Systemic multiple aneurysms of the extracranial internal carotid artery, intracranial vertebral artery, and visceral arteries: case report.

A rare case of systemic multiple aneurysms located in the extracranial internal carotid artery, intracranial vertebral artery, and intraperitonial arteries is described. A 56-year-old woman was referred to our hospital with suspected rupture of an aneurysm of the right extracranial internal carotid artery. Digital subtraction angiography demonstrated a giant aneurysm in the right extracranial internal carotid artery and an aneurysm of fusiform type of the left intracranial vertebral artery. The extracranial carotid artery aneurysm was successfully resected, with end-to-end anastomosis of the internal carotid artery, preserving the cranial nerves. Five days later, an aneurysm of the left hepatic artery ruptured unexpectedly and was treated with emergency surgery. Other aneurysms in the liver and spleen were identified on postoperative celiac angiography. The patient subsequently underwent an operation for a left intracranial vertebral artery aneurysm by proximal clipping.     

De novo cerebral aneurysms manifesting as repeated subarachnoid hemorrhage and cerebral ischemic stroke--case report

A 29-year-old man suffered repeated subarachnoid hemorrhage and cerebral ischemic stroke over a period of 6 years. Cerebral angiography at each episode disclosed development of multiple de novo aneurysms at the bilateral middle cerebral arteries (MCAs), internal carotid arteries, right anterior cerebral artery, and right vertebral artery. Two of the ruptured aneurysms were treated by surgical and endovascular treatment, but he died of the effects of rupture of a de novo right MCA aneurysm. Histological examination at autopsy disclosed marked degenerative changes in all layers of the cerebral vessels, which were probably congenital in origin.     

Traumatic aneurysm occurring after surgical procedure of large cerebral aneurysm

A case of intracranial traumatic aneurysms occurring after surgical treatment of a large cerebral aneurysm is reported. A 56-year-old man was admitted to our department with complaints of headache, nuchal pain and nausea. Left carotid angiography (Lt-CAG) revealed a large aneurysm, measuring 20 mm in maximum diameter, of the azygos anterior cerebral artery. Successful clipping operation was performed on day 17 of subarachnoid hemorrhage. Unfortunately, small cortical branches were pulled out during the procedure from the right pericallosal artery. The postoperative Lt-CAG showed formation of two other aneurysms. Second operation was done on day 28 after the first operation. These aneurysms were located at the previously injured sites on the right pericallosal artery. From the history sited above, we diagnosed them as traumatic aneurysms. The second operation resulted in successful obliteration of these two traumatic aneurysms. Literature review yielded 25 similar cases, and the authors discuss the etiologic factors of the traumatic aneurysm due to surgical procedure.     

A 10-year follow-up of extracranial–intracranial bypass for the treatment of bilateral giant internal carotid artery aneurysms in a patient with fibromuscular dysplasia: case report

Cervicocephalic fibromuscular dysplasia (FMD) is an idiopathic, non-inflammatory and non-atherosclerotic arteriopathy which usually affects small- and medium-sized cervical arteries distributed at the atlas and axis interspace. Few cervicocephalic FMD patients are associated with multiple intracranial aneurysms which may rupture or develop. So the authors describe a cervicocephalic FMD patient with a history of right oculomotor palsy in 2000. Angiography revealed bilateral internal carotid artery (ICA) aneurysms and a fusiform aneurysm in right vertebral artery. Typical “string-of-beads” phenomenon was observed in V2 segment of left vertebral artery. The right ICA giant aneurysm was treated by right ICA occlusion and superficial temporal artery (STA)-middle cerebral artery (MCA) bypass at that time. Five years later, the patient presented with paroxysmal weakness in right limbs. The subsequent angiography showed the enlargement of left ICA aneurysm. It was treated satisfactorily with left external carotid artery-saphenous vein-MCA bypass and left ICA ligation. During the long-term follow-up, the patient kept no neurological deficit and the angiography showed good patency of bilateral grafts and the lesions in bilateral vertebral arteries remained unchanged.     

