Endosaccular embolization for a ruptured distal anterior inferior cerebellar artery aneurysm.

We report a rare case of a ruptured distal anterior inferior cerebellar artery aneurysm that was successfully treated by endosaccular embolization, and review the literature on the results of endovascular surgery for this condition.

[A case of open head injury caused by electric saw].

A rare case of traumatic injury caused by an electric saw is herein described. A 75-year-old male patient was admitted to our hospital as an emergency patient. At the time of the patient's admission, he was fully conscious with no neurological deficits. Computed tomography revealed an intracerebral hematoma in the right frontal lobe, traumatic subarachnoid hemorrhage and pneumocephalus. Emergency surgery was performed at 4 hours 30 minutes after the injury. After a right frontal craniectomy, the intracerebral hematoma was completely evacuated. We applied sufficient debridement. The patient had neither intracranial infection nor vascular injury. We believe that the early operation for the sake of safety was therefore effective for this patient.

[Infectious aneurysm rerupture caused by delayed diagnosis: an operative case report].

A 21-year-old febrile woman with sudden onset of headache and semicoma was transferred to our institute. CT and 3D-CT angiography showed subaracnoid hemorrhage and intracranial hemorrhage in the left hemisphere due to a saccular aneurysm at the occluded M2 portion of the middle cerebral artery (MCA). Her present illness started with a toothache and lumber pain 3 weeks earlier. Echocardiography revealed active infective endocarditis. We could have treated her by administering antibiotics, but during a cerebral angiography, she became comatose due to an aneurismal rerupture. Immediately, an emergency operation for aneurismal trapping was performed, but she died 19 days later because of left hemispheric swelling. We report a relatively rare case of infectious aneurysm at the proximal artery and discuss the pitfalls of its diagnosis and treatment. We should educate general physicians about infectious endocarditis because misdiagnosis or delayed diagnosis of infectious aneurysm due to endocarditis results in unpleasant outcomes. We should treat infectious aneurysm at the proximal side artery by first administering antibiotics, and if necessary, subsequent direct surgery of the aneurismal trapping should be performed with a bypass. Unnecessary invasive treatment must be avoided while the disease is in the active infectious stage.

Age dependence of fusion of primary occipital sutures: a radiographic study.

PURPOSE: When linear lucency is present in the occipital bone on radiographs throughout childhood, differential diagnosis becomes important because some primary sutures are similar to fractures. The authors here chronicled the normal development of ossification centers, sutures, and synchondroses in the chondrocranium by radiographic examination. METHODS: One hundred and twenty-seven children, aged from newborns to 6 years and without any skull base deformities, were referred to for radiographs of Towne's projection. RESULTS: In the occipital bone at birth, three primary sutures could be identified. At the age of 0-3 years, occipital and innominate sutures started to fuse, this being complete by 4 years, whereas mendosal sutures persisted until 6 years of age, after which no primary sutures could be seen. CONCLUSION: The complex process of skull base development features a step-wise process sutural closure for which radiographic standards allow differential diagnosis from fractures with judgment of the timing.

Intracranial vertebral artery dissection with subarachnoid hemorrhage: clinical characteristics and outcomes in conservatively treated patients.

OBJECT: Intracranial vertebral artery (VA) dissection with subarachnoid hemorrhage is notorious for frequent rebleeding and a poor prognosis. Nevertheless, some patients survive with a good final outcome. The factors associated with the prognosis of this disease are not fully understood and appropriate treatment strategies continue to be debated. The authors retrospectively evaluated the clinical features of conservatively treated patients to elucidate the relationship between the clinical and angiographic characteristics of the disease and final outcomes. METHODS: This study includes 24 patients who were treated by conservative methods between 1990 and 2000. Conservative treatment was chosen because of delayed diagnosis, poor clinical condition, or anatomical features such as bilateral lesions and contralateral VA hypoplasia. Of nine patients with an admission Hunt and Kosnik Grade I or II, eight had good outcomes (mean follow-up period 8 years and 4 months). All 15 patients with Grade III, IV, or V died and in 10 of these the cause of death was rebleeding. Among the 24 patients, 14 suffered a total of 35 rebleeding episodes; in 10 (71.4%) of these 14 patients rebleeding occurred within 6 hours and in 13 (93%) within 24 hours. Compared with the survivors, there was a female preponderance (0.022) among patients who died. These patients also had significantly shorter intervals between onset and hospital admission (p = 0.0067), a higher admission Hunt and Kosnik grade (p = 0.0001), a higher incidence of prehospitalization (p = 0.0296) and postadmission (p = 0.0029) rebleeding episodes, and a higher incidence of angiographically confirmed pearl-and-string structure of the lesion (p = 0.0049). CONCLUSIONS: In our series of preselected patients, poor admission neurological grade, rebleeding episode(s), and lesions with a pearl-and-string structure were predictive of poor outcomes. Our findings indicate that patients with these characteristics may be candidates for aggressive attempts to prevent rebleeding during the acute stage. Patients without these characteristics may be good candidates for conservative treatment, especially those who survive the acute phase without rebleeding.

