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.     

Two cases of giant fusiform aneurysm presenting ischemic attacks

It is said that major clinical sign of giant fusiform aneurysm is so-called mass sign compressing surrounding tissues and ischemic attack caused by the aneurysm is very rare. The authors experienced such uncommon two patients with partially thrombosed fusiform aneurysm who developed ischemic attack. Case 1: A 68-year-old man was admitted to our hospital in semicomatous state with ocular bobbing and decorticate posture of sudden onset. Enhanced CT scans taken at admission showed a presence of homogenously enhanced mass continuing to bilateral posterior cerebral arteries, which compressed the pons from right ventro-lateral side (Fig. 1 a,b). Plain CT scan taken 10 days after admission demonstrated extensive low density area in the pons (Fig. 1c). Basilar artery and P1 segment of the right posterior cerebral artery are ectatic, tortuous and elongated (Fig. 2a). The ectatic basilar artery was displaced upward and posteriorly (Fig. 2b). He developed locked-in syndrome and died of pneumonia six months after admission. At autopsy, large aneurysm measuring 3.5 X 2.0 X 1.9 cm was verified in the basilar artery (Fig. 3a). Cross section of the basilar artery aneurysm showed that laminated thrombosis nearly occupied the lumen with partially unobstructed portion (Fig. 3b). Also, horizontal section of the pons demonstrated a presence of old infarction located in the perforating arteries territory (Fig. 3c). Case 2: A 42-year-old man was initially hospitalized in 1978 because of multiple intracranial meningiomas and subtotal removal of meningiomas located in the tuberculum sellae and the foramen magnum was performed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Spontaneous Total Thrombosis of Distal Superior Cerebellar Artery Aneurysm

Summary. We report the case of an aneurysm of the distal segment of the superior cerebellar artery (SCA) which showed complete spontaneous thrombosis. Initial angiography performed in another institution showed 3 non-ruptured aneurysms located on the right distal SCA, C3 segment of the right internal carotid artery (ICA) and left basilar artery (BA) – SCA bifurcation. The patient had two episodes of transient cerebellar ataxia of the right hand before admission to our hospital, but no neurological signs were noted on admission. Computed tomography (CT) and magnetic resonance image (MRI) showed a thrombosed mass on the right cerebellar peduncle, and angiography showed no filling of the right SCA from its origin. A follow up angiogram 9 month after endovascular surgery for other aneurysms showed no recanalization of SCA or the aneurysms. There are no previous reports of total spontaneously thrombosed non-giant aneurysms of the distal segment of the SCA.     

Successful obliteration of a ruptured partially thrombosed giant m1 fusiform aneurysm with coil embolization at distal m1 after extracranial-intracranial bypass.

Proximal occlusion or trapping combined with EC-IC bypass is usually employed as a definite treatment for a giant fusiform aneurysm in cases where it is impossible to apply clips and do vascular reconstruction. Endovascular treatment is very important as an alternative or combined technique if direct surgery is impossible. The authors report a young male who presented with a 2 nd episode of intracranial bleeding in basal ganglion and subarachnoid hemorrhage with mild right hemiparesis. His 3D-CT scan revealed left ruptured partially thrombosed giant M1 fusiform aneurysm and left unruptured C3 saccular aneurysm. He underwent STA-MCA bypass with attempted M1 reconstruction and a week later attempted total occlusion of the M1 aneurysm with coils. But only a ruptured point at the distal M1 was occluded which, however, resulted in temporary mild right hemiparesis and aphasia. A month later when he was supposed to have his 2 nd coiling procedure his angiogram demonstrated spontaneous and complete obliteration of both the M1 and C3 aneurysms without any new neurological deficit, so no further endovascular procedure was attempted. The discussion is based on this case and previous reports regarding difficult giant M1 fusiform aneurysms, its treatment and spontaneous thrombosis of aneurysmal sac after bypass and distal occlusion. Conclusions are drawn that 1) spontaneous thrombosis of M1 and C3 aneurysms should be the result of hemodynamic alteration in both aneurysms due to a lower flow velocity induced by distal bypass and distal occlusion of M1, 2) combined distal bypass and endovascular obliteration of the aneurysmal sac with coils is a good alternative if vascular reconstruction is difficult or impossible.     

