Giant aneurysm of the pericallosal artery causing acute subdural hematoma--case report

A 66-year-old female presented with a very rare giant aneurysm of the distal pericallosal artery. She lost consciousness and was admitted. Computed tomography demonstrated a subdural hematoma over the left cerebral convexity and a mass in the frontal lobe. Cerebral angiography disclosed a giant aneurysm located on the distal segment of the right pericallosal artery. The subdural hematoma was removed and the aneurysmal neck was clipped, but she died 15 days after the operation. Autopsy found the giant aneurysm (33 x 30 x 27 mm) on the distal segment of the right pericallosal artery. Highly atheromatous changes were recognized in part of the aneurysmal wall, the arteries near the circle of Willis, and the distal anterior cerebral artery (ACA) adjacent to the aneurysm. There were no anomalous vessels such as azygos ACA. Giant aneurysms situated beyond the genu of the corpus callosum are extremely rare. Atherosclerosis was probably a major etiological factor in this case.     

Giant aneurysm of the azygos anterior cerebral artery associated with acute subdural hematoma--case report.

A ruptured giant aneurysm of the azygos anterior cerebral artery (ACA) associated with an acute subdural hematoma (SDH) occurred in a 67-year-old male with two episodes of sudden severe headache and transient loss of consciousness. Neurologically, he had mild weakness of the left lower extremity. Computed tomography showed an elliptical heterogeneous hyperdense mass in the interhemispheric fissure in front of the corpus callosum and an acute SDH on the right. Angiography disclosed a giant aneurysm (2.8 x 2.0 cm) at the distal end of the azygos ACA. Removal of the SDH and aneurysmal neck clipping achieved a good outcome. Successive small bleedings may allow the aneurysmal dome to develop adhesions to the arachnoid membrane, and the final rupture will occur into the subdural space, resulting in a SDH.     

A case of posttraumatic delayed cerebral arterial spasm; case report and review of the literature on the pathogenesis]

A case of posttraumatic delayed cerebral arterial spasm is presented. A 71-year-old man was admitted to our hospital with head injury. Neurological examination on admission only revealed consciousness disturbance (Japan Coma Scale 30). CT scan 19 hours after the injury demonstrated a contusional hematoma in the right frontal lobe, faint subarachnoid hemorrhage in the left sylvian fissure and subdural hematoma in the interhemispheric fissure. His consciousness was disturbed on the 14th day. CT scan demonstrated a left subdural effusion, which was surgically evacuated. However, from the next day the patient developed left hemiparesis. Right carotid angiogram on the 17th day after the injury revealed multiple segmental arterial narrowing in the right anterior cerebral artery (ACA) and middle cerebral artery (MCA). We diagnosed a posttraumatic delayed cerebral arterial spasm. CT scan revealed low density areas in the right ACA and MCA territory. The pathogenesis of posttraumatic delayed arterial spasm is not yet well known. Now, four theories have been suggested as follows: (1) Subarachnoid hemorrhage, (2) Direct mechanical injury to the arterial wall, (3) Hypothalamus dysfunction, and (4) Disturbed autoregulation. In our case, three important factors are suggested. The first is direct injury to the artery, the second is cerebral contusion, and the third is subdural effusion.     

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.     

Spontaneous subfalcial transcallosal migration of a missile to the contralateral hemisphere causing deterioration in neurological status--case report

A 26-year-old man sustained a gunshot injury. Computed tomography (CT) demonstrated the missile in the right parietal region. Twenty-four hours later, the missile had moved towards the midline. Following slight deterioration in his neurological condition one week later, follow-up CT revealed that the missile had crossed the midline through the corpus callosum and was located in the left parietal region. CT during the second week demonstrated that the missile had stopped close to the left parietal bone. Spontaneous migration of a missile to the contralateral side via a subfalcial-transcallosal route with deterioration in neurological status is unusual. The missile may have moved under the influence of the intracranial pressure and pulsatile effect of the cerebrospinal fluid.     

Clinicopathological study of multiple gliomas--report of three cases.

