Characteristics and management of ruptured distal middle cerebral artery aneurysms

Summary Objective. Distal middle cerebral artery (dMCA) aneurysms are very rare with a reported frequency of 2–6%. Typically, patients with ruptured distal MCA aneurysms have poor clinical outcomes because often there is both a subarachnoid haemorrhage (SAH) and an intracerebral haematoma (ICH). The goals of this study were to identify the characteristics of the distal MCA aneurysms and evaluate the optimal treatment for a good outcome. Methods. The clinical, neuroradiological and operative records of 8 patients with a ruptured distal MCA aneurysm who underwent surgical management were reviewed retrospectively. The outcomes were presented according to the Glasgow Outcome Scale (GOS). Results. The clinical characteristics of the patients with ruptured dMCA aneurysms included the following: (1) a fusiform appearance in five out of eight (63%) patients. (2) Mean aneurysm size of 9.4 mm (range 2–35 mm). (3) The location being M2 (insular segment) in three, M2-3 junction in three, and M3 (opercular segment) in two patients. (4) Brain CT images revealed both SAH and an ICH in six of eight (75%) patients with the mean size of the ICH being 10 cc (range 5–25 cc). (5) Re-bleeding occurred in four out of eight (50%) of patients. All patients underwent early surgical treatment and the procedures used for surgical repair were, clipping in five patients, trapping in two, and trapping with end-to-end bypass surgery in one patient. Clinical outcomes were poor in two patients (death) due to severe brain swelling. Conclusions. In this study, dMCA aneurysms had a fusiform shape and a high re-bleeding rate; if ruptured, there was generally ICH and SAH. A good clinical outcome was associated with adequate control of brain swelling and early surgery to prevent re-bleeding.     

Comparison of Symptomatic Vasospasm after Surgical Clipping and Endovascular Coiling

Vasospasm, initial neurological damage, rebleeding, and periprocedural complications are associated prognostic factors for clinical outcomes after aneurysmal subarachnoid hemorrhage (SAH). In this study, factors related to delayed ischemic neurological deficit (DIND) are evaluated using data from our institute for the last 18 years. Data from 2001 to 2018 of patients with aneurysmal SAH who underwent surgical clipping (SC) or endovascular coiling (EC) within 7 days of onset were retrospectively analyzed. Cases of mortality within 5 days after treatment were excluded. Multivariate analysis was used to identify the risk factors for DIND. In total, 840 cases of SAH were assessed; among these cases, 384 (45.7%) and 456 (54.3%) were treated with SC and EC, respectively. The frequency of DIND in the EC group was significantly less than that in the SC group (11.8% vs. 17.7%; p = 0.016). In the results of multivariate analysis, internal carotid artery (ICA) aneurysm and hemorrhagic complications were the risk factors for DIND. Cilostazol administration and EC were significant factors for vasospasm prevention after aneurysmal SAH (odds ratio of ICA aneurysm: 1.59, hemorrhagic complications: 1.76, SC: 1.51, and cilostazol administration: 0.51, respectively). Cilostazol administration was also a significant factor in patients who were treated with EC. ICA aneurysm, treatment strategy, hemorrhagic complications, and cilostazol administration were associated with DIND. Oral administration of cilostazol and avoiding hemorrhagic complications were effective in DIND prevention. If both treatments are available for ruptured aneurysms, clinicians should choose EC on the basis of its ability to prevent DIND.     

