Ruptured cerebral fusiform aneurysm with mucopolysaccharide deposits in the tunica media in a patient with Marfan syndrome

Although aortic or cardiac complications are common in patients with Marfan syndrome, the presence of an intracranial aneurysm is comparatively rare. In this study, the authors report on their experience with resection of a ruptured fusiform aneurysm of the posterior cerebral artery in a 30-year-old woman with Marfan syndrome. Microscopic examination of the resected tissue showed many Alcian blue–staining deposits, consistent with the presence of mucopolysaccharide in the tunica media and focal fragmentation of the internal elastic lamina.

Serum inflammatory adhesion molecules and high-sensitivity C-reactive protein correlates with delayed ischemic neurologic deficits after subarachnoid hemorrhage

BACKGROUND

The purpose of the present study was to investigate the relationship between serum concentrations of the immunoglobulin-like superfamily, selectins, hsCRP, and the development of DIND in patients with aneurysmal SAH.

METHODS

Serum ICAM-1, VCAM-1, E-selectin, P-selectin, L-selectin, and hsCRP were measured in 33 patients with SAH who underwent aneurysmal clipping within 48 hours of the onset of symptoms. Serum samples were obtained during the early period (day 0) and the late period (day 7).

RESULTS

The serum concentrations of ICAM-1 (P = .009), VCAM-1 (P = .0383) and hsCRP (P = .0014) during the early period were significantly higher in patients with SAH than in control patients. Further, serum hsCRP concentration during the late period was significantly higher in patients with SAH than in control patients (P = 0033). Finally, serum concentrations of ICAM-1, VCAM-1, and hsCRP during the early (P = .0055, P = .0266, and P = .0266) and late (P = .0423, P = .0041, and P = .0004) period were significantly higher in patients with DIND than in patients without DIND.

CONCLUSIONS

Serum levels of ICAM-1, VCAM-1 and hsCRP during the early and late period following SAH correlate with DIND.

Wrap-clipping with polytetrafluoroethylene for ruptured blisterlike aneurysms of the internal carotid artery. Technical note

A technique combining wrapping and clip occlusion of aneurysms by using polytetrafluoroethylene (PTFE) for treatment of ruptured blisterlike aneurysms of the supraclinoid internal carotid artery (ICA) is described. The diameter of the abnormal arterial lesion along the long axis of the ICA and the distance between the origin of the ophthalmic artery and the origin of the posterior communicating artery (PCoA), or the origin of the PCoA and the origin of the anterior choroidal artery are measured intraoperatively; a strip of PTFE membrane is then trimmed with scissors to match this diameter and distance. After temporarily occluding the cervical ICA, the intracranial ICA that includes the lesion is wrapped with the strip of PTFE, and one or more aneurysm clips are applied parallel to the ICA. This procedure was successfully accomplished in six patients, all of whom had an uneventful postoperative course with no recurrent subarachnoid hemorrhage during the follow-up period. "Wrap-clipping" using PTFE is a useful procedure for management of ruptured blisterlike aneurysms of the ICA.

Treatment of vertebral artery aneurysms with transposition of the posterior inferior cerebellar artery to the vertebral artery combined with parent artery occlusion. Technical note

The authors describe transposition of the posterior inferior cerebellar artery (PICA) to the vertebral artery (VA) combined with parent artery occlusion for the treatment of VA aneurysms in cases in which a clip could not be applied because of the origin of the ipsilateral PICA. The aneurysm is trapped through a lower lateral suboccipital craniectomy. The PICA is then cut just distal to the aneurysm, and the PICA and VA proximal to the aneurysm are anastomosed in an end-to-end or end-to-side fashion. The surgical procedure was successfully performed in two patients, each of whom had hypoplastic occipital arteries (OAs). The PICA contralateral to the lesion was hypoplastic in one patient and distant to the ipsilateral PICA in the other patient. Mild transient dysphagia developed postoperatively in one patient due to glossopharyngeal and vagus nerve palsy, and the other patient had an uneventful postoperative course. In both patients, postoperative cerebral angiography demonstrated good patency of the transposed PICA. These results show that transposition of the PICA to the VA is a useful procedure for the reconstruction of the PICA when parent artery occlusion is necessary to exclude a VA aneurysm involving the origin of the PICA and when OA-PICA anastomosis or PICA-PICA anastomosis cannot be performed.

