of the crossing renal vessel was performed in each case. MATERIALS AND METHODS: Two patients presented with symptomatic congenital ureteropelvic junction obstruction after failed endopyelotomy in 1 and failed open retroperitoneal procedures in both. Preoperatively spiral computerized tomography angiography with a ureteropelvic junction protocol revealed crossing vessels in the 2 cases. This finding was confirmed at transperitoneal laparoscopic pyeloplasty. The ureter and renal pelvis were transposed anterior to the crossing vessels and 2 rows of running sutures were placed to complete the anastomosis. RESULTS: The 2 laparoscopic procedures were completed successfully. The anterior crossing vessels were preserved in each case. Currently the patients are asymptomatic and furosemide washout renal scan was normal. CONCLUSIONS: Spiral CT angiography reliably delineates the renal vascular anatomy in patients with ureteropelvic junction obstruction. This study may be valuable before planned open retroperitoneal ureteropelvic junction obstruction repair. Laparoscopic pyeloplasty may successfully manage anterior crossing vessels associated with secondary ureteropelvic junction obstruction.     

Embolization for aneurismal dilatation associated with ruptured dissecting anterior inferior cerebellar artery aneurysm with preservation of the parent artery: case report

We report a rare case of a ruptured dissecting anterior inferior cerebellar artery (AICA) aneurysm treated by endosaccular embolization with a Guglielmi detachable coil (GDC). An 85-year-old female presented with headache. Computed tomographic (CT) scan showed subarachnoid hemorrhage and intraventricular hemorrhage in the fourth ventricule. Cerebral angiography and 3D-CT angiography revealed an aneurysmal dilatation at the anterior pontine segment of the right AICA with a diagnosis of arterial dissection. The right posterior inferior cerebellar artery (PICA) was absent and the right AICA supplied the territory normally nourished by the right PICA. The aneurismal dilatation was occluded by endosacullar embolization with preservation of the AICA. The distal AICA aneurysm is rare and only seven cases treated with endovascular embolization have been reported. In these, six cases were treated by parent artery occlusion with coil and the subsequent three cases presented with ischemic complications. Only one case was treated by endosaccular embolization with GDC. To our knowledge, this is the second report of the distal AICA aneurysm treated by endosaccular embolization with GDC. Distal AICA aneurysms are briefly discussed while reviewing the literature.     

Dissecting aneurysm of the anterior cerebral artery requiring surgical treatment--case report

A 45-year-old male presented with spontaneous dissecting aneurysm in the anterior cerebral artery manifesting as headache persisting for several days and speech disturbance. Neurological and laboratory examinations showed no abnormalities. Magnetic resonance imaging revealed infarction in the right cingulate gyrus. Angiography revealed occlusion of the right A2. Repeat angiography 8 months later showed a saccular aneurysm had developed. The interhemispheric approach exposed the aneurysm at the junction between the right frontopolar artery and the pericallosal artery. The aneurysm was fusiform due to the right A2 dissection. The aneurysm was trapped and resected. One month after the operation, the patient was discharged without neurological deficits. Cases of dissecting aneurysms in the anterior cerebral artery with ischemic onset are usually treated conservatively. Cases requiring surgery include those due to trauma, growing aneurysms, giant aneurysms, and uncontrolled hypertension. Some dissecting aneurysms of the distal anterior cerebral artery require only resection without bypass surgery.     

Total arch replacement through a mediansternotomy for an aortic arch aneurysm with an aberrant right subclavian artery

The patient was a 77-year-old man. In 2004, he developed thrombosed aortic dissection extending from the distal aortic arch to the renal artery bifurcation. He was discharged after his condition improved with conservative treatment. He was followed up as an outpatient because there was an aneurysm, which measured 50 mm in diameter, at the aortic arch. Thereafter the aneurysm gradually enlarged. In May 2009, computed tomography (CT) showed that the aneurysm had increased to 10 cm in diameter and the patient began to have back pain. Thus, surgery was planned. CT revealed that the right subclavian artery originated distal to the left subclavian artery and coursed posterior to the esophagus and trachea. Surgery was performed using median sternotomy. Arch replacement and right subclavian artery reconstruction were performed under hypothermic circulatory arrest with selective cerebral perfusion. The right subclavian artery was controlled at the right border of the trachea, and cerebral perfusion was performed at this site. An end-to-side anastomosis to the reconstructed right common carotid artery was performed by an anterior tracheal approach. The patient had no cerebral complications and his postoperative course was uneventful.     

