Intracerebral hemorrhage from a ruptured aneurysm at the site of anastomosis 27 years after superficial temporal artery-middle cerebral artery bypass

A 77-year-old female presented with a very rare case of intracerebral hemorrhage (ICH) from a ruptured aneurysm at the site of the anastomosis 27 years after superficial temporal artery-middle cerebral artery (STA-MCA) bypass manifesting as sudden onset of unconsciousness and right hemiparesis. Computed tomography (CT) on admission demonstrated massive ICH in the left frontoparietal region. Magnetic resonance angiography showed good patency of the anastomosis and no obvious aneurysm, but three-dimensional CT (3D-CT) angiography revealed a small aneurysm at the site of the left STA-MCA anastomosis. Emergency evacuation of the hematoma was performed, and the aneurysm was trapped and resected after ligation. After the operation, she continued to exhibit deep consciousness disturbance. Unfortunately, her general condition grew steadily worse and she died 3 months later. Patients who undergo STA-MCA anastomosis should be carefully followed up by periodical imaging examinations. 3D-CT angiography is very useful to detect aneurysm formation at the anastomosis site.     

Focal hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in a patient with moyamoya disease. Case report

Superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis is a standard surgical therapeutic option in patients with moyamoya disease. Most patients experience improvement in their clinical symptoms immediately after surgery. The authors report on the case of a 39-year-old man with moyamoya disease who suffered from temporary and frequent neurological deterioration after undergoing a left STA-MCA anastomosis. Hemodilution and hypervolemia therapies did not improve his course. Technetium-99m hexamethylpropyleneamine oxime single-photon emission tomography scans demonstrated focal intense accumulation of the tracer in the frontal operculum on the side of the surgery. Although diffusion-weighted magnetic resonance (MR) imaging demonstrated no abnormalities except for the postoperative change, perfusion-weighted MR images and MR digital subtraction angiography revealed focal hyperperfusion in the left frontal operculum where the cerebral perfusion reserve was severely disturbed preoperatively. This evidence strongly supports the notion that focal hyperperfusion observed after STA-MCA anastomosis could occur in the poor perfusion reserve area preoperatively and could cause temporary neurological deterioration.     

Navigation-guided clipping of a de novo aneurysm associated with superficial temporal artery-middle cerebral artery bypass combined with indirect pial synangiosis in a patient with moyamoya disease

De novo aneurysms associated with superficial temporal artery (STA)-middle cerebral artery (MCA) bypass are an extremely rare complication of direct revascularization surgery for moyamoya disease (MMD). The basic pathology of MMD includes fragility of the intracranial arterial wall characterized by medial layer thinness and waving of the internal elastic lamina. However, the incidence of newly formed aneurysms at the site of anastomosis currently remains unknown. Among 317 consecutive direct/indirect combined revascularization surgeries performed for MMD, we encountered a 52-year-old woman manifesting a de novo aneurysm adjacent to the site of anastomosis 11 years after successful STA-MCA bypass with encephalo-duro-myo-synangiosis (EDMS). Although the patient remained asymptomatic, the aneurysm gradually increased in diameter to more than 6 mm with the formation of a daughter sac, and a computational fluid dynamic study revealed low wall shear stress at the aneurysm dome. The patient underwent microsurgical clipping of the aneurysm using a neuro-navigation system that permitted the minimally invasive dissection of the temporal muscle flap used for EDMS at the site of the aneurysm without affecting pial synangiosis. The aneurysm was successfully occluded using a titanium clip without complications. The postoperative course was uneventful, and the patient was discharged without neurological deficits. De novo aneurysms associated with STA-MCA bypass for MMD may be safely treated with microsurgical clipping, even in cases initially managed by a combined revascularization procedure that includes complex pial synangiosis. We recommend the application of the neuro-navigation system for the maximum preservation of pial synangiosis during this procedure.     

A ruptured middle cerebral artery aneurysm originating from the site of anastomosis 20 years after extracranial-intracranial bypass for moyamoya disease: case report

BACKGROUND: Direct revascularization through a superficial temporal artery-middle cerebral artery (STA-MCA) bypass is often performed to prevent ischemic or hemorrhagic attack in patients with moyamoya disease. This is the first reported case of aneurysm formation and rupture due to an STA-MCA bypass in a patient with moyamoya disease. CASE DESCRIPTION: A 52-year-old man who had undergone bilateral STA-MCA bypass for caudate hemorrhage due to moyamoya disease 20 years previously suffered from sudden-onset unconsciousness. Computed tomography revealed a massive intracerebral hematoma (ICH) in the left frontoparietal region. Angiography showed good patency of the anastomoses and stage IV moyamoya disease. However, no other abnormality was found. Emergency evacuation of the hematoma was performed. The patient's postoperative course was uneventful, but consciousness disturbance of sudden onset occurred 1 month later. Computed tomography showed a hematoma in the lateral ventricle and acute hydrocephalus. Repeat angiography revealed an aneurysm on the left side of the anastomosis. Bilateral ventricle drainage tubes were inserted, and the aneurysm was clipped. A ventriculoperitoneal shunt was later performed. CONCLUSION: In patients with moyamoya disease who have undergone extracranial-intracranial bypass surgery, progressive hemodynamic stress may cause the formation of de novo aneurysms after a postoperative period of several decades. Imaging examinations should therefore be performed periodically for follow-up, and a de novo aneurysm should be suspected in a patient who has an unusual ICH.     

