Intracranial aneurysm as a possible complication of osteogenesis imperfecta: a case series and literature review.

Osteogenesis imperfecta (OI) is an inherited disease characterized by bone fragility due to impaired type I collagen. Although orthopedic management is improving, other complications are poorly understood. We describe three patients with OI with unruptured intracranial aneurysm (IA) detected by magnetic resonance angiography (MRA) screening of 14 patients. Case 1 was a 73-year-old woman with type 1 OI with blue sclera, vertebral compression fractures, and impaired hearing. Lumbar spine bone mineral density (BMD) was preserved (young adult mean (YAM): 86%). MRA revealed an IA in the right internal carotid artery. Case 2 was a 43-year-old man with type 4 OI and leg-length discrepancy due to left femoral neck fracture. Lumbar spine BMD was decreased (YAM: 61%). MRA showed an IA in the left anterior cerebral artery. Case 3 was a 35-year-old woman with type 3 OI with blue sclera, dentinogenesis imperfecta, deformity of the long bones, and severe scoliosis. She had undergone spine surgery and needed wheelchair assistance. The YAM of the femoral neck BMD was 71%. MRA indicated an IA in the right posterior communicating artery. The prevalence of IA in our series of patients with OI was 21%, which is higher than the reported prevalence of unruptured IA in the Japanese general population (2.2%), suggesting that IA may be a complication of OI. Our literature review revealed no cases of OI with unruptured IA, but 11 cases of OI with subarachnoid hemorrhage. IA seems unrelated to OI type, sex, or age. We recommend MRA of adults with OI.

Unlike severe periodontitis, caries does not associate with intracranial aneurysms or aneurysmal subarachnoid hemorrhage.

PURPOSE: Periodontal diseases and caries are common oral diseases that predispose to tooth loss if untreated. In this study, we investigated whether loss of teeth or caries associate with intracranial aneurysm (IA) pathology similar to periodontal diseases. METHODS: A total of 166 patients with either IA or aneurysmal subarachnoid hemorrhage (aSAH) underwent oral examination in Kuopio University Hospital and Tampere University Hospital. Findings were compared to geographically matched controls acquired from cross-sectional Health2000 survey. This study consisted of three sequential steps. First, we compared the number of missing teeth and prevalence of caries in IA and aSAH patients and geographically matched control population, second step was a multivariate analysis including other risk factors, and third step was a 13-year follow-up of the Health2000 survey participants with missing teeth or caries at baseline. RESULTS: Loss of teeth did not significantly differ between IA patients and controls. In logistic regression model adjusted for known risk factors and demographic data, 1-4 caries lesions (OR: 0.40 95%Cl 0.2-0.9, p = 0.031) was associated with lack of IAs, while age (OR: 1.03 95%Cl 1.01.1 p = 0.024), current smoking (OR: 2.7 95%Cl 1.4-5.1, p = 0.003), and severe periodontitis (OR: 5.99 95%Cl 2.6-13.8, p < 0.001) associated to IA formation. In the cox-regression, severe periodontitis at baseline increased the risk of aSAH (HR: 14.3, 95%Cl 1.5-135.9, p = 0.020) during a 13-year follow-up, while caries or missing teeth did not. CONCLUSION: Unlike severe periodontitis, caries does not increase the risk of IAs and aSAHs. However, cariogenic bacteria may participate to IA pathology by disseminating to circulation via inflamed gingival tissue.

Periodontitis and gingival bleeding associate with intracranial aneurysms and risk of aneurysmal subarachnoid hemorrhage.

