Haemangioma calcificans presenting as intracranial haemorrhages during pregnancy

A 33-year-old female with intracerebral haemorrhage during pregnancy, associated with subarachnoid and intraventricular haemorrhages, is presented. Intracranial haemorrhages during pregnancy are known to frequently result from cerebral aneurysms or arteriovenous malformations. We believe that this is caused by haemangioma calcificans and is noteworthy in considering the indications for surgical treatment for intracranial calcified lesions suggestive of cavernous haemangioma.     

Dissecting aneurysm of the middle cerebral artery associated with subarachnoid haemorrhage

A 73-year-old male with known hypertension presented with subarachnoid haemorrhage due to a ruptured dissecting aneurysm of the middle cerebral artery. Angiography showed a dilatation with proximal and distal narrowing of the right middle cerebral artery. Conservative treatment resulted in almost complete resolution of the angiographic abnormalities 6 months later. Dissecting aneurysms of the middle cerebral artery with haemorrhagic manifestations are extremely rare and are not generally recognized as a cause of subarachnoid haemorrhage. If angiography fails to demonstrate a saccular aneurysm in a patient with subarachnoid haemorrhage, a ruptured dissecting aneurysm may be a possible cause. Repeat angiography should be performed for definitive diagnosis. More knowledge about the natural course is essential before determining whether surgical treatment is always necessary.     

Simultaneous microsurgical and endovascular management of multiple cerebral aneurysms in acute subarachnoid haemorrhage.

Most aneurysms can be effectively managed using endovascular coiling or microsurgical clipping, but in an acute subarachnoid haemorrhage where there are multiple aneurysms identified, a sequential multimodal approach may prove more beneficial. This report involves a 31-year-old man who presented with sudden onset of severe headache and photophobia. A computed tomography brain scan revealed a diffuse grade II subarachnoid haemorrhagic pattern, and four-vessel angiography revealed two aneurysms: a right middle cerebral artery bifurcation aneurysm measuring 12 x 8 mm and a 4-mm basilar artery aneurysm associated with a fenestration at the confluence of the vertebral arteries. It was not possible to determine which aneurysm or aneurysms were responsible for the haemorrhage using the customary criteria. The patient underwent sequential endovascular coiling of the vertebrobasilar aneurysm without delay, followed immediately by microsurgical clipping of the right middle cerebral artery aneurysm, under a single anaesthetic. The postoperative course was uneventful. This method is a treatment option for acute subarachnoid haemorrhage where there are multiple aneurysms. It is a logical progression of management that could be employed at any experienced neurovascular centre; the employment of a sequential multimodal approach from the integration of these techniques is beneficial to the patient because it decreases morbidity and mortality.     

Epileptic seizures in patients with vascular brain lesions

In a group of 1621 patients with vascular brain lesions (849 males, 772 females) the authors found seizures in 108 cases (56 males, 52 females): in 26 cases of subarachnoid haemorrhage (aneurysms), 6 cerebral haemorrhages, 24 cerebral arterial thromboses, 18 atherosclerosis of brain vessels, 13 cases of embolia, 4 cases of transient cerebral ischaemia, 4 cases of vertebrobasilar insufficiency, 4 cases of cerebrocardiac syndromes, 2 cases of cerebral form of the Winiwarter-Buerger disease and 1 cases each of cerebellar haemorrhage and aortic arch syndrome. In 8 cases family history of epilepsy was elicited. The authors suggest administration of anticonvulsants in justified cases.     

Megadolichobasilar artery and acute cerebrovascular pathology

Sixteen patients with a megadolichobasilar artery and acute cerebrovascular symptoms are reported. All were explored by computerized tomography and vertebral angiography. Nine had transient ischaemic attacks or definitive ischaemic lesions, whereas 7 had subarachnoid or intracerebral haemorrhage. Among the patients with ischaemic troubles, vertebro-basilar insufficiency and pontine infarction were the most common clinico-radiological findings. Among the patients with intracranial haemorrhage, 4 had associated aneurysms or arteriovenous malformations, while 3 had subarachnoid or intracerebral haemorrhage with no vascular malformations on the angiograms. The possible relationships between the megadolichobasilar anomaly and the cerebral ischaemic or haemorrhagic pathologies are discussed also from a review of the pertinent literature.     

