Transluminal angioplasty and intra-arterial papaverine for the treatment of cerebral vasospasm after ruptured arteriovenous malformations

BACKGROUND: This is the first report on the use of intra-arterial papaverine and percutaneous transluminal angioplasty in two patients with severe, symptomatic cerebral vasospasm who suffered ruptured arteriovenous malformations (AVMs). CASE DESCRIPTIONS: The source of hemorrhage was a venous aneurysm in the first case and a pedicular aneurysm of the distal posterior inferior cerebellar artery in the second case. In both cases, the AVMs were located in the superior vermis and there was minimal subarachnoid hemorrhage. The first patient underwent removal of the AVM before the period of cerebral vasospasm and the second patient underwent removal of the AVM after the cerebral vasospasm had resolved. The outcome was excellent in the first patient and poor in the second patient. CONCLUSION: Arteriovenous malformation with ruptured aneurysms may be at high risk for cerebral vasospasm even when there is minimal subarachnoid hemorrhage. We recommend early treatment of AVMs with ruptured pedicular, intranidal, or venous aneurysms to avoid rebleeding and to allow for aggressive treatment of cerebral vasospasm. The management of cerebral vasospasm after AVM rupture is discussed.     

Subarachnoid hemorrhage secondary to spinal arteriovenous malformation and aneurysm. Report of a case and review of the literature

A patient with recurrent subarachnoid hemorrhage was seen initially with intermittent signs and symptoms of intracranial and spinal cord dysfunction. Myelography and spinal angiography revealed an arteriovenous malformation (AVM) and aneurysm of the spinal cord. Extensive investigation failed to reveal any intracranial lesion. The relationship of subarachnoid hemorrhage at a spinal level to the development of remote neurological abnormalities is discussed, and previous reports of aneurysms associated with spinal AVM are reviewed.     

Disappearance of the co-existing aneurysm and arteriovenous malformation after wrapping of aneurysm (author's transl)

The authors reported a case of an arteriovenous malformation associated with an aneurysm on its feeding vessel that is the left anterior inferior cerebellar artery. A housewife, aged 56-years, was admitted to our hospital with severe headache, nausea and vomiting. On admission, lumbar puncture revealed grossly bloody CSF. Neurological examination revealed meningeal irritation sign, horizontal nystgmus and disturbance of left auditory acuity. Bilateral carotid and retrograde brachial arteryography revealed an AVM near the left cerebellopontine angle and a small aneurysm of the left anterior inferior cerebellar artery at the left internal auditory meatus. At operation, the aneurysm was wrapped with a muscle piece and no surgical intervention for AVM. Post-operative course was uneventful except for disterbance of the left auditory acuity. Follow-up angiographies revealed a change of size the aneurysm and AVM and finaly failed to demonstrate the aneurysm and AVM demonstrated preoperatively. The spontaneous regression of the AVM might be due to the post-operative brain swelling and adhesion. We also speculated that the spontaneous disappearance of the aneurysm might be due to the decreased blood flow of parent artery by the spontaneous regression of the AVM. It is very rare that an aneurysm of anterior inferior cerebellar artery co-existed with AVM, and resulted in thrombosis of the aneurysm and regression of the AVM after wrapping alone.     

Chronic myelogenous leukemia received unrelated bone marrow transplantation following surgical resection of cerebral arteriovenous malformation--first case report

We report a 15-year-old boy with chronic myelogenous leukemia who received unrelated bone marrow transplantation (uBMT) after surgical resection of cerebral arteriovenous malformation (AVM). The incidence of cerebral hemorrhage caused by rupture of cerebral ABM in cases of BMT is uncertain. However, since the risk of rupture of AVM was supposed to increase due to both severe thrombocytopenia after intensive chemotherapy and increased intracranical pressure because of total body irradiation (TBI) as preconditioning therapy for BMT, we have first carried out surgical resection of the cerebral AVM, and subsequently performed uBMT. This resulted in a favorable clinical course without serious complications.     