Oral bacteria DNA has been found in intracranial aneurysms (IA) and a high prevalence of periodontitis was reported in IA patients. We investigated whether periodontitis associates with IA formation and aneurysmal subarachnoid hemorrhage (aSAH). First, we compared in a case-control setting the prevalence of periodontal disease in IA patients (42 unruptured IA, 34 ruptured IA) and in age- and gender-matched controls (n = 70) from the same geographical area (Health 2000 Survey, BRIF8901). Next, we investigated whether periodontitis at baseline associated with aSAH in a 13-year follow-up study of 5170 Health 2000 Survey participants. Follow-up data was obtained from national hospital discharge and cause of death registries. Univariate analysis, logistic regression, and Cox-regression were used. Periodontitis (≥ 4mm gingival pocket) and severe periodontitis (≥ 6mm gingival pocket) were found in 92% and 49% of IA patients respectively and associated with IAs (OR 5.3, 95%CI 1.1-25.9, p < 0.000 and OR 6.3, 95%CI 1.3-31.4, p < 0.001, respectively). Gingival bleeding had an even stronger association, especially if detected in 4-6 teeth sextants (OR 34.4, 95%CI 4.2-281.3). Severe periodontitis in ≥ 3 teeth or gingival bleeding in 4-6 teeth sextants at baseline increased the risk of aSAH during follow-up (HR 22.5, 95%CI 3.6-139.5, p = 0.001 and HR 8.3, 95%CI 1.5-46.1, p = 0.015, respectively). Association of periodontitis and gingival bleeding with risk of IA development and aSAH was independent of gender, smoking status, hypertension, or alcohol abuse. Periodontitis and gingival bleeding associate with increased risk for IA formation and eventual aSAH. Further epidemiological and mechanistic studies are indicated.

Onyx embolization of a ruptured anterior inferior cerebellar artery in a neonate.

Aneurysmal subarachnoid hemorrhage (SAH) is rare in neonates. The authors present a unique report of a neonate with SAH from anterior inferior cerebellar artery (AICA) aneurysm rupture that was successfully treated with Onyx embolization. This case report demonstrates the utility of Onyx embolization for posterior circulation aneurysms in neonates and the successful management of SAH in this population.

[A case of newly diagnosed moyamoya disease in a pregnant patient with a ruptured aneurysm of the distal anterior choroidal artery embolized using N-butyl cyanoacrylate].

Here we describe a rare case of a pregnant patient with a ruptured aneurysm of the distal anterior choroidal artery(AChA)that was embolized using n-butyl cyanoacrylate(NBCA). The 32-year-old patient was 24 weeks pregnant. She suddenly suffered from headache and vomiting. On admission, she was somnolent with left hemiparalysis and had a manual muscle test score of 1/5. Computed tomography(CT)images revealed a cerebral hemorrhage from the right temporal lobe to the lateral ventricle with intraventricular hemorrhage. Cerebral angiography showed severe stenosis at the terminal portion of the right internal carotid artery and a surrounding abnormal vascular network. She was diagnosed with unilateral moyamoya disease, and a direct surgical evacuation of the hemorrhage was performed on the same day. The following day, cerebral angiography showed enlargement of a distal AChA aneurysm that, as suspected, had caused the hemorrhage. The aneurysm was treated by the injection of 20% NBCA into the distal AChA and the aneurysm. After surgery, magnetic resonance imaging showed ischemic changes in the ventral posterolateral nucleus of the thalamus without neurological deficits. The patient became lucid, and the left hemiparalysis improved. The rest of the pregnancy was uneventful. At 37 weeks, she delivered a normal baby by elective caesarean section. When treating pregnant patients with moyamoya disease and a ruptured cerebral artery aneurysm, it is extremely important to cooperate with obstetricians to ensure a safe pregnancy and delivery.

Stent-assisted coil embolization of intracranial aneurysms using Solitaire stent.

OBJECTIVE: To report patients with intracranial wide-necked or complex aneurysms who underwent Solitaire stent-assisted coil embolization. MATERIALS AND METHODS: Retrospective analysis of 28 patients with intracranial wide-necked or complex aneurysms. Eighteen of the patients presented with an acute subarachnoid hemorrhage. Thirty-one aneurysms were treated with the support of different applications (n = 32) of the Solitaire AB stents followed by the standard coiling procedure (n = 30). RESULTS: Successful positioning of the remodeling device was obtained in all the cases. One stent required repositioning after full deployment. There were four thromboembolic complications (12.5%) and two hemorrhagic complications (6.25%), which caused three deaths. No permanent procedural morbidity was observed in the surviving patient. Angiographic results included 26 complete occlusions (83.9%), three neck remnants (9.7%) and two incomplete occlusions (6.4%). CONCLUSION: Although the initial technical and clinical results of Solitaire stent-assisted coiling of aneurysms was reported to be encouraging in recent reports, we had encountered higher thromboembolic and hemorrhagic complications in our patients.

