Rapid regrowth of a successfully coiled traumatic pericallosal aneurysm

Regrowth of an intracranial aneurysm is a known complication of endovascular coiling. We report a patient with a traumatic pericallosal aneurysm which was initially treated successfully with endovascular coiling. Six-month follow-up angiography showed aneurysm regrowth with migration of the coils. To our knowledge, recurrence of a coiled pericallosal aneurysm of traumatic etiology has not been previously reported. Endovascular coiling may not be the best primary treatment for traumatic pericallosal artery aneurysms.     

Magnetic resonance angiography image guidance for the microsurgical clipping of intracranial aneurysms: a report of two cases

To describe the integration of magnetic resonance angiography (MRA) in neuronavigation procedures for microsurgery of intracranial aneurysms. MRA was combined with standard magnetic resonance image (MRI) acquisition in the image-guided planning for the microsurgical clipping of a saccular aneurysm in two patients (one 3-mm large middle cerebral artery and one 8-mm large pericallosal artery aneurysm, diagnosed by catheter angiography in both patients) using two different neurosurgical navigation systems. Conventional 3-D T1-weighted MRI with gadolinium and MRA pulse sequences were acquired in frameless stereotactic conditions the day before surgery and thereafter registered, allowing the definition a minimally invasive straight trajectory to the aneurysm neck. MRA-guided neurosurgery allowed a direct approach to the aneurysms at their proper location, reducing the invasiveness of the approach by tailoring the bone opening and reducing the duration and extension of brain retraction. The technique also avoided unnecessary dissection and exposure of the main trunks and collateral vessels. The aneurysms were successfully eradicated without complication. Integration of MRA in the planning and neuronavigation procedure for intracranial aneurysms may minimize the morbidity related to the surgical approach. This technique may be applicable more routinely using standard neuronavigation equipment.     

外伤性胼周动脉瘤

报告２例减速性颅脑伤所致的胼周动脉瘤，伤后经治疗症状好转，分别于伤后２５和３３天再次恶化。经头颅ＣＴ和颈动脉造影（ＣＡＧ））确诊后手术。指出患者脑外伤经治疗症状好转或消失，数天或数周后又恶化，ＣＴ发现一侧额叶内血肿伴脑室积血，是外伤性胼周动脉瘤破裂的典型表现，应进一步做ＣＡＧ确诊，及时手术预后良好。文中讨论了胼周动脉损伤的机制。     

Magnetic resonance angiography image guidance for the microsurgical clipping of intracranial aneurysms: a report of two cases

Abstract

To describe the integration of magnetic resonance angiography (MRA) in neuronavigation procedures for microsurgery of intracranial aneurysms. MRA was combined with standard magnetic resonance image (MRI) acquisition in the image-guided planning for the microsurgical clipping of a saccular aneurysm in two patients (one 3-mm large middle cerebral artery and one 8-mm large pericallosal artery aneurysm, diagnosed by catheter angiography in both patients) using two different neurosurgical navigation systems. Conventional 3-D T1-weighted MRI with gadolinium and MRA pulse sequences were acquired in frameless stereotactic conditions the day before surgery and thereafter registered, allowing the definition a minimally invasive straight trajectory to the aneurysm neck. MRA-guided neurosurgery allowed a direct approach to the aneurysms at their proper location, reducing the invasiveness of the approach by tailoring the bone opening and reducing the duration and extension of brain retraction. The technique also avoided unnecessary dissection and exposure of the main trunks and collateral vessels. The aneurysms were successfully eradicated without complication. Integration of MRA in the planning and neuronavigation procedure for intracranial aneurysms may minimize the morbidity related to the surgical approach. This technique may be applicable more routinely using standard neuronavigation equipment.     

Serious Blood-Brain Barrier Disruption after Coil Embolization of Unruptured Intracranial Aneurysm : Report of Two Cases and Role of Immediate Postembolization CT Scan

Abnormal contrast enhancement on brain computed tomography (CT) scan after diagnostic or interventional angiography is not rare, and has known to be induced by temporary blood-brain barrier (BBB) disruption from contrast media. Furthermore, it has been regarded as clinically subtle, but reported to have no symptom or mild transient symptoms. However, we recently experienced two cases of serious BBB disruption during the acute period after coiling of an unruptured intracranial aneurysm. One patient presented with an unruptured paraclinoid internal carotid artery (ICA) aneurysm on the right and the other with an unruptured right supraclinoid ICA aneurysm. Both patients showed similar findings on immediate postembolization CT scan and clinical courses after coiling. Typical radiological, clinical characteristics of BBB disruption were described. In addition, the role of immediate postembolization CT scan are also discussed.     

