Dissecting aneurysm of the anterior temporal artery: case report

A 65-year-old woman presented a rare dissecting aneurysm of the anterior temporal artery (ATA) manifesting as headache. Computed tomography and magnetic resonance imaging revealed a mixed-density mass in the horizontal segment of the middle cerebral artery. Emergent angiography demonstrated aneurysmal dilatation and a thrombosed mass in the sylvian fissure. Infectious aneurysm was excluded. She underwent emergent surgery to reduce the risk of repeated infarction and hemorrhage. The distal side of the ATA manifested occlusive changes suggestive of arterial dissection. The proximal side of the ATA was ligated and the lesion was excised. Histological examination confirmed that the aneurysmal dilatation was attributable to arterial dissection due to disruption of the internal elastic lamina. Distal dissecting aneurysms may occur in the absence of infectious disease. We recommend that ruptured distal dissecting aneurysms be treated surgically in the acute stage immediately after detection.     

Embolization for aneurismal dilatation associated with ruptured dissecting anterior inferior cerebellar artery aneurysm with preservation of the parent artery: case report

We report a rare case of a ruptured dissecting anterior inferior cerebellar artery (AICA) aneurysm treated by endosaccular embolization with a Guglielmi detachable coil (GDC). An 85-year-old female presented with headache. Computed tomographic (CT) scan showed subarachnoid hemorrhage and intraventricular hemorrhage in the fourth ventricule. Cerebral angiography and 3D-CT angiography revealed an aneurysmal dilatation at the anterior pontine segment of the right AICA with a diagnosis of arterial dissection. The right posterior inferior cerebellar artery (PICA) was absent and the right AICA supplied the territory normally nourished by the right PICA. The aneurismal dilatation was occluded by endosacullar embolization with preservation of the AICA. The distal AICA aneurysm is rare and only seven cases treated with endovascular embolization have been reported. In these, six cases were treated by parent artery occlusion with coil and the subsequent three cases presented with ischemic complications. Only one case was treated by endosaccular embolization with GDC. To our knowledge, this is the second report of the distal AICA aneurysm treated by endosaccular embolization with GDC. Distal AICA aneurysms are briefly discussed while reviewing the literature.     

Distal anterior choroidal artery aneurysm following iatrogenic posterior cerebral artery occlusion

Aneurysms of the anterior choroidal artery are uncommon and account for only 2–5% of all intracranial aneurysms. Distal anterior choroidal artery aneurysms are rare and the pathogenesis of this aneurysm may be different from typical proximal ones. We describe an unusual case of ruptured de novo distal anterior choroidal artery aneurysm in a 55 year-old man who had previously undergone endovascular proximal occlusion for a fusiform aneurysm of the ipsilateral posterior cerebral artery (PCA). A comprehensive review of literature using Medline, PubMed and all related journals was also performed. Only 34 reported distal AchoA aneurysms were found: 16 associated with moyamoya disease, 10 idiopathic, two with atherosclerosis, two with arteriovenous malformation, two dissecting, one infectious and one due to trauma. It is probable that the increased hemodynamic stress within the AchoA contributed to the formation and rupture of the reported aneurysm. This late complication needs to be considered when large intracranial vessels are iatrogenically occluded in the management of complex intracranial aneurysms.     

Middle cerebral artery dissecting aneurysm causing intracerebral hemorrhage 4 years after the non-hemorrhagic onset: a case report

BACKGROUND: We report a case of dissecting middle cerebral artery (MCA) aneurysm causing intracerebral hemorrhage 4 years after the non-hemorrhagic onset. CASE DESCRIPTION: A 30-year-old male was diagnosed with an unruptured dissecting MCA aneurysm after a severe pulsating headache in August 1993. Angiography revealed dilatation of the distal portion of the temporo-occipital artery. During 2 years of follow-up, there were no significant changes on magnetic resonance imaging. In August 1997, he became comatose because of massive intracerebral hemorrhage caused by a dilated fusiform dissecting aneurysm. Emergency surgery and postoperative mild hypothermia resulted in full recovery. CONCLUSION: To date only 30 cases of dissecting MCA aneurysm have been reported and for unruptured aneurysms, surgical intervention was not chosen. However, the present case strongly suggests that long-term follow-up is necessary in patients with unruptured dissecting aneurysms of the anterior circulation, especially those with ectatic components.     

