Brain abscess following cerebral infarction: a case report

The authors report a case of brain abscess following cerebral infarction. A 73-year-old man was admitted to our clinic with symptoms of right hemiparesis and total aphasia. CT scan revealed abnormal low density area in the left fronto-temporo-parietal region. Cerebral angiography demonstrated occlusion of the left middle cerebral artery at the M1 portion. On the 16th hospital day, an episode of generalized seizure with high fever appeared, and intermittent high fever persisted thereafter. Two months after admission, CT scan revealed several cystic lesions with marked ring enhancement at the site of cerebral infarction, suggesting multiple abscesses. Aspirations of left frontal and parietal abscesses were accomplished and the cultures of the pus disclosed Proteus vulgaris. Due to progressive hydrocephalus, a ventriculoperitoneal shunt was constructed one month later. Repeated CT scans showed a gradual diminution of the abscesses. It is considered that the blood-brain barrier is broken and the local immunological system against bacteria may be weakened when the brain is damaged by ischemia. Brain abscess seems to be developed in such circumstances even under the influence of transient bacteremia which originates in other parts of the body. Therefore the possibility of cerebral abscess should be suspected if patients with cerebral infarction suffer from the symptoms such as fever, neck stiffness or disturbance of consciousness.     

Three cases of non-traumatic acute subdural hematoma]

The authors present three cases of non-traumatic acute subdural hematoma showing interesting clinical features and operative findings. Case 1: A-50-year-old male was admitted because of sudden headache and epileptic seizure. Computed tomographic (CT) scan showed a right thin subdural hematoma, but cerebral angiography demonstrated no pathological findings, that might cause acute subdural hematoma on the follow-up CT scans. The hematoma changed to a chronic one within only 15 days, which was proved by the operation. Case 2: A 52-year-old male was hospitalized because of loss of consciousness. CT scan revealed a right subdural hematoma without subarachnoid hemorrhage and cerebral angiography demonstrated a right middle cerebral artery aneurysm. The hematoma was surgically proved to be due to rupture of the aneurysm. Case 3: A 52-year-old male was admitted because of headache, vomiting and left motor weakness. CT scan showed a thick right subdural hematoma and right carotid angiography revealed two internal carotid artery aneurysms. It was surgically certified that the subdural hematoma was caused by a tear in a cortical artery attached to the dura, not by the rupture of the aneurysms. Clinical cause and pathogenesis of so-called "non-traumatic" or "spontaneous" acute subdural hematomas were discussed, and the importance of emergency angiography for this condition is stressed.     

Agenesis of the left internal carotid artery, common carotid artery and main trunk of the external carotid artery associated with multiple cerebral aneurysms: case report

A case of agenesis of the left internal carotid artery, common carotid artery and main trunk of external carotid artery with multiple cerebral aneurysms is presented. No similar case has been reported before. A 70-year-old man who had severe headache was admitted to the neurological department of Matsuyama Shimin Hospital. On admission he demonstrated nuchal rigidity and motor aphasia. CT scan revealed subarachnoid hemorrhage with intracerebral hematoma in the left temporal area. Right common carotid angiography, bilateral retrograde brachial angiography and aortography demonstrated an agenesis of the left internal carotid artery, common carotid artery and main trunk of external carotid artery with aneurysms of the anterior communicating artery, left middle cerebral artery and basilar tip. And these revealed that the left middle cerebral artery was fed from the basilar artery via the dilated left posterior communicating artery, and the left ophthalmic artery was originated from the left middle cerebral artery. CT of the base of the skull revealed no carotid canal on the left side. We confirmed these findings by operation. The importance of altered hemodynamic forces on the circle of Willis produced by the agenesis of the internal carotid artery and the embryological considerations are discussed.     

