1/31. subarachnoid hemorrhage from vertebral artery dissecting aneurysms involving the origin of the posteroinferior cerebellar artery: report of two cases and review of the literature.OBJECTIVE AND IMPORTANCE: Few reports have been published on ruptured vertebral artery dissecting aneurysms in which the posteroinferior cerebellar artery (pica) arises from the aneurysm wall, and there is ongoing debate as to the proper management of this type of aneurysm. This article describes two patients. CLINICAL PRESENTATION: Both patients presented with subarachnoid hemorrhage and were admitted to our institution on the day of rupture. Computed tomography revealed that the subarachnoid hemorrhage was located mainly in the posterior fossa. cerebral angiography demonstrated a vertebral dissecting aneurysm involving the origin of the pica. In one patient, the pica was very large. INTERVENTION: One patient was treated by trapping, with the pica involved in the trapped segment. Postoperatively, the patient experienced transient mild hoarseness and dysphasia but recovered completely. The other patient, whose pica was very large, was initially treated by endovascular proximal occlusion. This resulted in marked enlargement of the distal part of the aneurysm, indicating a need for surgical treatment. A clip was applied to the origin of the pica after anastomosis of the occipital artery to the pica. The patient recovered well and was discharged with no neurological deficits. CONCLUSION: The ideal method of treatment for patients with dissecting aneurysms of the vertebral artery involving the pica origin is complete isolation of the aneurysm by trapping, with revascularization of the pica. However, trapping alone is one possible treatment option. If proximal clipping alone is carried out, follow-up angiography is mandatory to observe any changes in the aneurysm.- - - - - - - - - - ranking = 1keywords = subarachnoid (Clic here for more details about this article) |
2/31. Cerebellar hemorrhage after coil embolization for a ruptured vertebral dissecting aneurysm.BACKGROUND: We present a case of ruptured vertebral dissecting aneurysm that exhibited cerebellar hemorrhage after successful embolization of the vertebral artery including the dissected site. CASE PRESENTATION: A 59-year-old man suffered a sudden onset of severe occipital headache when he looked up. Computed tomography demonstrated subarachnoid hemorrhage. Angiography revealed a right vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery. Endovascular embolization of the aneurysm was performed with preservation of the posterior inferior cerebellar artery. The next day, the patient suffered a cerebellar hemorrhage in the vermis. The intracranial pressure was controlled by external ventricular drainage. The patient was discharged with mild cerebellar ataxia and bilateral abducens nerve palsy. CONCLUSION: In a case of vertebral dissecting aneurysm distal to the posterior inferior cerebellar artery, blood circulation in the vertebral arterial system may change after embolization of the aneurysm. In our case, the preserved posterior inferior cerebellar artery might have been hemodynamically stressed postoperatively, resulting in cerebellar hemorrhage. Therefore, strict control of blood pressure is essential in the acute stage after occlusion of the aneurysm.- - - - - - - - - - ranking = 0.5keywords = subarachnoid (Clic here for more details about this article) |
3/31. pathology of a dissecting intracranial aneurysm.The pathological findings of six autopsy cases of dissecting intracranial aneurysm are studied. Clinically, all cases exhibited systemic hypertension or left ventricular hypertrophy. Macroscopically, all cases exhibited rupture of the vertebral artery and subarachnoid hemorrhage. Two types of lesion were present. First, all cases showed the formation of a dilatated pseudoaneurysm with widespread disruption of the entire arterial wall, which was composed of thin adventitia. Second, a medial disruption of the arterial wall and subadventitial dissecting hemorrhage, which formed a false lumen and stenosis of the 'true' lumen of the artery, was also found. However, these lesions were found to be connected to the site of rupture. The autopsy cases within 1 day of onset of intracranial dissecting aneurysm showed the formation of fibrin thrombus, a marked degree of leukocyte infiltration and necrosis of the arterial wall at the site of the lesion. The cases that survived more than 1 week showed smooth muscle cell proliferation, macrophage accumulation and lymphocytic infiltration. No arteriosclerosis was found in any lesion studied. These data suggest that the disruption of the entire arterial wall might initially occur and cause medial disruption and subadventitial hemorrhage. hypertension and arteriosclerosis might function as causal and protective factors in the pathogenesis of dissecting intracranial aneurysms, respectively.- - - - - - - - - - ranking = 0.5keywords = subarachnoid (Clic here for more details about this article) |