Size of ruptured intracranial saccular aneurysms in patients in Izumo City,Japan

BackgroundA community-based study was conducted to evaluate the factors related to the size of ruptured aneurysms and the effects of aneurysm size on clinical features.MethodsData from 358 patients with subarachnoid hemorrhage (SAH) treated between 1980 and 1998 in Izumo, Japan, were reviewed. In 285 of these patients, the sizes of the ruptured aneurysms were determined.ResultsAneurysm diameter was less than 5 mm in 68 patients, at least 5 to less than 10 mm in 137 patients, and 10 mm or more in 80 patients. Aneurysm size tended to increase with patient age. Age (≥60 years of age) and cigarette smoking were independently associated with aneurysms of 5 mm or more in diameter. Multiple aneurysms were positively and anterior cerebral artery aneurysms were inversely related to aneurysms of 10 mm or more in diameter. The larger the aneurysm, the worse was the World Federation of Neurosurgical Societies grade. The risk of rebleeding was higher in patients with larger (≥10 mm) aneurysms than in those with smaller (<10 mm) aneurysms. The incidences of diffuse severe SAH on computed tomographic scans in patients with SAH alone, symptomatic vasospasm, and hydrocephalus were higher in patients with larger (≥5 mm) aneurysms than in those with smaller (<5 mm) aneurysms. The larger the aneurysm, the worse was either functional outcome or the 6-month and 2-year survival rates.ConclusionAge, cigarette smoking, multiple aneurysms, and aneurysm site appear to be related to the size of ruptured aneurysms. Patients with larger aneurysms seem to have a worse clinical condition and more severe SAH, resulting in higher incidences of rebleeding, symptomatic vasospasm and hydrocephalus, and a worse outcome.     

Subdural hematoma due to ruptured intracranial aneurysm.

Subdural hematoma (SDH) was observed in 15 of 484 cases of aneurysmal subarachnoid hemorrhage (SAH). There were four males and 11 females, with ages ranging from 39 to 75 years. The clinical grades (Hunt and Hess) on admission were 11 in three cases, III in two, IV in four, and V in six. The ruptured aneurysms were located in the middle cerebral artery (MCA) in six cases, anterior communicating artery in three, internal carotid artery in two, and distal anterior cerebral artery (ACA) in two, with two cases unconfirmed. A high proportion of aneurysms occurred in the MCA and distal ACA. Aneurysmal neck clipping and removal of SDH were performed in the acute stage of seven cases, without intraoperative rerupture. The outcomes 1 year after SAH of the seven patients undergoing surgery were good recovery in five, but in two, vegetative state due to preoperative rerupture or medical complications. All eight patients without surgical intervention died. A good prognosis for patients with ruptured intracranial aneurysms accompanied by SDH can be expected with direct surgical intervention in the acute stage, even if the clinical grade on admission is poor.     

Intraoperative radical clot removal therapy using a bipolar irrigation system for prevention of cerebral vasospasm following subarachnoid hemorrhage

To investigate cerebral vasospasm following subarachnoid hemorrhage (SAH), 65 cases were analyzed by the incidence of delayed ischemic neurological deficit (DIND). Eighty-four consecutive cases, who underwent surgery within 72 hours of SAH, were retrospectively analyzed. Sixty-five of these patients had diffuse subarachnoid hemorrhage in CT scan and had aneurysms of the anterior circulation. They were divided into two groups according to the operative procedure: Group A (35 cases) had radical clot removal therapy with urokinase in 5% glucose solutions using a bipolar irrigation system; Group B (30 cases) had conventional clot removal using manual irrigation. There were no significant differences between these two groups for age or pre-operative WFNS grade. The incidence of DIND was 17.1% in group A and 40.0% in groupB; this was a significant difference. Radical clot removal therapy was effective in preventing DIND due to vasospasm.     

Significance of the cerebral venous system in the development of DIND in subarachnoid hemorrhage]

The significance of superficial venous system in the development of delayed ischemic neurological deficit (DIND) was studied retrospectively in 18 patients with ruptured aneurysm of the middle cerebral artery (MCA). Neck clipping of the aneurysms was performed via the pterional approach within 72 hours after onset of subarachnoid hemorrhage. All patients were in grade I or II of the Hunt and Hess Grading, and in group 2 or 3 on Fisher's CT classification. The age ranged from 32 to 71 with 48.1% being the mean age. The aneurysm was located on the left side in 5 patients, and on the right side in 13 patients. Arterial and venous phase were evaluated on the pre-and post operative angiograms in these patients. Arterial narrowing was divided into localized and diffuse types according to the degree, and its distribution in the arterial tree. In the venogram, opacification of the superficial sylvian veins (SSV) was the main thing evaluated. Arterial narrowing was observed in 16 cases (9; localized, 7; diffuse). In some cases, visualization of the SSV was poor or fair, and in others it was normal. DIND, including motor deficit or disturbance of consciousness, developed in 10 cases (transient; 6, permanent; 4). The patients with normal visualization of SSV on the postoperative angiogram had good outcome, even if they had diffuse arterial narrowing. On the other hand, the outcome was only fair or poor in those patients who had poor visualization of the SSV, irrespective of arterial narrowing.(ABSTRACT TRUNCATED AT 250 WORDS)     

Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms

OBJECT: Some authors have questioned the need to perform cerebral angiography in patients presenting with a benign clinical picture and a perimesencephalic pattern of subarachnoid hemorrhage (SAH) on initial computerized tomography (CT) scans, because the low probability of finding an aneurysm does not justify exposing patients to the risks of angiography. It has been stated, however, that ruptured posterior circulation aneurysms may present with a perimesencephalic SAH pattern in up to 10% of cases. The aim of the present study was twofold: to define the frequency of the perimesencephalic SAH pattern in the setting of ruptured posterior fossa aneurysms, and to determine whether this clinical syndrome and pattern of bleeding could be reliably and definitely distinguished from that of aneurysmal SAH. METHODS: Twenty-eight patients with ruptured posterior circulation aneurysms and 44 with nonaneurysmal perimesencephalic SAH were selected from a series of 408 consecutive patients with spontaneous SAH admitted to the authors' institution. The admission unenhanced CT scans were evaluated by a neuroradiologist in a blinded fashion and classified as revealing a perimesencephalic SAH or a nonperimesencephalic pattern of bleeding. Of the 28 patients with posterior circulation aneurysms, five whose grade was I according to the World Federation of Neurosurgical Societies scale were classified as having a perimesencephalic SAH pattern on the initial CT scan. The data show that the likelihood of finding an aneurysm on angiographic studies obtained in a patient with a perimesencephalic SAH pattern is 8.9%. Conversely, ruptured aneurysms of the posterior circulation present with an early perimesencephalic SAH pattern in 16.6% of cases. CONCLUSIONS: This study supports the impression that there is no completely sensitive and specific CT pattern for a nonaneurysmal SAH. In addition, the authors believe that there is no specific clinical syndrome that can differentiate patients who have a perimesencephalic SAH pattern caused by an aneurysm from those without aneurysms. Digital subtraction angiography continues to be the gold standard for the diagnosis of cerebral aneurysms and should be performed even in patients who have the characteristic perimesencephalic SAH pattern on admission CT scans.     

Volumetric quantification of Fisher Grade 3 aneurysmal subarachnoid hemorrhage: a novel method to predict symptomatic vasospasm on admission computerized tomography scans

OBJECT: Predicting which patients with aneurysmal subarachnoid hemorrhage (SAH) will develop delayed ischemic neurological deficit (DIND) due to vasospasm remains subjective and unreliable. The authors analyzed the utility of a novel software-based technique to quantify hemorrhage volume in patients with Fisher Grade 3 aneurysmal SAH. METHODS: Patients with aneurysmal SAH in whom a computerized tomography (CT) scan was performed within 72 hours of ictus and demonstrated Fisher Grade 3 SAH were analyzed. Severe DIND was defined as new onset complete focal deficit or coma. Moderate DIND was defined as new onset partial focal deficit or impaired consciousness without coma. Fifteen consecutive patients with severe DIND, 13 consecutive patients with moderate DIND, and 12 consecutive patients without DIND were analyzed. Software-based volumetric quantification was performed on digitized admission CT scans by a single examiner blinded to clinical information. There was no significant difference in age, sex, admission Hunt and Hess grade, or time to admission CT scan among the three groups (none, moderate, or severe DIND). Patients with severe DIND had a significantly higher cisternal volume of hemorrhage (median 30.5 cm3) than patients with moderate DIND (median 12.4 cm3) and patients without DIND (median 10.3 cm3; p < 0.001). Intraparenchymal hemorrhage and intraventricular hemorrhage were not associated with DIND. All 13 patients with cisternal volumes greater than 20 cm3 developed DIND, compared with 15 of 27 patients with volumes less than 20 cm3 (p = 0.004). CONCLUSIONS: The authors developed a simple and potentially widely applicable method to quantify SAH on CT scans. A greater volume of cisternal hemorrhage on an admission CT scan in patients with Fisher Grade 3 aneurysmal SAH is highly associated with DIND. A threshold of cisternal hemorrhage volume (> 20 cm3) may exist above which patients are very likely to develop DIND. Prospective application of software-based volumetric quantification of cisternal SAH may predict which patients will develop DIND.     