Megadolichobasilar artery and acute cerebrovascular pathology

Sixteen patients with a megadolichobasilar artery and acute cerebrovascular symptoms are reported. All were explored by computerized tomography and vertebral angiography. Nine had transient ischaemic attacks or definitive ischaemic lesions, whereas 7 had subarachnoid or intracerebral haemorrhage. Among the patients with ischaemic troubles, vertebro-basilar insufficiency and pontine infarction were the most common clinico-radiological findings. Among the patients with intracranial haemorrhage, 4 had associated aneurysms or arteriovenous malformations, while 3 had subarachnoid or intracerebral haemorrhage with no vascular malformations on the angiograms. The possible relationships between the megadolichobasilar anomaly and the cerebral ischaemic or haemorrhagic pathologies are discussed also from a review of the pertinent literature.     

Distal posterior cerebral artery aneurysm associated with multiple aneurysms

True congenital peripheral aneurysms of the cerebral arteries are rare and may constitute a special entity. We report a rare case of nonmycotic peripheral aneurysm of the posterior cerebral artery (PCA) found in association with aneurysms of distal middle cerebral artery (MCA), junction between basilar artery (BA) and superior cerebellar artery (SCA) and MCA trunk. Our present case was a 37-year-old man with a history of abrupt loss of consciousness. Cerebral angiography revealed a right PCA aneurysm originating at the junction between the trunk of the PCA and the posterior temporal branch, and also aneurysms of the right distal MCA, at the right BA–SCA junction and at the trunk of right MCA just distal to the anterior temporal artery. Distal PCA aneurysm causing subarachnoid hemorrhage was successfully clipped and all the other aneurysms were treated in a one-stage procedure. Pathological examination of the surgically excised distal PCA aneurysmal sac demonstrated no infectious etiology. There have not been any similar cases showing an association of vascular anomalies with distal PCA aneurysm. This is the only reported case with the association of nonmycotic peripheral aneurysms involving the MCA and PCA.     

Subarachnoid haemorrhage in identical twins.

A pair of identical twins both of whom died of subarachnoid haemorrhage from ruptured anterior communicating artery aneurysms are reported. These twins are compared to the three other reported twins with ruptured cerebral aneurysms.     

Detection of cerebral artery fenestrations by computed tomography angiography

Background and purposeCerebral artery fenestrations (CAF) are rare congenital variations usually diagnosed by digital subtraction angiography (DSA). The aim of this study was to examine the frequency of occurrence of fenestrations in cerebral arteries and their coexistence with cerebral aneurysms in computed tomography angiography (CTA).Material and methodsAll reports of cerebral CTA (1140) performed in one institution from March 2005 to December 2007 were analysed. We found 40 patients with single fenestrations of the intracranial arteries. All 40 examinations were retrospectively reviewed for location of vascular malformations and presence of aneurysms or subarachnoid haemorrhage (SAH). Medical histories of those patients were then analysed for evidence of SAH and referral reasons for CTA.ResultsForty fenestrated arteries were found in CTA: 18 basilar arteries (45%), 16 anterior cerebral arteries (40%), 4 anterior communicating arteries (10%) and one middle cerebral artery (2.5%). Only one vertebral artery fenestration was found due to the technique of the examination. Six patients (15%) with fenestrated arteries had a total of 8 aneurysms, although only one aneurysm was ipsilateral to the fenestration. In 8 cases of SAH, two were with no evidence of vascular malformation. The coexistence of CAF and aneurysms in CTA amounted to 15% (6/40), but the incidence of ipsilateral aneurysm was only 2.5% (1/40) and it affected the anterior cerebral artery.ConclusionsBasilar artery fenestration is the most frequent observed fenestration in CTA, followed by anterior cerebral artery and anterior communicating artery fenestrations. Coexistence of fenestration and aneurysm is uncommon in CTA examination.     

Cerebral aneurysms in children.

Childhood intracranial saccular aneurysms are rare, accounting for only 0.6-4.6% of all aneurysms. This paper presents two such cases. A 12-year-old boy developed sudden severe headaches. CT indicated subarachnoid hemorrhage in the bilateral sylvian fissure. Angiography failed to demonstrate any vascular lesions. Repeat angiography, however, revealed a 2 mm aneurysm on the right A-1. A miniclip was successfully applied to obliterate the aneurysm. The postoperative course was uneventful. In the second case, a 3-year-old boy, CT incidentally revealed a bullet-shaped high density area. Angiography demonstrated a large aneurysm arising from the insular portion of the prefrontal branch of middle cerebral artery. This large aneurysm with a broad-based neck was successfully clipped, employing the angioplastic and/or tandem clipping, despite the fact the prefrontal artery unfortunately was compromised in postoperative angiography. The patient was doing well postoperatively. Spontaneous subarachnoid hemorrhage (SAH) in childhood is uncommon. However, when children with SAH is encountered, angiography should be performed repeatedly even if the first angiogram does not demonstrate any vascular abnormality. Childhood aneurysms are increasingly being found incidentally in CT scans. The differences between child and adult aneurysms in regard to site, size, sex predominance, clinical features, and surgical outcome are discussed.     

