Background and purpose: It is important to understand pregnancy-associated stroke because it is a major cause of maternal death. Cortical subarachnoid hemorrhage (c-SAH) occurs in some patients with pregnancy-associated stroke, and the clinical course is relatively good. Methods: By reviewing the patients’ medical records, we retrospectively investigated 5 cases in which c-SAH developed during pregnancy. Results: All patients developed c-SAH during the postpartum period, and clinic-radiological findings of reversible cerebral vasoconstriction syndrome (RCVS) and/or posterior reversible encephalopathy syndrome (PRES) were noted. The prognosis in all cases was good. Conclusion: The development of c-SAH during pregnancy could be associated with RCVS and PRES. Although the prognosis is relatively good, careful radiological follow-up is required.

This report describes a case of multiple cerebral mycotic aneurysms causing subarachnoid hemorrhage (SAH) that were confirmed at autopsy. An 83-year-old male was admitted with a durable headache that was treated with corticosteroid. Findings on MRI were normal throughout the hospital stay. A suffused sudden consciousness disturbance (JCS 200) occurred on hospital day 58. Head CT showed a SAH and digital subtraction angiography (DSA) revealed an aneurysm at the internal carotid artery (ICA; C2) that was treated by coil embolization. Although we suspected a mycotic cerebral aneurysm, fungal antibodies, blood cultures, and cerebral spinal fluid cultures were negative. Left hemiparesis appeared on postoperative day (POD) 5 and MRI revealed a new infarction in the right basal ganglia and several new aneurysms in the ICA. Despite a repeat coil embolization to prevent aneurysm rupture, the patient fell into a coma on the following morning, and CT confirmed the recurrence of SAH. He died on POD 7, and a pathological autopsy was performed with the written, informed consent of his family. The results showed significant fungal infection and inflammation in the aneurysmal wall and dura mater of the skull base.

A 65-year-old man was admitted to our hospital with a history of sudden onset of paresis in his upper limb and face on the right side. He had a history of untreated hypertension and dyslipidemia over a long period. Brain CT scan showed acute intracranial hemorrhage 10 mm in diameter in the left frontal subcortical area, and MR angiography showed the left A1 and the distal portion of the left M1 occlusion. Digital subtraction angiography (DSA) revealed severe atherosclerotic change in the intracranial arteries and several small aneurysms in the distal part of the left lenticulostriate artery developed as a collateral artery of the M1 and A1 occlusion. He was diagnosed with intracranial hemorrhage caused by the rupture of a distal cerebral aneurysm and was treated conservatively with strict antihypertensive therapy and rehabilitation. Three months later, he was discharged from our hospital without any neurological deficits. He kept receiving antihypertensive therapy and underwent follow-up DSA after 2 years. Distal cerebral aneurysms disappeared, and the left M1 and A1 remained occluded. This is a rare case of distal lenticulostriate artery aneurysms that disappeared with a conservative therapy in a patient with atherosclerotic intracranial artery occlusion.

Paroxysmal sympathetic hyperactivity (PSH) is defined as a paroxysmal and repetitive hyperactivity syndrome of autonomic nervous system. While in the case of transient PSH, symptomatic therapy might be effective, the prognosis was dismal in the continuous case. The PSH is thought to result from autonomic dysfunction related to brain damage involving with the deep brain structures. However, there are few reports of PSH following cerebral stroke. Here, we report a case of continuous PSH due to multiple cerebral strokes treated with intrathecal baclofen (ITB) therapy. Initially, he developed lacunae infarction at the age of 51 and was diagnosed as protein C deficiency. After that, he suffered several cerebral strokes such as putaminal hemorrhage and bilateral lacunae infarction. He remained left hemiplegia and dysarthria as sequelae, however, he had been still living at home. In this time, he was admitted to our hospital with intermittent limb stiffness at the age of 60 years. MRI showed new small cerebral infarction of left corona radiata. On admission, he was able to move his right limbs around. However, he was getting worse during a few days and showed whole body stiffness, high fever, tachycardia, hypertension, tachypnea, and diaphoresis continuously. Therefore, the patient was diagnosed as PSH and treated with ITB for spasticity. Six weeks after ITB therapy, the symptoms of PSH have been dramatically improved as well as the reduction of spasticity. It was suggested that the accumulation of small brain lesions can induce PSH, and ITB might be an effective treatment for PSH.

Case 1: A 43-year-old man suddenly developed a headache. Head computed tomography revealed subarachnoid hemorrhage, and initial magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) showed the left vertebral artery (VA) occlusion. No other potential source of bleeding was detected. The next day, MRA showed recanalization of the left VA. Subsequent DSA showed irregular fusiform dilatation of the left VA, indicating recanalization of the VA dissecting aneurysm that was the bleeding source. Endovascular occlusion of the parent artery of the left VA was performed immediately. Case 2: A 63-year-old man presented with severe headache with obvious deterioration 2 days after onset. Head computed tomography revealed subarachnoid hemorrhage, and initial MRA showed right VA occlusion. Head MRA performed 7 h after the initial examination showed recanalization of the right VA, and DSA confirmed aneurysmal dilatation of the right VA. Craniotomy and trapping of the right VA were performed. In cases of a ruptured VA dissecting aneurysm with acute occlusion of the parent artery, close follow-up neuroimaging is essential because of the possibility of early recanalization of the VA.

