Cerebral vasospasm evaluated by computed tomography in a patient with ruptured cerebral aneurysm

Summary Low density areas on computed tomography were correlated with changes in the neurological state of a patient who had cerebral vasospasm after subarachnoid hemorrhage from a ruptured anterior communicating aneurysm. No aneurysm was revealed on repeated angiograms initially because of vasospasm, but a low density area was found in the inferior part of the left frontal lobe. Following an attack of low blood pressure on the 12th day his neurological state deteriorated and CT disclosed low density areas in the inferior part of both frontal lobes. The aneurysm was finally disclosed and operated successfully on the 49th day when cerebral vasospasm had disappeared completely.     

Simultaneous presentation of subcortical hemorrhage,subdural hemorrhage,and cerebral infarct in a hemiplegic patient

A 90-year-old, non-hypertensive woman presented gait disturbance followed by falls. She had developed a lacunar infarction in the right frontal lobe 1 month previously that subsequently resulted in subtle motor weakness in the left lower extremity. At presentation, the patient showed motor weakness in the left upper and lower extremities with normal findings on blood test. Cranial computed tomography (CT) revealed a subcortical hemorrhage in the anterior part of the right frontal lobe that was accompanied by perilesional edema. In addition, two small subdural hematomas, apparently in the acute phase, were found. Magnetic resonance imaging performed immediately after the CT revealed hyperacute infarct in the right precentral gyrus adjacent to the previous infarct. It was hyperintense on the diffusion-weighted imaging but indistinct on the fluid-attenuated inversion recovery sequence. In addition, findings suggesting cerebral contusions were not observed. Based on these, we assumed that the patient''s symptoms were mainly derived from the infarct and the subdural hemorrhages had developed in association with falls. However, it was unclear whether the infarct had developed before or after the formation of subcortical hemorrhage. Traumatic and non-traumatic intracranial hemorrhage and cerebral infarcts may present simultaneously. When intracranial hemorrhages appearing on CT do not adequately explain the patient''s neurological findings, undetected cerebral ischemia should be assumed.     

Migrating subdural hematoma without subarachnoid hemorrhage in the case of a patient with a ruptured aneurysm in the intrasellar anterior communicating artery

Acute spontaneous subdural hematoma without the presence of a subarachnoid hemorrhage as a result of a ruptured aneurysm is rare. We present the case of a patient with an aneurysm of the intrasellar anterior communicating artery that caused hemorrhage solely into the subdural space. The hemorrhage then migrated down the spinal canal. Our case is unique because all these 3 rare processes occurred in a single patient. Identification of the cause of this type of hemorrhage in a timely fashion is crucial to the management of such a patient.     

Acute massive subdural hematoma caused by rupture of internal carotid artery aneurysm during angiography: a case report

We present a case of acute, massive subdural hemorrhage caused by rupture of an internal carotid artery aneurysm during the procedure of cerebral angiography. To our knowledge, a case like the present one has been reported only once in the English-language literature. The incidence, mechanisms, treatment, and prognosis of (1) subdural hematoma, caused by rupture of cerebral aneurysm, and (2) re-rupture of aneurysm during the angiography procedure are discussed. Electronic Publication     

联合血管内外神经介入技术治疗急性期破裂颅内动脉瘤

目的　评估联合血管内外神经介入技术治疗急性期破裂颅内动脉瘤 (aneurysm ,AN)的疗效。方法　对 4 0例急性破裂期AN采用电解脱弹簧圈栓塞 ,随后穿刺腰蛛网膜下腔 ,导丝导向的微导管在透视下插管至枕大池 ,2h后注入 10万U尿激酶 (UK)溶解血块并经微导管持续引流血性脑脊液。根据CT复查结果决定是否继续注射UK。结果　AN栓塞及枕大池插管均获成功 ,无技术相关并发症 ,术后 3～ 7d时的CT见所有患者脑池内的出血消失。除 1例有一过性症状性脑血管痉挛 (CVS)外 ,其余患者无症状性CVS、所有患者无AN再出血。结论　联合血管内外神经介入技术既闭塞了AN ,又清除了蛛网膜下腔积血 ,可防止再出血和继发性CVS的发生 ,达到了对因、对症治疗的双重目的。     

