Intravenous thrombolysis in thromboembolic occlusion of the A1 segment of the left anterior cerebral artery only

This case describes the treatment of an 84-year-old male patient with acute bi-frontal ischemic stroke, due to thromboembolic occlusion of the A1 segment of the left anterior cerebral artery (ACA) only. The National Institutes of Health Stroke Scale (NIHSS) was 11. Intravenous fibrinolysis was performed with a good outcome. Repermeabilization of both ACA was demonstrated by imaging and, 24 h after treatment, NIHSS was 0. Although intravenous thrombolysis is mostly used for middle cerebral artery occlusion, this case emphasizes the benefit of this treatment for an ischemic stroke due to embolization of the A1 segment of the left ACA only. It is all the more original in that it describes an unusual treatment for this arterial territory, and with this anatomic particularity.     

Unusually prolonged progressing stroke: an expanding anterior cerebral artery infarction.

Progressive clinical deterioration over a period of weeks coupled with MRI evidence of infarction growth is quite uncommon. In this report, we describe a patient with an occluded left anterior cerebral artery (ACA) at the origin of the A2 segment. His symptoms attributable to a posteriorly located small infarction within the ACA territory slowly progressed during the following 8 weeks. A follow-up MRI revealed that the infarction had expanded to involve the whole region of the left ACA. Occasional patients like ours indicate that stroke is a dynamic disorder with an extremely variable clinical course and state of tissue injury.     

Revascularization for Symptomatic Occlusion of the Anterior Cerebral Artery Using Superficial Temporal Artery

Isolated symptomatic occlusion of the anterior cerebral artery (ACA) is a rare condition and until date, only few cases regarding the revascularization of the ACA have been reported. This paper reports on successful attempt to revascularize the ACA using superficial temporal artery (STA) in patient with isolated symptomatic occlusion of the ACA. A 69-year-old man presented with several episodes of transient weakness involving left lower extremity. Cerebral angiography showed occlusion of the right ACA at the A2 segment. After medical treatment failure, the patient underwent STA-ACA bypass surgery. Subsequent to surgery, there was immediate disappearance of transient ischemic attack and follow-up angiography showed favorable revascularization of the ACA territory. Bypass surgery can be considered in the patients with symptomatic occlusion of the ACA, who have experienced failure in medical treatment.     

Anomalous internal carotid anastomosis to contralateral anterior cerebral artery

BACKGROUND: Many anomalies and variants in vascular anatomy have been reported in relation to the anterior cerebral artery (ACA). PATIENTS AND METHODS: We encountered an apparently novel anomaly in a 30-year-old man admitted for disturbance of consciousness following a traffic accident. Computed tomography revealed an acute subdural hematoma and subarachnoid hemorrhage. RESULTS AND CONCLUSIONS: No vascular abnormalities related to the hemorrhage were detected by conventional angiography, so we concluded that the bleeding was of traumatic origin. Anomalous origin of the ACA was disclosed incidentally, with both A1 segments arising from the right internal carotid artery; no normal A1 segment of the left ACA was visualized. We discuss possible bases for this anomalous origin.     

