Left Supraclinoid Internal Carotid Artery Research Articles

Bilateral infraoptic origin of the anterior cerebral artery: illustrative case.

A bilateral infraoptic origin of the anterior cerebral arteries (ACAs) is a rare anatomical variant that can be encountered during anterior skull base surgery. The ACAs arise from the internal carotid artery (ICA) at the level of the ophthalmic artery and course medially, traveling inferior to the ipsilateral optic nerves. Herein, the authors discuss the different configurations of the anatomical variant, its prevalence, and hypotheses leading to the variable configuration of this anomaly. A 67-year-old woman presented with worsening dizziness over a week-long period and was found to have a large left sphenocavernous meningioma with optic, cavernous, and suprasellar extension. The tumor incorporated the left supraclinoid ICA and its branches. She underwent a left modified orbitozygomatic craniotomy for tumor resection. Early identification of the aberrant ACA anatomy was crucial in avoiding vascular injury. While this variant is typically encountered during the treatment of vascular pathologies-namely, intracranial aneurysms-its existence should be kept in mind during the treatment of any anterior skull base pathology. Failure to account for the presence of this variant may lead to potential intraoperative complications.

Abstract 213: Successful Mechanical Thrombectomy in Acute Stroke With Pre‐interventional Thrombolysis‐Induced Intracerebral Hemorrhage: Case Report

Introduction Intravenous thrombolytics (IVT) and mechanical thrombectomy (MT) have become the standards of care for treating patients with large vessel occlusion (LVO) acute ischemic strokes (AIS) [1‐4}. Intracerebral hemorrhage (ICH) is a main complication of IVT, with prevalence reported around 3.2% in a large multicentered meta‐analysis [2,6]. However, limited data remains about the safety and efficacy for patients to undergo MT with IVT associated pre‐interventional ICH as no randomized control trials or standard of care guidelines are available [2,4,5,7]. Methods NA Results 56‐yo male with history of alcohol abuse presented via EMS as a stroke alert with acute onset right hemiplegia, global aphasia, right facial droop, and leftward gaze preference two hours prior to arrival. RACE 10+ with NIHSS 24. No known history antiplatelet or anticoagulation use. Computerized Tomography (CT) Brain scan showed left middle cerebral artery (MCA) hyperdense sign with left insular cortical ribboning. CT angiography (CTA) showed near occlusive stenosis of the left carotid bulb with an acute thrombus within Supraclinoid Internal Carotid Artery (ICA) extending into the Left MCA and origin of Left Anterior Cerebral Artery (ACA). Patient was emergently administered IV‐tissue Plasminogen Activator (IV‐tPA) and taken for endovascular thrombectomy. During initial angiogram, after crossing the stenotic cervical bulb, the left Supraclinoid ICA and MCA occlusions were visualized. There was longitudinal partially occlusive thrombus extending from the M1 into the M2 divisions. No opacification of the inferior M2 branch was visualized, with perfusion deficit over the temporal, parietal and frontal regions. Additionally, extravasation of contrast was seen within the left basal ganglia region, concerning for hemorrhagic transformation from IV‐tPA. Reversal of IV‐tPA was initiated, and patient was given cryoprecipitate, platelets, and tranexamic acid. Decision to undergo MT was made secondary to severity of debilitating neurologic symptoms, age, and large perfusion deficit observed. He underwent single pass complete recanalization, TICI 2C using Stent retriever and aspiration. Left ICA stenting was not completed secondary to hemorrhagic transformation. Repeat CT Brain confirmed moderate left frontal lobe hemorrhage with vasogenic edema and 3mm left‐to‐right midline shift. No neurosurgical intervention required. Magnetic resonance imaging (MRI) Brain showed left cerebral hematoma with mass effect, acute infarct within left caudate nucleus, and minimal posterior cortical restricted diffusion without hemorrhagic conversion. Patient was monitored for 1 week with serial brain imaging. Patient was discharged on Aspirin 81 mg daily to inpatient rehabilitation with NIHSS 21, mRS 4 (0 prestroke). Today, in rehab he ambulates with walker with moderate expressive aphasia and right upper extremity weakness. Plan to follow‐up 2‐month post‐hospitalization for left ICA stenting. Conclusion While pre‐interventional IVT‐associated ICH in AIS with LVO are rare, few cases have been shown to have positive neurological outcomes [2,5,7]. We demonstrate a unique case of early identification of reperfusion hemorrhage on fluoroscopy with prompt reversal initiated. The decision to continue with MT based on downstream occlusion of basal ganglia hemorrhage not at further risk of expansion from reperfusion. The patient did well on follow‐up imaging despite the hemorrhage. Further randomized control clinical trials are required to establish best care guidelines, safety, and efficacy.