Bilateral distal anterior cerebral artery aneurysms associated with polycystic kidney and liver disease; a case report]

A patient who had bilateral distal anterior cerebral artery aneurysms and a right middle cerebral artery aneurysm in association with polycystic kidney and liver disease is reported. A 57-year-old woman was referred to our center with headache and disturbance of consciousness. On admission, her level of consciousness as evaluated by the Japan Coma Scale was 10. CT revealed subarachnoid hemorrhage, especially in the interhemispheric fissures. Right carotid angiography demonstrated bilateral distal anterior cerebral artery aneurysms and a right middle cerebral artery aneurysm. All three aneurysms were clipped in a one-stage procedure. The patient was discharged without any neurological deficits two weeks after the operation. Bilateral distal anterior cerebral artery aneurysms are extremely rare. This is the first report of such aneurysms and a right middle cerebral artery aneurysm in association with polycystic kidney and liver disease. The etiology of these aneurysms is discussed.     

Valve replacement in infective endocarditis with mycotic cerebral aneurysm. Report of a case with successful operation

A 49 year-old woman was hospitalized with headache and left-sided weakness. Computed tomographic scan and carotid angiogram revealed mycotic aneurysms of the bilateral middle cerebral artery with intracranial bleeding. Although all blood cultures were sterile, her physical examination suspected mitral regurgitation due to infective endocarditis and mycotic cerebral aneurysms. Severe congestive heart failure developed immediately after successful clipping for ruptured mycotic aneurysm of the right middle cerebral artery and then mitral valve replacement with prosthetic valve was performed 3 months after craniotomy. At operation, infective endocarditis on the mitral valve was confirmed. Her postoperative course was uneventful and the second craniotomy for aneurysm of the left middle cerebral artery has been planning.     

Extracranial internal carotid occlusion and coexisting ipsilateral intracranial internal carotid aneurysm

A rare case of extracranial internal carotid occlusion with a coexisting ipsilateral internal carotid aneurysm is reported. A 50-year-old male had a sudden onset of severe headache, vomiting and right motor weakness on May 14, 1984. Two days later the patient was transferred to our hospital. On admission he was alert but presented with nuchal rigidity and right moderate hemiparesis. He had an episode of a blunt head injury 12 years previously, but no history of hypertension, diabetes mellitus or cerebral stroke. A computed tomography revealed mild subarachnoid hemorrhage and mild ventricular dilatation. A cerebral angiography did not demonstrate any aneurysms but it revealed occlusion of the right internal carotid artery at the cervical bifurcation. The repeated angiography on May 31 disclosed a saccular aneurysm arising anteromedially at the level of the junction of the right posterior communicating artery and the internal carotid artery. The cervical internal carotid artery remained occluded at the same site. The middle cerebral artery was supplied through the well-developed posterior communicating artery, and the right anterior cerebral artery was supplied through the anterior communicating artery. Clipping of the aneurysm was attempted but it was forcibly trapped because of premature bleeding on June 5. The right V-P shunt was performed for the progressive ventricular dilatation on June 12. The patient was discharged with no paresis on June 20. It has been well known that the uni- or bilateral carotid occlusion, whatever the origins are, are often associated with cerebral aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of persistent primitive proatlantal intersegmental artery (proatlantal artery I) with aneurysm--a case report

A 70-year-old woman was admitted to our hospital with attack of SAH. On admission, she was semi-comatose with no other neurological deficit. Left carotid angiography revealed an aneurysm of the anterior communicating artery and a large abnormal vessel connecting the left external carotid artery and the left vertebral artery. This large anastomotic vessel was thought to be primitive proatlantal intersegmental artery (proatlantal artery I). Right carotid angiography revealed a coiling of the right internal carotid artery and hypoplasia of the right A1 portion. Left retrograde brachial angiography revealed aplasia of the left vertebral artery. After admission her consciousness gradually improved but 17 days after admission she died of rerupture of the aneurysm. Autopsied brain showed that the left vertebral artery, namely proatlantal artery, was almost as large as the basilar artery and its macroscopical appearance was similar to other arteries. It was also obvious that the right vertebral artery was hypoplastic. As the rate of combination of the persistent artery with the intracranial aneurysm is relatively high, the authors think that some congenital factor may affect the occurrence of intracranial aneurysms.     

Anterior inferior cerebellar artery aneurysm, carotid bifurcation aneurysm, and dural arteriovenous malformation of the tentorium in the same patient

An exceptional combination of intracranial vascular malformations is reported: distal anterior inferior cerebellar artery (AICA) aneurysm, carotid bifurcation aneurysm, and dural arteriovenous malformation (DAVM) of the tentorium. The AICA aneurysm was the source of recurrent subarachnoid and cerebellar hemorrhage, revealed only after repeated vertebral angiography. After external drainage of associated hydrocephalus, both aneurysms were successfully clipped and the dural malformation was subtotally embolized. The literature concerning AICA aneurysms, DAVMs, and combined intracranial vascular malformations is reviewed and discussed.     