Intraventricular hemorrhage in adults

A series of 54 adult patients with intraventricular hemorrhage diagnosed by computed tomography (CT scan) is described. Hypertension, arterial aneurysm, and arteriovenous malformation (AVM) accounted for 83% of the cases. Three categories of clinical presentation are defined. CT scan reliably demonstrated the presence and distribution of blood within the ventricular system, including the third and fourth ventricles. The increased density caused by intraventricular blood was seen to disappear in 12 days. An intracerebral hematoma was identified in 78% of cases. Surgical treatment was beneficial in only a small number of cases.     

Histological findings of gallbladder mucosa in 95 control subjects and 80 patients with asymptomatic gallstones

BACKGROUND AND PURPOSE: Decisions on invasive arteriovenous malformation (AVM) treatment are currently based on natural-course risk estimates of AVM bleeding and assumptions on morbidity from cerebral hemorrhage in general. However, morbidity of AVM hemorrhage has rarely been reported. We sought to assess the morbidity of intracranial hemorrhage in patients with cerebral AVMs. METHODS: From a prospective AVM database, 119 patients were analyzed: 115 had a hemorrhage as the diagnostic event, and 27 of them suffered a second hemorrhage during follow-up; an additional 4 patients had other diagnostic symptoms but bled during follow-up. The type (parenchymal, subarachnoid, intraventricular) and location of AVM hemorrhage were determined by CT/MR brain imaging. Disability and neurological impairment were assessed with the Barthel Index, the Rankin Scale, and the National Institutes of Health Stroke Scale, with a mean follow-up time of 16.2 months. RESULTS: Of the 115 incident hemorrhages, 34 (30%) were subarachnoid, 27 (23%) parenchymal, 18 (16%) intraventricular, and 36 (31%) in combined locations. In 54 patients (47%; 95% confidence interval [CI], 38% to 56%) the incident hemorrhage resulted in no neurological deficit, and an additional 43 patients (37%; 95% CI, 28% to 46%) were independent in their daily activities (Rankin 1). Fifteen patients (13%; 95% CI, 7% to 19%) were moderately disabled (Rankin 2 or 3), and 3 (3%; 95% CI, 0% to 6%) were severely disabled (Rankin > or =4). Parenchymal hemorrhages were most likely to result in a neurological deficit (52%). Type and morbidity of hemorrhage during follow-up were similar to incident events. Twenty (74%) of 27 patients with both incident and follow-up hemorrhages were normal or independent (Rankin 0 or 1). None of the patients with a hemorrhage during follow-up died during the observation period. CONCLUSIONS: Hemorrhage from cerebral AVMs appears to have a lower morbidity than currently assumed. This finding encourages a reevaluation of the risks and benefits of invasive AVM treatment.     

Successful surgical removal of a large arteriovenous malformation in a patient with hemophilia: case report

OBJECTIVE AND IMPORTANCE: This is the first reported case of the successful surgical removal of a large arteriovenous malformation (AVM) in a patient with hemophilia A. CLINICAL PRESENTATION: A 19-year-old male patient was admitted to our department with intracranial hemorrhage. He had previously been diagnosed with hemophilia A and a cerebral AVM. Carotid angiography revealed a large AVM in the right temporal and parietal lobes. The neurological and neuroradiological findings, especially those of single photon emission computed tomography, identified an area of devitalization around the lesion, which was thought to reduce the risk of new deficits resulting from surgical manipulation. INTERVENTION: We resected the AVM in conjunction with supplemental infusions of Factor VIII before, during, and after the operation. A slight cerebral hemorrhage on the 7th postoperative day was observed despite control with Factor VIII, but the patient was discharged without any new deficits. CONCLUSION: We evaluated and managed all problems of a patient with multiple complications and achieved a medical cure.     

