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.     

Arteriovenous malformation of the scalp: case report and review of the literature

BACKGROUND: Arteriovenous malformations (AVMs) of the scalp are relatively rare, and their precise natural course remains to be elucidated. We encountered a patient with a scalp AVM that progressively enlarged over the course of 3 years by capturing feeders from intracranial arteries. To our knowledge, ours is the first serial angiographic depiction of the growth of a scalp AVM and the development of a de novo aneurysm in the superior temporal artery (STA) that performed as a feeder. CASE DESCRIPTION: This 21-year-old female consulted us in 1998 complaining of right tinnitus and a pulsating mass in the retroauricular region. The initial angiogram revealed an AVM in the right temporo-parietal subcutaneous space with feeders from the STA, an occipital artery, a posterior auricular artery, and a middle meningeal artery (MMA). Three years later, she complained of enlargement of the lesion, increased tinnitus, and alopecia. Repeat angiographic study revealed the presence of a nidus and the appearance of new feeders from a contralateral MMA and an ipsilateral middle cerebral artery; there was a de novo saccular aneurysm in the right STA. On the day preceding surgery, the left MMA was embolized to control intraoperative bleeding. The AVM was removed totally without any dermal complications. CONCLUSION: This case suggests that scalp AVMs can become enlarged by capturing subcutaneous or intracranial feeders, and that the consequent hemodynamic stress may induce de novo aneurysms in scalp AVMs. Capillary endothelial cells were strongly immunostained for vascular endothelial growth factor.     

Diagnostic cerebral angiography in spontaneous intracranial haemorrhage: a guide for developing countries

OBJECTIVE: Spontaneous intracranial haemorrhage constitutes 18-40% of all stroke cases. Indications for cerebral angiography to find underlying potentially treatable vascular abnormalities are not clear. This study determined which intracranial haemorrhage patients need cerebral angiography by correlating computed tomography (CT) findings, age and hypertension history with cerebral angiography findings. METHODS: A total of 54 patients (8-79 years) with intracranial haemorrhage who underwent both CT examination and six-vessel cerebral angiography were studied over a 2-year period. Cerebral angiography was repeated within 6 weeks if the first angiogram was negative. RESULTS: Angiography detected vascular lesions in 50% of cases (aneurysm 38.9% and arteriovenous malformation, AVM, 11.1%). In the aneurysm group, angiographic yield was 34.3% whereas in the AVM group, it was 37.9%. Subarachnoid haemorrhage (SAH) combined with other types of haemorrhage (such as intracerebral haemorrhage, ICH) was not significantly correlated with the likelihood of finding a vascular lesion, both aneurysm and AVM (p = 0.157). Age less than 50 years had significant correlation (p = 0.021) in the AVM group as well as in the aneurysm group (p < 0.001). A history of hypertension was associated with both aneurysm (p = 0.039) and AVM (p = 0.008). No patients with deep intracerebral haematoma had vascular lesions. The presence of an intravascular haemorrhage (IVH) had significant correlation with aneurysm (p = 0.008) but not AVM. There was no significant difference in mean age between patients with and without a vascular lesion (p = 0.134). CONCLUSION: Cerebral angiography is justified in patients with ICH accompanied by pure SAH (p = 0.001). Other factors associated with finding a vascular lesion were a history of hypertension and the presence of IVH. Diagnostic cerebral angiography is indicated for patients with ICH and SAH and IVH with a history of hypertension, regardless of age.     

Spontaneous middle cerebral artery occlusion with moyamoya-like vessels associated with contralateral middle cerebral artery aneurysm; a case report]

A case of spontaneous middle cerebral artery occlusion with moyamoya-like vessels associated with contralateral middle cerebral artery aneurysm is reported. A 23-year-old male was admitted to our hospital with complaints of severe headache and vomiting. On admission CT scan demonstrated subarachnoid hemorrhage with high density in the left Sylvian fissure and suggested a ruptured left middle cerebral artery aneurysm. Carotid angiograms demonstrated a left middle cerebral artery aneurysm and an occlusion of the right middle cerebral artery at its origin with moyamoya-like vessels. There was no occlusion or stenosis in the bilateral intracranial internal carotid arteries. Furthermore, bilateral vertebral angiograms were also normal. The aneurysm was successfully clipped. The postoperative course was uneventful and the patient was discharged with no neurological deficit. So far as we could ascertain, there have been only 21 cases reported previously of spontaneous middle cerebral artery stenosis or occlusion with moyamoya-like vessels. According to angiographic studies and transcranial Doppler ultrasound findings, we are more inclined to believe that hemodynamic changes secondary to arterial occlusion lead to the formation and growth of aneurysms of the contralateral middle cerebral artery.     

