Postoperative discitis due to Propionibacterium acnes: a case report and review of the literature

BACKGROUND: A rare case of a growing dissecting aneurysm, which was located at the horizontal (A1) segment of the anterior cerebral artery (ACA), is reported. CASE DESCRIPTION: A 53-year-old woman experienced left hemiparesis and alien hand syndrome. A computerized tomography scan showed an infarction in the right frontal lobe, and cerebral angiography revealed a false lumen and intimal flap at the A1 segment of the ACA. Magnetic resonance angiography demonstrated that the stenosis progressed 6 months later and improved 1 year later. Cerebral angiography showed a saccular-like aneurysm 2 years later. The surgery was planned for prevention of aneurysmal rupture. The aneurysm, which was cocoon shaped, was exposed surgically and was resected. Histological examination of the aneurysm showed arterial dissection. The postoperative course was uneventful without additional neurological deficits. CONCLUSION: This is the first case report of A1 dissecting aneurysm presenting with an ischemic event in the literature. The sequential change of the configuration was curious to develop aneurysmal dilatation in 2 years. Long-term follow-up is necessary even after disappearance of the arterial dissection.     

Dissecting aneurysm of the anterior cerebral artery with persistent pearl & string sign on cerebral angiograms over a period of eight years]

We present a rare case of a dissecting aneurysm of the left anterior cerebral artery (ACA) with persistent pearl & string sign on cerebral angiograms over a period of 8 years. A 43-year-old woman with disturbance of consciousness and right sided hemiparesis was conservatively treated. Computed tomographic (CT) scan revealed a low-density area in the left frontal lobe. Initial angiography, which was performed at 6 months after the onset, showed a pearl & string sign at the A2 portion of the left ACA. After 8 years, repeat angiography again showed persistent pearl & string sign at the same portion of the left ACA. We discussed the changes in findings usually obtained in cerebral angiography concerning dissecting aneurysms in ACA.     

Multiple spontaneous dissecting aneurysms of the anterior cerebral and vertebral arteries

A 50-year-old woman presented with rare multiple dissecting aneurysms that appeared first in the anterior cerebral artery (ACA) and shortly afterwards in the vertebral artery (VA). She initially suffered sudden motor weakness in the left lower limb due to acute brain infarction. Angiography revealed diffuse string sign in the right ACA. Conservative treatment resulted in resolution of the deficits. Follow-up angiography performed 1 year later revealed recovery of the ACA stenosis. Fourteen days later, she complained of sudden headache and became comatose. Computed tomography showed diffuse subarachnoid hemorrhage. Angiography revealed a new right VA dissecting aneurysm involving the posterior inferior cerebellar artery (PICA). The orifice of the dissection was not apparent in the operative field and the dissection extended to the median. The patient underwent extracranial right VA ligation, clipping of the proximal PICA, and revascularization between the right occipital artery and distal PICA. Her postoperative course was uneventful and she was discharged without neurological deficits. VA dissecting aneurysms involving the PICA without evident orifice or extending over the median can be treated by extracranial ligation with clipping of the PICA, followed by revascularization.     

Dilated outer diameter of the dissected artery: acute bilateral anterior cerebral artery dissection evaluated by repeat magnetic resonance cisternography. Case report

A 42-year-old male patient presented with an anterior cerebral artery (ACA) dissection manifesting as sudden onset of severe headache. Initial computed tomography revealed faint subarachnoid hemorrhage in the frontal region. Initial angiography showed tapering stenosis at the A(2) segment of right ACA. The patient was admitted to our hospital and treated conservatively. Magnetic resonance (MR) imaging and angiography did not detect intramural hematoma, intimal flap, or double lumen at the stenotic right A(2) segment. The ACA dissection was difficult to confirm based on the findings on day 0. ACA dissection was confirmed by improvement of the right ACA stenosis on follow-up angiography on day 14. On the other hand, MR cisternography revealed a fusiform dilatation of the vascular outer contour at the right A(2) on day 0, which had resolved on day 14. Cerebral angiography and MR cisternography similarly suggested asymptomatic contralateral (left) A(2) dissection on day 14. Fusiform dilatation of the vascular outer contour at the affected segment on MR cisternography may be indicative of arterial dissection in the acute phase.     

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.     