Case report: MR imaging of fat necrosis of the breast associated with lipid cyst formation following conservative treatment for breast carcinoma

A hypertensive 72-year-old male presented with a ruptured arteriovenous malformation (AVM) manifesting as hematoma indistinguishable from common putaminal hemorrhage on precontrast computed tomography scan. The AVM was located in the proximal sylvian region fed by branches of the anterior and middle cerebral arteries. The AVM was totally removed. Although bleeding from AVM in the elderly is uncommon, the cause of even common hypertensive hemorrhage should be identified by other imaging techniques such as magnetic resonance imaging and cerebral angiography to allow the optimum treatment.     

Rupture of a previously documented small asymptomatic intracranial aneurysm in a patient with autosomal dominant polycystic kidney disease. Case report

Intracranial aneurysms are common extrarenal manifestations of autosomal dominant polycystic kidney disease (ADPKD). Although their natural history is not completely understood, small asymptomatic intracranial aneurysms in patients with ADPKD often are not treated but are followed with serial magnetic resonance (MR) angiography. The authors report the unique case of a patient with ADPKD who bled from a previously documented asymptomatic 3-mm intracranial aneurysm. This 42-year-old man with ADPKD suffered a subarachnoid hemorrhage (SAH) from a 7-mm left pericallosal artery aneurysm. This aneurysm was clipped and the patient made an excellent recovery. An irregular asymptomatic 3-mm right middle cerebral artery (MCA) aneurysm had also been demonstrated on angiography. While the patient was considering elective surgery for the MCA aneurysm, he suffered a hemorrhage from this lesion 10 weeks after the initial SAH. The aneurysm was clipped and the patient made a satisfactory recovery (he was moderately disabled). In this report the authors indicate that small asymptomatic intracranial aneurysms are not always innocuous in patients with ADPKD, and they suggest that treatment should be strongly considered for these lesions in this group of patients when there is a history of SAH or the aneurysm is irregular in appearance. Because MR angiography studies may not adequately define the configuration of small aneurysms and irregularity may easily be missed, conventional angiography is recommended for patients with ADPKD who are found to have an intracranial aneurysm on screening with MR angiography.     

Pulmonary arteriovenous malformation in the neonate

Pulmonary arteriovenous malformation (AVM) is a congenital condition, but because the symptoms usually do not occur until middle age, the diagnosis is often delayed. The authors report on a neonate, diagnosed at 2 weeks of age, who was treated by lobectomy at 35 months of age. This prompted a review of the diagnosis, pathophysiology, and treatment of pulmonary AVM. In the literature there are approximately 500 cases of pulmonary AVM. Special attention is given to the reports involving children. Eight cases have been reported in which the diagnosis was made in the first year of life. In two series, a chest roentgenogram showed abnormalities in all affected patients. Because of the strong association of pulmonary AVM with hereditary telangiectasia (Rendu-Osler-Weber syndrome), it is recommended that family members of affected patients be screened by chest roentgenograms for pulmonary AVM.     

Utility and feasibility of assessing myocardial mechanics after bypass

The authors present the case of a 34-year-old man struck over the left mastoid region by a hockey puck, who suffered a fatal rupture of a left vertebral artery berry aneurysm. He became apneic within seconds of the injury and had no brainstem reflex within minutes. The postmortem examination showed massive subarachnoid hemorrhage in the posterior fossa and the remnants of a berry aneurysm near the intradural origin of the left vertebral artery, 11 mm proximal to the posterior inferior cerebellar artery. Rupture of a saccular aneurysm as a result of head trauma is rare. This is the first reported case of a posterior circulation aneurysm rupture as a result of head trauma.     

Intracranial hemorrhage in achondroplasia

The neurological manifestations of achondroplasia include megalencephaly, hydrocephalus, and progressive myelopathy or radiculopathy secondary to spinal stenosis. Subarachnoid and intracerebral hemorrhage have not been previously reported in association with achondroplastic dwarfism. This report describes two patients with achondroplasia who have died secondary to intracranial hemorrhage. At autopsy, the source of hemorrhage was found to be an arteriovenous malformation of the choroid plexus in one case and a ruptured aneurysm of the left middle cerebral artery in the other.     

