Left Middle Cerebral Artery Aneurysm Research Articles

S119. Low threshold Linked Quadri-Polar (LQP)-TceMEP during left middle cerebral artery aneurysm clipping: A case report

Introduction Traditional TceMEP stimultion (one anode and one cathode) during aneurysm surgery is limited due to the use of higher stimulation intensity ( ∼ 150 V) activating the motor tract at a subcortical level, bypassing the cortical and superficial subcortical level. (LQP)-TceMEP technique has the advantage of using two anodes and two cathodes stimulating electrodes bilaterally. Using lower threshold stimulation allows widening the range of current spread, and may activate a more cortical or superficial subcortical level. Methods A 65 year old female underwent an elective surgery for a left MCA bifurcation clipping. No history of neurological disease or contraindication for intraoperative neurophysiological monitoring (IONM). Image : 7 mm AP by 5 mm transverse by 6.5 mm cranio-caudal posteriorly projecting saccular aneurysm at the left middle cerebral artery (MCA) bifurcation. Baselines were obtained prior to incision, and Desfluorane:3.0%, Propofol:75 g/kg/min. Remifentanil 0.3 g/kg/min, was implemented for this case. We strongly recommend TIVA for this type of cases. SSEPs (MN-UN-PTN). (LQP)-TceMEP at low threshold (40–48 V), train of 4, ISI 1.5, PW:75. CMAP were recorded from distal muscles: brachioradialis or flexor carpi radialis, abductor pollicis brevis, first dorsal interosseous and abductor hallucis. EEG. Results After placement of the first temporary clip at the M1 position there were no (LQP)-TceMEP changes noted at 48 V/150 mA. After another temporary clip was placed at the aneurysm neck, the potentials remain stable at 48 V/152 mA. After placement of a longer clip at the base of the neck of the aneurysm, the (LQP)-TceMEP showed significant changes at 48 V/150 mA and the intensity was increased to 54 V/158 mA with no improvement noted; the surgical team was notified. The upper and lower extremities cortical component of the SSEPs remain unchanged related to aneurysm clipping.After approximately 20 min the (LQP)-TceMEP was able to be evoked, however at a higher stimulation intensity (60 V), which we hypothesized to be bypassing the area of injury. Conclusion The use of the (LQP)-TceMEP technique gave us the opportunity to monitor the motor pathway continuously without patient movement related to transcranial stimualtion and without interfering with the surgical procedure due to the low stimulation used in this case, (40–48 V). With low threshold stimulation, we assume activation of the motor tract at a cortical or superficial subcortical level without bypassing critical brain areas. (TIVA) strongly recommend (not in this case), we had reliable responses throughout the case (until the aforementioned incident), which was also dependent on the patient’s preexisting conditions and body type. After surgery, the patient demonstrated a pure motor deficit (right hemiplegia), expressive aphasia (Broca’s area) and normal sensation. Imaging studies showed cortical (left inferior frontal lobe) and subcortical stroke. Three months after surgery the patient recovered movement and speech.

Embolectomy Through Aneurysm Wall for Iatrogenic Occlusion of M1 Portion During Coil Embolization: Technical Note for Transaneurysmal Embolectomy

We describe the technique for surgical "transaneurysmal" embolectomy in a patient with subarachnoid hemorrhage and multiple cerebral aneurysms who manifested large-vessel occlusion during coil embolization. An 84-year-old woman with subarachnoid hemorrhage and bilateral internal carotid artery (ICA)-posterior communicating artery and bilateral middle cerebral artery aneurysms (MCAs) was admitted to our institution. We performed clipping to the left ICA and MCAs; however, we could not find the rupture point of both aneurysms. We chose to treat 2 aneurysms on the other side by coil embolization. After complete coil embolization of a right ICA aneurysm, angiograms showed occlusion of the right MCA just proximal to an MCA aneurysm. Considering the risk of bleeding of an untreated MCA distal to the occlusion by endovascular thrombectomy, we performed open transaneurysmal embolectomy at the occlusion site and surgical clipping of the MCA. After cutting the aneurysmal wall, we inserted a suction tube into the cut surface of the aneurysm. The clot was gradually and completely pulled through the cut surface of the aneurysm. Finally, the aneurysm was completely clipped with titanium clips to preserve the M1 and M2 branches. Different from usual surgical thrombectomy, suturing the vessel wall is not required for transaneurysmal embolectomy and the area of brain ischemia is confined. Aneurysms with the fragile wall may rupture during clearance of tissue on the aneurysmal surface, and suction may increase vessel damage. Transaneurysmal thrombectomy may be useful and safe for large-vessel occlusion just distal to cerebral aneurysms.