Treatment of ruptured fusiform aneurysm in the posterior cerebral artery with posterior cerebral artery-superior cerebellar artery anastomosis combined with parent artery occlusion: case report

BACKGROUND

Surgical management of a fusiform aneurysm in the PCA sometimes requires occlusion of the parent artery. In such cases, reconstruction of the PCA may prevent the development of postoperative visual field defects.

CASE DESCRIPTION

A 30-year-old woman with a fusiform aneurysm in the P2 of the left PCA presented with subarachnoid hemorrhage. The left superficial temporal artery and OA were hypoplastic. Left temporal craniotomy revealed that the lateromesencephalic ambient segment of the SCA and the posterior half portion of the P2 segment ran parallel and near each other, and that the calibers of both arteries were relatively consistent. Thus, the 2 arteries were anastomosed in a side-to-side fashion, and the anterior half of the left P2 segment was occluded by clipping proximal and distal to the aneurysm that was located at the left P2 segment just distal to the junction to the posterior communicating artery. The patient had an uneventful postoperative course, and postoperative cerebral angiography demonstrated resolution of the aneurysm, with perfusion of the left PCA from the left SCA via the anastomosis.

CONCLUSIONS

Posterior cerebral artery-superior cerebellar artery anastomosis is a useful method of achieving PCA reconstruction in the context of a PCA aneurysm requiring occlusion of the parent vessel and when superficial temporal artery or OA-PCA anastomosis cannot be performed.

Revascularization and Parent Artery Occlusion for Giant Internal Carotid Artery Aneurysms in the Intracavernous Portion Using Intraoperative Monitoring of Cerebral Hemodynamics

OBJECTIVE:

Therapeutic parent artery occlusion with or without revascularization is a useful surgical technique for the management of a giant aneurysm located in the intracavernous portion of the internal carotid artery (ICA). The purpose of the present study was to determine whether intraoperative cortical blood flow (CoBF) monitoring during surgical parent artery occlusion could identify patients who required bypass with a saphenous vein graft (high flow bypass).

METHODS:

Eleven patients with a giant aneurysm located in the intracavernous portion of the ICA underwent superficial temporal artery-middle cerebral artery bypass. CoBF was monitored intraoperatively in all patients using a thermal diffusion flow probe. The lowest CoBF during test occlusion of the ICA under functioning superficial temporal artery-middle cerebral artery bypass was determined, and the ratio of the value to the CoBF immediately before test occlusion of the ICA was calculated in the frontal and temporal lobes. When the CoBF ratio in the frontal or temporal lobe was less than 0.9, high flow bypass grafting was elected.

RESULTS:

Of the eleven patients undergoing superficial temporal artery-middle cerebral artery bypass, five patients underwent concomitant high flow bypass grafting. Postoperative cerebral ischemic events did not occur in any patient over a follow-up period ranging from 3 to 60 months. Postoperative cerebral angiography showed resolution of the aneurysm and patency of the bypass in all patients.

CONCLUSION:

Intraoperative CoBF monitoring using a thermal diffusion flow probe during surgical parent artery occlusion for giant intracavernous carotid artery aneurysms can identify patients who require concomitant high flow bypass grafting.

