Intracranial Dissecting Aneurysms Research Articles

4.解離性脳動脈病変について

4.解離性脳動脈病変について

Vertebrobasilar artery dissection presenting with simultaneous subarachnoid hemorrhage and brain stem infarction: case report

Background Intracranial dissecting aneurysms have been associated with subarachnoid hemorrhage (SAH) or cerebral ischemia. We encountered a patient presenting with simultaneous subarachnoid hemorrhage and brainstem infarction caused by a dissecting aneurysm of the vertebrobasilar artery, which was diagnosed by magnetic resonance imaging (MRI) but did not show abnormal findings on cerebral angiography. Case description A 55-year-old man had sudden onset of headache and left abducens palsy. Computed tomography revealed a subarachnoid hemorrhage localized in the left prepontine cistern and the left cerebellomedullary fissure. Cerebral angiography showed neither a saccular aneurysm nor fusiform dilatation causing the subarachnoid hemorrhage. MRI demonstrated a small infarction in the left dorsal pons, and an intramural hematoma of the left vertebral artery and lower basilar artery. Conclusion This is a rare case of a vertebrobasilar dissecting aneurysm that simultaneously caused both SAH and brain stem infarction. MRI should be performed in the acute phase of SAH of unknown origin to determine the possible coexistence of a dissecting aneurysm, as occurred in this case.

Endovascular reconstruction of intracranial arteries by stent placement and combined techniques

The authors investigated the feasibility, safety, and short-term outcome of stent treatment for intracranial aneurysms, stenoses, and dissections. One hundred twenty-three consecutive patients with intracranial saccular, dissecting, and fusiform aneurysms, atherosclerotic lesions, and dissections were selected for intracranial stent implantation with or without adjunctive coil placement. One hundred eleven patients (mean age 47 years, range 3-73 years) underwent stent treatment; 12 patients (9.8%) were not treated. These 111 patients were divided into four groups: in Group 1 there were 62 patients with saccular aneurysms; Group 2 included nine patients (10 lesions) with dissecting or fusiform aneurysms; in Group 3 there were 36 patients with symptomatic intracranial atheromatous stenoses of more than 50%; and Group 4 included four patients with symptomatic intracranial dissections. All patients underwent computerized tomography scanning and/or magnetic resonance imaging and cerebral digital subtraction angiography preoperatively. Of the 72 aneurysms in Groups 1 and 2, 59 (82%) were treated with combined endovascular stent implantation and endosaccular coil placement. In 67 aneurysms (93%) we achieved complete or nearly complete obliteration. All patients with arterial narrowing achieved residual stenoses of less than 30% postangioplasty. One patient required repeated angioplasty. The morbidity rate in the series was 10.9% and the mortality rate was 6.3%. These findings indicate that stent treatment is feasible and seems to be an effective modality for arterial reconstruction. This versatile tool allows the treatment of a wide variety of challenging intracranial lesions.

Spontaneous dissecting aneurysms of anterior and middle cerebral artery associated with brain infarction: A case report and review of the literature

BACKGROUND Intracranial dissecting aneurysms have been reported with increasing frequency and are recognized as a common cause of stroke. In some reviews and case reports, attempts have been made to compare the outcomes of surgical and medical treatments. However, the appropriate management of dissecting aneurysms in the anterior circulation remains controversial, especially in patients who also manifest cerebral infarction. CASE DESCRIPTION A 45-year-old male was diagnosed as having a dissecting aneurysm of the right middle cerebral artery (MCA) with cerebral infarction. In the course of conservative treatment, he developed a new cerebral infarction in the territory of the right anterior cerebral artery (ACA). Repeat cerebral angiograms revealed an increase in the aneurysmal dilatation of the right M2 and the appearance of a segmental dilatation of the right A2. He continued to be treated conservatively and his course was satisfactory. On subsequent angiograms, we observed resolution of the right A2 dissection and no further progression of the dilatation of the right M2. CONCLUSION This is the first reported case of simultaneous idiopathic dissecting aneurysms of different major arterial branches in the anterior circulation. Our review of the literature disclosed 36 and 23 cases, respectively, of dissecting aneurysms of the ACA and MCA. Many previously reported patients with these dissecting aneurysms involving subarachnoid hemorrhage (SAH) underwent surgery, which resulted in better outcome. More than half of the patients with ACA and MCA dissecting aneurysms had cerebral infarction. All ACA dissecting aneurysms involving ischemia occurred in the A2 region. The outcomes of both surgical and conservative management were equally satisfactory. On the other hand, in patients with MCA dissecting aneurysms, the area of ischemia frequently involved the M1 region; in these patients, conservative treatment resulted in poor outcomes. Therefore, revascularization distal to the compromised artery should be considered in patients with MCA-dissecting aneurysms who have ischemia. Careful interpretation of serial angiograms and/or magnetic resonance (MR) images is necessary because of the possibility of disease progression. If the aneurysmal size increases or there is progression of ischemic symptoms in the course of conservative treatment, surgery must be urgently evaluated.

