Subarachnoid hemorrhage due to a ruptured intracranial vertebral artery aneurysm associated with cerebrovascular fibromuscular dysplasia: case report

Fibromuscular dysplasia (FMD) is comprised of a group of nonatherosclerotic and noninflammatory arterial diseases. Cerebrovascular FMD occurs more frequently in women, and the mean age at which it is diagnosed is 50 years. The most common angiographic pattern of cerebrovascular FMD is the "string-of-beads" deformity at the extracranial internal carotid artery. We report the case of a 52-year-old woman who presented with a sudden severe headache and went into a deep coma. She had been complaining of headaches for 2 weeks, but no specific imaging findings were obtained. A computed tomography scan obtained on admission showed a diffuse subarachnoid hemorrhage (SAH) from the cerebellomedullary cistern to the basal cistern with evidence of clot in the fourth and third ventricles. We performed digital subtraction angiography and made the diagnosis of cerebrovascular FMD. Right carotid angiography and left vertebral angiography showed the classic "string-of-beads" pattern with multiple constrictions of the lumen. Left carotid angiography showed a long segment of tubular stenosis. Right vertebral angiography also revealed the "string-of-beads" pattern and a ruptured aneurysm at the intracranial segment, which presented as a diverticulum-like outpouching. The patient was treated with conservative measures but passed away on the 23rd day of hospitalization. An autopsy was not performed. To our knowledge, during the last three decades, there are only four previous reports which showed intracerebral ruptured aneurysms of the vertebral artery or its branch in adults with cerebrovascular FMD. We demonstrate and discuss the radiologic findings here.     

Maffucci's syndrome associated with intracranial enchondroma and aneurysm: case report

Maffucci's syndrome is a rare, congenital mesodermal dysplasia combined with dyschondroplasia and hemangiomatosis. Enchondromatous involvement of the skull bones is rare in this syndrome. A rare case of Maffucci's syndrome associated with enchondroma at the skull base, left internal carotid artery aneurysm, and goiter is reported. Two other previously reported cases of Maffucci's syndrome with associated aneurysms and the present case suggest that Maffucci's syndrome may be associated with aneurysm.     

A case of ruptured aneurysm associated with spinal arteriovenous malformation presenting with hematomyelia: case report

BACKGROUND

Spinal cord arteriovenous malformation (AVM) associated with spinal aneurysm is not particularly rare, but cases presenting with hematomyelia are relatively rare compared to those with subarachnoid hemorrhage (SAH). We report a rare case of successfully treated spinal AVM associated with ruptured aneurysm presenting with hematomyelia.

CASE DESCRIPTION

A 52-year-old male was admitted to our hospital with sudden onset of tetraplegia, respiratory disturbance, and superficial sensory disturbance. Computed tomography revealed hematomyelia at the level of C3–4. Gadolinium-enhanced magnetic resonance imaging showed small, enhanced lesions. Angiography revealed an intradural perimedullary arteriovenous malformation associated with two aneurysms on the feeding arteries. Administration of high-dose methylprednisolone gradually ameliorated his symptoms. Direct surgical obliteration was performed on the 30th day after the onset. The bilateral C3 cervical radicular arteries and the nidus were coagulated. Angiography performed after surgery showed neither the aneurysms nor the nidus. He was discharged with only mild weakness in the left upper extremity and mild left hypesthesia 3 months after surgery, and was fully independent.

CONCLUSION

We report a case of hematomyelia caused by ruptured aneurysm associated with spinal arteriovenous malformation that was successfully treated with surgical obliteration.     

