Intraaneurysmal embolization of an unruptured basilar tip aneurysm associated with moyamoya disease.

We describe a patient with moyamoya disease associated with an unruptured basilar tip aneurysm which was treated by endovascular embolization using Guglielmi detachable coils (GDCs). A 53-year-old man presented with left hemiparesis persisting for 3 mon ths before admission. Cerebral angiography revealed occlusion of the bilateral middle cerebral arteries and the left anterior cerebral artery, stenosis of the right anterior cerebral artery, and basal moyamoya vessels. In addition, a saccular small aneurysm was seen at the top of the basilar artery. The aneurysm was completely embolized by intraaneurysmal GDCs. Direct surgical clipping is often selected for the treatment of posterior fossa aneurysms in moyamoya disease. However, complete clipping is usually difficult due to the difficulties in operative technique associated with moyamoya disease. We suggest that the endovascular treatment using GDCs is comparatively safe and effective for the treatment of surgically difficult aneurysms in patients with moyamoya disease.     

Obliteration of bilateral dissecting aneurysms of the vertebral arteries following repeated subarachnoid hemorrhage: a case report

A 51-year-old man presented with loss of consciousness when he underwent urological examination at another hospital. CT scans showed subarachnoid hemorrhage, and cerebral angiography showed bilateral dissecting aneurysms of the vertebral arteries. Following ventricular drainage, the lesion was managed conservatively with blood pressure control but again ruptured on day 8. Cerebral angiography revealed narrowing of both the dissecting aneurysms. On day 11, the right vertebral artery had been spontaneously obliterated and the right dissecting aneurysm was filled in a retrograde fashion via the left vertebral artery. Proximal occlusion of the right vertebral artery was performed to prevent recanalization. Two months later, cerebral angiography revealed that both vertebral arteries were obliterated and the basilar artery and right posterior inferior cerebellar artery were filled via the right posterior communicating artery. The present case demonstrated that the hemodynamic status of bilateral dissecting aneurysms of the vertebral artery changed variably indicating the necessity of careful angiographic observation.     

Obliteration of bilateral dissecting aneurysms of the vertebral arteries following repeated subarachnoid hemorrhage: A case report

Abstract

A 51-year-old man presented with loss of consciousness when he underwent urological examination at another hospital. CT scans showed subarachnoid hemorrhage, and cerebral angiography showed bilateral dissecting aneurysms of the vertebral arteries. Following ventricular drainage, the lesion was managed conservatively with blood pressure control but again ruptured on day 8. Cerebral angiography revealed narrowing of both the dissecting aneurysms. On day 11, the right vertebral artery had been spontaneously obliterated and the right dissecting aneurysm was filled in a retrograde fashion via the left vertebral artery. Proximal occlusion of the right vertebral artery was performed to prevent recanalization. Two months later, cerebral angiography revealed that both vertebral arteries were obliterated and the basilar artery and right posterior inferior cerebellar artery were filled via the right posterior communicating artery. The present case demonstrated that the hemodynamic status of bilateral dissecting aneurysms of the vertebral artery changed variably indicating the necessity of careful angiographic observation.     

Early operation of ruptured basilar artery aneurysm associated with bilateral carotid occlusion (moyamoya disease)

A 34-year-old Caucasian man presented with subarachnoid hemorrhage. Angiography revealed bilateral carotid occlusion at the cavernous sinus and an aneurysm at the basilar artery bifurcation. The whole brain was supplied with blood from the basilar artery and posterior cerebral arteries through a large number of collateral vessels to the internal carotid artery bifurcation, middle cerebral and anterior cerebral arteries: the moyamoya phenomenon. The aneurysm was clipped within hours of the subarachnoid hemorrhage. The relation between moyamoya disease and basilar artery aneurysms is discussed and some surgical and management considerations are given.     