Nucleotide substitutions at the -6 position in the promoter region of the factor IX gene result in different severity of hemophilia B Leyden: consequences for genetic counseling

A case of vessel perforation by a guide wire during an interventional neuroradiological procedure is reported. The patient was a 59-year-old woman with a left frontal basal arteriovenous malformation (AVM) fed by the left anterior cerebral artery. Transarterial embolization of the AVM was attempted. During the procedure, vessel perforation by the guide wire occurred at the left A1-A2 junction and resulted in subarachnoid hemorrhage, which stopped spontaneously. The patient developed progressive obstructive hydrocephalus, and surgical treatment was performed. The AVM was totally removed after ventricular drainage, and the arterial perforation site was explored. When clot around the left A1-A2 junction was removed, hemorrhage recurred. This hemorrhage was similar to what has been observed when a small perforating artery was avulsed. The hemorrhage site was coagulated under temporary occlusion of both A1 segments. Surgical intervention was probably not necessary for this type of bleeding if it had stopped spontaneously, because the rebleeding from the small pinhole would be unlikely, and the operation was more hazardous than the usual aneurysmal surgery.     

Spontaneous subarachnoid hemorrhage first from an intracranial and then from a spinal arteriovenous malformation. Case report

A patient presented with spontaneous subarachnoid hemorrhage (SAH) from a cerebral arteriovenous malformation (AVM) which was later totally removed at surgery. The patient presented again with a new SAH from a spinal AVM that was also totally removed at surgery. Coexistence of spinal and cerebral arteriovenous malformations are exceedingly rare and hemorrhage from each is not previously reported. This case emphasizes the importance of investigating the spinal canal in otherwise unexplained spontaneous SAH.     

Surgical implication of aortic dissection on long-term outcome in Marfan patients

We herein review our 17-year surgical experience for the treatment of ascending aortic aneurysm in patients with Marfan syndrome to clarify the risks of increased mortality and reoperation. The subjects consisted of 15 patients who had all undergone surgery for the aortic root and ascending aorta at Niigata University Hospital between July 1978 and January 1995. Aortic valve replacement and ascending aortic wrapping were performed in 5 patients, Bentall or Cabrol operation in 6, and combined aortic arch reconstruction and Cabrol operation in 2, as the initial surgery. Patients who had an aortic dissection (Stanford type A) at initial surgery were assigned to group I (n = 7), while those with an aortic root aneurysm were assigned to group II (n = 8). In group I, 3 patients required a second operation for the remaining aortic arch aneurysm, and 1 died due to a late rupture of the distal aneurysm. In group II, no patient needed a reoperation; however, 1 died due to an intracranial hemorrhage and another due to composite valve graft failure and distal dissection. The results thus indicate that aortic dissection seems to affect long-term outcome, and therefore the combined repair of the aortic root and transverse arch is recommended in Marfan patients with aortic dissection involving the transverse aortic arch.     

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.     

Anterior communicating artery aneurysm rupture: an unusual cause of acute subdural hemorrhage

A case of acute subdural hemorrhage caused by rupture of an anterior communicating artery aneurysm is presented. The patient is a young man who presented with an acute onset of neurologic symptoms; computed tomography revealed subdural hemorrhage in the absence of associated subarachnoid or intraparenchymal bleeding.     

Pancreaticoduodenal artery aneurysm--a life-threatening cause of gastrointestinal hemorrhage: case report and review of the literature

Gastrointestinal bleeding caused by erosion of a pancreaticoduodenal artery aneurysm in patients with pancreatitis is a rare but potentially life threatening disease. In this case report, the successful treatment of a patient bleeding from a ruptured pancreaticoduodenal artery aneurysm is described. A review of the literature of reported cases discusses the value of early angiographic intervention in patients with unexplained gastrointestinal hemorrhage and suspected rupture of an aneurysm.     