Superficial temporal artery-middle cerebral artery anastomosis in a patient of temporal arteritis with internal carotid artery occlusion: a case report

Temporal arteritis is a rare systemic autoimmune disease and the arteritic process in this case of temporal arteritis involved large and medium-size arteries. Temporal arteritis with internal carotid artery (ICA) occlusion is very rare. We report a case of temporal arteritis with ICA occlusion following superficial temporal artery (STA) -middle cerebral artery (MCA) anastomosis, together with steroid therapy. A 73-year-old female presented with a headache, visual disturbance of left side, and suppression of activity. Left STA was inflammatory and overswelling. Magnetic resonance angiography (MRA) and angiography revealed occlusion of the left internal carotid artery (ICA) at the cervical portion and lowering of vascular reserve on PAO SPECT. Diagnosis as temporal arteritis was conclusive due to the clinical presentation, laboratory studies, and left temporal artery biopsy, so steroid pulse therapy was initiated. Inflammation of left STA disappeared after steroid therapy, but left ICA occlusion on angiography and lowering of vascular reserve on SPECT remained for 3 months afterwards. Because of this, STA-MCA anastomosis was performed. There were no complications after the operation and the donor artery has been patent for two years. Temporal arteritis with ICA occlusion that requires extracranial-intracranial bypass (EC-IC bypass) is very rare. STA-MCA anastomosis with steroid therapy is effective for the prevention of cerebral infarction.     

Cerebral hyperperfusion syndrome associated with non-convulsive status epilepticus following superficial temporal artery-middle cerebral artery anastomosis. Case report

A 77-year-old man developed cerebral hyperperfusion syndrome with temporal deterioration of consciousness and worsening of left hemiparesis on the 6(th) postoperative day following superficial temporal artery-middle cerebral artery (STA-MCA) anastomosis for right M(1) occlusion. Electroencephalography (EEG) revealed frequent ictal discharges in the right hemisphere, although convulsive seizures were not apparent. Administration of anticonvulsants was performed based on the diagnosis of non-convulsive status epilepticus (NCSE). Complete recovery from hyperperfusion syndrome was achieved with rapid improvement of EEG findings. The present case demonstrates the pathophysiological mechanism of hyperperfusion syndrome associated with NCSE after STA-MCA anastomosis.     

Temporary neurologic deterioration due to cerebral hyperperfusion after superficial temporal artery-middle cerebral artery anastomosis in patients with adult-onset moyamoya disease

BACKGROUND: Surgical revascularization for moyamoya disease prevents cerebral ischemic attacks by improving CBF, but little is known about the change in CBF and its effect on neurologic status during the acute stage after revascularization. METHODS: 123I-IMP-SPECT was performed 1 and 7 days after STA-MCA anastomosis on 34 sides of 27 consecutive patients with adult-onset moyamoya disease (6 men, 21 women; 22-62 years old). The follow-up period ranged from 5 to 28 months (mean, 17.6 months). RESULTS: Thirteen patients (13 sides, 38.2%) suffered temporary neurologic deterioration due to hyperperfusion several days after surgery, which was sustained for several days (7.4 days in average). Postoperative magnetic resonance imaging/angiography showed the STA as a higher intensity signal than the preoperative finding without ischemic changes in all 13 patients. Postoperative SPECT revealed focal intense increase in CBF at the sites of anastomosis in all 13 patients. Eleven patients (32.4%) had transient focal neurologic deficit mimicking ischemic attack. Two patients (5.9%) had cerebral hyperperfusion syndrome associated with subarachnoid hemorrhage extending to the ipsilateral sylvian cistern. Symptoms were relieved by intensive blood pressure control, and no patients had permanent neurologic deficit or delayed neurologic deterioration during the follow-up period. CONCLUSIONS: Surgical revascularization including STA-MCA anastomosis is a safe and effective treatment for moyamoya disease, although temporary neurologic deterioration due to hyperperfusion could occur at a substantial rate. Routine CBF measurement is recommended for accurate diagnosis of postoperative hyperperfusion in moyamoya disease because its treatment is contradictory to that for ischemia.     

Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: a case report

BACKGROUND: Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. CASE DESCRIPTION: We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. CONCLUSION: Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.     

