Recurrence of a vertebral artery dissecting pseudoaneurysm after successful stent-supported coil embolization: case report

OBJECTIVE AND IMPORTANCE: Dissecting aneurysms of the intracranial vertebral artery are increasingly recognized as a cause of subarachnoid hemorrhage. We present a case involving technical success of the stent-supported coil embolization but with recurrence of the dissecting pseudoaneurysm of the intracranial vertebral artery. The implications for the endovascular management of ruptured dissecting pseudoaneurysms of the intracranial vertebral artery are discussed. CLINICAL PRESENTATION: A 36-year-old man with a remote history of head injury had recovered functionally to the point of independent living. He experienced the spontaneous onset of severe head and neck pain, which progressed rapidly to obtundation. A computed tomographic scan of the head revealed subarachnoid hemorrhage centered in the posterior fossa. The patient underwent cerebral angiography, which revealed dilation of the distal left vertebral artery consistent with a dissecting pseudoaneurysm. INTERVENTION: Transfemoral access was achieved under general anesthesia, and two overlapping stents (3 mm in diameter and 14 mm long) were placed to cover the entire dissected segment. Follow-up angiography of the left vertebral artery showed the placement of the stents across the neck of the aneurysm; coil placement was satisfactory, with no residual aneurysm filling. Approximately 6 weeks after the patient's initial presentation, he developed the sudden onset of severe neck pain. A computed tomographic scan showed no subarachnoid hemorrhage, but computed tomographic angiography revealed that the previously treated left vertebral artery aneurysm had recurred. Angiography confirmed a recurrent pseudoaneurysm around the previously placed Guglielmi detachable coils. A test balloon occlusion was performed for 30 minutes. The patient's neurological examination was stable throughout the test occlusion period. Guglielmi detachable coil embolization of the left vertebral artery was then performed, sacrificing the artery at the level of the dissection. After the procedure was completed, no new neurological deficits occurred. On the second day after the procedure, the patient was discharged from the hospital. He was alert, oriented, and able to walk. CONCLUSION: We appreciate the value of preserving a parent vessel when a dissecting pseudoaneurysm of the intracranial vertebral artery ruptures in patients with inadequate collateral blood flow, in patients with disease involving the contralateral vertebral artery, or in patients with both. However, our case represents a cautionary note that patients treated in this fashion require close clinical follow-up. We suggest that parent vessel occlusion be considered the first option for treatment in patients who will tolerate sacrifice of the parent vessel along its diseased segment. In the future, covered stent technology may resolve this dilemma for many of these patients.     

Agenesis of the right internal carotid artery with intracerebral hemorrhage: case report

A 45-year-old woman was admitted to our department because of intracerebral hemorrhage. Neurological examination showed upward gaze palsy, right hemihypesthesia including face and nuchal rigidity. CT scan demonstrated a high density spot in the left quadrigeminal plate. Postcontrast CT scan demonstrated an abnormal vessel in the left midbrain. We suspected the presence of an arterio-venous malformation (AVM) and angiography was performed. Left vertebral angiography demonstrated early filling as far as the basal vein of Rosenthal with the contrast medium. However, no nidus suggesting AVM was observed. The right middle cerebral artery was fed via an anastomotic vessel (anomalous posterior communicating artery) from basilar bifurcation. Right carotid angiography demonstrated only the right external carotid artery indicating the absence of the right internal carotid artery. The bone target image of thin slice CT scan of the cranial base also disclosed the absence of the right carotid canal. 123I-IMP SPECT demonstrated no hypoperfusion area in the right cerebral hemisphere. The usefulness of the thin slice CT scan in the cranial base was discussed.     

