Spontaneous thrombosis of a fusiform aneurysm arising from the distal posterior cerebral artery: case report

A 58-year-old woman complaining of a mild headache was admitted to our hospital. MRI 3 months before admission revealed a round lesion at the right quadrigeminal cistern. Cerebral angiograms demonstrated a fusiform aneurysm arising from the parietooccipital artery, which is the distal branch of the right posterior cerebral artery. Repeated MRI and cerebral angiograms performed on admission demonstrated complete thrombosis of an aneurysm and the parent artery without any clinical symptoms. This is the first case of complete spontaneous thrombosis of an aneurysm of the distal posterior cerebral artery. The mechanism of its development and spontaneous thrombosis in a fusiform aneurysm is discussed.     

Cerebral embolic stroke and arm ischemia in a teenager with arterial thoracic outlet syndrome: a case report

A rare presentation of arterial thoracic outlet syndrome (TOS) is described in a young woman. Arterial TOS caused by a cervical rib produced acute upper extremity ischemia due to subclavian artery aneurysm formation. Clinical presentation also included left hemiparesis caused by right subclavian artery thrombosis and retrograde embolization of thrombus via the common carotid artery to the right middle cerebral artery distribution. Surgical repair of the subclavian artery was performed, but permanent neurologic deficit remained. Acute thrombosis of the right subclavian artery can produce cerebrovascular complication. The assessment of such risk in patients with arterial TOS is warranted and the arterial lesion corrected surgically.     

Concurrent thrombosis of cerebral and femoral arteries in a patient with nephrotic syndrome

Although venous thrombosis is a frequently encountered problem in nephrotic syndrome, the occurrence of arterial thrombosis is much less common, and is usually associated with a poor prognosis. To the best of our knowledge, there has been only one reported case of concurrent cerebral and femoral artery thrombosis, that of a 23-year-old male who finally died. Herein, we report a case of a 35-year-old woman with nephrotic syndrome. She developed cerebral and femoral arterial thrombosis simultaneously when the nephrotic syndrome relapsed. Immediate thrombectomy of the femoral artery, followed by anticoagulation and immunosuppressive therapy, were employed. The patient recovered completely and is now doing well. Our experience indicates that multiple artery thrombosis in nephrotic patients may not necessarily carry a poor outcome if early and aggressive treatment can be undertaken.     

A rare vascular complication of transsphenoidal surgery

We report a rare case of anterior cerebral artery (ACA) thrombosis following transsphenoidal surgery in a case of growth hormone secreting pituitary macroadenoma. During the surgery, there was arachnoid breach with cerebrospinal fluid (CSF) leak. Post operatively, she became blind in both eyes for which re-exploration was done. A computed tomographic (CT) scan 16 hours after surgery showed a large tumor bed haematoma which was explored transcranially. During surgery, the right A1 was thrombosed while the ICA and middle cerebral artery (MCA) were patent as confirmed by post-operative magnetic resonance imaging (MRI). However, she died on the second post-operative day. ACA thrombosis following transsphenoidal surgery has not been reported before. A review of literature and possible mechanism of this complication has been discussed.     

A case of septic cavernous sinus thrombosis with sequential dynamic angiographic changes. A case report

A case of intracavernous aneurysm secondary to septic cavernous sinus thrombosis demonstrating sequential dynamic angiographic changes is reported. Serial angiograms of a 32-year-old man with septic cavernous sinus infection revealed a normal study, stenosis, recovery of stenosis, and aneurysmal formation. Superficial temporal-middle cerebral artery anastomosis and internal carotid artery ligation were performed because of progressive ophthalmoplegia. Neurological deficit rapidly disappeared. Anigiographic changes and surgical treatment of septic cavernous sinus thrombosis are discussed.     

