A large vertebrobasilar junction aneurysm grown at the proximal end of basilar artery fenestration--usefulness of balloon occlusion test with 99mTc-HMPAO SPECT under induced hypotension and consideration in therapeutic strategies

A 48-year-old lady suffered a transient loss of consciousness. CT and MRI revealed a large vascular lesion compressing the left lower pons. Angiography revealed a large aneurysm at vertebro-basilar junction, dome of which projected anteriorly and left to midline. Her previous vertebral angiogram taken 10 years ago when she suffered a subarachnoid hemorrhage from the left MCA aneurysm, had showed a fenestration of lower basilar artery without apparent aneurysm. Bilateral super-selective vertebral angiograms revealed that the aneurysm arose at the proximal end of the fenestration, and vertebrobasilar junction was incorporated into the aneurysm indicating broad neck aneurysm. The left posterior communicating artery was well developed. Balloon test occlusion (BTO) of bilateral vertebral artery was performed under normotension and induced hypotension. 99mHM-PAO SPECT was used to examine cerebral blood flow (CBF) during hypotensive BTO. The patient tolerated the test and CBF imaging showed insignificant sight decrease in bilateral cerebellar hemispheres. Exploration of the aneurysm was carried out by the right far lateral suboccipital approach. Bilateral vertebral arteries and the right segment of the basilar artery fenestration were identified. Neck clipping of the aneurysm with reconstruction of the parent vessels were tried with fenestrate clip. However, narrow operative field and large dome of the aneurysm made it hard to identify the left segment of the fenestration. Neck clipping was given up and clipping of bilateral vertebral arteries were performed distal to posterior inferior cerebellar artery with three body clippings. The patient showed moderate postoperative left lower nerve palsy, which was gradually improved in several weeks. Follow-up angiography revealed no opacification of the aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Giant fusiform basilar artery aneurysm: endovascular treatment by flow reversal in the basilar artery

We report a patient presenting with subarachnoid haemorrhage due to rupture of a giant fusiform aneurysm of the proximal basilar artery. The aneurysm was successfully treated by reversing blood flow in the basilar artery by balloon occlusions of both vertebral arteries proximal to the posterior inferior cerebellar artery origins. Substantial thrombosis and regression of the aneurysm was evident 4 months later.     

Intravascular stent and endovascular coil placement for a ruptured fusiform aneurysm of the basilar artery. Case report and review of the literature

The authors demonstrate the technical feasibility of using intravascular stents in conjunction with electrolytically detachable coils (Guglielmi detachable coils [GDCs]) for treatment of fusiform, broad-based, acutely ruptured intracranial aneurysms and review the literature on endovascular approaches to ruptured aneurysms and cerebral stent placement. A 77-year-old man presented with an acute subarachnoid hemorrhage of the posterior fossa. A fusiform aneurysm with a broad-based neck measuring 12 mm and involving the distal vertebral artery (VA) and proximal third of the basilar artery (BA) was demonstrated on cerebral angiography. The aneurysm was judged to be inoperable. Six days later a repeated hemorrhage occurred. A 15-mm-long intravascular stent was placed across the base of the aneurysm in the BA and expanded to 4 mm to act as a bridging scaffold to create a neck. A microcatheter was then guided through the interstices of the stent into the body and dome of the aneurysm, and GDCs were deposited for occlusion. The arteriogram obtained after stent placement demonstrated occlusion of the main dome and body of the aneurysm. The coils were stably positioned and held in place by the stent across the distal VA and BA fusiform aneurysm. Excellent blood flow to the distal BA and posterior cerebral artery was maintained through the stent. There were no new brainstem ischemic events attributable to the procedure. No rebleeding from the aneurysm had occurred by the 10.5-month follow-up evaluation, and the patient has experienced significant neurological improvement. Certain types of intracranial fusiform aneurysms may now be treated by combining intravascular stent and GDC placement for aneurysm occlusion via an endovascular approach. This is the first known clinical application of this novel approach in a ruptured cerebral aneurysm.     