Two cases of spontaneous occlusion of the internal carotid artery due to a giant intracranial internal carotid artery aneurysm

Although spontaneous thrombosis of a giant intracranial aneurysm is comparatively common, its parent artery occlusion is rare. Recently we experienced two cases in which spontaneous thrombosis of giant intracranial internal carotid artery aneurysm and occlusion of its parent artery were occurred. Case 1. A 49-year-old man, complaining esotropia was referred to us by an ophthalmologist. He had no particular past history. Neurological examination revealed left oculomotor, abducens palsy and disturbance of left trigeminal first branch. CT scan revealed a round high density mass in the left middle fossa. The size was 3 cm in diameter. Left CAG revealed severe stenosis of left internal carotid artery and in delayed phase, faint shadow was seen near posterior clinoid process. MRI revealed a high intensity mass of the intraaneurysmal thrombus in the left middle fossa with small low intensity area indicating residual lumen. With conservative treatment, the symptom was gradually improved and one month after admission, complete occlusion of the left internal carotid artery was seen by angiography. The patient returned to his previous occupation. Case 2. A 21-year-old man was admitted to our hospital complaining dysarthria and left hemiparesis. He had been diagnosed as left internal carotid giant aneurysm 5 years before when he had suffered from right visual disturbance. Neurological examination revealed left hemiparesis and dysarthria. CT scan revealed high density mass which extended from the base of the right middle fossa to the third ventricle.(ABSTRACT TRUNCATED AT 250 WORDS)     

Traumatic occlusion of the extracranial internal carotid artery. Report of two cases

Two cases of tapered occlusion of the unilateral internal carotid artery after head and facial injury are reported. The first was a 42-year-old male admitted because of left hemiparesis 3 hours after receiving blows to the face. Computed tomography (CT) scan obtained 10 hours after injury showed an area of slight low density in the right frontotemporal region. Carotid angiography demonstrated tapered occlusion of the right cervical internal carotid artery. A large cerebral infarction had developed in the right hemisphere and the patient died 10 days after the traumatic incident. The second case involved a 45-year-old male hospitalized with aphasia and right hemiparesis about 1 month after incurring a depressed fracture of the left temporal bone. CT revealed two small low-density areas in the left corona radiata, and carotid angiography disclosed tapered occlusion of the left cervical internal carotid artery. The neurological signs gradually improved after anticoagulant therapy. Early diagnosis of traumatic cervical carotid artery occlusion may be difficult in the absence of apparent cervical trauma with focal cerebral symptoms appearing after a lucid interval. No definitive management has been established and the prognosis is poor. It is emphasized that unusual neurological symptoms following head or cervical trauma should provoke suspicion of carotid artery injury, which, on diagnosis, should be promptly treated.     

Two cases of ruptured fusiform aneurysm of the proximal anterior cerebral artery (A1 segment)

Two rare cases of fusiform aneurysms of A1 segment of the anterior cerebral artery are reported. Case 1: A 62-year-old woman was admitted with sudden onset of severe headache and loss of consciousness, on August 22, 1982. CT scan showed subarachnoid hemorrhage at the basal cisterns. Left carotid angiography revealed a spindle shaped aneurysmal dilatation in the A1 segment of the anterior cerebral artery. Four-vessel angiography was performed twice but no other aneurysm was found. She was treated conservatively and the clinical course was not eventful. She was discharged with no neurological deficit one month after the admission. Case 2: A 49-year-old man complained of sudden onset of severe headache, nausea and vomiting on August 24, 1986. He was transferred to a local hospital and CT scan showed subarachnoid hemorrhage at the basal cisterns. Angiography revealed a fusiform aneurysm of the proximal anterior cerebral artery. He was referred to our hospital on the day of onset. He was operated on via bifrontal interhemispheric approach. The fusiform aneurysm of A1 segment was trapped successfully using temporary occlusion of A1 and A2 bilaterally under the administration of Sendai-Cocktail. V-P shunt was performed 1 week after the aneurysmal operation. The post-operative course was uneventful. He was discharged with no neurological deficit three months after operation. As far as we know, there are 6 cases of fusiform aneurysm of A1 segment of anterior cerebral artery in the literature. In this report, our two cases were described and treatment of such aneurysms were discussed.     