4/31. Different roles of arteriosclerosis in the rupture of intracranial dissecting aneurysms.AIMS: Although intracranial dissecting aneurysm (IDA) is a newly described variant of the brain aneurysms that affects mainly the vertebrobasilar arterial system, its pathogenesis remains obscure. We aimed to clarify the role of arteriosclerosis in the pathogenesis of IDA based on histopathological findings in seven autopsy cases of IDA. methods AND RESULTS: All cases exhibited systemic hypertension or left ventricular hypertrophy. Macroscopically, all cases exhibited subarachnoid haemorrhage. Two types of dissection were recognized in the vertebral artery. Six of seven IDA cases showed a widespread disruption of the entire thickness of the arterial wall with the formation of a dilated pseudoaneurysm, which consisted of thin adventitia (arterial wall disruption type). Medial disruption of the arterial wall and subadventitial dissecting haemorrhage were also found, resulting in the formation of a false lumen and stenosis of the 'true' lumen of the artery. However, these lesions were connected to the site of rupture of the entire arterial wall. Within 1 day after onset of IDA, the autopsy cases showed formation of fibrin thrombus, marked leucocyte infiltration and necrosis of the arterial wall at the site of the lesion. Cases that survived more than 1 week showed smooth muscle cell proliferation, macrophage accumulation and lymphocytic infiltration in the lesions. These cases showed no atherosclerotic plaque, but non-atherosclerotic fibrocellular intima. The thickness of intima and media was significantly less in the vertebral artery of IDA patients than that of non-IDA patients with systemic hypertension. On the other hand, the remaining case showed severe atherosclerosis with haemorrhage into the lipid core without connection to the arterial lumen (intra-atheromatous plaque haemorrhage type). However, unusual arterioles and neovascularization of the intra-and peri-arterial walls were observed. CONCLUSIONS: Our results suggest that disruption of the entire arterial wall may be a critical event in the development of IDA and result in the medial disruption and subadventitial haemorrhage. Non-atheromatous intima might function as a protective factor in arterial wall disruption. On the other hand, atherosclerosis may predispose to intra-atheromatous plaque haemorrhage type of IDA through intramural haemorrhage originating from the newly formed vessels.- - - - - - - - - - ranking = 3.494320985509keywords = subarachnoid haemorrhage, subarachnoid, haemorrhage (Clic here for more details about this article) |
5/31. Pathological mechanism and three-dimensional structure of cerebral dissecting aneurysms.OBJECT: The goal of this study was to investigate the pathological mechanism and precise three-dimensional (3D) structure of cerebral dissecting aneurysms in association with their clinical course. methods: Nine aneurysm specimens were excised from eight patients. Of the nine aneurysms, seven arose from the vertebral artery, one from the anterior cerebral artery, and one from the superior cerebellar artery. Eight aneurysms were accompanied with subarachnoid hemorrhage (SAH) and one with infarction. Seven aneurysms were obtained at autopsy and two were obtained during surgery (trapping and bypass). All nine aneurysms were sectioned into serial axial slices measuring 5 to 10 microm in thickness. Taking each slice as an element, we reconstructed the 3D structure of the aneurysm. The true lumen communicated with a pseudolumen through the disrupted portion of the internal elastic lamina (IEL) in all nine aneurysms. The ruptured portion was located just above the disrupted IEL. Two aneurysms had an exit back into the true lumen. but the other seven had no such exit. CONCLUSIONS: The primary mechanism by which a cerebral dissecting aneurysm is created is by the sudden disruption of the IEL. The plane of dissection extends through the media. The majority of aneurysms have one entrance into the pseudolumen (entry-only type). This type is associated with an unstable clinical course. Some cerebral dissecting aneurysms have both an entrance and exit (entry-exit type). This type of aneurysm occasionally contains a constant flow of blood through the pseudolumen and is clinically more stable than entry-only aneurysms.- - - - - - - - - - ranking = 0.5keywords = subarachnoid (Clic here for more details about this article) |
6/31. A ruptured dissecting aneurysm of the vertebral artery: comparison of angiographic and histological findings.We present autopsy findings in a patient with a dissecting aneurysm of the vertebral artery causing subarachnoid haemorrhage. We sectioned the artery longitudinally and compared it with the angiogram, which showed the "pearl-and-string". Histological examination showed a pseudoaneurysm covered by adventitia alone, forming the "pearl". Internal elastic lamina and media were destroyed, and haematoma extended in the subadventitial space of the wall of the pseudoaneurysm. Media thickened by haematoma caused the "string", narrowing the parent artery. alcian blue staining showed that stratified internal elastic lamina in the aneurysm and the parent artery, had undergone marked mucoid degeneration, which may have been responsible for the dissection.- - - - - - - - - - ranking = 3.330525507369keywords = subarachnoid haemorrhage, subarachnoid, haemorrhage (Clic here for more details about this article) |