Evolving methods in genetic epidemiology. IV. Approaches to non-Mendelian inheritance

Dissecting aneurysm of the basilar artery is a rare but increasingly recognized entity, with a frequently fatal or morbid outcome. Unlike the well established proximal occlusion and trapping approaches to vertebral artery dissections, surgical intervention for basilar lesions has been limited to wrapping techniques for arterial wall reinforcement. We report a case of midbasilar dissecting aneurysm successfully treated by clipping the proximal basilar artery below the level of the anterior inferior cerebellar arteries, allowing retrograde flow via the posterior communicating arteries to provide continued basilar perfusion. With the growing recognition of basilar dissection and pseudoaneurysm formation there is a need for improved therapeutic options. We suggest that definitive treatment can be achieved using the principle of proximal occlusion and flow reversal, and review the pertinent literature on basilar artery dissection.     

Pterional craniotomy via a transcavernous approach for the treatment of low-lying distal basilar artery aneurysms

OBJECT: The author describes a surgical procedure in which pterional craniotomy is performed via a transcavernous approach to treat low-lying distal basilar artery (BA) aneurysm. This intradural procedure is compared with the extradural procedure described by Dolene, et al. METHODS: The addition of a transcavernous exposure to the standard pterional intradural transsylvian approach allows a lower exposure of the distal BA behind the dorsum sellae. The technical steps involved in this procedure are as follows: 1) removal of the anterior clinoid process: 2) entry into the cavernous sinus medial to the third nerve; 3) packing of the venous channels of the cavernous sinus lying between the carotid artery and the pituitary gland to open this space; 4) removal of the posterior clinoid process and the portion of the dorsum sellae that is exposed from within the cavernous sinus; and 5) removal of the exposed dura mater to obtain additional exposure of the peri-mesencephalic cistern. Eight cases of aneurysms of the distal BA are presented to illustrate how this approach can help in their surgical treatment. CONCLUSIONS: Using the standard pterional approach, these distal BA aneurysms were found to be either too low relative to the posterior clinoid process for adequate exposure or there was insufficient room for temporary clipping of the BA proximal to the lesion. The addition of a transcavernous exposure eliminated these technical problems and aneurysm clipping could be accomplished in each case.     

More children are unable to get dental care than any other single health service

True congenital peripheral aneurysms of the cerebral arteries are rare and may constitute a special entity. We report a rare case of nonmycotic peripheral aneurysm of the posterior cerebral artery (PCA) found in association with aneurysms of distal middle cerebral artery (MCA), junction between basilar artery (BA) and superior cerebellar artery (SCA) and MCA trunk. Our present case was a 37-year-old man with a history of abrupt loss of consciousness. Cerebral angiography revealed a right PCA aneurysm originating at the junction between the trunk of the PCA and the posterior temporal branch, and also aneurysms of the right distal MCA, at the right BA-SCA junction and at the trunk of right MCA just distal to the anterior temporal artery. Distal PCA aneurysm causing subarachnoid hemorrhage was successfully clipped and all the other aneurysms were treated in a one-stage procedure. Pathological examination of the surgically excised distal PCA aneurysmal sac demonstrated no infectious etiology. There have not been any similar cases showing an association of vascular anomalies with distal PCA aneurysm. This is the only reported case with the association of nonmycotic peripheral aneurysms involving the MCA and PCA.     

Duplication of the extracranial internal carotid artery

We describe a case of duplication of the left internal carotid artery from a point 1 cm distal to the origin to the proximal petrous segment where the vessel reunites. Duplication and fenestration of the internal carotid artery are discussed. A review of embryologic development is presented. Identification of these entities is important, especially in patients who require surgical intervention involving the internal carotid artery.     

A histomorphological study in age related changes in the elastic fiber system of the basilar artery

The aim of the study was to quantify the distribution of elastic fibers within the wall of the basilar artery. Three age groups were studied: 1) 0-1 yr.; 2) 20-50 yr. 3) > 50 yr. A histomorphometrical study was undertaken using an estimation of the linear density of the components of the fibrous elastic tissue system: the full length in the proximal and distal segments of the basilar artery was evaluated. Our results showed that: The elastic tissue of the basilar artery is not evenly distributed throughout the tunica media. Compared to the 0 to 1-year age group, mature elastic, elauninic and oxytalan fibers decreased with age. In all age groups the linear density of the mature elastic fibers was more evident in the proximal than in the distal segment of the artery.     

