A 54-year-old man was admitted to our hospital with complaint of sudden headache. The patient had suffered two episodes of transient headache before admission. Computed tomography (CT) revealed acute subdural hematoma (ASDH) on the right side of the cerebral convexity with bilateral extension along the tentorium cerebelli without signs of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH). Three-dimensional CT angiography and conventional cerebral angiography revealed a left A1-A2 junction aneurysm. Neck clipping of the aneurysm was performed. The aneurysm extended inferiorly, with the dome embedded in the chiasmatic cistern and tightly adhered to the arachnoid membrane. There was no evidence of hematoma in the subarachnoid space. The patient was discharged without neurological deficit. Ruptured aneurysms resulting in ASDH without SAH or ICH are very rare. Radiological investigation such as three-dimensional CT angiography should be performed to find the causative aneurysm in a patient with ASDH with a history of repeated headaches and without traumatic signs or episodes, and the appropriate treatment should be planned with expediency.
A 77-year-old woman presented with an extremely rare exclusively intra-meatal anterior inferior cerebellar artery (AICA) aneurysm manifesting as subarachnoid hemorrhage. The aneurysm was located at a non-branching site of its meatal loop, deeply inside the internal auditory canal. The ipsilateral posterior inferior cerebellar artery was hypoplastic and the affected AICA supplied a wide vascular territory in the right cerebellum. The patient underwent microsurgical trapping of the distal AICA aneurysm in the acute stage. Collateral back flow to the parent artery was poor, so right occipital artery (OA)-AICA anastomosis was performed prior to aneurysm trapping. The postoperative course was uneventful, and magnetic resonance imaging after surgery did not demonstrate any ischemic change. Postoperative angiography showed complete disappearance of the AICA aneurysm and the apparently patent OA-AICA bypass. She did not suffer neurological deficit except for right incomplete hearing disturbance, and postoperative single photon emission computed tomography demonstrated absence of hemodynamic compromise in the cerebellum. OA-AICA anastomosis with aneurysm trapping could be the optimal surgical management of the AICA aneurysm located exclusively inside the internal auditory canal, especially if the parent artery supplies a wide vascular territory.
A 64-year-old woman with subarachnoid hemorrhage manifesting as sudden onset of severe headache visited our hospital on post-onset day 8. Diagnostic cerebral digital subtraction angiography revealed an aneurysm located at the left internal carotid-anterior choroidal artery with diffuse cerebral arterial spasm. Coil embolization was selected because of diffuse spasm in spite of parent artery elongation at the extra-cranial portion. A small portion of the coil migrated to the parent artery, but coil embolization was successfully completed. The patient developed delayed spasm, which required arterial fasudil hydrochloride injection. After the acute phase of subarachnoid hemorrhage, the patient's symptoms disappeared. However, on day 24 after subarachnoid hemorrhage, the patient showed right hemiparesis and total aphasia, and skull radiography revealed that the migrated coil had moved into the M1 portion of the left middle cerebral artery. Craniotomy was performed to retrieve the coil and clip the aneurysm neck. However, the migrated coil could not be retrieved because of adhesion to the arterial wall. Delayed coil migration is very rare in the chronic phase.
A 60-year-old man was admitted to our hospital with sudden onset of motor aphasia, Gerstmann syndrome, and incomplete right hemiparesis one week after administration of chemotherapy for mucosa-associated lymphoid tissue (MALT) lymphoma. Computed tomography showed an intracerebral hematoma in the left subcortical area. Cerebral angiography revealed 2 aneurysms on the distal middle cerebral artery (MCA) that increased in size in the course of 2 weeks. The aneurysms were excised and a bypass placed using a superficial temporal artery (STA) graft. Histological study showed no bacteria, infiltration of inflammatory cells, or lymphoma cells in the aneurysm wall. The chemotherapy against MALT lymphoma was highly effective, so we presumed that the lymphoma cells had disappeared. The source of the distal MCA aneurysms was thought to be oncotic. Distal MCA aneurysms caused by MALT lymphoma are extremely rare. Surgical reconstruction using the STA may be effective in patients with ruptured distal MCA aneurysms if the wall is intact.
A 31-year-old man presented with a ruptured right extracranial vertebral artery aneurysm associated with neurofibromatosis type 1, manifesting as acute onset of right neck and shoulder pain, and right supraclavicular mass. Three-dimensional computed tomography angiography showed a large aneurysm involving the right extracranial vertebral artery associated with a pseudoaneurysm. The aneurysm was successfully treated by transarterial endovascular trapping with detachable coils. Extracranial vertebral artery aneurysm is rare, but the mortality of ruptured cases is extremely high, so early diagnosis and early treatment are important. The present case shows that endovascular treatment was very effective.