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.     

Distal anterior choroidal artery aneurysm associated with an arteriovenous malformation. Intraoperative localization and treatment

BACKGROUND

Distal anterior choroidal artery aneurysms are rare. The outcome of patients with distal anterior choroidal artery aneurysms has been poor, and the treatment of such aneurysms is surgically challenging.

CASE DESCRIPTION

The authors describe the case of an 8-year-old girl with a ruptured distal anterior choroidal artery aneurysm associated with an arteriovenous malformation (AVM). The patient experienced sudden onset of headache and vomiting. Computed tomography revealed an intraventricular haemorrhage, and cerebral angiography demonstrated an aneurysm arising from the distal portion of the right anterior choroidal artery. The patient also had an AVM in the ipsilateral temporal lobe fed by the branches of the middle cerebral artery. A right frontotemporal craniotomy was performed with the aid of intraoperative angiography to eliminate both the AVM and the aneurysm. Intraoperative angiography was helpful in confirming the complete removal of the AVM and in accurate localization of the small and deeply placed distal anterior choroidal artery aneurysm. Both the AVM and the aneurysm were successfully treated and the patient was discharged without any neurological deficits.

CONCLUSION

This case is the youngest reported patient with a distal anterior choroidal artery aneurysm. This report is also the first to describe an association of such an aneurysm with an AVM. The etiology of the aneurysm formation in this case and surgical strategy for deeply placed vascular lesions are discussed.     

Distal anterior cerebral artery mirror aneurysms and middle cerebral artery aneurysms

A 52-year-old woman presented with bilateral distal anterior cerebral artery (ACA) mirror aneurysms, in addition to two right middle cerebral artery (MCA) aneurysms. The left distal ACA and right MCA aneurysms were clipped through right interhemispheric and right pterional craniotomies. The right distal ACA aneurysm was thrombosed. Distal ACA aneurysms tend to be multiple, but mirror aneurysms are rare, especially in the absence of congenital vascular anomaly. Single stage unilateral craniotomy is recommended for surgical treatment.     

Four cases of the infectious cerebral aneurysms

The authors evaluated various clinical courses of ruptured infectious cerebral aneurysms associated with infective endocarditis in 4 patients. The first case: A 60-year-old male, who had a large hematoma resulting from rupture of a distal anterior cerebral artery aneurysm at the left frontal lobe co-existing with cerebral infarction at the right temporo-occipital lobe, with complications of renal and liver embolisms and pyogenic spondylitis, was treated with antibiotic therapy. However, he died of rupture of another newly formed aneurysm 29 days after onset. The second case: A 71-year-old female presented cerebral infarction in the right occipital lobe at onset. Two days later, abrupt occurrence of a large hematoma at the left parietal lobe led to deterioration of her consciousness. She underwent emergent evacuation of a large hematoma containing the infectious cerebral aneurysm proven histologically afterwards. The third patient: A 49-year-old female was suffered from a large hematoma and subdural hematoma accompanied distal posterior cerebral artery aneurysm at the right occipital lobe. She was operated by removal of the hematoma and the aneurysm proven as a bacterial infectious aneurysm. The fourth patient: A 71-year-old female had hemiplegia caused by a brain abscess and cerebral hemorrhage in the right temporal lobe and a distal middle cerebral artery aneurysm adjacent to the same region. Trapping of the aneurysm was undertaken and clinical course was uneventful. Attention needs to be paid to the various cerebrovascular condition arising from the bacterial embolus of infective endocarditis.     

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.     

Frameless stereotaxy-assisted clipping of distal anterior cerebral artery aneurysm: technical note and case series.

OBJECTIVE: Microsurgery for the clipping of cerebral aneurysms requires a working knowledge of the anatomy of the cerebral vasculature and its relationship to landmarks on the surface of the brain and along the skull base. However, for more distally located aneurysms of the anterior cerebral artery (ACA), locating the lesion can prove frustrating and may require much more extensive interhemispheric dissection than is otherwise needed for proximal control, exposure of the aneurysm, and clip application. We report a case series of five patients in which frameless stereotaxy and CT angiographic data sets were used to minimize the extent of surgery required to clip distal ACA aneurysms. CLINICAL PRESENTATIONS: Five patients were found to have distal ACA aneurysms during the work-up of subarachnoid hemorrhage or other neurologic symptoms. The patients comprised two with subarachnoid hemorrhage, one with dizziness, one with stroke, and one with migraines and polycystic kidney disease. Each patient was found to have an aneurysm at the pericallosal/callosal marginal junction. INTERVENTION: All five patients underwent a right parasagittal craniotomy and clipping of a distal ACA aneurysm. The location of the craniotomy and subsequent interhemispheric dissection were guided by CT angiographic data sets and computer-assisted frameless stereotaxy. CONCLUSION: Frameless stereotaxy using a CT angiographic data set is a useful adjunct to routine microsurgery in the clipping of distal ACA aneurysms. Its use obviates the need for extensive interhemispheric dissection, allows the surgeon to gain proximal control and expose the aneurysm more efficiently, and should minimize complications related to unwitting aneurysm exposure.     