Management outcome for ruptured anterior circulation aneurysms with a Hunt and Hess clinical grade of III in patients in the 9th decade of life.

BACKGROUND: This study was conducted to define general guidelines for rational clinical decision-making with respect to patients older than 80 years who present with ruptured anterior circulation aneurysms and a Hunt and Hess clinical grade of III.METHODS: The 29 consecutive patients enrolled in this study were treated at 4 participating centers between 1995 and 1998. All were 80 years or older on admission and met 7 eligibility criteria. The decision to treat surgically or non-surgically was made individually at each center. The outcome at discharge was assessed using the Glasgow Outcome Scale (GOS); the Barthel Score (BS) was used to determine the patients' quality of life after discharge.RESULTS: Of 15 surgically treated patients, 4 died before discharge and 8 were discharged in poor condition. Of these, 7 died of unrelated causes within 2 years of the SAH and one is living in a nursing home. Three patients with middle cerebral artery (MCA) aneurysms made a good recovery; they are currently living at home. Of the 14 conservatively treated patients, 10 died during their hospital stay mainly because of rebleeding that occurred within 3 weeks of the subarachnoid hemorrhage (SAH). Three others who were discharged in poor condition died of systemic illness within 2 years. The remaining patient is living in a nursing home with a BS value of 0.CONCLUSIONS: The outcomes for patients treated conservatively were catastrophic. Even in surgically treated patients, favorable outcomes were rare; the best results were achieved in surgically treated patients with MCA aneurysms.     

Early infarction detected by diffusion-weighted imaging in patients with subarachnoid hemorrhage

Purpose

Early infarction that occurs at the time of initial subarachnoid hemorrhage (SAH) due to rupture of an aneurysm is a poorly understood phenomenon. We investigate the frequency of early infarction using diffusion-weighted images (DWI) at the time of admission. We then discuss the pathogenesis of infarction.

Materials and methods

This study included 85 SAH patients who underwent serial DWI on admission. Early infarction detected by DWI and clinical features were investigated retrospectively.

Results

The overall incidence of DWI-detected early infarction at the time of SAH onset was 8% (7 of 85 cases). In all seven patients, early infarctions were asymptomatic on admission. Types of early infarction seen on DWI included infarcts occurring in the territory of the vessel harboring a ruptured aneurysm (solitary, three cases) and infarcts occurring outside the territory of the vessel (multiple, two cases; solitary, two cases). Six of seven patients eventually developed delayed ischemic neurological deficit (DIND) and computed tomography (CT)-detected and DWI-detected delayed extensive infarction. Four of seven patients with early infarction had an unfavorable outcome. The occurrence of DWI-detected early infarction on admission was significantly correlated with delayed angiographic vasospasm, DIND, CT-detected delayed infarction, DWI-detected delayed infarction, and unfavorable outcome.

Conclusions

In the present study, DWI-detected early infarction at the time of SAH onset was correlated with the occurrence of delayed extensive ischemic lesions. We believe that performing DWI at the time of admission is useful for evaluating the primary ischemic insult, which might play an important role in the pathogenesis of early brain injury and delayed vasospasm-related complications.     

Aneurysms at the early branch of middle cerebral artery

The cortical arteries arising from the proximal (Ml) segment of the middle cerebral artery (MCA) are called "early branches". We retrospectively analyzed clinical features in 10 patients with aneurysms located at the early branches of MCA. The incidence of these aneurysms was 9.5% among 95 MCA aneurysms. Patients consisted of 4 males and 6 females. Ages were 33-77 years old (average of 54.4). Four patients presented with subarachnoid hemorrhage (2 of them had intracerebral hematoma). The aneurysms were classified into 2 groups, the group of the early frontal branch (EFB: 7 cases) and the early temporal branch (ETB: 3 cases). All aneurysms were smaller than 6mm in diameter. The surgical treatment was performed through the pterional approach. Poor outcome occurred in 3 ruptured aneurysms of EFB (MD 1, SD 1, and D 1). At surgery, it is necessary to produce the working space by dissecting sylvian fissure sufficiently and to prevent ischemic complication by avoiding injury of the lenticulostriate arteries (LSA).     