Neurogenic pulmonary edema

Neurogenic pulmonary edema (NPE) is usually defined as an acute pulmonary edema occurring shortly after a central neurologic insult. It has been reported regularly for a long time in numerous and various injuries of the central nervous system in both adults and children, but remains poorly understood because of the complexity of its pathophysiologic mechanisms involving hemodynamic and inflammatory aspects. NPE seems to be under-diagnosed in acute neurologic injuries, partly because the prevention and detection of non-neurologic complications of acute cerebral insults are not at the forefront of the strategy of physicians. The presence of NPE should be high on the list of diagnoses when patients with central neurologic injury suddenly become dyspneic or present with a decreased P(a)o(2)/F(i)o(2) ratio. The associated mortality rate is high, but recovery is usually rapid with early and appropriate management. The treatment of NPE should aim to meet the oxygenation needs without impairing cerebral hemodynamics, to avoid pulmonary worsening and to treat possible associated myocardial dysfunction. During brain death, NPE may worsen myocardial dysfunction, preventing heart harvesting.     

Midaortic syndrome in childhood associated with a ruptured cerebral aneurysm: a case report

BACKGROUND: We present a patient with a midaortic syndrome who presented with subarachnoid hemorrhage caused by rupture of an anterior communicating artery aneurysm.CASE DESCRIPTION: A 14-year-old boy with midaortic syndrome was admitted to our hospital because of subarachnoid hemorrhage due to rupture of an anterior communicating artery aneurysm. He also developed acute renal failure due to previously controlled hypotension. After blood dialysis, successful clipping of the aneurysm was performed. The postoperative course was complicated by malignant renovascular hypertension due to midaortic syndrome. Medical treatment failed to control his hypertension; left primary nephrectomy improved his condition.CONCLUSION: Although midaortic syndrome is rare, it may be significant as a cause of cerebral hemorrhage in childhood.     

Neurogenic pulmonary edema: treatment with dobutamine

In the case of a patient with complicating subarachnoid hemorrhage, an infusion of dobutamine was followed by a massive diuresis and regression of severe neurogenic pulmonary edema. It is suggested that the reduction in total peripheral vascular resistance and the increase in cardiac contractility accounts for the observed beneficial effect and indicate that dobutamine is a suitable drug for the treatment of neurogenic pulmonary edema.     

Peripheral ophthalmic artery aneurysm associated with multiple intracranial aneurysms: a case report

Peripheral intraorbital ophthalmic artery aneurysms are rare. We here present a case of intraorbital ophthalmic artery aneurysm, associated with multiple anterior circulation aneurysms. The asymptomatic ophthalmic artery aneurysm was not treated. However, the symptomatic ones were embolized.     

Uncommon presentation of ruptured intracranial aneurysm during surgical evacuation of chronic subdural hematoma: case report

BACKGROUND: There are many factors that predispose an aneurysm to rupture, but there are few real, demonstrable causes that lead to rupture of the aneurysmal sac with a precise cause-effect mechanism. CASE DESCRIPTION: We report a 74-year-old male patient with chronic subdural hematoma after head trauma, who underwent surgery for evacuation of the hematoma. During surgery, there was sudden copious loss of blood from the drainage tubes that were positioned subdurally. Immediate cerebral computed tomography scan and angiography revealed a subarachnoid hemorrhage at the level of the basal cisterns from a ruptured basilar apex aneurysm. We discuss the cause-effect relationship between the surgery with its positioning of subdural drains and the rupture of a previously unrecognized cerebral aneurysm. CONCLUSIONS: The rupture of an unknown, previous "unruptured" aneurysm after craniotomy with subdural positioning of drainage, must be considered a possible complication.     

Subarachnoid hemorrhage caused by ruptured intracranial fusiform aneurysm associated with microscopic polyangiitis