颞浅动脉-大脑中动脉分流术在颅内复杂动脉瘤手术中的应用

目的 探讨颞浅动脉（STA）-大脑中动脉（MCA）分流术在颅内复杂动脉瘤手术中的应用效果。方法 回顾性分析开颅夹闭术治疗的2例颅内复杂动脉瘤的临床资料。夹闭动脉瘤前,先行STA-MCA分流术。结果 1例破裂动脉瘤,DSA显示右侧颈内动脉后交通段巨大动脉瘤（责任动脉瘤）+左侧颈内动脉后交通段镜像动脉瘤,伴双侧胚胎型大脑后动脉,先行STA-MCA分流术,再行动脉瘤孤立术。1例未破裂动脉瘤,DSA显示MCA分叉部大型动脉瘤位,MCA M2段下干粗大,上干纤细,上干起始部均成为瘤颈的一部分,先行STA-MCA分流术,再行动脉瘤夹闭术。2例术后均无明显神经功能障碍,CTA示动脉瘤不显影、吻合口通畅,CTP显示脑灌注良好;术后6个月,改良Rankin量表评分0分1例,1分1例。结论 STA-MCA分流术能够延长安全临时阻断的时间,在动脉瘤孤立和载瘤动脉闭塞后提供保护性血流,在理想情况下双支STA分流术还可以提供高流量血流,替代复杂的桡动脉或大隐静脉分流术,简化手术操作。这项技术有利于提高颅内复杂动脉瘤的治愈率,降低手术并发症的发生率。     

颈内动脉球囊闭塞术后产生对侧新生动脉瘤

目的 在国内献中首次报道1例床突旁动脉瘤(AN)病人在行载瘤动脉球囊闭塞术后5年出现对侧后交通AN并破裂。方法 行急诊手术夹闭该新生动脉瘤。结果 病人仍死于严重的颅内高压。回顾献共发现29例35个因颈动脉闭塞术后出现的新生AN，主要位于前、后交通动脉。结论 颈动脉闭塞后对侧血流代偿性增加可能是导致AN的原因，对大型AN应尽量采用保留载瘤动脉的方法；如闭塞载瘤动脉，应进行长期的影像学随访。     

A case of symmetrical aneurysms at the bilateral middle cerebral arteries associated with the deep seated arteriovenous malformation in the midline]

A case of symmetrical aneurysms at the bilateral middle cerebral arteries (MCA) associated with the deep seated arteriovenous malformation (AVM) in the midline was presented. Because symmetrical aneurysms at the MCA are 1.17% of all aneurysms, and those associated with the deep seated AVM in the midline are very rare. A 75-year-old female suffered from a sudden onset of a severe headache and a loss of consciousness, and was admitted to our department on June 14, 1996. Computed tomography(CT) showed a subarachnoid hemorrhage (SAH) in the right sylvian fissure (Fisher's Group 4). Bilateral symmetrical MCA's aneurysms and the deep seated AVM were clarified by angiography. The symmetrical aneurysms stood out anterior lateral side and the right aneurysm had bleb. On the other hand, the afferent vessels of the AVM were the branches of bilateral posterior cerebral arteries, and the efferent vessel was the vein of Galen. So we determined SAH due to right MCA aneurysm, and performed the neck clipping of the ruptured aneurysm. The symmetrical aneurysms at the MCA associated with AVM in midline have not been reported. Each parent's artery was not connected each other. These origins, therefore, are suggested to be related not only to acquired factors like hypertension, hemodynamic stress etc, but also to a congenital factor. The origin of the saccular aneurysm is suggested congenital either but it isn't definite.     

Bilateral hypoplastic internal carotid arteries with multiple cerebral aneurysms

A 60-year-old man with massive subarachnoid hemorrhage is reported. Radiologically, bilateral occlusion of the internal carotid arteries and multiple cerebral aneurysms of the saccular type were detected. Postmortem examination revealed that the internal carotid arteries were markedly diminutive and completely occluded by mesenchymal fibrous tissue. The pathogenesis of the diminutive internal carotid arteries and the cerebral aneurysms were briefly discussed.     