无蛛网膜下腔出血的大脑中动脉动脉瘤破裂

目的总结无蛛网膜下腔出血（SAH）的大脑中动脉（MCA）动脉瘤破裂的临床特点。方法对6例在首次CT扫描上表现为脑内出血（ICH），或壁内出血（IMH）而无SAH的MCA动脉瘤破裂患者的临床表现、影像学检查、治疗方法和预后进行回顾性总结。结果本组首次CT扫描时间为起病后0—2d，表现为单纯ICH者4例，IMH者2例。DSA和手术证实为MCA动脉瘤破裂。开颅动脉瘤切除1例，夹闭5例，其中4例同时行血肿清除术。术后无死亡。结论MCA动脉瘤破裂首次CT扫描可仅表现为ICH或IMH而无SAH，与动脉瘤的部位、出血量以及CT扫描时间相关。     

Early surgical repair of large intracranial saccular aneurysms

Summary Among 302 patients with cerebral aneurysms admitted between 1981 and 1986, 63 had a large (45) or giant (18) aneurysm with a diameter of more than 12 mm and 24 mm, respectively. 24 of these 63 patients were admitted early after a subarachnoid haemorrhage (SAH) so as to allow surgical repair within 72 hours. Eight of them were inoperable for various reasons and could not undergo definitive surgical repair and died. 16 patients underwent craniotomy and clipping of the aneurysm. 77% of the patients in preoperative grades I-IV made a good recovery with no or minimal neurologic deficit. During the same period 84% of patients with small aneurysms made a good recovery.The present data indicate, that large aneurysms rupture with a similar incidence compared to small aneurysms; saccular large ruptured aneurysms can be operated upon early with similar results as small aneurysms. However, devastating initial bleeds and poor outcome occur more frequently in patients with ruptured giant than in patients with small aneurysms. Most of the patients with ruptured giant aneurysms are comatose on early admission and cannot be considered for early surgery. Their poor prognosis is further reduced by a high rebleeding rate.     

Rupture of previously documented asymptomatic unruptured aneurysms--aneurysm size: risk factor for aneurysm rupture

The natural history of asymptomatic unruptured aneurysms is not clear. We conducted a follow up study of 100 patients (since 1993) with 122 asymptomatic unruptured aneurysms that had not been operated on. We report five patients with previously documented asymptomatic unruptured aneurysms smaller than 10 mm in diameter that subsequently ruptured. Among the 100 patients, five had suffered subarachnoid hemorrhage (SAH) due to rupturing of an aneurysm. Of the 5 cases, 1 was male and 4 were female, with ages ranging from 59-73 years (mean age, 68 years). The aneurysms were on the MCA in 3, on the BA-SCA in 1, on the IC-PC in 1. The maximal diameter of the aneurysms at diagnosis ranged from 4.5 to 8 mm. The period from discovery to SAH was from 4 to 69 months and the cumulative rate of rupture of the aneurysms was 1.5 percent per year. Four of the 5 cases increased in size after the rupture. In our series, 2 of the 5 cases showed enlargement and the development of an aneurysmal bleb in the follow up MRA and 3D-CTA. The present study demonstrates that five asymptomatic unruptured aneurysms less than 10 mm in diameter subsequently ruptured. We ought to seriously consider the assertion published in the New England Journal of Medicine (Dec. 10, 1998), that unruptured aneurysms less than 10 mm in diameter have a very low probability of subsequent rupture.     

