Left A1 Research Articles

A case control study to evaluate abnormal lipid profiles in elderly Koreans using radial artery pulse signals

Aim of the studyThis study sought to determine whether radial artery pulse signal changes in the patients with abnormal blood lipid profiles provide diagnostic information to evaluate dyslipidemia. Materials and methodsIn this case control study, 113 elderly people were divided into two groups, a normal lipid group and an abnormal lipid group, based on their blood lipid test results. Multivariate logistic regression analysis of these two groups was conducted to identify the significant radial artery pulse signals to evaluate abnormal lipid profiles and receiver operating characteristic (ROC) curve analysis was used to evaluate the logistic model. ResultsThe abnormal lipid group displayed significantly different radial artery pulse signals compared with the normal lipid group (A1: primary amplitude of left artery; τ1: primary phase of left artery; τ2: secondary phase of left artery; σ2/σ1: ratio of the shape of the primary wave to the shape of the secondary wave of right artery). A predictive value for abnormal lipid profiles was obtained using binary logistic regression, which included age, gender, left A1 from step 1, left τ1 from step 2, left τ2 from step 3, and right σ2/σ1 from step 2. ROC curve analysis assessed the accuracy of the test for abnormal lipid profile diagnosis (AUC=0.854). ConclusionsAge, gender, A1 (primary amplitude), τ1 (primary phase), τ2 (secondary phase), σ2/σ1 (ratio of the shape of the primary wave to the shape of the secondary wave) derived from radial artery pulse signals may be used to assess abnormal lipid profiles in elderly Koreans.

Abstract TP84: Delayed Ipsilateral Intraparenchymal Hemorrhage After Neuroform Stent Assisted Coiling of Intracranial Aneurysms

Background: Delayed ipsilateral intraparenchymal hemorrhage (IPH) has been reported following technically successful treatment of intracranial aneurysms using flow-diverting stents (Pipeline embolization device) in 8.5% of patients and does not appear to be related entirely to dual antiplatelet therapy. We report a similar phenomenon in Neuroform-assisted coiling. Methods: Neuroform-assisted coiling patients were entered into a prospective registry at our institution. Procedural and 30 day complications were recorded. Delayed ipsilateral IPH cases within 30 days were reviewed. Results: Between 11/2002 and 7/2012, 98 patients had Neuroform-assisted coiling of 100 cerebral aneurysms, 8 acutely ruptured. Intra-procedurally, there were 3 thromboembolic events and 4 hemorrhages due to vessel or aneurysm perforation (not necessarily symptomatic). After the procedure but within 30 days follow-up (available for 92 patients), there were 6 TIA’s, 2 minor strokes and 1 SAH. There were 2 cases of ipsilateral IPH (2%). One was a 60-year-old man who had stent-assisted coiling of an ACOM aneurysm (Neuroform from right A1 into left A2). He was on aspirin 81 mg and clopidogrel 75 mg daily with a PRU (P2Y12 reaction units) of 72 on day of procedure. Despite decreasing clopidogrel dosing to every other day, he had a frontal lobe IPH 7 days later (Figure 1) with a PRU of 59. The other IPH (Figure 2) occurred in a 70-year-old man 14 days after Y-stent assisted coiling of an MCA aneurysm. He was on clopidogrel 75 mg and warfarin (INR 2.0) for prior pulmonary embolism and dural venous sinus thrombosis. Both patients recovered without neurological deficit. Conclusion: Recently described in flow diversion, delayed ipsilateral IPH is not limited to flow-diverting stents. Though less frequent, a potential for this may exist following any intracranial stenting procedure, possibly related to hemorrhagic conversion of microembolic phenomenon while on dual antiplatelets or anticoagulation.

