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.     

Diagnosis and treatment of nontraumatic dissecting aneurysm in the middle cerebral artery]

Two cases of nontraumatic dissecting aneurysm of the middle cerebral artery (MCA) are reported. A 59-year-old woman presented with subarachnoid hemorrhage, mainly in the right sylvian fissure. On admission, the right carotid angiogram revealed a dissecting aneurysm with a double lumen extending from segment M1 to M2 of the right MCA, and an unruptured saccular aneurysm in the right internal carotid artery. Emergency surgery revealed a discolored protrusion of the arterial wall in the right MCA, which was thought to be the cause of her subarachnoid hemorrhage. The protrusion of the arterial wall was clipped and coated with Bemsheet soaked in Biobond. However, disturbance of consciousness persisted and she died of paralytic ileus two months after the operation. The other patient was a hypertensive 33-year-old woman with right hemiparesis and motor dysphasia. CT scans obtained on the day of admission showed no abnormalities. She was treated conservatively with clinical improvement, but CT scans obtained 3 days after the ictus revealed an infarction deep in the left frontal lobe. A left carotid angiogram was made 4 days after ictus and demonstrated severe stenosis of the proximal segment of the left MCA with poor filling of its superior trunk. Despite improvement of her hemiparesis, CT scans obtained 3 weeks after the ictus showed hemorrhagic infarction in the left frontal lobe. Repeat left carotid angiogram revealed a double lumen in the C1 and M1 portions with improvement of the previous severe stenosis of the M1. The 23 reported cases of DA in the MCA with our cases are reviewed and their neuroradiological and clinical features are discussed.     

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.     

Dissecting aneurysm of the middle cerebral artery (M1-2 portion) with subarachnoid hemorrhage: a case report

We report a SAH case of a ruptured dissecting aneurysm of the middle cerebral artery following parietooccipital subcortical hemorrhage. A 68-year-old woman was admitted to our hospital, complaining of headache. On admission she was alert with left homonymous hemianopsia. A CT scan disclosed subcortical hemorrhage in the right parieto-occipital lobe. An angiogram revealed no abnormal vessels. Seven days after admission, she suddenly lapsed into unconsciousness with left hemiparesis. A CT scan demonstrated subarachnoid hemorrhage with a right sylvian hematoma. A second angiogram revealed fusiform dilatation of the M2 branches and aneurysmal dilatation at the M1-M2 bifurcation. Following conservative therapy, she died 21 days after admission. The relationship between subcortical hemorrhage and the subsequent subarachnoid hemorrhage was not certain. We discuss and review the treatment of a dissecting aneurysm of the middle cerebral artery.     

Dissecting aneurysm of the middle cerebral artery: case report

We present a surgical case of a dissecting aneurysm of the right middle cerebral artery associated with subarachnoid hemorrhage and intracranial hemorrhage. A 61-year-old woman with consciousness disturbance and left hemiplegia was referred to our hospital. She had suffered severe headache for a week. CT scan showed a subarachnoid hemorrhage in the right Sylvian fissure and intracranial hemorrhage in the right putamen. The right carotid angiogram revealed string sign in M1 portion and occlusion at M2 lower branch of the right middle cerebral artery. On the 12th day, we undertook surgery to confirm whether it was a dissecting aneurysm or not. In the operation, it was reddish in the M1 portion corresponding to the "string sign" and dark-purplish in the lower M2 portion corresponding to an "aneurysm-like lesion". To prevent bleeding, the arterial wall in the M1 portion was coated using muscle. Though the left hemiplegia was unchanged, the postoperative course was uneventful. The patient was transferred to another hospital and underwent rehabilitation. There has been no reccurrence during the four years since surgery. The middle cerebral artery dissecting aneurysm is extremely rare. We presented this case with review of the literature.     

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)     

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.     