Usefulness of CT angiography for demonstrating cerebral aneurysms

We report the usefulness of computed cerebral angiotomography (CT angiography) for demonstrating cerebral aneurysm and the clinical significance of CT angiography for ruptured cerebral aneurysm. Our modified method of CT angiography was easy and less time-consuming. Fifteen seconds after starting a single bolus injection, 1 ml/kg/25 seconds via cubital vein, of contrast medium (60% urograffin), 5 serial 5 mm thick-CT slices were scanned in every 6.5 seconds including 2 seconds of interval, beginning from an axial level 20 mm above the orbitomeatal line and ending at a level 40 mm. A total of 103 patients were examined in this report, consisting of 70 unruptured asymptomatic, 8 unruptured symptomatic (oculomotor nerve palsy) and 25 subarachnoid hemorrhage (SAH). Seven unruptured aneurysms in 4 asymptomatic cases, 2 unruptured aneurysms in 2 symptomatic cases 27 aneurysms in 24 SAH cases were suspected by CT angiography. Of these 36 aneurysms suspected by CT angiography 32 aneurysms were confirmed by cerebral angiography. The detection rate of CT angiography in this report was 89%, higher than those of previous reports. Thirteen aneurysms were located at internal carotid-posterior communicating artery (ICPC) junction. 11 at anterior communicating artery (Acom), 7 at middle cerebral artery (MCA). CT angiography showed a false positive findings in 4 cases, which were all located at Acom. Four aneurysms were not detected in CT angiography, which were all located at MCA and were very small (2-3 mm) in diameter. There were no deteriorated cases during and after CT angiography. We suggest that CT angiography is a useful and safe method for predicting the location of not only unruptured but ruptured aneurysms.     

Clinical course in poor grade patients with ruptured intracranial aneurysms and extensive subarachnoidal clot]

Three hundred and eight cases with ruptured intracranial aneurysms and variable amounts of subarachnoidal clot were evaluated clinically with special emphasis on the natural course of poor grade patients. Clinical severity was classified according to the Glasgow Coma Scale (GCS); severe cases (score 3-8) and mild cases (score 9-15). Patients were further divided into four groups based on the preoperative clinical course, and on whether radical surgery was performed or not. Group A, severe cases without radical surgery (17 patients, mean GCS score 4.2); group B, severe cases (which had undergone) radical surgery (24 cases, mean GCS score 5.5); group C, patients considered as severe cases on admission that had improved to mild cases before radical surgery (3 patients, mean GCS score 11.7); group D, mild cases which had undergone radical surgery (254 cases, mean GCS score 14.3). CT findings after their last bleeding episode were evaluated in each group using subarachnoid hemorrhage (SAH) score from "0"-"3" according to the severity of SAH. In addition, the SAH-B (brainstem) score ("0"-"9") was also evaluated. In this score, the amount of SAH in each perimesencephalic cistern (a. prepontine or interpeduncular cistern, b. ambient cistern, c. quadrigeminal cistern) was considered with a possible score of "0"-"3" for each cistern. (No patient had a concurrent intracerebral or intraventricular hematoma causing a mass effect on CT scan). All cases in group A died except one patient that remained in a vegetative state. All of them had severe subarachnoidal clot (mean SAH score 2.9, SAH-B score 8.2). In group B, in patients with same scores (mean SAH score 2.8, mean SAH-B score 7.3), the outcome was as follows: 6 patients (33.3%) had full recovery or were capable of self-management, 6 patients (33.3%) were partially or fully dependent, and 12 patients (50%) were either in vegetative state or died. Patients in groups C and D with good outcome had significantly less amount of SAH, especially in the perimesencephalic cistern (group C--mean SAH score 2.3, mean SAH-B score 3.7, group D--mean SAH score 1.9, mean SAH-B score 3.3). It is concluded that duration and level of unconsciousness in the cases of SAH without concurrent hematoma causing mass effect, has a good correlation with the severity of SAH in the perimesencephalic cisterns.(ABSTRACT TRUNCATED AT 400 WORDS)     

An analysis of vasospasm following early surgery for intracranial aneurysms

Summary 41 patients with ruptured intracranial aneurysms were all submitted to an early operation, (within 3 days from SAH), and evaluated with regard to the results of treatment. In this group, vasospasm has influenced the outcome more than other causes, accounting for 58% of morbidity and 64% of mortality. On the basis of our experience with 380 patients suffering from SAH and all submitted to a CT scan, the presence of consistent intracisternal blood in the CT scan at admission has shown to be the main risk factor resulting in vasospasm. Therefore, the group with early surgery has been compared, on the basis of the CT scan picture, to a group of 76 patients in which surgery had been delayed at least 10 days after SAH. Whilst the incidence of vasospasm has been very similar in the groups compared, the incidence of neurological deterioration brought about by spasm has been higher in patients waiting for surgery (55%, against 36% in the group with early surgery). Avoidance of clinical deterioration has not been always possible with early surgery, even after careful cleansing of the cisterns from clots, as was shown by 2 of our cases. It is concluded that vasospasm does not seem to influence the outcome of early surgery to a greater extent than it would during the natural course of subarachnoid haemorrhage.     

