Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: a case report and review of the literature

BACKGROUND

Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction.

CASE DESCRIPTION

A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2.

CONCLUSION

This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.     

Aneurysms of the proximal anterior cerebral artery

The authors report eight cases of aneurysm of the anterior cerebral artery proximal to the anterior communicating artery (A1 segment). In six of these cases, the aneurysms arose from the proximal anterior cerebral artery at the origin of either a cortical branch (on case), the accessory middle cerebral artery (one case), or a perforating branch (four cases). In another case the aneurysm arose at the proximal end of the fenestration, whereas in the one remaining case no branch was present at the site of the aneurysmal neck.     

Aneurysm of distal anterior cerebral artery associated with azygos anterior cerebral artery

Summary An aneurysm arising from the distal anterior cerebral artery distal to the bifurcation of the azygos anterior cerebral artery is reported. A review of the literature emphasizes the rarity of this lesion.     

Dissecting aneurysms of the anterior cerebral artery and accessory middle cerebral artery. Case report

A 66-year-old woman presented with dissecting aneurysms of the anterior cerebral artery (ACA) and accessory middle cerebral artery (MCA) manifesting as subarachnoid hemorrhage but without radiological evidence of the dissecting aneurysms. Intraoperative observation revealed that the vessel walls were dark purple in color, a typical finding of dissecting aneurysm. The abnormal A1 segment was trapped and the dissecting aneurysm of the accessory MCA was wrapped. In the case of SAH of unknown origin, dissecting aneurysm should always be kept in mind even if the angiogram does not show any abnormal finding. This is the first reported case of dissecting aneurysm of the accessory MCA.     

大脑前动脉近端动脉瘤的显微外科治疗

目的探讨大脑前动脉近端动脉瘤(A1动脉瘤)的临床特征及外科手术技巧。方法1995年6月～2003年12月间共治疗颅内动脉瘤患者362例,其中A1动脉瘤占2．2％(8例),对A1动脉瘤患者的临床资料进行回顾性分析。结果所有动脉瘤均位于A1穿动脉的起始部,起源于内侧远端纹状体动脉的3例,内侧近端纹状体动脉的5例。术中发现后方指向的6例,下方指向的2例。8个动脉瘤均为囊性动脉瘤,其中6例为小动脉瘤,平均直径6．9mm。全组动脉瘤经手术夹闭,患者预后优7例,良1例。结论手术治疗A1动脉瘤保护A1穿动脉和选用合适的瘤夹是预防缺血性并发症的关键。     

Traumatic middle cerebral artery aneurysm: case report and review of the literature

Traumatic intracranial aneurysms are rare. A case of traumatic middle cerebral artery aneurysm was presented. A 66-year-old man sustained a severe head injury in a bicycle accident. Serial computed tomography and angiography showed the delayed intracerebral hemorrhage caused by the traumatic middle cerebral artery aneurysm. The aneurysm was trapped and removed. Histological examination clearly revealed the pseudoaneurysm. Traumatic middle cerebral aneurysms were reviewed.     

大脑中动脉分叉部动脉瘤的血管内治疗

目的总结大脑中动脉分叉部动脉瘤的诊断和血管内治疗方法。方法 2010年1月-2011年6月,收治32例大脑中动脉分叉部动脉瘤患者并行血管内治疗。男12例,女20例;年龄35～81岁,平均49.5岁。患者均有突发头痛病史,其中2例有意识障碍伴一侧肢体活动受限;22例有高血压病史。术前Hunt-Hess分级:Ⅰ级10例,Ⅱ级15例,Ⅲ级7例;Fisher分级:Ⅱ级24例,Ⅲ级8例。16例患者应用单微导管弹簧圈栓塞,7例应用双微导管弹簧圈栓塞,4例应用球囊辅助弹簧圈栓塞,4例应用单支架辅助弹簧圈栓塞,1例应用双支架辅助弹簧圈栓塞。结果术后即刻数字减影血管造影检查示,除2例单微导管弹簧圈栓塞者获近乎致密栓塞外,余均获致密栓塞。术中18例蛛网膜下腔广泛出血,行腰大池置管持续引流3～7 d;余14例有少量蛛网膜下腔出血,术后间断腰椎穿刺缓慢释放血性脑脊液。术后1周颅脑CT示蛛网膜下腔出血量明显减少。术后1 d,2例出现局部脑缺血,经尼莫同等药物抗血管痉挛治疗1周后缓解。32例均获随访,随访时间4～17个月。患者无动脉瘤破裂再出血,术后3例一侧肢体瘫痪,1例术后失语,余无并发症及后遗症发生。术后3、6个月及1年复查计算机断层摄影血管造影术示致密栓塞的动脉瘤未再通。结论选择合适的介入治疗方法,大脑中动脉分叉部动脉瘤的血管内治疗是安全、可靠的。     

