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Rajagopal N, Yamada Y, Balaji A, Kawase T, Kato Y. Rare cases of multiple unruptured intracranial aneurysms: Illustrative report and review on management options. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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Rajagopal N, Balaji A, Yamada Y, Kawase T, Kato Y. Etiopathogenesis, clinical presentation and management options of mirror aneurysms: A comparative analysis with non-mirror multiple aneurysms. INTERDISCIPLINARY NEUROSURGERY 2019. [DOI: 10.1016/j.inat.2019.100535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Rajagopal N, Yamada Y, Balaji A, Kawase T, Kato Y. Multiples of multiple: Case series of mirror aneurysms and review of literature. Int J Surg Case Rep 2019; 61:141-146. [PMID: 31362238 PMCID: PMC6675932 DOI: 10.1016/j.ijscr.2019.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/14/2019] [Indexed: 11/29/2022] Open
Abstract
Incidentally detected unruptured mirror intracranial aneurysms are on the rise due to advanced imaging modalities. Further studies are required to elucidate theories of development, inheritance pattern and the need for screening of 1st-degree relatives with twin aneurysms. Treatment strategy for mirror aneurysms should be customised based on the location, size, morphology and clinical manifestations of each patient. Randomised control trials that compare [single/multistage] clipping and coiling of mirror aneurysms are necessary to decide the best intervention strategy.
Introduction Mirror aneurysms are a rare subtype of multiple aneurysms, located in identical or adjacent arterial segment bilaterally. We report a case series of 3 such patients amongst whom one of them had 3 sets of mirror aneurysms and the other patient had 2 sets of mirror aneurysm on the same arterial segment which has not been reported till date. Methods A retrospective analysis of 3 patients with incidentally detected multiple mirror aneurysms, who were treated with microsurgical clipping and coiling, was conducted. A systematic search was performed using the PUBMED database and relevant articles were reviewed with particular attention to incidence, associated conditions, risk factors and management strategies. Written informed consent was obtained from all of the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request. This research work has been reported in line with the PROCESS criteria (Agha et al., 2018). Results All the 3 patients were females with incidentally detected multiple mirror aneurysms. All the 3 patients were known Hypertensives. All the aneurysms were successfully clipped by a multistage, bilateral craniotomy except the one in the cavernous ICA, for which an endovascular procedure is planned. All of them had an uneventful postoperative course with the CT angiogram showing obliteration of all the clipped aneurysms except the one in the cavernous ICA. Conclusions Multiple mirror aneurysms represent a rare occurrence of a diverse pathology. Both these described types of cases have not been reported so far in the literature. The treatment strategy for mirror aneurysms should be determined individually based on the location, size, and morphology of the aneurysms, as well as, on the clinical manifestations of each patient.
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Affiliation(s)
- Niranjana Rajagopal
- Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bangalore, India.
| | - Yasuhiro Yamada
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Arun Balaji
- Department of Neurosurgery, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India
| | - Tsukasa Kawase
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
| | - Yoko Kato
- Department of Neurosurgery, Fujita Health University, Banbuntane Hotokukai Hospital, Nagoya, Japan
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Gomez-Figueroa E, Cardenas-Saenz O, Quiñones-Pesqueira G, Cervantes-Uribe R, Calleja-Castillo JM. Bilateral Third Nerve Palsy in Mirror Aneurysms of the Posterior Communicating Arteries. Eur J Case Rep Intern Med 2018; 5:000912. [PMID: 30756060 PMCID: PMC6346830 DOI: 10.12890/2018_000912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 06/09/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Bilateral third cranial nerve palsy has only been reported in a handful of conditions including some with inflammatory, tumoural and vascular causes. An urgent imaging study is mandatory to rule out vascular aetiology, mainly aneurysmal subarachnoid haemorrhage (aSAH). CASE PRESENTATION A 28-year-old Hispanic woman presented to the emergency department with a 21-day history of a sudden-onset and severe headache that on three occasions was accompanied by transient loss of awareness, the last episode occurring a week previously. The simple CT image showed minimal bleeding at the level of the perimesencephalic cisterns, with evidence of SAH. An angioCT revealed a 5×6 mm bilobed saccular aneurysm of the right posterior communicating artery and a 2×2 mm saccular aneurysm in the posterior left communicating artery. CONCLUSIONS A mirror aneurysm is found in 2-25% of aSAH cases. To date there is no consensus about the optimal management of patients with these findings. LEARNING POINTS The presence of third cranial nerve palsy should always raise the suspicion of an aneurysm.Subarachnoid haemorrhage is the most common cause of a thunderclap headache.Aneurysmal subarachnoid haemorrhage requires surgical management in all cases.