Thrombosis and recanalization of a blister-like aneurysm: letter to the editor

Dear Editor, We would like to report the first case of a complete thrombosis and recanalization of a blister-like aneurysm. The partial or complete spontaneous aneurysmal thrombosis is reported by multiple authors and ranges between 13 and 20 % of giant aneurysms [4]. This phenomenon has been exceptionally reported in nongiant aneurysms and has never been documented with a blister-like aneurysm. A 54-year-old man was diagnosed with a subarachnoid hemorrhage (SAH) of Fisher grade III (GCS: 14). Arteriography showed an aneurysm of the left MCA bifurcation. Four days after its complete clipping, the patient deteriorated due to a new SAH. An aneurysm on the left A1 segment was disclosed. The patient died 72 h after this second SAH. The autopsy demonstrated a ruptured blister-like aneurysm of A1, which was probably also responsible for the first SAH (Fig. 1). Blister-like aneurysms account for only 1 % of all intracranial aneurysms [1]. They are characterized by their small size and a broad base. Their very thin wall is associated with growth in short intervals and rapid evolution towards the rupture [2]. The diagnosis of blister-like aneurysms, uneasy to distinguish from normal variants, remains complicated [5]. In our case, the blister-like ICA was not visualized at the first CT angiography. The occurrence of false-negative cerebral angiography in acute non-traumatic SAH is 5 %. The main cause of SAH with negative angiogram is a nonvisualized aneurysm. The incidence of ruptured ICA disclosed at a delayed angiography is about 16 %. Five possible reasons have been reported: inadequate angiography, obliteration of aneurysm by the hemorrhage, aneurysm thrombosis, an aneurysm too small to be visualized, and lack of aneurysm filling due to vasospasm [6]. The hypothesis the most probable is thrombosis of the aneurysm shortly after its rupture preventing its visualization at the first angiography. The spontaneous aneurysmal thrombosis is well known in giant aneurysms [4]. Intrinsic factors influencing its occurrence are the aneurysm morphology (narrow neck), the presence of endothelial lesion and hemodynamic patterns in the parent artery. An extrinsic factor can be the compressive effect exerted by the hematoma around the aneurysm. In many cases, aneurysmal thrombosis has an unfavorable natural evolution with the occurrence of thromboembolic events, recanalization, and bleeding [3]. In non-giant aneurysms, such in blister-like ones, this process is poorly documented and not understood. Such an occurrence seems to be exceptional. We report, for the first time, a complete thrombosis and recanalization of a blister-like aneurysm, disclosed after a D. Tassigny :G. Vaz : C. Raftopoulos (*) Department of Neurosurgery, University Hospital St-Luc, Universite Catholique de Louvain (UCL), Avenue Hippocrate, 10, 1200 Brussels, Belgium e-mail: christian.raftopoulos@uclouvain.be

Microsurgical anatomy of the anterior cerebral artery in Indian cadavers

The microanatomy features of cerebral arteries may be variable and may be different in different ethnic groups. To study the anterior cerebral artery (ACA) anatomy in North-West Indian cadavers. Microanatomy features of the ACA were studied in 15 formalin fixed human cadaveric brains under microscope. The outer diameter, length, and number of perforating branches with respective anomalies were measured for each of the following vessels: ACA (proximal A1 segment to distal A2 segment), anterior communicating artery (ACoA), Recurrent artery of Heubner (RAH), and callosomarginal artery and photographed for documentation. The mean length and external diameter of right and left A1 segment was 12.09 mm and 12.0 mm and 2.32 mm and 2.36 mm respectively. Narrowing, duplication, and median ACA were seen in 6.6%, 3.3% and 6.6% of the vessels respectively. Complex ACoA type was seen in 40% cadavers. RAH originated at an average point of 0.2 mm distal to ACoA, but in one cadaver it arose 5 mm proximal to ACoA. Double RAH was found in 26.6%. The course of RAH in relation to A1 was superiorly in 60%, in anteriorly 30% and posteriorly in 10% of cadavers. The orbitofrontal artery (OFA) and frontopolar artery (FPA) arose from A2 in 83.3% to 40% respectively. The mean distance of OFA and FPA from ACoA was 4.17 mm and 8.5 mm respectively. After giving rise to central, callosal and cortical branches, pericallosal artery terminated near the splenium of the corpus callosum or on the precuneus as the inferomedial parietal artery. Knowledge of the microvascular anatomy is indispensable and it is mandatory to be aware of the possible variations in the anomalies to minimize morbidity.