Treatment of giant intracranial aneurysms with saphenous vein extracranial-to-intracranial bypass grafting: indications,operative technique,and results in 29 patients

OBJECTIVE: The treatment of giant intracranial aneurysms is a challenge because of the limitations and difficulty of direct surgical clipping and endovascular coiling. We describe the indications, surgical technique, and complications of saphenous vein extracranial-to-intracranial bypass grafting followed by acute parent vessel occlusion in the management of these difficult lesions. METHODS: Between January 1990 and December 1999, 29 patients with giant intracranial aneurysms underwent 30 saphenous vein bypass grafts followed by immediate parent vessel occlusion. There were 11 men and 18 women with a mean follow-up period of 62 months. Twenty-five patients harbored aneurysms involving the internal carotid artery, 2 had middle cerebral artery aneurysms, and 2 had aneurysms in the basilar artery. Serial cerebral or magnetic resonance angiograms were obtained to assess graft patency and aneurysm obliteration. RESULTS: All 30 aneurysms were excluded from the cerebral circulation, with 28 vein grafts remaining patent. Two patients had graft occlusions: one because of poor runoff and the other because of misplacement of a cranial pin during a bypass procedure on the contralateral side. Other surgical complications included one death from a large cerebral infarction, homonymous hemianopsia from thrombosis of an anterior choroidal artery after internal carotid artery occlusion, and temporary hemiparesis from a presumed perforator thrombosis adjacent to a basilar aneurysm. CONCLUSION: With appropriate attention to surgical technique, a saphenous vein extracranial-to-intracranial bypass followed by acute parent vessel occlusion is a safe and effective method of treating giant intracranial aneurysms. A high rate of graft patency and adequate cerebral blood flow can be achieved. Thrombosis of perforating arteries caused by altered blood flow hemodynamics after parent vessel occlusion may be a continuing source of complications.     

Non-penetrating trauma to the carotid artery with secondary thrombosis and embolism: Treatment by Thrombolysin

Summary A case of partially occluding post-traumatic thrombosis of the internal carotid artery and secondary embolism of the middle cerebral artery is reported. The patient was treated with Thrombolysin with coincident resolution of clinical symptoms and signs and clearing of the lesions on arteriography. This may have been fortuitous.The subject of traumatic carotid artery thrombosis is reviewed in detail, and its pathophysiology is discussed, especially in relation to facts known about occlusive vascular disease secondary to atherosclerosis and related embolie phenomena. Suggestions are made concerning the treatment of this condition, especially with regard to developing rational criteria for opening vascular beds through evaluation of collateral cerebral blood flow. The uses of microvascular surgical techniques and thrombolytic therapy are considered.     

Acquired Pial and Dural Arteriovenous Fistulae following Superior Sagittal Sinus Thrombosis in Patients with Protein S Deficiency: A Report of Two Cases

Two patients with protein S deficiency with acquired multiple pial and dural arteriovenous fistulae (AVFs) following superior sagittal sinus (SSS) thrombosis are reported. Case 1 is a 38-year-old male with protein S deficiency who developed generalized seizure due to SSS thrombosis. Local fibrinolysis was achieved in the acute stage. His 10-month follow-up angiogram revealed an asymptomatic acquired dural AVF arising from the middle meningeal artery and the anterior cerebral artery with drainage to the thrombosed cortical vein in the right frontal lobe. Furthermore, his 2-year follow-up angiogram revealed a de novo pial AVF from the middle cerebral artery in the Sylvian fissure with drainage to the cortical vein initially thrombosed. However, this asymptomatic pial AVF caused bleeding in the ipsilateral cerebral hemisphere 12 years after onset, whereas the dural AVF spontaneously disappeared. Surgical disconnection was successfully performed to eliminate the source of hemorrhage. Case 2 is a 50-year-old male with a past history of SSS thrombosis with protein S deficiency who developed pulsatile tinnitus and generalized seizure. His angiogram showed a cortical dural AVF in the left parietal lobe and a sporadic dural AVF involving the right sigmoid sinus. The parietal lesion was eliminated by transarterial embolization followed by craniotomy. However, a de novo pial AVF emerged from the middle cerebral artery adjacent to the previously treated lesion. Of four cortical AVFs in two patients, thrombosis of cortical veins caused by protein S deficiency might play an important role in their formation. Long-term follow-up is required because this peculiar disorder has an unusual clinical course.     

Dissecting aneurysm of the posterior cerebral artery treated with proximal ligation.

A rare case of a dissecting aneurysm of the P3 segment of the right posterior cerebral artery is presented that seems to have occurred in association with mild head injury. The patient was treated surgically because of repeated intramural hemorrhage and enlargement of the aneurysm. Proximal ligation produced thrombosis of the aneurysm without resulting in infarction in the region of the posterior cerebral artery. The mechanisms of the dissection, diagnosis, and treatment are briefly discussed.     