Dissecting aneurysms of intracranial carotid circulation.

Clinical features of nontraumatic dissecting aneurysms of intracranial carotid circulation remain unclear because investigation of this disease has been limited to case reports. The aim of this study was to investigate the clinical features of this disease through the use of cooperatively collected cases. The cases diagnosed as dissecting aneurysms of intracranial carotid circulation on the basis of clinical signs and neuroradiological findings in 46 stroke centers from 1995 through 1999 were collected, and their clinical features were analyzed. Forty-nine cases of dissecting aneurysms of intracranial carotid circulation were collected. Thirty-two patients presented with subarachnoid hemorrhage (SAH), and 17 presented with cerebral ischemia. The ratio of this disease to all intracranial dissecting aneurysms treated in the same institutes for the same period was 19.1%, and the ratio of SAH resulting from this disease to SAH of unverified origin treated in the same institutes for the same period was 6.2%. The predominant site of lesion was the internal carotid artery in 18 of 32 patients (56%) with SAH and the anterior cerebral artery in 13 of 17 patients (76%) with cerebral ischemia. The predominant angiographic findings were that stenosis with dilatation occurred in 20 of 32 patients (63%) with SAH and stenosis without dilatation was seen in 11 of 17 patients (65%) with cerebral ischemia. Poor prognosis was seen in 21 of 32 patients (66%) with SAH, which was due largely to rebleeding seen preoperatively, during operation, and even postoperatively when clipping or wrapping of the aneurysmal bulge was performed. Nontraumatic dissecting aneurysm of intracranial carotid circulation is not as rare as expected. It seems to be one of the important causes of SAH of unverified origin.

頭蓋内椎骨解離性動脈りゅう出血例の治療成績

The natural history and treatment strategy of intracranial dissecting aneurysm in the vertebrobasilar (V-B) system remains controversial. We report 10 cases of ruptured intracranial dissecting aneurysm in the V-B system and review the literature with focus on the analysis of serial angiographic findings, treatment, and long-term outcome.All patients were conservatively managed under careful blood pressure control, and angiography was carried out depending on the patient's condition. Surgical or endovascular intervention was chosen when morphological changes leading to rebleeding were recognized by follow-up angiography. Craniotomy in 3 patients and coiling in 3 patients was performed. No rebleeding occurred during the follow-up period in any of the 10 patients, and all cases resulted in favorable outcome.These results suggested that ruptured intracranial dissecting aneurysms of the V-B system could be treated conservatively, avoiding rebleeding under careful control of blood pressure in the acute stage. Alternatively, surgical or endovascular treatment should be considered if angiographical changes that may lead to risk of rebleeding are noted.

The vasculopathy of autosomal dominant polycystic kidney disease: Insights from animal models

A 37-year-old white man with autosomal dominant polycystic kidney disease (ADPKD) was admitted to Boston's Beth Israel Hospital with sudden severe headache of two-hour duration. He was unconscious on admission. Emergency angiography revealed a ruptured 15 mm cerebral aneurysm. Emergency surgery to clip the aneurysm was unsuccessful, and the patient died 36 hours after admission. His serum creatinine was 3.2 mg/dL on admission; the rest of his laboratory values were within normal limits. A request for an autopsy was denied. At age 20, the patient and his then 15-year-old sister had abdominal ultrasound examinations that revealed bilateral renal cysts, consistent with the diagnosis of ADPKD. At age 32, the patient had a sudden, relatively severe, acute myocardial infarction (MI). Cardiac catheterization revealed three-vessel disease, and he subsequently underwent a triple coronary artery bypass operation. Throughout his medical course, the patient's blood pressure was in the 120/80 to 140/80 mm Hg range while he was taking lisinopril, 10 mg/day, which was started after his MI. The patient's mother has ADPKD and end-stage renal disease, and she is on hemodialysis. She recently underwent unsuccessful renal transplantation. There is no known family history of cerebral aneurysms. However, the mother had two cerebrovascular accidents and recovered from both. The patient's father had an MI at age 32, but he lived to age 64. A paternal uncle also died at an early age of an MI. The patient's younger sister was later screened for cerebral aneurysms and the test was negative. The patient's two young children have not been screened for ADPKD.