くも膜下出血と脳梗塞を同時にきたした前大脳動脈解離の1例

A 49-year-old woman presented with a sudden onset of right hemiparesis and motor aphasia. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subarachnoid hemorrhage (SAH) localized in the interhemispheric fissure and cerebral infarction in the territory of the left anterior cerebral artery (ACA). Digital subtraction angiography (DSA) demonstrated segmental narrowing and dilatation at the left A2 segment, leading to a diagnosis of ACA dissection. The day after the onset, we planed trapping of the dissecting portion and A3–A3 side-to-side anastomosis. As a result, we performed only the wrapping of the dissection portion, because the dissection was longer than we expected. Neither aneurysmal dilatation nor narrowing progressed almost six months after the operation. This case indicates wrapping is also effective as a treatment of dissecting aneurysms, and it is important to consider longer-than-expected ACA dissections.

Sex-dependent hemispheric asymmetries for processing frequency-modulated sounds in the primary auditory cortex of the mustached bat.

Species-specific vocalizations of mammals, including humans, contain slow and fast frequency modulations (FMs) as well as tone and noise bursts. In this study, we established sex-specific hemispheric differences in the tonal and FM response characteristics of neurons in the Doppler-shifted constant-frequency processing area in the mustached bat's primary auditory cortex (A1). We recorded single-unit cortical activity from the right and left A1 in awake bats in response to the presentation of tone bursts and linear FM sweeps that are contained within their echolocation and/or communication sounds. Peak response latencies to neurons' preferred or best FMs were significantly longer on the right compared with the left in both sexes, and in males this right-left difference was also present for the most excitatory tone burst. Based on peak response magnitudes, right hemispheric A1 neurons in males preferred low-rate, narrowband FMs, whereas those on the left were less selective, responding to FMs with a variety of rates and bandwidths. The distributions of parameters for best FMs in females were similar on the two sides. Together, our data provide the first strong physiological support of a sex-specific, spectrotemporal hemispheric asymmetry for the representation of tones and FMs in a nonhuman mammal. Specifically, our results demonstrate a left hemispheric bias in males for the representation of a diverse array of FMs differing in rate and bandwidth. We propose that these asymmetries underlie lateralized processing of communication sounds and are common to species as divergent as bats and humans.

Recovery of Normal Hemodynamic Activities after Long-term Medication in a Patient with Left Internal Carotid Arterial Occlusion

Aspirin, clopidogrel, cilostazol, and statins are thought to reduce the risk of cerebral infarction in patients with intracranial arterial stenosis. We present a case of multiple intracranial arterial stenoses in which increased cerebral blood flow (CBF) was demonstrated after long-term medical therapy. A 68-year-old man with a history of cerebral infarction showed complete occlusion of the left internal carotid artery with severe stenoses in the A1 segment of the left anterior cerebral artery (ACA) and the left posterior communicating artery resulting in poor visualization of the left middle cerebral artery (MCA) on magnetic resonance angiography (MRA). Administration of aspirin and clopidogrel prevented ischemia from recurring for 1 year; however, the stenoses never improved. Technetium-99m-L, L-ethylcysteinate dimer single-photon emission computed tomography (SPECT) demonstrated a significant decrease in CBF in the territory of the left MCA. Anastomosis between the superficial temporal artery and the MCA was recommended to the patient because no supplementary blood supply was expected through either the left A1 or posterior communicating artery. However, the patient refused surgery because of the associated risks. To enhance vasodilation, clopidogrel was replaced by cilostazol. One year later, the stenoses had partially improved. Further treatment with aspirin, cilostazol, simvastatin, and nateglinide contributed to the significant increase in CBF with normal hemodynamics, as shown with acetazolamide-loading SPECT. The goal of treatment for intracranial arterial stenosis is to supply sufficient blood flow to the brain rather than to completely dilate the stenotic artery. Long-term treatment with aspirin, cilostazol, simvastatin, and nateglinide might help increase CBF in some patients with intracranial arterial stenosis.