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Affiliation(s)
- Enrique Gomez-Figueroa
- Vascular Neurology Department, Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | - Omar Cardenas-Saenz
- Vascular Neurology Department, Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
| | | | - Roberto Cervantes-Uribe
- Vascular Neurology Department, Instituto Nacional de Neurologia y Neurocirugia, Mexico City, Mexico
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Kühn AL, Kan P, Srinivasan V, Rex DE, de Macedo Rodrigues K, Howk MC, Wakhloo AK, Puri AS. Flow diverter for endovascular treatment of intracranial mirror segment internal carotid artery aneurysms. Interv Neuroradiol 2018; 25:4-11. [PMID: 30081693 DOI: 10.1177/1591019918792536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND To evaluate the feasibility and efficacy of the pipeline embolization device in the treatment of unruptured intracranial mirror segment aneurysms. METHODS Out of a total of 338 subjects, 14 were identified harboring a total of 32 internal carotid artery mirror segment aneurysms that were treated with the pipeline embolization device and were consecutively enrolled into our study. We collected data on patient demographics, modified Rankin scale (mRS) at admission, aneurysm characteristics, clinical outcome at discharge, 3-9 and at 12-18 months as well as angiography results at follow-up. RESULTS Patients' mean age was 52.9 years; baseline mRS was 0 in all subjects. Pipeline embolization device placement was successful in all cases. Post-treatment mRS remained 0 in 13/14 patients. One patient experienced a small intraparenchymal hemorrhage and subarachnoid hemorrhage, associated with a frontoparietal infarction resulting in right upper extremity weakness and aphasia (post-treatment mRS 3). His mRS evaluation remained stable at the 3-9-month follow-up. Three to 9-month follow-up angiography (13/14 subjects) showed complete aneurysm occlusion in 24/30 aneurysms (80%), near complete and partial occlusion in three of 30 (10%) aneurysms each. At the 9-month follow-up, one patient experienced a complete occlusion of the anterior temporal artery branch but did not present with any clinical deficits. No mRS changes were encountered over a median 6-month follow-up period. Mid-term follow-up angiography (12-18 months) available in eight of 14 subjects showed complete aneurysm occlusion in all patients. Mild intimal hyperplasia was observed in one patient. CONCLUSIONS Flow diversion technology can be used for the treatment of unruptured mirror segment aneurysms in selected patients.
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Affiliation(s)
- Anna Luisa Kühn
- 1 Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, USA
| | - Peter Kan
- 2 Department of Neurosurgery, Baylor College of Medicine, Houston, USA
| | - Visish Srinivasan
- 2 Department of Neurosurgery, Baylor College of Medicine, Houston, USA
| | - David E Rex
- 1 Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, USA
| | - Katyucia de Macedo Rodrigues
- 1 Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, USA
| | - Mary C Howk
- 1 Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, USA
| | - Ajay K Wakhloo
- 1 Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, USA
| | - Ajit S Puri
- 1 Department of Radiology and New England Center for Stroke Research, University of Massachusetts, Worcester, USA
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Choi HH, Cho YD, Yoo DH, Lee J, Mun JH, An SJ, Kang HS, Cho WS, Kim JE, Han MH. Intracranial Mirror Aneurysms: Anatomic Characteristics and Treatment Options. Korean J Radiol 2018; 19:849-858. [PMID: 30174473 PMCID: PMC6082764 DOI: 10.3348/kjr.2018.19.5.849] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 02/03/2018] [Indexed: 11/29/2022] Open
Abstract
Objective Mirror aneurysms are generally considered as a subset of multiple aneurysms, defined as aneurysms occurring bilaterally and symmetrically on the same-named vessels. Although not infrequent, the characteristics of mirror aneurysms are not well studied. This investigation was conducted to elucidate the anatomic features of such lesions and examine treatment options. Materials and Methods A retrospective review was conducted, aimed at 172 patients treated for 344 mirror aneurysms between January 2007 and December 2015. Aneurysms of similar nature but in asymmetric locations on the same-named vessels were excluded. All available records were examined and lesion characteristics, as well as treatment outcomes were assessed. Results In study subjects (n = 172), mirror aneurysms most often involved middle cerebral artery bifurcation (n = 83), followed by a paraclinoid internal carotid artery (n = 50) and posterior communicating artery (n = 21). Most of the lesions (95.3%) measured ≤ 10 mm, and in 126 patients (74.6%), the size ratios were > 50%. Of the 344 aneurysms studied, coil embolization was undertaken in 217, surgical clipping in 62, and observation alone (no treatment) in 65. Coil embolization and surgical clipping were done bilaterally in 83 and 12 patients, respectively. In 12 patients, combined coiling and clipping were implemented on each side. Single-stage coil embolization of both the aneurysms was performed in 73 patients, with excellent post-procedural (85.6%) and follow-up (86.8%) occlusive results. There was no procedure-related morbidity or mortality. Conclusion By adopting different treatment strategies to different configurations and vascular sources, mirror aneurysms can be safely and effectively treated. If feasible, single-stage coil embolization should be considered as a reasonable treatment option for mirror aneurysms.