Local fibrinolytic therapy in ischemic carotid pathology

Sixteen patients underwent local fibrinolytic therapy for thrombosis or embolism of the main trunk or intracranial branches of the Internal carotid artery. There were eight cases of complete thrombosis of the internal carotid artery, five proximal stenoses of the internal carotid artery with extensive thrombus, one thrombus of the carotid siphon and two middle cerebral artery emboli. Indications for treatment Included transient ischemic attacks in 11 cases, cerebral ischemia after carotid arteriography in two cases, and after surgery for atheromatous lesions of the carotid bifurcation In three cases. The fibrinolytic therapy was initiated during carotid surgery in three cases, where extended thrombosis of the internal carotid artery was discovered, which was Inaccessible to a Fogarty catheter. The other 13 cases were treated during arteriography procedures. Lysis of the clot was always obtained. One patient died of hematoma of the frontal lobe. All other patients survived and showed neurologic Improvement. The neurologic outcome was dependent on the duration and the degree of initial ischemia. Fibrinolytic therapy appears to be beneficial therapy for certain cases of cerebral ischemia.     

Thrombosis of a giant aneurysm after extracranial-intracranial bypass.

A patient presenting with a giant, fusiform middle cerebral artery aneurysm underwent extracranial to intracranial bypass grafting before permanent occlusion of the aneurysm. The patient was to return 4 months later for endovascular treatment. Arteriography obtained before obliteration revealed complete aneurysmal thrombosis. No further treatment was deemed necessary. Factors predisposing to thrombosis are discussed.     

Unusual positional compression of the internal carotid artery causes carotid thrombosis and cerebral ischemia

This article reports an unusual case of positional compression of internal carotid artery resulting in carotid thrombosis and stroke in a 37-year-old man. A patient was operated urgently for a free-floating thrombotic mass in the internal carotid artery. Open thrombectomy was performed in acute phase of stroke for prevention of the recapitulative cerebral thromboembolism. Hemiplegia completely disappeared within 7 months.     

Rupture of previously unruptured giant carotid aneurysm after superficial temporal-middle cerebral artery bypass and internal carotid occlusion

A 51-year-old woman with an unruptured giant aneurysm of the internal carotid artery was treated by gradual occlusion of the internal carotid artery in the neck combined with a superficial temporal artery to middle cerebral artery bypass graft. Visual field defects improved after the operation, and thrombosis of the aneurysm was confirmed by angiography and computed tomography. Nevertheless, a fatal hemorrhage occurred 34 days after the final turn of the Selverstone clamp. The possible mechanism of rupture of the apparently thrombosed aneurysm is discussed. There is a risk of rupture of the aneurysm as long as the aneurysmal lumen remains after proximal ligation, no matter how small it may be.     

Postoperative peri-axillary seroma following axillary artery cannulation for surgical treatment of acute type A aortic dissection

The arterial cannulation site for optimal tissue perfusion and cerebral protection during cardiopulmonary bypass (CPB) for surgical treatment of acute type A aortic dissection remains controversial. Right axillary artery cannulation confers significant advantages, because it provides antegrade arterial perfusion during cardiopulmonary bypass, and allows continuous antegrade cerebral perfusion during hypothermic circulatory arrest, thereby minimizing global cerebral ischemia. However, right axillary artery cannulation has been associated with serious complications, including problems with systemic perfusion during cardiopulmonary bypass, problems with postoperative patency of the artery due to stenosis, thrombosis or dissection, and brachial plexus injury. We herein present the case of a 36-year-old Caucasian man with known Marfan syndrome and acute type A aortic dissection, who had direct right axillary artery cannulation for surgery of the ascending aorta. Postoperatively, the patient developed an axillary perigraft seroma. As this complication has, not, to our knowledge, been reported before in cardiothoracic surgery, we describe this unusual complication and discuss conservative and surgical treatment options.     

Carotid artery thrombosis associated with lupus anticoagulant

A young man with cerebral infarction and circulating lupus anticoagulants was found to have a partially occluding intraluminal thrombosis in the left internal carotid artery. Immediate thrombectomy and medical therapy was followed by gradual partial clinical improvement. Pathologic examination revealed an organized thrombus with diffuse hypersensitivity vasculitis of the small arteries in a skin and muscle biopsy specimen. Increased physician awareness may lead to more prompt diagnosis and treatment of this unusual clinical syndrome.     