Dissecting aneurysm of the anterior choroidal artery: angiographical and MR imaging findings

BACKGROUND Intracranial dissecting aneurysms are relatively rare. We present a rare case of a dissecting aneurysm originating from the anterior choroidal artery; this is the first reported case. CASE DESCRIPTION A 42-year-old man suffered sudden onset of right hemiparesis and dysarthria. Computed tomography on admission revealed a small low density area in the posterior limb of the internal capsule. MR imaging revealed aneurysmal dilatation of the anterior choroidal artery, and angiography revealed aneurysmal dilatation and stasis of dye in the venous phase at the anterior choroidal artery, which resolved in the chronic stage. CONCLUSION We describe a rare case of a dissecting aneurysm of the anterior choroidal artery. The radiological findings were characteristic of dissecting aneurysms in spite of the rare location.

Clinical picture of intracranial non-traumatic dissecting aneurysm.

Non-traumatic intracranial arterial dissection has been accepted as a unique entity of 'cerebral infarction in otherwise healthy young adults', and is particularly prevalent in Western countries. A recent data collection and analysis have revealed additional clinical features. The nationwide study in Japan conducted in 1996 has provided new information on the natural history and current treatment of intracranial dissecting aneurysms in Japan. The incidence of symptomatic dissection was found to be much higher in the vertebrobasilar system than in the carotid system. The mean age of the patients was 51.3 years. Patients with carotid lesions were younger (mean 43.8 years). The male/female ratio was 2: 1. Fifty-eight percent of patients presented with subarachnoid hemorrhage. Recurrence was more frequent in patients with subarachnoid hemorrhage (14%) than in patients with no hemorrhage (4.2%). Common radiological findings were dilatation, 'pearl and string' sign and narrowing of the affected artery. Surgical treatment involved a variety of procedures including proximal occlusion, entrapment, wrapping and endovascular embolization. Patients with subarachnoid hemorrhage (61%) underwent surgical treatment more frequently than patients with no hemorrhage (17%). Good recovery was achieved in 64% of all patients. Outcome was better in patients with no subarachnoid hemorrhage compared with those with hemorrhage.

3-07-09 Intracranial dissecting aneurysms: Magnetic-resonance-angiography findings

3-07-09 Intracranial dissecting aneurysms: Magnetic-resonance-angiography findings

O-23-333 - Diagnosis and treatment of nontraumatic intracranial dissecting aneurysm presenting with subarachnoid hemorrhage

O-23-333 - Diagnosis and treatment of nontraumatic intracranial dissecting aneurysm presenting with subarachnoid hemorrhage

椎骨解離性動脈瘤

Recently there have been reports of intracranial dissecting aneurysms. Most authors recommended proximal ligation of the vertebral artery or trapping as the modality of treatment.However, we have had cases in which reconstruction of vertebral arteries with fenestrated clips were performed. Vertebral artery dissecting aneurysms were classified into two groups based on angiograms. One group is the one-side type, which indicates that dissection occurred on one side, and the other is the whole-around type, which points to the progression of the dissection as a whole around the artery. From April 1973 to March 1993 we operated on 1,304 cases of intracranial aneurysms, including 41 vertebral aneurysms. Eleven of the latter were suspected to have dissecting aneurysms based on angiograms and surgery. Six out of 7 cases had one-side type dissecting aneurysms, which were clipped directly and the vertebral arteries were reconstructed. One unsuccessful case had been an aged patient when surgery was done prior to the development of fenestrated clips. Two out of 4 cases had whole-around type aneurysms and underwent proximal clipping and trapping. One case became worse after the second day of trapping because of retrograde thrombosis. Two patients, for whom surgery was contraindicated because of bad neurological condition, died.

“Dolichoectatic” Intracranial Vertebrobasilar Dissecting Aneurysm

We report five patients with intracranial vertebrobasilar dissecting aneurysms, all of whom had ischemic symptoms. Angiographically, four of the five cases revealed distention and elongation of the vertebrobasilar artery like dolichoectasia and one irregular stenosis, the so-called "string sign". Magnetic resonance imaging disclosed all dolichoectatic dissecting lesions by demonstrating intimal flaps, double lumen, or subacute clot in the false lumen. We also present a successful demonstration of slow flow in the false lumen by gradient refocused magnetic resonance imaging scan with partial flip angle by the cardiac gating method. It is suggested that many of the classical "dolichoectasia" may include dissecting lesions.