Safety and Efficacy of Intravenous Tirofiban as Antiplatelet Premedication for Stent-Assisted Coiling in Acutely Ruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE:Stent-assisted coiling of intracranial aneurysms requires antiplatelet therapy, typically aspirin and clopidogrel to prevent thromboembolic complications. There is a substantial concern that tirofiban may increase the risk of hemorrhage when used as an antiplatelet premedication in ruptured intracranial aneurysms. Our aim was to evaluate the safety and efficacy of intravenous tirofiban administration, instead of oral dual antiplatelet agents, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms.MATERIALS AND METHODS:We conducted a retrospective review of a data base containing a consecutive series of patients who underwent stent-assisted coiling for acutely ruptured intracranial aneurysms between March 2010 and January 2015. Intravenous tirofiban was administered to all patients before stent-assisted coiling, instead of premedication with loading doses of aspirin or clopidogrel.RESULTS:Forty patients with 41 aneurysms received intravenous tirofiban and underwent stent-assisted coiling. None of the patients had a newly developed intracerebral hemorrhage, subarachnoid hemorrhage, or intraventricular hemorrhage. Intraprocedural aneurysmal rupture occurred in 2 patients (5%). Cerebral infarction developed in 2 patients (5%). Ventriculostomy-related hemorrhage was seen in 2 of 10 patients in whom ventriculostomy was performed before or after coiling. Thirty-four (85%) patients had a good outcome (Glasgow Outcome Score of 4 or 5) at the time of discharge, but 1 patient died of cardiac arrest. None of the patients developed thrombocytopenia, retroperitoneal, gastrointestinal, or genitourinary bleeding related to tirofiban administration.CONCLUSIONS:In our study, tirofiban showed a low risk of symptomatic hemorrhagic or thromboembolic complications. Tirofiban may offer a safe and effective alternative as an antiplatelet premedication during stent-assisted coiling of acutely ruptured intracranial aneurysms.

Results from the International Subarachnoid Aneurysm Trial showed that the endovascular management of intracranial aneurysm is a safe, effective, and sometimes preferable treatment option.¹ However, endovascular treatment of ruptured wide-neck aneurysms is still a challenge to neurointerventionalists because of the controversy surrounding the use of stent placement as an adjuvant therapy for the coiling of acutely ruptured aneurysms, due to the need for antiplatelet medications. Stent-assisted procedures are particularly prone to thromboembolic complications, with a reported rate of thromboembolic events of 7%–15% during stent-assisted coiling.^2–4 Therefore, there is a need for preoperative antiplatelet therapy with optimal anticoagulation during the procedures, even with subarachnoid hemorrhage. However, there is no consensus about when and how patients should be loaded with antiplatelet medication before the procedure.Glycoprotein IIb/IIIa antagonists have attracted attention for the prevention or treatment of thromboembolism during coiling of intracranial aneurysms,^5–7 but the increased risk of intracranial hemorrhage following glycoprotein IIb/IIIa inhibition remains a substantial concern. Moreover, the safety and efficacy data regarding the use of tirofiban in endovascular aneurysm treatment are lacking.The objective of our study was to evaluate the safety and efficacy of intravenous tirofiban, instead of clopidogrel and aspirin, as an antiplatelet premedication for stent-assisted coiling in patients with acutely ruptured intracranial aneurysms.     

Infantile acute subdural hemorrhage probably caused by injury to the diploic channels

A 6-month-old, previously healthy boy hit the right frontal region of his head against the corner of a plastic toy box. At presentation, a small area with scalp discoloration was noted in the right frontal region. Head computed tomography at the level of discoloration revealed an intracranial hematoma, 5 mm in maximal thickness, below the coronal suture. In addition, there were bony bridges connecting the frontal and parietal bones. Furthermore, a linear crack was found in the diploe of the frontal bone in contact with the coronal suture. Cerebral MRI confirmed linear hyperintensity between the inner tables. We assumed that a kind of ping-pong ball fracture was caused by the head blow, centering on the coronal suture, resulting in rupture of contacting diploic channels and tear of the dura mater, and forming a subdural hematoma. Acute subdural hemorrhage may be caused by an insignificant blow to the coronal suture in infantile patients with underdeveloped cranial bones and sutures, accompanied by subtle external findings.     