Bacterial intracranial aneurysms associated with infectious endocarditis--report of 3 cases

Three cases of bacterial intracranial aneurysms associated with infective endocarditis are reported. All of the patients were successfully treated by various combinations of cardiac surgery, neurosurgery and chemotherapy with antibiotics. Case 1: A 39-year-old female was admitted with the complaint of sudden onset of severe headache following persistent fever of several month's duration. CT scan revealed a left frontal old hematoma and angiography detected an aneurysm located in the frontal ascending branch of the left middle cerebral artery. After 2 weeks' antibiotic therapy, the second angiography showed the aneurysm to be decreased in size. The third angiography, performed 2 weeks after cardiac valve replacement for infective endocarditis, demonstrated complete resolution of the aneurysm. Case 2: A 19-year-old male entered hospital with high fever and chills. In addition to infective endocarditis, CT scan and angiography revealed an aneurysm arising from the distal portion of the left posterior cerebral artery. The patient was treated with high dose antibiotics and then his general condition improved. However, angiography examined 4 weeks after the initial study demonstrated the aneurysm to be apparently enlarged. Therefore, the aneurysm was excised before cardiac surgery. Repeated angiography after valve replacement showed no further aneurysm. Case 3: A 30-year-old female was admitted on the diagnosis of infective endocarditis and meningitis. CT scan showed abnormal density areas in the right frontal lobe and the left temporal lobe.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of a basilar bifurcation aneurysm associated with common carotid artery occlusion

A case of a basilar bifurcation aneurysm associated with common carotid artery occlusion is reported. A 40-year-old woman was admitted to our hospital with severe headache and nausea. On admission, no neurological abnormality was observed. CT scan showed thin subarachnoid hemorrhage in the basal cistern. Left vertebral angiograms revealed a basilar bifurcation aneurysm located in the high position. Also, the left internal and external carotid arteries were supplied through the anastomotic muscle branches of the left occipital and vertebral artery. The trunk of the left common carotid artery was not visualised from its origin on the aortogram. CT scan at the level of C6 showed thinning of the left common carotid artery and contrast enhancement study indicated occlusion. Neck clipping of the aneurysm was successfully performed by right trans-sylvian approach. Right zygomatic arch was removed to obtain a wider operative field for avoiding further retraction of the brain tissue. The postoperative course was uneventful except transient disorientation for two weeks. It has been well known that internal carotid artery occlusion may be associated with cerebral aneurysm in some cases. However, it seemed to be a rather rare case that the common carotid artery occlusion due to arteriosclerosis was associated with cerebral aneurysm. Hemodynamic factor was positively suggested for aneurysmal formation in this case.     

Aneurysm of the extracranial internal carotid artery treated by neck resection and end-to-end anastomosis under the administration of brain protective substances

A case of aneurysm of the extracranial internal carotid artery treated by aneurysmal neck resection and end-to-end anastomosis of the internal carotid artery under the administration of Sendai Cocktail, which is composed of 20% mannitol solution, dexamethasone and vitamin E and has brain protective effects from ischemia. The patient, a 55-year-old man, was admitted to Yonezawa City Hospital on October 11, 1984, with chief complaints of transient consciousness disturbance and left hemiparesis. On admission, no neurological deficit was found but pulsatile fixed mass was found in the right submandibular region. CT scan revealed multiple low density areas in the right cerebral hemisphere and right upper cervical mass, which was enhanced in a part. Right carotid angiography revealed aneurysm of the extracranial internal carotid artery. On October 31, 1984, operation was performed. In the operative procedure, it needed temporary occlusion of the right carotid artery for 143 minutes and 14 minutes, because the aneurysm severely adhered to surrounding tissue and extended to the skull base. Collateral circulation through the circle of Willis was poor in this case but ischemic complication was not found. On November 20, 1984, he discharged without neurological deficit. Postoperative angiography, one year after the operation, showed good flow through the site the primary end-to-end anastomosis.     