Bacterial intracranial aneurysms associated with infectious endocarditis--report of 3 cases

Three cases of bacterial intracranial aneurysms associated with infective endocarditis are reported. All of the patients were successfully treated by various combinations of cardiac surgery, neurosurgery and chemotherapy with antibiotics. Case 1: A 39-year-old female was admitted with the complaint of sudden onset of severe headache following persistent fever of several month's duration. CT scan revealed a left frontal old hematoma and angiography detected an aneurysm located in the frontal ascending branch of the left middle cerebral artery. After 2 weeks' antibiotic therapy, the second angiography showed the aneurysm to be decreased in size. The third angiography, performed 2 weeks after cardiac valve replacement for infective endocarditis, demonstrated complete resolution of the aneurysm. Case 2: A 19-year-old male entered hospital with high fever and chills. In addition to infective endocarditis, CT scan and angiography revealed an aneurysm arising from the distal portion of the left posterior cerebral artery. The patient was treated with high dose antibiotics and then his general condition improved. However, angiography examined 4 weeks after the initial study demonstrated the aneurysm to be apparently enlarged. Therefore, the aneurysm was excised before cardiac surgery. Repeated angiography after valve replacement showed no further aneurysm. Case 3: A 30-year-old female was admitted on the diagnosis of infective endocarditis and meningitis. CT scan showed abnormal density areas in the right frontal lobe and the left temporal lobe.(ABSTRACT TRUNCATED AT 250 WORDS)     

Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation: case report

BACKGROUND: Vertebral artery injury during posterior C1-2 transarticular screw fixation occurs in approximately 3% of patients and may remain asymptomatic or result in arteriovenous fistulae, occlusion, narrowing, or dissection of the vertebral artery, and lead to transient ischemic attacks, stroke, or death. CASE DESCRIPTION: This is the first report of a pseudoaneurysm resulting from damage to the vertebral artery during the procedure. This 31-year-old male underwent posterior C1-2 transarticular screw fixation for unstable os odontoideum. Injury to the left vertebral artery occurred while the hole for the left screw was being drilled. Temporary control of bleeding with local pressure was followed by immediate postoperative angiography that revealed a left vertebral artery pseudoaneurysm. Although the patient remained asymptomatic, therapeutic anticoagulation was instituted 6 hours postoperatively. Increasing size of the pseudoaneurysm was noted on routine follow-up angiography 4 weeks later. Endovascular occlusion of the pseudoaneurysm and left vertebral artery, with preservation of vertebrobasilar flow through the right vertebral artery, was accomplished without neurological consequence. CONCLUSIONS: Vertebral artery pseudoaneurysm complicating posterior C1-2 transarticular screw fixation may be effectively treated with endovascular approaches.     

Combination of intravascular surgery and surgical operation for occipital subcutaneous arteriovenous fistula in a patient with neurofibromatosis type I

We presented a case of neurofibromatosis type I (NF-1) associated with an extracranial arteriovenous fistula (AVF) fed by the occipital and vertebral artery. A 20-year-old man was referred to our hospital because of an occipital subcutaneous pulsatile mass. A CT scan showed a huge subcutaneous enhanced mass. Angiography revealed that the occipital AVF was fed by bilateral occipital arteries, the left ascending pharyngeal artery, the left middle cerebral artery, and the left vertebral artery with-abundant communication with the subcutaneous veins. Endovascular treatment by using both coil and glue (Eudragid) embolization via the occipital artery successfully obliterated the AVF. Subsequently surgical operation was performed. Postoperative angiography showed the disappearance of the AVF. Combination of intravascular surgery and surgical operation should be considered as an effective treatment for NF-1 associated with AVF.     

Three cases of non-traumatic acute subdural hematoma]

The authors present three cases of non-traumatic acute subdural hematoma showing interesting clinical features and operative findings. Case 1: A-50-year-old male was admitted because of sudden headache and epileptic seizure. Computed tomographic (CT) scan showed a right thin subdural hematoma, but cerebral angiography demonstrated no pathological findings, that might cause acute subdural hematoma on the follow-up CT scans. The hematoma changed to a chronic one within only 15 days, which was proved by the operation. Case 2: A 52-year-old male was hospitalized because of loss of consciousness. CT scan revealed a right subdural hematoma without subarachnoid hemorrhage and cerebral angiography demonstrated a right middle cerebral artery aneurysm. The hematoma was surgically proved to be due to rupture of the aneurysm. Case 3: A 52-year-old male was admitted because of headache, vomiting and left motor weakness. CT scan showed a thick right subdural hematoma and right carotid angiography revealed two internal carotid artery aneurysms. It was surgically certified that the subdural hematoma was caused by a tear in a cortical artery attached to the dura, not by the rupture of the aneurysms. Clinical cause and pathogenesis of so-called "non-traumatic" or "spontaneous" acute subdural hematomas were discussed, and the importance of emergency angiography for this condition is stressed.     