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.     

Multiple intracranial aneurysms. A very peculiar case of 8 sylvian aneurysms

Reports vary with respect to frequency of multiple aneurysm but they are observed in an average of 13% of intracranial aneurysm cases. Multiple aneurysms generally involve several intracranial vascular trunks but those affecting the vertebrobasilar system and middle cerebral artery are the most common combinations. It is rare for more than two lesions to be located on the trunk of a same vessel. These data emphasize the exceptional nature of the clinical case presented. The eight aneurysms detected in this patient were all situated on the left sylvian artery and its proximal collaterals. Rupture of one of the aneurysms had provoked haemorrhage into sylvian fissure. All eight aneurysms were treated by eleven clamps during the course of a one-stage operation. Full recovery, with completely normal clinical and review arteriographic results, was obtained despite the postoperative onset of a right hemiplegia with aphasia.     

Association of cerebral arteriovenous malformation and cerebral aneurysm. Diagnosis and management

Summary Between 1979 and 1989, 7 patients were admitted, with cerebral arteriovenous malformations (AVM) and associated aneurysms (7% of the AVM patients and 2% of the aneurysm patients admitted during the same period). 6 of these patients were admitted because of an intracranial haemorrhage (in 3 of them the AVM, angiographically occult, was discovered at surgery). The last patient was referred for seizures.Preoperatively it was supposed that the haemorrhage was related to the aneurysm in 3 cases, and to the AVM in 3 cases. But surgery allowed one to correct this supposition. Haemorrhage was due to AVM rupture in all 6 cases, and no aneurysm had ruptured. Overall three situations were demonstrated in this series: aneurysm and occult AVM (3 cases); AVM and independent aneurysm in the same area (2 cases); large AVM and aneurysm on a feeding artery (2 cases). All 6 patients admitted for haemorrhage were operated upon, at one operation in 5 of them. Both the malformations were excluded in these six patients. For the patient admitted for seizure, intra-vascular embolization of the AVM was performed, the aneurysm was not treated. The pathogenesis of the association AVM-aneurysm is discussed. In the authors' opinion, haemodynamic relationship should be considered in two cases (large AVM and aneurysm on a feeding vessel). For the other 5 cases, both the AVM and the coexisting aneurysm may be the end-result of a common congenital vascular malformation syndrome.     

Intraoperative digital subtraction angiography and the surgical treatment of intracranial aneurysms and vascular malformations

Intraoperative digital subtraction angiography using commercially available equipment was employed to confirm the precision of the surgical result in 105 procedures for intracranial aneurysms or arteriovenous malformations (AVM's). Transfemoral selective arterial catheterization was performed in most of these cases. A radiolucent operating table was used in all cases, and a radiolucent head-holder in most. In five of the 57 aneurysm procedures, clip repositioning was required after intraoperative angiography demonstrated an inadequate result. In five of the 48 AVM procedures, intraoperative angiography demonstrated residual AVM nidus which was then located and resected. In two cases intraoperative angiography failed to identify residual filling of an aneurysm which was seen later on postoperative angiography, and in one case the intraoperative study failed to demonstrate a tiny residual fragment of AVM which was seen on conventional postoperative angiography. Two complications resulted from intraoperative angiography: one patient developed aphasia from cerebral embolization and one patient developed leg ischemia from femoral artery thrombosis. This technique appears to be of particular value in the treatment of complex intracranial aneurysms and vascular malformations.     

Two cases of azygos anterior cerebral artery aneurysm (author's transl)]

Two cases with azygos anterior cerebral artery were reported from an analysis of 37 cases of distal anterior cerebral artery aneurysm. Case 1 was a 57-year-old woman. She had an attack of subarachnoid hemorrhage two months before admission to our clinic. The anterior cerebral artery was not demonstrated on the right carotid angiogram, and an azygos anterior cerebral artery was visualized on the left carotid angiogram. The aneurysm was situated at the distal end of the azygos artery. Case 2 was a 71-year-old hypertensive woman. Subarachnoid hemorrhage occurred 6 days before admission to our clinic. The left carotid angiography with contraleteral compression revealed an azygos artery and an aneurysm in its middle part. The azygos arteries in both cases were confirmed at operation and aneurysmal necks were managed without any serious deficit. The distal anterior cerebral artery aneurysm is frequently accompanied by azygos artery. This vascular anomaly may cause a hemodynamic change and may be one of the factors of aneurysmal formation at this part.     