Mistaken identity: a case of false positive on CT angiography.

We describe the case of a 42-year-old female presenting with subarachnoid haemorrhage from a posterior inferior cerebellar artery (PICA) aneurysm rupture on intracranial digital subtraction angiography (DSA). One year postoperatively, the patient was followed with CT angiography and was reported to show a de novo aneurysm at the bifurcation of the left inferior cerebellar artery (ICA). Subsequent DSA revealed an aberrant vein crossing over the ICA bifurcation on mask phase images. This is the first reported case of a such a reason for a 'false positive' on CT angiography (CTA). The case demonstrates that although CTA has a reported high specificity, careful interpretation of multiple views is required to diagnose intracranial aneurysms when compared to the 'gold' standard of CTA.     

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.     

Disappearance of a cerebral aneurysm--an unusual angiographic event.

Spontaneous thrombosis of cerebral aneurysms demonstrated by angiography is infrequent. This article describes angiographically documented spontaneous thrombosis of an intracranial aneurysm at the posterior cerebral-posterior communicating artery junction in a 40-year-old woman. The initial angiogram done on 16th day after an episode of subarachnoid haemorrhage showed a medium sized aneurysm. Subsequent angiograms done on 30th, 40th and 60th day failed to demonstrate the aneurysm. The factors leading to this rare event remain obscure.     

Ruptured fusiform cerebral aneurysm in a neonate

An 11-day-old male infant presented with subarachnoid and intraventricular haemorrhage caused by a ruptured intracranial aneurysm. Magnetic resonance (MR) angiogram and digital subtraction angiography (DSA) revealed a fusiform aneurysm 10 mm in diameter supplied by the proximal segment of the anterior cerebral artery (A1), with both distal segments (A2) arising from the aneurysm. The right A1 was aplastic. There have been 13 previous case reports of neonatal cerebral artery aneurysms, but only 1 of these has been fusiform. None of the earlier reports has mentioned dysplastic segments or other anomalies of the circle of Willis.

     

Coil embolization of ruptured frontopolar artery aneurysm: Case report

Distal anterior cerebral artery aneurysms are infrequent. The most common location is at the bifurcation of the pericallosal and callosomarginal arteries. Cerebral artery anomalies can sometimes, at least partially, explain aneurysm formation in less common locations in relation to hemodynamic stress caused on the vascular wall. We report a very rare case of subarachnoid hemorrhage due to a ruptured frontopolar artery aneurysm as a part of an anomalous anterior cerebral artery complex that was, for the first time, treated with endovascular coiling.     

Meningeal hemorrhage at a neurological intensive care unit. Study of a series of 234 unselected cases

In a 6-year-period, 234 cases of subarachnoid haemorrhage were observed in a neurological intensive care unit: 74 were male and 69 were female, aged from 15 to 94 years. In 15 cases no other investigation than C.T. scan or lumbar puncture was performed. In 143 patients, cerebral angiography demonstrated a ruptured aneurysm of cerebral vessels and 99 were operated. The prognosis was poor in old age, with aneurysms located on the anterior part of the circle of Willis, severe neurological involvement and extensive subarachnoid or ventricular haemorrhage. A recurrence of the haemorrhage occurred in 18 cases and cerebral ischaemia was present in 69 patients. The mortality rate of patients with ruptured aneurysms was 47.5 p. 100 (30.4 p. 100 when operated). Seventeen patients probably had a ruptured cerebral aneurysm but cerebral angiography was not conclusive; 12 of them died. In 15 other cases, the haemorrhage was related to cerebral angiomas (3 cases), endocarditis (2), coagulation disorders (6), cranial trauma (3) and Moya-Moya disease (1). In 44 patients, the aetiology of subarachnoid haemorrhage was unknown and the mortality rate was 14 p. 100. The poor prognosis of subarachnoid haemorrhage, worse than in neurosurgical series, is emphasized. It may be explained by the lack of selection of the patients in a non-surgical department.     