Delayed traumatic intracerebral hemorrhage associated with dolichoectasia of the middle cerebral artery

A 74-year-old man tripped while walking. He had not been administered antiplatelet or anticoagulation therapy. At presentation, the patient was well-oriented, with a blood pressure of 130/91 mmHg, while present with tetraplegia and numbness in the upper extremities. Blood work revealed normal findings, while magnetic resonance imaging of the cervical spine revealed severe cord compression at the C3/4 and C4/5 levels. Cranial computed tomography (CT) showed elongated masses in the Sylvian fissures without intracranial hemorrhage. CT taken 2 days later revealed an intraparenchymal hemorrhage located mainly in the right putaminal region, while the patient showed no signs of neurological deterioration. Three-dimensional CT angiography (3D CTA) demonstrated marked ectasia and elongation in the right internal carotid, bilateral middle cerebral, and left anterior cerebral arteries. The patient was conservatively managed. Repeat 3D CTA performed 3 months later showed no de novo abnormalities in the ectatic cerebral arteries. It is assumed that the delayed traumatic intracerebral hemorrhage was caused by disruption of the perforating vessels arising from the ipsilateral dolichoectatic middle cerebral artery. Periodical surveillance neuroimaging is recommended for patients with head trauma who are simultaneously diagnosed with incidental dolichoectasia, especially when complicated with cervical cord injury.     

Risk Factors for Early Hemorrhagic Complications after Endovascular Coiling of Ruptured Intracranial Aneurysms

BACKGROUND AND PURPOSE:The risk factors of early hemorrhagic complications after endovascular coiling are not well-known. We identified the factors affecting early hemorrhagic complications, defined as any expansion or appearance of hemorrhage shown by head CT in the initial 48 hours after coiling.MATERIALS AND METHODS:We retrospectively reviewed a series of 93 patients who underwent coiling for a ruptured saccular aneurysm between 2006 and 2012 at our hospital.RESULTS:Five patients showed early hemorrhagic complications, and all involved an expansion of the existing intracerebral hematoma immediately after coiling. The associated risk factors were accompanying intracerebral hemorrhage at onset (P < .001), postoperative antiplatelet therapy (P < .001), and thromboembolic complications (P = .044). In the accompanying intracerebral hemorrhage group, the associated risk factors were postoperative antiplatelet therapy (P = .044) and earlier initiation of coiling (9.8 ± 6.5 versus 28.1 ± 24.0 hours, P = .023). Early hemorrhagic complications were significant risk factors for worse clinical outcome (modified Rankin Scale, 2.02 ± 2.21 versus 4.4 ± 2.30, P = .022). None of the 93 patients showed further hemorrhage after the initial 48 hours after coiling.CONCLUSIONS:The accompanying intracerebral hemorrhage at onset, thromboembolic complications, postoperative antiplatelet therapy, and earlier initiation of coiling were the risk factors for early hemorrhagic complications.

A recent guideline stated that endovascular coiling should be considered if ruptured aneurysms were judged to be technically amenable to both endovascular coiling and neurosurgical clipping.¹ Consequently, the use of coiling for ruptured saccular cerebral aneurysms has been increasing. One problem is that the incidence of periprocedural hemorrhagic complications within 30 days was reportedly high in the endovascular arm of a study,² and they were reported to be associated with high mortality and morbidity.³ The risk factors for such early hemorrhagic complications are not well-known. Although the word “rebleeding” is often used for perioperative hemorrhagic complications, it is also unclear whether “rebleeding” is really caused by a rerupture of the aneurysm or is due to other mechanisms. Therefore, we analyzed cases of coiling for ruptured saccular aneurysms in which early hemorrhagic complications had occurred within 48 hours after coiling, to identify factors affecting these complications.     

Intravenous thrombolysis in patient with vertebrobasilar dolichoectasia and antiplatelet medication

Introduction: While the overall incidence of vertebrobasilar dolichoectasia (VBD) is less than 0.05%-0.06%, it is not uncommon in patients experiencing acute stroke. The influence of VBD on the outcome of intravenous (IV) thrombolysis therapy has not been widely studied. We present the following case of IV thrombolysis use in a patient experiencing acute stroke, who had an increased risk of bleeding due to prior antiplatelet use, and who had concomitant VBD. Case presentation: A 62-year-old man presented with weakness in the left extremities that had begun 1 hour prior to admission. The patient had a history of coronary artery disease and had been regularly taking antiplatelet medication. Upon arrival, the patient was in a decreased level of consciousness, with severe dysarthria, left central facial palsy, left lateralization, and a National Institute of Health Stroke Scale (NIHSS) score of 17. Computed tomography scan of the head showed no intracranial hemorrhage. The patient was administered IV thrombolysis at 2 hours and 45 minutes after symptom onset. Within the first 24 hours, the patient''s NIHSS score decreased from 17 to 12, and the final NIHSS score prior to discharge was 7. The Head and neck angiography of this patient revealed VBD. Conclusion: This case demonstrated that IV thrombolysis is safe and effective for use in patients with acute ischemic stroke who have a history of antiplatelet usage and who experience concomitant VBD.     