Histological patterns of atherosclerotic plaques in unstable angina patients vary according to clinical presentation

Aneurysms of the cervical vertebral artery (VA) are uncommon; they are often caused by trauma or spontaneous dissection. A fusiform aneurysm without evidence of atherosclerosis or dissection has not been reported previously. A 46-year-old man presented with a pontine infarct. Imaging revealed a fusiform aneurysm of the left VA at the C5-6 level, with occlusion of the basilar artery. Associated minor anomalies included fusion of the vertebral bodies of C5 and C6, cervical rib and platybasia. The left VA arose directly from the aortic arch and entered the transverse foramen at the C4 level. Hyperextension and left lateral flexion of the neck caused kinking of the VA proximal to the aneurysm. Turbulent flow in the aneurysm lumen was noted on angiography.     

Fenestration of the basilar artery associated with persistent primitive trigeminal artery

A 39-year-old male presented with a putaminal hemorrhage. Angiography disclosed the incidental findings of association of basilar artery fenestration and persistent primitive trigeminal artery. This is the first report of this association of congenital anomalies of the cerebral vessels.     

Association between exposure to crystalline silica and risk of sarcoidosis

A 56-year-old male with two mycotic aneurysms associated with infective endocarditis was treated by endovascular surgery before mitral valve replacement. Angiography revealed a ruptured proximal aneurysm and an unruptured distal aneurysm on the right middle cerebral artery. The ruptured aneurysm was successfully treated with an interlocking detachable coil, and patency of the parent artery was preserved. The unruptured distal aneurysm disappeared as a result of antibiotic therapy. Endovascular surgery of the mycotic aneurysm is less invasive and more effective than craniotomy under general anesthesia for patients with infective endocarditis.     

Long-term results of arthroscopic meniscectomy

A 13-year-old boy with a rare giant fusiform aneurysm at the horizontal portion of the middle cerebral artery (M1) presented with progressively severe throbbing headache. The aneurysm was reconstructed by tandem application of nine fenestrated clips and coating of the remnant of the aneurysm. However, he was readmitted 3 months later because of recurrent aneurysms at the proximal and distal M1 portions which had been coated. The aneurysms were trapped after rupture occurred during a second operation. Aneurysm trapping combined with superficial temporal artery-middle cerebral artery bypass surgery may be a better method to treat such aneurysms.     

Exclusion of a sciatic artery aneurysm and an obturator bypass

This case report describes surgical treatment in a sciatic artery aneurysm with hypoplastic external iliac and femoral arteries. An obturator bypass grafting procedure from the internal iliac artery to the distal sciatic artery was performed after aneurysmal exclusion was achieved by proximal and distal ligation. This method offers an acceptable option for surgery in some types of sciatic artery aneurysms.     

Ruptured fusiform cerebral aneurysm in a neonate

An 11-day-old male infant presented with subarachnoid and intraventricular haemorrhage caused by a ruptured intracranial aneurysm. Magnetic resonance (MR) angiogram and digital subtraction angiography (DSA) revealed a fusiform aneurysm 10 mm in diameter supplied by the proximal segment of the anterior cerebral artery (A1), with both distal segments (A2) arising from the aneurysm. The right A1 was aplastic. There have been 13 previous case reports of neonatal cerebral artery aneurysms, but only 1 of these has been fusiform. None of the earlier reports has mentioned dysplastic segments or other anomalies of the circle of Willis.     

Primitive hypoglossal artery associated with basilar artery aneurysm

A case of persistent primitive hypoglossal artery, accompanied by a basilar bifurcation aneurysm, is reported. The persistent primitive hypoglossal artery was seen on the right side and the left vertebral artery was hypoplastic. The right vertebral artery was absent, while a normal sized posterior communicating artery was seen on the right side at the operation on the aneurysm. The combination of a basilar bifurcation aneurysm and a persistent primitive hypoglossal artery is rare. A review of related reports has been made.     