Treatment of mycotic intracranial aneurysms

Two patients with mycotic intracranial aneurysms were successfully treated with only antibiotic therapy. One patient, who had subacute bacterial endocarditis, rheumatic valvular disease, and an abscessed tooth, sustained a subarachnoid hemorrhage from a ruptured right middle cerebral artery trifurcation aneurysm. The other patient, who had Turner's syndrome and probable congenital aortic stenosis, developed multiple neurological findings during an ipisode of acute bacterial endocarditis precipitated by an infected ingrown toenail; a false aneurysm of the distal left middle cerebral artery and two lesions involving the left superior cerebellar artery were found. A study of the literature shows that only 45 patients with mycotic intracranial aneurysms have received adequate antibiotic therapy and angiographic documentation. Statistically, there does not appear to be a clear-cut advantage to antibiotic plus surgical therpy over antibiotic alone. In fact, in 21 patients who underwent serial angiography, lesions were smaller in six and not visualized in 11. In four patients the aneurysms increased in size; in two others fresh lesions formed. The author proposes the following diagnostic and therapeutic regimen: 1) earliest possible diagnosis of the underlying disorder; 2) appropriate antibiotic therapy; 3) early four-vessel cerebral angiography and follow-up studies every 2 to 3 weeks; study; 5) definitive operation upon completion of antibiotic therapy if the lesion is larger or the same size; and 6) postoperative angiography to evaluate the effectiveness of treatment and to search for interim lesions.     

Subarachnoid hemorrhage from intracranial dissecting aneurysms of the anterior circulation. Two case reports.

Two rare cases of intracranial dissecting aneurysms of the anterior circulation associated with subarachnoid hemorrhage (SAH) are described. A 56-year-old female presented with a dissecting aneurysm in the proximal segment of the left middle cerebral artery. Proximal occlusion of the affected artery and a superficial temporal artery-middle cerebral artery anastomosis were performed, but the outcome was poor. A 61-year-old male presented with a dissecting aneurysm in the proximal segment of the left anterior cerebral artery. Clipping was enhanced by a piece of fascia lata, allowing patency of the affected artery with a satisfactory outcome. Dissecting aneurysm of the carotid system should be considered in a patient with SAH but no evidence of berry aneurysm.     

Extracorporeal circulation with deep hypothermia and circulatory arrest in the treatment of intracranial arterial aneurysms

Extracorporeal circulation with circulatory arrest and deep hypothermia in surgery on certain giant intracranial arterial aneurysms or on aneurysms difficult to access is described. The series includes a giant left carotid aneurysm, an aneurysm of the basilar artery bifurcation, a patient with two aneurysms, one on the right middle cerebral artery and the other at the end of the basilar artery, and a fourth patient with two aneurysms, one on the right middle cerebral and the other on the right carotid. Closed-thorax extracorporeal circulation with femoral cannulation was performed on all the patients. Surgical procedure is described and the advantages and disadvantages discussed. Results are encouraging. The authors suggest that the technique be used during surgical treatment of certain intracranial aneurysms that are in awkward positions or are very large in size. They emphasize that the procedure should be confined to exceptional cases.     

A case of ruptured middle cerebral artery aneurysm with acute subdural hematoma after clipping of the aneurysm nine years previously

It is known well that acute subdural hematoma develops most frequently after head injury, and secondly from pathological lesions such as intracranial ruptured aneurysm or AVM. A case of ruptured middle cerebral artery aneurysm which was clipped nine years before resulting in acute subdural hematoma is reported. At 6 pm on July 21, 1988, a 53-year-old woman with severe headache starting at 4:20 pm was transferred to our hospital. She suffered from herniated signs; Conscious disturbance; anisocoria; positive OCR; decerebrate posture. An emergency CT showed right acute subdural hematoma with severe midline shift. Following a decompressing craniotomy at 9 pm, the subdural clot was evacuated. It measured 90g in volume and the underlying cortex was normal. There was no evidence of SAH. Right carotid angiography three weeks after the first operation showed a middle cerebral artery aneurysm at the site of a clip which had been applied nine years ago. A second operation was performed on August 30, 1988. Via the right pterional route, the middle cerebral artery aneurysm was clipped successfully with a Sugita's clip replacing the first clip. We concluded that the regrowth and rebleeding of the middle cerebral artery aneurysm which had been clipped nine years before was most probable. She was discharged with slightly decreased consciousness and right motor weakness, on November 13, 1988.     

