Migration of lipiodol into lateral ventricles after embolization of cerebral arteriovenous malformation: a case report.

N-butyl cyanoacrylate (NBCA) has been used to embolise brain arteriovenous malformations (AVMs) for over 30 years. It is a mixed with lipiodol in varying proportions. We report a 22-year-old male with intraventricular hemorrhage from a ruptured intranidal AVM aneurysm in the left temporal lobe. The intranidal aneurysm and the nidus were successfully embolized using a 20% NBCA and lipiodol mixture without any complications according to computed tomography (CT) immediately after treatment. Scattered high-density spots were observed in both lateral ventricles on CT 5 days after embolization, suggesting migration of lipiodol. We speculated that the aneurysm was a pseudoaneurysm whose wall protruded into the inferior horn of the left lateral ventricle, and the lipiodol in the NBCA migrated into the ventricles after the thin part of the wall ruptured. The patient developed pyrexia due to chemical meningitis, which responded to steroid treatment for one month.

Coadjuvant Treatment of Vasospasm in Ruptured Unsecured Cerebral Aneurysms with Aggressive Angioplasty, Intra-Arterial Nimodipine, and Aneurysm Embolization.

BACKGROUND: Vasospasm is a major cause of morbidity and mortality in patients after aneurysmal subarachnoid hemorrhage. Early treatment of ruptured aneurysms is advocated; delayed intervention complicates the treatment strategy leading to significant vasospasm and poor prognosis. We report an endovascular protocol for occlusion of the unsecured aneurysm and angioplasty for vasospasm in a single session. METHODS: Between January 2011 and May 2017, among 660 patients with aneurysmal subarachnoid hemorrhage, 24 patients with significant vasospasm and unsecured ruptured cerebral aneurysm were reviewed. Continuous nimodipine drip through a pressure line of the guiding catheter was set up. Aggressive angioplasty with a compliant balloon catheter either before or after embolization of the aneurysm in the major branches of vasospastic territory was performed. The goal was complete embolization of the aneurysm. RESULTS: Of 24 patients, 17 had ischemic symptoms at presentation, and the average delay from aneurysm rupture to presentation was 7.58 days. Angioplasty and nimodipine drip were performed on all patients. Severity of vasospasm was significantly reduced, and outcome improved in each patient. Two patients required a second angioplasty. In 20 patients, embolization of aneurysms was achieved without any aneurysmal sac or residual neck. Clinical outcome was good recovery (modified Rankin Scale score 0-2) in 23 patients (95.8%) and moderate disability in 1 patient (modified Rankin Scale score 3). CONCLUSIONS: Aggressive endovascular treatment of patients with unsecured ruptured cerebral aneurysm and associated vasospasm is safe and effective.

Paradoxical undressing associated with subarachnoid hemorrhage in a non-hypothermia case?

Paradoxical undressing is a phenomenon characterizing some fatal hypothermia cases. The victims, despite low environmental temperatures, paradoxically remove their clothes due to a sudden feeling of warmth. In this report, we describe a case of suspected paradoxical undressing in a non-hypothermia case. The victim, a 51-year-old Caucasian man, was found dead wearing only sneakers and socks. All other clothing was found in his car. Postmortem investigations allowed the hypothesis of hypothermia to be ruled out and revealed the presence of a ruptured cerebral aneurysm that caused a subarachnoid hemorrhage, the latter responsible for the death. The absence of any elements suggesting a voluntary undressing or any third party's DNA profile or involvement along with the possibility that the subarachnoid hemorrhage might have determined a hypothalamic injury, somehow rendered conceivable the hypothesis of an inappropriate feeling of warmth due to hemorrhage-induced dysregulation of the hypothalamic temperature-regulating centers.

A Case of Ruptured Aneurysm of the Proper Esophageal Artery with Symptomatic Mediastinal Hematoma.