Development of 'De novo' Aneurysm after Therapeutic Carotid Occlusion

Carotid occlusion is an inevitable therapeutic modality for the treatment of complex aneurysms such as giant, traumatic, and intracavernous aneurysms. Late complications of carotid occlusion include ''de novo'' aneurysm formation at a distant site because of hemodynamic changes in the circle of Willis. We report a case of de novo aneurysm in a vessel that appeared to be normal on initial angiography. The patient developed an anterior communicating artery aneurysm and marked growth of a basilar bifurcation aneurysm 9 years after trapping of the left internal carotid artery for the treatment of a ruptured large saccular aneurysm involving ophthalmic and cavernous segments. We propose that patients who undergo therapeutic carotid occlusion should be periodically followed by magnetic resonance angiography or computed tomographic angiography to evaluate the possibility of de novo aneurysm formation; this advice is in line with previous reports.     

Endovascular treatment of posterior cerebral aneurysm associated with Moyamoya disease

PURPOSE: A patient with moyamoya disease associated with a ruptured posterior cerebral artery aneurysm treated by endovascular embolization is presented. CASE REPORT: A 47-year-old woman was admitted with severe headache to our hospital. Computed tomography demonstrated subarachnoid haemorrhage. Cerebral angiography revealed evidence of moyamoya disease and a saccular aneurysm at the P1 segment of the left posterior cerebral artery. CONCLUSION: Endovascular embolization was performed using Guglielmi detachable coil (GDC), and the aneurysm was completely occluded with preservation of the parent artery. Endovascular treatment using GDC seems comparatively safe and effective for the treatment of cerebral saccular aneurysms in patients with moyamoya disease.     

Anterior communicating artery aneurysm associated with an infraoptic course of anterior cerebral artery and rare variant of the persistent trigeminal artery: a case report and literature review

Infraoptic course of the precommunicating segment of the anterior cerebral artery (A1) is a rare anomaly. Furthermore, the presence of this anomaly associated with persistent trigeminal artery variant has been reported in the literature only once. We present a patient who had infraoptic course of A1 associated with an ipsilateral persistent trigeminal artery variant arising from the right internal carotid artery with no apparent connection to the basilar artery. The persistent trigeminal artery variant supplied to the right posteroinferior cerebellar artery territory. The patient also had hypoplastic left vertebral artery, superior cerebellar arteries originating from posterior cerebellar arteries bilaterally, and a bilobed aneurysm of the anterior communicating artery. The aneurysm was clipped and the infraoptic course was verified during the surgery. The post-operative course was uneventful and a follow-up arteriogram on the 7th postoperative day revealed successful obliteration of the aneurysm.We reviewed the literature with respect to presentation, associated vascular anomalies, imaging, associated cerebral aneurysms and other cerebral abnormalities, and treatment of the associated aneurysms. A discussion of the embryogenesis of this rare anomaly is also provided.     

椎基底动脉瘤的手术治疗

目的 探讨手术治疗椎基底动脉瘤的方法.方法 26例28个椎基底动脉瘤患者.动脉瘤破裂出血9例;16例基底动脉瘤,10例椎动脉瘤.5例基底动脉顶部动脉瘤经翼点入路,5例基底动脉顶部和2例基底动脉上段动脉瘤用额颞颧(切断颧弓、扩大中颅窝底)入路,4例基底动脉中段动脉瘤采用乙状窦前(岩骨)和远外侧联合入路.10例椎动脉瘤中,4例椎动脉瘤采用乙状窦前(岩骨)和岩骨联合入路,6例取用远外侧-枕骨髁联合入路.11例术中临时阻断血管时间延长或可能影响开通血管患者行血管搭桥术,其中颈内动脉大脑后动脉P2段移植搭桥2例,颈外动脉与大脑后动脉P2段移植搭桥4例,椎动脉移植搭桥2例,枕动脉与小脑后下动脉搭桥3例.结果 术后恢复正常工作,无神经功能障碍者:基底动脉顶端动脉瘤9例,基底动脉干动脉瘤5例,椎动脉瘤10例,良好率为92%.1例基底动脉顶端动脉瘤患者术后有严重神经功能缺失,生活不能自理;1例基底动脉主干动脉瘤术后穿通动脉闭塞引起中脑缺血,术后20 d死亡.结论 选择适合的颅底手术入路有利于术中获得充分的手术操作空间.对于单纯手术夹闭困难的动脉瘤,用血管移植搭桥的方法,可以避免因夹闭动脉瘤和临时阻断载瘤动脉出现术后脑缺血.     