Intracranial bacterial aneurysms--report of two cases with special reference to operative indications

Two cases of intracranial bacterial aneurysms caused by bacterial endocarditis are reported. Case 1 was a 20-year-old male who underwent mitral valve annuloplasty because of mitral regurgitation due to mitral valve prolapse syndrome 3 year prior to this admission. He was referred when a large intracerebral hemorrhage of the right frontal lobe ruptured into the lateral ventricle was seen in computed tomography (CT) scan on admission. An aneurysm at the distal portion of precentral artery of the middle cerebral artery (MCA) was found by right carotid angiography. Emergency evacuation of the hematoma and trapping of the aneurysm were performed. Another three aneurysms, located at the distal portion of contralateral left precentral artery of MCA, the left posterior cerebral artery (PCA) and the right anterior falx artery were found in the subsequent angiogram. The latter two aneurysms developed while receiving antibiotics. The aneurysms of PCA and MCA were trapped surgically. However, the aneurysm of anterior falx artery disappeared spontaneously under antibiotic therapy without surgery. Case 2 was a 21-year-old female who underwent cardiac surgery one month prior to presentation for aortic insufficiency and coarctation of the aorta. She was referred to our clinic because of sudden loss of consciousness, aphasia and right hemiparesis. CT scan and left carotid angiography showed a large hematoma in the left frontal lobe and an aneurysm at the distal portion of the opercular-frontal artery. Emergency ventricular drainage was performed. The operation for evacuation of the hematoma and clipping of aneurysm was performed 10 days later. However, at the operation the aneurysm neck was only partially clipped in order to prevent the obstruction of efferent vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dissecting vertebral aneurysm with subarachnoid hemorrhage after ischemic onset on the same day: a case report

We report a case of a dissecting vertebral aneurysm with subarachnoid hemorrhage (SAH) after ischemic onset on the same day. A 48-year-old man had abrupt vertigo and nausea. CT & MRI on admission showed no abnormality, but he complained of left hemiparesis after admission. Twelve hours after the ischemic onset he suddenly complained of severe headache and his consciousness deteriorated. The follow-up CT showed diffuse SAH. Cerebral angiography showed occlusion of the right vertebral artery at the origin of the posterior inferior cerebellar artery (PICA) and segmental stenosis of the left vertebral artery at the portion distal to the vertebral PICA junction. We treated the patient conservatively. Four days later, he suddenly fell into a coma, but CT showed no bleeding. Because of this we suspected brain stem ischemia due to deterioration of vertebral dissection. The patient died 8 hours after the ischemic reattack. We report difficulty of treatment of a dissecting vertebral aneurysm with simultaneous ischemia and subarachnoid hemorrhage.     

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 septic intracranial aneurysms--successful treatment with surgical and conservative therapy in the same case

Here reported is a case of multiple septic intracranial aneurysms which were successfully treated with surgical and conservative therapy. A 44-year-old man was admitted to our hospital because of headache, vomiting and visual disturbance. He had had a fever and had been under treatment for a respiratory tract infection during the preceding 3 months. Physical examination on admission revealed pansystolic heart murmur over the cardiac apex. Neurological examination revealed neck stiffness, papilledema and right homonymous hemianopsia. Laboratory data showed the presence of inflammatory process. A CT scan showed a high density area in the left occipital region, and vertebral angiography showed a saccular aneurysm on a distal branch of the left occipitotemporal artery. Fourteen days after admission, the operation of clipping the neck of the aneurysmal artery was performed and the hematoma evacuated to lower the increased intracranial pressure. He had been well after the operation until 3 weeks later when a follow-up angiography showed a new unruptured aneurysm on a distal branch of the right middle cerebral artery with a relapse of the infection. Then, he was treated with appropriate antibiotics and antifibrinolytic agents. A repeated angiography 1 month later showed resolution of the aneurysm. The mechanism of resolution of septic aneurysm and its treatment are discussed.     

Anterior thalamoperforating artery aneurysm associated with internal carotid artery occlusion: case report.

OBJECTIVE AND IMPORTANCE: We describe a rare case of a ruptured distal anterior thalamoperforating artery aneurysm associated with right internal carotid artery occlusion. CLINICAL PRESENTATION: A 59-year-old woman experienced sudden occipital headache, vomiting, and subsequent coma as a result of massive intraventricular hemorrhage. An initial angiogram revealed only an occlusion of the right internal carotid artery just distal to the posterior communicating artery. Repeat angiography 1 month later, however, revealed a saccular aneurysm at a distal anterior thalamoperforating artery in addition to the occlusion of the internal carotid artery. INTERVENTION: We approached this aneurysm through the right temporal horn after opening the ambient cistern. The aneurysm, which was located in the brain parenchyma just medial to the temporal horn, was successfully resected. CONCLUSION: This rare aneurysm probably developed as a result of hemodynamic stress on the anterior thalamoperforating artery after occlusion of the internal carotid artery and/or secondary to chronic hypertension.