Brain abscess (Part 5)--Brain abscess following internal carotid occlusion (author's transl)]

Three cases of brain abscess following an occlusion of the internal carotid artery were reported. Case 1: A 6-year-old girl with congenital heart disease was admitted with headache, disturbance of consciousness and left hemiparesis. Right carotid angiography revealed an occlusion of the right internal carotid artery. After 6 months, she was readmitted with high fever. CT scan revealed a low density area and a ring-like shadow at the same site of cerebral infarction. Case 2: A 69-year-old man was admitted in semicoma and with right hemiplegia. Left angiography revealed an occlusion of the left internal carotid artery. After 2 months, a brain abscess was noted in the infarcted area. Case 3: A 20-year-old man with congenital heart disease, was admitted due to headache, vomiting and high fever. CT scan revealed a brain abscess in the right frontal lobe. Carotid angiography showed bilateral internal carotid artery occlusion. We concluded that diminution of cerebral oxygen and encephalomalacia are predisposing factors to the evolution of brain abscess.     

A case of post-traumatic pseudoaneurysm on the posterio meningeal artery

A case is reported of post-traumatic delayed appearance of a pseudoaneurysm on the posterior meningeal artery. In the immediate post-traumatic stage, the patient had mild disturbance of consciousness, mild subarachnoid hemorrhage, and mid-line skull fracture of the posterior cranial fossa. At 15 hours after the trauma, the patient suddenly developed deep coma and respiratory arrest. CT scanning showed further spreading of the subarachnoid hemorrhage and newly detected subdural hemorrhage. After the patient regained spontaneous respiration, cerebral angiography was performed 24 hours after admission. This initial angiography showed no aneurysm, but at 17 days after the trauma, follow-up angiography demonstrated the delayed appearance of an aneurysmal dilatation on the posterior meningeal artery. The aneurysm was resected surgically and proved to be a pseudoaneurysm. Having developed normal pressure hydrocephalus afterwards, the patient received a V-P shunt, and was discharged 150 days after the trauma with no major neurological deficit. We discussed the indication for and timing of angiography for detecting pseudoaneurysms. Posterior meningeal artery pseudoaneurysms should be resected surgically, because intravascular surgery through the vertebral artery involves considerable risk of embolic complications.     

椎动态MRA在预椎病变中的应用

目的：探讨椎动脉核磁共振血管成像（Magnetic resonace angiographyMRA)在颈椎病变中的应用价值,方法：本组8例,男5例,女3例。年龄7－42岁,平均26岁。病变范围C1－C6,X线片及CT显示椎体均有破坏,其中4例侵犯－侧横突,横突孔被包裹在病灶组织内。术后病理证实颈椎结核4例,慢性炎症1例,嗜酸性肉芽肿2例,血管瘤1例。全部患者术前行椎动态MRA检查,观察双侧椎动脉成像及走行。结果：3例患侧椎动脉发生扭曲并偏移向中线,2例椎动脉局部受压,3例椎动脉平直行走无扭曲。无1例椎动脉阻塞、管壁侵蚀,假性动脉瘤形成。结论：结椎病变如肿瘤,结核,炎症等常造成椎动脉走行变异,前瞻性MRA检查是预防中椎动脉损伤的有效方法。     

Cervical vessel injury after blunt trauma

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.     

螺旋CT血管成像在椎动脉型颈椎病的临床应用

目的　报告螺旋CT血管成像在椎动脉型颈椎病中的应用结果。方法　应用螺旋CT血管成像 (SCTA)技术 ,对 2 0例椎动脉颈椎病患者的椎动脉进行三维重建 ,观察椎动脉的形态及其毗邻结构。结果　椎动脉平直 ,无压迫 4例 ,其中 2例血管痉挛变细 ;椎动脉迂曲改变 ,无血管受压 5例 ;椎动脉迂曲、狭窄 ,明显受压 10例 ;畸形 1例。结论　认为SCTA对椎动脉型颈椎病的诊断和治疗有重要的临床意义     