Two cases of azygos anterior cerebral artery aneurysm (author's transl)]

Two cases with azygos anterior cerebral artery were reported from an analysis of 37 cases of distal anterior cerebral artery aneurysm. Case 1 was a 57-year-old woman. She had an attack of subarachnoid hemorrhage two months before admission to our clinic. The anterior cerebral artery was not demonstrated on the right carotid angiogram, and an azygos anterior cerebral artery was visualized on the left carotid angiogram. The aneurysm was situated at the distal end of the azygos artery. Case 2 was a 71-year-old hypertensive woman. Subarachnoid hemorrhage occurred 6 days before admission to our clinic. The left carotid angiography with contraleteral compression revealed an azygos artery and an aneurysm in its middle part. The azygos arteries in both cases were confirmed at operation and aneurysmal necks were managed without any serious deficit. The distal anterior cerebral artery aneurysm is frequently accompanied by azygos artery. This vascular anomaly may cause a hemodynamic change and may be one of the factors of aneurysmal formation at this part.     

Unilateral nerve deafness due to rupture of a right vertebral artery aneurysm. Case report

A 49-year-old female with no history of hearing disturbance developed sudden onset of headache and was admitted with no neurological deficits other than mild nuchal rigidity. Computed tomography (CT) showed subarachnoid hemorrhage. Four-vessel cerebral angiography disclosed no aneurysm. A second angiogram obtained on the 14th day showed vasospasm of the bilateral posterior cerebral arteries and right anterior inferior cerebellar artery, but still failed to demonstrate an aneurysm. Following the second angiography, she developed mild disturbance of consciousness and cerebellar ataxia of the right limbs, and repeat CT showed an infarct in the right cerebellar hemisphere. When she regained consciousness a few days later, she was completely deaf on the right side. The third angiography revealed a right vertebral artery dissecting aneurysm. Following clipping of the proximal portion of the right vertebral artery, she did well and was discharged, although right cerebellar ataxia and deafness persisted. Neuro-otological evaluation, including pure-tone audiography, auditory brainstem responses, electrocochleography, and caloric testing, indicated that her deafness resulted from ischemia in the territory of the right internal auditory artery due to vasospasm.     

Dissecting aneurysm of the posterior inferior cerebellar artery; a case report]

A case of a dissecting aneurysm of the left posterior inferior cerebellar artery caused by giant cell angiitis is presented. A 22-year-old woman was admitted on August 30, 1990, with sudden onset of severe occipital headache and vomiting. Neurological examination on admission only showed severe meningismus. CT scan demonstrated subarachnoid hemorrhage and a small hematoma in the 4th ventricle. A left vertebral angiogram demonstrated that the left posterior inferior cerebellar artery was occluded at the lateral medullary segment. We diagnosed subarachnoid hemorrhage from a dissecting aneurysm. On the day following admission, the patient underwent a left suboccipital craniectomy. The posterior inferior cerebellar artery was enlarged for a distance of about 8 mm and there was typical purplish-red appearance in the dissecting aneurysm. This aneurysm was excised after trapping. The histological diagnosis was primary localized giant cell angiitis without systemic involvement. The etiology of the intracranial dissecting aneurysm is obscure, but this report suggests that cerebral angiitis can be considered as an important factor.     

Ruptured cerebral aneurysm of the median artery of the corpus callosum (accessory anterior cerebral artery): case report

A rare case of ruptured cerebral aneurysm of median artery of corpus callosum (accessory anterior cerebral artery: Acc ACA) is reported. A 66-year-old hypertensive female suddenly lost consciousness for 5 minutes and later complained of severe headache. On admission, the next day, consciousness was clear and she showed no neurological deficit except for right motor weakness. CT scan revealed subarachnoid hemorrhage, and carotid angiography showed triplicated anterior cerebral artery with a saccular aneurysm on the Acc ACA. Twenty hours after the onset, an operation was performed to clip the aneurysm neck. Post-operative course was uneventful and she was discharged on the 25th postoperative day without neurological deficits. When the median artery of corpus callosum(MACC), a branch of anterior communicating artery distributes to one or to both hemispheres, it is called Acc ACA. It is thought to be a vascular anomaly and which has an incidence of 20%. However, cases of aneurysm of MACC (or Acc ACA) have not been reported and our case is considered to be the first.     