A dissecting aneurysm of the posterior inferior cerebellar artery was reduced spontaneously during conservative therapy: case report

We report here a case of a patient with a dissecting aneurysm of the anterior medullary segment of the posterior inferior cerebellar artery (PICA) which presented with Wallenberg's syndrome. A 32-year-male presented with an unusual case of Wallenberg's syndrome due to a dissecting aneurysm of the PICA manifesting as a sensation of heaviness in the occipital region and vertigo. The occipital symptoms persisted and vertigo and vomiting developed after 6 days. Numbness developed on the left side of the patient's face, and hyperalgesia on the right side of the body. The diagnosis of Wallenberg's syndrome was based on the above findings. MRI revealed infarction of the lateral aspect of the medulla oblongata and MR angiography revealed dilatation in the proximal portion of the left PICA. Digital subtraction angiography revealed that the left vertebral artery was essentially normal, but there was a spindle-shaped dilatation in the proximal portion of the left PICA. We carried out conservative therapy at the patient's request and 3D-CTA revealed that the dissecting aneurysm was markedly reduced in size seven months after the onset. Dissecting aneurysms of the intracranial posterior circulation have been shown to be less uncommon than previously thought. However, those involving the PICA without involvement of the vertebral artery at all are extremely rare. The natural history of the dissecting PICA aneurysm was unknown, and the indication for surgical treatment of such aneurysms remains controversial. Management options are conservative treatment, open surgical treatment including wrapping, trapping, and resection with reconstruction, but almost all of the patients underwent radical treatment to prevent rupture of the aneurysm. However we had no knowledge of the risk of rupture of a PICA dissecting aneurysm presenting with ischemic symptoms. We have reviewed the well-documented 15 cases of dissecting aneurysms of the PICA reported in the literature and we discuss the management of the dissecting PICA aneurysm presenting with ischemic symptoms.     

Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: a case report and review of the literature

BACKGROUND

Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction.

CASE DESCRIPTION

A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2.

CONCLUSION

This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.     

Subarachnoid hemorrhage in the presence of both intracranial dissecting and saccular aneurysms--two case reports

Two patients presented with subarachnoid hemorrhage (SAH) associated with both intracranial dissecting and saccular aneurysms. Case 1, a 48-year-old woman, had a saccular aneurysm of the right internal carotid artery and dissecting aneurysms of the bilateral vertebral arteries. Case 2, a 52-year-old man, had three saccular aneurysms in the anterior circulation and a dissecting aneurysm of the unilateral vertebral artery. A saccular aneurysm was responsible for the SAH in both patients. Ruptured saccular aneurysms were treated with surgical clipping and unruptured dissecting aneurysms remained untreated. SAH recurred due to bleeding from an untreated dissecting aneurysm 4 days after the initial SAH in Case 1. Triple-H therapy, which causes increased hemodynamic stress, was not administered for symptomatic cerebral vasospasm after SAH in Case 2, because of the risk of bleeding from the untreated dissecting aneurysm, and the patient suffered cerebral infarction. The risk factors for this rare association are unclear, but both patients were smokers and had hypocholesterolemia including low apolipoprotein E levels. The clinical management of patients with SAH and both dissection and saccular aneurysms is complicated. Asymptomatic dissecting aneurysm has a benign clinical course in general, but hemodynamic stress related to stroke may induce abrupt development of dissecting aneurysms. Prophylactic obliteration during the acute stage of SAH may provide better outcomes if the unruptured dissecting lesion appears as obvious aneurysmal dilatation or pearl-and-string sign and is safely treatable with endovascular trapping.     