Blunt Traumatic Cerebrovascular Injury and Stroke: The Need for a High Index of Suspicion when Initial Vascular Imaging is Negative - A Single Center Case Series. (P14-5.019)

<h3>Objective:</h3> NA <h3>Background:</h3> Acute ischemic stroke (AIS) from traumatic cerebrovascular injury (TCVI) leads to approximately 4800 US strokes annually; often as sequelae of cervical arterial dissection. CT angiography (CTA) is typically used for screening, but this modality has limitations of low sensitivity, particularly for low-grade dissections. Our case series illustrates the importance of high index of suspicion in trauma patients to pursue further vessel imaging when there is unexplained AIS. <h3>Design/Methods:</h3> Case series. <h3>Results:</h3> Our series consists of 2 patients admitted to Trauma ICU following motor vehicle collisions. The 1st patient was a 22-year-old woman with left precentral gyrus infarction on diffusion-weighted MRI. Initial CTA showed dissection of cervical right internal carotid artery (ICA) which did not explain her infarction. Echocardiogram was also unrevealing so digital subtraction angiography was pursued, which revealed dissection of the left supraclinoid ICA not seen on CTA. The 2nd patient was a 15-year-old man with bilateral frontal infarctions on diffusion-weighted MRI. His initial CTA showed dissection of cervical left ICA. There was no explanation for his right frontal infarction on further workup so CTA was repeated after 4 days, which showed additional dissection involving the right cervical ICA not seen initially. Etiology of AIS in both cases was unexplained initially but repeat or alternate imaging helped unveil previously undetected ipsilateral dissections. <h3>Conclusions:</h3> Undetected traumatic dissection can result in devastating neurologic sequelae including further strokes and worsening dissection. It can also lead to unnecessary workup such as thrombophilia testing in younger patients. These patients are often hidden from the view of neurologists as they are typically managed by trauma surgeons and literature regarding TCVI is predominantly in surgical journals. We hope to increase awareness and emphasize the importance of a high index of suspicion to pursue further vessel imaging in unexplained stroke so that appropriate treatment can be initiated rapidly. <b>Disclosure:</b> Dr. Asif has nothing to disclose. Dr. Habib has nothing to disclose. Dr. Samkutty has nothing to disclose.