Disseminated mucormycosis with renal involvement

A case of fatal disseminated mucormycosis causing bilateral renal artery thrombosis, parenchymal and collecting system invasion and destruction, and extrinsic perirenal and proximal ureteral compression is presented. In addition to acute renal failure meningoencephalitis, cerebral hemorrhagic infarction and septic enterocolitis were contributing causes of death.     

大鼠上矢状窦闭塞模型脑血流和脑组织血氧饱和度的变化

目的　探讨大鼠上矢状窦闭塞模型脑血流与脑组织血氧饱和度的变化。方法　利用大鼠上矢状窦闭塞模型 ,激光多谱勒扫描法测定脑表 2 5处局部脑血流 (lCBF)和脑组织血氧饱和度 ,以 2 5处lCBF的中位数代表区域脑血流 (rCBF)。荧光血管造影技术检测上矢状窦闭塞情况和血栓扩展情况。大鼠分为以下 3组 :A组 ,对照组 (n =5 ) ;B组 ,上矢状窦结扎组 (n =8) ;C组 ,上矢状窦结扎加上矢状窦内注入血栓形成因子 (n =10 )。结果　C组上矢状窦结扎加上矢状窦内注入血栓形成因子后rCBF与脑组织血氧饱和度明显降低 (P <0 .0 5 ) ,B组上矢状窦结扎后rCBF降低(P <0 .0 5 ) ,15min后又恢复到结扎前水平。B组的平均动脉压较A、C组增高 15 %左右 (P <0 .0 5 )。结论　急性上矢状窦闭塞血栓扩展到脑皮层静脉后rCBF和脑组织血氧饱和度降低 ,脑血管造影及rCBF和脑组织血氧饱和度监测可早期诊断上矢状窦闭塞 ,提升脑灌注压可以延长静脉窦血栓形成的治疗时间窗。     

Thrombolytic therapy for delayed, in-hospital stroke after cardiac surgery

Five patients who had delayed stroke after cardiac surgery underwent intraarterial administration of a fibrinolytic agent for thromboembolism (n = 4) or thrombosis (n = 1) of the cerebral artery. Complete recanalization of the occluded artery was obtained in 3 patients and partial recanalization in 2. Additional angioplasty for basilar artery stenosis was performed in 1 patient. No patients exhibited rebleeding into the pericardial space or wound bleeding. All patients survived with moderate or full functional recovery. Immediate cerebral angiography and local thrombolysis may improve functional outcome and survival in patients with postcardiotomy cerebral thromboembolism.     

EC-IC bypass surgery using a long vein graft--reconstructive procedures for the occluded long vein grafts

EC-IC bypass using a long vein graft has an advantage creating a large amount of blood flow immediately after the anastomosis, but on the other hand, disadvantage of relatively frequent incidence of the vein graft occlusion. In this report, we present three kinds of reconstructive operative procedures for the stenotic or occluded long vein grafts. Type A: A long vein graft bypass between external carotid and posterior cerebral artery was found occluded intraoperatively by the thrombosis occurred where the vein graft was injured during harvesting. Reconstruction was made simply by resecting the occluded segment of the graft and end-to-end suturing. Type B: A long vein graft used in subclavian artery-middle cerebral artery bypass was occluded three days postoperatively at the supraclavicular fossa by bleeding from the anastomosis site. The vein graft was found compressed and thrombosed. We reconstructed the occluded bypass by resecting the occluded supraclavicular segment and interposing a short vein graft with end-to-end anastomosis. Then, thrombectomy of the remaining vein graft was followed. Type C: A long vein graft used in external carotid-middle cerebral artery bypass stenosed at the anastomosis site with the external carotid artery a day after the operation. The stenotic bypass was successfully reconstructed by bridging a new short vein graft from another portion of the external carotid artery on the long vein graft distal to the stenotic site. All the long vein grafts we have done reconstructive surgery have been working well one to four years follow-up periods. So, we conclude that whenever a long vein graft occludes it should be reconstructed promptly before the vein graft becomes necrotic.     

Giant aneurysm of the middle cerebral artery: angiographic analysis of blood flow.

The authors report a giant aneurysm of the middle cerebral artery with subarachnoid hemorrhage and without intraluminal thrombosis; by serial angiography, the turbulent blood flow within the aneurysm was demonstrated. The aneurysm was clipped successfully.