Stroke in Senegalese Young Women: About 109 Cases

Considered for a long time as pathology of the elderly, stroke is more and more frequent in the young subject, 12 to 15% of the stroke occurs in the people under 50 years old. The situation is alarming because the consequences are tragic on the economic and social levels. We will be interested in the stroke of the young women. This is a cross-sectional descriptive study over 22 month in neurology department in Fann teaching hospital, period from August 2012 to June 2014. This allowed to the compilation of 109 patients with stroke according to the WHO definition and aged between 16 and 50 years. This study focuses on 109 women aged between 17 and 50 years with an average age of 39.95 years. The most representative age range is between 36 and 45 years. Only 3.7% of patients had a level of education higher than baccalaureate, 59.6% were not in school.57.8% had an ischemic stroke and 42.2% had a hemorrhagic stroke, with an average age of 39 years for ischemic stroke and 40 years for hemorrhagic stroke. The most important cardiovascular risk factors for ischemic stroke were dyslipidemia (73%), high blood pressure (42.9%), sedentary lifestyle (38.1%), and estrogen-progestin contraception intake were found in 23.8 % of cases. According to the TOAST classification, the etiology is embolic heart disease (25.4%), macroangiopathy (17.5%), microangiopathy (7.9%), others (15.9%), and in 41.2% of the patients the etiology is not found. The main cardiovascular risk factors in hemorrhagic stroke were hypertension (80.4%), dyslipidemia (58.7%), sedentarily (59.1%), migraine (23.9%) an oestroprogestative contraception intake (6.5%).The etiologies of hemorrhagic stroke are arterial hypertension (80.4%), left middle cerebral artery aneurysm (6.5%), arteriovenous malformation (4.3%), infectious arteritis (4.3%), hemostasis disorder (2.2%), and undetermined origin (2.2%). Bad eating habits, sedentary lifestyle lead an increase cardiovascular risk factors and, at the same time, the stroke rate in young women. Prevention must go through a good awareness-raising policy.

Endovascular rescue treatment through stent positioning after surgical clipping of intracranial aneurysms complicated by parent artery obstruction

During aneurysm clipping, ischemic complications may occur and require a rescue treatment, usually surgical. We present two such cases that required urgent rescue treatment, performed through an endovascular route. Our...

24. Continuous EEG-SEP monitoring in acute brain injury: Unstable SEP trend preceding neurological deterioration

We describe two patients with acute brain injury who underwent continuous EEG-SEP monitoring: an unusual phase of SEPs amplitude instability preluded to cerebral perfusion alterations in one case and to neurological deterioration up to brain death in the other. Raw and quantitative EEG were continuously recorded. Cortical SEPs after stimulation of median nerves were recorded every hour, with amplitude and latency automatically trended. Patient 1 had a subarachnoid hemorrhage due to a left Middle Cerebral Artery (MCA) aneurysm rupture. Increase of intracranial pressure required left decompressive craniectomy. EEG-SEP monitoring was started on day 7, showing a prolonged instability of left SEP: left MCA vasospasm with temporo-parieto-occipital hypoperfusion was demonstrated. After treatment, hypoperfusion and SEP improved. Patient 2 suffered from a right MCA ischemic stroke, treated with systemic thrombolysis. After four days GCS dropped to 5–6, CT showed a severe hemispheric edema requiring a right decompressive craniectomy. Right SEP was absent but left SEP was normal. On day 6 EEG-SEP monitoring was started, showing left SEP instability and gradual deterioration until day 9, when SEP suddenly and permanently disappeared. On day 10 the brain dead of the patient was declared. In acute brain injury, SEP instability during continuous monitoring is an infrequent pattern, with a high risk of neurological deterioration.