Serial angiography in a spontaneous dissecting anterior cerebral artery aneurysm

Intracranial dissecting aneurysms are uncommon, and little is known concerning the natural history of these lesions. In this paper we present a rare case of dissecting aneurysm of the anterior cerebral artery in which a true diagnostic sign of “double lumen” was demonstrated. Sequential changes in angiographic features shown on serial angiographic studies are described, and diagnosis is briefly discussed.

Rebleeding from intracranial dissecting aneurysm in the vertebral artery.

We describe two patients with rebleeding from intracranial vertebral artery dissecting aneurysms during the acute stage. One patient had excellent results after emergency surgery. A review of recent reports including 60 patients with this disorder revealed a rebleeding rate of 30%, mostly during the acute stage. This suggests that a ruptured dissecting aneurysm in the vertebral artery is at risk for rebleeding during the acute stage, similar to a saccular aneurysm in the same location.

頭蓋内解離性動脈瘤の診断

The clinical, operative and pathological characteristics of intracranial dissecting aneurysms are presented. A review of the literature suggests that these types of intracranial aneurysms are being recognized with increasing frequency and can be characterized by its symp-tomatology and radiological patterns. For this five years, 31 cases with intracranial dissecting aneurysm were treated in our institute. The mean age and the site of aneurysm are assumed almost the same as that of previous reports, but the incidence of extravascular bleeding is 58% in our series, which may be higher than that of previous reports. Although the cause or mechanism of intracranial dissecting aneurysm has yet to be sufficient clarified and it largely depends upon future multilateral studies, but we would like to emphasize that the diagnosis is most important in this disease. It has been considered that“double lumen”on angiogram is a true diagnostic sign of dissecting aneurysm. Only four cases of 31 showed“double lumen”, but no one showed it in acute stage. 17 cases (55%) showed“string and pearl”sign and 72% of the cases with ruptured dissecting aneurysm revealed it in acute stage. From these results, it seems to be quite all right to consider that“string and pearl”sign should be the true diagnostic sign in acute stage like as“double lumen”in chronic stage. We have obtained some interesting information through detailed examinations about surgical treatment of intracranial dissecting aneurysms. But we will mention it in detail on another occasion. Finally, we will conclude by listing the above-mentioned important points of the investigation about the di-agonosis of intracranial dissecting aneurysms.

Vertebral Dissecting Aneurysm associated with Medial Mucoid Degeneration

An autopsy case of intracranial vertebral dissecting aneurysm associated with medial mucoid degeneration is reported and 54 cases of vertebro-basilar dissecting aneurysm in the literature are reviewed. A 37-year-old man with history of hypertension was admitted in a semicomatose state. Computed tomographic scan showed severe subarachnoid hemorrhage (SAH), especially in the posterior fossa with ventricular reflux, and vertebral angiography disclosed a fusiform dilatation with proximal narrowing of the left vertebral artery and narrowing in the midportion of the basilar artery. Continuous ventricular drainage was performed, but the patient died from rebleeding on the 14th hospital day. Autopsy revealed massive SAH around the brain stem and a fusiform aneurysm of the left vertebral artery. Microscopic examination demonstrated a local thickening of the wall with tearing of the intima and the media. A hematoma between the media and the adventitia communicated with the true lumen of the artery. The muscular layer was replaced by myxomatous connective tissue. The basilar artery had mild fibrous thickening of the intima and duplication of the internal elastica. The medial mucoid degeneration was discovered by iron-colloid stain in the intracranial arteries, especially in the vertebro-basilar system. However, arteriosclerotic change was minimal. The authors emphasize that SAH as initial symptom and hypertension as predisposition occur more frequently in vertebro-basilar dissecting aneurysms than previously described.

Intracranial Hemorrhage Produced by Spontaneous Dissecting Intracranial Aneurysm

Two patients with intracranial dissecting aneurysms were seen initially because of acute hemorrhage. One patient died, and a false dissecting aneurysm secondary to atherosclerosis was found at autopsy. In the other patient, the appearance of the carotid arteriogram was typical of a dissection. Because of the propensity of these aneurysms to rupture, caution is indicated in the use of anticoagulants or vasopressors in patients with evolving cerebral infarction secondary to intracranial arterial dissection.

Bilateral dissecting aneurysms of the intracranial internal carotid arteries in an 8-year-old boy.

Nontraumatic intracranial dissecting aneurysms have rarely been reported as the cause of acute infantile and childhood hemiplegia. The present case is unique because dissecting aneurysms occurred bilaterally in two clinically distinct episodes. A recent dissecting aneurysm of the right intracranial internal carotid artery was present with a healed dissecting aneurysm of left internal carotid artery in an 8-year-old boy.