Anterior Cerebral Artery Dissection Presenting Subarachnoid Hemorrhage and Cerebral Infarction

A 35-year-old man presented with simultaneous occurrence of subarachnoid hemorrhage (SAH) and cerebral infarction (CI) caused by anterior cerebral artery (ACA) dissection. He complained of sudden onset of left frontal headache and his symptoms progressed to consciousness disturbance and right hemiparesis. Computed tomography and magnetic resonance imaging demonstrated SAH localized in the left interhemispheric fissure and CI in the territory of the left ACA. Right carotid angiography demonstrated a long double lumen sign at the left A2 to A4 segment of the left ACA, leading to a diagnosis of the combined type of CI and SAH caused by ACA dissection. Although many surgeons have previously tried to perform endovascular treatment, we selected only medication in this case, and his neurological findings gradually improved. Only 9 cases including the present case presented with simultaneous occurrence of SAH and CI caused by ACA dissection. Many of these patients showed stenosis with dilatation of ACA on carotid angiography. The prognoses of these patients were good. However, many SAH patients with dissecting aneurysm had poor prognoses. To improve the strategy for managing ACA dissection, we need to accumulate a greater number of such cases in the future. We also recommend that angiography should be performed in the patients with ACA dissection.

Bilateral Caudate Nucleus Infarction Associated with a Missing A1 Segment

We describe a case of bilateral caudate nucleus infarction caused by cardioembolic stroke associated with a variant circle of Willis. The patient was an 81-year-old man with atrial fibrillation who presented with a sudden disturbance of consciousness. When he became more alert a few days later, he was abulic with no spontaneous speech or activity. A magnetic resonance imaging scan of the brain revealed cerebral infarction of bilateral caudate nucleus heads and the left frontal lobe. The left A1 segment was absent on 3-dimensional computed tomography angiography. One year later, abulia had completely resolved. Bilateral caudate nucleus infarction with variant circle of Willis is rare.

Accuracy of CT angiography in the assessment of the circle of Willis: comparison of volume-rendered images and digital subtraction angiography

Computed tomography angiography (CTA) is increasingly used for non-invasive imaging of the cerebrovascular diseases. To evaluate the accuracy of CTA in the assessment of the variation of the segment calibers of the circle of Willis. One hundred and 17 patients with acute SAH (51 men and 66 women, mean age 50.9 years) who underwent CTA using a 16 detector-row CT scanner and DSA were evaluated retrospectively. The CTA and DSA studies were performed within 24 h after the onset of symptoms and within 24 h of each other. A total of 819 arterial segments (A-comA, right and left A1 segment, right and left P-com A, and right and left P1 segment) of the circle of Willis were determined to be aplastic (grade 1), hypoplastic (grade 2), or normal-sized (grade 3) by blinded observers evaluating CTA volume-rendered images. The CTA results were then compared with findings on the corresponding DSA images (reference standard). The overall agreement between CTA and DSA was 92.4%. We had 62 (7.6%) cases of disagreement (58 cases of under-estimation and four cases of over-estimation by CTA) between tow modalities. The sensitivity and specificity of CTA in the detection of aplastic and normal-sized segments were more than 90%. In contrast, subgroup analysis of the hypoplastic segments showed a sensitivity of 52.6% and a specificity of 98.2%. CTA is highly accurate in the assessment of anatomical variations of the circle of Willis; however, its sensitivity is limited in depicting hypoplastic segments.