PMON129 Pituitary Adenoma Co-Secreting GH, Prolactin and ACTH

Abstract Background Pituitary adenomas co-secreting GH, Prolactin and ACTH are rare. Clinical Case A 38-year-old male with a past medical history of depression and type 2 diabetes mellitus was seen in the endocrinology clinic for an evaluation of acromegaly. In the preceding four years, the patient had experienced an enlargement of his hands and feet, hyperhidrosis, development of an underbite, snoring, daytime somnolence, erectile dysfunction, headaches, and blurry vision. His visual fields were normal. Physical exam: BP 137/85, BMI 39 kg/m2. He had coarse facial features, acral changes of his hands and feet, and wide spacing of his teeth. There was a notable absence of facial plethora, abdominal obesity with thin extremities, proximal muscle weakness, purple abdominal striae, and galactorrhea. Initial laboratory results: GH 16.9 ng/mL (0.05-3 ng/ml), IGF-1 1,109 ng/mL (82-242 ng/mL), Prolactin (PRL) 96.9 ng/ml (5-20 ng/ml), testosterone 34 ng/dL (200-1000 ng/dL), LH 2.3 miu/ml (1.4–12 miu/ml), FSH 4.8 miu/ml (1.5-12 miu /ml), ACTH 197.6 pg/mL (7.2- 63.3 pg/mL), 0800 cortisol 16.2 ug/dL (5-29 ug/dL), 24-hour urine free cortisol 56.84 mcg (3.5-40 mcg), HS salivary cortisol 0.242 (&amp;lt;0.359 ug/dL), overnight 1 mg Dexamethasone suppression test cortisol 6.9 mcg/dL (&amp;lt; 1.8 mcg/dL), normal Free T4 and TSH, and A1c 9.7%. A pituitary MRI revealed a 3.9 cm lobulated, intra and supra-sellar mass with mass effect on the optic chiasm and 75% encasement of the left supra-clinoid internal carotid artery. Neurosurgery performed an endoscopic, endonasal partial resection of the pituitary tumor. The histology was diagnostic of an adenoma, and immunohistochemical staining was positive for GH and PRL, but not ACTH. Post-op lab results: GH 1.07 ng/ml, IGF-1 353 ng/ml, PRL 9.6 ng/ml, testosterone 41 ng/dL, ACTH 68.2 pg/ml, cortisol 4.5 ug/dL, 24-hr urine free cortisol 8 mcg, HbA1c 5.7%. Discussion The intent of this case presentation is to report the rare finding of a pituitary tumor co-secreting GH, ACTH, and Prolactin. The diagnosis of acromegaly was confirmed by significant elevations of GH and IGF-1. The diagnosis of subclinical Cushing's disease was confirmed by elevated ACTH level, 24-hr urine free cortisol, and failed dexamethasone suppression test. The elevated PRL may have been due to tumor PRL secretion or stalk effect. The reduction of these parameters after surgery corroborated the presence of pleurihormonal secretion. This patient's findings support screening for co-secretion of multiple pituitary hormones in patients with acromegaly. Reference Pleurihormonal ACTH-GH Adenoma: Case Report and Systematic Literature Review World Neurosurg 2018 114: 158-164 Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

Acute Ischemic Stroke Caused by Detachment of Cardiac Papillary Fibroelastomas

Cardiac papillary fibroelastomas are associated with a high risk of systemic embolization in spite of benign nature. We report a case of 85-year-old patient with left supraclinoid internal carotid artery occlusion who treated with aspiration thrombectomy. Despite of the absence of residual mass on echocardiography, we could analyze pathologic specimens using retrieved embolus and confirmed cardiac papillary fibroelastoma as a rare cause of stroke.

Abstract 1122‐000165: Endovascular Intervention for a Thrombotic Adverse Event During Andexanet Alfa Infusion