Stevens-Johnson Syndrome Associated With Intravenous Acetazolamide Administration for Evaluation of Cerebrovascular Reactivity-Case Report-

A 62-year-old man with left middle cerebral artery stenosis manifesting as transient ischemic attack underwent evaluation of regional cerebrovascular reactivity to acetazolamide using single photon emission computed tomography. Three days after intravenous administration of acetazolamide, erythematous eruptions of various sizes appeared on his back and spread over almost his entire body. Subsequently, painful ulcerations developed on his lips, and oral and nasal mucosa, and the conjunctiva became hyperemic, indicating Stevens-Johnson syndrome. The results of the lymphocyte transformation test were positive to only acetazolamide. Stevens-Johnson syndrome, also known as erythema multiforme major, can be life-threatening, and may be induced by intravenous administration of acetazolamide.

Early Revascularization in a Patient With Perfusion Computed Tomography/Diffusion-Weighted Magnetic Resonance Imaging Mismatch Secondary to Acute Vertebral Artery Occlusion-Case Report-

A 67-year-old woman with a recent history of recurrent ischemic stroke secondary to right vertebral artery stenosis suffered acute onset of left homonymous hemianopsia and the medial longitudinal fasciculus syndrome, which resolved with hyperdynamic therapy. However, consciousness deteriorated 6 hours later. Perfusion computed tomography (CT) revealed regions of prolonged mean transit time in the bilateral cerebellar hemispheres, vermis, brainstem, and right occipital lobe, which were more extensive than the ischemic lesions demonstrated by diffusion-weighted magnetic resonance (MR) imaging. Subsequent cerebral angiography showed occlusion of the right vertebral artery. The patient underwent emergent left superficial temporal artery to left superior cerebellar artery bypass. Postoperatively she demonstrated resolution of the preoperative perfusion CT/diffusion-weighted MR imaging mismatch and improved neurological deficits. Early revascularization in a patient with perfusion CT/diffusion-weighted MR imaging mismatch following acute vertebrobasilar stroke can lead to improvement in cerebral perfusion and neurological function.

Anxiety before and after surgical repair in patients with asymptomatic unruptured intracranial aneurysm

BACKGROUND

Ruptured intracranial aneurysm is a serious condition with high mortality and morbidity. Patients notified of the presence of the unruptured intracranial aneurysm may become anxious because of the fear of rupture. We prospectively investigated the anxiety of patients with unruptured intracranial aneurysm before and after surgery.

METHODS

Thirty-seven patients with an asymptomatic unruptured intracranial aneurysm were enrolled, 13 men and 24 women aged 32 to 70 years (mean age, 57.2 years), who underwent surgical repair of the aneurysm. The anxiety of patients was assessed one month before and after surgery using the Japanese version of the State-Trait Anxiety Inventory.

RESULTS

The trait anxiety scores, which refer to stable personality factors reflecting the general level of fearfulness, did not change significantly after surgery. In contrast, the state anxiety scores, which refer to transient anxiety that varies according to the situation, decreased significantly after surgery (p = 0.001, paired t test). Only the preoperative high state anxiety scores among the multiple variables were associated with the significant decrease in state anxiety after surgery (p = 0.0183, logistic regression analysis).

CONCLUSIONS

The anxiety of patients with asymptomatic unruptured intracranial aneurysm significantly decreased after surgery. Anxiety of patients with asymptomatic unruptured intracranial aneurysm may deserve attention in deciding whether to treat the aneurysm.

Brain temperature and cerebral blood flow imaging in patients with severe subarachnoid hemorrhage: report of two cases

BACKGROUND

Temperature reversal, which is defined as observation of higher brain temperature than systemic temperature followed by lower brain temperature than systemic temperature, implies a poor prognosis in patients with severe subarachnoid hemorrhage (SAH). Serial regional cerebral blood flow (CBF) imaging using single-photon emission tomography (SPECT) was performed in 2 patients with severe SAH who showed temperature reversal.

CASE DESCRIPTION

54-year-old woman and a 55-year-old man with severe SAH underwent ventricular drainage using a catheter that allowed monitoring of the brain temperature. SPECT imaging in these two patients showed that CBF was preserved before the occurrence of the temperature reversal and was exhausted afterwards. These patients died within 2 to 3 days.