An autopsy case of persistent primitive hypoglossal artery with multiple cerebral aneurysms

An autopsy case of persistent primitive hypoglossal artery (PPHA) with multiple cerebral aneurysms is reported. A 54-year-old man with subarachnoid hemorrhage was admitted to Kuwana Hospital three days after the onset. The patient was stuporous and had stiffness of the neck. A computed tomogram showed hematoma in the interhemispheric fissure, subarachnoid hemorrhage in the basal cisterns and bilateral Sylvian fissures, and maxked dilatation of ventricles. Cerebral angiogram revealed the left PPHA and multiple aneurysms at the right anterior cerebral artery (A 2) (ruptured), anterior communicating artery, left anterior cerebral artery (A 1), left internal carotid-anterior choroidal artery junction, right internal carotid artery (C 1), and right middle cerebral artery. Neck clipping of the ruptured aneurysm and ventricular drainage were performed on the day of admission. Eight days after admission he died of rupture of the residual aneurysm. In pathological study, the PPHA was originated from the extracranial portion of the left internal carotid artery, 2 cm distal from the cervical carotid bifurcation, entered the intracranial space through the hypoglossal foramen, and turned into the basilar artery. There were six aneurysms which were shown on cerebral angiogram and another aneurysm on the left anterior inferior cerebellar artery. Microscopic examination revealed atherosclerotic change of the PPHA, true aneurysmal changes of the seven aneurysms and defect of tunica media (Forbus' medial gap) at all of the arterial bifurcations without early aneurysmal changes.     

Distal anterior choroidal artery aneurysm associated with an arteriovenous malformation. Intraoperative localization and treatment

BACKGROUND

Distal anterior choroidal artery aneurysms are rare. The outcome of patients with distal anterior choroidal artery aneurysms has been poor, and the treatment of such aneurysms is surgically challenging.

CASE DESCRIPTION

The authors describe the case of an 8-year-old girl with a ruptured distal anterior choroidal artery aneurysm associated with an arteriovenous malformation (AVM). The patient experienced sudden onset of headache and vomiting. Computed tomography revealed an intraventricular haemorrhage, and cerebral angiography demonstrated an aneurysm arising from the distal portion of the right anterior choroidal artery. The patient also had an AVM in the ipsilateral temporal lobe fed by the branches of the middle cerebral artery. A right frontotemporal craniotomy was performed with the aid of intraoperative angiography to eliminate both the AVM and the aneurysm. Intraoperative angiography was helpful in confirming the complete removal of the AVM and in accurate localization of the small and deeply placed distal anterior choroidal artery aneurysm. Both the AVM and the aneurysm were successfully treated and the patient was discharged without any neurological deficits.

CONCLUSION

This case is the youngest reported patient with a distal anterior choroidal artery aneurysm. This report is also the first to describe an association of such an aneurysm with an AVM. The etiology of the aneurysm formation in this case and surgical strategy for deeply placed vascular lesions are discussed.     

Ruptured dissecting aneurysms of the A1 segment of the anterior cerebral artery: three case reports and a review of the literature

Dissecting aneurysms in the anterior cerebral artery (ACA), although rare, can cause ischemic and/or hemorrhagic stroke. Hemorrhagic dissecting aneurysms in the A1 portion of the ACA are often associated with a poor prognosis. We retrospectively investigated three rare cases of hemorrhagic dissecting aneurysms in the A1 portion. Dissecting aneurysms were diagnosed by carotid angiography or computed tomography angiography to visualize morphological changes in the vessel. All patients presented with diffuse subarachnoid hemorrhage. In one case, computed tomography angiography performed at the onset of the subarachnoid hemorrhage revealed fusiform dilatation at the right ACA (A1), which did not appear on a magnetic resonance angiogram obtained 1 year prior to the onset of the subarachnoid hemorrhage. In the other two cases, A1 dissecting aneurysms were diagnosed from a growing aneurysmal bulge revealed at a non-bifurcated site via repeated carotid angiography. Two patients underwent surgical intervention (trapping or clipping), and their outcome was favorable, whereas the third patient died of delayed rebleeding before receiving surgical treatment. Hemorrhagic dissecting aneurysms in the A1 portion cause severe subarachnoid hemorrhage. Surgical treatments that include revascularization are necessary to prevent rebleeding, and direct surgery is recommended, particularly at the A1 portion.     

