A technique for reconstruction of a giant extracranial internal carotid artery aneurysm: A technical note.

Background: Surgery is effective for extracranial internal carotid artery (EICA) aneurysms. However, the risk of cranial nerve injury associated with surgical repair, such as graft-assisted resection and extracranial-intracranial bypass techniques, is relatively high. Here, we report two cases of surgical treatment for EICA aneurysms and describe the surgical techniques and strategies to avoid cranial nerve injury. Methods: Two patients presented to our facility with an increasing cervical pulsatile mass and no neurological symptoms. Angiography showed a large aneurysm in the cervical internal carotid artery. Surgical treatment was performed to prevent rupture of the aneurysm. In both patients, the aneurysm was strongly attached to the vagus nerve. The aneurysm and vagus nerve were carefully dissected using a low-power bipolar (20 Malis; 3 watts), leaving connective tissue on the vagus nerve side. Results: The aneurysm was detached from the vagus nerve without injury. Based on intraoperative findings, one patient underwent clipping, and the other underwent aneurysmectomy and primary closure for aneurysm obliteration and angioplasty. Both patients were discharged without any cranial nerve dysfunction. Conclusion: The selection of a strategy based on intraoperative findings and low-power bipolar cutting is important for the treatment of extracranial carotid artery aneurysms to preserve cranial nerves.

[Well Differentiated Liposarcoma of a Lung:Report of a Case].

A 61-year-old woman was referred for further evaluation of an intracystic nodule in her left upper lung. Computed tomography( CT) showed a 15 mm nodule in a pulmonary cyst adjacent to aortic arch and mediastinum. Fluorodeoxyglucose-positron emission tomography (FDG-PET)-CT showed little uptake of FDG in the lesion. No abnormality was found in the bronchoscopy findings. On imaging findings, the possibility of pulmonary aspergilloma was considered, but the serological findings were inconsistent, and surgical resection of the lesion was performed for both diagnosis and treatment. The final pathohistological diagnosis was well differentiated liposarcoma. No adjuvant therapy was performed and the patient has been well without recurrence for 2 years after the surgery. We report a rare case of well differentiated liposarcoma of a lung mimicking pulmonary aspergilloma.

Entrectinib Response to ROS1-Fusion-Positive Non-Small-Cell Lung Cancer That Progressed on Crizotinib with Leptomeningeal Metastasis: A Case Report.

Introduction: C-ros oncogene 1 (ROS1) translocation is an oncogenic driver-mutation identified in 1-2% of non-small-cell lung cancer (NSCLC) cases. Although crizotinib, a tyrosine kinase inhibitor (TKI) against ALK/ROS1, is known to be effective against ROS1-fusion-positive NSCLC, such cases sometimes progress with brain metastases. The most frequently reported crizotinib-resistance mutation is ROS1 G2032R, and some studies have found that even newly developed ROS1 TKIs, such as entrectinib and lorlatinib, show a decreased efficacy against it. The optimal therapies for ROS1-fusion-positive NSCLC and how such cases can be sequenced have not yet been established. Case Presentation: We herein report a patient with ROS1-fusion-positive NSCLC diagnosed at 34 years old. Crizotinib was started at the diagnosis and switched after 25 months to cisplatin/pemetrexed/bevacizumab once the disease progressed with multiple brain metastases that were resistant to stereotactic radiation therapy. The cytotoxic chemotherapy stabilized the patient's condition for 17 months until he developed leptomeningeal metastasis (LM). He underwent lumboperitoneal shunting and whole-brain radiotherapy, followed by crizotinib re-administration. Despite crizotinib treatment, his neurological symptoms, such as double vision, headache, weakness in the legs, and walking difficulties, progressed. Eventually, subsequent entrectinib treatment was initiated, which resolved all of the symptoms mentioned above. Regrettably, liquid next-generation sequencing had failed to detect the resistance mechanism due to minimal ctDNA in this case. Conclusion: These findings imply that sequential entrectinib administration may be effective in patients with disease progression limited to central nervous system metastases during crizotinib administration.