Three cases of multiple gliomas with postmortem findings including a rare case of multicentric glioma are presented. A 59-year-old female was hospitalized with decreased mental activity and gait disturbance. Computed tomographic (CT) scans and magnetic resonance (MR) images showed two independent mass lesions in the left frontal and the right temporal lobes, shown by postmortem to have no communication. Histologically, they were a gemistocytic astrocytoma and an anaplastic astrocytoma, respectively. Therefore, multicentric glioma was diagnosed. A 66-year-old male was admitted with slow mentation and gait disturbance. CT scans and MR images demonstrated two mass lesions; one overriding the bilateral frontal lobes through the corpus callosum and the other in the left temporal lobe. Postmortem examination showed that both lesions were glioblastoma and the left temporal tumor was accompanied by subarachnoid dissemination. A 29-year-old male was hospitalized with gustatory hallucination and convulsions of the right upper extremity. CT scans revealed two mass lesions in the right frontal and the left temporal lobes. MR images demonstrated communication between the two lesions through the corpus callosum. The left temporal tumor developed into the occipital lobe and another new lesion appeared in the right temporal lobe despite chemotherapy and irradiation. Postmortem examination revealed communication between the three masses through the corpus callosum. Histologically, all three tumors were glioblastoma. Multicentric gliomas have been reported at various incidences from 2.3 to 9.1%. However, multicentric gliomas with multiple tumors of different histologies are very rare and only 16 cases have been reported. MR imaging is more valuable than CT scanning to detect communication between two or more lesions.     

Ruptured cerebral aneurysm of the median artery of the corpus callosum (accessory anterior cerebral artery): case report

A rare case of ruptured cerebral aneurysm of median artery of corpus callosum (accessory anterior cerebral artery: Acc ACA) is reported. A 66-year-old hypertensive female suddenly lost consciousness for 5 minutes and later complained of severe headache. On admission, the next day, consciousness was clear and she showed no neurological deficit except for right motor weakness. CT scan revealed subarachnoid hemorrhage, and carotid angiography showed triplicated anterior cerebral artery with a saccular aneurysm on the Acc ACA. Twenty hours after the onset, an operation was performed to clip the aneurysm neck. Post-operative course was uneventful and she was discharged on the 25th postoperative day without neurological deficits. When the median artery of corpus callosum(MACC), a branch of anterior communicating artery distributes to one or to both hemispheres, it is called Acc ACA. It is thought to be a vascular anomaly and which has an incidence of 20%. However, cases of aneurysm of MACC (or Acc ACA) have not been reported and our case is considered to be the first.     

Three cases of acute interhemispheric subdural hematoma

Traumatic acute subdural hematomas over the convexity of the cerebral hemispheres are often encountered, but acute interhemispheric subdural hematomas are rare. Fourty-eight cases of acute subdural hematomas was admitted to our hospital between 1977 and 1986, and three cases of them (6%) were located in the interhemispheric subdural space. In this paper, these three cases are reported with 20 documented cases. Case 1: an 81-year-old female was admitted to our hospital because of headache, nausea and vomiting. She hit her occiput a week ago. CT scan demonstrated contusion in the right frontal lobe and a high density in the interhemispheric space of the right frontal region. Her complaints disappeared gradually by conservative therapy and she returned to her social life. Case 2: a 50-year-old male fell downstairs and hit his vertex. As he lost consciousness, he was admitted to our hospital. He was stuporous and had left-hemiparesis. Skull X-ray film showed fracture line extending from the right temporal bone to the left parietal bone across the midline. CT scan revealed intracerebral hematoma in both frontal lobe and right parietal lobe and subarachnoid hemorrhage in the basal cistern and Sylvian fissure of the right side. And interhemispheric subdural hematoma in the right parietal region was visualized. Angiography demonstrated a lateral displacement of the right callosomarginal artery and an avascular area between the falx and the callosomarginal artery. After admission his consciousness recovered and convulsion was controlled by drug. Left-hemiparesis was improved by conservative therapy and he was discharged on foot.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of symptomatic traumatic cerebral vasospasm associated with hyponatremia

The pathogenesis and clinical course of traumatic cerebral vasospasm (TCV) are not yet fully understood. We report a case of delayed symptomatic TCV exaggerated by hyponatremia in spite of minor subarachnoid hemorrhage. A 77-year-old woman was admitted to our hospital with multiple injury caused by a traffic accident. Glasgow coma scale on admission was 8, and CT scan revealed right temporal lobe contusion, thin sub-arachnoid hemorrhage in the right sylvian cistern and right temporal bone fracture. The patient's consciousness level and CT findings improved gradually, but on the 11th day, she suddenly fell into a comatose state. No apparent change was observed on the CT scan, but her serum sodium level was markedly low (113 mEq/L). Under the suspicion of hyponatremia induced consciousness disturbance, sodium replacement therapy was commenced. She showed transient neurological recovery, but on day 13, worsening of left hemiparesis and a new low density area on CT were observed. Vasospasms of the right M2 proximal portion were confirmed by cerebral angiogram, so we performed intraarterial papaverine infusion leading to good extension of spastic vessels, but regrettably, there was no neurological recovery. In general, subarachnoid blood plays an important role in the delayed development of cerebral vasospasm, following not only aneurysmal rupture but also head injury. TCV tends to pass subclinically, but secondary water and electrolyte imbalance may unexpectedly cause TCV to manifest itself clinically. We can confirm that with this patient management of electrolyte balance following head injury was the most important strategy to avoid symptomatic TCV.     