7/31. Intravascular graft stent treatment of a ruptured fusiform dissecting aneurysm of the intracranial vertebral artery: technical case report.OBJECTIVE AND IMPORTANCE: An innovative stenting technique to treat a difficult case of a fusiform aneurysm of the intracranial vertebral artery (VA), with restoration of the vessel lumen, is described. CLINICAL PRESENTATION: A 58-year-old patient experienced sudden pain in the upper cervical spine, followed by a severe headache. He underwent computed tomographic evaluation, which demonstrated subarachnoid hemorrhage in the prepontine cistern. A fusiform aneurysm of the distal right VA and critical stenosis of the left VA were detected in digital subtraction angiograms. The patient experienced a new subarachnoid hemorrhaging episode, and urgent endovascular treatment was planned. INTERVENTION: The patient underwent angioplastic and stenting procedures in the left VA, with good results. Forty-eight hours later, an endovascular procedure was performed to treat the right VA aneurysm. We decided to use a graft stent (Jostent graft stent; Jomed, Conroe, TX) instead of a balloon to preserve the arterial lumen. The complete procedure was well tolerated by the patient, and he was discharged, without symptoms, 48 hours later. CONCLUSION: The patient was discharged, without neurological deficits, 48 hours after completion of the endovascular procedure, with clopidogrel (75 mg/d) and aspirin (325 mg/d) therapy. This treatment was discontinued after 4 weeks. According to our search of the medical literature, this is the first clinical case in which an intracranial fusiform aneurysm was permanently sealed with a graft stent.- - - - - - - - - - ranking = 1keywords = subarachnoid (Clic here for more details about this article) |
8/31. The use of CT-angiography for monitoring thrombus formation after balloon occlusion of a dissecting vertebral artery pseudoaneurysm.We present a 49-year-old man with a subarachnoid haemorrhage from a dissecting vertebral artery (VA) pseudoaneurysm treated with a proximal balloon occlusion. The clinical course was complicated by the sudden appearance of a lateral medullary syndrome (Wallenberg), which completely resolved after anticoagulant therapy. During this course, CT-angiography (CTA) enabled monitoring of both the progression and partial resolution of the thrombus in the occluded VA. An anatomical variant of a perforating artery originating from the VA proximal to the posterior inferior cerebral artery (pica) was subsequently demonstrated, explaining the ischemic event. The value of CTA in clinical management is discussed. The prophylactic use of anticoagulant therapy especially in the case of a perforating artery to the lateral medulla originating proximally to the pica, is suggested.- - - - - - - - - - ranking = 3.330525507369keywords = subarachnoid haemorrhage, subarachnoid, haemorrhage (Clic here for more details about this article) |
9/31. Simultaneous dissection of intra- and extracranial vertebral artery. Report of two cases and review of literature.Two patients who developed subarachnoid haemorrhage are presented. The first patient was a 41-year-old woman whose angiograms showed right extracranial vertebral artery (VA) dissection starting at the C2 level extending to the intracranial VA near the VA union. Proximal occlusion of the right VA by the endovascular approach was performed. The second patient was a 57-year-old man whose angiograms showed the left intracranial VA dissection distal to the posterior inferior cerebellar artery and an extracranial aneurysmal dilatation of the left VA at the C1 level and extracranial VA dissection in the V3 portion of the right VA. Left intracranial VA dissection was surgically trapped, and the remaining lesions were conservatively treated.Simultaneous dissection of the intracranial and extracranial portions of the VA is rare. Such lesions usually cause brain ischaemia, but may cause intracranial subarachnoid haemorrhage.- - - - - - - - - - ranking = 6.6610510147381keywords = subarachnoid haemorrhage, subarachnoid, haemorrhage (Clic here for more details about this article) |
10/31. A case of segmental mediolytic arteriopathy involving both intracranial and intraabdominal arteries.Segmental mediolytic arteriopathy (SMA) is an uncommon nonatherosclerotic and nonvasculitic arteriopathy. This disease is characterized by lytic degeneration of the arterial media, intramural dissection and thrombosed or ruptured aneurysm. SMA mainly involves the intraabdominal arterial system, resulting in intraabdominal and retroperitoneal hemorrhage. However, only a few cases of SMA with involvement of intracranial arteries have been reported. Here, we present a case of SMA developing subarachnoid hemorrhage due to dissection of the internal carotid and vertebral arteries. This patient was a 48-year-old male who died 13 days after admission for sudden loss of consciousness. Computed tomography showed subarachnoid hemorrhage. At autopsy, the affected vessels included the right vertebral, left internal carotid, superior mesenteric, bilateral renal and left external iliac arteries. Histopathologically, the arteries showed segmental lytic degeneration and disappearance of medial smooth muscle cells, medial dissection and formation of pseudo-aneurysms, the wall of which consisted of a thin membrane of the adventitia. These histopathological features mimicked an entire wall dissection type of intracranial dissecting aneurysm, which exclusively affects the vertebro-basilar system. Thus, SMA should be considered a possible underlying disease in patients with spontaneous dissection of intracranial arteries.- - - - - - - - - - ranking = 1keywords = subarachnoid (Clic here for more details about this article) |
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