Association of PD-L1 tumor proportion score ≥20% with early resistance to osimertinib in patients with EGFR-mutated NSCLC.

BACKGROUND: The relationship between epidermal growth factor receptor tyrosine kinase inhibitor (EGFR-TKI) resistance, including osimertinib, and programmed cell death-ligand 1 (PD-L1) expression status in EGFR-mutated non-small cell lung carcinoma (NSCLC) remains unclear. PATIENTS AND METHODS: We retrospectively analyzed 64 patients with unresectable advanced or metastatic NSCLC carrying EGFR exon 19 deletions (ex19del) or EGFR exon 21 L858R substitutions (L858R) who received osimertinib as the first-line treatment. We compared progression-free survival (PFS) between eligible patients with PD-L1 tumor proportion scores (TPS) ≥20% and PD-L1 TPS <20% using the Kaplan-Meier survival plots with a log-rank test. Multivariate analysis was performed to examine the poor prognostic factors of PFS. RESULTS: The PD-L1 TPS ≥20% group included 22 cases (median [range] age: 70.5 [33-86] years; 10 women [45.5%]; 11 current or ex-smokers [50%]); ECOG performance status (PS) of 0-1/2/3/4 was noted in 16/4/1/1 patients, respectively. The PD-L1 TPS <20% group included 42 patients (median [range] age 73 [43-88] years; 29 women [69%]; 12 current or ex-smokers [28.6%]); ECOG PS of 0-1/2/3/4 was noted in 33/6/3/0 cases, respectively. The median PFS was 9.1 and 28.1 months in the PD-L1 TPS ≥20% and PD-L1 TPS <20% groups, respectively (log-rank p = 0.013). Multivariate analysis revealed that PD-L1 TPS ≥20% was associated with PFS (hazard ratio: 2.35, 95% confidence interval: 1.09-5.08, p = 0.030). CONCLUSION: PD-L1 TPS ≥20% in patients with EGFR-mutated NSCLC may be associated with early resistance to osimertinib.

A case of infectious intracranial aneurysm that formed and ruptured within a few days after occlusion of the proximal middle cerebral artery by infective endocarditis.

Background: Embolic cerebral infarction and infectious intracranial aneurysms (IIAs) are well-known central nervous system complications of infective endocarditis (IE). In this report, we describe a rare case of cerebral infarction caused by the occlusion of the M2 inferior trunk due to IE, followed by the rapid formation and rupture of IIA. Case Description: A 66-year-old woman was admitted to the hospital with a diagnosis of IE and embolic cerebral infarction after being brought to the emergency department with a 2-day history of fever and difficulty walking. After admission, she was immediately started on antibiotic therapy. Three days later, the patient suddenly became unconscious, and a head computed tomography (CT) scan showed massive cerebral hemorrhage and subarachnoid hemorrhage. Contrast-enhanced CT showed a 13-mm large aneurysm in the left middle cerebral artery (MCA) bifurcation. An emergency craniotomy was performed, and intraoperative findings revealed a pseudoaneurysm at the origin of the M2 superior trunk. Clipping was considered difficult, so trapping and internal decompression were performed. The patient died on the 11th day after surgery due to the worsening of her general condition. The pathology of the excised aneurysm was consistent with a pseudoaneurysm. Conclusion: IE may cause occlusion of the proximal MCA and rapid formation and rupture of IIA. It should be noted that the location of IIA may be a short distance away from the occlusion site.

Diagnostic and prognostic biomarkers for progressive fibrosing interstitial lung disease.