CONCLUSIONS

Temperature reversal may indicate the exact time when absence of brain perfusion occurs, causing irreversible brain damage.

Brain and systemic temperature in patients with severe subarachnoid hemorrhage

BACKGROUND

The significance of brain temperature (BT) in patients with severe brain damage remains unclear. This study investigated the relationships between BT, systemic temperature (ST), and clinical outcome in patients with severe subarachnoid hemorrhage.

METHODS

Thirty-one comatose patients with severe subarachnoid hemorrhage underwent ventricular drainage immediately after admission. The ventricular catheter also allowed monitoring of BT. ST was continuously measured using a bladder catheter with thermistor probe.

RESULTS

BT at the start of the monitoring was lower than ST in four patients, and all died of brain swelling. BT was higher than ST at first but later fell below ST ("temperature reversal") in 12 patients, who all died of acute brain swelling. BT was higher than ST throughout the monitoring in 15 patients. Five of these patients died of causes other than brain swelling such as rerupture of the cerebral aneurysm, multiple organ failure, or respiratory failure. The other 10 patients survived with various degrees of disability.

CONCLUSIONS

Observation of BT and ST can predict the outcome of severe subarachnoid hemorrhage.

[A case of left occipital lobe hemorrhage in a patient with progressive systemic sclerosis: evaluation of cerebral angiography and histology]

Involvement of the central nervous system is uncommon in progressive systemic sclerosis, with only 2 reported cases associated with intracerebral hemorrhage detected by neuroimaging. A 55-year-old woman with a 10-year history of scleroderma presented with left occipital lobe hemorrhage manifesting as headache and vomiting. She had no signs of hypertension, diabetes mellitus and hyperlipidemia. CT and MRI, on admission, showed left occipital lobe hemorrhage with ventricular rupture and acute left subdural hematoma. Serial cerebral angiography was performed on day 0, day 7 and day 14, and found no evidence of aneurysm, arteriovenous multiformation or tumor stain in the left occipital lobe. However, the bilateral anterior cerebral arteries showed increasing segmental narrowing suggestive of vasculitis. Histological examination of a section from the brain cortex adjacent to the hemorrhage revealed no evidence of vasculitis, fibrinoid degeneration or amyloid deposition. Focal vasculitis may have occurred secondary to the homorrhagic lesion.

Sonic detection system for cervical and intracranial vascular disease

A sonic analysis system was developed for the detection of cervical and intracranial vascular disease (CVD). In this study, sound signals detected through the patient's forehead were analyzed using a short-time Fourier transformation method, and data were evaluated according to the intensity of spectra. A total of 49 patients with CVD and 34 control subjects were studied and classified into four grades according to the intensity of the spectra. The true positive rate was 83.7% in patients with CVD, and the true negative rate was 94.1% in the control group. The sensitivity and specificity of this analysis system were 83.7% and 5.9%, respectively. The true positive rates for cerebral stenosis/occlusion, cerebral aneurysm, and arteriovenous malformation/fistula were 85.7%, 73.7%, and 100%, respectively. The future goal is clinical application as a mass-screening test for brain disease. This system shows potential for this purpose, and further development will continue.

Sonic analysis for detection of cervical and intracranial vascular disease

A sonic analysis system was developed for the detection of cervical and intracranial vascular disease. The system analyzes recorded sound signals converted to digital data, and plots the frequency, time interval after the QRS wave of the electrocardiogram, and amplitude on the graph using contour lines. Sonic analysis of 22 patients with and 23 patients without cerebrovascular disease identified a characteristic pattern of disease called the "circular pattern." Five of 10 patients with internal carotid artery stenosis, four of seven with cerebral aneurysms, three with cerebral arteriovenous malformation, and two of two with dural arteriovenous malformation showed the circular pattern. Only one of 23 control patients showed the circular pattern. This system is a promising method for cost-effective mass screening for the early detection of cerebrovascular disease.