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.     

A case of anterior communicating artery aneurysm with occlusion of the bilateral middle cerebral arteries

A patient with ruptured anterior communicating artery aneurysm associated with occlusion of the bilateral middle cerebral arteries is presented. A 70-year-old woman was hospitalized for sudden onset of severe headache and vomiting. She was alert, and no neurological deficit was found. CT scan showed a subarachnoid hemorrhage. Cerebral angiogram demonstrated occlusion of the bilateral middle cerebral arteries and ruptured anterior communicating artery aneurysm. After operation, she fully recovered and was able to walk at the time of discharge. In aneurysmal formation, we know from the literatures that hemodynamic stress plays an important role. In this case, occlusion of the bilateral middle cerebral arteries caused hemodynamic stress on the anterior cerebral arteries and anterior communicating artery. It is suggested that this is a causative factor of aneurysmal formation under systemic hypertension.     

Somatosensory evoked potential monitoring of temporary middle cerebral artery occlusion during aneurysm operation

Somatosensory evoked potentials (SEPs) in response to median nerve stimulation were used as a guide to cortical function during temporary occlusion of the distal M1 segment of the middle cerebral artery (MCA) in the surgical treatment of five large aneurysms of the MCA bifurcation. MCA occlusion times ranged from 8 to 19 minutes under moderate hypothermia at 28.8 degrees to 30.3 degrees C. SEPs were preserved for variable times during MCA occlusion, ranging from no increase in latency after 13 minutes of occlusion to severe deterioration after 6 minutes. In no case was MCA occlusion maintained for longer than 3 minutes in the presence of a severely disturbed SEP. Recovery of the SEP to its preoperative relationship with that of the nonoperated hemisphere was seen in all cases before the end of operation. All patients were awake after rewarming at the end of operation without any neurological deficit. Monitoring the SEP pertaining to the territory of a cerebral artery during its temporary occlusion can help avoid ischemic damage and will allow the surgeon to take advantage of the several benefits of this technique in aneurysm surgery.     

Ruptured distal middle cerebral artery aneurysm

OBJECT: Ruptured distal middle cerebral artery (MCA) aneurysms are uncommon, and their clinical and radiological features are poorly understood. To clarify characteristics of these lesions, the authors undertook a retrospective analysis of nine patients with ruptured distal MCA aneurysms. METHODS: The medical records of patients who underwent surgical repair of ruptured intracranial aneurysms between 1988 and 2002 at Shinshu University Hospital and its affiliated hospitals were retrospectively evaluated. The authors found only nine patients with a ruptured distal MCA aneurysm, and their clinical, neuroimaging, and intraoperative findings were evaluated. CONCLUSIONS: This study of nine patients with distal MCA aneurysms is the largest series to date. Eight lesions were saccular aneurysms that were clipped and the remaining one was a mycotic aneurysm that was trapped. Eight of the nine patients suffered cerebral hematomas with subarachnoid hemorrhage. All patients had good outcomes after obliteration of their aneurysm, although their preoperative condition was not good.     

Subarachnoid hemorrhage in an adolescent with spontaneous occlusion of the left middle cerebral artery and reconstruction by collateral vessels (Moyamoya phenomenon)

A case of a 12-year-old girl with subarachnoid hemorrhage and a hematoma in the pineal region is reported. With cerebral angiography, an occlusion of the left middle cerebral artery and its reconstruction by numerous dilated lenticulostriate collateral vessels were demonstrated. Subarachnoid hemorrhage in children with Moyamoya phenomenon is a rare event that may result from rupture of dilated collateral vessels or associated microaneurysms     

Ruptured aneurysm at a duplicated middle cerebral artery with accessory middle cerebral artery

Summary. Although many cerebral vascular anomalies are widely recognized, others are less well known or unclassified. Accessory middle cerebral artery (MCA) and duplicated MCA are among uncommon anomalies. We present a very rare case of subarachnoid haemorrhage due to rupture of a saccular aneurysm arising from a duplicated middle cerebral artery which was associated with an accessory middle cerebral artery.     

Paradoxical association of moyamoya syndrome with large middle cerebral artery aneurysm and subarachnoid hemorrhage. Case report

A 69-year-old woman was admitted to our hospital because of fluctuating dysarthria during the past 2 months. Magnetic resonance imaging revealed old cerebral infarction of the left cerebral hemisphere with acute subarachnoid hemorrhage in the left sylvian fissure. Cerebral angiography showed a large saccular aneurysm, 14 mm in diameter, at the bifurcation of the left middle cerebral artery (MCA) in association with moyamoya vasculopathy with atherosclerosis, including steno-occlusive changes at the bilateral terminal internal carotid arteries and abnormal net-like vessels at the base of the brain. She underwent microsurgical neck clipping of the large aneurysm followed by superficial temporal artery-MCA anastomosis without complication. Intraoperative findings showed no evidence of aneurysm rupture, suggesting that the subarachnoid hemorrhage was due to the intrinsic pathology of moyamoya vasculopathy. The postoperative course was uneventful, and the patient was discharged without neurological deficit. Association of moyamoya syndrome with large MCA aneurysm is extremely rare, and formation of large aneurysm at the vascular territory of an occluded vessel is apparently unique.     

Anterior communicating artery aneurysm associated with bilateral occlusion of the middle cerebral artery--case report

A female who had had no previous cerebrovascular events suffered a subarachnoid hemorrhage and was referred to our hospital. Angiography revealed an anterior communicating artery aneurysm and bilateral occlusion of the middle cerebral artery at its origin. She exhibited mild ischemic symptoms after clipping of the aneurysm, possibly as a consequence of disturbance of the collateral blood flow during surgery. This is the third such case reported in the literature.     

Surgery for unruptured middle cerebral artery aneurysm

Although a large number of patients with unruptured middle cerebral artery (MCA) aneurysms (AN) have been treated by surgical clipping in Japan, there has yet been no comprehensive study investigating the surgical risks based on a quantitative evaluation of the extensive existing body of patient records. This systematic review was conducted to determine morbidity of the procedure by performing a meta-analysis of the literature. The authors used a PubMed and J-stage search from 2000 to 2011 for studies containing the surgical clipping of the unruptured MCA AN. There were 21 articles, containing a total 1,323 cases of unruptured AN with morbidity specifically located in the MCA. 54 cases indicated significant neurological deficits for a morbidity rate of 4.1% (95% CI; 3.0-5.1). A limited number of studies disclosed an incremental increase in morbidity with the size of the aneurysm. Smaller MCA AN (7±3 mm) presented a lower morbidity of 1.48%, whereas giant MCA AN (>25 mm) corresponded with a higher morbidity of 27.8%. Factors consistently associated with high morbidity included incorporated MCA branches, plaque at the neck of the AN, an unclippable configuration, and M1 superior wall AN. Complex aneurysms required a wide array of intracranial bypass procedures, yielding morbidity of 23.4% (95% CI; 20.9-25.9). This is the first systematic review and quantitative meta-analysis of the surgical complications related to unruptured MCA AN.