覆膜支架治疗颈内动脉假性动脉瘤合并海绵窦瘘一例报告并文献复习

目的 报告1例使用覆膜支架治愈颈内动脉假性动脉瘤合并颈内动脉海绵窦瘘(CCF).方法 患者因外伤后右侧上睑下垂、眼肌麻痹、眼球突出、结膜水肿2周来院,血管造影显示:右侧颈内动脉海绵窦假性动脉瘤合并CCF,患者接受覆膜支架介入治疗.结果 Jostent球囊扩张支架置于动脉瘤颈部,经反复扩张后动脉瘤和CCF均不显影.术后患者恢复良好.结论 尽管Jostent覆膜支架用于颅内血管病的治疗仍然存在一些问题,但为颈内动脉海绵窦动脉瘤和CCF的介入治疗提供了一种有效的方法 .     

Traumatic aneurysm of the cortical branch of the middle cerebral artery

A 22-year-old patient is described in whom sudden deterioration developed on the 9th day after severe craniocerebral trauma. Left common carotid angiography demonstrated an aneurysm on a cortical branch of the middle cerebral artery and subdural haematoma. During the operation the aneurysm was excluded from the circulation.     

Cerebral embolism following trivial trauma in children--report of three cases]

Three cases of cerebral embolism secondary to trivial trauma are reported. Case 1: A 12-year-old male suffered a severe headache followed by a generalized convulsion after he turned his head when he was flying a kite. A neurological examination on admission demonstrated right hemiparesis and aphasia. A CT revealed a low density in the left putamen, temporal lobe and frontal lobe. Left carotid angiography (CAG) showed irregular narrowing of the internal carotid with an embolic occlusion and narrowing of the middle cerebral artery with the intraluminal presence of emboli both in the anterior and middle cerebral arteries. He is now doing well but has right hemiparesis. Case 2: This 6-year-old female could not grasp chopsticks and had neck pain 10 minutes after being pulled up by the right arm by her father. Neurological examination demonstrated a right hemiparesis and aphasia. A CT scan and magnetic resonance imaging (MRI) of the head showed an infarcted area in the left caudate head, anterior limb of the internal capsule and putamen. Left CAG revealed an obstruction of the trunk of the middle cerebral artery. She has slight weakness in her right extremities. Case 3: This 11-year-old female noted a weakness in her left lower limb soon after her hair was pulled backward. On admission, a neurological examination failed to demonstrate any abnormality. CT showed an ill defined low density lesion in the right putamen. MRI revealed a high intensity lesion in a T2 weighted image. Right CAG showed an irregularity of the arterial wall in the cavernous portion of the right internal carotid artery.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of Wyburn-Mason syndrome

A extremely rare case of unilateral retinocephalic vascular malformation (Wyburn-Mason syndrome) was reported. A 5 year-old girl was seen to a ophthalmologist complaining of exophthalmus of her left eye after trauma on her face for the past 2 months. On ophthalmologic examinations, retinal arteriovenous malformation was recognized in her left eye and she was referred to neurosurgical service for the evaluation on occurrence of traumatic carotid cavernous fistula. Plain CT did not show any abnormality but enhanced CT revealed an abnormally enhanced lesion in the thalamus and basal ganglia and along to the left optic nerve. Left carotid angiography and vertebral angiography revealed a huge arteriovenous malformation in the left thalamus and basal ganglia extending to the left orbita. The arteriovenous malformation was fed from the C3 segment of the carotid artery, anterior, middle and posterior cerebral arteries, and drained to the internal cerebral vein and basal vein. The intraorbital part of the malformation was mainly fed from the external cerebral artery. She was diagnosed as Wyburn-Mason syndrome. We stressed in the paper that enhanced CT was useful for the diagnosis of the Wyburn-Mason syndrome.     