Cortical Subarachnoid Hemorrhage in Behcet's Disease

ObjectiveCortical subarachnoid hemorrhage (cSAH) can be resulted from by a wide variety of causes. A cSAH probably associated with Behcet's disease is herein reported for the first time.Case reportA 58-year-old male with stable Behcet's disease evaluated for sudden onset headache. Emergency computed tomography disclosed cSAH in the left frontal sulci. A ruptured middle cerebral artery cortical branch aneurysm was found. Surprisingly, this aneurysm obliterated completely after diagnostic catheter angiography.ConclusionThis case highlights three important points; First, non-mycotic (non-infectious) distal cerebral artery aneurysms may rarely cause cSAH. Second, distal dissecting aneurysms may rarely become obliterated after diagnostic cerebral angiography. Third, such aneurysms may be one of the long-term consequences of vascular inflammation in Behçet's disease.     

Characteristics of intracranial aneurysms and subarachnoid haemorrhage in patients with polycystic kidney disease

Background and Purpose: Subarachnoid haemorrhage is a common cause of death in patients with autosomal dominant polycystic kidney disease (ADPKD), but little is known about specific characteristics of subarachnoid haemorrhage and intracranial aneurysms in this group of patients. We performed a systematic review on site, size and number of aneurysms, age at time of rupture, gender, and family history in patients with ADPKD and intracranial aneurysms. We also studied the frequency of ADPKD in patients with subarachnoid haemorrhage treated in our hospital. Methods: We performed a MEDLINE search and checked the reference lists of all relevant publications to identify all articles published from 1980 to 2000 on intracranial aneurysms or subarachnoid haemorrhage in ADPKD. We studied our database of patients with subarachnoid haemorrhage treated between 1978 and 1999 for the presence of ADPKD. Results: We included 53 articles on 369 ADPKD patients (139 [54 %] women) with 462 intracranial aneurysms. Of the 273 aneurysms with specified locations 105 (38 %) were located on the middle cerebral artery in and on the anterior communicating artery in 83 patients (30 %). In 253 patients with data about relatives, the family history was positive for intracranial aneurysms or subarachnoid haemorrhage in 102 (40 %). The average age at which subarachnoid haemorrhage had occurred in 258 was 41 years; of 158 in whom the gender was given; 96 (52 %) were women. Of the 160 patients with data on outcome, 69 (43 %) had died as the result of the subarachnoid haemorrhage. Of the 1147 patients treated for aneurysmal subarachnoid haemorrhage in our institution (mean age 53 years; 65.5 % women), 5 (0.44 %) had ADPKD. Conclusions: Compared with data on patients without ADPKD, subarachnoid haemorrhage in patients with ADPKD occurs not only often in a familial setting of subarachnoid haemorrhage, but also at an earlier age and more often in men. In patients with ADPKD, the most frequent site of aneurysms is the middle cerebral artery. The proportion of patients with ADPKD among all patients with subarachnoid haemorrhage is very small. Received: 17 April 2002, Received in revised form: 11 October 2002, Accepted: 16 October 2002 Correspondence to Professor Gabriel J. E. Rinkel     

Diagnosis of unruptured asymptomatic cerebral aneurysms by magnetic resonance angiography

The purpose of this study was to assess the incidence of unruptured asymptomatic cerebral aneurysms detected by magnetic resonance angiography (MRA). Three thousand patients without major neurological deficit had undergone MRA. MRA was obtained using three-dimensional time-of-flight method. Among the 3000 patients examined, 80 unruptured asymptomatic aneurysms were discovered in 68 patients (2.3%). Twenty-six were located on the internal carotid artery, 28 on the middle cerebral artery, 17 on the anterior communicating artery, 1 on the posterior cerebral artery and 8 on the vertebro-basilar artery. Thirty-seven patients underwent surgery. Mortality was zero and morbidity was 5%. Three patients who declined surgery died of subarachnoid haemorrhage in the ensuing 2.5 years.     

Giant unruptured anterior communicating artery aneurysm presenting with seizure.

Giant aneurysms of the anterior communicating artery (AComA) are rare. The clinical presentation of giant AComA aneurysms is usually associated with the mass effect of the space-occupying lesion or with subarachnoid haemorrhage. A giant AComA aneurysm presenting with a seizure has only been reported twice previously. We report a 70-year-old female patient, in whom a single seizure was the only symptom of a giant AcomA aneurysm, with no neurological deficit. The diagnosis of unruptured giant AComA aneurysm was made with cranial CT, MRI and angiography. The patient refused surgical intervention, was treated with anti-epileptic therapy and has been asymptomatic for 7 months. We suggest that elderly patients presenting with a first seizure need detailed evaluation and giant aneurysms, which may be confused with other intracranial space-occupying lesions, need to be considered in the differential diagnosis.