[Elective cerebral arteriovenous malformation treatment with onyx after coil embolization of ruptured, flow-realeted aneurysm of the posterior circulation]. / Planowe endowaskularne leczenie malformacji t9tniczo-zylnej mózgu za pomocaa substancji typu Onyx, po embolizacji coilami peknietego przeplywozaleznego tetniaka krazenia tylnego mózgu.

Intracranial arteriovenous posterior circulation malformation was planned to embolize by onyx injection after acute coil embolization of ruptured flow-realeted aneurysm of posterior cerebral artery. Control angiography revealed completely embolized malformation with normal vessel patency at the end of procedure. There were no adverse events related to this procedure and no neurologic deficit at the discharge.

Rothia dentocariosa causing intracranial mycotic aneurysm and ischaemic stroke.

We describe a case of subacute bacterial endocarditis and mycotic brain aneurysm caused by Rothia dentocariosa due to untreated dental caries. R. dentocariosa is a rare cause of endocarditis that has a high incidence of aneurysmal and haemorrhagic complications. All patients with intracranial aneurysms who have signs of systemic infection should be considered to have mycotic aneurysms until proven otherwise. Dental habits should be included in regular medical assessment and dental care should be considered for patients presenting with infectious symptoms.

Evaluating the Safety and Efficacy of Various Endovascular Approaches for Treatment of Infectious Intracranial Aneurysms: A Systematic Review.

OBJECTIVE: A review of endovascular cerebral mycotic aneurysm treatment with Onyx liquid embolic, N-butyl-2-cyanoacrylate (NBCA), or coil embolization has not been reported. The authors conduct a systematic review on endovascular treatment methods of mycotic aneurysms. METHODS: A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2020. All studies assessing outcomes related to endovascular Onyx embolization, NBCA embolization, or coiling were included. RESULTS: A total of 73 studies were ultimately selected including 180 (67% male) patients comprising 243 aneurysms treated endovascularly. The mean age was 38.2 ± 17.6 years, and the most common symptom on presentation was headache (31%). Most aneurysms were located on the middle cerebral artery (52.5%), and over half presented with rupture (53.8%). Coiling was the most commonly employed technique (50.4%), and obliteration rates were comparable across coiling, NBCA, and Onyx (99.1%, 100%, 100%, respectively). Complication rates were also comparable (4.3% vs. 15.2% vs. 8.1%). CONCLUSIONS: Embolization for infectious intracranial aneurysm appears to be an effective treatment option for mycotic aneurysms. Embolization rates were comparable among coiling, NBCA, and Onyx embolization. Noninferiority among these modalities cannot be demonstrated given the retrospective nature of this review, evolution of endovascular techniques over the years, and changes in treatment paradigms in the past 2 decades. Ideally, further prospective research will be necessary to find which treatment method offers the lowest complication rates and the best outcomes for patients with mycotic aneurysms.

Flow diverter stents with hydrophilic polymer coating for the treatment of acutely ruptured aneurysms using single antiplatelet therapy: Preliminary experience.

BACKGROUND: The use of flow diverter stent (FDS) has limitations in cases of subarachnoid haemorrhage caused by ruptured aneurysm, due to the need for double antiplatelet therapy and the delay in the aneurysm occluding. The p48 MW and the p64 MW (Phenox) are available with Hydrophilic Polymer Coating (HPC), that reduces the risk of thrombus formation. Purpose of this study is to evaluate the safety and efficacy of p48 and p64 MW HPC with single antiplatelet therapy for the acute treatment of ruptured aneurysm. METHODS: We retrospectively evaluated all patients treated for acutely ruptured aneurysms with a p48 MW HPC or p64 MW HPC from October 2019 to April 2020 using single antiplatelet therapy. For each patient, we considered demographic and aneurysm-related data, clinical presentation, size and location of the implanted flow diverter stent, intra- and post-procedural complications, aneurysm occlusion. RESULTS: Seven patients were included. The ruptured aneurysms were four saccular, two blister-like and one dissecting, six in the anterior and one in posterior circulation. No intraprocedural stent thrombosis and rebleeding was observed. In two cases the aneurysm is completely excluded, in one patient it was found only neck perfusion, in three cases there were mild reduction of the sac and in one case there was a persistent perfusion. No patients needed retreatment in this series. CONCLUSION: In our experience, FDS HPC appears a potential treatment option in selected cases. Our study is limited by small population and short-term follow-up. We report our preliminary data, but further investigations are necessary.

