[Possible Cerebral Infarction due to Multiple Segmental Cerebral Vasospasms after Carotid Artery Stenting: A Case Report].

A 62-year-old man was admitted due to consciousness disturbance and motor aphasia. Magnetic resonance (MR) images demonstrated watershed infarctions in the territory of the left middle cerebral artery, occlusion of the left internal carotid artery, and severe stenosis of the right internal carotid artery at the neck. He was treated with a recombinant tissue plasminogen activator. One month later, angiography revealed recanalization of the left internal carotid artery with residual severe stenosis at the neck. We attempted carotid artery stenting (CAS) on the left internal carotid artery, but could not pass the guide wire through the stenosis. Therefore, we performed CAS on the right carotid artery instead. At the second day after CAS, the patient showed consciousness disturbance, right hemiparesis, and motor aphasia. MR images showed a new infarction in the left cerebral hemisphere and bilateral multifocal segmental arterial constrictions. By keeping his blood pressure at a high enough level for one week, his symptoms were relieved, and MR images showed resolution of the vessel constrictions. From this case, we can conclude that this kind of multiple segmental vasospasms after CAS require contrasting treatments to those for hyperperfusion syndrome. Interventionalists should be aware of this condition and its treatments.

[A clinical feature and therapeutic strategy in pituitary adenomas associated with intracranial aneurysms].

We studied the clinical feature and treatment strategy of pituitary adenomas associated with intracranial aneurysms. Among 102 pituitary adenoma patients (mean age: 54.8 years old) who received MR angiography and/or 3D-CT angiography, seven patients (6.9%) had intracranial aneurysms. The association of an aneurysm was more common in large size adenomas (p<0.05). According to the location of the aneurysms, five patients had these in the paraclinoid portion or cavernous portion of the internal carotid artery. Using MR images, we classified the aneurysms associated with pituitary adenomas as non-adjacent, adjacent, and intra-adenoma types. In non-adjacent types, an aneurysm is located apart from the adenoma, and has less chance of exposure during transsphenoidal surgery. In adjacent types, an aneurysm is located adjacent to the adenoma, and could be exposed during transsphenoidal surgery. In intra-adenoma types, an aneurysm is encased in the adenoma. In non-adjacent type aneurysms, a resection of the pituitary adenoma can be carried out before aneurysm treatment due to the low risk of rupture during surgery. In adjacent types, a tumor resection can precede aneurysm treatment in cases of low rupture risk aneurysms and untreatable aneurysms. In intra-adenoma types, adenoma resection should come after treatment of the aneurysms. Neurosurgeons should be careful about not only the presence of aneurysms in preoperative images during transsphenoidal surgery planning, but also their locations and proximity to adenomas. Such information may be crucial in deciding the order of treatment.