Spontaneous subarachnoid haemorrhage from rupture of an anterior communicating artery aneurysm in a patient with pituitary macroadenoma

The presence of a cerebral aneurysm in patients with pituitary adenoma is a rare event. Diagnostic suspicion may stem from magnetic resonance imaging, which should lead to complementary investigation. As for treatment, even in conditions in which there has been no previous bleeding, the simultaneous approach should be considered, prioritising the aneurysm most of the time.The present report describes the case of a patient with a history of pituitary macroadenoma, who had undergone a partial transsphenoidal resection ten years earlier. Admission to our service occurred after a sudden headache followed by mental confusion. A cranial computed tomography showed subarachnoid haemorrhage and expansive suprasellar lesion. Cerebral angiography showed a saccular aneurysm of the anterior communicating complex. The patient underwent a surgical procedure for microsurgical clipping of the aneurysm and partial resection of the pituitary tumour. We have also included a brief review of the literature on this subject.     

Amnesia following the rupture and repair of an anterior communicating artery aneurysm.

Clinical analysis and neuropsychological criteria derived from experimental studies of human amnesic syndromes, particularly the alcoholic Korsakoff's syndrome, have been used to characterise an unusual form of amnesia that occurred in two patients after rupture of an anterior communication cerebral artery aneurysm. Intraoperative observation and multiple CT scans did not reveal focal brain damage. Arteriography showed that both patients had arterial vasospasm. The amnesia has persisted over three years since the surgery. Study of the characteristics of their amnesia showed several features in common with other amnesic syndromes, including severely depressed free recall, and less depressed recognition of visual and verbal material. Chronic amnesic syndromes with characteristics of classical amnesic syndromes occur infrequently after rupture and repair of intracranial aneurysms, and, if not caused by parenchymal haemorrhage, may follow pre-operative vasospasm.     

Memory disorders following rupture of anterior communicating artery aneurysm. 22 cases

Twenty-two patients who underwent surgery for ruptured aneurysm of the anterior communicating artery were investigated by a battery of neuropsychological tests, including memory evaluation tests. According to the results obtained at these tests the patients were divided into three groups: 1) 7 patients had no memory disorders; 2) 10 patients presented with memory disorders affecting memory; their complaints concerned behavior, and the memory deficit was discovered at neuropsychological examination; 3) 5 patients presented with an obvious amnesic syndrome, and the tests confirmed a severe learning deficit and a severe forgetting while recognition remained normal in 4 patients. Age, residual lesions at CT and electrophysiological signs of focalization correlated well with the residual neuropsychological disorders. Leaving aside quantitative aspects, the memory deficits observed in the second and third groups seemed to be qualitatively different and might correspond to different anatomical and functional sequelae.     

Amnesia after anterior communicating artery aneurysm rupture

We studied 11 patients with amnesia and personality change after surgical repair of ruptured anterior communicating artery ( ACoA ) aneurysm. CT and clinical evidence suggested that infarction in the territory of the ACoA was responsible for amnesia and personality change. The medial septal nuclei, the paraventricular nucleus of the anterior hypothalamus, and the medial forebrain bundle are the primary areas of potential interest in these cases. Gross infarction in the frontal lobes is not a requirement for the syndrome.     

Memory disturbances following anterior communicating artery rupture.

Thirty patients with lesions due to the rupture and repair of an aneurysm of the anterior communicating artery were compared neuropsychologically with 27 patients with ruptures but no lesions and 30 normal control subjects. Patients with combined lesions in the basal forebrain and striatum (n = 5), or basal forebrain, striatum, and ventral frontal cortex (n = 7), had severe memory deficits, whereas patients with lesions in the basal forebrain (n = 7) or the striatum (n = 5) alone showed virtually no deficits. Patients with lesions of the basal forebrain and ventral frontal cortex together (n = 6) showed mild memory deficits. In contrast to the memory effects, emotional changes were most pronounced in patients with striate lesions alone. Basal forebrain or ventral frontal lesions ameliorated rather than aggravated the emotional effects of striate lesions. It is suggested that the basal forebrain and the striatum form links of different pathways related to mnemonic information processing. Both systems may be able to compensate for a dysfunction of the other, but lesions of both systems together may lead to strong and unrecoverable memory deficits.     