Ultrasonic Doppler assessment of hemodynamics in gradual carotid ligation

Hemodynamic changes were examined with an ultrasonic Doppler flowmeter and with a sound-spectrograph in 5 patients with internal carotid giant aneurysms or with recurrent laryngeal cancer undergoing gradual carotid occlusion. The ultrasonic Doppler technique was useful for preoperative assessment of intracranial cross-filling and as a practical guide for the graded reduction of blood flow in the carotid artery. The degree of flow increase in the contralateral carotid artery when the ipsilateral carotid artery was totally occluded was greater in postoperative gradual occlusion than in intraoperative rapid occlusion. In one patient with bilateral internal carotid artery giant aneurysms, whose left internal carotid artery had already been ligated at its origin, gradual occlusion of the right internal carotid artery was performed after the bilateral superficial temporal artery-middle cerebral artery (STA-MCA) anastomoses. Flow in the donor artery of the right STA-MCA anastomosis developed with increasing occlusion of the right internal carotid artery.     

A case of bilateral extracranial carotid artery aneurysms caused by Takayasu's arteritis]

We describe here successful surgical treatment of a rare case of a rapidly enlarged aneurysm due to Takayasu's arteritis. A 22-year-old woman presented with a 1-month history of hoarseness and left neck pain. Contrast-enhanced computerized tomography showed an unruptured partially thrombosed aneurysm, and angiography revealed a large aneurysm of the common carotid artery. After hospitalization, the symptoms, interestingly, resolved spontaneously. While angiography at 2 weeks after admission showed the aneurysm to have reduced in size, 2 months later it showed the left common carotid artery aneurysm to be substantially enlarged in size and aneurysmal formation of the right external carotid artery. Surgical intervention was performed for the left common carotid artery aneurysm because rapid enlargement indicated the risk of aneurysmal rupture, and the thrombosis might cause embolic occlusion of the cerebral arteries. The left common carotid artery including enlarged aneurysm was trapped and anastomosed with a Gore-Tex graft (6-mm inner diameter) to left internal carotid artery. Histological examination of the arterial wall showed inflammatory change, destruction of the medial elastic fibers, and granulation with multinucleated giant cells. The postoperative course was uneventful, and no new vascular lesion was observed 3 years after operation. We demonstrated the bilateral extracranial carotid artery aneurysms caused by Takayasu's arteritis, which was the first case to be reported in the literature.     

Bilateral Superior Cerebellar Artery Infarction after Stent-Angioplasty for Internal Carotid Artery Stenosis

Spontaneous bilateral cerebellar infarction in the territory of the superior cerebellar arteries is extremely rare. Occasionally there have been reports of bilateral cerebellar infarction due to vertebrobasilar atherosclerotic occlusion or stenosis, whereas no report of bilateral cerebellar infarction due to complicated hemodynamic changes. In this report, we present a patient with bilateral cerebral infarctions related to stenoses of bilateral internal carotid arteries, in whom vertebrobasilar system was supplied by multiple collaterals from both posterior communicating arteries and right external carotid artery. We performed stent-angioplasty of bilateral internal cerebral arterial stenosis, and then acute infarction developed on bilateral superior cerebellar artery territories. The authors assumed that the infarction occurred due to hemodynamic change between internal carotid artery and external carotid artery after stent-angioplasty for stenosis of right internal carotid artery.     