We report a case of Y-shaped anterior spinal artery (ASA) branching from the dissection side of the hemorrhagic vertebral artery dissection (VAD). A 43-year-old man presented with subarachnoid hemorrhage (SAH) due to the rupture of the VAD. One ASA originating from the dissection site and the other from the distal side of the VA joined into a single vessel. The triple-catheter technique for the internal trapping of the VAD was effective for the preservation of the ASA. This is the first case of fusion of two ASAs branching from the unilateral VA. Accurate observation is necessary for embolization around the VA union, ASA, and brainstem perforators.

Since MRI arterial spin labeling (ASL) is a non-invasive imaging technique for the evaluation of cerebral circulation, it is gathering attention in recent years as a screening manner. Although the previous reports suggest a good correlation between ASL and ¹⁵O-PET, the findings of ASL in the pathologic situation, such as ischemia, hyperperfusion and so on, are not established yet. In this report, we demonstrated the features of ASL compared with ¹⁵O-PET in two cases of moyamoya disease with a delay of cerebral circulation and postoperative hyperperfusion. Case 1 showed a delay of cerebral circulation that affects arterial transit time (ATT) verified by cerebral angiography. Although the finding of ASL indicates overestimation by short post-labeling delay (PLD) (1500 msec) due to prolonged ATT, there is a good correlation between ASL with long PLD (2500 msec) and cerebral blood flow (CBF) by ¹⁵O-PET. On the other hand, there is a good correlation between ASL with short PLD (1500 msec) and CBF by ¹⁵O-PET in Case 2 with postoperative hyperperfusion. Therefore, ASL is non-invasive and simple imaging technique, however, we need to judge the imaging from ASL based on the consideration of ATT.

Case 1: A 39-year-old man developed right vertebral artery (VA) dissection with sudden headache after neck flexion. The patient was treated conservatively, and the symptoms of headache and dissection improved. Six months later, he experienced a similar headache. Repeated magnetic resonance imaging showed the enlargement of a VA aneurysm. Endovascular internal trapping was performed, and the symptoms were relieved. Case 2: A 48-year-old man experienced headache resulting from left VA dissection, and antihypertensive treatment was started. Follow up magnetic resonance angiogram showed the enlargement of the aneurysm. He was treated with coil embolization using a vascular reconstruction device. Previous studies have indicated that the enlargement of dissecting aneurysms is observed only in the relatively early phase, at 3 weeks in most cases. Prolonged headache may suggest the enlargement of dissecting aneurysms; therefore, patients with prolonged headache should undergo more aggressive follow-up.

Trastuzumab is a humanized monoclonal antibody against the human epidermal growth factor receptor 2 (HER2). It prolongs disease-free survival in patients with breast cancers or advanced gastric cancers that overexpress the HER2 resulting in improving total survival. However, cardiac dysfunction and congestive heart failure have been observed, particularly when trastuzumab is given with anthracycline. We report a case of a 50-year-old woman with HER2-positive breast cancer who suffered a cerebral embolism three times because of cardiac failure induced by trastuzumab and epirubicin. She complained sudden dyspnea and right hemiparesis, and followed by conscious disorder. Magnetic resonance imaging and angiography revealed a cortico-subcortical small infarction due to left MCA occlusion. She was received intravenous recombinant tissue plasminogen activator (rt-PA) and her symptoms were improved. Furthermore, second cerebral embolism was occurred in the contralateral MCA territory on the next day. Her left ventricular ejection fraction (LVEF) was 23.8% on admission. Serious heart failure was not improved within a few days. Embolus into cerebral circulation was considered to migrate from left ventricle due to serious contraction failure. Emergency catheter thrombectomy was done and right MCA was recanalized. However, cerebral embolism was repeated in the left MCA territory on 16th hospital days, and she was treated conservatively, then successfully recovered with rehabilitation. This case suggests the risk of cerebral embolism after epirubicin and trastuzumab therapy because of their cardiotoxicity and following serious heart failure.

Cleidocranial dysplasia (CCD) is a rare congenital skeletal disorder, whose estimated prevalence is one per about two hundred thousand persons. In this article, a very rare occurrence of bilateral middle cerebral artery aneurysms complicated by CCD was reported. An 87-year-old woman was referred to our hospital with gait disturbance. Head CT revealed left insular hematoma and left Sylvian subarachnoid hemorrhage, and CT angiography revealed bilateral middle cerebral artery aneurysms. On visiting our department, she presented with dysmorphic facial appearance and skeletal anomalies. She was diagnosed as CCD by X-ray and bone image 3DCT. We suspected subarachnoid hemorrhage due to ruptured left middle cerebral artery aneurysm, and performed neck clipping of the left aneurysm. But, the intraoperative finding showed a non-ruptured aneurysm. The post-operative course of the patient was satisfactory, and she was recovered up to the premorbid ADL level and released from the hospital. An extensive literature search has revealed only one case of cerebral artery aneurysm complicated by CCD. Therefore, our case was considered as a very rare.

According to the presenting data, serum potassium level was not significant between severity and outcome of subarachnoid hemorrhage (SAH). Therefore, we think that even blood sugar concentration are enough for a predictive index after SAH.