A Rare Case of Streptococcus alactolyticus Infective Endocarditis Complicated by Septic Emboli and Mycotic Left Middle Cerebral Artery Aneurysm.

To date, S. alactolyticus endocarditis complicated by middle cerebral artery aneurysm has not been reported. We describe the case of a 65-year-old female with a history of hypertrophic cardiomyopathy with left ventricular outflow tract obstruction presenting with confusion and a apical holosystolic murmur. Angiography of the brain identified new bilobed left middle cerebral artery aneurysm. Serial blood cultures grew S. alactolyticus, and aortic and mitral valve vegetation were discovered on transesophageal echocardiography. The patient was treated with antimicrobial therapy, mitral and aortic valve replacements, and microsurgical clipping of cerebral aneurysm. This case serves to highlight the pathogenicity of a sparsely described bacterium belonging to the heterogenous S. bovis complex.

E-133 preliminary experience with pulserider as an adjunctive device for endovascular treatment of aneurysms at a bifurcation

Background While there have been technical advances in endovascular treatment options for a wide variety of intracranial aneurysms not all aneurysms are suitable for coil embolization. Wide neck aneurysms at a bifurcation have remained technically challenging and coil retention is a valid concern. However, the PulseRider® (Pulsar Vascular, San Jose, CA USA) was recently introduced as an adjunctive device specifically designed to provide a scaffold at the neck of bifurcation aneurysms. The technology is specifically designed for complex bifurcations aneurysms to provide neck reconstruction and coil support. It provides coverage only where it is needed allowing for a low metal to artery ratio; this along with intraluminal patency is a significant advantages over current Y-stenting. Methods This is a review of data on eight (8) patients that had anterior and two (2) that had posterior circulation aneurysms. There were eight (8) females and two (2) males and the average age was 51 (range 41 to 62). The aneurysms were referred to as wide-neck when the dome/neck ratio was 1.5 and/or neck length was 4 mm. Results Overall, 10 patients were treated with the PulseRider device. Of the 10 patients treated two (2) had basilar artery aneurysms that had ruptured more than six (6) years prior and required retreatment. One patient had subarachnoid hemorrhage prior to treatment of a ruptured basilar apex and left middle cerebral artery (MCA) aneurysms but treatment with the PulseRider was for a right unruptured MCA. One patient with an Acom that had ruptured and was treated six (6) months prior had recurrence on follow-up. An unsuccessful attempted clipping was followed by endovascular treatment with PulseRider and coils. One other patient had residual aneurysm on one (1) week follow-up angiogram post craniotomy and was then treated with PulseRider and coils. All but one patient were started on dual anti-platelet therapy (Aspirin and Clopidogrel) prior to endovascular treatment. Because a decision was made to use the PulseRider intra-operatively in one patient there was an adjustment in heparin dosage and intravenous (IV) Aspirin 500 mg. was givenFollow-up angiography was done at 6 months on 2 patients and complete or near-complete (>95%) embolization was achieved in all patients and the branch vessels remained patent. The PulseRider adapted easily to the geometry of the aneurysm and the branch vessels allowing placement inside the aneurysm, in the branch vessels or in a hybrid manner with one side of the arch in the aneurysm and the other in a branch vessel. There was technical success related to placement of the device in all cases. All procedures were completed without complications. There were no neurological deficits. Conclusion Although this is a small series preliminary results are quite promising with good angiographic occlusion of the aneurysms. It will be necessary however, to obtain long term results on a larger series of patients in order to prove the safety and efficacy of this device as a treatment option. Disclosures H. Nahser: 6; C; support for Travel to meetings by various companies. A. Chandran: 6; C; Travel expenses to conferences by various companies. M. Puthuran: 6; C; travel expenses to conferences by various companies. P. Eldridge: 6; C; travel expenses to conferences by various companies. T. Patankar: 6; C; travel expenses to conferences by various companies. T. Goddard: 6; C; Travel expenses to conferences by various companies.