Anatomical landmarks for hemispherotomy and their clinical application

OBJECT: The authors introduce the surgical concept of the central core of a hemisphere, from which anatomical structures are disconnected during most current hemispherotomy techniques. They also propose key anatomical landmarks for hemispherotomies that can be used to disconnect the hemisphere from its lateral surface around the insula, through the lateral ventricle toward the midline. METHODS: This anatomical study was performed in five adult cadaveric heads following perfusion of the cerebral arteries and veins with colored latex. Anatomical landmarks were used in five hemispheric deafferentations. The central core of a hemisphere consists of extreme, external, and internal capsules; claustrum; lentiform and caudate nuclei; and thalamus. Externally, this core is covered by the insula and surrounded by the fornix, choroid plexus, and lateral ventricle. During most hemispherotomies, the surgeon reaches the lateral ventricle through the frontoparietal opercula or temporal lobe; removes the mesial temporal structures; and disconnects the frontal lobe ahead, the parietal and occipital lobes behind, and the intraventricular fibers of the corpus callosum above the central core. After a temporal lobectomy, the landmarks include the choroid plexus and posterior/ascending portion of the tentorium to disconnect the parietal and occipital lobes, the callosal sulcus or distal anterior cerebral artery (ACA) to sever the intraventricular fibers of the corpus callosum, and the head of the caudate nucleus and ACA to detach the frontal lobe. CONCLUSIONS. These landmarks can be used in any hemispherotomy during which a cerebral hemisphere is disconnected from its lateral surface. Furthermore, they can be used to perform any resection around the central core of the hemisphere and the tentorial incisura.     

Microsurgical anatomy of the distal anterior cerebral artery

The microsurgical anatomy of the distal anterior cerebral artery (ACA) has been defined in 50 cerebral hemispheres. The distal ACA, the portion beginning at the anterior communicating artery (ACoA), was divided into four segments (A2 through A5) according to Fischer. The distal ACA gave origin to central and cerebral branches. The central branches passed to the optic chiasm, suprachiasmatic area, and anterior forebrain below the corpus callosum. The cerebral branches were divided into cortical, subcortical, and callosal branches. The most frequent site of origin of the cortical branches was as follows: orbitofrontal and frontopolar arteries, A2; the anterior and middle internal frontal and callosomarginal arteries, A3; the paracentral artery, A4; and the superior and inferior parietal arteries, A5. The posterior internal frontal artery arose with approximately equal frequency from A3 and A4 and callosomarginal artery. All the cortical branches arose more frequently from the pericallosal than the callosomarginal artery. Of the major cortical branches, the internal frontal and paracentral arteries arose most frequently from the callosomarginal artery. The distal ACA of one hemisphere sent branches to the contralateral hemisphere in 64% of brains. The anterior portions of the hemisphere between the 5-cm and 15-cm points on the circumferential line showed the most promise of revealing a recipient artery of sufficient size for an extracranial-intracranial artery anastomosis. The distal ACA was the principal artery supplying the corpus callosum. The recurrent artery, which arose from the A2 segment in 78% of hemispheres, sent branches into the subcortical area around the anterior limb of the internal capsule.     

Two cases of elderly patients with ruptured AVM with contrast medium extravasation during cerebral angiography]

Two cases are reported of elderly patients who experienced intracranial extravasation of contrast medium (CM) during carotid angiography (CAG) for ruptured cerebral arteriovenous malformations (AVM). The first patient, an 87-year-old male with no history of hypertension, was admitted immediately following a loss of consciousness after swimming in a pool. CT scan revealed a large intracranial hematoma in the left frontal lobe. CAG performed 1 hour after his arrival revealed a small AVM, fed by the left anterior cerebral artery with concomitant extravasation of CM. The patient's condition subsequently deteriorated and he died the following day. The second patient, a 71-year-old female, was admitted to our hospital in a comatose state after complaining of a severe headache. CT scan revealed a right parietal lobe hemorrhage extending into the ventricles. CAG was performed and demonstrated a small AVM in the right parietal lobe with extravasation of CM. Following emergency removal of the hematoma and AVM, the patient regained consciousness although some motor deficits persisted. A literature review revealed that only 6 cases of CM extravasation with ruptured AVM have been previously reported. The 4 previous cases involved patients 9, 15, 33 and 66-year-old, the younger three of which had a good outcome. The patients reported here were much older, and had a much less favorable outcome. Thus, AVM with CM extravasation may have a better prognosis in younger individuals.     