Multiple cerebrovascular occlusive disease associated with neurofibromatosis

Multiple cerebrovascular occlusive disease is rarely seen in patients with neurofibromatosis. Two cases of such lesions are presented and literatures dealing with the clinical and angiographical aspects of this occlusive disease are reviewed. Case 1; A 38-year-old normotensive man had sudden onset of vomiting, left hemiparesis and disturbance of consciousness, one day before the admission. He had family history of neurofibromatosis, and examination showed café au lait spots over the body. CT scans revealed a subcortical hematoma in the right temporal lobe. Angiogram revealed multiple occlusive lesions of the cerebral arteries, including occlusions of the right internal carotid artery (ICA) at the distal end, middle (MCA) and anterior (ACA) cerebral artery at the proximal portion, and stenosis of the left ICA and ACA. Abnormal vascular networks at the base of the brain were also seen bilaterally. Decompressive craniectomy, removal of the hematoma and bilateral ventricular drainage were performed. Postoperative course was excellent. Angiogram performed five and a half years later, during which time without any surgical procedures, demonstrated no apparent angiographic differences from the previous one. Case 2; A 29-year-old woman without family history of neurofibromatosis presented with sudden onset left hemiparesis. Café au lait spots were found over the body. A CT scan revealed small infarctions in the territory of the right MCA, and angiogram demonstrated multiple occlusive lesions of the cerebral arteries, including stenosis of the bilateral ICA, the left MCA, both ACAs at the proximal portion, and the right posterior cerebral artery, and occlusions of the right MCA.(ABSTRACT TRUNCATED AT 250 WORDS)     

Infarction in the territory of the anterior choroidal artery due to embolic occlusion of the internal carotid artery--report of two cases

A case with infarction in the territory of the anterior choroidal artery (AChA) due to embolic occlusion of the internal carotid artery (ICA) is rare. We described two cases and investigated the mechanism of the territory of the AChA. Case 1 was a 69-year-old man. Case 2 was a 71-year-old woman. The neurological examination in both cases showed left homonymous hemianopsia, left facial palsy, left hemiparesis and left hemisensory disturbance. CT scan in these cases showed infarctions of the right uncus, amygdaloid nucleus, genu and posterior limb of the internal capsule, globus pallidus, lateral geniculate body and tail of the caudate nucleus. The right common carotid angiogram showed a complete occlusion of the ICA at its cervical segment in case 1 and at its carotid siphon in case 2. In both cases, the left carotid injection visualized the right anterior cerebral artery and right middle cerebral artery via the anterior communicating artery well, but the right AChA was not visualized. In case 1, the collateral pathways from the right external carotid artery (ECA) and the right posterior communicating artery (PCoA) to the right ICA were not supplied and the precommunicating segment of the right posterior cerebral artery was hypoplastic. In case 2, the collateral pathway from the right ECA to the right ICA was not supplied.(ABSTRACT TRUNCATED AT 250 WORDS)     

前交通动脉复合体临床解剖学的3D-DSA研究

目的探讨前交通动脉复合体的3D-DSA的特点,为前交通动脉瘤治疗提供参考。方法回顾性分析30例全脑3D-DSA检查阴性患者的影像学资料,测量大脑前动脉A1和A2段、回返动脉直径,以及大脑前动脉A1段与颈内动脉、大脑前动脉A1段与A2段夹角。结果左、右侧大脑前动脉A1段直径分别为(1.91±0.36)mm和(1.81±0.36)mm,长度分别为(13.0±1.60)mm和(14.0±2.28)mm;左、右侧大脑前动脉A2段直径分别为(1.88±0.38)mm和(1.69±0.36)mm;左侧和右侧回返动脉直径分别为(0.50±0.15)mm和(0.42±0.13)mm;右侧大脑前动脉A1段与A2段夹角为(94.13±23.59)度,左侧大脑前动脉A1段与A2段夹角为(97.74±25.19)度,右侧大脑前动脉A1段与右侧颈内动脉夹角为(89.14±16.61)度,左侧大脑前动脉A1与左侧颈内动脉夹角为(82.30±21.06)度。结论前交通动脉复合体存在较多的变异,充分了解其解剖学3D-DSA的特点对处理前交通动脉瘤具有重要意义。     

A case of juvenile cerebral infarction caused by bilateral anterior cerebral artery dissection]

A 38-year-old man was admitted to our hospital with headache, dysarthria and paraparesis. Brain CT and diffusion MRI disclosed cerebral infarction at bilateral anterior cerebral artery (ACA) territories. His symptoms and signs deteriorated in several days despite intensive antithrombotic therapy, resulting in right hemiparesis, akinetic mutism, memory disturbance, change of personality, urinary incontinence, forced grasping, and starting delay of speech and motion. Cerebral angiography demonstrated occlusion with contrast pooling at the right ACA A2 portion. Stenosis and dilatation were found at left ACA A2 portion. An intimal flap was also demonstrated on serial angiography. This case was diagnosed as cerebral infarction caused by dissection of bilateral ACA. Although no definite primary arteriopathy was demonstrated, bilateral dissection could be occurred simultaneously.     

