We report 3 cases of the ruptured anterior communicating artery aneurysm growing in the fenestration of the anterior communicating artery (ACoA). In preoperative angiography, it was difficult to demonstrate the whole images of an aneurysm including the neck. The body of an aneurysm was partially divided by the distal ACoA. The posterior part of an aneurysm is larger than the anterior one and projected posteriorly in all cases. The distal ACoA made a string with no blood flow in 2 cases. In the operation, the neck dissection is relatively difficult because of the existence of the distal ACoA near the neck of the aneurysm. It was necessary to cut the distal ACoA in 1 case and trap the right Al portion with the aneurysm in another case. The body of an aneurysm was clipped on each side of the fenestration in the other case. These aneurysms with the fenestration of the ACoA were considered to be difficult for clipping. Great care must be taken to clipping procedures for the complete obliteration of such aneurysms.
IDC (Target Therapeutics, Fremont, CA) is a new embolic material to treat aneurysms. Part of the coil and its pusher are connected by an interlocking mechanism, and the coil is retrievable if the connecting part is in a microcatheter. Endovascular treatment was performed for 6 cases of cerebral aneurysms, including 3 of ruptured aneurysm with IDC. These comprised 4 cases of saccular aneurysm and 2 cases of dissecting aneurysm. These aneurysms located in the internal carotid artery in 3 cases, vertebral artery in 2 cases, and basilar artery in 1 case. The endovascular procedures include 4 intra-aneurysmal coil packings and 2 proximal occlusions. Complete occlusion of the aneurysm was obtained in 5 cases, but only partial occlusion was achieved in 1 case. During the procedure, no major complications occurred. After endovascular treatment, no rebleeding occurred. But embolic complications occurred in 2 cases, including transient ischemic attack and minor stroke. We conclude that endovascular treatment of cerebral aneurysms with IDC is a useful alternative, especially for surgically difficult aneurysms.
We analyzed the type and the distribution of low density areas (LDAs) on CT scans caused by vasospasm, and investigated the relation between LDAs and clinical features, focusing on the influence of aging on CT findings. The subjects of this study are 159 patients (70 males and 89 females) who underwent aneurysm surgery within 7 days after the onset of hemorrhage over the past 14 years and were followed up by sequential CT scans. They were divided into 2 aged groups: (A)≤59 yrs (96 patients), (B) 60 yrs≤(63 patients). Of the 159 patients, 55 (35%) developed symptomatic vasospasm. Subsequent CT scans showed 66 LDAs in 42 patients (26%). There was no significant difference in incidence of symptomatic vasospasm and LDAs between the 2 age groups. Multiple LDAs and bilateral involvement were frequently observed in the aged group. We advocated the following classification for the appearance of LDAs: (1) Major type, (2) Branch type, (3) Perforator type, (4) Subcortical type and (5) Watershed type. The Major type often appeared as a single LDA. In contrast, most of the subcortical type and a number of the Branch and Perforator types were concomitant with other types of LDAs. The Watershed type was not observed alone. The outcome of the Major type was significantly worse than that of other types of LDAs. The outcome of the Branch and Perforator types was not unfavorable unless eloquent areas were involved. However, the Subcortical and Watershed types were usually accompanied by other types of LDAs that caused poor prognosis. In the aged group, the Subcortical and Watershed types were frequently observed. This finding suggests that elderly patients may lack sufficient compliance to tolerate ischemic insult after vasospasm.
Inferior wall aneurysms of the internal carotid artery represent a special group of the internal carotid artery aneurysms. These aneurysms arise from the inferior wall of the internal carotid artery and project inferiorly into the carotid and interpeduncular cisterns. The lesions are large, have an ill-defined or absent neck, and may be fusiform, often including more than half the circumference of the internal carotid artery. They frequently show significant sclerosis with calcification and are often partially to subtotally thrombosed. The origins of the posterior communicating and anterior choroidal arteries may be included within the neck. We have experienced 5 cases with aneurysms at this location, 4 in women and 1 in a man. Ages range from 67 to 78. All patients presented with subarachnoid hemorrhage. Surgery was performed in all cases in the acute stage. Four patients were treated by creation of a neck and clipping of aneurysm and 1 by coating with Bemsheet. GR was achieved in only 1 patient. One patient treated by coating alone developed rerupture postoperatively, but recovered to MD. Three patients showed cerebral infarction caused by intraoperative temporary occlusion of the internal carotid artery. They remained SD or VS. Because of the characteristics of these aneurysms, it is not possible to give a standard approach to operation as has been given for the more frequent internal carotid artery aneurysms. Each case must be individually evaluated, and several treatment methods tailored to each particular lesion. In respect to timing of the surgery, delayed surgery also should be considered.