Spontaneous intracranial internal carotid artery dissection treated by intra-arterial thrombolysis and superficial temporal artery-middle cerebral artery anastomosis in the acute stage--case report--

A 22-year-old man presented with sudden onset of right retro-orbital headache followed by left hemiparesis. Right carotid angiography demonstrated almost total occlusion of the intracranial internal carotid artery (ICA) and severe stenosis of the middle cerebral artery (MCA), presumably caused by arterial dissection. Local arterial injection of urokinase was performed 2 hours after onset. The ICA became patent, but the M2 portion of the MCA was still occluded, and the left hemiparesis did not improve. Superficial temporal artery-MCA anastomosis was immediately performed. The left hemiparesis disappeared completely 6 days after this procedure. Angiography 2 weeks after the onset revealed occlusion of the ICA, and maintenance of blood flow to the right cerebral hemisphere via the anastomosis. Magnetic resonance imaging showed small infarcts in the right cerebral cortex. Repeat angiography after 5 months showed recanalization of the right ICA and the right MCA. Combination of thrombolytic therapy and bypass surgery may be a useful treatment option for patients with sudden occlusion of the intracranial artery caused by dissection.     

Agenesis of the right internal carotid artery associated with complicated anastomosis of middle cerebral artery: a case report

A 57-year-old female was admitted to our hospital because of headache, nausea, and vomiting. Head CT scan demonstrated subarachnoid hemorrhage. Cerebral angiography showed the absence of the right internal carotid artery, and skull base CT of the bone window level revealed the absence of the right carotid canal. The right middle cerebral artery (MCA) and anterior cerebral artery (ACA) were opacified from the left internal carotid artery. The right A1 portion was hypoplastic and the distal portion of the right M1 portion was replaced by several minute complicated anastomotic vessels connected to the right M2 portion. The right MCA territory was mainly supplied by collateral flow from the right ACA and the right posterior cerebral artery via the leptomeningeal anastomosis. These was neither aneurysm nor arteriovenous malformation. The second angiography, 1 week after the initial angiography, showed the same hemodynamic pattern and aneurysms were not found. We diagnosed the patient as agenesis of the right internal carotid artery and the etiology of subarachnoid hemorrhage was suspected to be a rupture of the anastomotic vessels between the right M1 and M2. She was discharged on the 21st hospital day without any neurological deficit.     

Neurofibromatosis with occlusion of the internal carotid artery: case report

Vascular lesions of the central nervous system in neurofibromatosis (NF) are uncommon. Cerebral arterial occlusive diseases in NF have been documented in only 29 patients. This paper reports a case of a 16-year-old male having occlusion of the right internal carotid artery with NF. He was admitted with an episode of clonic convulsion and left hemiparesis at the age of five years. On admission, he had multiple café-au-lait spots, depigmentation and fibroma molle throughout his body. Neurological examination revealed left hemiparesis with hypereflexia and pathological reflex on the left side. CT scan showed brain atrophy of the right hemisphere and low density area in the white matter of the right frontal lobe. Cerebral angiography showed occlusion at the extracranial portion of the right internal carotid artery. He underwent STA-MCA bypass on the right side. On histological examination of a section of STA, the intimal layer was thickened by elastofibrosis. The mechanisms of arterial occlusion in patients with NF are discussed with review of the literature.     