A case of CNS aspergillosis developing orbital apex syndrome and causing mycotic aneurysm and the subsequent cerebral infarction]

A 79-year-old woman, with no immune deficit, had presented progressive visual disturbance, diplopia and ptosis of her left eye over 2 weeks. T1-weighted MR images with gadolinium showed a heterogeneously enhanced lesion extending from the left orbital apex along the optic nerve to the cavernous sinus. Although we could not detect fungus by a transsphenoidal biopsy, we suspected fungal infection because of high level of galactomanan antigen in serum. Despite antifungal chemotherapy, her symptoms did not improve. CT image on day 40 showed an aneurysm in the left internal carotid artery, on day 43 cerebral infarction in the left internal carotid artery distribution and on day 45 she died. Autopsy disclosed that aspergillus hyphae invaded the left sphenoid sinus, cavernous sinus and wall of the aneurysm. In this case, fungal infection in the frontal skull base including orbital apex caused mycotic aneurysm in the intracavernous portion of the left internal carotid artery. Skull base aspergillosis presenting orbital apex syndrome is itself rare and in addition, the occurrence of cerebral infarction in the mycotic aneurysm has hardly been reported. We should have cerebrovascular disease in mind as a complication of CNS aspergillosis.     

Two cases of intracranial fibromuscular dysplasia whose repeated angiography disclosed progression of the lesion

Fibromuscular dysplasia (FMD) is well known owing to the characteristic angiographical finding of a "string of beads" appearance, but intracranial involvement with this disease is extremely rare. Moreover, to our knowledge, only seven cases that had repeated angiograms disclosed progression of FMD lesion in the literature. Such cases of intracranial FMD which showed progression in the follow-up angiography are reported. Case 1: A 8-year-old boy was referred to our hospital because of aphasia and right hemiplegia following right hemiconvulsion. Left carotid angiography on the 7th day from the onset revealed a "string of beads" appearance involving the left middle cerebral artery from M1 to M2 portion. He was treated with low molecular dextran, urokinase and steroid. After these drugs were administered, his speech was normalized. A repeat left angiogram performed two months later disclosed definite increase in the degree of stenosis associated with FMD. Perivascular sympathectomy around common and internal carotid artery and superior cervical ganglionectomy on the left side carried out on the 70th day from the onset. Postoperative left carotid angiogram showed improvement of the stenosis markedly, and the motor disturbance was improved gradually. Case 2: A 34-year-old woman presented with head dullness and disorientation suddenly. Left carotid angiogram on the third day from the onset showed a "string of beads" appearance from C1 to M1 portion. Follow-up angiography three days later revealed some progression of the stenosis. Furthermore a repeat left angiogram disclosed occlusion of left internal carotid artery at the C2 portion. Left STA-MCA bypass surgery was performed on the 61st day from the onset.(ABSTRACT TRUNCATED AT 250 WORDS)     

Disappearance of a middle cerebral artery aneurysm associated with Moyamoya syndrome after revascularization in a child: case report

Introduction  Pediatric Moyamoya disease is rarely associated with intracranial aneurysms. We report a case of a 7-year-old girl with an antecedent of persistent craniopharyngeal canal, who presented with a history of choreiform movements. Materials and methods  A Moyamoya disease was found with an unruptured left middle cerebral artery aneurysm on her first angiography. Conservative treatment was chosen for the aneurysm and she underwent indirect revascularization by encephalosynangiosis using the multiple bur-hole technique for her Moyamoya disease. Abnormal movements were improved. Control angiogram at 6 months showed development of intracranial–extracranial anastomoses with complete resolution of the aneurysm. Aneuryms including the major arteries of the basal arterial circle occur as a by-product of the high velocity and blood flow secondary to the arterial stenosis. Blood flow modification after revascularization often lead to spontaneous regression and disappearance of these aneurysms. Conclusion  Therefore, a conservative treatment of these proximal aneurysms must be chosen after encephalosynangiosis.     

