Middle cerebral artery thrombolysis through the contralateral internal carotid artery--case report

A 63-year-old male presented with sudden onset of right hemiplegia and global aphasia. On admission he was stuporous. Computed tomography (CT) revealed no abnormalities except for right intraventricular meningioma found incidentally. Emergency angiography confirmed complete occlusion of the left internal carotid artery (ICA) and left M1 trunk whereas the left ICA bifurcation remained patent. The ipsilateral ICA was permanently occluded with two detachable balloons to prevent thrombus migration into the distal ICA and middle cerebral artery (MCA), followed by thrombolysis of the clot in the ipsilateral M1 through the contralateral ICA with urokinase (total dose 420,000 U) under systemic heparinization. Partial recanalization of the ipsilateral MCA was accomplished. The time interval from onset to recanalization was about 3 hours. Postoperative CT showed no hemorrhagic transformation. Slight right paresis and mild motor aphasia persisted 2 months later and he was transferred to a rehabilitation facility. Thrombolysis of the MCA embolism can be performed through the contralateral ICA in the presence of ipsilateral ICA occlusion.     

Nondysplastic saccular aneurysm of the internal carotid artery

An unusual case of nondysplastic saccular aneurysm associated with elongation of the extracranial internal carotid artery is reported. The artery was normal except for a punch-hole defect in the media, which distinguished it from true fibromuscular dysplasia. Although neurologic symptoms and treatment were not specific, this case is interesting in that the exact cause of the aneurysm remains unknown.     

Ruptured P1-2 junction aneurysm associated with bilateral agenesis of the internal carotid artery

We report a case of bilateral agenesis of the internal carotid artery which was revealed by oclulomotor palsy and subarachnoid hemorrhage. Angiography showed a ruptured aneurysm of the left P1-2 junction and bilateral absence of the internal carotid artery. In surgery, it was necessary to use temporary clipping several times to adjust the aneurismal clipping. Complete clipping easily compromised the middle cerebral circulation. This case suggested that STA-MCA bypass should be considered in the surgery of agenesis of the internal carotid artery in which the preoperative hemodynamic status is usually normal.     

Ruptured dissecting aneurysm of the vertebral artery associated with occlusive internal carotid artery dissection--case report

A 64-year-old male presented with subarachnoid hemorrhage. Angiography showed a dissecting aneurysm of the right vertebral artery (VA), and severe stenosis of the right internal carotid artery (ICA). He was treated conservatively in the early stage. Repeat angiography showed enlargement of the dissecting aneurysm of the VA and partial resolution of the stenosis of the right ICA. Intraaneurysmal coil embolization with proximal coil occlusion was performed following a balloon occlusion test. The postoperative course was uneventful. Based on the neuroradiological findings, the stenotic lesion of the right ICA was considered to be due to dissection. Analysis of serial changes in dissecting lesions in the craniocervical arteries is important for the correct choice of treatment, especially in patients with multi-vessel dissections. The surgical options should be determined on an individual basis.     

Unilateral agenesis of the internal carotid artery in a patient with ruptured aneurysm of the anterior communicating artery; a case report]

This 27-year-old female suffered from subarachnoid hemorrhage. Angiography revealed a ruptured aneurysm of the anterior communicating artery. Unilateral absence of the right internal carotid artery was also demonstrated angiographically. Both the right anterior and middle cerebral arteries were perfused from the left carotid artery via the anterior communicating artery. Absence of the right carotid canal was proved on bone CT. Neuroradiological difficulties in differential diagnosis between agenesis and aplasia of the internal carotid artery were discussed. Subsequently, a diagnosis of adult type unilateral agenesis of the internal carotid artery with collateral circulation was made. The mechanism of association of cerebral aneurysm in patients with agenesis of the internal carotid artery was also discussed. From our experience, abnormal vascular anatomy should be carefully studied prior to direct surgery for a ruptured aneurysm in patients with unilateral agenesis of the internal carotid artery.     