Serial angiographical changes of a ruptured dissecting vertebral aneurysm

A 54-year-old woman presented a subarachnoid hemorrhage from a ruptured dissecting aneurysm on the right vertebral artery. A right vertebral angiogram revealed a fusiform dilatation distal to the right posterior inferior cerebellar artery and "pseudo lumen" was observed in a delayed arterial phase. Conservative treatment was carried out, and the patient condition gradually improved. An angiographical examination for planned endovascular treatment 46 days after the onset, revealed the normalization of the formerly dilated caliber of the right vertebral artery with only a minor luminal irregularity. However, 83 days after the onset, right vertebral angiogram showed reappearance of the fusiform dilatation. The right vertebral angiogram obtained 204 days after the onset showed that the dilated segment of the dissecting aneurysm had become normalized to a slight degree. The serial angiographical changes of the dissecting site might have been due to regression and organization following transient thrombosis of intramural hematoma. Such drastic changes within a short period have not been reported yet. In conclusion, careful repeated follow-up is recommended in monitoring aneurysmal formation during the early to chronic phase after rupture of a dissecting aneurysm. The repetition of angiography is important, because later, if angiography has been performed only once, aneurysmal dilatation may be overlooked. One has to be aware of such changes, because such changes may alter the clinician's decision about treatment, as they did in our case.     

Aneurysm in the horizontal segment of the anterior cerebral artery confirmed by cerebral vasospasm--case report.

A rare aneurysm in the horizontal segment (A1) of the right anterior cerebral artery was found in a 58-year-old male presenting with subarachnoid hemorrhage. No obvious bleeding source was observed on the day of onset, but 7 days later, a definite diagnosis was made based on the discovery of cerebral vasospasm by a repeat angiogram. The aneurysm was clipped via the right frontotemporal approach 15 days after onset. He suddenly developed neurological symptoms such as consciousness disturbance, right hemiplegia, and aphasia on the 4th postoperative day, when remission of the cerebral vasospasm was confirmed by transcranial Doppler ultrasound examinations and cerebral angiography. The ischemic symptoms were probably due to cerebral embolus caused by intraluminal thrombi, which had formed during the maximum phase of vasospasm and became detached during the remission phase.     

Ruptured cerebral aneurysms missed by initial angiographic study

The authors reviewed the computed tomographic (CT) scans of patients with subarachnoid hemorrhage whose initial angiograms were negative, to investigate the validity of CT scans in predicting the presence of an angiographically missed aneurysm in such patients. During the past 14 years, additional angiograms have been obtained for 38 of the 45 patients with subarachnoid hemorrhage whose initial angiograms disclosed no aneurysm. Aneurysms were found in 8 patients; 7 on the anterior communicating artery and 1 at the junction of the internal carotid and posterior communicating arteries. CT scans were taken within 4 days after subarachnoid hemorrhage in 31 patients. Analysis of these scans showed that the second angiogram revealed 1) an aneurysm in 21% of the patients with a thin layer of subarachnoid blood and in 63% of those with a thick layer; 2) no aneurysm in the patients without subarachnoid blood; and 3) an aneurysm of the anterior communicating artery in 70% of the patients who showed a considerable amount of blood in the basal frontal interhemispheric fissure. These results suggest that if CT scans show thin or thick subarachnoid blood, angiographic study should be repeated early in the course. If a considerable amount of blood is shown in the basal frontal interhemispheric fissure, it is highly probable that an aneurysm is hidden on the anterior communicating artery, even if the angiogram is negative for an aneurysm.     