Cerebral vasospasm is a major complication associated with subarachnoid hemorrhage (SAH). Previous publications on the diagnostic value of transcranial Doppler sonography (TCD) reported conflicting results concerning predictive capacities for evaluating vasospasm only by measuring flow velocities. And the necessity to examine other indices on TCD examinations was stressed. In this study, for the evaluation of the arterial spasms, the flow velocities and the Doppler wave-forms in TCD were analyzed in 89 consecutive patients (Grades I to III of Hunt & Kosnik grading) with ruptured intracranial aneurysms. Delayed ischemic neurological deficits (DINDs) accompanying arterial spasms were detected in 21 patients (23.6%). Twelve of these (13.5%) recovered from DINDs within 3 weeks. The flow velocities on TCD could be classified into 3 types according to their mean blood flow velocities (MBFV). They consisted of: 1) high pattern type, in which the MBFV had increased more than 100 cm/s (42 cases, 47.2%), b) normal pattern type, in which the MBFV were measured as 50-100 cm/s (38 cases, 42.7%), c) low pattern type. in which the MBFV was less than 50 cm/s (9 cases, 10.1%). From observation of the Doppler frequency, the sound of signals, and displayed waveforms, 7 characteristic findings were evaluated. i) Filling-in of the systolic window, ii) appearance of negative flow components (reverse flow) in the systolic phase, iii) reverse flow in the diastolic phase, iv) contour oscillation, v) high-intensity frequency (systolic spindle), vi) musical murmur, and vii) disappearance of pulsatility. From the observation of these 7 components, we made a“spasm score”on TCD records. The score was 5.3±1.5 in 21 patients with DINDs (the score was 6.0±1.6 in 9 patients with permanent DINDs, and was 4.8±1.2 in 12 patients with transient DINDs), and 1.8±1.9 in 68 patients without DINDs (p<0.005). Thirteen patients out of 15 in whom the score was 6 or more suffured DINDs, and 4 patients, in whom the score was 7, suffured prolonged DINDs. But of 36 patients in whom the score was 0 or 1, no patient suffured DINDs. Of these 7 components of Doppler findings,“reverse flow”was the most significant. It remains to be seen whether the examination of these indices can give additional information in cases of SAH and allow prediction of impending DINDs. A significant increase in the 7 indices was found as the severity of vasospasm increased, and there was a strong relation between the indicies. The spasm score on TCD seemed to be very useful in the diagnosis and evaluation of DINDs in patients with vasospasms after SAH.
We evaluate the causative factors of deterioration after surgery for ruptured aneurysm in the cases of Grade I or II, where good outcomes are generally anticipated. In cases operated on within 3 days after SAH, poor outcome was found in 8 cases (13%) out of 56 cases in Grade I. Poor outcome was also found in 12 cases (11%) out of 110 cases in Grade II. Causes of deterioration in Grade I were vasospasm (VS) in 4, common carotid artery occlusion with unknown causes in 1 and other complications in 3. In Grade II causes, patients deteriorated because of VS in 6, surgical procedures for high-positioned BA aneurysm, VA dissecting aneurysm and IC aneurysm. In cases operated on between 4 and 14 days after SAH, outcome was poor in 4 (6%) out of 74 Grade I cases. Outcome was also poor in 2 (9%) out of 23 Grade II cases. Causes of deterioration in Grade I were surgical procedures for ICA-AN and VBA-AN, VS in 1, complication in 1. In Grade II causes were surgical procedure for dorsal ICA-AN and, VS in 1. In cases operated on the day 15 or later after SAH, outcome was poor in 8 (4%) out of 222 Grade I cases. Cause of deterioration in this group were surgical procedures for VBA-AN in 3, ICA-AN and MCA-AN in 1, VS in 1 and other complications in 2. In summary, VS was the cause of deterioration in many cases of the early operation group, especially in patients over 65 years old. In the late operation group, surgical procedures were the most common cause of deterioration, especially in patients over 65 years old and in cases with VB aneurysm.
We report 3 cases of calcified, large aneurysm of the middle cerebral artery and discuss surgical techniques for handling of this special type of aneurysm. The aneurysms were visualized as calcified mass lesions on computerized tomography. Plain craniograms showed different patterns of calcification; partial, cup-like and eggshell-like appearances. These aneurysms were clipped using a multiple clipping technique, and endaneurysmal microendarterectomy was applied before clipping in 1 case. Preoperative evaluation of the degree of calcification and the thickness of the wall near the neck is important to decide the surgical strategy. The distribution of the hard calcification is estimated better on plain craniograms than CT scan, because the latter tends to overestimate the calcification. Kinking or stenosis of the parent arteries is prevented by the multiple clipping technique in aneurysms with a relatively thin wall, but the endaneurysmal microendarterectomy should be applied, if the hard calcification and thrombus involves the neck.