Mediastinal aneurysms are rare but potentially life-threatening. Among these, bronchial artery aneurysms are most frequently reported, whereas up to now aneurysms of the proper esophageal artery had never been reported. A 69-year-old woman was referred to our hospital for treatment of a massive mediastinal hematoma. Enhanced computed tomography and selective proper esophageal arteriography revealed a 5-mm aneurysm in the proper esophageal artery that arises from the thoracic aorta at the Th8 level and has an anastomotic branch with the bronchial artery peripherally. Transcatheter arterial embolization was successfully performed using a mixture of N-butyl cyanoacrylate and lipiodol (1:3 ratio, 0.3 ml). Post-embolization angiography showed no filling into the aneurysm. The patient recovered with no complications and was discharged on the 25th post-procedure day.

Endovascular Therapy for Ruptured Cerebral Aneurysms in the Elderly: Poor Accessibility of the Guiding Catheter and Use of Local Anesthesia as the Predictors of Procedure-Related Rupture.

BACKGROUND: Endovascular therapy is favored for ruptured intracranial aneurysms in the elderly. However, poor accessibility to the aneurysm through the parent artery and use of local anesthesia in this age group may predispose to intraprocedural complications. OBJECTIVE: To evaluate whether age-related poor access to the ruptured target aneurysm and use of local anesthesia are associated with increased incidence of procedure-related rupture during endovascular embolization. METHODS: A total of 117 patients with 117 ruptured aneurysms underwent endovascular embolization at a single institution. Correlation of increasing age with poor accessibility of the guiding catheter was analyzed. In addition, the distance from the aneurysm to the guiding catheter was investigated to identify an association with incidence of procedure-related rupture. Correlation of local anesthesia with procedure-related rupture was also evaluated in the multivariable analysis. RESULTS: Increasing age was significantly associated with poor accessibility of the guiding catheter (P = .001, Mann-Whitney U test). Procedure-related rupture occurred in 9 of 117 aneurysms (7.7%). Longer distance between distal aneurysms and low-positioned guiding catheters carried a higher risk of procedure-related rupture than a shorter distance between proximal aneurysms and high-positioned guiding catheters (odds ratio, 19.3; 95% confidence interval, 1.84-201; P = .01, multivariable analysis). Use of local anesthesia was also a significant risk factor of procedure-related rupture by multivariable analysis. CONCLUSION: Increasing age was correlated with poor accessibility of the guiding catheter in endovascular embolization of ruptured intracranial aneurysms. Distally located aneurysms treated through a low-positioned guiding catheter and use of local anesthesia increased the risk of procedure-related rupture.

Angiography-assisted computed tomography for the detection and intervention of a subtle aneurysm of the omentum.

Intra-abdominal hemorrhage caused by omental artery rupture is a rare condition traditionally diagnosed via exploratory laparotomy in hemodynamically unstable patients. We experienced a case in which contrast-enhanced multidetector computed tomography (MDCT) and digital subtraction angiography did not identify the rupture site, whereas CT during left omental arteriography depicted a small 4-mm aneurysm. The lesion was then embolized with microcoils and N-butyl cyanoacrylate lipiodol glue. We consider that performing a CT during selective arteriography could be useful in cases in which the rupture site is unclear with other imaging techniques such as contrast-enhanced MDCT and digital subtraction angiography.

Acupuncture for cerebral vasospasm after subarachnoid hemorrhage: a retrospective case-control study.