No biomarkers have been identified in bronchoalveolar lavage fluid (BALF) for predicting fibrosis progression or prognosis in progressive fibrosing interstitial lung disease (PF-ILD). We investigated BALF biomarkers for PF-ILD diagnosis and prognosis assessment. Overall, 120 patients with interstitial pneumonia who could be diagnosed with PF-ILD or non PF-ILD were enrolled in this retrospective study. PF-ILD was diagnosed according to Cottin's definition. All patients underwent bronchoscopy and BALF collection. We evaluated blood and BALF parameters, high-resolution computed tomography (HRCT) patterns, and spirometry data to identify factors influencing PF-ILD diagnosis and prognosis. On univariate logistic analysis, age, sex, the BALF white blood cell fraction (neutrophil, lymphocyte, eosinophil, and neutrophil-to-lymphocyte ratio), BALF flow cytometric analysis (CD8), and an idiopathic pulmonary fibrosis/usual interstitial pneumonia pattern on HRCT were correlated with PF-ILD diagnosis. Multivariate logistic regression analysis revealed that sex (male), age (cut-off 62 years, area under the curve [AUC] 0.67; sensitivity 0.80; specificity 0.47), white blood cell fraction in BALF (NLR, neutrophil, and lymphocyte), and CD8 in BALF (cut-off 34.2; AUC 0.66; sensitivity, 0.74; specificity, 0.62) were independent diagnostic predictors for PF-ILD. In BALF, the NLR (cut-off 8.70, AUC 0.62; sensitivity 0.62; specificity 0.70), neutrophil count (cut-off 3.0, AUC 0.59; sensitivity 0.57; specificity 0.63), and lymphocyte count (cut-off 42.0, AUC 0.63; sensitivity 0.77; specificity 0.53) were independent diagnostic predictors. In PF-ILD patients (n = 77), lactate dehydrogenase (cut-off 275, AUC 0.69; sensitivity 0.57; specificity 0.78), Krebs von den Lungen-6 (cut-off 1,140, AUC 0.74; sensitivity 0.71; specificity 0.76), baseline forced vital capacity (FVC) (cut-off 1.75 L, AUC 0.71; sensitivity, 0.93; specificity, 0.46), and BALF neutrophil ratio (cut-off 6.0, AUC 0.72; sensitivity 0.79; specificity 0.80) correlated with death within 3 years. The BALF cellular ratio, particularly the neutrophil ratio, correlated with the diagnosis and prognosis of PF-ILD. These findings may be useful in the management of patients with interstitial pneumonia.

Programmed cell death ligand 1 measurement study in granulocyte colony-stimulating factor-producing lung cancer: an observational study.

BACKGROUND: Granulocyte colony-stimulating factor (G-CSF)-producing lung cancer induces severe inflammation and a high white blood cell (WBC) count and is associated with poor prognosis. A recent case of G-CSF-producing lung adenocarcinoma showed high expression of programmed cell death ligand 1 (PD-L1) and was treated with pembrolizumab as first-line therapy, which was extremely effective. We hypothesized that G-CSF-producing lung cancers are associated with high PD-L1 expression. METHODS: This retrospective study included patients diagnosed with lung cancer at Yokohama Municipal Citizen's Hospital (Kanagawa, Japan) between 2009 and 2019. The PD-L1 status of 13 patients with high plasma G-CSF levels (≥40 pg/mL) was assessed by conducting immunohistochemical analysis of tissue samples. RESULTS: Of the total patients, 11 were men and 2 were women, with a median age of 74 years (70-85 years). Four, five, and three patients had adenocarcinoma, squamous cell carcinoma, and others, respectively. The median G-CSF level and WBC count were 85.5 pg/mL (range, 40.8-484 pg/mL) and 15,550/µL (range, 6,190-56,800/µL), respectively. The PD-L1 tumor proportion scores (TPSs) were ≥50%, 1%-49%, and <1% in 9, 1, and 3 patients, respectively. The median overall survival time was 7.3 months. Pembrolizumab was administered in six patients as first-line treatment, with two patients showing partial response, one patient with stable disease, and three patients with progressive disease. All six patients had a PD-L1 TPS of ≥50%. CONCLUSION: G-CSF-producing lung cancers may be associated with increased PD-L1 expression. Although immune checkpoint inhibitors are an important treatment option for G-CSF-producing tumors, their effects are limited.

Early Enteral Nutrition with High-Protein Whey Peptide Digestive Nutrients May Improve Prognosis in Subarachnoid Hemorrhage Patients.