A case of aneurysm of the peripheral middle cerebral artery presenting putaminal hemorrhage--pitfall in diagnosis]

A case mimicking hypertensive putaminal hemorrhage which was first treated by CT-guided stereotactic aspiration and eventually diagnosed as a sequence of the ruptured aneurysm of the left peripheral middle cerebral artery on postoperative angiography is presented. This 41 old, right-handed, hypertensive female suffered sudden onset of headache and right hemiparesis. Next day hematoma was evacuated by the CT-guided stereotactic aspiration because of progressive deterioration of the consciousness and patient recovered well. Fourteen days after the evacuation when she presented mild right hand weakness and motor aphasia, angiography revealed a saccular aneurysm with broad neck derived from left posterior parietal artery. A neck clipping necessitated an additional anastomosis between superficial temporal artery and distal middle cerebral artery because of parent artery stenosis. Postoperatively she is doing well with slight motor aphasia. Among the typical hypertensive putaminal hemorrhage diagnosed on CT scan, it is stressed that there may be a possibility of ruptured aneurysm situated on the peripheral middle cerebral artery.     

DSA、CT与MRI融合影像对颅内多发假性动脉瘤的诊治价值（附1例报告并文献复习）

目的 报告1例通过DSA、CT与MRI融合影像联合神经导航诊治颅内多发假性动脉瘤患者的手术经验及体会。方法 回顾性分析1例外伤性颅内多发假性动脉瘤患者的临床资料,包括病史、症状、体征、影像学检查、手术过程及病理结果,总结DSA、CT与MRI融合影像对颅内多发假性动脉瘤的诊治价值及临床应用。结果 患者为25岁女性,车祸多发伤入院,经术前DSA检查为左侧大脑前A2段及胼周动脉多发假性动脉瘤,术前经3D-DSA与CT融合影像确定出血责任动脉瘤,经3D-DSA与MRI融合影像解决了精确定位,在神经导航指引下,一期手术完成了两个动脉瘤夹闭并切除。经病理证实为外伤性假性动脉瘤。结论 DSA与CT融合图像可以帮助判定多发动脉瘤中出血的责任动脉瘤,DSA与MRI融合图像输入神经导航为脑深部不能行介入栓塞治疗的颅内动脉瘤开创了新方法。     

An autopsy case of subarachnoid and intracerebral hemorrhage and necrotizing angitis associated with methamphetamine abuse

We report an autopsy case of methamphetamine-related intracranial hemorrhage and vasculitis. The possible relationship between drug usage and the occurrence of intracranial bleeding and cerebral vasculitis in such patients is discussed. A 22-year-old woman died after an intravenous injection of unknown dose of methamphetamine. A computed tomography head scan demonstrated massive subarachnoid hemorrhage and hematoma in corpus callosum. Cerebral angiography revealed nonfilling of bilateral intracranial carotid arteries and extravasation of contrast medium from right pericallosal artery which was visualized retrogradely via vertebral artery. Postmortem studies showed cerebral edema, subarachnoid and intracerebral hemorrhage, and intracranial vasculitis in the absence of aneurysm, arteriovenous malformation or chronic hypertension. Histological findings of necrosis of blood vessel walls with destruction of the elastica and smooth muscle layer, and without leukocytotic infiltration of the blood vessel walls were observed in order of anterior cerebral, middle cerebral, vertebral, posterior cerebral and basilar arteries. These angiographic and histological evidence suggests that such hemorrhage results from the development of fibrinonecrosis in the large intracerebral vessels, in addition to a sudden rise in blood pressure.     