Acquired stuttering associated with callosal infarction: a case report

A 66-year-old right-handed man with acquired stuttering was reported. He complained of paresis in his left leg and speech dysfluency. He was not aphasic in terms of comprehension and writing. His speech dysfluency was mainly characterized by initial syllable repetitions. He has apraxia with his left hand, but has neither agraphia with his left hand nor crossed optic ataxia. MRI showed cerebral infarction in the truncus of the corpus callosum, and angiography revealed occlusion of the right anterior cerebral artery. 99mTc HM-PAO SPECT showed decreased blood flow in the right frontal lobe. Within six months of its onset, the patient's speech dysfluency had diminished. As the causative lesion for acquired stuttering, we proposed a hemispheric lesion in addition to a callosal lesion.     

Pontine infarction induced by injury of the perforating branch of the basilar artery after blunt head impact: case report

A 77-year-old male pedestrian was hit by a car. On admission, he had disturbance of consciousness and left hemiplegia. Computed tomography (CT) indicated only left frontal subcutaneous hematoma and minor hemorrhage in the left frontal lobe, suggesting axonal injury. CT on hospital day 2 revealed a low density area in the right paramedian pons, but CT angiography showed no dissection or occlusion of the vertebrobasilar artery. The diagnosis was pontine infarction resulting from shearing force injury to the paramedian branch of the basilar artery. He was transferred to another hospital for rehabilitation without improvement of symptoms on hospital day 51. Paramedian pontine infarction tends to occur in patients with risk factors for arteriosclerosis, including hypertension, diabetes mellitus, hyperlipidemia, or smoking. The present elderly patient had hypertension and hyperlipidemia, so arteriosclerosis in the paramedian branch may have contributed to his susceptibility to such injury.     

Clinical study of two cases of traumatic cerebellar injury

Two cases of traumatic cerebellar injury complicated with a traumatic medial longitudinal fasciculus (MLF) syndrome or cerebellar mutism were reported, and the cause of these mechanisms was discussed: Case 1: A 9-year-old boy who struck his head in the occipital region during an automobile accident was operated on for a delayed traumatic intracerebellar hematoma. The operation improved the level of his consciousness but MLF syndrome was noticed. The mechanism of traumatic MLF syndrome was discussed in relation to vascular injury and to neurovascular friction. The outcome of the syndrome including our case, which recovered spontaneously, seemed to support the theory of neurovascular injury. Case 2: A 6-year-old boy who struck his head in the temporooccipital region during an automobile accident was admitted to our hospital without conciousness. On admission, contusion of the temporal lobe and left cerebellar hemisphere was demonstrated by a computerized tomography (CT) and magnetic resonance imaging (MRI). A mute state (cerebellar mutism) was recognized after his recovery of consciousness. The cause of the cerebellar mutism was thought to be an injury of the cerebellar vermis or left cerebellar hemisphere. The findings of CT scan and MRI in our case suggested that the cause of the cerebellar mutism was the contusion of these areas.     

Two cases of distal anterior cerebral artery aneurysm associated with accessory anterior cerebral artery

An accessory anterior cerebral artery (accessory ACA) is a rare anomalous vessel arising from the anterior communicating artery as a median artery of triplicated ACA. It is considered a large median artery of the corpus callosum and distributes to one or both hemispheres. The cases of an accessory ACA aneurysm are extremely rare; however, we experienced two cases of unruptured aneurysm growing at the distal portion of an accessory ACA. Two females, aged 66 and 67 years, respectively, separately consulted our hospital as a result of chronic headaches. Brain MR angiography and following DSA in the first patient demonstrated a triplicated ACA and an aneurysm located just above the corpus callosum growing from the distal portion of the accessory ACA. MRI and MR angiography in the second patient depicted a triplicated ACA and an aneurysm from the accessory ACA as with the first case. Neck clipping of the aneurysm was performed using an interhemispheric approach in both cases. These aneurysms appeared to present the same intraoperative findings as other unruptured aneurysms growing at the usual positions.     