OBJECTIVES: To examine the possibility of acupuncture as a new promising treatment to prevent delayed cerebral vasospasm, retrospective comparison was done of patient outcomes in patients with subarachnoid hemorrhage (SAH) treated with and without acupuncture. MATERIALS AND METHODS: Twenty (20) patients with SAH were treated after their ruptured aneurysms had been secured. Acupuncture treatments were applied to the bilateral Zusanli (ST36) and Neiguan (PC6) once a day for 2 weeks, starting within 3 days of the aneurysm rupture. The incidence of angiographic vasospasm and delayed ischemic neurological deficit (DIND), the patient's functional status at discharge, and mortality rate were analyzed. Patient outcomes were compared with those of an age- and severity-matched comparison group composed of patients treated in the hospital without acupuncture. RESULTS: None of the patients who received acupuncture died. Angiographic vasospasms occurred in 5 patients (25.0%) and DIND in 2 (10%). In terms of functional impairment, the modified Rankin score at discharge was ≤2 in 7 patients (35%). In the control group, angiographic vasospasms occurred in 10 patients (55.6%) and DIND in 7 (38.9%), similar to the reported incidence in conventionally treated patients. CONCLUSIONS: Patients with SAH who received acupuncture had a significantly lower incidence of DIND and significantly improved function at discharge, suggesting that acupuncture is effective in preventing cerebral vasospasm. In light of these promising results, a randomized controlled trial is warranted to determine the efficacy of acupuncture in a clinical setting.

N-butyl cyanoacrylate embolization for pseudoaneurysms complicating pancreatitis or pancreatectomy.

PURPOSE: To evaluate the clinical effectiveness and safety of transcatheter arterial embolization with n-butyl cyanoacrylate (NBCA) for pseudoaneurysms complicating pancreatitis or pancreatectomy. MATERIALS AND METHODS: Twelve procedures were performed in nine patients (seven men and two women; mean age, 60.6 years) for pseudoaneurysms that occurred secondary to pancreatitis or as a consequence of pancreatic juice leakage at the site of pancreatectomy. For embolization, NBCA was mixed with iodized oil at a ratio of 1:1-1:4; in one patient with failed selective catheterization of the target vessel, the mixture ratio was 1:9. Technical and clinical success rates, recurrent bleeding, procedural complications, serum amylase level, and clinical outcome were determined for each procedure. RESULTS: Embolization was technically successful in all procedures, with no recurrent bleeding documented from the initially treated territory. In three procedures, we encountered additional bleeding vessels at 11, 33, and 49 days after the procedures, which were successfully managed by a second embolization in each case. There were no major complications related to the procedures. As minor complications, in two procedures, the embolized material overflowed beyond the target vessels; however, no clinically significant ischemic events were observed in the embolized territories. Serum amylase did not increase compared with initial levels after any of the procedures. Seven patients were discharged after clinical improvement. Two patients died 2 and 3 weeks after the embolization as a result of multiple organ failure not associated with the procedure. CONCLUSIONS: In this limited series, NBCA embolization was found to be feasible and effective for pseudoaneurysms as a complication of pancreatitis or pancreatectomy.

Blood flow disturbance in perforating arteries attributable to aneurysm surgery.

OBJECT: The object of this study was to investigate patients with cerebral infarction in the area of the perforating arteries after aneurysm surgery. METHODS: The authors studied the incidence of cerebral infarction in 1043 patients using computed tomography or magnetic resonance imaging and the affected perforating arteries, clinical symptoms, prognosis, and operative maneuvers resulting in blood flow disturbance. RESULTS: Among 46 patients (4.4%) with infarction, the affected perforating arteries were the anterior choroidal artery (AChA) in nine patients, lenticulostriate artery (LSA) in nine patients, hypothalamic artery in two patients, posterior thalamoperforating artery in five patients, perforating artery of the vertebral artery (VA) in three patients, anterior thalamoperforating artery in nine patients, and recurrent artery of Heubner in nine patients. Sequelae persisted in 21 (45.7%) of the 46 patients; 13 (28.3%) had transient symptoms and 12 (26.1%) were asymptomatic. Sequelae developed in all patients with infarctions in perforating arteries in the area of the AChA, hypothalamic artery, or perforating artery of the VA; in four of five patients with posterior thalamoperforating artery involvement; and in two of nine with LSA involvement. The symptoms of anterior thalamoperforating artery infarction or recurrent artery of Heubner infarction were mild and/or transient. The operative maneuvers leading to blood flow disturbance in perforating arteries were aneurysmal neck clipping in 21 patients, temporary occlusion of the parent artery in nine patients, direct injury in seven patients, retraction in five patients, and trapping of the parent artery in four patients. CONCLUSIONS: The patency of the perforating artery cannot be determined by intraoperative microscopic inspection. Intraoperative motor evoked potential monitoring contributed to the detection of blood flow disturbance in the territory of the AChA and LSA.