Computed tomographic evolution of post-traumatic subdural hygroma in young adults

Summary The authors report on two cases of post-traumatic subdural hygroma that were encountered in young adults. Serial computed tomograms were taken immediately following trauma and for more than 4 weeks thereafter. In the case of a 28-year-old man with a skull fracture, an initial CT scan revealed a thin crescentic subdural collection in the right frontal area. A successive CT scan on the 36th postoperative day revealed developed subdural hygroma, and the CSF-like fluid was surgically evacuated. In the second case, involving an 18-year-old man, a very thin bifrontal subdural collection was found on the initial CT scan, and on the 15th post-traumatic day CT scan demonstrated a bifrontal subdural hygroma. No surgical treatment was carried out, and the follow-up CT scan on the 29th post-traumatic day demonstrated no change in size. The two young patients were slightly symptomatic during the period involved, and the repeat unenchanced CT scans showed subdural lesions of less than brain density, even in the chronic stage.     

Computed tomographic and digital subtraction angiography evaluation of ophthalmic-ethmoidal artery dural arteriovenous fistula

Ophthalmic-ethmoidal dural arteriovenous fistula (DAVFs) is a rare type of dural arteriovenous fistulas and usually presenting with spontaneous subarachnoid hemorrhage, subdural hemorrhage or ocular symptoms. We present a case of a 59-year old gentleman presenting with acute headache, vomiting and generalized weakness. CT study of the brain revealed a large left frontal hematoma and abnormal aneurysmal sac with dilated cortical vein, communicating with the superior sagittal sinus. Conventional angiography confirmed diagnosis of ruptured ophthalmic-ethmoidal DAVF, resulting in a frontal intra-axial hemorrhage. Anterior fossa DAVFs are extremely rare, difficult to diagnose and treat. CT angiography is initial method of diagnosis, but digital substruction angiography remains the gold standard of confirming dural fistulas.     

A rare combination of complications of ruptured carotid artery aneurysm: A case report.

The giant aneurysm of the subclinoid portion of the internal carotid artery is a relatively rare disease that can present serious complications. We present the case of a 40-year-old guy who was suffering from a headache and had complete ophthalmoplegia in his right eye. A brain scan shows a right temporal subdural hematoma, associated with subarachnoid hemorrhage, and total Sylvian subacute ischemic stroke. CT angiography and MRI showed a ruptured and partially thrombosed aneurysm of the subclinoid portion of the right internal carotid artery complicated by subarachnoid hemorrhage, a right subdural temporal hematoma, and total Sylvian ischemic stroke. Our purpose is to recognize the possibility of an aneurysmal rupture when evaluating an acute subdural hematoma, alone or in combination with Ischemic stroke.     

Ruptured hepatic artery aneurysms in a patient with systemic lupus erythematosus: Case report

Spontaneous hemorrhage caused by ruptured left hepatic artery branch aneurysms occurred in a 49-year-old man with systemic lupus erythematosus Following evaluation by computerized tomography and angiography, transcatheter embolization of the left hepatic artery resulted in hemostasis. The various etiologies of hepatic artery aneurysms are discussed. This case demonstrates that systemic lupus erythematosus must be considered in the differential diagnosis of hepatic artery aneurysms and spontaneous hepatic hemorrhage.     

Meningioma presenting as an acute subdural hematoma

Most subdural hematomas occur as a sequel of trauma. Non-traumatic subdural hematomas may be found in patients with ruptured aneurysm, arteriovenous malformation, dural arteriovenous fistula, amyloid angiopathy, renal insufficiency, and cocaine abuse. Hypervascular primary and metastatic tumors may also present with subdural hematomas. We present the MR imaging features in a patient who presented with an acute subdural hematoma presumably caused by an underlying meningioma.     