Long-Lasting Narrowing of the Parent Artery after Bilateral Clipping of Mirror-image Aneurysms of Distal Anterior Cerebral Arteries: A Case Report

Because multiple intracranial aneurysms are not rare, accurate preoperative detection of asymptomatic aneurysms is important. In this paper, we report a ruptured distal anterior cerebral artery (DACA) aneurysm associated with an unruptured mirror-image aneurysm in a 62-year-old man presenting with headache. Although delayed vasospasm after subarachnoid hemorrhage has been reported to persist for 2 to 3 weeks, angiographic parent artery narrowing was far more prolonged in our case. Computed tomography revealed a subarachnoid hemorrhage in the interhemispheric and right sylvian fissures and a right frontal lobe hematoma. Digital subtraction angiography demonstrated bilateral symmetric saccular aneurysms of DACAs. On the day of admission, both aneurysms were clipped using an interhemispheric approach in a one-stage procedure, and the hematoma was aspirated. Angiography performed 8 days after the surgery demonstrated a residual aneurysm neck on the left side. Follow-up digital subtraction angiography performed on day 42 from onset showed resolution of the residual aneurysm neck along with narrowing of the left A2. However, at 7 months, the A2 narrowing had lessened. The location of the bilateral aneurysms near the midline facilitated a single approach but necessitated the application of juxtaposed clips. Regarding the pathogenesis of the bilateral aneurysms, previous reports have suggested symmetry of congenital anatomic defects and hemodynamic stress as potential causes. The persistent narrowing that was observed could have resulted from proliferative vasculopathy or from fibrosis possibly induced by the clips.

Three-Dimensional Morphometry of the A1 Segment of the Anterior Cerebral Artery With Neurosurgical Relevance.

Despite research in the anatomical sciences for the last 200 years, some structures of the human body remain controversial or incompletely described. One of these structures is the A1 segment of the anterior cerebral artery (ACA). To analyze the A1 segment of the ACA using novel stereoscopic methods because the 3-dimensional morphometry of the ACA is important to neurosurgeons. A digital-image computer-based system was used to analyze the A1 segment of 230 ACAs derived from computed tomography. Data analysis included the inner diameter, length, and volume and calculation of A1 symmetry, hypoplasia, and deviation, and tortuosity indexes. Hypoplasia of the A1 segment was found in 0.87% and only on the right sides, whereas asymmetry was found in 42.6% and was more common in female patients. Right A1 segments tended to be longer in male patients, and this reached significance. Also of significance was the correlation of an increased length with age. Right A1 segments tended to have greater volumes, and this was significant in a comparison of male and female patients. Tortuosity indexes tended to be greater for left sides, but deviation indexes tended to be greater on the right sides. Morphometric data of the A1 segment of the ACA as analyzed in the present study may be of utility to the neurosurgeon. Right A1 segments tend to be more tortuous, more deviated, longer, and narrower than left A1 segments.

Perforator Infarction after Placement of a Pipeline Flow-Diverting Stent for an Unruptured A1 Aneurysm: Fig 1.

Flow-diverting stents such as the Pipeline embolization device (PED; ev3, Irvine, California) or Silk (Balt, Montmorency, France) were recently introduced in clinical practice for the treatment of fusiform and wide-neck intracranial aneurysms. These stents are designed to divert the flow in the parent artery, with reduction of inflow in the aneurysm leading to thrombosis. The devices have 30%–35% metal surface-area coverage (as opposed to approximately 10% for conventional intracranial stents) to promote flow diversion and, at the same time, to keep open branch vessels and perforating arteries that are crossedbythedevice.Althoughthese2requiredpropertiesseemcontradictory, the first clinical results are promising in terms of both effectiveness and safety. 1 Recently, we treated a 68-year-old woman with an incidentally discovered large dumbbell aneurysm located on the left A1 segment (Fig 1A ,- B) with a PED. Because the first PED that was placed shortened more than we expected, it did not completely cover the neck of the aneurysm, and a second PED was placed telescopically with overlap on the aneurysm neck only and with some protrusion in the middle cerebral artery (Fig 1C). Immediately after the procedure, the patient appeared apathetic and hemiparetic on the right side. MR diffusion imaging showed infarction in the left basal ganglia in the territories of the lenticulostriate arteries arising from the A1 segment