Aneurysm at the origin of the accessory middle cerebral artery

An aneurysm at the junction of the accessory middle cerebral artery and the horizontal portion of the anterior cerebral artery is reported. The importance of this anomalous artery is discussed with regard to the genesis of aneurysms of the anterior cerebral artery.     

Ruptured anterior communicating artery aneurysms associated with fenestration of the anterior cerebral artery

Two patients with ruptured anterior communicating artery aneurysms associated with fenestration of the anterior cerebral artery are reported. In the literature, only 12 angiographic demonstrations of fenestration of the anterior cerebral artery have been reported. All fenestrations were limited to the distal half of the A1 portion, and seven of the 12 cases were associated with aneurysms. The high incidence of coexisting fenestration and aneurysm suggests that congenital factors may play a role in the pathogenesis of cerebral aneurysm.     

Aneurysms associated with fenestrated anterior cerebral arteries. Report of four cases and review of the literature

Four cases of aneurysms associated with a fenestrated anterior cerebral artery are presented. The combination of aneurysms and fenestration of the anterior cerebral artery is rare, and nine cases including ours have been reported. In all cases fenestrations were found within the distal two-thirds of the horizontal portion of the anterior cerebral artery. It may be presumed that fenestration of the anterior cerebral artery is the remnant of the plexiform anastomosis in the fetal stage, especially between the anterior cerebral artery and the primitive olfactory artery.     

Ruptured distal middle cerebral artery aneurysm: Case report

INTRODUCTIONThis report describes a rare case of a distal middle cerebral artery (dMCA) aneurysm.PRESENTATION OF CASEThat developed a right intracerebral haematoma and subarachnoid haemorrhage. It was treated by surgical exploration and clipping via pterional approach.DISCUSSIONClinical findings and surgical approaches of dMCA aneurysm are different from proximal middle cerebral artery (MCA) aneurysms. Microneurosurgical clipping is the most effective treatment of dMCA aneurysm.CONCLUSIONWe comprehensively review the literature related to these rare aneurysms within the temporal lobe, surgical anatomy of the dMCA aneurysm.     

A case of posterior cerebral artery aneurysm associated with idiopathic bilateral internal carotid artery occlusion: case report

BACKGROUND: Aneurysms of the posterior circulation are challenging lesions to neurosurgeons, despite improvements in microsurgical techniques and advances in skull base approaches. We present a rare case of a posterior cerebral artery (PCA)-posterior communicating artery (PcomA) junction aneurysm associated with bilateral internal carotid artery (ICA) occlusion successfully treated with an endovascular procedure. CASE DESCRIPTION: A 57-year-old female presented with sudden onset of severe headache and loss of consciousness. CT scan showed diffuse subarachnoid hemorrhage and acute hydrocephalus. The patient developed severe neurogenic pulmonary edema and shock. Although her neurogenic pulmonary edema did not resolve, she recovered from shock. However, her general condition was so critical and her vital signs so unstable, that direct surgery under general anesthesia was considered too risky. A cerebral angiogram showed complete occlusion of both internal carotid arteries without any Moyamoya vessels. A saccular aneurysm located at the right PCA-PcomA junction was seen. To obliterate the aneurysm and prevent rerupture, the patient underwent coil embolization via an endovascular approach under sedation with local anesthesia. The balloon remodeling technique was useful to prevent occlusion of parent arteries. Finally, four interlocking detachable coils (IDC) with a total length of 44 cm were used to completely obliterate the aneurysm using the balloon remodeling technique. The patient made a full recovery after treatment and the aneurysm remained obliterated 2 years after coil embolization. CONCLUSIONS: We emphasize the advantages of the endovascular approach for the patient in critical condition. We believe that this is the first report of a PCA-Pcom junction aneurysm associated with bilateral ICA occlusion without moyamoya disease.     