Cerebral hyperperfusion syndrome resulting in subarachnoid hemorrhage after carotid artery stenting

A 64-year-old, right-handed man underwent endovascular treatment for internal carotid artery stenosis after experiencing a left-hemispheric transient ischemic attack. ¹⁵O-gas and H ₂ ¹⁵ O positron emission tomography revealed slightly reduced cerebral blood flow (CBF), elevated cerebral blood volume, and severely reduced cerebral vasoreactivity in the ipsilateral hemisphere as determined by an acetazolamide challenge test. The patient underwent left carotid artery stenting (CAS) via a prefemoral approach under local anesthesia without any complications. Follow-up examinations performed 20 h postoperatively showed subarachnoid hemorrhage (SAH) and cerebral hyperperfusion syndrome (CHS) in the left frontal lobe. Although it is a relatively rare phenomenon, SAH resulting from CHS was determined to be specifically caused by CAS. In this case, the causes of SAH may have been related to multiple factors including increased regional CBF, loss of cerebrovascular autoregulation, contrast agent-mediated disruption of major cerebral vessels, and strong antiplatelet therapy.     

Fat deposition adjacent to chronic subdural hematoma: CT demonstration

Computed tomography of the head in a patient with bilateral chronic subdural hematomas demonstrated areas of fat density closely approximating the hematomas. The persistent fatty nature of the CT finding was confirmed by subsequent magnetic resonance and CT performed 1 month and 3 years later. Although an intracerebral hemorrhage with transient presence of fatty material has been described in an alcoholic hyperlipemic patient, this case shows fatty deposition adjacent ot subdural hemorrhage without any known predisposing factors.     

Embolization of spontaneous rupture of an aneurysm of the ovarian artery supplying the uterus with fibroids

We report a case of spontaneous retroperitoneal hemorrhage caused by rupture of an aneurysm of the right ovarian artery in a 55-year-old woman. Diagnosis was achieved by computed tomography and arteriography. The ruptured aneurysm was treated by transcatheter arterial embolization using microcoils and gelatin sponge particles. This is the first case of rupture of an aneurysm of the ovarian artery not related to pregnancy, and the third case of embolization of a ruptured ovarian artery aneurysm in the literature. We illustrate the usefulness of embolization in treatment of an ovarian artery aneurysm without surgery.     

非常见部位急性硬膜下血肿CT诊断(附26例报告)

目的　提高对非常见部位急性硬膜下血肿CT表现的认识。方法　头颅外伤后在 2 4h内行CT检查 1 9例 ,2～ 3d内行CT检查 7例。经治疗后在 1～ 4周内复查CT。结果　单纯表现为大脑镰急性硬膜下血肿 7例 ,小脑幕急性硬膜下血肿 5例。额颞底部急性硬膜下血肿 2例。脑挫裂伤、脑内血肿伴有大脑镰急性硬膜下血肿 3例 ,伴有小脑幕急性硬膜下血肿 2例 ,颞顶部急性硬膜下血肿伴有大脑镰急性硬膜下血肿 2例 ,大脑镰、小脑幕急性硬膜下血肿伴有蛛网膜下腔出血 5例。 2 6例大脑镰与小脑幕急性硬膜下血肿均发生在单侧。大脑镰急性硬膜下血肿的形态有的在中线呈细线状 ,有的呈粗线状。血肿厚度 0 .3～ 1 .5cm不等。小脑幕急性硬膜下血肿表现为片状、新月形。结论　大脑镰、小脑幕和额颞底部急性硬膜下血肿是发生在少见部位的特殊类型急性硬膜下血肿 ,只要对此类血肿有所认识 ,CT检查不难确诊 ,但有时需要与蛛网膜下腔出血鉴别     

Falx and interhemispheric fissure on axial CT: II. Recognition and differentiation of interhemispheric subarachnoid and subdural hemorrhage

Interhemispheric hyperdensity or unenhanced computed tomography was originally considered a sign of subarachnoid hemorrhage, the "falx sign." It has since been identified as a normal feature and has also been seen with interhemispheric subdural hemorrhage. To determine the differential features of interhemispheric hemorrhage, 50 patients with subarachnoid hemorrhage and 32 patients with interhemispheric subdural hematomas were reviewed. Subarachnoid hemorrhage produced anterior interhemispheric hyperdensity only, with a zigzag contour and extension from the calvarium to the rostrum of the corpus callosum. Interhemispheric subdural hematomas produce unilateral crescentic hyperdensities that are largest in the posterior superior part of the fissure, behind and above the splenium of the corpus callosum. Interhemispheric hyperdensity in children is more complex. Because the anterior part of the fissure is narrow in younger patients, subarachnoid hemorrhage may go undetected. Likewise, interhemispheric subdural hematomas in children are smaller and more difficult to recognize. They produce asymmetric thickening of the falx shadow with extension over the tentorium. They are, however, of great significance since they are generally seen in abused patients and carry a poor prognosis.