Central Nervous System vasculitis associated with Hepatitis C virus infection: A brain MRI-supported diagnosis

BackgroundThe Hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, being the Central Nervous System (CNS) rarely involved.Case reportWe report a case of a 54 year-old black man with arterial hypertension who presented with progressively worsening headaches, apathy, somnolence and left hemiparesis. Brain MRI showed an acute ischemic lesion in the left anterior cerebral artery (ACA) and an old ischemic infarct in the right ACA territory. Brain MRI with gadolinium revealed mural thickening and contrast enhancement of the A1 and A2 segments of the ACAs, of the middle and distal basilar artery and of the P1 segment of the left posterior cerebral artery, suggesting active vasculitis. Digital angiography confirmed those irregularities and stenosis. Laboratory evaluation revealed ESR (73 mm/h), transaminase elevation, elevated HCV viral load genotype 2, positive IGRA, negative cryoglobulins, CSF protein elevation with oligoclonal bands (mirror pattern) and no pleocytosis; investigation excluded other infectious causes. Pegylated interferon alpha-2a and ribavirin, corticotherapy and tuberculosis prophylaxis were started with clinical and imagiological improvement.ConclusionThe typical inflammation signs of the vascular wall demonstrated by the gadolinium-enhanced MRI strengthened the hypothesis of CNS vasculitis. The association with HCV infection is rare but should be investigated once specific therapeutic is required.     

Ruptured Saccular Aneurysm Arising from Fenestrated Proximal Anterior Cerebral Artery : Case Report and Literature Review

The aneurysm arising from fenestrated proximal anterior cerebral artery (ACA) is considered to be unique. The authors report a case of a 59-year-old woman who presented with a subarachnoid hemorrhage (SAH) secondary to a ruptured aneurysm originating from the fenestrated A1 segment of right ACA. The patient had another unruptured aneurysm which was located at the right middle cerebral artery bifurcation. She was successfully treated with surgical clipping for both aneurysms. From the previously existing literatures, we found 18 more cases (1983-2011) of aneurysms associated with fenestrated A1 segment. All cases represented saccular type of aneurysms, and 79% of the patients had SAH. There were three subtypes of the fenestrated A1 aneurysms depending on the anatomical location, relative to the fenestrated segment. The most common type was the aneurysms located on the proximal end of fenestrated artery (82%). Azygos ACA and hypoplastic A1 were frequently accompanied by the aneurysm (33% and 31%, respectively), and multiple aneurysms were shown in three cases (16%). Considering that fenestrated A1 segment is likely to develop an aneurysm, which has high risk of rupture, early management may benefit patients with aneurysms accompanied by fenestrated proximal ACA.     

神经影像辅助下双侧大脑前动脉分布区急性脑梗死发病机制研究-附4例病例报道

目的 借助现代神经影像方法探讨双侧大脑前动脉(anterior cerebral artery,ACA)分布区梗死可能的机制.方法 回顾性分析4例急性双侧ACA分布区脑梗死患者的临床及头MRI、MRA或血管造影等影像学资料.结果 4例患者均有脑血管病危险因素,包括高血压、糖尿病、高脂血症、吸烟等.动脉硬化及血管变异是双...     

BIPLEDs in akinetic mutism caused by bilateral anterior cerebral artery infarction.