A case report of ruptured internal carotid artery aneurysm with contralateral oculomotor nerve paresis

We report a case of ruptured internal carotid artery aneurysm with contralateral oculomotor nerve paresis. A 69-year-old female experienced a sudden onset of severe headache. Left-sided mydriasis, absence of light reflex, disability of left ocular movement and ptosis were identified. Computed tomography scan revealed massive subarachnoid hemorrhage. Cerebral angiography showed a right internal carotid artery aneurysm. No abnormal finding was observed in the left internal carotid artery or basilar artery. Magnetic resonance imaging did not show thrombosed aneurysm. The oculomotor nerve paresis lasted for ten days. Ruptured right internal carotid artery aneurysm was surgically confirmed and repaired. We speculated that the contralateral oculomotor nerve paresis was the consequence of bloody jet flow from the ruptured aneurysm.     

Ruptured intracranial aneurysm associated with spontaneous occlusion of internal carotid artery

Summary Out of 921 patients diagnosed and treated for intracranial aneurysm in 5 cases (0,5%) the co-existence of ruptured aneurysm and occlusion of the internal carotid artery was found. 4 patients were treated surgically-aneurysm clipping-without serious post-operative complications and 6 months follow-up showed satisfactory results. In 4 of 5 cases the aneurysm was located on the anterior communicating artery (ACA); this fact may support the hypothesis concerning a possible role of enhanced blood flow in aneurysm formation and rupture. In cases with good collateral blood flow extra-/intracranial bypass before aneurysm occlusion seems not to be necessary. The risk of operation in those patients is not as high, as might be expected.     

Ruptured saccular aneurysm associated with duplication of the vertebral artery

A case of a ruptured aneurysm arising from a duplicated segment of the intracranial portion of the vertebral artery is reported. This particular association, which can be explained by the embryological development of the vertebral artery, has not been described previously.     

Ruptured aneurysm associated with partially duplicated posterior communicating artery--case report

A 65-year-old woman presented with a ruptured saccular aneurysm associated with a rare variation of the posterior communicating artery (PcoA), partially duplicated PcoA. The PcoA with this variation forked just distal to the aneurysmal neck, and the two branches independently merged into the posterior cerebral artery. Initial clipping failed to isolate the aneurysm from one of the two branches, so the aneurysmal dome continued to pulsate and bleed. Temporary clipping of the proximal internal carotid artery revealed the fork of the two branches just distal to the aneurysmal neck. A curved Yasargil clip was used to clip the aneurysm and preserve the PcoA and branches. Careful observation of this PcoA variation is needed because the arterial structures may be hidden by the thickened arachnoid membrane.     

Ruptured internal carotid artery bifurcation aneurysm presenting with only intracerebral hemorrhage without subarachnoid hemorrhage--case report

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.     

Ruptured internal carotid -posterior communicating artery aneurysm associated with an anomalous hyperplastic anterior choroidal artery and aneurysm: case report

We report a rare case of a ruptured internal carotid-posterior communicating artery (IC-PcomA) aneurysm associated with an anomalous hyperplastic anterior choroidal artery (AchoA) and aneuysm. A 64-year-old woman was admitted to our hospital because of a sudden onset of headache. CT scan showed subarachnoid hemorrhage. Left internal carotid angiograms showed a saccular aneurysm at the IC-PcomA region. Left posterior cerebral artery filling from the fetal type PcomA and an anomalous hyperplastic AchoA originating from the internal carotid artery (ICA) were also revealed. Left vertebral angiograms (Allcock test) revealed the left ICA and an anomalous hyperplastic AchoA via the fetal type PcomA. The patient was surgically treated through the left pterional transsylvian approach. The ruptured aneurysm was observed at the IC-PcomA region. The unruptured small aneurysm was found on just distal to the ruptured aneurysm. The PcomA and an anomalous hyperplastic AchoA were not observed behind the ICA. To prevent bleeding, the ruptured aneurysm and unruptured small aneurysm were clipped. Postoperative left internal carotid angiograms demonstrated no aneurysm was observed at the IC-PcomA region. The patency of the fetal type PcomA and an anomalous hyperplastic AchoA were preserved. The 7 reported cases of a intracranial aneurysm associated with an anomalous hyperplastic AchoA with our case are reviewed and their neuroradiological and clinical features are discussed.     