Clipping of bilateral MCA aneurysms and a coiled ACOM aneurysm through a modified lateral supraorbital craniotomy

We showcase the microsurgical clipping of a left middle cerebral artery (MCA) aneurysm-(B) done through a modified right lateral supraorbital craniotomy, as well as clipping of a previously coiled anterior communicating (ACOM) artery aneurysm-(C) and a bilobed right MCA aneurysm-(A). Splitting of the right sylvian fissure is initially performed following which a subfrontal approach is used to expose and dissect the contralateral sylvian fissure. The left MCA aneurysm is identified and clipped. The ACOM aneurysm is then clipped following multiple clip repositioning based on flow measurements. The right MCA aneurysm is then identified and each lobe is clipped separately. The first picture showcased in this video is a side to side right and left ICA injection in AP projection. In this picture, (A) points to the bilobed right MCA aneurysm, (B) to the left middle cerebral artery (MCA) aneurysm, and (C) to the previously coiled anterior communicating (ACOM) artery aneurysm. The red dotted line shows that both MCA aneurysms lie within the same plane which makes it easier to clip both of them, through one small craniotomy. The video can be found here: http://youtu.be/4cQC7nHsL5I .

Stress-induced cardiomyopathy and possible link to cerebral executive function: a case report.

To the Editor: A complex and poorly understood relationship exists between cerebral and cardiac function.1 Stress produces a range of physiological responses that are relevant to cardiovascular and cerebrovascular disease. Upon stress perception, the hypothalamic-pituitary-adrenocortical (HPA) and sympatho-adrenomedullary axes are activated, increasing bioavailability of cortisol, epinephrine, and norepinephrine.2 Given the reliance of both cardiac and cerebral function on the integrity of this system, any impairment in the form of overstimulation or understimulation may manifest as cardiac and cerebrovascular pathology as illustrated in the case report below. Case report. Ms A, a 56-year-old woman with known hypertension and hypercholesterolemia, was admitted with chest pain following an argument with a family member. She had no history of ischemic heart or neurologic disease. On presentation, she was noted to be confused. Physical examination was unremarkable with no focal neurologic or cardiac abnormality identified. Further investigations revealed troponin T and creatine kinase peak concentrations of 1.15 μg/L (reference range, < 0.03 μg/L) and 614 U/L (reference range, < 180 U/L), respectively. Admission electrocardiogram (ECG) demonstrated sinus rhythm without ischemic changes (Figure 1). Computed tomography scan of the brain was unremarkable. She continued to experience amnesia over the first 12 hours after her admission; amnesia had resolved by the following day. An urgent neurology consultation was sought, and the diagnosis of transient global amnesia was made on the basis of the patient’s clinical features. Figure 1. A 12-Lead Electrocardiogram (A) At Admission, Showing Normal Sinus Rhythm, and (B) 15 Hours Later, Demonstrating Deep T-Wave Inversion Over Leads V2–V5 (anterolateral leads) Resembling Acute Coronary Ischemia Ms A was admitted to the coronary care unit; serial ECG monitoring showed biphasic and deep T-wave inversion over the anterolateral leads (see Figure 1). She underwent coronary angiography, which showed “smooth” coronary arteries and apical “ballooning” on left ventriculography consistent with takotsubo cardiomyopathy. Magnetic resonance imaging of the brain identified an incidental 6-mm left middle cerebral artery aneurysm with no associated hemorrhage or ischemia. Her final diagnoses were stress-induced (takotsubo) cardiomyopathy and transient global amnesia. Adrenergic receptors are abundant throughout the brain,3 myocardium,4 and coronary arteries.5 It is well established that catecholamine signaling through β-adrenergic receptors mediates endogenous regulation of complex central nervous system processes such as attention, arousal, learning, and memory3,6–8 as well as important cardiac functions such as chronotropy, inotropy, and lusitropy. There is general consensus that this “cerebro-cardiac” process occurs via the β-adrenoceptor–mediated cyclic-AMP (cAMP)–dependent protein kinase pathway.9–11 A growing body of evidence suggests that cortisone and epinephrine may also impair memory retrieval and therefore contribute to the mechanism of peritraumatic amnesia. de Quervain and colleagues reported that stress and infusion of cortisone impair memory retrieval in rats12 and humans.13 Sadowski et al10 demonstrated that infusion of epinephrine resulted in impairment of place and response learning. Furthermore, detrimental effects of cortisone on hippocampal function during memory retrieval have been shown to require concurrent norepinephrine-dependent activation of the basolateral part of the amygdala,14,15 which may be via an inhibitory G protein–coupled suppression of cAMP signaling.16,17 Altogether, memory formation, consolidation, and retrieval seem to be a function of β1-adrenergic receptor function, and stress impairs memory retrieval by exerting its action on the β2-adrenergic receptor. Catecholamine overstimulation has been suggested as the key pathogenetic factor in takotsubo cardiomyopathy. This cardiac syndrome is now increasingly recognized by the mental health practitioner as either a disease association18,19 or a complication of a psychiatric treatment, such as electroconvulsive therapy.20,21 Although the exact pathogenesis has not been fully elucidated, data from animal,22 imaging,23 and myocardial histologic24 studies indicate that overactive β-adrenergic signaling, in the presence of supraphysiological catecholamine concentrations, plays a significant role in mediating this phenomenon. Given the density of β-adrenergic receptors are greatest25 in the apical segments of the myocardium, Lyon and colleagues4 suggest these receptors are important in this disease phenomenon, which explains the apical propensity of transient myocardial stunning seen in takotsubo cardiomyopathy. Our case report provides a collection of cardiac and cerebral clinical findings that would support the common mechanistic link described in our review. Further understanding of this complex, dynamic relationship is required to formulate a more targeted preventive and therapeutic management strategy.