Dissecting aneurysm of the middle cerebral artery (M1-2 portion) with subarachnoid hemorrhage: a case report

We report a SAH case of a ruptured dissecting aneurysm of the middle cerebral artery following parietooccipital subcortical hemorrhage. A 68-year-old woman was admitted to our hospital, complaining of headache. On admission she was alert with left homonymous hemianopsia. A CT scan disclosed subcortical hemorrhage in the right parieto-occipital lobe. An angiogram revealed no abnormal vessels. Seven days after admission, she suddenly lapsed into unconsciousness with left hemiparesis. A CT scan demonstrated subarachnoid hemorrhage with a right sylvian hematoma. A second angiogram revealed fusiform dilatation of the M2 branches and aneurysmal dilatation at the M1-M2 bifurcation. Following conservative therapy, she died 21 days after admission. The relationship between subcortical hemorrhage and the subsequent subarachnoid hemorrhage was not certain. We discuss and review the treatment of a dissecting aneurysm of the middle cerebral artery.     

Dissecting aneurysm of the posterior communicating artery

Summary. A 36-year-old male presented with an extremely rare dissecting aneurysm of the posterior communicating artery manifesting as severe occipital headache. Magnetic resonance (MR) imaging revealed a partially thrombosed aneurysm of the right posterior communicating artery and angiography showed the pearl and string sign. Three months later, repeat angiography showed that the aneurysm was completely thrombosed and the posterior communicating artery was occluded. Magnetic resonance (MR) imaging showed an intimal flap. These neuroradiological findings demonstrated that the aneurysm was a dissecting aneurysm of the right posterior communicating artery. He was discharged with no neurological deficit.     

Ischemic stroke due to dissection of the middle cerebral artery treated by superficial temporal artery-middle cerebral artery anastomosis--case report

A 62-year-old man presented with dissection of the right middle cerebral artery (MCA) manifesting as mild headache, right hemiparesis, and slurred speech. Magnetic resonance (MR) imaging and MR angiography revealed fresh infarction in the right basal ganglia, and severe stenosis and dilatation of the right MCA. Digital subtraction angiography approximately 24 hours after admission revealed a linear contrast defect indicating an intimal flap of the M(1) segment. The diagnosis was dissection of the MCA. His neurological deficits improved gradually. Although he was neurologically stable, diffusion-weighted MR imaging revealed enlarging infarct size over the right MCA territory, and the right M(1) segment had progressive stenosis. Superficial temporal artery (STA)-MCA anastomosis was performed on the 26th day. Follow-up angiography showed good patency of the STA-MCA anastomosis, repair of the dissection of the M(1) segment, and improvement of the flow in the MCA. The patient was discharged from our hospital with no neurological deficits. Although the dissection in this case was spontaneously repaired, STA-MCA anastomosis was useful to get through a critical time. If the stenosis shows further progression or the infarction size enlarges, STA-MCA anastomosis may be effective.     

Cerebral infarction following pituitary apoplexy--case report

A 29-year-old man presented with lethargy, headache, high fever, and visual disturbance. Neurological examination showed mydriatic pupil, ptosis, diminished light reflex, and ophthalmoplegia on the left. Magnetic resonance (MR) imaging showed the typical findings of pituitary apoplexy, and cerebral angiography disclosed mild narrowing of the A1 segment of the left anterior cerebral artery (ACA). Transsphenoidal tumor resection was performed. Transient severe right hemiparesis occurred directly after the operation. Computed tomography demonstrated cerebral infarction in the territory of the left Heubner's and medial lenticulostriate arteries. Pituitary apoplexy followed by cerebral infarction is very rare. Vasospasm of the perforating arteries of the ACA probably caused the cerebral infarction. Subarachnoid blood or vasoactive agents released from the tumor were the most likely cause of the vasospasm. MR imaging findings of contrast enhancement around the vessels may indicate reactive processes around the vessels.     

Diagnosis and treatment of nontraumatic dissecting aneurysm in the middle cerebral artery]