未破裂前交通動脈瘤術中に緊急Ａ３Ａ３バイパスが必要となった症例―予期せぬ動脈損傷への対処法に関する考察―

It is clearly important to avoid damage to the major arterial trunk during surgery. However, it is also useful to consider how to address problems associated with an unexpected arterial injury. We report a case in which a left proximal A2 occlusion and urgent A3A3 anastomosis were performed for arterial injury during surgery for an unruptured anterior communicating artery aneurysm. When an arterial injury occurs, closing of the arterial defect should first be attempted by stitching or clipping. If this is impossible, it might be necessary to occlude the artery and perform vascular reconstruction. However, there are 2 major problems in a case requiring urgent vascular reconstruction such as A3A3 anastomosis: the difficulty of suturing vessels in a deep and narrow field, and the requirement for further preparation of vascular components to make them adequate for vascular reconstruction. Good judgment and prompt performance of the procedure is required to avoid ischemic complications.

Processing of broadband stimuli across A1 layers in young and aged rats

Presbycusis can be considered a slow age-related peripheral and central deterioration of auditory function which manifests itself as deficits in speech comprehension, especially in noisy environments. The present study examined neural correlates of a simple broadband noise stimulus in primary auditory cortex (A1) of young and aged Fischer–Brown Norway (FBN) rats. Age-related changes in unit responses to broadband noise bursts and spontaneous activity were simultaneously recorded across A1 layers using a single shank, 16-channel electrode. Noise bursts were presented contralateral to the left A1 at 80 dB SPL. Aged A1 units displayed increased spontaneous (29%), peak (24%), and steady state response rates (38%) than did young A1 units. This was true across all A1 layers, although age-related differences were significantly greater for layers I–III (43% vs 18%) than lower layers. There was a significant age-related difference in the depth and duration of post-onset suppression between young and aged upper layer A1 units. The present functional differences across layers were consistent with studies showing greatest losses of gamma-aminobutyric acid (GABA) markers in superficial layers of A1 and with anatomic studies showing highest levels of inhibitory neurons located in superficial cortical layers. The present findings were also consistent with aging studies suggesting loss of functional inhibition in other cortical sensory systems.

Emergency endovascular Stent graft and coil placement for internal carotid artery injury during transsphenoidal surgery

Background An internal carotid artery (ICA) injury is an uncommon but potentially fatal complication of transsphenoidal surgery. Case Description We report a 61-year-old male patient with a right cavernous ICA injury sustained during transsphenoidal surgery and who underwent endovascular Stent graft placement. The ICA trapping was not indicated because of the absence of the left A1 on preoperative magnetic resonance angiography. During Stent graft placement, the ICA wall could not be completely fit with a stent due to its stiff nature and the carotid curve. The gap between the stent and the ICA wall was filled using a coiling procedure on the first postoperative day. Conclusions Endovascular Stent graft placement for posttranssphenoidal carotid artery injury is a useful technical adjunct to the management strategy and has the potential to minimize the risk of having to sacrifice the ICA. In cases of incomplete reconstruction of the Stent graft placement due to its stiff nature and the carotid curve, an additional coiling procedure could be helpful to obliterate the gap between the stent and the ICA wall. To avoid carotid injury during transsphenoidal surgery, careful preoperative evaluation of vascular structures and meticulous surgical technique are necessary.

Intra-aneurysmal flow patterns and wall shear stresses calculated with computational flow dynamics in an anterior communicating artery aneurysm depend on knowledge of patient-specific inflow rates