Postoperative discitis due to Propionibacterium acnes: a case report and review of the literature

BACKGROUND: A rare case of a growing dissecting aneurysm, which was located at the horizontal (A1) segment of the anterior cerebral artery (ACA), is reported. CASE DESCRIPTION: A 53-year-old woman experienced left hemiparesis and alien hand syndrome. A computerized tomography scan showed an infarction in the right frontal lobe, and cerebral angiography revealed a false lumen and intimal flap at the A1 segment of the ACA. Magnetic resonance angiography demonstrated that the stenosis progressed 6 months later and improved 1 year later. Cerebral angiography showed a saccular-like aneurysm 2 years later. The surgery was planned for prevention of aneurysmal rupture. The aneurysm, which was cocoon shaped, was exposed surgically and was resected. Histological examination of the aneurysm showed arterial dissection. The postoperative course was uneventful without additional neurological deficits. CONCLUSION: This is the first case report of A1 dissecting aneurysm presenting with an ischemic event in the literature. The sequential change of the configuration was curious to develop aneurysmal dilatation in 2 years. Long-term follow-up is necessary even after disappearance of the arterial dissection.     

Spontaneous dissection of the anterior cerebral artery presenting subarachnoid hemorrhage and cerebral infarction: a case report

A case is reported of anterior cerebral artery dissecting aneurysm presenting with subarachnoid hemorrhage and cerebral infarction. A 50-year-old man presented with sudden onset of weakness of the left lower limb was admitted to our hospital. CT scan on admission showed a subarachnoid hemorrhage in the interhemispheric fissure and CT on the 6th day demonstrated a cerebral infarction on the right medial frontal lobe. A carotid angiogram 12 hours after the onset showed no aneurysmal lesion, but, the angiogram repeated 11 days after the onset revealed an aneurysmal dilatation with distal narrowing at the right A2-A3 segment. To prevent rebleeding, we performed a wrapping procedure through the interhemispheric route on the 18th day after onset. The postoperative course was uneventful. We reviewed 27 previously reported cases with symptomatic dissecting aneurysm confined to the anterior cerebral artery.     

Vertebrobasilar artery dissection presenting with simultaneous subarachnoid hemorrhage and brain stem infarction: case report

BACKGROUND: Intracranial dissecting aneurysms have been associated with subarachnoid hemorrhage (SAH) or cerebral ischemia. We encountered a patient presenting with simultaneous subarachnoid hemorrhage and brainstem infarction caused by a dissecting aneurysm of the vertebrobasilar artery, which was diagnosed by magnetic resonance imaging (MRI) but did not show abnormal findings on cerebral angiography. CASE DESCRIPTION: A 55-year-old man had sudden onset of headache and left abducens palsy. Computed tomography revealed a subarachnoid hemorrhage localized in the left prepontine cistern and the left cerebellomedullary fissure. Cerebral angiography showed neither a saccular aneurysm nor fusiform dilatation causing the subarachnoid hemorrhage. MRI demonstrated a small infarction in the left dorsal pons, and an intramural hematoma of the left vertebral artery and lower basilar artery. CONCLUSION: This is a rare case of a vertebrobasilar dissecting aneurysm that simultaneously caused both SAH and brain stem infarction. MRI should be performed in the acute phase of SAH of unknown origin to determine the possible coexistence of a dissecting aneurysm, as occurred in this case.     