Two cases of nontraumatic dissecting aneurysm of the middle cerebral artery (MCA) are reported. A 59-year-old woman presented with subarachnoid hemorrhage, mainly in the right sylvian fissure. On admission, the right carotid angiogram revealed a dissecting aneurysm with a double lumen extending from segment M1 to M2 of the right MCA, and an unruptured saccular aneurysm in the right internal carotid artery. Emergency surgery revealed a discolored protrusion of the arterial wall in the right MCA, which was thought to be the cause of her subarachnoid hemorrhage. The protrusion of the arterial wall was clipped and coated with Bemsheet soaked in Biobond. However, disturbance of consciousness persisted and she died of paralytic ileus two months after the operation. The other patient was a hypertensive 33-year-old woman with right hemiparesis and motor dysphasia. CT scans obtained on the day of admission showed no abnormalities. She was treated conservatively with clinical improvement, but CT scans obtained 3 days after the ictus revealed an infarction deep in the left frontal lobe. A left carotid angiogram was made 4 days after ictus and demonstrated severe stenosis of the proximal segment of the left MCA with poor filling of its superior trunk. Despite improvement of her hemiparesis, CT scans obtained 3 weeks after the ictus showed hemorrhagic infarction in the left frontal lobe. Repeat left carotid angiogram revealed a double lumen in the C1 and M1 portions with improvement of the previous severe stenosis of the M1. The 23 reported cases of DA in the MCA with our cases are reviewed and their neuroradiological and clinical features are discussed.     

Spontaneous intracranial internal carotid artery dissection treated by intra-arterial thrombolysis and superficial temporal artery-middle cerebral artery anastomosis in the acute stage--case report--

A 22-year-old man presented with sudden onset of right retro-orbital headache followed by left hemiparesis. Right carotid angiography demonstrated almost total occlusion of the intracranial internal carotid artery (ICA) and severe stenosis of the middle cerebral artery (MCA), presumably caused by arterial dissection. Local arterial injection of urokinase was performed 2 hours after onset. The ICA became patent, but the M2 portion of the MCA was still occluded, and the left hemiparesis did not improve. Superficial temporal artery-MCA anastomosis was immediately performed. The left hemiparesis disappeared completely 6 days after this procedure. Angiography 2 weeks after the onset revealed occlusion of the ICA, and maintenance of blood flow to the right cerebral hemisphere via the anastomosis. Magnetic resonance imaging showed small infarcts in the right cerebral cortex. Repeat angiography after 5 months showed recanalization of the right ICA and the right MCA. Combination of thrombolytic therapy and bypass surgery may be a useful treatment option for patients with sudden occlusion of the intracranial artery caused by dissection.     

Trapping and vascular reconstruction for ruptured fusiform aneurysm in the proximal A1 segment of the anterior cerebral artery

A 65-year-old woman presented with subarachnoid hemorrhage (SAH). Angiography detected a small bulge in the A1 segment of the right anterior cerebral artery (ACA). The patient was managed conservatively. Ten days after the initial SAH, the patient suffered a second SAH. Cerebral angiography demonstrated a fusiform aneurysm in the right A1 segment and vasospasm in the left A1 segment. The aneurysm of the right A1 segment was trapped and the right superficial temporal artery (STA) was end-to-end anastomosed to the distal portion of the right A1 segment. The patient had no postoperative cerebral ischemic events. Postoperative cerebral angiography revealed that the bypass flow through the right STA perfused the right ACA territories. STA-A1 end-to-end anastomosis can prevent cerebral ischemic events following parent vessel occlusion or microsurgical trapping for fusiform cerebral aneurysms in the A1 segment without sufficient collateral flow to the ipsilateral ACA territory from the contralateral ACA.     

Intracranial bilateral vertebral artery dissection during anticoagulation after cerebral venous and sinus thrombosis (CSVT)

Summary A 37-year-old woman presented with cerebral venous and sinus thrombosis (CVST). During the period of anticoagulation she developed asymptomatic dissection of the intracranial segments of both vertebral arteries with an enlarging false aneurysm on the right side. Endovascular occlusion of the pathological segment of the right vertebral artery including the dissecting aneurysm and conservative management of the other side resulted in complete recovery without neurological complications.     

Dissecting aneurysm of the anterior temporal artery: case report

A 65-year-old woman presented a rare dissecting aneurysm of the anterior temporal artery (ATA) manifesting as headache. Computed tomography and magnetic resonance imaging revealed a mixed-density mass in the horizontal segment of the middle cerebral artery. Emergent angiography demonstrated aneurysmal dilatation and a thrombosed mass in the sylvian fissure. Infectious aneurysm was excluded. She underwent emergent surgery to reduce the risk of repeated infarction and hemorrhage. The distal side of the ATA manifested occlusive changes suggestive of arterial dissection. The proximal side of the ATA was ligated and the lesion was excised. Histological examination confirmed that the aneurysmal dilatation was attributable to arterial dissection due to disruption of the internal elastic lamina. Distal dissecting aneurysms may occur in the absence of infectious disease. We recommend that ruptured distal dissecting aneurysms be treated surgically in the acute stage immediately after detection.     