Spontaneous bilateral carotid and vertebral artery dissections associated with multiple disparate intracranial aneurysms, subarachnoid hemorrhage and spontaneous resolution. Case report and literature review

Spontaneous bilateral carotid and vertebral artery dissections (CADs and VADs) are rare. A 29-year-old female presented with a collapse, 4 weeks after a sudden onset of severe neck and shoulder pain. CT scan revealed diffuse subarachnoid hemorrhage (SAH) and early hydrocephalus. Angiography revealed bilateral CADs and VADs, along with multiple fusiform and saccular aneurysms. Systemic vessels - including the renal arteries - were normal, and no risk factors or underlying vasculopathy were apparent. The presumed source of SAH (a posterior cerebral artery aneurysm) was successfully clipped. Each dissection, by contrast, was managed conservatively with heparin prophylaxis; and spontaneous CAD and VAD resolution occurred within 6 months. We present a unique case of four-vessel dissection associated with multiple disparate saccular and fusiform aneurysms. We suspect that underlying vasculopathy - perhaps novel - may become apparent with time.     

Glue Embolization of Ruptured Anterior Thalamoperforating Artery Aneurysm in Patient with Both Internal Carotid Arteries Occlusion

Thalamoperforating artery aneurysms are rarely reported in the literature. We report an extremely rare case of ruptured distal anterior thalamoperforating artery aneurysm which was treated by endovascular obliteration in a patient with occlusion of both the internal carotid arteries (ICAs) : A 72-year-old woman presented with severe headache and loss of consciousness. Initial level of consciousness at the time of admission was drowsy and the Glasgow Coma Scale score was 14. Brain computed tomography (CT) scan was performed which revealed intracerebral hemorrhage in right basal ganglia, subarachnoid hemorrhage, and intraventricular hemorrhage. The location of the aneurysm was identified as within the globus pallidus on CT angiogram. Conventional cerebral angiogram demonstrated occlusion of both the ICAs just distal to the fetal type of posterior communicating artery and the aneurysm was arising from right anterior thalamoperforating artery (ATPA). A microcatheter was navigated into ATPA and the ATPA proximal to aneurysm was embolized with 20% glue. Post-procedural ICA angiogram demonstrated no contrast filling of the aneurysm sac. The patient was discharged without any neurologic deficit. Endovascular treatment of ATPA aneurysm is probably a more feasible and safe treatment modality than surgical clipping because of the deep seated location of aneurysm and the possibility of brain retraction injury during surgical operation.     

Internal carotid-posterior communicating artery aneurysm associated with unusually short posterior communicating artery

We report two cases of a ruptured internal carotid-posterior communicating artery aneurysm in which the ipsilateral posterior communicating artery is short and the P1 and P2 segments of the posterior cerebral artery are long. Unique angiographic and operative findings are described. Vertebral angiography with carotid compression is recommended to diagnose this rare variation. Recognition of this variation is important to avoid an inadvertent occlusion of arteries behind the aneurysm at the time of clipping.     

A case of enlarged infundibular dilatation diagnosed by vertebral angiograms with carotid compression and neuroendoscope]

A case of enlarged infundibular dilatation diagnosed by vertebral angiograms with carotid compression was reported. A 57-year-old woman suffered from headache. She underwent MRA which revealed left internal carotid artery aneurysm. Left common carotid angiograms suggested a left saccular internal carotid artery aneurysm (4 mm x 6 mm) without a posterior communicating artery. However, it was confirmed to be an enlarged infundibular dilatation on left vertebral angiograms with carotid compression. It was confirmed at operation microscopically and neuroendoscopically, and the dilatation was treated by coating. When carotid angiograms reveal no posterior communicating artery, it is difficult to differentiate the origin of posterior communicating artery from internal carotid artery-posterior communicating artery junction aneurysms. Vertebral angiograms with carotid compression is useful for the differentiation for the exact diagnosis.     

An acute experimental model of saccular aneurysms in the rat

A new and reproducible saccular aneurysm model has been developed at the bifurcation of the common carotid artery in rats. The details of the experimental methods and results are described. It is strongly suggested that the internal elastic lamina is a critical layer in saccular aneurysm formation, because an experimental saccular aneurysm can be produced immediately by transluminally damaging the inside of the arterial wall at the bifurcation of the common carotid artery. This saccular aneurysm model has several advantages: (i) it can be induced quickly and the success rate approaches 100% in rats; (ii) this technique can produce satisfactory experimental saccular aneurysms for other aneurysm studies, and in the future it will also be possible to use this technique to produce experimental saccular aneurysms in cerebral arteries of large animals.