Familial cerebral aneurysms in three families, with two sibling pairs

The authors describe two pairs of siblings and a mother-son with cerebral aneurysms and the characteristics of familial intracranial aneurysms are briefly discussed. Family 1: A 54-year-old hypertensive woman (case 1) developed subarachnoid hemorrhage and a saccular aneurysm at the proximal portion of the left anterior cerebral artery was demonstrated on the angiogram. An azygos anterior cerebral artery was found as an associated anomaly. A 53-year-old hypertensive woman (case 2), a younger sister of case 1, suffered from subarachnoid hemorrhage and a saccular aneurysm at the distal portion of the right anterior cerebral artery was found on the angiogram. Vertebral angiogram showed bilateral fenestration of the extracranial vertebral arteries as a coincidental anomalies. Neck clipping for the aneurysms were successfully done in these two cases. Family 2: A 52-year-old hypertensive woman (case 3) suffered from subarachnoid hemorrhage and vertebral angiogram demonstrated a saccular aneurysm at the distal portion of the right posterior inferior cerebellar artery. The aneurysm was re-bled before surgical intervention and she died five days after admission. A 65-year-old hypertensive woman (case 4), an elder sister of case 3, was admitted with subarachnoid hemorrhage. Vertebral angiogram showed a saccular aneurysm on the proximal portion of the left posterior inferior cerebellar artery at the junction of the vertebral artery and a massive extravasation of the contrast medium from the aneurysm. The patient died three days after the onset before surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multiple "mirror" aneurysms involving intracavernous carotid arteries and vertebral arteries: case report

BACKGROUND: Bilateral intracavernous carotid artery aneurysms are rare. Moreover, the proportion of vertebrobasilar aneurysms in association with multiple aneurysms is extremely low. We describe a rare case of "mirror" aneurysms on the bilateral intracavernous carotid and bilateral vertebral arteries. CASE DESCRIPTION: A 54-year-old male suffered from ophthalmic pain and oculomotor palsy on the left side. Cerebral angiography disclosed a giant left cavernous aneurysm and large asymptomatic aneurysms on the right intracavernous carotid artery and bilateral vertebral arteries. The cavernous sinus syndrome on the left side was successfully treated by left carotid artery ligation. However, 2 years later, severe subarachnoid hemorrhage (SAH) occurred. Computed tomography revealed thick clots densely distributed in the basal cisterns and third and fourth ventricles, indicating that the SAH originated from one of the vertebral artery aneurysms. Consciousness disturbance progressed rapidly, leading to cardiopulmonary arrest. CONCLUSION: The literature contains no case of mirror intracranial aneurysms involving both intracavernous carotid and vertebral arteries. Multi-staged surgical techniques with optimal combinations of direct clipping, ligation or trapping, and endovascular embolization may be essential for patients with multiple aneurysms to avoid SAH.     

Bilateral distal anterior cerebral artery aneurysm associated with supreme anterior cerebral artery: case report]

A 67-year-old woman presented with bilateral distal anterior cerebral artery aneurysms manifesting as consciousness disturbance. Computed tomography revealed subarachnoid hemorrhage in the interhemispheric fissure, right sylvian fissure, and a hematoma in the right frontal lobe and lateral ventricles. Angiography showed bilateral symmetrical aneurysms located on the pericallosal artery at the bifurcation of the callosomarginal artery. The operation was performed on the day the patient was admitted. The aneurysms were clipped via the interhemispheric approach, and the hematoma was aspirated. Operative view demonstrated rupture of the left aneurysm, and supreme anterior cerebral aneurysm. Postoperative angiography showed disappearance of the aneurysms and an intact bilateral anterior cerebral artery. The patient was discharged with mild organic mental syndrome. However, a few days later, she was admitted again with a high fever and died of complications due to sepsis. Pathological view showed clipped aneurysms and the connection of the bilateral distal anterior cerebral artery with the so-called supreme anterior communicating artery.     