Transvenous embolization for craniocervical junction epidural arteriovenous fistula with a pial feeder aneurysm.

Arteriovenous fistulas at the craniocervical junction are rare vascular malformations with frequent hemorrhagic presentations, which may have a concurrent pial feeder aneurysm. A 65-year-old man presented with subarachnoid hemorrhage and angiography showed an epidural arteriovenous fistula at the C-2 level with an anterior spinal feeder aneurysm without perimedullary venous drainage. Transarterial coil embolization of the ruptured aneurysm and partial Onyx embolization of the shunt led to thrombosis of the aneurysm. However, three years later angiography showed an increased shunt flow and recurrence of the aneurysm. Transvenous embolization of the shunt using coils and Onyx yielded complete obliteration of the shunt, thus leading to occlusion of the aneurysm. This case demonstrates that partial transarterial embolization of arteriovenous fistula leaves a risk of rebleeding, whereas complete obliteration of the shunt with a transvenous approach can lead to disappearance of the flow-related aneurysm without embolization of the aneurysm itself.

Orofacial neuralgia associated with a middle cerebral artery aneurysm.

Chronic orofacial pain of neuropathic origin can present diagnostic and management dilemmas to dental practitioners and also affects the patient's quality of life. Intracranial aneurysms are a potential cause of stroke (e.g. sub-arachnoid haemorrhage) that is usually associated with, high rates of mortality and morbidity. A patient who had been previously managed for symptoms of temporomandibular joint disorder (TMD) presented with sharp, shooting pain of moderate intensity. It was precipitated by swallowing, and radiated to the right throat, posterior border of the mandible, ear and temporomandibular joint. Clinical and radiological investigations ruled out odontogenic pain, TMD and other more common types of facial pain. Magnetic resonance imaging revealed a 7 × 6 mm aneurysm in the right middle cerebral artery (MCA) which was subsequently surgically clipped. Interestingly, the facial pain resolved after this procedure. Compression of the insular region of the brain innervated by the trigeminal, glossopharyngeal and vagus nerves provides a plausible explanation for the pain reported. To our knowledge, this is the first case of facial neuralgia associated with an aneurysm in the MCA which emphasizes the importance of a multidisciplinary approach in the diagnosis and management of unusual cases of chronic orofacial pain.

Curative embolization of cerebral arteriovenous malformations (AVMs) with Onyx in 101 patients.

INTRODUCTION: Onyx has emerged in the recent years as a new embolic material. We present our experience with Onyx in the curative embolization of brain cerebral arteriovenous malformations (AVMs). METHODS: We retrospectively reviewed the files of all patients that we had treated with Onyx embolic material for a brain AVM during the last 4 years. We identified 101 patients who underwent a total of 219 sessions of embolization. RESULTS: The treatment has been concluded in 52 patients; in this group, total occlusion was obtained in 28 (53.9%) patients and near-total occlusion was obtained in 18 (34.6%). The respective figures based on the 101 patients of the study cohort are 28/101 (27.7%) and 18/101 (17.8%). More embolization sessions are to be carried out on the remaining 49 patients. There were three deaths, and eight patients had permanent neurological deficits with a resulting morbidity of 8% and mortality of 3%. CONCLUSION: High rates of total or near-total occlusion of brain AVMs can be achieved with multiple sessions of Onyx embolization with acceptable morbidity and mortality.

Circumstances, activities, and events precipitating aneurysmal subarachnoid hemorrhage.

Medical records of 513 patients with aneurysmal subarachnoid hemorrhage were reviewed to analyze the factors precipitating aneurysmal rupture. There was no seasonal difference in incidence. A significantly higher incidence was observed during 6:00 AM to 9:00 AM and 6:00 PM to 9:00 PM when engaging in daily routines such as defecation/micturition, brushing teeth/washing face/dressing, eating/drinking, and taking a bath. These activities are associated with a Valsalva maneuver that results in sudden pressure changes across the aneurysmal wall precipitating aneurysmal rupture. Aneurysmal rupture occurred most frequently during talking, chatting, watching television, or staying home without any strenuous physical activity. Considering the time spent, the highest incidence rate was found during defecation/micturition. There was no significant difference between men and women or between younger and older age groups regarding activities or events preceding aneurysmal rupture. Hypertension was the most common pre-existing medical problem. The main results are the same as those of the previous study except for aging of the patients.