INTRODUCTION: Akinetic mutism is described as a result of many disorders. Bilateral infarction of the anterior cerebral artery (ACA) territory is reported rarely, however, often leading to akinetic mutism. CASE REPORT: We report a 70 year-old man with akinetic mutism due to bilateral ACA infarction. Electroencephalography, 24h after admission, showed bilateral independent periodic lateralized epileptiform discharges (BIPLEDs) in the frontal region and diffuse theta and polymorphic delta activity. DISCUSSION: Postanoxic encephalopathy, central nervous system infection and chronic seizure disorders are the major causes of BIPLEDs. However, BIPLEDs may occur in bilateral ACA territory infarction.     

Involuntary masturbation and hemiballismus after bilateral anterior cerebral artery infarction

Ischemia of the areas supplied by the anterior cerebral artery is relatively uncommon. In addition, combined hemiballismus and masturbation have rarely been reported in patients with cerebrovascular disease. We describe herein a 62-year-old right-handed man simultaneously exhibiting right side hemiballismus and involuntary masturbation with the left hand after bilateral infarction of the anterior cerebral artery territory. Right side hemiballismus was related to the disruption of afferent fibers from the left frontal lobe to the left subthalamic nucleus. Involuntary masturbation using the left hand was exclusively linked to a callosal type of alien hand syndrome secondary to infarction of the right side of the anterior corpus callosum. After 2 weeks, these abnormal behaviours were completely extinguished. This report stresses the wide diversity of clinical manifestations observed after infarction of the anterior cerebral artery territory.     

Compression of the visual pathway by anterior cerebral artery aneurysm

Visual failure is an uncommon presenting symptom of an intracranial aneurysm. It is even more uncommon in aneurysms arising from the anterior cerebral artery (ACA). We presented 2 patients with an aneurysm of the A1 segment of the anterior cerebral artery causing visual field defects. One patient presented with a complete homonymous hemianopia due to compression of the optic tract by a giant aneurysm of the proximal left A1 segment. The second patient had an almost complete unilateral anopia caused by compression of the optic nerve and chiasm by an aneurysm of the distal part of the A1 segment with a small chiasmatic hemorrhage and ventricular rupture.     

Bilateral anterior cerebral artery territory infarction in the differential diagnosis of basilar artery occlusion

Summary Two patients with bilateral anterior cerebral artery (ACA) territory infarction are presented whose initial diagnosis was basilar artery occlusion. Both had tetraparesis; in one it was asymmetrical. Both had their eyes open and did not respond to command except that after a delay they followed with their eyes a smoothly moving object; this was the only sign of awareness. One patient had a clear vertical gaze palsy in the upward and downward direction unaccompanied by pupillary abnormalities. Computed tomography revealed fresh bilateral ACA infarction in both patients; occlusion in the hind brain circulation was excluded by angiography in one. Both patients suffered from atrial fibrillation, so cardiac embolism was the most likely cause of the stroke. We conclude that bilateral ACA territory infarction should be considered in the differential diagnosis of basilar artery occlusion, even if accompanied by vertical gaze palsy.     

Clinical symptoms of bilateral anterior cerebral artery territory infarction

Bilateral anterior cerebral artery (ACA) territory infarction is rare and its associated symptoms are still not well understood. We evaluated the clinical symptoms of four patients with bilateral ACA infarction. The common clinical features were various primitive reflexes and parkinsonian symptoms including akinesia, rigidity and hypophonia. Frontal release signs were present in all patients with ACA infarction even without direct involvement of the prefrontal cortex. Enhanced glabellar tap response, previously not reported in patients with ACA infarction, was the most consistent finding, and electrophysiological studies confirmed hyperexcitability of the late component of the blink reflex. The bilateral lesions in the deep white matter may be associated with the observed symptoms, reflecting functional disconnection of the medial prefrontal-subcortical circuitry.     