Digital subtraction angiography and dynamic computed tomography for evaluating the hemodynamics in cases of giant intracranial aneurysm

Dynamic computed tomography (CT) and digital subtraction angiography were used for postoperative evaluation of the hemodynamic changes in five patients with giant or large intracranial aneurysms. The lesions in four of these cases were giant or large aneurysms of the internal carotid artery, and were treated by occlusion of the cervical internal carotid artery and superficial temporal-middle cerebral artery anastomosis. The lesion in the fifth case was a giant aneurysm of the right vertebral artery, which was treated by proximal clipping of the vertebral artery. Preoperative digital subtraction angiography revealed aneurysmal staining, and dynamic CT scanning indicated the rapid transit of contrast medium in the dome of the aneurysm. Dynamic CT scanning immediately after operation indicated a low flow state in all of the aneurysms, suggesting that they were thrombosed. Although within a few months the peripheral edges of the aneurysms became enhanced, dynamic CT scanning revealed a slower transit of contrast medium through the centers of the aneurysms than in the basilar artery, and digital subtraction angiography failed to demonstrate aneurysmal staining, suggesting that the aneurysms remained thrombosed. The present data indicate that dynamic CT scanning and digital subtraction angiography may be useful for relatively noninvasive evaluation of the hemodynamic changes in patients with giant intracranial aneurysms.     

A case of multiple mycotic intracranial aneurysms presenting with subdural hematoma]

A patient with subdural hematoma associated with multiple mycotic intracranial aneurysms is reported. A 22-year-old woman presented with headache and disturbance of consciousness. A CT showed subdural hematoma at the tentrium and the left cerebral convexity. Conservative treatment and was used and she was discharged 10 days later. However, follow-up CT demonstrated a parenchymal hematoma in the right posterior temporal lobe. Cerebral angiography demonstrated a large right posterior cerebral aneurysm and multiple right middle cerebral aneurysms. A cardiac ultrasonography showed a verruca at the mitral valve. The posterior cerebral aneurysms increased in size and one new middle cerebral aneurysm appeared at follow-up angiography one week later. Endovascular treatment with coils was applied for the right posterior cerebral aneurysm, and others were treated with antibiotic therapy under serial observation, using MR angiography. She was discharged without any symptoms two months after embolization. Follow-up angiography at one year after embolization showed disappearance of the aneurysms. The possibility of mycotic aneurysm should be considered in the differential diagnosis of non-traumatic acute subdural hematoma.     

Spontaneous middle cerebral artery occlusion with moyamoya-like vessels associated with contralateral middle cerebral artery aneurysm; a case report]

A case of spontaneous middle cerebral artery occlusion with moyamoya-like vessels associated with contralateral middle cerebral artery aneurysm is reported. A 23-year-old male was admitted to our hospital with complaints of severe headache and vomiting. On admission CT scan demonstrated subarachnoid hemorrhage with high density in the left Sylvian fissure and suggested a ruptured left middle cerebral artery aneurysm. Carotid angiograms demonstrated a left middle cerebral artery aneurysm and an occlusion of the right middle cerebral artery at its origin with moyamoya-like vessels. There was no occlusion or stenosis in the bilateral intracranial internal carotid arteries. Furthermore, bilateral vertebral angiograms were also normal. The aneurysm was successfully clipped. The postoperative course was uneventful and the patient was discharged with no neurological deficit. So far as we could ascertain, there have been only 21 cases reported previously of spontaneous middle cerebral artery stenosis or occlusion with moyamoya-like vessels. According to angiographic studies and transcranial Doppler ultrasound findings, we are more inclined to believe that hemodynamic changes secondary to arterial occlusion lead to the formation and growth of aneurysms of the contralateral middle cerebral artery.     

Endovascular treatment for intracranial mycotic aneurysms prior to cardiac surgery.

The management of patients with infective endocarditis complicated by intracranial mycotic aneurysms is controversial. We present the case of a 21-year-old man who suffered from mitral regurgitation with small vegetations due to infective endocarditis. The problem was associated with a ruptured aneurysm on the right anterior cerebral artery and an unruptured aneurysm on the left middle cerebral artery. Endovascular embolization of these aneurysms and subsequent mitral valve repair led to a successful outcome.     

Intracerebral hematoma due to ruptured nontraumatic middle meningeal artery aneurysm--case report.