Cerebral aneurysms in identical twins

The hypothesis that genetic factors play a role in the genesis of cerebral aneurysms may be supported by clinical analysis of cerebral aneurysms in identical twins. In addition to reporting the present case, we review the literature on clinical features and genetical considerations in this matter. A forty-two-year-old male presented with subarachnoid hemorrhage (SAH) due to a left MCA aneurysm. At the age of 39, his identical twin brother also had SAH due to a ruptured left MCA aneurysm. This identical twin brother and his father's sisters died of SAH. Venous blood of the patient and his parents was collected to determine apolipoprotein E, angiotensinogen, angiotensin-converting enzyme, and very low density lipoprotein receptor genes. This analysis suggested a strong genetic association of apolipoprotein E epsilon4 with the pathogenesis. Including our cases, 13 cases of cerebral aneurysms in identical twins have been reported. There was a total of 37 aneurysms. Six twins had the same sites of aneurysm. These aneurysms show a tendency to be small in size, and to cause a high frequency of SAH occurring at a similar age. In young adults, cerebral aneurysms in identical twins tend to rupture. A screening diagnosis should be carried out as early as possible on an asymptomatic twin when the other has been discovered to have a ruptured cerebral aneurysm. Preventive treatment and systemic genome-wide linkage study should be conducted.     

Observation of de novo formation and growth of an intracranial aneurysm: a case report

We observed a de novo formation and growth of an aneurysm in a 43-year-old woman who was followed up after treatment of a subarachnoid hemorrhage (SAH). In 2002, the patient, whose mother had a history of SAH, presented with SAH at the age of 36. Three-dimensional computed tomography angiography (3D-CTA) and digital subtraction angiography showed an aneurysm in the right internal carotid-posterior communicating artery. The aneurysm was clipped and postoperative course was uneventful without neurological deficit. The patient was followed up by 3D-CTA and magnetic resonance angiography every 6 months, because of an untreated small aneurysm, 3 mm in diameter, in the left middle cerebral artery (MCA). The MCA aneurysm remained unchanged but a de novo aneurysm, 1.5 mm in diameter, developed in the right anterior cerebral artery (ACA) 6 years after the first surgery. The ACA aneurysm grew to 4 mm in diameter during the following 10 months but the MCA aneurysm remained unchanged. Both aneurysms were clipped in one session. The MCA aneurysm had a smooth wall but the ACA aneurysm had an irregular and thin wall. The postoperative course was uneventful. Young female patients who have developed SAH with familial history, like this case, should receive long-term follow up to check whether a de novo aneurysm has developed.     

Emergency treatment of cerebral aneurysms with large haematomas

Of 469 patients with subarachnoid haemorrhage (SAH) from ruptured intracranial aneurysms, 31 had large intracerebral haematomas and were treated as emergency cases at the University Central Hospital, Kuopio, Finland during 1979-1985. The haematomas were evacuated and the aneurysms clipped immediately after diagnosis with CT and angiography. The mean diameter of the haematomas was 48 mm. Of the 31 patients 15 died. Mortality was lower for patients with aneurysms of the middle cerebral artery and for those with a better clinical grade (Gr. IV) at the time of the operation (41%); all patients with dilated pupils in grade V died. Five patients returned to work, and 10 are living a useful and independent life at home. Because early CT is increasingly used as the first diagnostic tool in vascular catastrophies, the pressure for early emergency treatment of aneurysmal intracerebral haematoma is increasing. The almost 100% mortality with conservative treatment should be compared to the 41% mortality with selection of the surgical candidates.