Multiple intracranial mycotic aneurysm. Report of a case (author's transl)]

A case of intracranial mycotic aneurysm was reported, in whom repeated cerebral angiographies demonstrated the seccessive appearance of multiple aneurysms in a short term after the septic cerebral infection, and the importance of repeated angiography in the treatment of the intracranial mycotic aneurysm was stressed. A 44-year old male who had heart failure developed suddenly a left hemiparesis with irritable meningial signs on Nov. 3, 1973. The right carotid angiography carried out on Nov. 16 in an admitted hospital showed partial obliteration of cortical branches of the middle cerebral shift of the anterior cerebral artery due to the cerebral infarction. No aneurysm was demonstrated in the angiogram. The second angiography of the right carotid and vertebral artery was done on the admission of Dec. 18. The previously shown contralateral shift of the anterior cerebral artery was remarkably decreased, and an aneurysm of 3 mm in diameter was recognized at the cortical branch of the right middle cerebral artery on the parietal region. Any aneurysm was not revealed by the vertebral angiography. The third angiography of bilateral carotid and vertebral artery was performed on Dec. 25. The previously revealed aneurysm increased in size. Multiple aneurysms was demonstrated at the anterior branches of the insular artery. The vertebral angiography demonstrated multiple aneurysms at the peripheral portion of the bilateral posterior cerebral arteries. The patient was improved neurologically after the administration of antibiotics, and was discharged on Dec. 27 on the convenience of his family and would be followed in conservative cares.     

Ruptured cerebral aneurysm not detected by magnetic resonance angiography in juvenile autosomal dominant polycystic kidney

Recently, it has been reported that magnetic resonance angiography (MRA) is useful for screening and following up cerebral aneurysms in patients with autosomal dominant polycystic kidney disease (ADPKD). However, a patient was encountered with a ruptured cerebral aneurysm that was not detected by routine MRA. The patient, a 29-year-old man with ADPKD, was followed up at our hospital for more than 5 years. Ten months after an MRA examination, he suddenly developed severe headache. Brain computed tomography revealed subarachnoid hemorrhage. Digital subtraction angiography detected an aneurysm with a diameter of approximately 2 mm in the anterior communicating artery. Clipping of the aneurysm was immediately performed and he recovered without sequela after operation. Magnetic resonance angiography is useful to detect cerebral aneurysms, but it can not detect aneurysms measuring less than 4 mm.     

Dissecting aneurysm of the anterior cerebral artery requiring surgical treatment--case report

A 45-year-old male presented with spontaneous dissecting aneurysm in the anterior cerebral artery manifesting as headache persisting for several days and speech disturbance. Neurological and laboratory examinations showed no abnormalities. Magnetic resonance imaging revealed infarction in the right cingulate gyrus. Angiography revealed occlusion of the right A2. Repeat angiography 8 months later showed a saccular aneurysm had developed. The interhemispheric approach exposed the aneurysm at the junction between the right frontopolar artery and the pericallosal artery. The aneurysm was fusiform due to the right A2 dissection. The aneurysm was trapped and resected. One month after the operation, the patient was discharged without neurological deficits. Cases of dissecting aneurysms in the anterior cerebral artery with ischemic onset are usually treated conservatively. Cases requiring surgery include those due to trauma, growing aneurysms, giant aneurysms, and uncontrolled hypertension. Some dissecting aneurysms of the distal anterior cerebral artery require only resection without bypass surgery.     