A case of iatrogenic carotid artery dissection treated with radial artery graft

A case of iatrogenic intracranial artery dissection is reported. A 52-year-old female developed severe headache and nausea. Brain CT showed diffuse subarachnoid hemorrhage. On admission, carotid angiography revealed an aneurysm in the right middle cerebral artery and the intact right internal carotid artery. The aneurysm was clipped successfully. Carotid angiography on day 7 revealed dissection in the right internal carotid artery. Repeated angiograms at 10 and 31 days showed progression of the carotid artery dissection. Findings of ECD-SPECT on day 31 (Balloon occlusion test) suggested low perfusion of the right internal carotid artery territory. The patient underwent surgical reconstruction of the right internal carotid artery using a radial artery. She presented with right abducens nerve palsy three days after the radial artery graft. The patency of the radial artery graft was proved by the post-operative angiography. Internal carotid artery dissection may occur spontaneously or as a result of trauma. An iatrogenic dissection is an uncommon complication of cerebral angiography. There are no evidence-based guidelines for the treatment although anticoagulation therapy is most commonly used. The present case emphasizes the usefulness of radial artery graft for traumatic carotid artery dissection.     

Coincidental cerebral aneurysm with brain tumor: report of three cases

We report three cases of coincidental cerebral aneurysm with brain tumor. The incidence of such cases has been said to be 0.3 to 0.7% of all brain tumor cases, and, in our experience, has been 0.9% of 315 patients with brain tumor during the last decade. Case No. 1 was a 60-year-old female suffering from subarachnoid hemorrhage followed by left oculomotor nerve palsy due to rupture of left ICPC aneurysm, with left convexity meningioma which was found incidentally during preoperative cerebral angiography. Case No. 2 was a 47-year-old female suffering from headache, right exophthalmos, and bilateral papilledema. Preoperative CT scan and angiographies revealed right sphenoidal ridge meningioma and unruptured right middle cerebral aneurysm. Case No. 3 was a 28-year-old male with acromegaly. Pituitary adenoma and unruptured anterior communicating artery aneurysm were found preoperatively by CT scan and by angiography, respectively. All cases were well diagnosed preoperatively and surgically treated successfully.     

Endovascular coil embolization for ruptured aneurysm associated with persistent primitive anterior choroidal artery--case report

An 18-year-old man presented with a rare case of a ruptured internal carotid artery (ICA)-persistent primitive anterior choroidal artery (PPAchA) manifesting as sudden onset of headache. Computed tomography (CT) showed subarachnoid hemorrhage. Three-dimensional CT angiography showed a saccular aneurysm at the right ICA-AchA region. Right internal carotid angiography showed a PPAchA and saccular aneurysm. Endovascular treatment of the aneurysm achieved complete aneurysm occlusion.     

Aplasia of the right internal carotid artery presenting with callosal hemorrhage: case report and review of the literature

A 73-year-old woman without a history of cerebral ischemia suffered from sudden onset headache. Brain computed tomography (CT) showed intracerebral hemorrhage in the corpus callosum with intraventricular hemorrhage and thin subarachnoid hemorrhage in the basal cistern. Cerebral angiography showed narrowing of the right internal carotid artery just distal to its origin in the neck and abrupt occlusion just after branching of the ophthalmic artery with moyamoya-like vessels. The right A2 segment showed irregular dilatation and stenosis. The right middle cerebral artery was supplied from the basilar artery via the right posterior communicating artery. There was neither aneurysm nor arteriovenous malformation. Thin-slice bone-window CT of the skull base revealed hypoplasia of the right carotid canal. Aplasia of the right internal carotid artery was diagnosed. The origin of the hemorrhage was thought to be the irregularly opacified right A2 segment, which had been subjected to long-standing hemodynamic stress as collateral vessel.     

A mital valve reconstruction of infective endocarditis with brain abscess and intracranial mycotic aneurysm

A case is reported of a brain abscess and an intracranial mycotic aneurysm associated with infective endocarditis caused by streptococcus intermedius. A 60-year-old man with a history of fever presented aphasia and right hemiparesis. A computed tomographic scan of the head revealed a low-density area with ring enhancement in the left parietal lobe consistent with a brain abscess. An angiography demonstrated an aneurysm on the distal branch of the middle cerebral artery compatible with a mycotic aneurysm. Doppler echo cardiography showed severe mitral regurgitation by chordal ruptures. The brain abscess and intracranial mycotic aneurysm were resolved under appropriate antibiotic therapy for eight weeks. Then, the mitral valve was reconstructed by replacement of the chordae tendineae with expanded polytetrafloroethylene suture and annuloplasty. The patient had no neurologic deficit except for paresthesia in the right hand, and had no mitral regurgitation at discharge.     