Ex-vivo release of Pipeline Embolization Device polytetrafluoroethylene (PTFE) sleeves for improved distal landing zone accuracy in-vivo: A technical note.

BACKGROUND: Distal landing zone accuracy is critical in some intracranial aneurysms treated with the Pipeline Embolization Device (PED), and delayed opening of the distal end of the device can complicate the procedure. Here, we report a technical nuance that facilitates accurate placement of the distal end of the PED by ex-vivo, pre-implantation release of the PED Flex polytetrafluoroethylene (PTFE) sleeves. TECHNICAL NOTE: The PED Flex is partially pushed out of the introducer sheath ex-vivo, pre-implantation until the distal PED opens entirely and the PTFE sleeves are located distal to the device. Without inverting the PTFE sleeves, the PED is carefully pulled back into the introducer sheath placing the PTFE sleeves inside the device. The PED is loaded into the microcatheter and advanced toward the site of implantation. When the PED is initially deployed and pushed out of the microcatheter, it opens immediately and provides an anchor for the remainder of the deployment process. We present a video (supplementary material) that illustrates the technique along with an illustrative case. CONCLUSION: Ex-vivo, pre-implantation release of the PTFE sleeves is an option in aneurysm treatment where distal landing accuracy is critical. Even without the protection of the PTFE sleeves, our clinical observation shows that the PED can be advanced safely through the microcatheter in selected cases.

Independent predictors of shunt-dependent normal pressure hydrocephalus after aneurysmal subarachnoid hemorrhage.

BACKGROUND: Normal pressure hydrocephalus frequently develops after subarachnoid hemorrhage. It can often be difficult, however, to predict shunt dependency. The purpose of this study was to identify predictors of shunt-dependent normal pressure hydrocephalus (SDNPH) after aneurysmal subarachnoid hemorrhage (aSAH). METHODS: The incidence of SDNPH in 139 consecutive patients who underwent surgery for aSAH in the Department of Neurosurgery Tokyo Medical and Dental University between January 2008 and December 2011 was evaluated. The patientage, Glasgow Coma Score, World Federation of Neurosurgical Societies grade, Hunt and Hess grade, modified Fisher group, modified Rankin Scale, duration of external drainage of cerebrospinal fluid (CSF), gender, aneurysm location, presence of intraventricular hemorrhage, surgical method (clip or coil), and presence of acute hydrocephalus were analyzed. RESULTS: Forty-seven of 139 patients (33.8%) underwent shunt operation. Fifteen of these 47 patients were assessed to have high-pressure hydrocephalus and excluded. Thirty-two SDNPH patients (23.0%) were compared with 84 patients without hydrocephalus (60.4%). An age of 65 years or over (OR 5.51;95%CI 1.97-15.40), a GCS of 13 or less (OR 3.82;95%CI 1.38-10.60), and CSF drainage for a duration of 12 days or more (OR 3.63;95%CI 1.30-10.14) were independently associated with SDNPH. CONCLUSIONS: SDNPH after aSAH in our study showed no correlations with three of the parameters previously identified as risk factors for shunt-dependent hydrocephalus, namely, the amount of SAH, the presence of IVH, or acute hydrocephalus. Instead, a longer duration of CSF drainage correlated with SDNPH as an independent factor. These data suggest that a longer duration of CSF drainage may be one of the risk factors for SDNPH after aSAH.

[Difficulties in microsurgical treatment of aneurysms after coiling]. / Trudnosci w mikrochirurgicznym leczeniu tetniaków tetnic mózgowych uprzednio zaopatrzonych spiralami (MDS).

BACKGROUND AND PURPOSE: The paper presents our own experience with microsurgical clipping of the cerebral aneurysms previously treated using endovascular techniques. MATERIAL AND METHODS: The presented clinical material consists of 3 patients treated in such a way. A group of 60 patients was embolized. An initial satisfactory effect of endovascular treatment was verified within 12 months of observation. Control radiological examinations--plane skull x-ray and cerebral angiography (DSA)--revealed coil displacement and recanalization of the aneurysm. In each case a surgical clipping of the aneurysms was performed. RESULTS: Proper clipping of previously coiled aneurysms sometimes presents a serious problem. Certain difficulties included rebuilding of the aneurysmal wall with a change of anatomical configuration in vessel ramifications. CONCLUSIONS: Qualification for endovascular treatment and the existing risk of introduction of additional coils into the aneurysm sac was discussed in connection with our observations. Problems concerning surgical treatment of initially embolized cerebral aneurysms were discussed and illustrated. Radiological monitoring of patients after endovascular treatment was proposed.