A syndrome of spontaneous cerebral and cervical artery dissections with angiolipomatosis. Report of two cases

A primary or systemic arteriopathy is frequently suspected in patients with spontaneous cerebral or cervical artery dissections. The authors report on two patients with such dissections accompanied by angiolipomatosis, a previously unreported association, and propose a common developmental defect in these patients. A 50-year-old man with subcutaneous angiolipomatosis developed painful monocular blindness. Angiography studies revealed a spontaneous extracranial internal carotid artery (ICA) dissection and an ipsilateral fusiform intracranial ICA aneurysm. The ICA dissection was treated with aspirin, and after 6 months a craniotomy was performed. The aneurysm was found to be fusiform; it involved the entire supraclinoid portion of the ICA, and was wrapped with cotton. A 49-year-old man with a congenitally bicuspid aortic valve and subcutaneous angiolipomatosis developed posterior neck pain. Magnetic resonance imaging and angiography demonstrated a fusiform distal vertebral artery aneurysm. A craniotomy was performed and the aneurysm was found to incorporate the posterior inferior cerebellar artery as well as a perforating artery: the lesion was wrapped cotton. The tunica media of the arteries of the head and neck as well as the aortic valvular cusps are derived from neural crest cells, and angiolipomatosis has been associated with tumors of neural crest derivation. These associations indicate that a neural crest disorder may be the underlying abnormality in these patients.     

Angiographically occult, progressively expanding, giant vertebral artery aneurysm. Case report

Hunterian ligation is a well-known treatment for complex aneurysms not amenable to direct microsurgical clip application. After proximal parent vessel occlusion, cerebral angiography is typically used to confirm aneurysm thrombosis. The authors report on a vertebral artery (VA) aneurysm that had progressively expanded and caused brainstem compression after hunterian ligation, despite nondiagnostic findings on both conventional and computed tomography (CT) angiography at multiple time points. This 64-year-old woman underwent hunterian ligation of a 1.8-cm VA aneurysm at the origin of the right posterior inferior cerebellar artery. An immediately postoperative conventional angiogram and follow-up CT angiograms obtained 5 and 6 years postligation confirmed complete obliteration of the lesion. Nine years after the initial surgery, however, the patient experienced neurological deterioration. Although CTs showed substantial aneurysm enlargement together with pontine compression, angiograms once again demonstrated complete right VA occlusion with no retrograde filling of the aneurysm. On reexploration, the aneurysm was effectively debulked, clipped, and obliterated. Arterial bleeding was found in the lesion neck, as was evidence of microrecanalization. Hunterian ligation for complex aneurysms carries the risk of microrecanalization and lesion expansion despite nondiagnostic angiography. Although this ligation procedure remains a viable treatment option in carefully selected patients, an extended follow-up evaluation period may be required even when imaging suggests aneurysm obliteration.     

Familial cerebral aneurysms in three families, with two sibling pairs

The authors describe two pairs of siblings and a mother-son with cerebral aneurysms and the characteristics of familial intracranial aneurysms are briefly discussed. Family 1: A 54-year-old hypertensive woman (case 1) developed subarachnoid hemorrhage and a saccular aneurysm at the proximal portion of the left anterior cerebral artery was demonstrated on the angiogram. An azygos anterior cerebral artery was found as an associated anomaly. A 53-year-old hypertensive woman (case 2), a younger sister of case 1, suffered from subarachnoid hemorrhage and a saccular aneurysm at the distal portion of the right anterior cerebral artery was found on the angiogram. Vertebral angiogram showed bilateral fenestration of the extracranial vertebral arteries as a coincidental anomalies. Neck clipping for the aneurysms were successfully done in these two cases. Family 2: A 52-year-old hypertensive woman (case 3) suffered from subarachnoid hemorrhage and vertebral angiogram demonstrated a saccular aneurysm at the distal portion of the right posterior inferior cerebellar artery. The aneurysm was re-bled before surgical intervention and she died five days after admission. A 65-year-old hypertensive woman (case 4), an elder sister of case 3, was admitted with subarachnoid hemorrhage. Vertebral angiogram showed a saccular aneurysm on the proximal portion of the left posterior inferior cerebellar artery at the junction of the vertebral artery and a massive extravasation of the contrast medium from the aneurysm. The patient died three days after the onset before surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

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.     