Dissecting aneurysm of the anterior choroidal artery: angiographical and MR imaging findings

BACKGROUND: Intracranial dissecting aneurysms are relatively rare. We present a rare case of a dissecting aneurysm originating from the anterior choroidal artery; this is the first reported case.CASE DESCRIPTION: A 42-year-old man suffered sudden onset of right hemiparesis and dysarthria. Computed tomography on admission revealed a small low density area in the posterior limb of the internal capsule. MR imaging revealed aneurysmal dilatation of the anterior choroidal artery, and angiography revealed aneurysmal dilatation and stasis of dye in the venous phase at the anterior choroidal artery, which resolved in the chronic stage.CONCLUSION: We describe a rare case of a dissecting aneurysm of the anterior choroidal artery. The radiological findings were characteristic of dissecting aneurysms in spite of the rare location.     

Dissecting aneurysms of the anterior cerebral artery and accessory middle cerebral artery. Case report

A 66-year-old woman presented with dissecting aneurysms of the anterior cerebral artery (ACA) and accessory middle cerebral artery (MCA) manifesting as subarachnoid hemorrhage but without radiological evidence of the dissecting aneurysms. Intraoperative observation revealed that the vessel walls were dark purple in color, a typical finding of dissecting aneurysm. The abnormal A1 segment was trapped and the dissecting aneurysm of the accessory MCA was wrapped. In the case of SAH of unknown origin, dissecting aneurysm should always be kept in mind even if the angiogram does not show any abnormal finding. This is the first reported case of dissecting aneurysm of the accessory MCA.     

Sagittal magnetic resonance imaging of intramural hematoma from non-traumatic dissection of the anterior cerebral artery. Case report

A 46-year-old woman presented with non-traumatic anterior cerebral artery dissection manifesting as sudden onset of headache and motor weakness of the right lower limb. Angiography revealed luminal narrowing of the left anterior cerebral artery from the A(3) portion to the distal portion. Sagittal T(1)-weighted magnetic resonance imaging showed hyperintensity due to an intramural hematoma around the flow void signal of the affected anterior cerebral artery. Sagittal magnetic resonance imaging should be performed in suspected cases of anterior cerebral artery dissection to detect the diagnostic finding of intramural hematoma.     

Subarachnoid Hemorrhage after an Ischemic Attack Due to a Bacterial Middle Cerebral Artery Dissecting Aneurysm: Case Report and Literature Review

A 78-year-old woman suffered sudden-onset left hemiparesis. There were no remarkable infectious findings. Computed tomography (CT) demonstrated a low-intensity area supplied by the right middle cerebral artery (MCA). The diagnosis was cerebral ischemia and she was conservatively treated with hyperosmotic fluids. Two days after the ischemic stroke she suddenly became comatose. CT showed diffuse subarachnoid hemorrhage (SAH) in the basal cistern associated with a right intra-Sylvian and a right frontal subcortical hematoma. Three-dimensional (3D)-CT angiography demonstrated occlusion of the M2 portion of the right MCA. Four days after the ischemic onset she died of brain herniation. Autopsy revealed arterial dissection in the intermediate membrane of the right MCA bifurcation and occlusion of the M2 portion of the thrombosed right MCA. Gram staining showed remarkable bacterial infection in the thrombus. SAH after an ischemic attack due to MCA dissection is extremely rare. We suspect that bacterial infection was involved in the formation of her fragile dissecting aneurysm.     

Dissecting aneurysm of the posterior inferior cerebellar artery; a case report]

A case of a dissecting aneurysm of the left posterior inferior cerebellar artery caused by giant cell angiitis is presented. A 22-year-old woman was admitted on August 30, 1990, with sudden onset of severe occipital headache and vomiting. Neurological examination on admission only showed severe meningismus. CT scan demonstrated subarachnoid hemorrhage and a small hematoma in the 4th ventricle. A left vertebral angiogram demonstrated that the left posterior inferior cerebellar artery was occluded at the lateral medullary segment. We diagnosed subarachnoid hemorrhage from a dissecting aneurysm. On the day following admission, the patient underwent a left suboccipital craniectomy. The posterior inferior cerebellar artery was enlarged for a distance of about 8 mm and there was typical purplish-red appearance in the dissecting aneurysm. This aneurysm was excised after trapping. The histological diagnosis was primary localized giant cell angiitis without systemic involvement. The etiology of the intracranial dissecting aneurysm is obscure, but this report suggests that cerebral angiitis can be considered as an important factor.     

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.