Occurrence of intracerebral aneurysm in an HIV-infected child: a case report

A 12-year-old female diagnosed with human immunodeficiency virus infection at age 1 was admitted to our hospital with complaints of headache, left hemiparesis, and blurry vision. On admission, her CD4+ count was 97 cells/mm(3) (13%) and her viral load 44,783 ribonucleic acid copies/mL. Treatment had been initiated 3 months before admission with lopinavir/ritonavir, lamivudine, and stavudine. A computed tomographic scan and magnetic resonance imaging of the head revealed an aneurysm of the right middle cerebral artery. A head angiographic scan was consistent with intracranial arteritis. Six months after the initiation of antiretroviral therapy, her CD4+ cell count was 226 cells/mm(3) (16%) and her viral load was undetectable (less than 50 copies ribonucleic acid/mL). Magnetic resonance angiography of the head performed 15 months after the diagnosis demonstrated resolution of the aneurysm and the intracranial arteritis. This case highlights the association of human immunodeficiency virus infection with the occurrence of intracerebral aneurysms in the context of human immunodeficiency virus-vasculopathy, as well as its improvement with highly active antiretroviral therapy.     

Intracavernous carotid artery aneurysms

Six patients with intracavernous carotid artery aneurysms (ICCAAns) were seen at our department from 1998 to 2002. All patients had only one intracranial aneurysm and their ages at diagnosis ranged from 36 to 72 years (median 56). Five were women and four had a history of hypertension. One patient was pregnant. All of the ICCAAns were symptomatic at diagnosis. Duration of symptoms was 2–30 days. On admission to our department, initial symptom was headache in four patients, visual loss in two, eye pain in one, third nerve paresis in two and subarachnoid hemorrhage (SAH) in one. Spontaneous thrombosis was present in two patients. All of the ICCAAns were saccular. Computed tomography (CT) was superior when compared with magnetic resonance imaging (MRI) for diagnosis of ICCAAns on admission. Angiography remains the gold standard for diagnosis and determination of specific anatomical details, which are necessary to plan treatment.     

Subarachnoid haemorrhage following rupture of an ophthalmic artery aneurysm presenting as traumatic brain injury

Head trauma may provoke subarachnoid haemorrhage. The question sometimes arises whether in patients with trauma and subarachnoid haemorrhage the latter is of traumatic or aneurysmal origin. We present a 49-year-old patient who fell from a truck, struck his head and was unconscious immediately. On the brain computed tomography (CT) scan subarachnoid haemorrhage was present, initially diagnosed as of traumatic origin. Four-vessel angiography revealed rupture of a left ophthalmic artery aneurysm. We review the literature and give recommendations for angiography in patients with trauma and subarachnoid haemorrhage.     

The relationship of blunt head trauma, subarachnoid hemorrhage, and rupture of pre-existing intracranial saccular aneurysms

Patients with a history of closed head trauma and subarachnoid hemorrhage are uncommonly diagnosed with an intracranial saccular aneurysm. This study presents a group of patients in whom a pre-existing aneurysm was discovered during work-up for traumatic subarachnoid hemorrhage. Without an accurate pre-trauma clinical history, it is difficult to define the relationship between trauma and the rupture of a pre-existing intracranial saccular aneurysm. We retrospectively reviewed 130 patients who presented to Detroit Receiving Hospital between 1993 and 1997 with a diagnosis of subarachnoid hemorrhage (SAH). Of these 130 patients, 70 were spontaneous, and 60 had a history of trauma. Mechanisms of trauma include motor vehicle accident, assault, or fall from a height. Of the 60 patients with subarachnoid hemorrhage and a history of trauma, 51 (86%) did not undergo conventional four-vessel angiography, and had no further neurological sequelae. Nine patients (14%) had a suspicious quantity of blood within the basal cisterns or Sylvian fissure and had a four-vessel angiogram. Five patients (8%) were diagnosed with a saccular intracranial aneurysm, and all underwent surgical clipping of the aneurysm. We conclude that the majority of patients (92%), with post-traumatic SAH do not harbor intracranial aneurysms. However, during initial evaluation, a high level of suspicion must be entertained when post-traumatic subarachnoid hemorrhage is encountered in the basal cisterns or Sylvian fissure, as 8% of our population were diagnosed with aneurysms.     

Mistaken identity: a case of false positive on CT angiography.

We describe the case of a 42-year-old female presenting with subarachnoid haemorrhage from a posterior inferior cerebellar artery (PICA) aneurysm rupture on intracranial digital subtraction angiography (DSA). One year postoperatively, the patient was followed with CT angiography and was reported to show a de novo aneurysm at the bifurcation of the left inferior cerebellar artery (ICA). Subsequent DSA revealed an aberrant vein crossing over the ICA bifurcation on mask phase images. This is the first reported case of a such a reason for a 'false positive' on CT angiography (CTA). The case demonstrates that although CTA has a reported high specificity, careful interpretation of multiple views is required to diagnose intracranial aneurysms when compared to the 'gold' standard of CTA.     