Bony Protuberances on the Anterior and Posterior Clinoid Processes Lead to Traumatic Internal Carotid Artery Aneurysm Following Craniofacial Injury

Traumatic intracranial aneurysms are rare, comprising 1% or less of all cerebral aneurysms. The majority of these aneurysms arise at the skull base or in the distal anterior and middle cerebral arteries or their branches following direct mural injury or acceleration-induced shearing force. We present a 50-year-old patient in whom subarachnoid hemorrhage (SAH) was developed as a result of traumatic aneurysm rupture after a closed craniofacial injury. Through careful evaluation of the three-dimensional computed tomography and conventional angiographies, the possible mechanism of the traumatic internal carotid artery trunk aneurysm is correlated with a hit injury by the bony protuberances on the anterior and posterior clinoid processes. This traumatic aneurysm was successfully obliterated with clipping and wrapping technique. The possibility of a traumatic intracranial aneurysm should be considered when patient with SAH demonstrates bony protuberances on the clinoid process as a traumatic aneurysm may result from mechanical injury by the sharp bony edges.     

Hyperhomocysteinemia Causes Severe Intraoperative Thrombotic Tendency in Superficial Temporal Artery-middle Cerebral Artery Bypass

Case: Two years ago, annual magnetic resonance imaging for unruptured right internal carotid artery aneurysm of a 47-year-old woman detected a cerebral infarct in her right occipital lobe which was unknown etiology and antiplatelet therapy was initiated. She presented with sensory disorder of her left fingers 4 months ago. Infarction in right parieto-occipital cortex and severe stenosis of right middle cerebral artery was revealed. Her laboratory test was normal except remarkably high homocysteine value. Regardless of dual anti-platelet therapy, she suffered from repeated minor stroke and the stenosis was progressing. Therefore, right superficial temporal artery – middle cerebral artery bypass was undertaken. Aspirin and clopidogrel were withdrawn 1 week before the surgery. Two branches were anastomosed with 2 separate frontal M4 branches. Although patency was confirmed immediately after the anastomosis, thrombus formation was revealed after 10 minutes. We needed to perform removal of the thrombus and re-anastomosis twice. Intraoperative administration of aspirin and ozagrel alleviated thrombotic tendency. After surgery, antiplatelet therapy and supplementation with folate and vitamin B were performed. Her postoperative course was uneventful and patency of both anastomoses was confirmed. Discussion: Controversy still exists regarding preoperative antiplatelet therapy before superficial temporal artery-middle cerebral artery bypass, and folates and B6-12 vitamins supplementation for hyperhomocysteinemia. Considering intraoperative thrombo tendency in our case, it is recommended to evaluate the homocysteine level before bypass surgery for intracranial stenosis especially for young patients or patients with unknown etiology. Before bypass surgery of the patient with hyperhomocysteinemia, continuation of perioperative antiplatelet drugs and supplementation with folates and B6-12 vitamins are mandatory.     

Sphenoid and Subdural Hemorrhage as a Presenting Sign of Ruptured Clinoid Aneurysm

Background

Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage.

Methods

Case report and review of the literature.

Results

We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence.

Conclusions

Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.     

Spontaneous Subdural Fluid Collection Following Aneurysmal Subarachnoid Hemorrhage: Subdural Hygroma or External Hydrocephalus?

Background

Subdural fluid collections (hygromas and effusions) in adults are usually seen following head trauma or overdrainage of cerebrospinal fluid (CSF) after CSF diversion procedures. We report an unusual case of subdural fluid collection that developed spontaneously 5 days after an aneurysmal subarachnoid hemorrhage (SAH). This patient neither had permanent CSF diversion procedure nor history of significant head trauma during her clinical course.

Methods

This study is a Case report of the patient suffering from an SAH.

Results

A 71-year-old woman suffered an SAH from a ruptured right-sided posterior communicating artery aneurysm. Computed tomography (CT) demonstrated diffuse SAH and signs of early hydrocephalus that did not require treatment. The aneurysm was treated with endovascular coil occlusion without any complications. Throughout her hospital course, she remained alert without neurological deficits. A large subdural fluid collection was discovered incidentally during a routine CT scan of the brain 5 days after the SAH. The patient remained asymptomatic; therefore, the collection was treated conservatively. It resolved spontaneously at five days after the initial diagnosis.

Conclusion

Subdural fluid collections following SAH can occur as a result of head trauma, external hydrocephalus, or as a treatment complication of CSF shunting and craniotomies. It is critical to differentiate simple hygromas from external hydrocephalus since their response to CSF diversion is entirely different.     