Dissecting aneurysms at the A1 segment of the anterior cerebral artery--two case reports

Two rare cases of dissections which involve the anterior cerebral artery (ACA) are reported. A 58-year-old woman presented with a ruptured dissecting aneurysm manifesting as sudden onset of severe headache and consciousness disturbance followed by aphasia, right hemiparesis, paresis of the left lower extremity, and choreoathetotic movements of the upper arms and face. Computed tomography and angiography revealed subarachnoid hemorrhage due to a dissecting aneurysm at the left A1 segment. The dissecting aneurysm was trapped surgically on the day of onset. Her neurological deficits disappeared within a month. A 39-year-old woman experienced continuous dull headache from the day before onset, and then suffered right hemiparesis. Magnetic resonance (MR) imaging revealed cerebral infarction at the left globus pallidus. Angiography and MR imaging revealed a dissecting aneurysm at the left A1 segment and occlusion of the left Heubner's artery. She received conservative treatment and her neurological findings were improved. Dissections or dissecting aneurysms involving the ACA can be classified into three types: Extension of a dissection to the ACA from the internal carotid artery, dissection at the A1 segment, and dissection at the A2-A4 segments. These types of dissection have distinct uniform clinical features.     

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.     

A ruptured aneurysm in the hypoplastic proximal anterior cerebral artery (A1 portion); case report

A case of ruptured aneurysm in the hypoplastic proximal anterior cerebral artery (A1 portion) is reported. This 25-years old man complained of the sudden onset of severe headache and vomiting on January 11, 1989. He was referred to our hospital on the same day, and CT scan revealed subarachnoid hemorrhage. Cerebral angiography on the next day revealed an aneurysm in the hypoplastic A1 portion of the right anterior cerebral artery, and no branch was present at the site of the aneurysmal neck. He was operated on using the right pterional approach. The A1 portion was trapped and the aneurysm was removed successfully. The histology of the aneurysm was that of the usual type of the saccular aneurysm. The post-operative course was uneventful. He was discharged with no neurological deficit two months after the operation. As far as we know, there has been no report on a ruptured aneurysm in the hypoplastic A1 portion. We also reviewed the 55 aneurysms in the A1 portion that have been reported in the literature.     

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.     

Dissecting aneurysm of the middle cerebral artery with subarachnoid hemorrhage showing complete occlusion at the M2 portion of the middle cerebral artery on preoperative angiograms: case report

We present a surgical case of a dissecting aneurysm of the middle cerebral artery associated with subarachnoid hemorrhage and intracranial hemorrhage. A 29-year-old man suddenly fell into a comatose state, and was referred to our hospital. CT scan showed diffuse subarachnoid hemorrhage and an intracerebral hematoma with marked midline shift located in the right frontal lobe. The right carotid angiogram revealed complete occlusion at the M2 portion of the middle cerebral artery, but failed to reveal any aneurysms in the rest of the intracranial circulation. We undertook emergent surgery to evacuate the hematoma and to confirm whether it was a dissecting aneurysm or not. After evacuation of the hematoma of the right frontal lobe, the Sylvian fissure was noticed to be widely opened. We detected a large dissecting aneurysm with a dark-purplish wall arising from the right M2 trunk, and we trapped the aneurysm. The postoperative course was uneventful and the patient gradually improved and was discharged without neurological deficits. We presented this case with a review of the literature.     

Spontaneous dissecting aneurysm of middle cerebral artery: a case report with review of the literature.

We report a case of a dissecting aneurysm of the middle cerebral artery (MCA) and its treatment strategies. A 50-year-old male patient presented with occipital and neck pain for 2 days. CT scan revealed subarachnoid hemorrhage (SAH) in the region of the right sylvian fissure. A left carotid angiogram showed a dissecting aneurysm of the left MCA (M1). He was treated surgically by a pterional trans-sylvian approach. Clipping was done along with additional reinforcement by wrapping to completely obliterate the neck of the aneurysm. On reviewing the literature, we think that dissecting aneurysms seem to be one of the important causes of SAH and cerebral infarction of unverified origin. If an MCA dissecting aneurysm is identified, especially located in the proximal portion, surgical treatment must be considered. These patients merit a close follow-up.