Vertebral arterial dissection with subarachnoid hemorrhage after ischemic onset

A case is reported of the vertebral arterial dissection presenting initially with cerebellar infarction, and which subsequently occurred with subarachnoid hemorrhage 14 days later. A 75-year old male was admitted because of vertigo and ataxia. MR T2-weighted imaging showed a hyperintensity areas on the left cerebellar hemisphere and MR angiography showed multiple stenotic lesions in the left vertebral artery. We diagnosed his illness as dissection of the left vertebral artery and antiplatelet therapy and the blood pressure control were carried out. Fourteen days after the onset, the patient complained of sudden onset of headache and subarachnoid hemorrhage was confirmed on CT scan. Proximal clip occlusion of the left vertebral artery and OA-PICA anastomosis was carried out immediately. The patient was discharged with slight truncal ataxia. We evaluated the features of this vertebral arterial dissection presenting with subarachnoid hemorrhage after ischemic stroke with reference to another reported cases.     

Pseudoaneurysm of the aortic arch after aortosubclavian bypass treated with endoluminal stent grafting--a case report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump f the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.     

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.     

Growing aneurysm presenting with Weber's syndrome and obstructive hydrocephalus--a case report

A case with two cerebral aneurysms, in which one at the origin of the left superior cerebellar artery (SCA) grew and presented with Weber's syndrome and obstructive hydrocephalus, is reported. The patient was a 69-year-old female, who had severe headache and vomited. On admission, neck stiffness was recognized. CT scan showed findings of subarachnoid hemorrhage. Angiograms demonstrated two saccular aneurysms at the right middle cerebral artery (MCA) bifurcation and at the origin of the left SCA. Craniotomy and neck clipping of the aneurysm at the right MCA was performed. After discharge, left oculomotor palsy appeared and gradually progressed. Severe headache and right hemiparesis suddenly occurred two years after the first attack. On the second admission, CT scan revealed high density on the brain surface and a well enhanced round lesion at the left ambient cistern. Left vertebral angiogram demonstrated increase in size of the aneurysm at the left SCA. The patient was discharged after conservative therapy. Drowsiness and urinary incontinence appeared, and she was admitted for the third time three years after the first admission. CT scan showed an enhancing mass lesion sized 25 X 30 mm beside the left midbrain and obstructive hydrocephalus. The aneurysm at the SCA no longer seen on the left vertebral angiogram. V-P shunt was performed. Both Weber's syndrome and obstructive hydrocephalus in this case indicate an aneurysmal natural history, in which aneurysm becomes gigantic and thrombosed spontaneously.     

Reliability of computed tomographic angiography in the diagnosis of brain death

OBJECTIVE: This study examined the validity of cerebral computed tomographic (CT) angiography in the diagnosis of brain death (BD) compared with conventional cerebral angiography. METHODS: This prospective, monocentric study was performed over a 24-month period and included 43 patients, at least 18 years of age, with clinical criteria of BD. All patients underwent cerebral CT angiography and then cerebral angiography. To confirm BD, the CT scan had to show the absence of perfusion of A2 anterior cerebral artery segments (A2-ACA), M4 middle cerebral artery segments (M4-MCA), P2 posterior cerebral artery segments (P2-PCA), basilar artery, internal cerebral veins, and finally the great cerebral vein. Cerebral angiography showed cerebral blood flow arrest at the level of the foramen magnum for posterior circulation and carotid siphon for anterior circulation. RESULTS: For 30 patients, BD was confirmed by both examinations. For 13 patients, cerebral angiography confirmed BD, whereas CT angiography still showed cerebral perfusion; the divergence rate was 30.2%. CONCLUSIONS: CT angiography seems to be a promising exam to confirm BD. However, the divergence with cerebral angiography is significant mainly concerning A2-ACA, which are proximal. It may be possible to only use the absence of opacification of M4-MCA, P2-PCA, basilar artery, and venous blood return to remain in conformity with the French law. In all cases, the international medical community should obtain a consensus for the interpretation of CT angiography to use it extensively as a complementary exam for BD.     