Microwave disinfection of denture base materials colonized with Candida albicans

OBJECT: Guglielmi detachable coil (GDC) technology is a valuable therapeutic alternative to the surgical treatment of ruptured or incidental intracranial aneurysms. The authors describe their technical and clinical experience in the use of the GDC technique in patients who underwent endovascular occlusion for the treatment of incidentally found intracranial aneurysms. METHODS: One hundred fifteen patients with 120 incidentally found intracranial aneurysms underwent embolization by means of the GDC endovascular technique. Ninety-one patients were females and 24 were males. Patient age ranged from 13 to 80 years. In 64 patients the incidental aneurysms were discovered when unrelated nonneurological conditions signaled the need for angiography or magnetic resonance angiography (Group 1). Twenty patients who presented with incidental aneurysms that were discovered during treatment for an acutely ruptured aneurysm underwent treatment of both types of aneurysm during the acute phase of subarachnoid hemorrhage (SAH) (Group 2). Sixteen patients with incidental aneurysms were treated during the chronic phase of SAH (Group 3). Group 4 included 15 patients who had incidental aneurysms associated with brain tumors or arteriovenous malformations. Angiographic results revealed complete or near-complete occlusion in 109 aneurysms (91%) and incomplete occlusion in five aneurysms (4%). Guglielmi detachable coil embolization was attempted unsuccessfully in six aneurysms (5%). One hundred nine patients (94.8%) remained neurologically intact or unchanged from their initial clinical status. Five patients (4.3%) deteriorated as a result of immediate procedural complications. All these complications occurred in the first 50 patients treated in the series. No clinical complications were observed in the last 65 patients. In one patient, a partially embolized aneurysm ruptured 3 years postprocedure. In Groups 1 and 3, the average length of hospitalization was 3.3 days. CONCLUSIONS: The evolution of GDC technology has proved to provide safe treatment of incidental aneurysms (a morbidity rate of 0% was achieved in the last 65 patients). The topography of the aneurysm and the clinical condition of the patient did not influence final anatomical or clinical outcomes. The GDC technology also confers a positive economic impact by decreasing hospital length of stay and by eliminating the need for postembolization intensive care.     

Unexpected results in long-term medically treated ruptured intracranial aneurysm including data on 14 patients followed more than 30 years each

This is the longest reported follow-up of patients with ruptured intracranial aneurysms treated entirely medically with hypotension. Patients with ruptured brain aneurysms, untreated except for plain bedrest, are at a well-recognized risk of recurrent hemorrhage. Some surgically treated patients also remain at risk of recurrent hemorrhage in follow-up. This is a review of results in patients whose active but entirely medical (hypotensive) treatment was started in the first 10 years of a 40-year study. It suggests a way of reducing risks in both of the above 2 groups. 53 consecutive patients with proven ruptured brain aneurysm(s) were treated as early as possible with medical-hypotensive therapy alone by the author and followed, personally, until death or, if they survived, for at least 30 years each (or until lost to follow-up). The patients included many considered to have been poor operative risks with some having been designated inoperable by the referring neurosurgeons. As part of the long-term follow-up, magnetic resonance angiography (MRA) has been begun. Long-term follow-up was defined as the time beginning after 9 weeks from (admission) hemorrhage. 9 patients had died during the earlier stages of hemorrhage (and treatment) i.e., before the 9 weeks period had elapsed; their data was presented previously. This yielded 44 patients for long-term follow-up. Only 2 patients (both had multiple aneurysms) on this regimen have died of either proven hemorrhage (1 patient) or presumed hemorrhage (1 patient). Most patients survived and maintained an excellent condition. Medical-hypotensive therapy of ruptured intracranial aneurysms has produced much better long-term results than expected. This is significant for (1) patients requiring medical treatment alone and (2) surgically treated patients who may benefit from additional long-term protection.