A 77-year-old woman suddenly lost consciousness and presented with right hemiparesis. Computed tomography showed a large subcortical hematoma in her left frontal lobe associated with subarachnoid hemorrhage. The first impression was hemorrhage due to a ruptured aneurysm of the middle cerebral or the internal carotid artery on the left. Left internal carotid angiography showed no aneurysm or vascular anomaly, but back flow of contrast medium into the external carotid artery disclosed two saccular aneurysms arising from the anterior branch of the left middle meningeal artery (MMA). Emergent surgical intervention confirmed that the hematoma was due to ruptured MMA aneurysm. Nontraumatic MMA aneurysm should be recognized as a possible causative lesion of intracranial hemorrhage despite the extremely low incidence. External carotid angiography should be performed in patients with intracranial hemorrhage in whom no vascular cause can be detected in the internal carotid system.     

An autopsy case of persistent primitive hypoglossal artery with multiple cerebral aneurysms

An autopsy case of persistent primitive hypoglossal artery (PPHA) with multiple cerebral aneurysms is reported. A 54-year-old man with subarachnoid hemorrhage was admitted to Kuwana Hospital three days after the onset. The patient was stuporous and had stiffness of the neck. A computed tomogram showed hematoma in the interhemispheric fissure, subarachnoid hemorrhage in the basal cisterns and bilateral Sylvian fissures, and maxked dilatation of ventricles. Cerebral angiogram revealed the left PPHA and multiple aneurysms at the right anterior cerebral artery (A 2) (ruptured), anterior communicating artery, left anterior cerebral artery (A 1), left internal carotid-anterior choroidal artery junction, right internal carotid artery (C 1), and right middle cerebral artery. Neck clipping of the ruptured aneurysm and ventricular drainage were performed on the day of admission. Eight days after admission he died of rupture of the residual aneurysm. In pathological study, the PPHA was originated from the extracranial portion of the left internal carotid artery, 2 cm distal from the cervical carotid bifurcation, entered the intracranial space through the hypoglossal foramen, and turned into the basilar artery. There were six aneurysms which were shown on cerebral angiogram and another aneurysm on the left anterior inferior cerebellar artery. Microscopic examination revealed atherosclerotic change of the PPHA, true aneurysmal changes of the seven aneurysms and defect of tunica media (Forbus' medial gap) at all of the arterial bifurcations without early aneurysmal changes.     

Aneurysm of anterior communicating artery associated with aortitis syndrome--a treated case by aneurysmal neck clipping (author's transl)

A rare case of the cerebral aneurysm associated with aortitis syndrome was reported. It seems to be the first case in which neck clipping was successfully performed for aneurysm of the anterior communicating artery. The patient was a 48-year-old female afflicted with pulseless disease. She was admitted to Iwate Central Hospital with severe headache, vomiting and unconsciousness on November 16, 1980. Her radial pulse was faint on the right side. The left carotid angiography revealed an aneurysm in the anterior communicating artery, and neck clipping of the aneurysm was performed 17 days after the onset. The right serial brachiocephalic arteriography revealed occlusion of the right brachiocephalic artery and the right common carotid artery. The serial aortography revealed stenosis of the left common carotid artery and the left vertebral artery. In the literature, 4 cases of those 7 cases associated with aortitis syndrome had aneurysms at the basilar bifurcation or basilar top. It seems to be the reason that the vertebral artery outlasts longer in aortitis syndrome. In our case, we can relate the aneurysmal formation of the anterior communicating artery to the hemodynamic overload of the left A1. General anesthesia in such cases was discussed.     

Multiple intracranial aneurysms and vascular abnormalities associated with neurofibromatosis type 1: a case report

We present an unusual case of multiple intracranial aneurysms, persistent primitive trigeminal artery (PPTA), and fenestration of the middle cerebral artery (MCA), associated with type 1 neurofibromatosis (NF 1). The patient was a 55-year-old woman in a state of semicoma. We observed widespread neurofibromas and café au lait spots on her trunk and limbs. Computed tomography (CT) scan revealed diffuse subarachnoid hemorrhage and right frontal intracerebral hemorrhage (WFNS grade IV, Fisher's classification group 4). Cerebral angiography showed two intracranial aneurysms at the anterior communicating artery, an aneurysm at the cavernous portion of the right carotid artery, a PPTA, and MCA fenestration. The patient remained in an apallic state, even after successful clipping of the anterior communicating artery aneurysms.