To evaluate if knowledge of patient-specific inflow data in computational fluid dynamics simulations is required for the accurate calculation of intra-aneurysmal flow patterns and wall shear stress in an aneurysm of the anterior communicating artery (AcomA). 3D digital subtraction angiography (3D-DSA) and phase contrast magnetic resonance (pcMRI) images were obtained in a 71-year old patient with an unruptured aneurysm of the anterior communicating artery (AcomA). A baseline computational flow dynamics simulation was performed using inflow boundary conditions measured with pcMRI. Intra-aneurysmal flow patterns, maximum, minimum and average values of wall shear stress and wall shear stress histograms were calculated. Five additional computational flow dynamics simulations were performed, in which simulated inflow from the right and left A1 segment was varied, while keeping the total inflow constant. Intra-aneurysmal flow patterns measured with pcMRI were qualitatively compared to intra-aneurysmal flow patterns derived from the simulations. Intra-aneurysmal flow patterns calculated in the baseline simulation were in good qualitative agreement with pcMRI measurements. Intra-aneurysmal flow patterns and wall shear stress changed considerably when inflow conditions were altered. Changes in the flow distribution between right and left A1 segments caused variations of the averaged wall shear stress as high as 43%. Intra-aneurysmal flow patterns and wall shear stress in an AcomA aneurysm calculated with computational flow dynamics depended strongly on the flow distribution between A1 segments. Patient-specific flow data measured with pcMRI obtained prior to computational flow dynamics are necessary for an accurate simulation of intra-aneurysmal flow patterns and calculation of wall shear stress in AcomA aneurysms. Further studies may indicate if wall shear stress calculated with computational flow dynamics can predict aneurysm growth and/or rupture.

Dissecting Aneurysm at the Proximal Anterior Cerebral Artery Treated by Parent Artery Occlusion

Aneurysms of the A1 segment of the anterior cerebral artery (ACA) are rare. We described the first documented endovascular treatment of an A1 portion dissecting aneurysm by parent artery occlusion. A 43-year-old man patient presented with subarachnoid hemorrhage. Cerebral angiography demonstrated a dissecting aneurysm of the left anterior cerebral artery (ACA) at A1 portion. Because of the dissecting nature of the A1 portion aneurysm, a 2.5x15-mm Neuroform stent was placed in the left A1 portion. However, regrowth of the aneurysm was found on the three month follow-up angiogram, so the aneurysm and the left A1 portion of ACA were occluded completely.

DELAYED SYMPTOMATIC COIL MIGRATION AFTER INITIALLY SUCCESSFUL BALLOON-ASSISTED ANEURYSM COILING

To describe delayed migration of a coil loop after adjunctive balloon remodeling of an anterior communicating artery aneurysm. A 56-year-old man with a subarachnoid hemorrhage from a small anterior communicating artery aneurysm underwent successful coil embolization with adjunctive balloon remodeling. Eight days after the procedure, the patient returned with the acute onset of right lower extremity paralysis. Magnetic resonance imaging demonstrated an acute left anterior cerebral artery territory infarction. Angiography demonstrated that this infarct was secondary to the delayed migration of a coil loop out of the aneurysm and into the left A1 to A2 junction. Delayed migration of a coil loop after adjunctive balloon remodeling represents a rare but potentially severe complication of this technique.

Dissecting Aneurysms of Bilateral Anterior Cerebral Artery Complicated by Subarachnoid Hemorrhage after Cerebral Infarction: A Case Report

Intracranial dissecting aneurysms have been increased due to recent advancements in diagnostic imaging. However there have been little article with subarachnoid hemorrhage and cerebral infarction occurring almost at the same time. We performed the surgical treatment and obtained good result. A 47-year-old male presented to our hospital with chief complaints of sudden headache and mild paralysis of the left lower extremity. Brain imaging at admission revealed cerebral infarction in the right frontal lobe and subarachnoid hemorrhage in the frontal convexy and anterior interhemispheric fissure. The left and right internal carotid angiography showed a bulging cerebral aneurysm at the left A1-A2 junction and stenosis and arterial dissections in the peripheral of the bilateral anterior cerebral artery. Wrapping was performed for the dissecting aneurysm of the left anterior cerebral artery. For the right anterior cerebral artery, trapping was performed at the A2 segment without vascular anastomosis. The patient's postoperative course was uneventful. A consensus has not been reached on the treatment for intracranial dissecting aneurysms. Proximal trapping without vascular reconstruction was performed for the right anterior cerebral artery without vascular anastomosis to prevent rebleeding. However no symptoms of neurological deficiency were observed. Proximal trapping of dissecting aneurysm seems to be a good option when patient's functional and life prognosis are taken into account in case that vascular reconstruction will be anticipated difficulty.