Introduction : Andexanet alfa is the only specific reversal agent for factor Xa inhibitors and received FDA approval in 2018. Here we report an early infusion adverse event in a patient with acute intraventricular hemorrhage (IVH) that received Andexanet alfa, with an unfavorable outcome. Methods : A 73‐year‐old male presented to our emergency department (ED) after he developed sudden onset of severe headache without other associated neurological symptoms. An outpatient brain MRI showed IVH, that remained stable in size (2.4 cm3) on a follow‐up head CT performed in our ED. CT angiogram showed a 60% stenosis of the left supraclinoid internal carotid artery. The patient was taking apixaban 5 mg twice daily for atrial fibrillation (last dose 5.5 hours prior to presentation). Results : The anticoagulation was reversed with Andexanet alfa, 400 mg bolus given at 18:30, followed by 480 mg infusion over 2 hours started at 19:00 (12 hours from last apixaban dose). At 19:00, he developed left middle cerebral artery (MCA) ischemic stroke symptoms (global aphasia) that resolved with head‐of‐the‐bed flattening. CT perfusion demonstrated left ICA territory mismatch (342 ml) and 76 ml core. Shortly after CT perfusion, the patient developed a persistent complete left MCA stroke syndrome with NIH stroke scale (NIHSS) score 23. Decision was made to perform emergent cerebral angiogram which demonstrated a large, fresh thrombus in the left cervical ICA. Thrombectomy was successful with TICI score 2B. Patient’s neurological status initially improved. However, despite this intervention, patient developed a large territory infarct. As neurologic status remained poor, family withdrew care and patient died. Conclusions : ANNEXA‐A and ANNEXA‐R were parallel trials of Andexanet alfa for factor Xa inhibitor reversal that demonstrated a transient increase in prothrombotic factors post Andexanet alfa infusion. Neither of these phase 3 trials nor the previous phase 2 trials reported a clinical thrombotic event very early during the infusion. The ANNEXA‐4 trial (Phase 3) enrolled subjects with active major bleeding on a factor Xa inhibitor and 10% developed a thrombotic event during the 30‐day follow‐up period. 41% of the thrombotic complications were acute ischemic stroke (AIS), 35% (5 patients) experienced an AIS in the first six days post‐administration and the earliest reported thrombotic event occurred day 1 post infusion. Our case report illustrates an early cerebrovascular thrombotic event with dismal outcome despite timely and effective mechanical reperfusion therapy, which could be due to vessel re‐obstruction in setting of a hypercoagulable state. We aim to make vascular neurologists, neurointensivists and neurosurgeons aware of this possible occurrence when reversing patients with factor Xa‐related intracranial hemorrhages.

A Posterior Communicating Segment Aneurysm of the Supraclinoid Internal Carotid Artery Treated with an Extracranial to Intracranial Bypass and Trapping.

Surgical treatment of giant aneurysms often poses significant challenges. Endovascular techniques have evolved exponentially over the last decades, and most of these complex aneurysms can be treated with flow-diverting techniques; however, successful obliteration of all giant aneurysms is not always possible with endovascular flow-diverting techniques. Although the need for microsurgical intervention has undoubtedly diminished, a versatile-thinking surgeon should keep in mind that obliteration of these aneurysms combined with revascularizing the distal circulation via extracranial–intracranial bypass techniques can provide a potentially life-long durable solution. The key to curing these pathologies is to utilize interdisciplinary decision making with a robust knowledge of the pros and cons of different treatment approaches. Herein, we present a case of a giant posterior communicating segment aneurysm of the left supraclinoid internal carotid artery (ICA), which was treated by obliteration ( Fig. 1 ). Extradural anterior clinoidectomy was used to provide exposure of the supraclinoidal ICA proximal to the aneurysm, and revascularization of the distal circulation was achieved with a common carotid artery to M2-superior trunk bypass using a radial artery interposition graft ( Fig. 2 ). The patient was a 62-year-old female who presented with vision loss in her left eye but was otherwise neurologically intact. She had a history of two unsuccessful flow-diverting stent placement attempts 2 months prior to this surgery. Postoperatively, the patient woke up without any deficits, with her left eye vision partially recovered and ultimately returning to normal at 1-year follow-up. Computed tomography (CT) angiography at a 1-year follow-up showed complete obliteration of the aneurysm and successful revascularization of the distal circulation. The link to the video can be found at: https://youtu.be/DsIuIJJj1l4 .

Successful microsurgical treatment of intracranial aneurysms in infants: a retrospective study and literature review.