Microanatomy of the perforators of the anterior communicating artery complex

We describe the microanatomy of the perforating arteries arising from the anterior communicating artery complex (5 mm distal of the anterior cerebral artery, the anterior communicating artery, and 5 mm proximal of the distal anterior cerebral artery). Thirteen unfixed human brains were used in this study. The origin and number of perforators are described, as is the site of brain penetration, and results are correlated with previous studies. The hemodynamics of blood flow in relation to the formation of an anterior communicating artery aneurysm and different surgical approaches are mentioned. The neuropsychological outcome after aneurysm clipping with regards to the pattern of blood supply from the anterior cerebral artery complex is also discussed.     

Concurrent subarachnoid hemorrhage due to ruptured aneurysm and hypertensive intracerebral hemorrhage--case report

A 64-year-old female presented with hypertensive thalamic hemorrhage concurrent with subarachnoid hemorrhage (SAH) due to a ruptured aneurysm manifesting as sudden onset of right hemiparesis followed by severe headache. The aneurysm was located in the basilar artery at the origin of the superior cerebellar artery, remote from the thalamic hematoma. The aneurysm was clipped 3 weeks after SAH. She was discharged with slight right hemiparesis. The method and timing of surgery for such patients depend on hematoma size, location of the aneurysm and hematoma, and neurological status. The intracerebral hemorrhage remote from the ruptured aneurysm should be treated initially if necessary, and the aneurysm clipped after the brain swelling has reduced.     

Video-assisted thoracoscopic closure of PDA--a case report and literature review

A 78-year-old man with a history of recent unexplained lower gastrointestinal bleeding presented to the emergency department with the acute onset of abdominal pain, tenesmus, and shock. Computed tomography of the abdomen showed a fistula between a common iliac artery aneurysm and the small intestine. Laparotomy demonstrated a saccular aneurysm of the common and proximal internal iliac arteries with fistulous communication to the distal ileum. Aneurysmectomy, arteriorrhaphy, and segmental ileal resection with primary anastomosis were successfully performed. This case illustrates a rare complication of an uncommon aneurysm, emphasizing the need for emergency physicians to consider complicated vascular disease in the evaluation of a patient with abdominal pain and shock.     

Aneurysm of the major vessels in neurofibromatosis

The case of a patient who presented with a ruptured aneurysm of the brachial artery and type I neurofibromatosis is presented. Angiography revealed a ruptured aneurysm of the brachial artery in the middle of the upper arm. Repair of the artery with autogenous vein grafting was impossible due to the extremely brittle brachial artery and accompanying veins. The blood supply distal to the aneurysm was secured by collaterals, and the aneurysm, including a relatively long portion of the brachial artery and veins adjacent to the aneurysm, was resected. The patient died of massive hemorrhage from the subclavian artery of the involved side 9 days postoperatively. Histological and immunohistological examinations of the tissues involved in the ruptured aneurysm were conducted. The resected brachial artery and veins were surrounded by hypertrophied tissue which tested positive for S-100 protein and negative for desmin and action. These findings suggest that the origin of the proliferating tissue was not mesodermal dysplasia, but neurofibroma occurring near or in the vessels. A ruptured aneurysm in a patient with neurofibromatosis should not be treated with reconstruction of the vessels. The treatment of choice is surgical or endovascular occlusion of the vessels involved.     

Fenestrated oculomotor nerve caused by internal carotid-posterior communicating artery aneurysm: case report

OBJECTIVE AND IMPORTANCE: The fenestrated oculomotor nerve associated with the internal carotid-posterior communicating artery aneurysm is very rare. CLINICAL PRESENTATION: A 48-year-old woman had a history of subarachnoid hemorrhage caused by a ruptured right middle cerebral artery aneurysm, which was wrapped with good postoperative course. Twenty years later, the patient suffered frontal headache with a mild oculomotor nerve paresis in the right side. Follow-up neuroimaging studies demonstrated a de novo right internal carotid-posterior communicating artery aneurysm. INTERVENTION: The aneurysm was exposed and clipped via a right pterional route. The fenestrated oculomotor nerve associated with the aneurysm was confirmed at surgery. CONCLUSION: We speculated that the fenestration was most likely caused, by the growth of the aneurysm.