Isolated intraventricular hemorrhage due to a ruptured vertebral artery aneurysm

A rare case of ruptured aneurysm originating from the vertebral artery, and presenting an isolated clot in the fourth ventricle is reported. The patient underwent surgery via a right lateral suboccipital craniectomy on the third day. As the aneurysm was huge and partially thrombosed, trapping was performed and completed successfully. If isolated intraventricular hematoma was found without obvious parenchymal hemorrhage or subarachnoid clot, the diagnosis of vertebral artery aneurysm should be considered as a possibility in addition to posterior inferior cerebellar artery aneurysm. Complete vertebral angiography is indispensable for the recognition of this condition.     

Choroid plexus metastasis of renal cell carcinoma causing intraventricular hemorrhage: a case report]

We report a rare case of choroid plexus metastasis of renal cell carcinoma causing intraventricular hemorrhage. A 75-year-old female was admitted to our hospital for SAH. Preoperative examination evoked suspicion of an anterior communicating aneurysm as a cause of SAH. Furthermore, there were lesions on the tuberculum sellae and in the left trigone of the lateral ventricle, which were enhanced by Gd-DTPA on MRI. The patient was operated on via the pterional approach on December 3, 1996, but no aneurysm was found. She underwent total removal of the tuberculum sellae mass, which was postoperatively proved to be a meningioma by histological examination. The intraventricular tumor was supposed to be a meningioma, but it was not treated surgically. Two months later, the patient presented hematuria and was diagnosed as having a right renal cancer and underwent right nephrectomy on March 18, 1997. However, postoperatively, disturbance of consciousness continued. A CT scan revealed intraventricular hemorrhage around the tumor in the trigone of the lateral ventricle on March 21. An emergency operation for tumor and clot removal succeeded in improving the patient's condition. Histological examination of the tumor revealed clear-cell type renal cell carcinoma. Solitary choroidal plexus metastasis from renal cell carcinoma is quite rare: only 5 cases have been reported. But only our case was accompanied by intraventricular hemorrhage. Renal cell carcinomas are divided into two types: a slowly progressive type and a rapidly progressive type. Four cases among the reported 5 cases were the slowly progressive type, and our case was regarded as being of the same type.     

Clipping of a Mycotic Basilar Trunk Aneurysm under Cardiac Arrest in a Pregnant AIDS Patient

We present the first case of a coccidioidomycosis mycotic anterior inferior cerebellar artery (AICA) aneurysm that was clipped under hypothermic cardiac standstill in a pregnant acquired immunodeficiency syndrome (AIDS) patient. A 24-year-old pregnant AIDS patient presented with intraventricular hemorrhage and hydrocephalus. Angiography revealed an 8-mm basilar trunk aneurysm with the right AICA protruding from the side wall of the aneurysm. The patient underwent a retrosigmoid craniotomy and direct clipping of the aneurysm under hypothermic cardiac standstill. At presentation, the patient had a poor grade due to subarachnoid and intraventricular hemorrhage. Despite her large posterior circulation aneurysm in the setting of AIDS with extensive coccidioidomycosis meningitis, the lesion was clipped successfully. To do so required the full range of neurosurgical repertoire, including a skull base approach and hypothermic cardiac standstill.     

Central neurocytoma revealed by intraventricular hemorrhage. A case report and review of the literature

A case of intraventricular tumor presenting with intraventricular hemorrhage in a 38-year-old man is reported. Initial symptoms were an acute onset of headache with projectile vomiting. CT-scan revealed intraventricular hemorrhage. Cerebral angiography did not show any vascular malformation. MRI study, performed initially and several days after, disclosed and confirmed the presence of an intraventricular mass. The patient was operated on via a transfrontal route, and a complete tumor removal was achieved. Pathological examination was consistent with a central neurocytoma. Two similar cases from the literature are discussed with respect to differential diagnosis and practical management considerations.     