Aneurysm growth and enlargement of pre-aneurysmal lesions

Three patients with cerebral aneurysms newly growing and enlarging for 2 to 10 years are reported. Case 1, a 54-year-old woman, had subarachnoid hemorrhage due to rupture of an intracranial aneurysm, growing from a small residual aneurysmal neck on the left internal carotid artery 10 years after the repair of the aneurysm. Case 2, a 63-year-old man, had a junctional dilatation on the left internal carotid-posterior communicating artery, developing into ruptured aneurysm about 10 years after the first hemorrhage. Case 3, a 52-year-old man, had multiple aneurysms on the bilateral bifurcations of middle cerebral arteries and left anterior cerebral artery-frontopolar artery junction. Angiography 2 years after the repair of the aneurysms revealed the new growth of a small aneurysm on the anterior cerebral artery at the junction of the fronto-orbital artery, developing from a localized vascular dilatation which had been recognized by the preoperative angiography. The existence of pre-aneurysmal lesions in arterial wall and the addition of hemodynamic impingement were thought to be one of the precipitating factors of aneurysmal formation. The pre-aneurysmal lesions in our study are as follows; a small part of thin wall of residual aneurysmal neck, a junctional dilatation, and a small evagination of arterial wall. It is necessary to discriminate a junctional dilatation and a small evagination of arterial wall from a small aneurysm with observation from multiple directions by the preoperative angiographic study. Our observations suggest that preaneurysmal lesions of the cerebral artery may develop into aneurysm and rupture, and hence the follow-up angiography is recommended for the cases with a preaneurysmal lesion or a small aneurysm for many years.     

Anomalous arrangement of the origins of the anterior choroidal and posterior communicating arteries. Case report.

A case of anomalous origin of the anterior choroidal and posterior communicating arteries in a 36-year-old woman with aneurysmal subarachnoid hemorrhage is presented. Preoperative four-vessel angiography revealed a reverse relationship of these vessels, wherein the anterior choroidal artery origin was proximal to the origin of the posterior communicating artery. This arrangement is extremely rare; the only other reported case was in a patient undergoing angiography prior to acoustic neurinoma resection. It is believed that this is the first case reported in a patient with subarachnoid hemorrhage from rupture of an aneurysm arising from a vessel of such anomalous origin.     

Ruptured Distal Anterior Choroidal Artery Aneurysm Presenting with Casting Intraventricular Haemorrhage

Summary This report describes a rare case of a distal anterior choroidal artery aneurysm which developed intraventricular haemorrhage without subarachnoid haemorrhage as shown on computerized tomographic (CT) scan. A 69-year-old hypertensive man suddenly became unconscious. An emergency CT scan showed a severe intraventricular haemorrhage and a small round low-dense lesion within the haematoma at the right trigone. The haematoma with obstructive hydrocephalus made the lateral ventricles larger on the right than on the left. CT scan could not detect any subarachnoid haemorrhage. Right interal carotid angiography revealed a saccular aneurysm at the plexal point of the right anterior choroidal artery. We approached the aneurysm and the small round lesion through the trigone via a right temporo-occipital corticotomy. We could clip the aneurysmal neck and remove the intraventricular haematoma and the papillary cystic mass (corresponding to the small round lesion on CT scan) totally in one sitting. Histological examination revealed the aneurysm to be a true one and the papillary cystic mass to be a choroid plexus cyst.     

Dissecting aneurysms of the anterior cerebral artery and accessory middle cerebral artery. Case report

A 66-year-old woman presented with dissecting aneurysms of the anterior cerebral artery (ACA) and accessory middle cerebral artery (MCA) manifesting as subarachnoid hemorrhage but without radiological evidence of the dissecting aneurysms. Intraoperative observation revealed that the vessel walls were dark purple in color, a typical finding of dissecting aneurysm. The abnormal A1 segment was trapped and the dissecting aneurysm of the accessory MCA was wrapped. In the case of SAH of unknown origin, dissecting aneurysm should always be kept in mind even if the angiogram does not show any abnormal finding. This is the first reported case of dissecting aneurysm of the accessory MCA.     