Dissecting aneurysm of the intracranial vertebral artery associated with proximal focal degeneration of the elastica: a comparative pathological study of the vertebral artery in patients with and without aneurysms.

BACKGROUND: The pathogenesis underlying intracranial dissecting aneurysms remains unclear. We performed a detailed study using vertebral artery specimens obtained at autopsy from patients with and without aneurysms to identify the primary abnormality resulting in weakness of the elastica. We compared our observations with those made in specimens manifesting the normal atherosclerotic process. METHODS: Using histologic methods, we examined intracranial vertebral artery specimens from two autopsied aneurysm patients and 13 autopsied control cases to compare the state of atherosclerosis and the weakness of the elastica at this aneurysm predilection site. RESULTS: Case 1: A 54-year-old woman with 2 dissecting aneurysms of the bilateral vertebral arteries (VA) who died from recurrent subarachnoid hemorrhage (SAH). Case 2: A 53-year-old woman who died from SAH. Microscopically, all 3 vertebral aneurysms were typical transmural dissecting aneurysms. They manifested areas of focal, severe degeneration of the elastic lamina and calcification at VA sites proximal to the aneurysms. These lesions could be differentiated from secondary changes attributable to the aneurysms because of their separate location only proximal to the site of aneurysmal rupture. Atherosclerotic changes were minimal in both cases. In the controls, the degenerative state of the elastic lamina of the VA reflected an atherosclerotic process. CONCLUSIONS: We postulate that focal degeneration of elastic tissue not involved in the atherosclerotic process was the vasculopathy resulting in aneurysm formation in our SAH cases.

Chronic cerebral venous hypertension model in rats.

Although cerebral venous hypertension is known as an important determinant factor for clinical manifestation and outcome in patients with dural arteriovenous malformation (AVM), the pathophysiology of that condition is not well understood. We have created a chronic rat model by cervical arteriovenous fistularization with jugular vein occlusion and examined effect of cerebral venous hypertension on cerebral blood flow regulation. This model may be suitable for investigating mechanisms of cerebrovascular alteration after venous hypertension.

Unusual accessory cranial sutures in pediatric head trauma--case report.

A one-year, 9-month-old boy presented with pediatric head trauma associated with unusual accessory cranial sutures. Radiography demonstrated unusual bilateral longitudinal linear bone defects extending from the foramen magnum to the mendosal sutures, and bilateral transverse linear bone defects around the foramen magnum. No swelling or soreness were found in the occipital area, and there was no past history of head trauma. Therefore, the bone defects were considered to be accessory cranial sutures. Complex developmental patterns of the occipital bone and the considerable normal variation of sutures may simulate fractures around the foramen magnum. The present case of accessory cranial sutures is another example.

Histologically classified venous angiomas of the brain: a controversy.

The term "venous angioma" (VA) usually refers to a developmental venous anomaly (DVA). However, a group of vascular malformations called VAs shows no venous abnormalities on angiography. The clinical and histological features of histologically classified VAs were studied in eight patients who presented with hemorrhage or seizures to reevaluate these venous anomalies. Angiography showed no venous abnormalities in six patients. Histological study included immunostaining for smooth muscle actin and glial fibrillary acidic protein. Surgical specimens of 10 cases of cavernous angiomas, 10 cases of arteriovenous malformations, and two cases of capillary telangiectasias were studied to compare these types of VAs. Angiographically occult VAs were surgically removed safely, whereas removal of DVAs was complicated by brain swelling and hemorrhagic infarction of the brain. Histological examination found angiographically occult VAs contained malformed and compactly arranged vessels with partly degenerated walls, whereas DVAs had dilated thin-walled vessels that were diffusely distributed in the normal white matter. This study of our cases and a review of the reported cases of VAs suggests that two different clinical and pathological entities are commonly categorized as "VA," angiographically occult VAs and DVAs. These two entities should be carefully distinguished.

Development of multiple cerebral arteriovenous malformations documented in an adult by serial angiography. Case report.

A 50-year-old woman with a parietal intracerebral hematoma was initially treated by hematoma evacuation. Initial preoperative and follow-up angiograms obtained 6 months later demonstrated no pial arteriovenous malformations (AVMs). She suffered a subarachnoid hemorrhage 8 years later. Results of follow-up cerebral angiography revealed the development of previously undetected multiple cerebral AVMs. This appears to be the first reported case of the development of multiple cerebral AVMs in an adult, demonstrated on serial angiography.

Successful stent placement for cervical artery dissection associated with the Ehlers-Danlos syndrome. Case report and review of the literature.

This 44-year-old man with Ehlers-Danlos syndrome (EDS) Type IV presented with hemiparesis and the Gerstmann syndrome. Left carotid artery (CA) angiography revealed a dissecting aneurysm with severe stenosis located in the common CA; the lesion was successfully treated with a stent graft. The patient's clinical course after endovascular surgery was uneventful, without occurrence of megacolon. The literature for spontaneous CA dissection in EDS Type IV cases is reviewed and points for investigation and treatment are discussed.