A case of arteriovenous malformation in a neonate

Although arteriovenous malformation (AVM) is considered a congenital disease, few cases of AVM are manifested clinically in the neonatal period. In this paper a neonatal case of AVM manifested as intracranial hemorrhage is reported. A newborn female infant 12 days after birth, was admitted to a hospital with the chief complaint of sudden onset of vomiting and fever. Neurological examination revealed left hemiparesis with bulging of the anterior fontanel. CT examination demonstrated a large mass lesion with hemorrhage in the right parietal lobe. The lesion was enhanced with contrast medium. Consent for surgery was not able to be obtained from her family, so she was treated conservatively. A gradually enlarging cyst surrounding the mass appeared in follow-up CT examination. Her left hemiparesis and bulging of the anterior fontanel remained unchanged, and a rather good general health condition was maintained. Consent for surgery was finally obtained from her parents and the patient was transferred to our hospital three months after the onset of the symptoms. Cerebral angiogram showed AVM with a big aneurysmal sac. The feeder arteries of the AVM arose from the right middle cerebral artery and the anterior cerebral artery. The drainers poured into the superior sagittal sinus. AVM was removed totally by right parietal craniotomy on the 24th January, 1989. Postoperatively, her left hemiparesis started to improve gradually. Her general condition was also good, and she showed no neurological deficits at the age of 8 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intra operative embolization of unresectable cerebral arterio-venous malformations. Occlusion attempt by means of a delayed polymerization mixture. Report of two cases (author's transl)

Two cases of unresectable intra-cranial arterio-venous malformation (AVM) are reported, treated by direct intra-operative embolization. A 50% mixture of Butyl-2-Cyano-Acrylate and Mono-Iodo-Stearate of Ethyle (Duroliopaque) was used after catheterization of some of the feeding cortical arteries. No intra-operative angiography was performed. The first patient, admitted after subarachnoid hemorrhage and presenting with a mild transient right hemiparesia and aphasia, showed evidence of a left temporal AVM with a left middle cerebral artery supply and contribution from the left cerebral posterior artery. The AVM was embolized with 3 cc of the mixture. A mild aphasia occurred after surgery and completely recovered after two weeks. Roughly half of the AVM was occluded on the postoperative angiograms. The second patient suffering from a long history of seizures had a huge right frontal AVM, with a right middle cerebral artery and right anterior cerebral artery supply, and contribution from a right lenticulostriate artery, the left anterior cerebral artery and the right posterior cerebral artery. The AVM was embolized with 7 cc of the mixture. A complete palsy of the left upper limb occurred after surgery, with complete recovery after two weeks. On the post-operative angiograms, more than three fourth of the AVM was occluded.     

Intracerebral hematoma due to ruptured nontraumatic middle meningeal artery aneurysm--case report.

A 77-year-old woman suddenly lost consciousness and presented with right hemiparesis. Computed tomography showed a large subcortical hematoma in her left frontal lobe associated with subarachnoid hemorrhage. The first impression was hemorrhage due to a ruptured aneurysm of the middle cerebral or the internal carotid artery on the left. Left internal carotid angiography showed no aneurysm or vascular anomaly, but back flow of contrast medium into the external carotid artery disclosed two saccular aneurysms arising from the anterior branch of the left middle meningeal artery (MMA). Emergent surgical intervention confirmed that the hematoma was due to ruptured MMA aneurysm. Nontraumatic MMA aneurysm should be recognized as a possible causative lesion of intracranial hemorrhage despite the extremely low incidence. External carotid angiography should be performed in patients with intracranial hemorrhage in whom no vascular cause can be detected in the internal carotid system.     