Spontaneous resolution of the unruptured dissecting aneurysms of bilateral vertebral arteries with conservative treatment: analysis of the transient enlargement of aneurysmal dilatation

A case of unruptured dissecting aneurysms of bilateral vertebral arteries was reported. A 47-year-old man was admitted to our hospital with right Wallenberg's syndrome. On the tenth hospital day, angiography revealed a pearl and string sign in the right vertebral artery and aneurysmal dilatation in the left vertebral artery. On the 38th hospital day, the pearl and string sign in the right vertebral artery was improved, but the aneurysmal dilatation in the left vertebral artery had enlarged. On the 222nd hospital day, angiography showed a spontaneous resolution of the aneurysmal dilatation in the left vertebral artery. He suffered no recurrence and returned to his previous life style. Because aneurysmal dilatation may be resolved spontaneously, especially in the chronic stage, surgery should not be undertaken lightly.     

Two cases of ruptured fusiform aneurysm of the proximal anterior cerebral artery (A1 segment)

Two rare cases of fusiform aneurysms of A1 segment of the anterior cerebral artery are reported. Case 1: A 62-year-old woman was admitted with sudden onset of severe headache and loss of consciousness, on August 22, 1982. CT scan showed subarachnoid hemorrhage at the basal cisterns. Left carotid angiography revealed a spindle shaped aneurysmal dilatation in the A1 segment of the anterior cerebral artery. Four-vessel angiography was performed twice but no other aneurysm was found. She was treated conservatively and the clinical course was not eventful. She was discharged with no neurological deficit one month after the admission. Case 2: A 49-year-old man complained of sudden onset of severe headache, nausea and vomiting on August 24, 1986. He was transferred to a local hospital and CT scan showed subarachnoid hemorrhage at the basal cisterns. Angiography revealed a fusiform aneurysm of the proximal anterior cerebral artery. He was referred to our hospital on the day of onset. He was operated on via bifrontal interhemispheric approach. The fusiform aneurysm of A1 segment was trapped successfully using temporary occlusion of A1 and A2 bilaterally under the administration of Sendai-Cocktail. V-P shunt was performed 1 week after the aneurysmal operation. The post-operative course was uneventful. He was discharged with no neurological deficit three months after operation. As far as we know, there are 6 cases of fusiform aneurysm of A1 segment of anterior cerebral artery in the literature. In this report, our two cases were described and treatment of such aneurysms were discussed.     

Antegrade recanalization of a completely embolized vertebral artery after endovascular treatment of a ruptured intracranial dissecting aneurysm. Report of two cases

Occlusion of the parent artery is a traditional method of treatment of unclippable cerebral aneurysms. Surgical or endovascular occlusion of the parent artery proximal to the aneurysm has been recommended for the treatment of dissecting aneurysms located in the vertebrobasilar circulation. Nevertheless, occlusion of the parent artery may not result in permanent exclusion of the aneurysm from the systemic circulation because, occasionally, postoperative rebleeding occurs after proximal occlusion. Alternatively, endovascular occlusion of the affected site, including the aneurysmal dilation, and parent artery, is a safe and reliable treatment for dissecting aneurysms. The authors present two rare cases of ruptured vertebral artery (VA) dissecting aneurysms that were treated by endovascular occlusion of the affected site including the aneurysm and parent artery by using Guglielmi detachable coils. In both cases the VA recanalized in an antegrade fashion during the follow-up period. Based on these unique cases, the authors suggest that a careful angiographic follow up of dissecting aneurysms is required, even in patients successfully treated with endovascular occlusion of the affected artery and aneurysm.