Distal anterior choroidal artery aneurysm in a patient with moyamoya disease: case report

OBJECTIVE AND IMPORTANCE: Distal anterior choroidal artery (AChA) aneurysms in moyamoya disease are rare, with few surgically verified reported cases. CLINICAL PRESENTATION: We report a rare case of distal AChA aneurysm associated with moyamoya disease in a 48-year-old man who presented with vomiting and severe headache. Computed tomographic scans revealed an intracerebral hematoma in the right temporoparietal lobe and a diffuse intraventricular hemorrhage. INTERVENTION: The hematoma was removed via computed tomography-guided stereotactic aspiration and ventricular drainage. Cerebral angiography showed a saccular aneurysm located at the distal branch of the right AChA. By means of magnetic resonance imaging, a small signal void lesion was detected in the periventricular area lateral to the trigone of the right lateral ventricle. The aneurysm was accurately accessed via a parietal cortical incision by use of magnetic resonance imaging-guided stereotactic localization. The aneurysm was successfully resected after undergoing trapping of the parent artery, and when the patient was discharged, he had no evidence of neurological deficit. The aneurysm was histologically verified to be a true aneurysm. CONCLUSION: Direct surgery should be considered in cases of ruptured distal AChA aneurysms located in the periventricular or intraventricular regions.     

Ruptured aneurysm of a posterior inferior cerebellar artery communicating artery. Case report and histological findings

A hypertensive 60-year-old man presented with a rare aneurysm arising from the posterior inferior cerebellar artery (PICA) communicating artery, manifesting as subarachnoid hemorrhage with intraventricular hemorrhage. Angiography showed a small aneurysm arising from a fine and tortuous artery interconnecting the bilateral vermian branches of distal PICAs. The right PICA was absent and its vermian territory was supplied by the left PICA through this communicating artery. The right anterior inferior cerebellar artery was also connected to the vermian branch of the right PICA. At surgery, a reddish and apparent fusiform aneurysm was noted at the top of the arterial loop under the cerebellar vermis. Microsurgical trapping and removal of the aneurysm was performed without complication. Histological examination demonstrated typical findings of a true aneurysm. Only four previous cases of aneurysm of the communicating artery between the bilateral distal PICAs have been reported. In all five reported cases including ours, the PICA communicating artery contributed to the collateral blood supply of the contralateral vermian territory based on vascular anomalies. Hemodynamic stress and congenital vulnerability may have caused this aneurysm. Trapping is suitable to treat this precarious aneurysm if other collateral vessels supply the contralateral vermian territory.     

Surgical treatment of a lenticulostriate artery aneurysm. Case report

A previously healthy 61-year-old man presented with basal ganglia hemorrhage caused by rupture of a small aneurysm arising from the distal lenticulostriate artery associated with moyamoya-like disease and manifesting as left hemiparesis and dysarthria. The patient underwent frontotemporal craniotomy. Neck clipping of the aneurysm was performed through the hematoma cavity. He was transferred for rehabilitation with left hemiparesis. Three-dimensional computed tomography angiography was very useful for preoperative planning and evaluation of the anatomical correlation between the aneurysm and the hemorrhage.     

A ruptured choroidal artery aneurysm of the anterior inferior cerebellar artery obliterated via the endovascular approach: case report

Intraventricular aneurysms associated with fourth ventricular hemorrhage are rare. A case of a ruptured aneurysm in a choroidal branch of the right anterior inferior cerebellar artery (AICA) is reported here. A 56-year-old man presented with sudden onset of vertigo and nausea. CT scan showed an intraventricular hemorrhage within the fourth ventricle. Cerebellar angiography showed an aneurysm at the choroidal artery branching from the right AICA. The patient rejected both general anesthesia and craniotomy, so endovascular embolization under local anesthesia was performed using Guglielmi detachable coils (GDCs) and a fibered platinum coil. The distal portion of the right AICA and the aneurysm were obliterated. His postoperative course was fairly satisfactory. He suffered from a minimal gait disturbance caused by truncal ataxia for several days after the operation. He was discharged from hospital without neurological deficit. There have been only a few articles about choroidal artery aneurysms. As treatment, direct surgery has been recommended in past cases, but endovascular embolization of the parent artery was successfully performed in this case. Not only direct surgery but also endovascular surgery may be regarded as the treatments of choice for intraventricular aneurysms, depending on the size of the parent artery.     