Ruptured intracranial aneurysm combined with multiple cerebral vessel anomalies; a case report

We report a very rare case of subarachnoid hemorrhage associated with fenestration of the anterior cerebral artery (ACA), the accessory middle cerebral artery (A-MCA) and the duplication of the middle cerebral artery (D-MCA). It seems that this is the first report of these combined intracranial vascular anomalies, although many authors have reported each anomaly in isolation. A 50-year-old male visited a local physician complaining of the sudden onset of a severe pulsating headache. A lumbar puncture showed bloody cerebrospinal fluid, and he was transferred to our institution. An emergency CT scan showed no apparent subarachnoid hemorrhage, but the left internal carotid angiography showed a saccular aneurysm at the origin of the D-MCA. Other anomalies, such as the fenestration of the ACA and the A-MCA, were also apparent during angiography. The ruptured aneurysm was safely clipped on the next day and the patient was discharged with no neurological deficits three weeks after the operation. The incidence of fenestration of the ACA is 0.2% in the angiographic series, and 0.1-7.2% at autopsy. Fenestration of the ACA is thought to be less than that of the vertebral artery. Ever since it was proposed by Teal et al, the term A-MCA has been restricted to an artery that arises from the ACA, and a branch arising from the internal carotid artery has been termed as the D-MCA. These anomalous vessels supply the cortex in the distribution of the middle cerebral artery. The angiographic incidence of A-MCA is about 4%, and six cases of aneurysm located at the origin of the A-MCA have been reported so far.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dissecting aneurysm of the middle cerebral artery: case report

We present a surgical case of a dissecting aneurysm of the right middle cerebral artery associated with subarachnoid hemorrhage and intracranial hemorrhage. A 61-year-old woman with consciousness disturbance and left hemiplegia was referred to our hospital. She had suffered severe headache for a week. CT scan showed a subarachnoid hemorrhage in the right Sylvian fissure and intracranial hemorrhage in the right putamen. The right carotid angiogram revealed string sign in M1 portion and occlusion at M2 lower branch of the right middle cerebral artery. On the 12th day, we undertook surgery to confirm whether it was a dissecting aneurysm or not. In the operation, it was reddish in the M1 portion corresponding to the "string sign" and dark-purplish in the lower M2 portion corresponding to an "aneurysm-like lesion". To prevent bleeding, the arterial wall in the M1 portion was coated using muscle. Though the left hemiplegia was unchanged, the postoperative course was uneventful. The patient was transferred to another hospital and underwent rehabilitation. There has been no reccurrence during the four years since surgery. The middle cerebral artery dissecting aneurysm is extremely rare. We presented this case with review of the literature.     

Association of cerebral aneurysm and dural arteriovenous malformation in the anterior cranial fossa: a case report

A case of dural arteriovenous malformation (AVM) in the base of the anterior cranial fossa associated with a ruptured anterior communicating aneurysm was reported in a 67-year-old man. The dural AVM was fed by the left anterior ethmoidal artery and drained by the left frontal ascending vein with a varicose dilatation. The aneurysm was clipped and the dural AVM was removed in two stages. Dural AVM in the base of the anterior cranial fossa is rare, and we could find only 17 previous reports. Two of them presented with exophthalmos, whereas the remaining 15 cases presented with an intracranial hemorrhage from rupture of the dural AVM. An association of an aneurysm with the dural AVM in this location has not been reported previously.     

Cerebral Aneurysm Associated with Persistent Primitive Olfactory Artery Aneurysm

Summary Persistent primitive olfactory artery is a rare vascular anomaly but has a clinical importance because of its high association with cerebral aneurysm. We describe a patient with bilateral persistent primitive olfactory arteries associated with an unruptured saccular aneurysm on the left persistent primitive olfactory artery. Seven reported cases with this anomalous artery including ours are reviewed and classified into two variants. This anomalous artery arises from the terminal portion of the internal carotid artery and courses anteromedially along the ipsilateral olfactory tract and makes a hair-pin curve posterior to the olfactory bulb, becoming the distal anterior cerebral artery (variant 1) or the ethmoidal artery (variant 2). Out of 7 reported cases, 4 cases are associated with saccular aneurysms. The aneurysm in variant 1 is located on the hair-pin curve at which an apparent arterial branch is sometimes absent. Two patients suffer from anosmia. Persistent primitive olfactory artery should be kept in mind because of its high association with intracranial saccular aneurysms and unique clinical presentation.