A case of bilateral extracranial carotid artery aneurysms caused by Takayasu's arteritis]

We describe here successful surgical treatment of a rare case of a rapidly enlarged aneurysm due to Takayasu's arteritis. A 22-year-old woman presented with a 1-month history of hoarseness and left neck pain. Contrast-enhanced computerized tomography showed an unruptured partially thrombosed aneurysm, and angiography revealed a large aneurysm of the common carotid artery. After hospitalization, the symptoms, interestingly, resolved spontaneously. While angiography at 2 weeks after admission showed the aneurysm to have reduced in size, 2 months later it showed the left common carotid artery aneurysm to be substantially enlarged in size and aneurysmal formation of the right external carotid artery. Surgical intervention was performed for the left common carotid artery aneurysm because rapid enlargement indicated the risk of aneurysmal rupture, and the thrombosis might cause embolic occlusion of the cerebral arteries. The left common carotid artery including enlarged aneurysm was trapped and anastomosed with a Gore-Tex graft (6-mm inner diameter) to left internal carotid artery. Histological examination of the arterial wall showed inflammatory change, destruction of the medial elastic fibers, and granulation with multinucleated giant cells. The postoperative course was uneventful, and no new vascular lesion was observed 3 years after operation. We demonstrated the bilateral extracranial carotid artery aneurysms caused by Takayasu's arteritis, which was the first case to be reported in the literature.     

Iatrogenic false aneurysm caused by surgery of a traumatic intracranial false aneurysm

A superficial temporal artery (STA) false aneurysm caused by surgery of a traumatic intracranial false aneurysm is reported. A 28-year-old man underwent craniotomy for aneurysm clipping 20 days after traumatic head injury. At surgery the aneurysm was a false aneurysm due to its avulsion from the parent artery without a real neck. A "clip wrapping" technique was used to repair the deficit on the parent artery. On postoperative Day 25, repeat digital subtraction angiogram (DSA) revealed a new right STA aneurysm, which was not apparent in the preoperative DSA. We feel that this aneurysm might have probably resulted from the iatrogenic injury to the STA during the initial surgery as the location of aneurysm was at the initial craniotomy site. The pathophysiology, etiology, surgical treatment and preventive measures of false aneurysms have been discussed.     

颅内动脉瘤破裂合并颅脑损伤5例分析

目的探讨颅内动脉瘤破裂合并颅脑损伤的临床特征,以此鉴别创伤性蛛网膜下腔出血。方法对我院近三年来收治的5例颅内动脉瘤破裂合并颅脑损伤患者的临床资料进行回顾性研究,总结其临床特征。结果 4例患者入院后急诊经CTA检查证实为颅内动脉瘤破裂出血,其中前交通动脉瘤2例,大脑中动脉瘤1例,颈内动脉-后交通动脉瘤l例;1例患者为动脉瘤再次破裂后行CTA检查示颈内动脉-后交通动脉瘤。急诊开颅血肿清除及动脉瘤夹闭术2例,动脉瘤夹闭术1例,血管内介入栓塞治疗术1例,药物保守治疗1例。恢复良好3例,重残1例,死亡l例。结论对伴有颅脑外伤史的蛛网膜下腔出血应注意考虑颅内动脉瘤破裂的可能,以便采取积极合理的治疗方案。     

Carotid stenting and cerebral hyperperfusion syndrome.

We present a patient who became hemiparetic and drowsy 30 min after insertion of a carotid artery stent for severe (>80%) asymptomatic left common carotid artery stenosis. A carotid angiogram at this time showed widely patent vessels. Non-contrast head computed tomography showed a diffuse increase in signal intensity in the distribution of the left middle cerebral artery. Repeat computed tomography 8 days later showed no evidence of cerebral infarction or haemorrhage. The patient's arm remained weak for several months. A diagnosis of cerebral hyperperfusion syndrome was made. The features of this unusual cause of stroke are reviewed.     

Traumatic middle cerebral artery occlusion from boxing.