Cerebral aneurysms in children.

Childhood intracranial saccular aneurysms are rare, accounting for only 0.6-4.6% of all aneurysms. This paper presents two such cases. A 12-year-old boy developed sudden severe headaches. CT indicated subarachnoid hemorrhage in the bilateral sylvian fissure. Angiography failed to demonstrate any vascular lesions. Repeat angiography, however, revealed a 2 mm aneurysm on the right A-1. A miniclip was successfully applied to obliterate the aneurysm. The postoperative course was uneventful. In the second case, a 3-year-old boy, CT incidentally revealed a bullet-shaped high density area. Angiography demonstrated a large aneurysm arising from the insular portion of the prefrontal branch of middle cerebral artery. This large aneurysm with a broad-based neck was successfully clipped, employing the angioplastic and/or tandem clipping, despite the fact the prefrontal artery unfortunately was compromised in postoperative angiography. The patient was doing well postoperatively. Spontaneous subarachnoid hemorrhage (SAH) in childhood is uncommon. However, when children with SAH is encountered, angiography should be performed repeatedly even if the first angiogram does not demonstrate any vascular abnormality. Childhood aneurysms are increasingly being found incidentally in CT scans. The differences between child and adult aneurysms in regard to site, size, sex predominance, clinical features, and surgical outcome are discussed.     

Acute spontaneous subdural hematoma of arterial origin

Acute spontaneous subdural hematoma (SDH) of arterial origin is very rare. We report a case of acute spontaneous SDH that showed contrast media extravasation from cortical artery on angiograms. A 58-year-old male patient developed sudden onset headache and right hemiparesis. Brain CT scan demonstrated acute SDH at left convexity. The patient was drowsy mentality on admission. He had no history of head trauma. Cerebral angiography was performed and revealed a localized extravasation of the contrast media from distal cortical MCA branch. After angiography, the patient deteriorated to comatose mentality. Decompressive craniectomy for removal of SDH was performed. We verified the arterial origin of the bleeding and coagulated the bleeding focus. The histological diagnosis was aneurysmal artery. He recovered after surgery with mild disability. In a case of acute spontaneous SDH, the possibility of a cortical artery origin should be considered.     

Ruptured aneurysm of distal posterior inferior cerebellar artery located at caudal loop]

We report an unusual case of subarachnoid hemorrhage (SAH) due to ruptured aneurysm originating at the caudal loop of posterior inferior cerebellar artery (PICA). The patient was a 77-year-old female presented with a sudden onset of headache and vomiting. Initial CT scan demonstrated a SAH with thick hematoma mainly in the cisterna magna. Vertebral angiogram revealed a saccular aneurysm arising from the tonsillomedullary segment of the left PICA, and communicating artery with supplying a territory of contralateral vermis as an anastmotic vessel. At surgery, no vessel branches were confirmed in the vicinity of the aneurysm, and this aneurysm was successfully clipped. In the fetus, numerous basilar and vertebral arteries are organized in plexiform formations around the brain stem. It has been suggested that the pathogenesis of such aneurysm or communicating artery could be related with a remnant of a primitive vertebrobasilar anastomosis. Based on these considerations, congenital vessel-wall weakness and hemodynamic stress associated with communicating artery may contribute to the development of distal PICA aneurysms.     

Headache and neck pain as only manifestations of spontaneous of the dissecting aneurysm vertebral artery--a case report]

A 57-year-old woman had noticed occipital headache and neck pain bilaterally 6 weeks before admission. The headache and neck pain persisted for 3 weeks, then disappeared. Cranial magnetic resonance (MR) image obtained 4 weeks after the onset demonstrated intramural hematoma adjacent to intracranial left vertebral artery. MR image did not show any abnormal lesions in the brain parenchyma. Although cranial MR angiography did not show any definite aneurysms, three-dimensional CT angiography (3D-CTA) obtained 6 weeks after the onset disclosed an aneurysm of the left vertebral artery. The vessel distal to the aneurysm was occluded. Because the left posterior inferior cerebellar artery originated from the aneurysm, we did not perform embolization using coils. Spontaneous dissecting aneurysm of the left vertebral artery was diagnosed based on the clinical, MR image, and 3D-CTA findings. The systolic blood pressure was maintained under 130 mmHg using antihypertensive agents. Thereafter, 3D-CTA obtained 6 months after the onset showed recanalization of the occluded vessel distal to the aneurysm. The size of the aneurysm was unchanged. During these 6 months, there were no ischemic or hemorrhagic stroke events. In the present patient, headache and neck pain were the only manifestations of spontaneous dissection of the vertebral artery.     