Confabulation following aneurysm of the anterior communicating artery.

Nine subjects with aneurysms of the anterior communicating artery (ACoA) and 17 subjects with other intracranial hemorrhages (ICH) were evaluated for confabulatory responses under two naturally occurring conditions: (1) when subjects were not oriented to person, place, month and year, (2) when subjects were fully oriented. Confabulation was observed in all 9 of ACoA patients both during disoriented and oriented periods. In contrast, 7/17 of the other ICH patients showed signs of confabulation while disoriented, whereas only one continued to display confabulatory tendencies while fully oriented. Confabulation was more severe in the ACoA group. These data suggest that the confabulation observed in the other ICH group may be secondary to an acute confusional state while the prolonged confabulation in ACoA patients may be a manifestation of a more primary cerebral disorder.     

Decompressive bifrontal craniectomy for malignant intracranial pressure following anterior communicating artery aneurysm rupture

There are a number of causes of raised intracranial pressure (ICP) following aneurysm rupture. These include primary and diffuse hypoxic brain injury, intracranial hematomas, cerebral ischemia or infarction, and obstructive hydrocephalus. More localized brain swelling can also occur: the result of vasogenic and cytotoxic edema resulting from overlying bleeding in the subar achnoid spaces. In the case of rupture of an anterior communicating artery (ACommA) aneurysm and interhemispheric subarachnoid hemorrhage (SAH), this swelling can occur in both frontal lobes and when extensive, and the resulting intracranial hypertension can be difficult to manage with ventricular drainage and medical treatment. We describe two patients in whom decompressive bifrontal craniectomy was associated with successful ICP management and good clinical outcomes.     

Posterior temporal haematoma associated with anterior communicating artery aneurysm rupture.

We report the case of a 68-year-old man who presented with symptoms suggesting an intracranial haemorrhage. A computed tomography scan showed subarachnoid haemorrhage associated with a remote posterior temporal intracerebral haematoma. Angiography revealed the presence of an anterior communicating artery aneurysm, which was subsequently clipped. Possible causes for the association of a distant intracerebral haematoma with rupture of an anterior communicating artery aneurysm are discussed. This uncommon association should be recognised to avoid incorrect identification of the origin of haemorrhage.     

Anatomy of executive deficit following ruptured anterior communicating artery aneurysm

Background and purpose: To evaluate behavioral and cognitive deficits following anterior communicating artery aneurysm rupture and determine critical lesion locations. Methods: We investigated 74 patients with standardized cognitive tests and behavioral inventory. Two examiners rated MRI signal abnormalities in 51 predetermined regions of interest. Classification tree analysis was used to select regions associated with each cognitive deficit. Results: Eleven patients presented behavioral executive deficits and 10 had cognitive executive deficit. Their presence depended on left hemisphere lesions only: (i) ventral striatum lesion was associated with behavioral executive deficit (P = 0.04), reduction of activities (P = 0.01), and hyperactivity (P = 0.02); (ii) superior frontal gyrus lesion, with cognitive executive deficit (P = 0.01), action initiation deficit (P = 0.02), and rule deduction deficit (P = 0.02); (iii) anterior half of centrum semiovale lesion, with Stroop inhibition deficit (P = 0.02); (iv) medial superior and middle frontal gyri lesions, with task coordination deficit (P = 0.01); and (v) middle frontal gyrus lesion, with words generation deficit (P = 0.02). Conclusion: This study supports that (i) cognitive executive deficits depend mostly on lateral prefrontal lesions, (ii) with locations varying according to executive process, and (iii) behavioral executive deficits are mainly due to left ventral striatum lesion in post‐aneurysmal damage.     