Therapeutic irradiation of brain tumor and cerebrovasculopathy

The first case was a 5-year-old girl treated with a total of 6000 rads after total removal of a left temporoparietal tumor extending into the basal ganglia. About 4 years after completion of the radiation therapy, she showed left hemiplegia and deterioration in her level of consciousness. A plain CT scan showed calcification in the region of the bilateral basal ganglia and low density area in the right fronto-parietal region. An enhanced CT revealed gyral enhancements in the pre- and postcentral gyrus of the right hemisphere. Left carotid angiograms showed a narrowing of the horizontal portion and an occlusion of the distal portion of the left anterior cerebral artery. The distal portion of the right anterior cerebral artery was filled through the anterior communicating artery. Right carotid angiograms revealed an occlusion of the terminal portion of the internal carotid artery, retrograde filling of the anterior and middle cerebral arteries by leptomeningeal anastomosis via the posterior cerebral artery, and partial filling of the anterior cerebral artery via the anterior falx artery. Preoperative arteriography did not show occlusion and stenosis of the cerebral arteries. Superficial temporal artery-middle cerebral artery anastomosis in the right hemisphere was performed. Regional cerebral blood flow measured during operation increased from 34 to 72 ml/100 gr/min due to the surgery. About two weeks after surgery, left hemiplegia disappeared completely. The second case was a 67-year-old man who had received radiotherapy, following surgery of a chromophobe pituitary adenoma. About one year after irradiation he began to complain of gait disturbance and dysarthria.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of pulmonary arteriovenous fistula associated with cerebellar abscess]

We report a rare case of pulmonary arteriovenous malformation (PAVM) with cerebellar abscess. The patient was 38-year-old woman who admitted to the local hospital for headache and fever. Subsequently, her condition became critical with consciousness disturbance, and hypoxemia. Brain computed tomography (CT) and chest CT revealed cerebellar abscess and PAVM. She was referred to our hospital for the surgery. Pulmonary angiography demonstrated multiple pulmonary arteriovenous fistulas in the right middle lobe and a single nodular pulmonary arteriovenous fistula in the right S8 (10 x 10 mm). After the drainage for the brain abscess, lobectomy of the right middle lobe and the excision of the nodal fistula in the right S8 were successfully performed in the two-staged operation. The patient has done well with no complication and her hypoxemia was improved.     

Successful intra-arterial fibrinolysis of the anterior choroidal artery in the acute stage of internal carotid artery occlusion: Case report

A 27-year-old man was admitted to our institution with the sudden development of right hemiparesis and dysarthria beginning an hour after the onset of symptoms on August 9, 1992. The patient was found on admission to have right hemiparesis (2/5), hemihypesthesia, hemianopia, dysarthria; he had transient atrial fibrillation. No abnormalities were detected on computed tomography (CT) scans, and cerebral blood flow studies undertaken following conventional CT scans revealed no low flow regions in the left cerebral hemisphere. But cerebral angiography disclosed an occlusion of the left internal carotid artery with well-developed cross-circulation via the anterior communicating artery and embolus lodged at the level of the anterior choroidal artery. Superselective fibrinolysis using Tracker-18 and 420,000 units of urokinase resulting in complete recanalization of the left anterior choroidal artery without distal migration of the embolus. Immediately after the procedure, his neurologic disturbance underwent complete resolution.

In summary, fibrinolysis could be performed but limited to anterior choroidal artery in a case with an occlusion of the internal carotid artery with well-developed cross-flow via the anterior communicating artery; the patient's neurologic condition may deteriorate suddenly if fibrinolysis is incomplete and the embolus migrates to the internal carotid artery.