Ruptured aneurysm at the origin of the accessory middle cerebral artery: case report

The accessory middle cerebral artery is a rare vascular anomaly of the brain. We describe a case of a ruptured aneurysm at the junction of the accessory middle cerebral artery and the horizontal portion of the anterior cerebral artery. The lesion was demonstrated by angiography and confirmed at surgery. No perforating arteries arising from this accessory artery were found. There have been only four previous reports of aneurysms located at the origin of the accessory middle cerebral artery. The relevant literature is briefly reviewed.     

Patch angioplasty to repair the arteriotomy defect in the wall of the middle cerebral artery after failure of superficial temporal artery-middle cerebral artery anastomosis in moyamoya disease--case report

A 65-year-old woman presented with moyamoya disease associated with a saccular aneurysm of the posterior cerebral artery. The surgical plan required superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis to be conducted before neck clipping of the aneurysm to provide collateral flow via the STA to prevent ischemia if temporary occlusion of the parent artery of the aneurysm was needed. However, the anastomotic procedure failed because the STA was occluded at the site of temporary clip application. End-to-end anastomosis of the STA was planned after excising the occluded site of the STA, but end-to-end anastomosis could not be performed because the donor artery was too short for anastomosis to the branch of the MCA. Therefore, patch grafting using a piece of wall of the STA was performed to repair the arteriotomy defect in the wall of the MCA, followed by neck clipping of the saccular aneurysm in the posterior circulation via the subtemporal approach. Vascular reconstruction can be recommended if arterial anastomosis between a superficial skin artery and a branch of the MCA is impossible due to an intraoperative accident or technical difficulty and reperfusion is necessary.     

Ruptured popliteal artery aneurysm: a case report

A high index of suspicion for popliteal aneurysms must be present when evaluating a popliteal mass. Though typically pulsatile, in the presence of chronic thrombosis, the absence of a pulse may make the diagnosis even more difficult. A case is presented that illustrates this point, where an 83-year-old man presents following the biopsy of what turned out to be a very large popliteal aneurysm. In the presence of chronic thrombosis and adequate collateral flow, decompression and ligation of any feeding vessels is typically sufficient. These patients must be followed lifelong for the development of other associated aneurysms.     

Ruptured ovarian artery aneurysm: a case report

Ruptured aneurysms of the ovarian artery are exceedingly rare. Five cases have been previously reported in the English-language literature, all occurred in the early postpartum period. The present report details another such case, the first, to my knowledge, to have been demonstrated by angiography or to have been treated nonoperatively.     

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

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

Ischemic stroke due to dissection of the middle cerebral artery treated by superficial temporal artery-middle cerebral artery anastomosis--case report

A 62-year-old man presented with dissection of the right middle cerebral artery (MCA) manifesting as mild headache, right hemiparesis, and slurred speech. Magnetic resonance (MR) imaging and MR angiography revealed fresh infarction in the right basal ganglia, and severe stenosis and dilatation of the right MCA. Digital subtraction angiography approximately 24 hours after admission revealed a linear contrast defect indicating an intimal flap of the M(1) segment. The diagnosis was dissection of the MCA. His neurological deficits improved gradually. Although he was neurologically stable, diffusion-weighted MR imaging revealed enlarging infarct size over the right MCA territory, and the right M(1) segment had progressive stenosis. Superficial temporal artery (STA)-MCA anastomosis was performed on the 26th day. Follow-up angiography showed good patency of the STA-MCA anastomosis, repair of the dissection of the M(1) segment, and improvement of the flow in the MCA. The patient was discharged from our hospital with no neurological deficits. Although the dissection in this case was spontaneously repaired, STA-MCA anastomosis was useful to get through a critical time. If the stenosis shows further progression or the infarction size enlarges, STA-MCA anastomosis may be effective.     

Ruptured aneurysm of bihemispheric anterior cerebral artery bifurcation: case report

It is well known that distal anterior cerebral artery (ACA) aneurysms are often associated with the anomalies of the ACA, of which azygos ACA and triple ACA have frequently been described. In this report, we present a rare case with a ruptured aneurysm arising from the bifurcation of the bihemispheric ACA, a rare anomaly of the ACA. A 63-year-old male suddenly developed severe headache, consciousness disturbance, and left hemiparesis, and was admitted to our hospital. Plain CT scans revealed subarachnoid clots that were densely distributed in the supracallosal cistern. Cerebral angiography demonstrated that the left pericallosal artery supplied blood flow to the bilateral parietal lobes through the bihemispheric arteries. A saccular aneurysm was found at their bifurcation. He underwent clipping surgery through interhemispheric approach. Postoperative course was uneventful. Special care should be taken not to occlude the bihemispheric arteries supplying to the bilateral parietal lobes during surgery.