Confirmation of blood flow in perforating arteries using fluorescein cerebral angiography during aneurysm surgery.

OBJECT: The authors performed fluorescein cerebral angiography in patients after aneurysm clip placement to confirm the patency of the parent artery, perforating artery, and other arteries around the aneurysm. METHODS: Twenty-three patients who underwent aneurysm surgery were studied. Aneurysms were located in the internal carotid artery in 12 patients, middle cerebral artery in six, anterior cerebral artery in three, basilar artery bifurcation in one, and junction of the vertebral artery (VA) and posterior inferior cerebellar artery in one. After aneurysm clip placement, the target arteries were illuminated using a beam from a blue light-emitting diode atop a 7-mm diameter pencil-type probe. In all patients, after intravenous administration of 5 ml of 10% fluorescein sodium, fluorescence in the vessels was clearly observed through a microscope and recorded on videotape. RESULTS: The excellent image quality and spatial resolution of the fluorescein angiography procedure facilitated intraoperative real-time assessment of the patency of the perforating arteries and branches near the aneurysm, including: 12 posterior communicating arteries; 12 anterior choroidal arteries; four lenticulostriate arteries; three recurrent arteries of Heubner; three hypothalamic arteries; one ophthalmic artery; one perforating artery arising from the VA; and one posterior thalamoperforating artery. All 23 patients experienced an uneventful postoperative course without clinical symptoms of perforating artery occlusion. CONCLUSIONS: Because the fluorescein angiography procedure described here allows intraoperative confirmation of the patency of perforating arteries located deep inside the surgical field, it can be practically used for preventing unexpected cerebral infarction during aneurysm surgery.

Does gender play a role in functional asymmetry of ventromedial prefrontal cortex?

We found previously in a lesion study that the right-sided sector of the ventromedial prefrontal cortices (VMPCs) was critical for social/emotional functioning and decision-making, whereas the left side appeared to be less important. It so happened that all but one of the subjects in that study were men, and the one woman did not fit the pattern very well. This prompted a follow-up investigation, in which we explored the following question: Does gender play a role in the development of defects in social conduct, emotional functioning and decision-making, following unilateral VMPC damage? We culled from our Patient Registry same-sex pairs of men or women patients who had comparable unilateral VMPC damage in either the left or right hemisphere. Two male pairs and one female pair were formed, and we included two additional women with unilateral right VMPC damage (8 patients in all). The domains of measurement covered social conduct, emotional processing and personality, and decision-making. We found a systematic effect of gender on the pattern of left-right asymmetry in VMPC. In men, there were severe defects following unilateral right VMPC damage, but not following left-sided damage. In women, there were defects following unilateral left VMPC damage; following right-sided damage, however, defects were mild or absent. The findings suggest that men and women may use different strategies to solve similar problems--e.g. men may use a more holistic, gestalt-type strategy, and women may use a more analytic, verbally-mediated strategy. Such differences could reflect asymmetric, gender-related differences in the neurobiology of left and right VMPC sectors.

Endovascular repair with bifurcated stent-grafts under local anaesthesia to improve outcome of ruptured aortoiliac aneurysms.