Vertebral artery decompression in a patient with rotational occlusion

Summary We report a patient who suffered drop attacks during head reclination. Computer tomography of the cervical spine demonstrated a stenotic right vertebral artery at C4/5. However, Doppler ultrasonography of the vertebral artery showed no abnormality. Angiography confirmed complete occlusion of the left vertebral and a stenosis of the right vertebral artery. Dynamic angiography indicated occlusion of the stenotic region on the right side during reclination of the head. Surgery using a posterior approach with decompression of the vertebral artery, lead to an excellent outcome and the patient left the hospital without any symptoms. Therefore, in patients with drop attacks and normal ultrasonography, a stenosis of the vertebral artery caused by a spondylophytic compression could still be the cause. At worst, the stenosis could lead to brain infarction if left untreated. Dynamic angiography is crucial for the diagnosis and surgical decompression has excellent results. Correspondence: Athanasios K. Petridis, M.D., Department of Neurosurgery, University of Schleswig Holstein, Campus Kiel, Schittenhelmstr. 10, 24105 Kiel, Germany.     

Idiopathic pseudo-aneurysm of intrathoracic left subclavian artery – a case report

We report an interesting case of left subclavian artery pseudo-aneurysm presenting in a 35 years old male patient with the chief complaints of pain in the back of left chest radiating to left arm for 6 months duration. The chest skiagram showed well defined homogenous round opacity measuring around 3 in. in diameter, involving the left upper zone towards the midline. Computed Tomography (CT) scan thorax showed thickening of soft tissues surrounding the proximal left subclavian artery. CT angiography stamped it as large aneurysmal dilatation of proximal left subclavian artery. On exploratory thoracotomy it was found to be a pseudoaneurysm which was repaired successfully. Pathological examination of the biopsy obtained from the arterial wall did not prove any specific etiology.     

A case of a basilar bifurcation aneurysm associated with common carotid artery occlusion

A case of a basilar bifurcation aneurysm associated with common carotid artery occlusion is reported. A 40-year-old woman was admitted to our hospital with severe headache and nausea. On admission, no neurological abnormality was observed. CT scan showed thin subarachnoid hemorrhage in the basal cistern. Left vertebral angiograms revealed a basilar bifurcation aneurysm located in the high position. Also, the left internal and external carotid arteries were supplied through the anastomotic muscle branches of the left occipital and vertebral artery. The trunk of the left common carotid artery was not visualised from its origin on the aortogram. CT scan at the level of C6 showed thinning of the left common carotid artery and contrast enhancement study indicated occlusion. Neck clipping of the aneurysm was successfully performed by right trans-sylvian approach. Right zygomatic arch was removed to obtain a wider operative field for avoiding further retraction of the brain tissue. The postoperative course was uneventful except transient disorientation for two weeks. It has been well known that internal carotid artery occlusion may be associated with cerebral aneurysm in some cases. However, it seemed to be a rather rare case that the common carotid artery occlusion due to arteriosclerosis was associated with cerebral aneurysm. Hemodynamic factor was positively suggested for aneurysmal formation in this case.     

A case of septic aneurysm complicated with simultaneous subdural and intracerebral hematoma

A case of septic aneurysms complicated with simultaneous subdural and intracerebral hematoma is presented. A 13-year-old girl had been operated on for endocardial cushion defect when she was 5 years old, and residual mitral regurgitation was followed up. She suddenly complained of headache, vomited and lost consciousness. She was brought to the Tokyo Women's Medical College Hospital by an ambulance. On arrival, she was semicomatose. Her left pupil was mydriatic and did not react to light. Right hemiparesis was noted. Systolic murmur was audible in the apical region of the heart. Laboratory data showed a mild anemia and a white cell count of 23,000. CT scan showed a subdural hematoma in the left frontotemporoparietal region and a small subcortical hematoma in the left occipital lobe. An emergency operation was carried out for the subdural hematoma. When the dura was opened, about 10 ml bloody CSF flowed out. A hematoma weighing about 50 g was removed. A bleeding point or an aneurysm could not be discovered on the dura, arachnoid membrane or surface of the brain at the operation. On the 15th day after the operation, when the fever was decreased, cerebral angiography was done. The left vertebral angiogram showed an aneurysm on a peripheral branch of the calcarine artery, which was considered the origin of the subcortical hematoma in the left occipital lobe. The left carotid angiogram showed no aneurysm. On the seventh day after that study, the aneurysm did not appear by left vertebral angiography. She was discharged with no neurological deficit. One month later, she was admitted again with a high fever.(ABSTRACT TRUNCATED AT 250 WORDS)