Intracranial aneurysms are extremely rare in infants, especially less than 1year old. This study aimed to analyze the frequency of infantile intracranial aneurysm in our department and investigate the clinical characteristics, treatment strategies, and outcomes of this disease. Six infants under 1year old in 4350 patients with intracranial aneurysms were retrospectively analyzed from January 2010 to December 2016. The patients (5 females and 1 male) ranged in age from 2 to 11 (mean age, 4.67) months. Four patients presented with generalized seizure and vomiting, 3 showed lethargy, 1 presented eye deviation, and 1 had right-sided hemiparesis. Radiographically, two aneurysms were localized in the middle cerebral artery (MCA) of the M2 segment, two were located in the M3 segment of MCA, one was located at left MCA bifurcation, and one was located at the nonbranching site of the left supraclinoid internal carotid artery. All these lesions were successfully managed with aneurysm clipping or resection, and the improvement of neurological deficits was achieved in all patients. Intracranial aneurysms should be considered in the differential diagnosis of infants who present with acute raised intracranial pressure. An improvement of neurological deficits is noted in infants who are managed promptly with microsurgical techniques of clipping during the long-term follow-up.

P-005 Evaluation of an Automatic Detection and Segmentation Tool for Flow Diverters (Pipeline™ Embolization Device) from C-arm CT Images

PurposeIn addition to stent-assisted coiling, endovascular treatment of intracranial aneurysms using flow diverters, like the Pipeline™ Embolization Device (PED), has become a viable treatment option. Visualization of the device after...

Sphenoid and Subdural Hemorrhage as a Presenting Sign of Ruptured Clinoid Aneurysm

Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage. Case report and review of the literature. We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence. Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.

E-010 Prolonged Neurologic Deterioration Following Acetazolamide Testing in the Acute Phase Following Ischaemic Stroke

BackgroundAcetazolamide induces cerebral vasodilatation and may be used to measure cerebrovascular reserve in patients with cerebral arteriopathy. While acetazolamide is known to induce transient neurologic deficits as a result of...

Supraclinoid internal carotid artery–inferior petrosal sinus arteriovenous fistula after high-voltage electrical burn injury

High-voltage electrical burns can cause immediate and long-term neurological and cerebrovascular injuries. The authors present a 21-year-old man who developed an intracranial arteriovenous fistula secondary to high-voltage electrical injury. CT angiography demonstrated a left supraclinoid internal carotid artery (ICA)–inferior petrosal sinus (IPS) fistula. A subsequent angiogram revealed an irregularity of the cavernous and supraclinoid ICA with stenosis involving the supraclinoid segment and a fistulous connection between the ICA and IPS distal to the ophthalmic take-off and proximal to the anterior choroidal artery. The patient underwent a decompressive hemicraniectomy and clip-wrapping of his ICA pseudoaneurysm with successful obliteration of the fistulous connection. To our knowledge, this is the first report of an intracranial arteriovenous fistula secondary to an electrical burn injury.

Complications Associated with Management of Aneurysmal Subarachnoid Hemorrhage in Patients with Fibromuscular Dysplasia: Case Report and Literature Review

Individuals with fibromuscular dysplasia (FMD) have a higher risk of developing cerebral aneurysms. When this subgroup of patients presents with aneurysmal subarachnoid hemorrhage, management of cerebral vasospasm can be particularly challenging, both because they may be more susceptible to developing refractory vasospasm and also because they are at a higher risk for extracranial vascular injury from treatment. A female with Hunt-Hess Grade-1, Fisher Grade-2 subarachnoid hemorrhage from a ruptured left supraclinoid internal carotid artery (ICA) aneurysm was incidentally diagnosed with FMD during angiography for endovascular treatment of the aneurysm. She developed severe cerebral vasospasm refractory to aggressive medical and endovascular therapy. Early during the course of her treatment, she developed a symptomatic ICA dissection with multiple small dissecting aneurysms from hypertensive therapy, requiring stent placement. During our management of this patient, a literature review demonstrated limited information regarding management strategies for these patients. Therefore, with this article we intend to convey our experience with potential complications from subarachnoid hemorrhage management in this subgroup of patients and to review the available literature regarding this topic.