A case of a traumatic middle cerebral artery occlusion resulting from a boxing injury is presented. A 22-year-old man, an amateur boxer, was admitted because of difficulty in speaking, that had appeared a day after a sparring fight. A computed tomographic scan showed low-density areas in the left globus pallidus and corona radiata. A carotid angiogram indicated complete occlusion of the left middle cerebral artery at its origin and an irregularity and narrowing of the left internal carotid artery in its supraclinoid portion. The patient was discharged 4 weeks after the admission with some persistent expressive dysphasia that diminished during the next month. The clinical features and mechanisms of the traumatic middle cerebral artery occlusion are discussed.     

A case of agenesis of the corpus callosum accompanied by a ruptured azygos anterior cerebral artery aneurysm and lipoma--a case report

A 53-year-old woman suffered from sudden onset of severe headache on February 28 in 1982. She was admitted to our hospital soon after onset. On admission, she had a severe headache and nausea, and her consciousness was drowsy. CT scan showed a marked subarachnoid hemorrhage with intracerebral and intraventricular hematoma, a separation of the lateral ventricles with enlargement of posterior horns, and deformity of anterior horn. By these findings, the patient was diagnosed as an agenesis of the corpus callosum with subarachnoid hemorrhage. Left carotid arteriogram revealed an azygos anterior cerebral artery and an aneurysm at the terminal portion of this artery. Surgery was performed on the 24 th day after subarachnoid hemorrhage. Operative finding revealed a little finger's head-sized tumor was situated over the right frontobasal artery. An azygos anterior cerebral artery aneurysm was clipped and tumor was removed. Pathological diagnosis of the tumor was a lipoma. Namely, she had an agenesis of the corpus callosum, an azygos anterior cerebral artery, an aneurysm and a lipoma. There are some reports in which an agenesis of the corpus callosum is accompanied with a lipoma and an azygos anterior cerebral artery is accompanied with an aneurysm. But a case of agenesis of the corpus callosum with an azygos anterior cerebral artery was rarely reported. So this rare case with these anomalies was reported and pathogenesis about the development of 4 anomalies was also discussed.     

Infectious aneurysmal rupture presenting as massive intracerebral hemorrhage in a preterm baby

Introduction Infectious intracranial aneurysms in infantile period are very rare, and there is no report of infectious intracranial aneurysm in preterm infant Case report A 43-day-old female infant, delivered at 29 weeks of gestation, presented with massive intracranial hemorrhage. Eighteen days after diagnoses of necrotizing enterocolitis, sepsis, and meningitis, the baby became lethargic with rigid left limbs. Imaging studies revealed a large hematoma in the right temporoparietal region and adjacent lateral ventricle. During removal of fresh hematoma, an actively bleeding nodular mass, contiguous with the distal middle cerebral artery branch, was found and excised from the parent vessel. Pathologic examination revealed a ruptured infectious intracranial aneurysm. After surgery, her neurologic status improved and she was doing well at 12 months’ follow-up with mild spastic hemiparesis. Conclusion To our knowledge, this is the first reported case of infectious intracranial aneurysm in the preterm infant, which was successfully treated with hematoma evacuation and resection of the aneurysm.     

Incorporation of extruded coils into the third nerve in association with third nerve palsy

The extrusion of the coil complex outside of the aneurysmal dome is thought to be an important mechanism by which the aneurysm neck and fundus recanalize, but the migration of the coil loops and their incorporation inside vital nervous structures has not been clearly described. We reviewed the medical literature on coil extrusion and migration and report a rare case of third nerve palsy due to direct damage caused by coil loop migration that resolved after surgery. A 25-year-old woman presented with subarachnoid hemorrhage and painful left third nerve palsy. The angiogram revealed a supraclinoid internal carotid aneurysm incorporating the origin of the left posterior communicating artery. Her aneurysm was coiled. The 8 month follow-up angiogram revealed a major recurrence of her aneurysm. It was decided to surgically clip the aneurysm. At surgery, coil loops were found in the subarachnoid space and embedded into the third nerve. At 1 month follow-up she had recovered well, and only had very subtle diplopia upon fatigue. Coil extrusion is a fairly common phenomenon that should be suspected in instances of major aneurysmal recurrence. Surgical treatment is recommended, and special care should be taken when mobilizing the extruded coil mass.