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Affiliation(s)
- Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul 06974, Korea
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Dong Hyun Yoo
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jeongjun Lee
- Department of Neurosurgery, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang 10326, Korea
| | - Jong Hyeon Mun
- Department of Neurosurgery, Kwangju Christian Hospital, Gwangju 61661, Korea
| | - Sang Joon An
- Department of Neurology, International St. Mary's Hospital, Catholic Kwandong University of Korea College of Medicine, Incheon 22711, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
| | - Moon Hee Han
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea.,Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul 03080, Korea
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Doddasomayajula R, Chung BJ, Mut F, Jimenez CM, Hamzei-Sichani F, Putman CM, Cebral JR. Hemodynamic Characteristics of Ruptured and Unruptured Multiple Aneurysms at Mirror and Ipsilateral Locations. AJNR Am J Neuroradiol 2017; 38:2301-2307. [PMID: 28982787 DOI: 10.3174/ajnr.a5397] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 08/01/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Different hemodynamic patterns have been associated with aneurysm rupture. The objective was to test whether hemodynamic characteristics of the ruptured aneurysm in patients with multiple aneurysms were different from those in unruptured aneurysms in the same patient. MATERIALS AND METHODS Twenty-four mirror and 58 ipsilateral multiple aneurysms with 1 ruptured and the others unruptured were studied. Computational fluid dynamics models were created from 3D angiographies. Case-control studies of mirror and ipsilateral aneurysms were performed with paired Wilcoxon tests. RESULTS In mirror pairs, the ruptured aneurysm had more oscillatory wall shear stress (P = .007) than the unruptured one and tended to be more elongated (higher aspect ratio), though this trend achieved only marginal significance (P = .03, 1-sided test). In ipsilateral aneurysms, ruptured aneurysms had larger maximum wall shear (P = .05), more concentrated (P < .001) and oscillatory wall shear stress (P < .001), stronger (P < .001) and more concentrated inflow jets (P < .001), larger maximum velocity (P < .001), and more complex flow patterns (P < .001) compared with unruptured aneurysms. Additionally, ruptured aneurysms were larger (P < .001) and more elongated (P < .001) and had wider necks (P < .001) and lower minimum wall shear stress (P < .001) than unruptured aneurysms. CONCLUSIONS High wall shear stress oscillations and larger aspect ratios are associated with rupture in mirror aneurysms. Adverse flow conditions characterized by high and concentrated inflow jets; high, concentrated, and oscillatory wall shear stress; and strong, complex and unstable flow patterns are associated with rupture in ipsilateral multiple aneurysms. In multiple ipsilateral aneurysms, these unfavorable flow conditions are more likely to develop in larger, more elongated, more wide-necked, and more distal aneurysms.
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Affiliation(s)
- R Doddasomayajula
- From the Bioengineering Department (R.D., B.J.C., F.M., J.R.C.), George Mason University, Fairfax, Virginia
| | - B J Chung
- From the Bioengineering Department (R.D., B.J.C., F.M., J.R.C.), George Mason University, Fairfax, Virginia
| | - F Mut
- From the Bioengineering Department (R.D., B.J.C., F.M., J.R.C.), George Mason University, Fairfax, Virginia
| | - C M Jimenez
- Neurosurgery Department (C.M.J.), University of Antioquia, Medellin, Colombia
| | - F Hamzei-Sichani
- Department of Neurosurgery (F.H.-S.), Mt. Sinai Medical Center, New York, New York
| | - C M Putman
- Interventional Neuroradiology (C.M.P.), Inova Fairfax Hospital, Falls Church, Virginia
| | - J R Cebral
- From the Bioengineering Department (R.D., B.J.C., F.M., J.R.C.), George Mason University, Fairfax, Virginia
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Lamback EB, Gouveia HR, Bulzico DA. Into the void: a giant aneurysm mimicking a macroprolactinoma. Endocrine 2017; 58:394-395. [PMID: 28889239 DOI: 10.1007/s12020-017-1419-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 09/02/2017] [Indexed: 10/18/2022]
Affiliation(s)
| | - Hugo Rodrigues Gouveia
- Department of Interventional Radiology, Brazilian National Institute of Cancer, Rio de Janeiro, Brazil
| | - Daniel Alves Bulzico
- Endocrinology Section, Federal Hospital of Lagoa, Rio de Janeiro, Brazil
- Endocrine Oncology Unit, Brazilian National Institute of Cancer - INCA, Rio de Janeiro, Brazil
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