Background and Objectives: Nutritional management in patients with subarachnoid hemorrhage (SAH) during the acute phase is important; however, there is no proper evidence or recommendations on the appropriate nutrients for early enteral nutrition. This study compared the influence the two different tube-feeding liquid diets for early enteral nutrition might have on the prognosis of patients with SAH. Materials and Methods: In a seven-year period, this single-center retrospective study included 245 patients with aneurysmal SAH who underwent craniotomy and aneurysm neck clipping and received enteral nutrition. The patients were divided into two groups according to the nutrient received: (1) high-protein whey peptide oligomeric formula diet (oligomeric group, 109 patients); and (2) high eicosapentaenoic acid-containing polymeric formula diet (polymeric group, 136 patients). The modified Rankin Scale (mRS) score at discharge was evaluated as the primary outcome. The presence or absence of diarrhea (watery stool and mushy stool) during the period from initiation of enteral nutrition to discharge from the stroke unit was also evaluated. Results: There were no significant differences in patient characteristics between groups. The time until initiation of enteral feeding in the oligomeric and polymeric groups was 2.8 ± 2.3 and 2.9 ± 2.2 days, respectively. The proportion of patients with mRS scores of 0-1 was significantly higher in the oligomeric group (25.7%) than in the polymeric group (14.7%) (p = 0.036), while the incidence of watery stool was significantly lower in the oligomeric group (15.8% to 34.3% in the polymeric group) (p = 0.003). Multivariate analyses confirmed that the oligomeric diet and the presence or absence of diarrhea significantly affected the mRS scores. Conclusions: The adoption of early enteral nutrition with high-protein whey peptide digestive nutrients might be associated with superior mRS scores at discharge and decreased diarrhea in patients with SA, indicating that the choice of nutrients might affect the outcome and prognosis.

Identification of Prognostic Factors in Surgically Treated Patients with Acute Epidural Hematoma.

CONTEXT: Only few comprehensive studies have investigated acute epidural hematoma (AEDH), and a low incidence of the lesion has been observed in comparison with other types of traumatic brain injuries such as subdural hematoma, traumatic subarachnoid hemorrhage, and contusion. AIM: This study aims to identify the prognostic factors of surgically treated AEDH. SETTINGS AND DESIGN: The medical records of 58 consecutive patients with surgically treated AEDH between September 2011 and 2018 were retrospectively reviewed. SUBJECTS AND METHODS: All patients were diagnosed with AEDHs using 5-mm-slice computed tomography (CT). Information regarding the following demographic and clinical characteristics was collected: age, sex, antithrombotic drug use, mechanisms of injury, time from onset to operation, neurological examination, vital signs, blood examination, and CT findings. STATISTICAL ANALYSIS USED: We analyzed prognostic factors in patients with AEDH using univariate and multivariate regression analyses. RESULTS: Univariate and multivariate regression analyses revealed that age (P < 0.01) and the Glasgow Coma Scale (GCS; P < 0.01) were independent predictive factors for good prognosis. In addition, receiver operating characteristics (ROC) analysis showed that an age of <55 years and a GCS score of >12 were optimal cutoff values for predicting good prognoses, with the areas under the ROC curve of 0.827 and 0.810, respectively. CONCLUSIONS: Age and GCS are useful predictors of prognosis in patients with surgically treated AEDH. These findings are appropriate prognostic indicators for urgent surgery performed to treat AEDH and intended to help clinicians make a prompt diagnosis.

Trans-lamina terminalis approach assisted by endovascular temporary basilar artery occlusion for high-positioned, recurrent, basilar tip aneurysm: A technical case report.

BACKGROUND: Coil embolization is increasingly becoming the surgical intervention of choice for cerebral aneurysms, particularly for those in the posterior circulation. However, in cases where it is difficult to perform coil embolization, microsurgical clipping is still required. CASE DESCRIPTION: We present a case of a high-positioned, ruptured, recurrent basilar tip aneurysm treated with a combination of microsurgical clipping through the trans-lamina terminalis approach and endovascular procedure. The technical considerations of this approach are discussed. CONCLUSION: Microsurgical clipping through the trans-lamina terminalis approach combined with an endovascular technique can be effective for basilar tip aneurysms. This approach is particularly useful for high-positioned, small, anterior projective aneurysms and cases with dilation of the third ventricle due to hydrocephalus or clot.