Peripheral aneurysms of the lateral posterior choroidal artery: clinical presentation and endovascular treatment: report of two cases

OBJECTIVE AND IMPORTANCE: To describe the clinical presentation and endovascular management of peripheral aneurysms of the lateral posterior choroidal artery. Aneurysms in this location are exceptionally rare and optimal treatment may be difficult. CLINICAL PRESENTATION: Two patients with peripheral aneurysms of the distal portion of the lateral posterior choroidal artery presented with headaches from extensive intraventricular hemorrhage. INTERVENTION: Endovascular surgical therapy by use of superselective n-butylcyanoacrylate embolization of the aneurysm and adjacent distal parent artery was successful in both patients. CONCLUSION: Patients with peripheral aneurysms of the lateral posterior choroidal artery usually present with intraventricular hemorrhage. They may be difficult to treat by open surgical techniques owing to their intraventricular location and the frequent inability to preserve the parent artery by aneurysm clipping. Instead, it is typical that either proximal parent artery occlusion or aneurysm trapping must be used. An equivalent endovascular surgical technique may be an attractive alternative method of management.     

Intraventricular occurrence of a melanocytoma

Melanocytomas are rare tumors of the central nervous system that are believed to arise from leptomeningeal melanocytes. A young girl presented with a contrast-enhancing cystic mass in the temporal horn of the left lateral ventricle. Microsurgical resection of a black-colored vascular tumor supplied by the anterior choroidal artery was performed. Appropriate immunohistochemical staining and electron microscope evaluations were used to confirm the pathological diagnosis. The patient made an excellent recovery; follow-up imaging revealed no recurrent or residual tumor. This is the first documented primary occurrence of a melanocytoma in an intraventricular location. The intraventricular occurrence of this tumor suggests that melanocytes may migrate into the choroidal fissure and may infrequently undergo neoplastic proliferation in that location. This case contains implications for the differential diagnosis of intraventricular tumors.     

Aplasia of the right internal carotid artery presenting with callosal hemorrhage: case report and review of the literature

A 73-year-old woman without a history of cerebral ischemia suffered from sudden onset headache. Brain computed tomography (CT) showed intracerebral hemorrhage in the corpus callosum with intraventricular hemorrhage and thin subarachnoid hemorrhage in the basal cistern. Cerebral angiography showed narrowing of the right internal carotid artery just distal to its origin in the neck and abrupt occlusion just after branching of the ophthalmic artery with moyamoya-like vessels. The right A2 segment showed irregular dilatation and stenosis. The right middle cerebral artery was supplied from the basilar artery via the right posterior communicating artery. There was neither aneurysm nor arteriovenous malformation. Thin-slice bone-window CT of the skull base revealed hypoplasia of the right carotid canal. Aplasia of the right internal carotid artery was diagnosed. The origin of the hemorrhage was thought to be the irregularly opacified right A2 segment, which had been subjected to long-standing hemodynamic stress as collateral vessel.     

A ruptured aneurysm at the peripheral collateral circulation of the anterior choroidal artery in a patient with moyamoya disease: a case report]

This 42-year-old man experienced a sudden onset of occipital headache. Neurological examination revealed a moderately disturbed consciousness and a moderate left hemiparesis. CT scan disclosed a hugh hematoma in the right temporo parietal lobe without intraventricular hemorrhage. A cerebral angiography demonstrated typical findings of moyamoya disease and a small saccular aneurysm at the peripheral portion of the right anterior choroidal artery, which was dilated at the collateral circulation to the parietal lobe. The hematoma was removed at once by a craniotomy. He became alert but mild hemiparesis persisted. MRI disclosed a small signal-void lesion lateral to the trigone of the right lateral ventricle. The angiography repeated three weeks after the removal of the hematoma showed the unchanged size of the aneurysm. Direct surgery for the aneurysm was performed via the right parietal transcortical approach. The aneurysm was reached under the guidance of the intraoperative angiography. Trapping of the parent artery and the excision of the aneurysm were performed. On the basis of the presence of an internal elastic lamina at the neck of the aneurysm, the surgical specimen was histologically verified to be a true aneurysm. Since the collateral circulation was well preserved during surgery, no worsening of the neurological manifestation was observed. In view of the unfavorable prognosis for a moyamoya patient with this type of the aneurysm, which often results in a massive ventricular or intracerebral hemorrhage, surgery directed to the aneurysm itself should be considered.     