Complications Associated with Management of Aneurysmal Subarachnoid Hemorrhage in Patients with Fibromuscular Dysplasia: Case Report and Literature Review

Individuals with fibromuscular dysplasia (FMD) have a higher risk of developing cerebral aneurysms. When this subgroup of patients presents with aneurysmal subarachnoid hemorrhage, management of cerebral vasospasm can be particularly challenging, both because they may be more susceptible to developing refractory vasospasm and also because they are at a higher risk for extracranial vascular injury from treatment. A female with Hunt-Hess Grade-1, Fisher Grade-2 subarachnoid hemorrhage from a ruptured left supraclinoid internal carotid artery (ICA) aneurysm was incidentally diagnosed with FMD during angiography for endovascular treatment of the aneurysm. She developed severe cerebral vasospasm refractory to aggressive medical and endovascular therapy. Early during the course of her treatment, she developed a symptomatic ICA dissection with multiple small dissecting aneurysms from hypertensive therapy, requiring stent placement. During our management of this patient, a literature review demonstrated limited information regarding management strategies for these patients. Therefore, with this article we intend to convey our experience with potential complications from subarachnoid hemorrhage management in this subgroup of patients and to review the available literature regarding this topic.

Endoscopic Extracapsular Removal of Pituitary Adenoma: The Importance of Pretreatment of an Adjacent Unruptured Internal Carotid Artery Aneurysm

The presence of an intracranial aneurysm together with a pituitary adenoma presents tremendous risk of subarachnoid hemorrhage, during transsphenoidal surgery, particularly when the aneurysm lies near the operative field. A left supraclinoid internal carotid artery aneurysm and a clinically nonfunctioning pituitary adenoma coexisted in a 57-year-old woman. Initially, the aneurysm was treated by endovascular coil placement, and then the patient underwent pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach. Pseudocapsule-based extracapsular total resection was safely performed, because of the extirpated risk of rupture of the coil-treated aneurysm. Recently, transsphenoidal pseudocapsule-based extracapsular resection approach for pituitary adenomas provides a more effective and safe alternative compared to the traditional intracapsular one because of its higher tumor removal and remission rates and lower recurrence rate. Compared with conventional subcapsular removal, pseudocapsule-based extracapsular resection has more risks of aneurysmal rupture that is located adjacent to pituitary adenoma. Thus, in a patient having a cerebral aneurysm with the proximity to the operative field, the cerebral aneurysm should be first treated with endovascular coil placement or direct surgical procedure; subsequently, pseudocapsule-based extracapsular resection of the pituitary tumor via a transnasal transsphenoidal endoscopic approach should be performed.

Reconstructive stent-buttressed coil embolization of a traumatic pseudoaneurysm of the supraclinoid internal carotid artery

It is critical that traumatic intracranial pseudoaneurysms should be removed completely from the parent artery because there is a possibility of significant morbidity and mortality from the high risk of rebleeding from any remnants of the pseudoaneurysm. However, the deconstruction of the parent artery has the risk of ischemic damage to the distal to the trapped artery. We describe a case of a successful reconstructive stent-buttressed coil embolization in a patient with a traumatic pseudoaneurysm of the intracranial internal carotid artery. A 30-year-old man with a stuporous mentality was admitted to our institution after a traffic accident. The initial computed tomography scan showed a diffuse subarachnoid hemorrhage and a pseudoaneurysm of the left supraclinoid internal carotid artery. A reconstructive endovascular treatment using stent-assisted coil embolization with a stent-within-a-stent technique was conducted in order to save carotid blood flow. The pseudoaneurysm was completely obliterated and the patient recovered without any neurological deficit. We suggest that multiple stent placements with coiling may be considered as a treatment option for intracranial traumatic pseudoaneurysms as a reconstructive treatment.