Predictors of subacute hematoma expansion requiring surgical evacuation after initial conservative treatment in patients with acute subdural hematoma.

BACKGROUND: The aim of this study was to clarify the factors associated with requiring subacute surgery in patients with acute subdural hematoma (ASDH) treated conservatively at admission. METHODS: Among the patients with ASDH admitted to our hospital from 2007 to 2018, we retrospectively reviewed data for 200 patients initially treated conservatively. We compared patients' characteristics, medical history, radiological findings, and clinical outcomes and differences between patients undergoing subacute surgery or no surgery. RESULTS: Of the 200 patients treated conservatively, 17 (8.5%) patients underwent subacute surgery due to deterioration of their clinical and/or computed tomography (CT) findings, while 183 (91.5%) patients did not undergo subacute surgery. There were significant differences in the presence of focal neurological deficits, modified Rankin Scale scores, degree of midline shift, hematoma thickness, hematoma volume, cella media index, Sylvian fissure ratio, and hematoma density between the two groups. CONCLUSIONS: Large hematoma, brain atrophy, and hematoma density may be useful predictors for the need for subacute surgery in patients with ASDH treated conservatively at admission. Intensive investigation of clinical findings or CT images is warranted in patients with adverse prognostic factors, even if their initial symptoms are mild.

Predictors of the Resolution of Cavernous Sinus Syndrome Caused by Large/Giant Cavernous Carotid Aneurysms After Parent Artery Occlusion with High-Flow Bypass.

OBJECTIVE: To evaluate the clinical results and factors related to the resolution of preoperative cranial neuropathy after internal carotid artery ligation with high-flow bypass in patients with symptomatic large or giant cavernous carotid aneurysms. METHODS: This study included 18 consecutive patients (15 women) with cranial neuropathy. All patients underwent therapeutic internal carotid artery ligation with high-flow bypass using a radial artery graft. Patient demographics, duration of symptoms, clinical outcomes, complications, and radiographic findings were retrospectively analyzed. The mean follow-up period was 31.0 months (range: 3-74 months). RESULTS: Patients' mean age was 66.6 years, and the mean aneurysm size was 23.7 mm. Six patients (33%) had partially thrombosed aneurysms. Preoperatively, 16 (89%) and 8 (44%) patients presented with ophthalmoplegia and facial pain, respectively. Bypass patency was confirmed in 15 patients (83%), and obliteration of the aneurysm was confirmed in all patients at the final follow-up. Preoperative ophthalmoplegia resolved in 10 patients (63%), and trigeminal pain resolved in all patients. Postoperative resolution of patients' ophthalmoplegia was significantly associated with age (P = 0.044), symptom duration before treatment (P = 0.042), and the degree of ophthalmoplegia (P = 0.046). The degree of postoperative residual ophthalmoplegia was positively correlated with the duration of ophthalmoplegia from onset to surgery (r = 0.619; P = 0.011). Preoperative trigeminal pain resolved regardless of the preoperative duration of this symptom in all patients. CONCLUSIONS: Early treatment is recommended when treating large or giant cavernous carotid aneurysms with cranial neuropathy. Complete resolution is possible in younger patients with partial neuropathy.

Factors related to improvement of cerebrovascular reserve after superficial temporal artery to middle cerebral artery anastomosis for patients with atherosclerotic steno-occlusive disease.