Brain abscess after endosaccular embolisation of a cerebral aneurysm

Endovascular embolization has become an important treatment option for cerebral aneurysms, along with surgical clipping. But few literatures mentioned infectious complications after coiling of aneurysms. We present a patient with a brain abscess that developed after endosaccular embolization of a left middle cerebral artery aneurysm. The brain abscess was located adjacent to the aneurysm and discovered more than 2months after embolization. We discuss the clinical implications of this rare complication and review the literature for infections related to the coils used for embolization of aneurysms.

Complete graft dehiscence 8 months after repair of acute type A aortic dissection

Acute type A aortic dissection is a dreaded differential diagnosis of acute chest pain. Long-term outcome mainly depends on pre-existing comorbidities and post-operative complications. We present a patient with aortic graft dehiscence and subsequent severe aortic regurgitation due to fungal graft infection 8 months after repair of acute type A aortic dissection. Redo aortic surgery had to be delayed for 28 days due to intracerebral haemorrhage caused by septic embolism and clipping of a mycotic left middle cerebral artery aneurysm. Surgery revealed a circumferentially detached graft at the site of the proximal anastomosis thereby forming a massive pseudoaneurysm. The patient underwent successful aortic root replacement using a Freestyle porcine root bioprosthesis (25 mm), followed by re-anastomosis of the coronary arteries and partial replacement of the ascending aorta with a 28 mm Dacron graft. The patient was discharged on day 67 in stable cardiac condition with persistent neurological deficits. This case highlights the challenging management of patients with aortic graft infection and neurological dysfunction after redissection of the ascending aorta who require redo cardiac surgery.

Surgical Management and Role of Medical Therapy in Ruptured Aneurysmal Neurocysticercosis

We describe the case of an 80-year-old Hispanic male with an acute subarachnoid hemorrhage (SAH) due to an inflammatory middle cerebral artery (MCA) aneurysm rupture. Two years prior to this episode, the patient had undergone a resection of a left intracranial neurocysticercosis lesion. A current CT, CTA and MRI showed significant SAH, a left MCA aneurysm and a cystic lesion compatible with neurocysticercosis. Intraoperatively, this aneurysm was found to be adjacent to a neurocysticercosis cyst, a diagnosis confirmed by surgical pathology. Only a few cases of subarachnoid hemorrhage due to an inflammatory brain aneurysm have been reported. Due to the associated higher incidence of intraoperative rupture and difficulty clipping, our paper highlights the importance of considering an inflammatory origin in patients with a history of neurocysticercosis and subarachnoid hemorrhage. This is the oldest patient on record reported for this diagnosis and surgery.