Massive hemoptysis due to Rasmussen aneurysm: detection with helicoidal CT angiography and successful steel coil embolization.

OBJECTIVE: To present the successful management of two cases of massive hemoptysis related to pulmonary aneurysms in patients with active tuberculosis. DESIGN AND SETTING: Retrospective study in the respiratory intensive care unit (ICU) of a university hospital. PATIENTS: Between July 1996 and January 2002, 46 cases of hemoptysis related to active tuberculosis needed ICU admission. In two cases, pulmonary aneurysm was the source of bleeding. RESULTS: Diagnosis was suspected on enhanced CT scan and confirmed by pulmonary angiograms. Transcatheter occlusion of pulmonary arterial circulation was successful. Both patients were alive at 1-year follow-up. CONCLUSIONS: Massive hemoptysis occurring in patients with active tuberculosis could arise from pulmonary aneurysms. In such cases, bronchial artery embolization is ineffective. Before referring those patients for emergency surgery, an alternative strategy using angiographic study and transcatheter occlusion of pulmonary arterial circulation might be of interest.

Endovascular treatment of experimental wide neck aneurysms: comparison of results using coils or cyanoacrylate with the assistance of an aneurysm neck bridge device.

BACKGROUND AND PURPOSE: Endovascular treatment of wide neck aneurysms often results in incomplete occlusion or aneurysm recurrence. The two goals of the present study were to compare results of coil embolization with or without the assistance of an aneurysm neck bridge device (ANBD) and to explore the use of this instrument to control cyanoacrylate embolization. METHODS: Wide necked bifurcation aneurysms were constructed in 28 dogs. Coil embolization of the aneurysms was performed 2 to 4 weeks later, with (n = 11) or without (n = 10) ANBD assistance. In seven other animals, embolization was performed with cyanoacrylate, injected under the protection of ANBDs. Angiographic results were compared immediately after and at 3 and 12 weeks. Neointima formation at the neck was also compared between groups at 12 weeks. RESULTS: Initial angiographic results and recurrences at 12 weeks were not significantly different in aneurysms coiled with or without ANBDs. Neointimal scores were also similar. The use of one ANBD at the neck was not sufficient to safely deliver cyanoacrylate into aneurysms. Cyanoacrylate embolization led to improved angiographic results (P =.05) and to better neointimal sealing of the neck of the aneurysms at 12 weeks (P =.004). CONCLUSION: ANBDs did not prevent recanalization and recurrences after coil embolization of wide neck aneurysms in this animal study. ANBD-assisted cyanoacrylate embolization was unsafe but could decrease recurrences at 12 weeks.

Distal lenticulostriate artery aneurysm rupture presenting as intraparenchymal hemorrhage: case report.

OBJECTIVE AND IMPORTANCE: Aneurysms involving the distal lenticulostriate artery branches are a rare cause of spontaneous intracerebral hemorrhage. We report a case of ruptured lenticulostriate aneurysm in an otherwise healthy patient and review the literature on this topic. CLINICAL PRESENTATION: Computed tomography showed a right basal ganglia hemorrhage in a 44-year-old Native American woman with acute left hemiparesis. Cerebral angiography showed a 2-mm aneurysm in a distal lenticulostriate artery branch. TECHNIQUE: A pterional craniotomy was performed on a delayed basis using computed tomographic angiography and frameless stereotactic guidance. The basal ganglia hematoma was evacuated, and the aneurysm was identified and clipped using microsurgical technique. Because the base of the aneurysm involved a portion of the parent vessel wall, it was wrapped with cotton and reinforced with cyanoacrylate glue. The patient did well after surgery and was discharged to home with outpatient rehabilitation on the third postoperative day. CONCLUSION: Although intraparenchymal hemorrhages are fairly common, the underlying vascular abnormality is rarely identified. Most are related to hypertensive vascular degeneration, rupture of a Charcot-Bouchard aneurysm, or both. When intracerebral hemorrhage occurs in young patients, however, aggressive investigation is warranted to rule out a structural vascular abnormality.