Traumatic internal carotid artery dissection due to compression by a helmet strap

It is well known that wearing a helmet can reduce the risk of head injury in a traffic accident. We report a case of traumatic cervical internal carotid artery dissection due to compression by the strap of a helmet after a motorcycle accident. A 21 year-old man fell off his motorcycle and his head was struck at the right parietal region. His helmet prevented head injury, but the helmet strap which was fixed around his neck compressed his cervical internal carotid artery. He lost consciousness and developed left hemiparesis two hours after being admitted to an emergency department. Cerebral angiography revealed dissection of he right cervical internal carotid artery. This lesion was treated successfully by stent placement two months after the accident. The cause of carotid dissection was thought to be compression of his neck by the helmet strap. If the strap of a helmet is fixed around the neck, it can cause carotid artery injury during an accident, so it can be concluded that the strap of a helmet should be fixed firmly at the chin.     

Bilateral traumatic hemorrhage in the basal ganglia: report of two cases

Hematomas of the basal ganglia in head injury have long been recognized by pathologists with an interest in head injury but their mechanism has not been revealed clearly. We report two cases of bilateral traumatic hemorrhage in the basal ganglia. Case #1, a 17-year-old male was admitted to our hospital immediately after a traffic accident. Neurological examination revealed that the patient was comatose and had right hemiparesis. CT scan showed bilateral hemorrhage of the basal ganglia and subarachnoid hemorrhage in the perimesencephalic cistern. MRI showed high signal intensity areas in the bilateral basal ganglia, perimesencephalic cistern, cerebral white matter and corpus callosum. The patient was diagnosed as having diffuse axonal injury coinciding with bilateral hemorrhage of the basal ganglia. Stereotactic aspiration for the hematoma of the left basal ganglia was carried out. Case #2, a 75-year-old male was admitted immediately after falling from the roof of his house. Neurological examination revealed no neurological deficit except for headache and nausea. CT scan on the day of injury revealed no abnormality. But CT scan 12 hours following the injury showed bilateral hemorrhage of the basal ganglia. Blood pressure of the patient was within normal range and he was diagnosed as having traumatic bilateral intracerebral hematoma. Conservative treatment was carried out and the patient was discharged 7 days after injury with no neurological deficit. The mechanism of traumatic hemorrhage of the basal ganglia has not been clear. In case #1, diffuse axonal injury (DAI) may have played an important role in the bilateral hemorrhage. But in case #2, non-DAI factor such as vasoparalysis syndrome may have existed.(ABSTRACT TRUNCATED AT 250 WORDS)     

Correlation of atrophy measures on MRI with neuropsychological sequelae in children and adolescents with traumatic brain injury

To examine the relationship between neuropsychological sequelae and atrophy parameters from magnetic resonance imaging (MRI) following paediatric moderate-to-severe traumatic brain injury (TBI), 19 head-injured children and adolescents were studied at least 6 years after injury. Three-dimensional MRI scans were obtained. A semi-automatic computerized method was used to estimate ventricular volumes and the corpus callosum area. Tests of intellectual, memory, visuospatial, frontal lobe, and motor speed functioning were administered to all patients and to 19 matched normal control subjects. Patients' performance significantly differed from controls in general intellectual function, visual memory, visuospatial and frontal lobe tests. The corpus callosum area correlated strongly with several measures involving processing speed and visuospatial function. Ventricular enlargement was less related to neuropsychological outcome. In conclusion, quantitative measurement of the corpus callosum on MRI reflects neuropsychological outcome better than ventricular dilation in paediatric patients.     

Anterior cerebral artery dissections manifesting as cerebral hemorrhage and infarction,and presenting as dynamic angiographical changes--case report

A 65-year-old woman presented with multiple dissecting aneurysms of the anterior cerebral artery (ACA) manifesting as hemiparesis on the right with dominance in the lower extremity. Computed tomography revealed hematoma in the left frontal lobe, corresponding to the area perfused by the callosomarginal artery. Initial angiography showed string sign and occlusion in the distal portion of the left callosomarginal artery and abnormal feeding suggesting double lumen of the A2 portion of the left ACA. The patient was treated conservatively under a diagnosis of multiple spontaneous dissecting aneurysms of the left ACA. Repeat angiography on Day 8 showed improvement of the string sign and occlusion in the left callosomarginal artery, and change of the double lumen of the A2 portion into string sign. Further angiography on Day 36 showed normalization of the left callosomarginal artery and improvement of the string sign in the A2 portion. Multiple spontaneous dissecting aneurysms of the ACA are extremely rare. Serial angiography beginning in the early stage will be important for correct diagnosis.