INTRODUCTION: acute haemodynamic changes and/or loss of abdominal muscle tone can occur during induction of general anaesthesia and may be the Achilles' tendon in endovascular aneurysm repair (EVAR) of ruptured aortoiliac aneurysms (rAIA). The purpose of this study was to evaluate the use of local anaesthesia (LA) for EVAR to overcome these limitations. METHODS: twenty-one consecutive patients with rAIA are included in this study. Twenty patients underwent EVAR under LA, and 1 patient was treated under general anaesthesia. Haemodynamics were stabilised during assessment of EVAR feasibility by CT-scan and during the procedure itself by controlled hypotension (MAP 50-60 mmHg) and moderate fluid resuscitation. RESULTS: median procedure time was 120 min. Haemodynamics remained stable in all but 3 patients who required transfemoral balloon occlusion of the supra-renal aorta. Perioperative intubation was necessary in 5 patients because of respiratory distress (n=3), or retroperitoneal access (n=2). Temporary deterioration of renal function occurred in 6 patients, with 2 requiring hemofiltration. CT-scan confirmed sealing of the rAIA in all patients at discharge. 30-day mortality was 9.5% (2 deaths). In the median follow-up of 19 months, there were no deaths, but 3 endovascularre-interventions, 1 crossover femoro-femoral bypass, and 1 open surgical graft repair. DISCUSSION: our series is the first to show that EVAR for rAIA can be safely performed under LA. This approach allows implantation of commercially available bifurcated SG and improves patient outcome.

Magnesium sulfate therapy after aneurysmal subarachnoid hemorrhage.

OBJECT: Vasospasm remains a significant source of neurological morbidity and mortality following aneurysmal subarachnoid hemorrhage (SAH), despite advances in current medical, surgical, and endovascular therapies. Magnesium sulfate therapy has been demonstrated to be both safe and effective in preventing neurological complications in obstetrical patients with eclampsia. Evidence obtained using experimental models of brain injury, cerebral ischemia, and SAH indicate that Mg may also have a role as a neuroprotective agent. The authors hypothesize that MgSO4 therapy is safe, feasible, and has a beneficial effect on vasospasm and, ultimately, on neurological outcome following aneurysmal SAH. METHODS: A prospective randomized single-blind clinical trial of high-dose MgSO4 therapy following aneurysmal SAH (Hunt and Hess Grades II-IV) was performed in 40 patients, who were enrolled within 72 hours following SAH and given intravenous MgSO4 or control solution for 10 days. Serum Mg++ levels were maintained in the 4 to 5.5 mg/dl range throughout the treatment period. Clinical management principles were the same between groups (including early use of surgery or endovascular treatment, followed by aggressive vasospasm prophylaxis and treatment). Daily transcranial Doppler (TCD) ultrasonographic recordings were obtained, and clinical outcomes were measured using the Glasgow Outcome Scale (GOS). The patients' GOS scores and the TCD recordings were analyzed using the independent t-test. Forty patients were enrolled in the study: 20 (15 female and five male patients) received treatment and 20 (11 female and nine male patients) comprised a control group. The mean ages of the patients in these groups were 46 and 51, respectively, and the mean clinical Hunt and Hess grades were 2.6 +/- 0.68 in the MgSO4 treatment group and 2.3 +/- 0.73 in the control group (mean +/- standard deviation [SD], p = 0.87). Fisher grades were similar in both groups. Mean middle cerebral artery velocities were 93 +/- 27 cm/second in MgSO4-treated patients and 102 +/- 34 cm/second in the control group (mean +/- SD, p = 0.41). Symptomatic vasospasm, confirmed by angiography, occurred in six of 20 patients receiving MgSO4 and in five of 16 patients receiving placebo. Mean GOS scores were 3.8 +/- 1.6 and 3.6 +/- 1.5 (mean +/- SD, p = 0.74) in the treatment and control groups, respectively. Significant adverse effects from treatment with MgSO4 did not occur. CONCLUSIONS: Administration of high-dose MgSO4 following aneurysmal SAH is safe, and steady Mg++ levels in the range of 4 to 5.5 mg/dl are easily maintained. This treatment does not interfere with neurological assessment, administration of anesthesia during surgery, or other aspects of clinical care. We observed a trend in which a higher percentage of patients obtained GOS scores of 4 or 5 in the group treated with MgSO4, but the trend did not reach a statistically significant level. A larger study is needed to evaluate this trend further.