Endarterectomy for narrowing of the external carotid artery in a patient who underwent extracranial-intracranial bypass for occlusion of the internal carotid artery--case report

A 56-year-old man had undergone extracranial-intracranial (EC-IC) bypass surgery for occlusion of the right internal carotid artery. Six years later, he complained of transient episodes of numbness in the left arm, occurring periodically over the previous 3 months. Neuroimaging showed the right external carotid artery was severely narrowed and cerebral blood flow (CBF) was diffusely low. Endarterectomy of the right external carotid artery was performed. Postoperative CBF was markedly improved, suggesting that EC-IC bypass became effective again by endarterectomy of a parent artery.     

Association of an epidermoid tumor with a cerebral aneurysm on the contralateral internal carotid artery

A 71-year-old female was evaluated for a sudden loss of consciousness. Initial computed tomography and cerebral angiography revealed a severe subarachnoid hemorrhage, a large cystic lesion in the left occipital region, and an aneurysm at the bifurcation of the internal carotid and the posterior communicating artery on the right side. As the subarachnoid hemorrhage was thought to be due to rupture of the aneurysm, we attempted to clip the aneurysmal neck at first, and 2 weeks later the cystic tumor was removed for the purpose of internal decompression. The extirpated specimen proved to be an epidermoid tumor. Association of a brain tumor and an cerebral aneurysm is very rare, especially a combination of an epidermoid tumor and a cerebral aneurysm, and until now only 2 cases have been reported to the best of our knowledge. Moreover, the epidermoid tumor of our case was located intracerebrally. The phenomenon that the internal carotid aneurysm was on the left side and the tumor on the right side may suggest that these 2 lesions originated quite coincidentally. It is controversial to decide which lesion and when to treat first in a case of association of a tumor and an aneurysm, and we discussed as to the surgical therapy reviewing literature.     

Infraoptic course of the anterior cerebral artery originating from the extradural internal carotid artery associated with contralateral internal carotid artery agenesis and multiple intracerebral aneurysms

A 63-year-old woman presented with infraoptic course of the anterior cerebral artery (ACA) originating from the extradural internal carotid artery (ICA) associated with contralateral ICA agenesis and multiple intracerebral aneurysms. The extradural origin of the infraoptic course of ACA was identified with constructive interference in steady state magnetic resonance (MR) imaging, and confirmed at surgery. The aneurysms were successfully clipped and embolized with coils. The anomalous artery of this rare anomaly almost always arises from the intradural ICA. MR imaging is useful for evaluating the anatomical details of this anomaly.     

Ruptured aneurysm arising from the anomalous anterior cerebral artery--case report.

A 64-year-old male presenting with subarachnoid hemorrhage had a saccular aneurysm arising from the anomalous anterior cerebral artery. The aneurysm was located on the curved mid-portion of the anomalous artery and extended underneath the right optic nerve. The aneurysm was clipped without unroofing the right optic canal. Postoperatively, he suffered from temporary mild deterioration of the right visual acuity. Hemodynamic stress may be important in the development of such aneurysms.     

Intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery in a patient with polycystic kidney disease

We report a rare case with polycystic kidney disease (PKD) having an intracranial internal carotid artery aneurysm associated with extracranial occlusion of the ipsilateral internal carotid artery. A 55-year-old man with chronic renal failure due to PKD presented with headache. CT scan and MRI showed no abnormal findings. MRA showed cervical occlusion of the right internal carotid artery and an ipsilateral intracranial carotid aneurysm. At surgery, the saccular aneurysm protruded anterolaterally at the C2 portion of the right internal carotid and was clipped. Hemodynamic stress of the blood flow through the posterior communicating artery and the fragility of arteries because of PKD were considered to be two main causes of aneurysmal formation in this case.     

Fenestration of the intracranial internal carotid artery--case report.

A rare case of fenestration of the intracranial internal carotid artery (ICA) was identified by angiography in a 51-year-old female with suspected subarachnoid hemorrhage. Only two similar cases have been reported previously. Fenestration tends to develop on the right side and near the bifurcation of the ophthalmic artery. Congenital factors at the 4 mm embryonic stage may be involved in the fenestration of the intracranial ICA.