A52 Monitoring Regional Cerebral Blood Flow by Termal Diffusion Flowmetry

Background: To measure the cerebral blood flow (rCBF), we used the thermal diffusion flowmetry (TD-rCBF). The TD microprobe was placed 25 mm below the cortical surface. Mean values are around 18 – 25 ml/100 g/min Case 1. A male of 34-year-old underwent surgery of right MCA (middle cerebral artery) and AcoA (anterior communicating artery) aneurysms. To observe effects of hypnotics on rCBF measured by TD-rCBF, propofol (4 mg/kg/h) and sevoflurane 0.7% were alternated, maintaining bispectral index between 45–60. Propofol series showed TD-rCBF (ml/100 g/min) values of 18, 25 and 23 Sevoflurane had values of 27, 32 and 41. Case 2. A 56-year old female suffered a subarachnoid hemorrhage (Hunt &Hess 1, Fisher 1. Aneurysm on right MCA was clipping. Median and tibial posterior somatosensory evoked potentials; a bilateral recording of motor evoked potentials elicited by transcranial electrical stimulation in upper and lower extremities. Events such as: placement of a temporal clip, the withdrawal of retractors and the weight of the temporal and frontal lobes on the clip showed sudden decreases of the blood flow to 0 ml/100 g/min. Evoked potentials did not change. Case 3 A 49-yr-old woman suffered a SAH (Hunt&Hess IV, Fischer IV. A left MCA aneurysm was treated with coils. After 24 of HSA, TD-rCBF values decreased to 7–10 ml/100 g/min, while Doppler ultrasonography showed normal values. The angiography revealed a severe vasospasm in the left MCA and AcoA territories. The nimodipine administration increased TD-rCBF values to 20 ml/100 g/min. Conclusions: The TD-rCBF showed in real-time, variations of rCBF induced by anaesthetics. This monitor detected changes of cerebral blood flow earlier than evoked potentials and transcranial Doppler ultrasonography.

未破裂左中大脳動脈瘤の治療後10年の経過で新生，増大した右脳底上小脳動脈瘤の1例

未破裂左中大脳動脈瘤の治療後10年の経過で新生，増大した右脳底上小脳動脈瘤の1例

Subarachnoid hemorrhage in a three-year-old-boy with left middle cerebral artery aneurysm

We report a case of three-year-old boy, who presented with a history of sudden onset of headache and vomiting. Neurologically he was conscious, oriented, and with no neurological deficits (Hunt and Hess grade-2) at the time of admission. Computed Tomography (CT) scan of the brain revealed intracerebral hemorrhage [Figure 1a] and intraventricular hemorrhage [Figure 1b]. Four-vessel cerebral angiogram revealed left middle cerebral artery aneurysm in the M-1 segment [Figure 2]. Left pterional craniotomy and clipping of the aneurysm was done.The postoperative period was uneventful and the patient was discharged on the eighth postoperative day without any neurological deficit. At 55 month follow-up, his Glasgow Outcome scale score was 5 and he had no functional or cognitive deficit.Pediatric cerebral aneurysms differ from adults, having male predilection, higher incidence of giant aneurysms, location at the internal carotid artery(ICA) bifurcation or posterior circulation, and less incidence of vasospasm.