Management of minor head injury: the value of early computed tomography and serum protein S-100 measurements

Computed tomography (CT) scan was performed within 6 h in 91 patients with minor head injury (MHI). Eight patients (9%) demonstrated intracranial lesions on CT scan (6 brain contusions, 1 brain edema and 1 extradural hematoma). No patient required craniotomy. In patients with normal CT scan, no complications to the head injury were observed. Patients with intracranial lesions were hospitalized significantly longer (mean 9.4 days) than patients without (mean 1.6 days). In a subgroup of 50 patients with normal CT scan, serum S-100 protein was measured on admission. Elevated S-100 levels were seen in 10 of 50 patients (0.5-2.4 mug/L, mean 1.1). These patients were hospitalized significantly longer (mean 3.4 days) compared to patients with normal CT scan and normal S-100 levels (mean 1.1 days). MHI patients with GCS 14-15 without neurological deficits can safely be discharged when CT scan is normal. Serum protein S-100 measurements appear to provide information about diffuse brain injury after MHI.     

A case of basilar artery fenestration with recurrent attacks of vertebrobasilar insufficiency

Fenestration of basilar artery is an uncommon vascular anomaly that is usually an incidental product on autopsy or angiography. None of the cases in the literature had clinical symptoms associated with this anomaly except for subarachnoid hemorrhage when accompanied with saccular aneurysm. We report a rare case of the basilar artery fenestration associated with clinical symptoms without any aneurysm. A 71-years-old male, who had been treated for labile hypertension and had had recurrent attacks of vertigo, nausea, sometimes diplopia or unsteady gait, for 5 years, was referred to our hospital on Sept. 13, 1985. One day prior to admission, he suddenly felt diplopia and vertigo and unsteady gait. His family noticed he was dysarthric. On admission, he was alert and normotensive. He complained of dysesthesia on the right half of the perioral region and his right fingers. A neurological examination showed a mild weakness and hyperactive deep tendon reflexes on his right leg. His motor coordination was almost normal, but he was unsteady when he stood on one foot with his eyes closed. Laboratory examinations were normal except for an elevated serum uric acid level. A chest x-ray film showed a sclerotic change of aorta and mild cardiomegaly. Left ventricular hypertrophy was observed on his ECG. His CT scans showed multiple lacunae and mild brain atrophy. On cerebral angiography, his basilar artery (BA) had a fenestration almost in its total length that divided the BA, like a duplication, into two components with a smaller diameter than normal.(ABSTRACT TRUNCATED AT 250 WORDS)     

Brain 3 D-CT angiography was a useful tool for diagnosis of internal carotid-posterior communicating artery aneurysm: a case of false negative 3 D-MRA]

A 75-year-old woman with hypertension suddenly developed ptosis in the left eyelid. Neurological examination revealed left oculomotor nerve palsy. Brain T 2-weighted imaging showed abnormal flow void sign in the proximal portion of left middle cerebral artery. Other MRIs, including gadolinium enhancement, were normal. However, brain 3 D-MRA, using time-of-flight sequence, did not disclose any intracranial aneurysms. 3 D-CT angiography revealed left internal carotid-posterior communicating artery (IC-PC) aneurysm. Maximum intensity projection display of CT angiography demonstrated the neck and head portions of IC-PC aneurysm (size = 8 mm). Furthermore, 3 D-CT angiography was beneficial for anatomical evaluation of the aneurysm and the surrounding bony structures. The false negative 3 D-MRA of our patient was thought to result from flow-related artifacts, slow blood flow in the aneurysm, the surrounding noise and the localization of aneurysm. False negative findings of cerebral aneurysms occasionally occur on 3 D-MRA or 3 D-CT angiography, in comparison with digital subtraction angiography. Thus, we should pay more attention to assessment of 3 D-MRA and 3 D-CT angiography in patients who have high risks of cerebral aneurysms.