Amnesia after basal forebrain damage due to anterior communicating artery aneurysm rupture

A 53-year-old male presented with a subarachnoid haemorrhage secondary to an anterior communicating artery aneurysm rupture. The aneurysm was successfully treated with intravascular coiling. Post-haemorrhage the patient showed a profound amnestic syndrome with deficits in anterograde (and also retrograde) memory, confabulation and personality changes consistent with the anterior communicating artery syndrome (ACAS). Magnetic resonance imaging showed basal forebrain and orbitofrontal infarction. The patient was treated with donepezil (a cholinesterase inhibitor) without symptomatic improvement or clinically meaningful change in his psychometric testing. The clinical and neuropsychological features and the pathological basis of the ACAS are reviewed.     

Subarachnoid haemorrhage following rupture of an ophthalmic artery aneurysm presenting as traumatic brain injury

Head trauma may provoke subarachnoid haemorrhage. The question sometimes arises whether in patients with trauma and subarachnoid haemorrhage the latter is of traumatic or aneurysmal origin. We present a 49-year-old patient who fell from a truck, struck his head and was unconscious immediately. On the brain computed tomography (CT) scan subarachnoid haemorrhage was present, initially diagnosed as of traumatic origin. Four-vessel angiography revealed rupture of a left ophthalmic artery aneurysm. We review the literature and give recommendations for angiography in patients with trauma and subarachnoid haemorrhage.     

探讨终板造瘘在前交通动脉瘤性蛛网膜下腔出血的临床应用

目的探讨终板造瘘在前交通动脉瘤性蛛网膜下腔出血患者中的临床应用。方法回顾性分析我院2014年7月至2016年7月的51例前交通动脉瘤性蛛网膜下腔出血患者,按照术中是否行终板造瘘分为造瘘组和非造瘘组,比较两组在住院时间、GOS分数及慢性脑积水等方面存在的差异。结果造瘘组和非造瘘组的脑积水发生率分别为8.3%和33.3%,差异具有统计学意义,造瘘组的住院时间为13.83±1.24(天)少于非造瘘组的15.39±1.90(天),造瘘组和非造瘘组的GOS评分分别为4.08±0.83分和3.30±0.82分,差异具有统计学意义,造瘘组的预后好于非造瘘组。结论终板造瘘对前交通动脉瘤性蛛网膜下腔出血患者可以减少住院时间及慢性脑积水的发生,有助于提高患者的预后。     

Posterior communicating artery aneurysm presenting with haemorrhage into an arachnoid cyst

A patient is reported on with a subarachnoid haemorrhage(SAH) from an aneurysm of the posterior communicating artery, who initially presented with a sentinel bleed into an arachnoid cyst andnormal magnetic resonance angiography (MRA) of the intracranial vasculature which led to a delay in diagnosis. Although this is a veryrare presentation of a relatively common condition, it is important torecognise the importance of intracystic haemorrhage in suchcircumstances as well as the limitations of MRA, as a delay indiagnosis may have serious clinical consequences.

     

前交通动脉瘤的显微手术治疗

目的介绍翼点入路治疗前交通动脉瘤的手术经验，提高手术疗效。方法回顾性分析56例前交通动脉瘤病人的临床表现、影像资料、手术治疗及预后情况。56例均行直接夹闭术，1例加做包裹术。结果治愈或良好47例，致残8例，死亡1例。随访5个月～3年，无动脉瘤再出血发生。结论翼点入路手术治疗前交通动脉瘤显露充分、术式成熟、并发症少，配合多种外科技术如临时阻断的应用、脑保护、控制性低血压等，可收到满意的手术疗效。     

血管内治疗前交通动脉瘤

目的 总结前交通动脉瘤血管内治疗的经验和体会,探讨血管内治疗前交通动脉瘤的效果和减少并发症发生的方法.方法 共栓塞前交通动脉瘤98例.依据Hunt-Hess分级:I级16例,Ⅱ级52例,Ⅲ级23例,Ⅳ级7例.术后积极行腰大池或腰穿引流血性脑脊液,采用3H疗法防治血管痉挛.结果 98个动脉瘤全部成功栓塞,随访3个月-3年,无再出血发生.结论 血管内治疗前交通动脉瘤是一种有效、确切的治疗方法.术后早期引流血性脑脊液、积极药物治疗是减少并发症的发生、提高治疗效果的重要方法.     