Occipital artery-anterior inferior cerebellar artery bypass with microsurgical trapping for exclusively intra-meatal anterior inferior cerebellar artery aneurysm manifesting as subarachnoid hemorrhage. Case report

A 77-year-old woman presented with an extremely rare exclusively intra-meatal anterior inferior cerebellar artery (AICA) aneurysm manifesting as subarachnoid hemorrhage. The aneurysm was located at a non-branching site of its meatal loop, deeply inside the internal auditory canal. The ipsilateral posterior inferior cerebellar artery was hypoplastic and the affected AICA supplied a wide vascular territory in the right cerebellum. The patient underwent microsurgical trapping of the distal AICA aneurysm in the acute stage. Collateral back flow to the parent artery was poor, so right occipital artery (OA)-AICA anastomosis was performed prior to aneurysm trapping. The postoperative course was uneventful, and magnetic resonance imaging after surgery did not demonstrate any ischemic change. Postoperative angiography showed complete disappearance of the AICA aneurysm and the apparently patent OA-AICA bypass. She did not suffer neurological deficit except for right incomplete hearing disturbance, and postoperative single photon emission computed tomography demonstrated absence of hemodynamic compromise in the cerebellum. OA-AICA anastomosis with aneurysm trapping could be the optimal surgical management of the AICA aneurysm located exclusively inside the internal auditory canal, especially if the parent artery supplies a wide vascular territory.     

Aneurysms associated with moyamoya disease

Seven cases of moyamoya disease accompanied by an aneurysm were studied. The patients, two males and five females, were 13 to 57 years old (average, 32). The cases were classified into two groups: Group A (five cases), in which the aneurysm was located within the moyamoya vessels, and Group B (two cases), in which the aneurysm was located within the circle of Willis and remote from the moyamoya vessels. In all Group A cases, the presenting episode was intracerebral and intraventricular hemorrhage due to rupture of the aneurysm. One patient suffered two separate attacks. In this case, the aneurysm disappeared spontaneously. In one of the two Group B cases, there was hemorrhage from an anterior communicating artery aneurysm. In the other case, with a basilar-superior cerebellar artery aneurysm, there was hemorrhage from the moyamoya vessels.     

Cerebral infarction along the distribution of perforating arteries during aneurysm surgery in a patient with pheochromocytoma--case report

A 58-year-old woman with refractory hypertension presented with subarachnoid hemorrhage. Digital subtraction angiography and three-dimensional computed tomography (CT) angiography revealed a ruptured left vertebral artery (VA) aneurysm and an unruptured left middle cerebral artery (MCA) aneurysm. The patient successfully underwent neck clipping of the left VA aneurysm. However, CT obtained just after the operation showed an asymptomatic cerebral infarction along the distribution of medial striate arteries of the right anterior cerebral artery in the caudate nucleus. The pathogenesis of the infarction was unknown. Before clipping surgery of the left MCA aneurysm, detailed examinations to find the cause of her refractory hypertension were performed. Laboratory tests revealed plasma serum level of norepinephrine at 15,521 pg/ml (normal range 100-450 pg/ml). Abdominal magnetic resonance imaging revealed a pheochromocytoma in the right adrenal gland. After preoperative management of the pheochromocytoma, the neck of the left MCA aneurysm was successfully clipped. When the patient awakened from anesthesia, she noticed right hemiparesis and motor aphasia. CT showed cerebral infarction along the distribution of lenticulostriate arteries of the left MCA in the putamen. Her symptoms gradually improved, and the pheochromocytoma was removed by laparoscopic surgery. Sustained severe hypertension and depletion of blood volume resulting from excess catecholamine release from the pheochromocytoma may have caused the complications. Hypervolemic fluid infusion and maintenance of normotensive blood pressure during surgery may avoid such ischemic events.     