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)     

Subarachnoid hemorrhage in a case of segmental arterial mediolysis with coexisting intracranial and intraabdominal aneurysms

The authors report the rare case of a 58-year-old man with segmental arterial mediolysis (SAM) with associated intracranial and intraabdominal aneurysms, who suffered subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm. This disease primarily involves the intraabdominal arterial system, resulting in intraabdominal and retroperitoneal hemorrhage in most cases. The patient presented with severe headache and vomiting. The CT scans of the head revealed SAH. Cerebral angiography revealed 3 aneurysms: 1 in the right distal anterior cerebral artery (ACA), 1 in the distal portion of the A(1) segment of the right ACA, and 1 in the left vertebral artery. The patient had a history of multiple intraabdominal aneurysms involving the splenic, gastroepiploic, gastroduodenal, and bilateral renal arteries. He underwent a right frontotemporal craniotomy and fibrin coating of the dissecting aneurysm in the distal portion of the A(1) segment of the right ACA, which was the cause of the hemorrhage. Follow-up revealed no significant changes in the residual intracranial and intraabdominal aneurysms. An SAH due to SAM with associated multiple intraabdominal aneurysms is extremely rare. The authors describe their particular case and review the literature pertaining to SAM with associated intracranial and intraabdominal aneurysms.     

Intracranial bacterial aneurysms--report of two cases with special reference to operative indications

Two cases of intracranial bacterial aneurysms caused by bacterial endocarditis are reported. Case 1 was a 20-year-old male who underwent mitral valve annuloplasty because of mitral regurgitation due to mitral valve prolapse syndrome 3 year prior to this admission. He was referred when a large intracerebral hemorrhage of the right frontal lobe ruptured into the lateral ventricle was seen in computed tomography (CT) scan on admission. An aneurysm at the distal portion of precentral artery of the middle cerebral artery (MCA) was found by right carotid angiography. Emergency evacuation of the hematoma and trapping of the aneurysm were performed. Another three aneurysms, located at the distal portion of contralateral left precentral artery of MCA, the left posterior cerebral artery (PCA) and the right anterior falx artery were found in the subsequent angiogram. The latter two aneurysms developed while receiving antibiotics. The aneurysms of PCA and MCA were trapped surgically. However, the aneurysm of anterior falx artery disappeared spontaneously under antibiotic therapy without surgery. Case 2 was a 21-year-old female who underwent cardiac surgery one month prior to presentation for aortic insufficiency and coarctation of the aorta. She was referred to our clinic because of sudden loss of consciousness, aphasia and right hemiparesis. CT scan and left carotid angiography showed a large hematoma in the left frontal lobe and an aneurysm at the distal portion of the opercular-frontal artery. Emergency ventricular drainage was performed. The operation for evacuation of the hematoma and clipping of aneurysm was performed 10 days later. However, at the operation the aneurysm neck was only partially clipped in order to prevent the obstruction of efferent vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Ruptured anterior spinal artery aneurysm: a case report

BACKGROUND

Spinal artery aneurysms are rare, and are usually found in association with arteriovenous malformations or coarctation of the aorta.

CASE REPORT

A 42-year-old man with a ruptured anterior spinal artery aneurysm is presented here. He experienced subarachnoid hemorrhage, which was confirmed by computed tomography. Magnetic resonance imaging revealed an aneurysm in front of the upper part of the medulla. Angiography demonstrated bilateral vertebral artery occlusion. Distal vertebral arteries and the basilar artery were perfused via the dilated anterior spinal artery, which originates in the right subclavian artery. The aneurysm was located at the distal part of the anterior spinal artery, and was successfully clipped through a lateral suboccipital craniotomy 2 months after bleeding from the aneurysm. After rehabilitation, the patient was able to walk with no apparent neurologic deficit.

CONCLUSIONS

This case suggests that the anterior spinal artery as a collateral route after bilateral vertebral arery occlusion is under hemodynamic stress, resulting in aneurysm formation and rupture.     

Clinicopathological studies of three cases of cerebral aneurysms associated with systemic lupus erythematosus

We report three cases of ruptured cerebral aneurysms associated with systemic lupus erythematosus (SLE). A 52-year-old woman (case 1) with a fifteen-year history of systemic lupus erythematosus suddenly lost consciousness. She was admitted in a state of deep coma. A computed tomography (CT) scan revealed acute hydrocephalus and diffuse subarachnoid hemorrhage in the basal, interhemispheric and bilateral Sylvian cisterns. Fifteen years prior to this admission, cerebral angiograms demonstrated no cerebral aneurysm. She underwent ventricular drainage immediately. Postoperatively, her condition did not improve, and she died on the 18th day. During the autopsy, two saccular cerebral aneurysms were found: one aneurysm was at the right middle cerebral artery bifurcation, and another one was on the anterior communicating artery, which had disruption of the internal elastic lamina and medial smooth muscle, and infiltration of inflammatory cells. In the major cerebral arteries, for example the bilateral internal carotid arteries, disruption or dissection of the internal elastic lamina, intimal fibrosis and transmural infiltration of inflammatory cells were observed. The second patient, a 36-year-old woman with a six-year history of SLE, was admitted to our hospital with sudden severe headache. A CT scan showed subarachnoid hemorrhage, and cerebral angiograms disclosed saccular cerebral aneurysms on the anterior communicating artery and the left superior cerebellar artery, and a fusiform one on the left posterior cerebral artery. Surgery was not recommended because of her multiple medical problems. Her consciousness improved gradually over 2 months. She was transferred to the department of internal medicine for treatment of renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)     