BACKGROUND: This study aimed to investigate factors related to improvement of hemodynamics and evaluated the usefulness of intraoperative Doppler for predicting postoperative hemodynamics in patients with cerebrovascular atherosclerotic steno-occlusive disease (CASD) of the internal carotid artery (ICA) or middle cerebral artery (MCA) who were treated with extracranial-intracranial (EC-IC) bypass surgery. METHOD: Forty-eight patients with CASD of the ICA or MCA who were treated by superficial temporal artery to middle cerebral artery bypass with a follow-up longer than 12 months were enrolled. Repeated transient ischemic attack or completed ischemic stroke was observed under optimal medical therapy in all patients. Intraoperative blood flow velocity of the MCA was evaluated by a Doppler flowmeter. Cerebral blood flow and cerebrovascular reserve (CVR) were evaluated using N-isopropyl-[123I] p-iodoamphetamine (IMP) single photon emission computed tomography (SPECT) preoperatively and 3 months after surgery. Imaging and clinical data were retrospectively reviewed. RESULTS: CVR was significantly increased postoperatively (p = 0.03). One year after the operation, two (4.2%) patients developed cerebral infarction. The change in MCA flow velocity just after anastomosis compared with pre-anastomosis proximal and distal of the anastomosis site was a median of 3.0 and 2.6 times, respectively. However, there was no significant association between changes in intraoperative MCA flow velocity and postoperative CVR. Multivariate analysis showed that the presence of a lower estimated glomerular filtration rate (eGFR) was an independent risk factor for a decrease in CVR (p = 0.036). CONCLUSIONS: A higher eGFR might have prognostic value for improvement in CVR after EC-IC bypass surgery in patients with CASD and misery perfusion.

Factors associated with early seizures after surgery of unruptured intracranial aneurysms.

OBJECTIVE: The aim of the study was to better define the incidence of and risk factors for early seizures after repair of unruptured intracranial aneurysms in modern microsurgical techniques. PATIENTS AND METHODS: The medical records of 414 consecutive patients who underwent neck clipping of unruptured intracranial aneurysms in our institution over a 5-year period were retrospectively reviewed. Clinical and neuroimaging variables were analyzed to investigate putative predictors of perioperative seizures using multivariate logistic regression analysis. RESULTS: Overall, 24 patients (5.8%) developed seizures within 14 days of surgery without routine prophylactic use of anticonvulsants. Eleven patients experienced partial seizures, while 13 experienced secondary generalized seizures. The interval between surgery and seizure onset was less than 6 h in 8 patients, 6-24 h in 3, and 1-14 days in 11. History of dialysis (odds ratio [OR] = 77.6, 95% confidence interval [CI] 7.5-1783.4, P < 0.001), and presence of cerebral contusion (OR = 5.1, 95% CI 1.3-16.9, P = 0.02) or infarction (OR = 13.9, 95% CI 3.9-48.5, P < 0.001) detected by postoperative computed tomography were independent and significant risk factors. No patients with early seizures went on to develop refractory epilepsy. CONCLUSIONS: Dialysis and iatrogenic brain damage were associated with a higher risk of early seizures after aneurysm surgery. Our data support the selective use of anticonvulsants during the perioperative period of elective aneurysm surgery.

Atypical postoperative radiographical findings in a patient with moyamoya disease: A case report.

Moyamoya disease is a chronic cerebrovascular disease characterized by spontaneous and progressive stenosis or occlusion of the internal carotid artery and its branches. Revascularization procedures have been shown to improve cerebral hemodynamics and decrease the risk of strokes, but several postoperative complications are known to occur.A 14-year-old girl with moyamoya disease with a history of left-sided revascularization surgery underwent right-sided revascularization. On postoperative day 4, she experienced a transient neurological event (left hemiparesis). Magnetic resonance imaging revealed large cortical and subcortical hyperintense lesions in the middle cerebral artery territory on diffusion-weighted imaging and apparent diffusion coefficient imaging. Subsequently, the radiographic findings improved within several days with resolution of the symptoms. This case is a reminder that hemodynamic complications can develop subacutely in patients who have undergone successful revascularization for moyamoya disease. The radiological features and mechanisms of this rare condition associated with revascularization surgery for moyamoya disease are discussed.

Results of Early High-Flow Bypass and Trapping for Ruptured Blood Blister-Like Aneurysms of the Internal Carotid Artery.