Two cases of spontaneous occlusion of the internal carotid artery due to a giant intracranial internal carotid artery aneurysm

Although spontaneous thrombosis of a giant intracranial aneurysm is comparatively common, its parent artery occlusion is rare. Recently we experienced two cases in which spontaneous thrombosis of giant intracranial internal carotid artery aneurysm and occlusion of its parent artery were occurred. Case 1. A 49-year-old man, complaining esotropia was referred to us by an ophthalmologist. He had no particular past history. Neurological examination revealed left oculomotor, abducens palsy and disturbance of left trigeminal first branch. CT scan revealed a round high density mass in the left middle fossa. The size was 3 cm in diameter. Left CAG revealed severe stenosis of left internal carotid artery and in delayed phase, faint shadow was seen near posterior clinoid process. MRI revealed a high intensity mass of the intraaneurysmal thrombus in the left middle fossa with small low intensity area indicating residual lumen. With conservative treatment, the symptom was gradually improved and one month after admission, complete occlusion of the left internal carotid artery was seen by angiography. The patient returned to his previous occupation. Case 2. A 21-year-old man was admitted to our hospital complaining dysarthria and left hemiparesis. He had been diagnosed as left internal carotid giant aneurysm 5 years before when he had suffered from right visual disturbance. Neurological examination revealed left hemiparesis and dysarthria. CT scan revealed high density mass which extended from the base of the right middle fossa to the third ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)     

Spontaneous partial thrombosis of an unruptured peripheral, superior cerebellar artery aneurysm: a case report]

A 52-year-old female suddenly developed headache and dizziness. On admission she complained of gait disturbance with dizziness but cranial nerve palsy could not be detected. CT scan revealed a mild high density lesion in the right ambient cistern and the density of the lesion had become much higher 5 days after admission. MRI revealed a homogeneous iso-intense lesion on T1WI, T2WI 2 days after admission and the lesion had changed to homogeneous high. The lesion was suspected to be a fresh thrombus. Right vertebral angiography showed a part of aneurysm arising from the ambient segment of the right superior cerebellar artery and we diagnosed the lesion as a partially thrombosed superior cerebellar artery aneurysm. About forty cases of peripheral superior cerebellar artery aneurysm have been described in the literature, but cases of spontaneous thrombosis of the aneurysms have been very rare. Spontaneous thrombosis of aneurysms was usually thought to occur in large aneurysms, but the aneurysm in our case was not large. We suspected that in our case spontaneous thrombosis may have been caused by occlusion of the parent artery of the aneurysm.     

A ruptured aneurysm of the distal posterior inferior cerebellar artery associated with basilar artery occlusion: a case report]

We presented a case of a distal posterior inferior cerebellar artery (PICA) aneurysm associated with basilar artery occlusion. A 66-year-old female was found unconscious at home and transferred to our hospital in a deep coma on February 9, 1991. Emergency CT scan revealed subarachnoid hemorrhage in the posterior fossa. She was treated conservatively because of her poor neurological status. The angiograms performed on February 13 showed occlusion of the basilar artery and a saccular aneurysm at the cortical branch of the PICA. The contrast material remained in the aneurysm for a long time throughout the venous phase. The left vertebral artery was markedly hypoplastic. The patient improved remarkably after admission and became almost alert late in February, although she still presented tetraparesis, dysfunction of lower cranial nerves and other neurological signs linked with the brain stem. The unusual angiographical findings in this case prompted us to perform the examination again, expecting some angiographical changes. The angiograms taken on March 15 revealed spontaneous disappearance of the aneurysm, although the basilar artery occlusion remained unchanged. The authors discussed some problems involved in this case, including the relation between the aneurysm and the arterial occlusion, and the mechanism of spontaneous disappearance of the aneurysm.     

Clinicopathological studies of three cases of cerebral aneurysms associated with systemic lupus erythematosus

We report three cases of ruptured cerebral aneurysms associated with systemic lupus erythematosus (SLE). A 52-year-old woman (case 1) with a fifteen-year history of systemic lupus erythematosus suddenly lost consciousness. She was admitted in a state of deep coma. A computed tomography (CT) scan revealed acute hydrocephalus and diffuse subarachnoid hemorrhage in the basal, interhemispheric and bilateral Sylvian cisterns. Fifteen years prior to this admission, cerebral angiograms demonstrated no cerebral aneurysm. She underwent ventricular drainage immediately. Postoperatively, her condition did not improve, and she died on the 18th day. During the autopsy, two saccular cerebral aneurysms were found: one aneurysm was at the right middle cerebral artery bifurcation, and another one was on the anterior communicating artery, which had disruption of the internal elastic lamina and medial smooth muscle, and infiltration of inflammatory cells. In the major cerebral arteries, for example the bilateral internal carotid arteries, disruption or dissection of the internal elastic lamina, intimal fibrosis and transmural infiltration of inflammatory cells were observed. The second patient, a 36-year-old woman with a six-year history of SLE, was admitted to our hospital with sudden severe headache. A CT scan showed subarachnoid hemorrhage, and cerebral angiograms disclosed saccular cerebral aneurysms on the anterior communicating artery and the left superior cerebellar artery, and a fusiform one on the left posterior cerebral artery. Surgery was not recommended because of her multiple medical problems. Her consciousness improved gradually over 2 months. She was transferred to the department of internal medicine for treatment of renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)     