Blister-like aneurysm of the anterior communicating artery

We report a recent experience with a blister-like aneurysm of the anterior communicating artery and suggest that this entity may be responsible for so-called non-aneurysmal haemorrhage when the distribution of blood is atypical.     

Extradural vertebral artery dissecting aneurysm causing subarachnoid haemorrhage

The authors report the case of a 37-year-old man who presented with subarachnoid haemorrhage (SAH) after rupture of an extradural vertebral artery dissecting aneurysm. The patient underwent a left lateral suboccipital craniotomy with removal of the medial part of the occipital condyle and the fusiform dilatation was coated. The angiograms 3 months after surgery showed aneurysm resolution and normal vessel calibre. To the authors' knowledge, it is the second reported case of extracranial vertebral aneurysm of its kind presenting as SAH. The result after surgery in this case indicates that coating of a dissecting aneurysm of the extracranial portion of the vertebral artery (VA) is a valid alternative surgical technique for the prevention of rebleeding.     

Subarachnoid haemorrhage in a patient with a left temporal arteriovenous malformation and an associated anterior communicating artery aneurysm

We report a patient who presented with a subarachnoid haemorrhage in the setting of both an arteriovenous malformation and an intracerebral aneurysm. It was felt that the aneurysm had bled and both abnormalities were treated surgically in a sequential manner. The problem of aneurysm combined with arteriovenous malformation is reviewed.     

Cognitive dysfunction after aneurysm of the anterior communicating artery.

The present study examined the nature of the amnestic syndrome following aneurysm of the anterior communicating artery (ACoA) in humans. Eleven ACoA and 13 subjects with intracranial hemorrhages (ICH) elsewhere in the brain were administered a battery of standard neuropsychological tests. The ACoA group performed significantly worse than the ICH controls on tests of delayed verbal memory and on the Wisconsin Card Sorting Test, despite significantly higher Full Scale IQ. No significant differences were observed between groups on tests of immediate recall, attention and concentration, and visuo-spatial functions, although the ACoA group tended to perform better on many of these tests. The results do not support the hypothesis that the cognitive impairments observed following ACoA aneurysm are the result of diffuse cortical damage. The role of specific anterior cerebral structures in defining the "ACOA syndrome" are discussed.     

经翼点入路前交通动脉瘤的显微手术治疗(附398例报告)

目的 总结经翼点入路显微手术夹闭前交通动脉痛的优缺点.方法 对398例前交通动脉瘤采用经翼点入路直接夹闭术的结果 进行回顾性分析.由于舣侧A1段常发育异常及相应的前交通动脉的血流方向的个体差异,动脉瘤的形态变化及生长方向不同,手术入路的定侧与难度亦有所不同.结果 本组病例中6例(Hunt-HessⅣ级2例, Ⅴ级4例)由于严重脑血管痉挛等并发症,分别于术后3 d至3周内死亡.随诊时间为3个月至22年不等,短期内全组病人均获得随诊,但长期随诊者为295例,97例失访.随访的病人中Ⅰ、Ⅱ级214例(72%)均恢复正常工作,Ⅲ级者42例(14%)恢复正常工作,23例(7.7%)生活自理,3例(1%)不能生活自理.Ⅳ级者中有4例(1.3%)恢复正常工作;Ⅴ级中有1例恢复正常工作,1例不能生活自理.结论 经翼点人路直接显微手术,是治疗前交通动脉瘤较为理想的方法.手术前仔细阅片,了解前交通动脉区的血管关系及血流变化,对于手术入路选择至关重要.