Proximal superficial temporal artery to proximal middle cerebral artery bypass using a radial artery graft: an anatomic approach

We present the use of radial artery graft for bypass of the proximal superficial temporal artery to the proximal middle cerebral artery. Six adult cadaver sites were used bilaterally. After apterional incision, 2×2-cm minicraniectomy was performed which began 2 cm behind the zygomatic process of the frontal bone. The superficial temporal artery was transsected before exposing the zygomatico-orbital artery branch. The proximal side of the radial artery graft was anastomosed end-to-end to the proximal superficial temporal artery and the distal side end-to-side to the proximal middle cerebral artery. The mean calibers of the proximal superficial temporal artery and largest trunk of the middle cerebral artery were 2.25±0.35 mm and 2.3±0.3 mm, respectively. The average graft length was 85±5.5 mm. We conclude that such bypasses are simpler than proximal middle cerebral artery revascularization using long vein grafts. This method proves that the caliber of the proximal superficial temporal artery is more suited to providing sufficient flow than the distal superficial temporal artery, and the graft is short. Such bypasses to the middle cerebral artery may be an alternative to those from the distal superficial temporal artery or extracranial carotid artery.     

'Mirror image' distal anterior cerebral artery aneurysms. A case report of two patients with review of literature

Summary.  We report two cases of patients with bilateral `mirror image' or `kissing' aneurysms at the distal anterior cerebral arteries who presented with subarachnoid haemorrhage and frontal intracerebral haematoma. Published online September 2, 2002 Correspondence: Mr. J. Sousa, Staff Village, Royal Preston Hospital, Sharoe green Lane, Preston, PR2 9HT.     

Intracranial aneurysms: Characteristics of aneurysms by site,with special reference to anterior communicating artery aneurysms

Data are presented from an unselected series of 212 aneurysm patients for aneurysms at three major sites: the internal carotid-posterior communicating artery junction, the anterior communicating artery, and the middle cerebral artery. More than 70% of the anterior communicating artery aneurysms occurred as single aneurysms; less than 30% of the middle cerebral artery aneurysms were single. Anterior communicating artery aneurysms showed a right-side predominance in males but not in females. Both males and females had significantly higher mean systolic and diastolic blood pressures for left-side anterior communicating artery aneurysms than for right-side aneurysms. A brief review of factors relevant to anterior communicating artery aneurysms is presented.     

Infraoptic anterior cerebral artery: review,report of two cases and an anatomical classification

Introduction  Infraoptic course of the pre-communicating anterior cerebral artery (A1) is a rare anomaly. In total, there are 42 examples reported in the literature. We report two further patients. The first had an intradural cerebral aneurysm at the low bifurcation of an internal carotid artery (ICA) with bilateral infraoptic course of A1. The second had right infraoptic course of A1 with associated left parietal cerebral arteriovenous malformation and is the first report of such an association. Discussion and conclusion  Overall, 59% of the examples were associated with cerebral aneurysms. Different terminology such as carotid–anterior cerebral artery anastomosis and infraoptic anterior cerebral artery has been used. Having analyzed the reports of infraoptic A1, we found the vascular configurations of the A1 could be better described by classifying them into four types. Such a classification can facilitate analysis of the embryogenesis explanation for this anomaly and the pathogenesis of the associated aneurysms. Besides, such a classification also has some practical implications.