In spite of recent advancements in the management of ruptured cerebral aneurysms, it is still difficult to decide whether surgery is indicated and if so when it should be performed for patients admitted with symptomatic vasospasm. While early surgery may protect the patient from rerupture, it may also increase the risk of worsening of vasospasm. We report 5 cases of vasospasm with aneurysmal subarachnoid hemorrhage (SAH). All these cases showed symptomatic and angiographical vasospasm on their admission 3-14 days after initial attack of SAH. Preoperative clinical gradings of Hunt and Kosnik were Grade 4 in 2 cases, Grade 3 in 2 cases and Grade 2 in 1 case. They were treated by early surgery with clipping followed by percutaneous transluminal angioplasty (PTA) immediately after surgery. Three patients returned to their occupations, while 2 died in spite of therapy. Early surgery in this series actually prevent further rupturing, but it is not clear whether PTA immediately after clipping may prevent further deterioration by progression of vasospasm. For selected cases especially with reversible ischemic brain damage, this combined treatment may offer more favorable results than late surgery with conservative management. Further investigation is necessary to determine the validity of this therapy.
We report 4 cases with a ruptured bacterial intracranial aneurysm. A 59-year-old male suddenly became disoriented. A CT scan revealed intracerebral hemorrhage in the right frontal lobe. He presented acute heart failure 4 days after the ictus. An echocardiogram showed perforation of the mitral valve and vegetation at the valve. MRI demonstrated intracerebral hematoma and 6 small round flow voids surrounded by lesions of high-signal intensity on T2-weighted images. Three peripheral aneurysms were depicted on cerebral angiograms. He underwent mitral valve replacement with a heterograft 3 weeks after the ictus. Two of the 3 bacterial aneurysms disappeared after administration of high-dose antibiotics, but an aneurysm arising at the right posterior cerebral artery enlarged and ruptured. He underwent excision of the aneurysm and was discharged from our hospital with homonymous hemianopsia 1 month after the second surgery. A 62-year-old female with continuous low grade fever for 6 months was diagnosed as having infective endocarditis. She suffered from sudden severe headache 2 weeks after the beginning of antibiotics administration. A CT scan revealed intracerebral hemorrhage in the right frontal lobe. Cerebral angiograms showed an aneurysm at the periphery of the middle cerebral artery. Since the aneurysm did not decrease in size for 2 weeks, we excised it. We did not perform any vascular reconstruction, because retrograde blood flow was confirmed at the orifice of the distal branch. She was discharged without any deficits 1 month after the surgery. A 46-year-old male having aneurysm of the ascending aorta and aortic regurgitation was admitted to our hospital for treatment of infective endocarditis. He suddenly entered a deep coma, and a CT scan demonstrated a hematoma with massive perifocal edema in the right frontal lobe. He underwent emergency evacuation of the hematoma. Intraoperatively, fresh bleeding from an irregular vascular lesion was seen. This lesion was excised and revealed to be a bacterial aneurysm by histopathological examination. His left hemiparesis was persistent postoperatively. A 60-year-old female, with a past-history of mitral valve replacement, was admitted to a local hospital for treatment of abdominal pain and hematuria. On the 19th hospital day, she suddenly became unconscious. A CT scan showed a massive intracerebral hematoma and she was transferred to our hospital. Cerebral angiography demonstrated an aneurysm at the periphery of the anterior cerebral artery. The aneurysm was considered to be a ruptured bacterial aneurysm. Her blood pressure could not be maintained and she died the next day. We discuss the therapeutic strategy for ruptured bacterial aneurysms and emphasize the efficacy of MRI in screening of bacterial intracranial aneurysms.
We report 4 cases of granulation formation after wrapping of cerebral aneurysm with cotton fiber. The cerebral aneurysms were wrapped with cotton fiber and reinforced with cyanoacrylates product. Granuloma was produced after wrapping in 2 cases, in 1 case of which the parent artery was completely obliterated. This complication might have been due to the operative technique: the aneurysm and circumference of the parent artery was completely wrapped with cotton fiber product. Inflammatory granulation reaction was also observed in the other 2 cases, suggesting that only a small quantity of cotton fiber should be used for wrapping.
We report a rare case of subarachnoid hemorrhage caused by a rupture of the aneurysm on the fenestrated vertebral artery (VA). A 60-year-old male was transferred to our hospital with a diagnosis of subarachnoid hemorrhage on February 23, 1992. Cerebral angiography revealed an aneurysm on the fenestration of the right VA. The fenestration was 36 mm long, and the aneurysm protruded from the central portion of the ventral artery of the fenestration. Clipping of the aneurysm was performed the next day via lateral suboccipital approach. A hypoglossal nerve, passing through the fenestration was found during the operation, but the distal portion of the nerve was hidden under the aneurysm. Postoperatively right hypoglossal nerve palsy appeared. We discuss the origin of the fenestrated VA, and the anatomical relationship between the fenestrated VA and the hypoglossal nerve.