Fenestration of a Supraclinoid Internal Carotid Artery Associated With Dual Aneurysms: Case Report

We present a rare case of fenestration of the left supraclinoid intracranial internal carotid artery with 2 associated aneurysms arising proximally and distally from the fenestration that were successfully treated with endovascular coil embolization. This is the first report of these types of aneurysms treated with coiling alone. A 47-year-old woman underwent a diagnostic workup; magnetic resonance angiography incidentally revealed 2 tandem aneurysms at the supraclinoid and paraclinoid portion of the left internal carotid artery. Angiography revealed fenestration of the left supraclinoid internal carotid artery with 2 aneurysms both proximal and distal to the fenestration. The patient underwent endovascular coil embolization of the aneurysms simultaneously. The smaller trunk was intentionally occluded to achieve complete packing of the proximal aneurysm. Both aneurysms were totally occluded, and no neurological deficits developed in the patient. Based on previous reports, fenestration has the potential to form an aneurysm, and there seemed to be a relatively high incidence of rupture if accompanied by aneurysm. Coiling is one good option to treat aneurysms and should be considered when multiple aneurysms exist because all aneurysms can be treated simultaneously. Proximal occlusion of the smaller trunk is acceptable because of a retrograde flow from the distal end, even if one exists.

Congenital hypoplasia of the Internal Carotid Artery

A newborn presented at 14 hrs of age with right sided clonic seizures and shrill cry. Magnetic Resonance Imaging of the brain showed left cerebral hemiatrophy with cystic changes in left fronto-parietal lobe and parasylvian region. The Magnetic Resonance Angiography revealed hypoplasia of left supraclinoid Internal Carotid Artery and hypoplasia and irregularity of vessel wall affecting the left Middle Cerebral Artery. Such an early presentation of this rare disorder has not been reported previously. Recognition of this anomaly has important implications during carotid and trans-sphenoidal surgery, in thromboembolic disease, and in the surveillance and detection of associated cerebral aneurysms.

Giant intracranial aneurysm in a 9-year-old boy with tuberous sclerosis

A 9-year-old boy with tuberous sclerosis complex (TSC) (confirmed 1.4 kb deletion in the TSC2 gene) was referred for surgery of an intracranial aneurysm. MRI demonstrated a flow void and signal intensity typical of a giant aneurysm of the left intracranial carotid artery. Cortical tubers, subependymal nodules and white matter lesions characteristic of tuberous sclerosis were also seen. Conventional cerebral angiography demonstrated a partially thrombosed, giant (35-mm) saccular aneurysm of the left supraclinoid internal carotid artery (ICA) (Fig. 1). Vascular lesions (stenoses, ectasia, aneurysm) are not common in TSC and have been found predominantly in peripheral vessels. Intracerebral localization of aneurysms is extremely rare, the ICA being most frequently involved. Only 16 TSC patients with intracranial aneurysms have been described [1, 2]. Beltramello et al. [1] reported an 11-year-old patient with a giant right ICA aneurysm and reviewed 14 previously published cases. Jones et al. [2] reported a large aneurysm of the midbasilar artery in a 19-month-old patient treated by endovascular embolization. The association of TSC and aneurysms of intracranial arteries, especially the ICA, seems to be not incidental [1].

Cerebral Mycotic Aneurysms Treated with a Neuroform Stent: Technical Case Report

We describe the first documented endovascular treatment of proximal intracranial mycotic aneurysms by a self-expanding, flexible, dedicated, intracranial Neuroform stent. Treatment with this stent rapidly obliterated the aneurysms, eliminated the need for additional coiling, and maintained the patency of the parent arteries. A 47-year-old male patient with infective endocarditis presented with ischemic stroke and minimal subarachnoid hemorrhage. Cerebral angiography demonstrated a fusiform aneurysm of the supraclinoid segment of the left internal carotid artery and horizontal segment of the left middle cerebral artery, with superimposing side-wall focal aneurysms. Despite antibiotic therapy, the focal aneurysms progressively enlarged, as demonstrated on a subsequent cerebral angiogram at Day 11. A 4-mm x 2-cm Neuroform stent was deployed along the fusiform aneurysm of the left supraclinoid internal carotid artery and the horizontal middle cerebral artery M-1 segment encompassing the focal side-wall aneurysms with preserved patency of the parent arterial segments. Endovascular stent placement can be an effective treatment for proximal intracranial mycotic aneurysms that fail to respond to medical therapy.