OBJECTIVE: The aim of this study is to clarify the efficacy and safety of early surgery using trapping of the affected internal carotid artery (ICA) and high-flow bypass between the second portion of the middle cerebral artery and cervical external carotid artery with radial artery graft for ruptured blood blister-like aneurysms (BBAs) arising from the anterior wall of the ICA. METHODS: Medical charts of 16 consecutive patients (7 men and 9 women; mean, 59 years) with subarachnoid hemorrhage (World Federation of Neurosurgical Societies grade I, n = 2; grade II, n = 5; grade III, n = 2; grade IV, n = 4; grade V, n = 3) caused by ruptured BBA surgically treated between July 2010 and October 2015 were retrospectively reviewed. Eleven patients underwent acute surgery within 24 hours after the onset, whereas surgery was performed between 3 and 17 days after the onset because of referral delay or associated vasospasm in 5 patients. All patients underwent the same surgical procedure. RESULTS: Elimination of the BBA and patency of the bypass were achieved in all patients. Postoperatively, 2 patients showed small infarction in the Heubner artery area, and 2 others suffered symptomatic vasospasm, but no patient suffered infarction in the posterior communicating/anterior choroidal artery territories. Identically, no patient showed ischemic optic neuropathy. At the last follow-up (mean, 36 months), favorable clinical outcome (good recovery or mild disability in Glasgow Outcome Scale) was achieved in 14 (88%) of the patients without rebleeding or refilling of the aneurysms. CONCLUSIONS: Early surgical repair of BBAs by trapping of the affected ICA with high-flow bypass is safe and effective treatment with satisfactory midterm outcome.

Oculomotor Nerve Palsy in a Patient with a Ruptured Middle Cerebral Artery Aneurysm.

We describe a case of acute oculomotor nerve palsy caused by a ruptured middle cerebral artery (MCA) aneurysm. A 59-year-old female presenting with headache and nausea was admitted to our hospital. Her consciousness was alert, and had no other neurological deficit without left oculomotor nerve palsy. A computed tomography (CT) showed SAH extending from left sylvian cistern to basal cistern. CT angiography revealed a left MCA aneurysm which protruded toward internal carotid artery. The patient was successfully treated with surgical clipping. The oculomotor nerve palsy resolved immediately after the surgery. Perioperative radiological evaluation revealed that there were no evidence of midbrain hemorrhage or stroke, vessel anomaly of basilar, posterior cerebral or superior cerebellar artery, vasospasm, and uncal herniation. Furthermore, intraoperative findings revealed that the aneurysm was projected toward the affected carotid cistern and oculomotor nerve. From these findings and time course of oculomotor nerve palsy, it is suggested that the jet flow of bleeding from the ruptured MCA aneurysm caused oculomotor nerve palsy in the patient. J. Med. Invest. 64: 165-167, February, 2017.

Ruptured posterior spinal artery aneurysm: intraoperative and histologic findings with appreciable thrombosis.

BACKGROUND CONTEXT: Little is known on the natural course of ruptured spinal artery aneurysm, and a treatment strategy remains to be elucidated. PURPOSE: This case report aims to describe a rare case of a posterior spinal artery aneurysm that showed progressive thrombosis following subarachnoid hemorrhage. STUDY DESIGN: This is a case report and literature review. METHODS: A 54-year-old man presented with subarachnoid hemorrhage due to posterior spinal artery aneurysm at the T10 level. The patient underwent surgery 19 days after onset. RESULTS: Most of the aneurysm appeared unenhanced on intraoperative indocyanine green video angiography, and total resection was performed. Histologic examination confirmed spontaneous thrombosis of the lesion. A review of the literature identified 19 cases of ruptured posterior spinal artery aneurysm. Thrombosed aneurysm and thrombosed parent artery were observed in 7 (44%) of the 16 cases treated with surgical or endovascular interventions. In the three cases treated conservatively, fatal rebleeding in the acute stage was noted in one case, whereas the lesion disappeared spontaneously in the chronic stage without rebleeding in two cases. CONCLUSIONS: Ruptured spinal artery aneurysms are prone to spontaneous thrombosis. The healing process of the lesion was well documented in the present case. Repeated angiographic follow-up offers a feasible alternative in the management of this fairly rare aneurysm.