Cerebral Infarction Along the Distribution of Perforating Arteries During Aneurysm Surgery in a Patient With Pheochromocytoma -Case Report-

A 58-year-old woman with refractory hypertension presented with subarachnoid hemorrhage. Digital subtraction angiography and three-dimensional computed tomography (CT) angiography revealed a ruptured left vertebral artery (VA) aneurysm and an unruptured left middle cerebral artery (MCA) aneurysm. The patient successfully underwent neck clipping of the left VA aneurysm. However, CT obtained just after the operation showed an asymptomatic cerebral infarction along the distribution of medial striate arteries of the right anterior cerebral artery in the caudate nucleus. The pathogenesis of the infarction was unknown. Before clipping surgery of the left MCA aneurysm, detailed examinations to find the cause of her refractory hypertension were performed. Laboratory tests revealed plasma serum level of norepinephrine at 15,521 pg/ml (normal range 100-450 pg/ml). Abdominal magnetic resonance imaging revealed a pheochromocytoma in the right adrenal gland. After preoperative management of the pheochromocytoma, the neck of the left MCA aneurysm was successfully clipped. When the patient awakened from anesthesia, she noticed right hemiparesis and motor aphasia. CT showed cerebral infarction along the distribution of lenticulostriate arteries of the left MCA in the putamen. Her symptoms gradually improved, and the pheochromocytoma was removed by laparoscopic surgery. Sustained severe hypertension and depletion of blood volume resulting from excess catecholamine release from the pheochromocytoma may have caused the complications. Hypervolemic fluid infusion and maintenance of normotensive blood pressure during surgery may avoid such ischemic events.

A rare association of ruptured left middle cerebral artery aneurysm and dextrocardia with situs inversus totalis

The association of dextrocardia with situs inversus totalis and ruptured cerebral aneurysm is a rare event. There have been no reports concerning this rare association in the literature. Asymmetric positioning of internal organs is one of the characteristics of vertebrates. The normal left–right anatomic positioning, situs solitus, does not occur normally always, leading to laterality defects. In this letter, we describe the clinical course of a patient with a ruptured aneurysm of the left middle cerebral artery and dextrocardia with situs inversus totalis, and discuss the radiological importance with the help of literature review of pathogenesis of this rare association. A 57-year-old woman was hospitalized with sudden onset of headache and nausea with a score on the Glasgow Coma Scale of 15 (E4V5M6). A computed tomography (CT) revealed subarachnoid hemorrhage. Routine chest X-ray on admission revealed dextrocardia. Serial angiography disclosed the right carotid artery and the right vertebral artery emanating directly from the aorta, and the left carotid artery and the left vertebral artery branching off from the left innominate artery (Fig. 1). The cannulation of the bilateral carotid and vertebral arteries was difficult due to this anomalous branching. Cerebral angiography showed a ruptured aneurysm of the right middle cerebral artery (Fig. 2).

Combined microsurgical and endovascular treatment of a giant left middle cerebral artery aneurysm

Giant fusiform aneurysms of the middle cerebral artery (MCA) bifurcation pose significant treatment challenges. A giant fusiform aneurysm of the left MCA in a pediatric patient, which persisted despite Hunterian...

Mediainfarkt nach Aneurysmacoiling

The report concerns a 44-year-old female patient with incidental left middle cerebral artery aneurysm. After endovascular therapy by coiling, a hemiparesis was observed following extubation. Disturbance of speech and disorientation added later. An infarct of the lenticular nucleus was found. The angiography showed an occlusion of a frontal opercular branch of the left middle cerebral artery. The fact-finding board for medical liability should investigate, if the infarct with continuous neurological deficits is explained by improper treatment and if the following management of complication was adequate. A neuroradiologic opinion was requested. Based on that, the board came to the result that no incorrect medical treatment was done.

De Novo Basilar Head Aneurysms -Two Case Reports-

We describe two rare cases of de novo basilar head aneurysms. The first patient presented with a ruptured basilar tip aneurysm, which developed de novo 5 years after the clipping of a left middle cerebral artery aneurysm. The second patient presented with a right basilar artery-superior cerebellar artery aneurysm, which developed de novo 3 years after the clipping of a right A(1) aneurysm. The formation of de novo aneurysm in the posterior circulation has significant implications for screening. Patients must be carefully examined not only at the sites of the initial aneurysm, but also at separate sites, including the posterior circulation, to evaluate the possibility of de novo appearance of another aneurysm.