A 44-year-old woman with microscopic polyangiitis (MPA) presented with a ruptured cerebral aneurysm. She was admitted to our hospital for further examination of progressive renal failure. She was found lying on the ward floor. Computed tomography showed subarachnoid hemorrhage, and digital subtraction angiography revealed a saccular-like aneurysm arising from the right distal posterior inferior cerebellar artery (PICA) at the non-branching site. We performed neck clipping of the right distal PICA aneurysm, which recurred 5 days after the operation. Second angiography demonstrated a right distal PICA aneurysm just above the site of the clip. Therefore, we performed trapping of the affected lesion with emergent bypass of the contralateral occipital artery to the ipsilateral PICA. Her postoperative course was uneventful until she coughed up blood and had gross hematuria 3 days after the second surgery. Histological examination of a renal biopsy specimen revealed crescentic glomerulonephritis. MPA was diagnosed on the basis of the cardinal symptoms, including progressive glomerular nephritis and the lung abnormality, as well as the presence of myeloperoxidase-antineutrophil cytoplasmic antibodies. After intensive treatment, she was discharged for rehabilitation without neurological deficit. MPA commonly affects small-sized vessels mainly in the kidneys and lungs and may lead to crescentic glomerulonephritis and pulmonary hemorrhage. MPA is rarely associated with aneurysms of medium-sized muscular vessels. Cerebral aneurysm is extremely rare in patients with MPA, but rupture of an intracranial fusiform aneurysm can be lethal, so screening of the intracranial vessels should be performed by magnetic resonance imaging in patients with MPA.     

A case of ruptured true posterior communicating artery aneurysm with neurogenic pulmonary edema treated early by GDC embolization

A case of ruptured true posterior communicating artery aneurysm with neurogenic pulmonary edema is presented. A 31-year-old male suffered the sudden onset of unconsciousness with respiratory dysfunction and pinkish foamy sputum. Computed tomography demonstrated diffuse subarachnoid hemorrhage and chest roentgenogram disclosed pulmonary edema. An emergency cerebral angiogram under controlled ventilation revealed that an aneurysm had arisen from the right posterior communicating artery itself. Subsequently GDC embolization and lumbar drainage were performed on day 0. The patient showed full recovery from pulmonary edema on day 6. He suffered multiple cerebral infarctions caused by vasospasm but he atlained a full recovery after 7 months. The follow-up angiogram showed complete obliteration of the aneurysm. This case report suggests that endovascular treatment with lumbar drainage is useful for severe aneurysmal SAH complicated with pulmonary edema in the acute stage.     

Neurogenic pulmonary edema in a fatal case of subarachnoid hemorrhage

Neurogenic pulmonary edema (NPE) is caused by a variety of central nervous system lesions and may appear as a subclinical complication. The fulminant form of NPE is always life-threatening. Many pathophysiologic mechanisms have been implicated in the development of NPE, but the exact interaction remains unknown. We report a case of a fulminant NPE with fatal consequences associated with a subarachnoid hemorrhage. Treatment focuses on ventilatory support and measures to reduce intracranial pressure.     

Subarachnoid hemorrhage from a peripheral intracranial aneurysm associated with malignant glioma: report of a case

The case of a patient who initially presented with a subarachnoid hemorrhage from an aneurysm of the distal left middle cerebral artery is reported. The aneurysm was later found to have occurred within a malignant glioma. Histological analysis showed tumor infiltrating the wall of the aneurysm. A causal relationship between growth of the tumor and development and rupture of the aneurysm is postulated.     

Medulla oblongata edema associated with neurogenic pulmonary edema. Case report

Neurogenic pulmonary edema (NPE) occurs in association with central nervous system disease without underlying cardiopulmonary problems. It is characterized by profound pulmonary vascular congestion and a fulminant clinical course. Although several reports document a role for experimental brain-stem lesions in the production of NPE, there have been only two studies in man correlating specific brain-stem lesions with NPE. The authors report a case of NPE occurring in a patient with von Hippel-Lindau disease and a dorsal medullary syrinx with postoperative dorsal medullary edema. The anatomical location of this patient's lesion is reviewed in the context of alternative theories of the pathogenesis of NPE.     

Infected intracranial aneurysm in an infant: case report

The case of a ruptured, infected intracranial aneurysm occurring in a 34-day-old child is reported. The child was brought for examination after a sudden onset of screaming and pallor, followed by focal seizures. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan revealed a large hematoma in the region of the left sylvian fissure. An angiogram demonstrated a 17-mm aneurysm arising from a small branch of the middle cerebral artery. At craniotomy, the hematoma was evacuated and an infected aneurysm was removed. The etiology, pathogenesis, and management of infected intracranial aneurysms is discussed. Our patient is the youngest in whom such an aneurysm has yet been reported.