Dissecting aneurysm of the anterior cerebral artery requiring surgical treatment--case report

A 45-year-old male presented with spontaneous dissecting aneurysm in the anterior cerebral artery manifesting as headache persisting for several days and speech disturbance. Neurological and laboratory examinations showed no abnormalities. Magnetic resonance imaging revealed infarction in the right cingulate gyrus. Angiography revealed occlusion of the right A2. Repeat angiography 8 months later showed a saccular aneurysm had developed. The interhemispheric approach exposed the aneurysm at the junction between the right frontopolar artery and the pericallosal artery. The aneurysm was fusiform due to the right A2 dissection. The aneurysm was trapped and resected. One month after the operation, the patient was discharged without neurological deficits. Cases of dissecting aneurysms in the anterior cerebral artery with ischemic onset are usually treated conservatively. Cases requiring surgery include those due to trauma, growing aneurysms, giant aneurysms, and uncontrolled hypertension. Some dissecting aneurysms of the distal anterior cerebral artery require only resection without bypass surgery.     

Bilateral distal anterior cerebral artery aneurysms associated with polycystic kidney and liver disease; a case report]

A patient who had bilateral distal anterior cerebral artery aneurysms and a right middle cerebral artery aneurysm in association with polycystic kidney and liver disease is reported. A 57-year-old woman was referred to our center with headache and disturbance of consciousness. On admission, her level of consciousness as evaluated by the Japan Coma Scale was 10. CT revealed subarachnoid hemorrhage, especially in the interhemispheric fissures. Right carotid angiography demonstrated bilateral distal anterior cerebral artery aneurysms and a right middle cerebral artery aneurysm. All three aneurysms were clipped in a one-stage procedure. The patient was discharged without any neurological deficits two weeks after the operation. Bilateral distal anterior cerebral artery aneurysms are extremely rare. This is the first report of such aneurysms and a right middle cerebral artery aneurysm in association with polycystic kidney and liver disease. The etiology of these aneurysms is discussed.     

Treatment of ruptured fusiform aneurysm in the posterior cerebral artery with posterior cerebral artery-superior cerebellar artery anastomosis combined with parent artery occlusion: case report

BACKGROUND: Surgical management of a fusiform aneurysm in the PCA sometimes requires occlusion of the parent artery. In such cases, reconstruction of the PCA may prevent the development of postoperative visual field defects. CASE DESCRIPTION: A 30-year-old woman with a fusiform aneurysm in the P2 of the left PCA presented with subarachnoid hemorrhage. The left superficial temporal artery and OA were hypoplastic. Left temporal craniotomy revealed that the lateromesencephalic ambient segment of the SCA and the posterior half portion of the P2 segment ran parallel and near each other, and that the calibers of both arteries were relatively consistent. Thus, the 2 arteries were anastomosed in a side-to-side fashion, and the anterior half of the left P2 segment was occluded by clipping proximal and distal to the aneurysm that was located at the left P2 segment just distal to the junction to the posterior communicating artery. The patient had an uneventful postoperative course, and postoperative cerebral angiography demonstrated resolution of the aneurysm, with perfusion of the left PCA from the left SCA via the anastomosis. CONCLUSIONS: Posterior cerebral artery-superior cerebellar artery anastomosis is a useful method of achieving PCA reconstruction in the context of a PCA aneurysm requiring occlusion of the parent vessel and when superficial temporal artery or OA-PCA anastomosis cannot be performed.     

Treatment of ruptured spontaneous saccular aneurysm in the central artery of the middle cerebral artery using bypass surgery combined with trapping - case report -

A 54-year-old man presented with a rare ruptured distal middle cerebral artery (MCA) aneurysm manifesting as subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm in the central artery of the left MCA. The patient underwent anastomosis between the superficial temporal artery and the central artery distal to the lesion followed by trapping and excision of the lesion. The postoperative course was uneventful. Histological examination of the excised specimen revealed a saccular aneurysm and absence of bacteria, inflammation, or neoplasm. The present case shows that a spontaneous saccular aneurysm can develop at the cortical segment of the MCA, and can be successfully treated with bypass surgery combined with trapping.     