Thalamic hematoma from a ruptured posterior cerebral artery aneurysm.

BACKGROUND: The location of parenchymal hemorrhage often indicates the site of the aneurysm in subarachnoid hemorrhage. CASE REPORT: We present the first case of a thalamus hematoma associated with a small ruptured (P1) posterior cerebral artery aneurysm with rapid washout of subarachnoid blood mimicking a ganglionic hemorrhage. CONCLUSION: Thalamus hematoma with subarachnoid hemorrhage points at a ruptured proximal posterior circulation aneurysm.

Anterior thalamoperforating artery aneurysm associated with internal carotid artery occlusion: case report.

OBJECTIVE AND IMPORTANCE: We describe a rare case of a ruptured distal anterior thalamoperforating artery aneurysm associated with right internal carotid artery occlusion. CLINICAL PRESENTATION: A 59-year-old woman experienced sudden occipital headache, vomiting, and subsequent coma as a result of massive intraventricular hemorrhage. An initial angiogram revealed only an occlusion of the right internal carotid artery just distal to the posterior communicating artery. Repeat angiography 1 month later, however, revealed a saccular aneurysm at a distal anterior thalamoperforating artery in addition to the occlusion of the internal carotid artery. INTERVENTION: We approached this aneurysm through the right temporal horn after opening the ambient cistern. The aneurysm, which was located in the brain parenchyma just medial to the temporal horn, was successfully resected. CONCLUSION: This rare aneurysm probably developed as a result of hemodynamic stress on the anterior thalamoperforating artery after occlusion of the internal carotid artery and/or secondary to chronic hypertension.

Intracerebral microdialysis of glutamate and aspartate in two vascular territories after aneurysmal subarachnoid hemorrhage.

Cerebral ischemia associated with subarachnoid hemorrhage may have severe consequences for neuronal functioning. The excitatory amino acid neurotransmitters glutamate and aspartate have been shown to be of particular importance for ischemia and ischemic neuronal damage. For seven patients who underwent early surgery for ruptured intracranial aneurysms, intracerebral microdialysis of glutamate and aspartate was performed to monitor local metabolic changes in the medial temporal (all seven patients) and subfrontal cortex (Patients 4 through 7). Samples were collected every 30 or 60 minutes, using an autosampler. The results show that extracellular glutamate and aspartate concentrations can rise to very high levels after surgery for subarachnoid hemorrhage and aneurysm. These increased levels of excitatory amino acids correlated well with the clinical course and neurological symptoms of the patients. Simultaneous sampling from two vascular territories (middle cerebral artery and anterior cerebral artery) also showed that a rise in extracellular glutamate and aspartate in one territory is not necessarily parallel with a rise in the other. The application of the microdialysis technique with an on-line assay system might be of value in the future for continuous monitoring of ischemic events to optimize treatment with, for example, blockers of glutamatergic neurotransmission.

[Endovascular treatment of cerebral aneurysms with selectively detachable platinum coils]. / Endovaskuläre Behandlung zerebraler arterieller Aneurysmen mit selektiv ablösbaren Platinspiralen.

In 14 patients (eight men, six women; mean age 58 [31-72] years) with intracranial aneurysm (basilar artery in nine, anterior branches in five) the aneurysm was occluded by electrically detachable platinum coils, advanced into the aneurysm introduced via a percutaneously introduced catheter system, under local anaesthesia and fluoroscopic control. Ten patients had acute subarachnoid haemorrhage (stage II-IV). In two patients several sessions were required before complete occlusion was achieved. In one patient, with a basilar artery aneurysm, the aneurysmal wall was perforated (angiographically demonstrated contrast-medium extravasation), but this remained clinically asymptomatic. There has been no recurrence or renewed bleeding during a follow-up period of 6-12 months. The method is a highly promising addition to the micro-neurosurgical treatment of such aneurysms. However, as long-term results are still awaited, indications for using the method should be strict and only those patients should be so treated in whom operation would be associated with a high risk or who are inoperable.