Spontaneous bilateral anterior cerebral artery occlusion resulting in akinetic mutism. A case report

An unusual case concerning a patient with akinetic mutism (AM) due to spontaneous bilateral anterior cerebral artery occlusion is reported. Brain CT scan revealed the presence of mild low density foci presenting an irregular enhancement, which followed the distribution of mesial frontal gyri and paracentral lobulus, bilaterally. Right and left carotid angiographies showed bilateral occlusion of the anterior cerebral artery. Our case is characterized by an exclusive localization of the infarction in the frontal cortex. This finding suggests that a limited damage involving the anterior cerebral arteries territory could be, on its own, responsible for the AM syndrome.     

Expression of a latent ophthalmic artery collateral circulation after extracranial–intracranial bypass

We present the case of an unexpected response by the cerebral vasculature to bypass surgery. A 66-year-old man sustained a subarachnoid haemorrhage and cerebral angiography showed a large fusiform anterior communicating artery (ACoA) aneurysm and an anomalous anterior circulation. The right A1 segment was hypoplastic and blood supply to the entire right A2 was from the left anterior circulation via the ACoA. The aneurysm was therefore not amenable to endovascular coiling or surgical clipping alone. An extracranial–intracranial bypass was performed to revascularize the territory of the right A2 independently of the ACoA to allow the latter vessel to be clipped. Although the bypass graft was patent on post-operative cerebral angiography, it was in fact only perfusing a limited, peripheral anterior cerebral artery territory. The bulk of the right anterior circulation was derived retrogradely by latent collaterals from the internal carotid and ophthalmic arteries via small dural vessels which were not apparent prior to surgery.     

Contralateral Transradial Access for Coil Embolization of Distal Anterior Cerebral Artery Aneurysm Associated With a Steep Ipsilateral A1-A2 Angle

ObjectiveEndovascular treatment of distal anterior cerebral artery aneurysms is commonly addressed via the ipsilateral A1 segment of the anterior cerebral artery. However, when the parent pericallosal artery has a sharp ipsilateral A1-A2 angle, catheterization through the ipsilateral A1 segment can potentially result in vessel injury, catheter kinking, and/or compromised/stagnant anterior cerebral artery flow. Here, we present a case of a distal anterior cerebral artery aneurysm associated with a steep ipsilateral A1-A2 angle treated with contralateral transradial coil embolization.Case presentationA 91-year-old woman presented with a ruptured left distal anterior cerebral artery aneurysm at the A3 segment. The parent pericallosal artery had a steep ipsilateral A1-A2 angle. To safely achieve coil embolization of the aneurysm, a contralateral transradial system via the right A1 segment was employed. Although a secondary ipsilateral transradial system was required for contrast injection, aneurysm obliteration was successfully achieved without vessel injury or system instability.ConclusionThe A1-A2 angle can be a key anatomical factor in the endovascular treatment of distal anterior cerebral artery aneurysms. The contralateral transradial system is a useful treatment option for distal anterior cerebral artery aneurysms associated with sharp ipsilateral A1-A2 angles. However, if the distal anterior cerebral artery aneurysm cannot be clearly visualized through the contralateral system, an ipsilateral system will be required for contrast injection.     

Unilateral internal carotid artery absence in trisomy 18

BackgroundInternal carotid artery (ICA) absence (agenesis or aplasia) is a rare congenital anomaly that is usually asymptomatic and found coincidentally. There has been no report showing a specific chromosomal abnormality causes ICA absence.Case reportsMR angiography in a Japanese male infant with trisomy 18 revealed left ICA absence with the left middle cerebral artery (MCA) and anterior cerebral artery (ACA) supplied from the ipsilateral posterior communicating artery and anterior communicating artery (ACoA), respectively, type A in Lie’s classification. Another Japanese male infant with trisomy 18 showed right ICA absence with the right ACA and MCA supplied from the ACoA, that is, type B in Lie’s classification.ConclusionThere have been no pathological or radiological reports of ICA absence in trisomy 18, however, it may be underestimated because the anomaly usually causes no clinical symptoms. It is necessary to evaluate further patients to clarify whether or not unilateral ICA absence is a characteristic congenital malformation.