Trapping and vascular reconstruction for ruptured fusiform aneurysm in the proximal A1 segment of the anterior cerebral artery

A 65-year-old woman presented with subarachnoid hemorrhage (SAH). Angiography detected a small bulge in the A1 segment of the right anterior cerebral artery (ACA). The patient was managed conservatively. Ten days after the initial SAH, the patient suffered a second SAH. Cerebral angiography demonstrated a fusiform aneurysm in the right A1 segment and vasospasm in the left A1 segment. The aneurysm of the right A1 segment was trapped and the right superficial temporal artery (STA) was end-to-end anastomosed to the distal portion of the right A1 segment. The patient had no postoperative cerebral ischemic events. Postoperative cerebral angiography revealed that the bypass flow through the right STA perfused the right ACA territories. STA-A1 end-to-end anastomosis can prevent cerebral ischemic events following parent vessel occlusion or microsurgical trapping for fusiform cerebral aneurysms in the A1 segment without sufficient collateral flow to the ipsilateral ACA territory from the contralateral ACA.     

A case of distal posterior cerebral artery aneurysm associated with occlusion of the internal carotid artery

Hemodynamic stress is considered one of the most important factors in the growth of cerebral aneurysms. The authors report a rare case of cerebral aneurysm located at the distal posterior cerebral artery (PCA) in which collateral circulation developed due to occlusion of the internal carotid artery (ICA). A 73-year-old male was admitted to our hospital with a sudden headache and nausea. Computerized tomography (CT) revealed an intracerebral hematoma in the right parieto-occipital lobe and the acute subdural hematoma in both the cerebral interhemispheric fissure and the convexity. Moreover, angiography revealed a saccular aneurysm at the P4 portion of the PCA. The right ICA was occluded at the cervical portion and collateral circulation which had developed in the PCA was extended to the region of the right middle cerebral artery. The aneurysm was clipped 15 days after admission without new neurological complications. This case demonstrates that increased hemodynamic stress plays a role in the growth and rupture of cerebral aneurysm.     

Spontaneous thrombosis of ruptured intracranial aneurysms during treatment with tranexamic acid (AMCA)

Summary Radiographically verified spontaneous disappearance of medium-sized arterial cerebral aneurysms is seldom reported, and only three times in connection with antifibrinolytic therapy (EACA). In our clinic repeat angiograms have shown non-filling of the aneurysms in three patients during treatment with tranexamic acid (AMCA) two, three, and four weeks respectively after primary bleeds. Initially, all three patients had severe radiological vasospasm associated with neurological deterioration. Follow-up angiograms have demonstrated partial reappearance of the aneurysm after one month in one patient and complete disappearance of the aneurysms in the other two patients after 9 and 22 months respectively. In two cases occlusion of cerebral arteries occurred. With regard to the higher risk of severe vasospasm and occlusion of cerebral arteries in our opinion it should not be a therapeutic goal to try to achieve a thrombosis of a ruptured aneurysm with antifibrinolytic drugs.The reason for spontaneous aneurysm thrombosis during treatment with AMCA may be a local inhibition of plasminogen activators in and around the aneurysm wall. It may also be related to the sympathomimetic property of the drug, with vasospasm and a subsequent flow-reduction inside the aneurysm or a possible interaction with other drugs and substances.     

Basilar bifurcation aneurysm associated with internal carotid artery occlusion. Report of two cases

Two cases of subarachnoid hemorrhage caused by rupture of a basilar bifurcation aneurysm associated with occlusion of the internal carotid artery (ICA) at the neck are presented. Case 1, a 71-year-old female, was hospitalized in a coma. Angiography demonstrated occlusion of the bilateral ICA, collateral blood supply through the branches of the foramen rotundum or vidian artery from the maxillary arteries and right posterior communicating artery, and a saccular aneurysm at the basilar bifurcation. The patient died 1 month later following rerupture of the aneurysm. Case 2, a 64-year-old male, was hospitalized for drowsiness. Angiography showed occlusion of the right ICA, collateral blood supply through a tortuous artery (a vidian artery), and a large aneurysm at the basilar bifurcation. Posterior circulation supplied anteriorly through the right posterior communicating artery. The patient died 1 month later because of rerupture of the aneurysm. Laminar thrombosis of the right ICA and an anastomotic vessel, seemingly a branch of the foramen rotundum or a vidian artery, were demonstrated by autopsy. The combination of cerebral aneurysm and collateral circulation is extremely rare in cases of occlusion of the ICA. The two cases described here suggest that hemodynamic stress is an important factor in the formation of cerebral aneurysms.