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

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

Ruptured saccular aneurysm of a dolichoectatic internal carotid artery in a patient with agenesis of the contralateral internal carotid artery--case report

A 42-year-old woman presented with very rare cases of ruptured saccular aneurysm of a dolichoectatic internal carotid artery (ICA) associated with agenesis of the contralateral ICA manifesting as sudden onset of severe headache and nausea without neurological deficits. Angiography and three-dimensional computed tomography demonstrated intraventricular hemorrhage with slight subarachnoid hemorrhage and dolichoectasia of the right ICA with agenesis of the contralateral ICA, as well as a saccular aneurysm of the ectatic right ICA. The aneurysm neck was clipped successfully. The patient remained ambulatory with no neurological deficits at discharge 15 days after the surgery. The saccular aneurysm in our case was formed in the dolichoectatic ICA, presumably due to both abnormal hemodynamics and abnormal arterial wall.     

Treatment of ruptured spontaneous saccular aneurysm in the central artery of the middle cerebral artery using bypass surgery combined with trapping - case report -

A 54-year-old man presented with a rare ruptured distal middle cerebral artery (MCA) aneurysm manifesting as subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm in the central artery of the left MCA. The patient underwent anastomosis between the superficial temporal artery and the central artery distal to the lesion followed by trapping and excision of the lesion. The postoperative course was uneventful. Histological examination of the excised specimen revealed a saccular aneurysm and absence of bacteria, inflammation, or neoplasm. The present case shows that a spontaneous saccular aneurysm can develop at the cortical segment of the MCA, and can be successfully treated with bypass surgery combined with trapping.     

Ruptured anterior spinal artery aneurysm: a case report

BACKGROUND

Spinal artery aneurysms are rare, and are usually found in association with arteriovenous malformations or coarctation of the aorta.

CASE REPORT

A 42-year-old man with a ruptured anterior spinal artery aneurysm is presented here. He experienced subarachnoid hemorrhage, which was confirmed by computed tomography. Magnetic resonance imaging revealed an aneurysm in front of the upper part of the medulla. Angiography demonstrated bilateral vertebral artery occlusion. Distal vertebral arteries and the basilar artery were perfused via the dilated anterior spinal artery, which originates in the right subclavian artery. The aneurysm was located at the distal part of the anterior spinal artery, and was successfully clipped through a lateral suboccipital craniotomy 2 months after bleeding from the aneurysm. After rehabilitation, the patient was able to walk with no apparent neurologic deficit.

CONCLUSIONS

This case suggests that the anterior spinal artery as a collateral route after bilateral vertebral arery occlusion is under hemodynamic stress, resulting in aneurysm formation and rupture.     

A case of large basal ganglia AVM totally removed by staged operation

Large basal ganglia AVMs have been deemed inoperable because of their location in critical structures. Nonetheless, the unfavorable natural history of an untreated ruptured AVM in a young patient induced us to approach these lesions. We presented a case of a large basal ganglia AVM totally removed by a three-staged operation. A 26-year-old man who had twice experienced intracranial hemorrhage was admitted for examination. On admission, mild left hemiparesis, hypesthesia and left hemianopsia were disclosed. CT scan showed the AVM was located in the posterior thalamus with the hematoma cavity laterally. Right carotid and vertebral angiograms demonstrated a large AVM, 5cm in diameter, supplied by the anterior choroidal artery (AchoA), the lateral lenticulostriate arteries (I-LSAs), the lateral posterior choroidal artery (LPchoA) and the thalamo-perforating artery. Drainage was via the internal cerebral vein and the basal vein of Rosenthal. MRI demonstrated more clearly the anatomical relationship of the nidus and surrounding structures. The patient underwent a three staged operation. At the first operation AchoA was interrupted in the inferior horn of the lateral ventricle (IHL) via the hematoma cavity using the trans-sylvian approach. The anterior part of the nidus was dissected with all except one of the I-LSAs being disconnected. At the next operation by occipital interhemispheric approach, some feeders from the posterior cerebral artery were coagulated and disconnected. The medial and posterior part of the nidus was dissected from the thalamus along with the choroid plexus of the trigone of the lateral ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)