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)     

Cerebral Aneurysm Associated with Persistent Primitive Olfactory Artery Aneurysm

Summary Persistent primitive olfactory artery is a rare vascular anomaly but has a clinical importance because of its high association with cerebral aneurysm. We describe a patient with bilateral persistent primitive olfactory arteries associated with an unruptured saccular aneurysm on the left persistent primitive olfactory artery. Seven reported cases with this anomalous artery including ours are reviewed and classified into two variants. This anomalous artery arises from the terminal portion of the internal carotid artery and courses anteromedially along the ipsilateral olfactory tract and makes a hair-pin curve posterior to the olfactory bulb, becoming the distal anterior cerebral artery (variant 1) or the ethmoidal artery (variant 2). Out of 7 reported cases, 4 cases are associated with saccular aneurysms. The aneurysm in variant 1 is located on the hair-pin curve at which an apparent arterial branch is sometimes absent. Two patients suffer from anosmia. Persistent primitive olfactory artery should be kept in mind because of its high association with intracranial saccular aneurysms and unique clinical presentation.     

Endovascular treatment of primitive persistent trigeminal artery aneurysm associated with middle cerebral artery aneurysm

We report the case of a primitive trigeminal artery aneurysm associated with an ipsilateral middle cerebral artery aneurysm. A 64-year-old Caucasian woman suffered from a severe acute headache. A head CT scan displayed subarachnoid hemorrhage and subsequent cerebral angiography showed right, wide-necked persistent trigeminal artery and ipsilateral middle cerebral artery aneurysms. The patient underwent embolization of both aneurysms with Guglielmi detachable coils. The association of a PPTA aneurysm and an ipsilateral MCA aneurysm has not been reported in the English literature.     

Postoperative rupture of an untreated aneurysm on the 3rd day after subarachnoid hemorrhage surgery

A 58-year-old male presented with severe consciousness disturbance and left hemiparesis. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) and acute subdural hematoma caused by a ruptured right middle cerebral artery aneurysm. The aneurysm was clipped and the hematoma was evacuated. The patient had almost recovered without new neurological deficits on the next day. Arterial systolic blood pressure was postoperatively controlled within 120 to 150 mmHg. Continuous ventricular and cisternal drainage from the level 10 cm above the external auditory meatus was performed to drain bloody cerebrospinal fluid and prevent vasospasm. Three days after surgery, the patient suddenly lapsed into a coma. CT demonstrated diffuse SAH and bilateral intraventricular hemorrhage caused by rupture of an anterior communicating artery aneurysm. Neck clipping was performed immediately. Unfortunately, the patient died of primary damage due to SAH 3 days after the second surgery. In this case, cisternal drainage was probably important in the aneurysm rupture because of decreased intracranial pressure and change in the perianeurysm environment. Postoperative management of patients with residual untreated aneurysms must consider the possibility that cisternal drainage may result in higher transmural pressure, leading to rupture of the untreated aneurysms.     

Surgery of incidental intracranial aneurysms

A series of nine patients with an unruptured asymptomatic aneurysm not associated with a ruptured aneurysm is discussed. Three had giant aneurysms. Two patients had bilateral aneurysms of the middle cerebral artery. Five had solitary aneurysms of the middle cerebral artery. One had an aneurysm of the anterior communicating artery. One had an ophthalmic aneurysm. All aneurysms were clipped. Two operations were necessary in the two patients with bilateral aneurysms. There was no mortality and no significant morbidity. Clipping of the aneurysm is recommended for those patients who have no other serious illness that significantly increases the surgical risk. If a combination of pituitary tumor and aneurysm is found, a subfrontal instead of transsphenoidal approach should be considered so as to treat both the tumor and aneurysm at the same operation.     

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.