Partially thrombosed middle cerebral artery-lenticulostriate artery aneurysm with native radiological examinations suggesting proximal lenticulostriate artery aneurysm: A case report.

BACKGROUND: Preservation of the lenticulostriate artery (LSA) is crucial. LSAs usually cannot be spared with LSA aneurysms, when surgical clipping/excision or endovascular embolization of the LSA itself is performed. On the other hand, the LSA should be separated and preserved for proximal middle cerebral artery (M1)-LSA aneurysms. CASE DESCRIPTION: We report a case of M1-LSA aneurysm with native radiological examinations suggesting LSA aneurysm. The highlight of this unusual case was that during surgery, the aneurysm orifice was almost covered with thrombus and blood flow in an aneurysm that appeared separate from M1. Partial thrombectomy-clip reconstruction was performed, and M1 and LSAs were well preserved. CONCLUSION: Even with currently developed radiological modalities, thrombosed intracranial aneurysms may be misdiagnosed, depending on intraluminal flow conditions. Intraoperative findings from craniotomy sometimes contribute to a better understanding of the pathophysiology and decisions on appropriate treatment strategy.

Ruptured Distal Medial Lenticulostriate Artery Aneurysm Treated With Transcortical-Transventricular Approach.

We report a case of a 48-year-old female who presented with abulia and headaches. Head CT (HCT) demonstrated a left caudate intracerebral hemorrhage (ICH) with extension into the left lateral ventricle. Diagnostic cerebral angiogram showed a left distal medial lenticulostriate artery (MLSA) aneurysm with remote left parietal Spetzler-Martin grade 3 arteriovenous malformation (AVM). The patient underwent an endoscope-assisted transcortical-transventricular approach to the distal MLSA aneurysm with complete excision and evacuation of the intraventricular hemorrhage (IVH) postoperatively; the patient had no further neurologic deficits and recovered well from her initial hemorrhage. Ruptured MLSA aneurysms are a very rare cause of spontaneous ICH. Urgent treatment of these aneurysms is needed to prevent further rebleeding. We present a novel operative technique utilizing an endoscope-assisted transcortical-transventricular approach to a ruptured distal MLSA aneurysm with successful excision of the aneurysm.

Endovascular Treatment of Distal Lenticulostriate Artery Aneurysm by Selective Catheterization of Artery with Balloon-Blocking Technique: 2-Dimensional Video Illustration.

We report the case of a 15-year-old male patient with polyarteritis nodosa who presented with ruptured lenticulostriate artery (LSA) aneurysm and was successfully treated with endovascular N-butyl-2-cyanoacrylate (Histoacryl, B. Braun, Melsungen, Germany) acrylic glue embolization. Selective catheterization of LSA is sometimes difficult even with a low-profile microcatheter (Magic 1.2 FM, Balt Extrusion, Montmorency, France) due to acute angulation at the origin of the artery. In this 2-dimensional video illustration of the roadmap in digital subtraction angiography, reproduced after informed consent of the patient, we illustrate the balloon blocking technique to safely and effectively navigate the microcatheter through the small perforator with difficult angulation at the origin. A Magic microcatheter was passed via a distal access catheter 070 (Concentric Medical, Mountain View, California, USA) 105 cm in the internal carotid artery. The Magic microcatheter advancement was supported with a 0.008-inch guidewire (Hybrid 008, Balt Extrusion, Montmorency, France). Initial catheterization of LSA even with a low-profile Magic microcatheter was difficult as the origin of LSA was acute angled. While trying the navigate the microcatheter into the perforator, it was continuously flopping into the distal M1 segment of the middle cerebral artery. The balloon microcatheter (Scepter XC 4 × 11mm, Microvention, Tustin, California, USA) was passed separately via 5 French Envoy guiding catheter (Codman, Raynham, Massachusetts, USA) 100 cm in the proximal ICA using a contralateral left femoral artery puncture. The Balloon microcatheter advancement into the middle cerebral artery was supported with a Traxcess 0.014-inch microguidewire (Microvention). It was then inflated just beyond the origin of LSA which provided support to the magic microcatheter and thus allowing its easy navigation into the LSA. Super-selective microcatheter injection confirmed filling of the LSA aneurysm. A dilute 33% concentration of the liquid embolic agent N-butyl-2-cyanoacrylate mixed with Lipiodol (Guerbet, Aulnay-sous-Bois, France) was injected slowly under direct vision. The final-check angiogram revealed complete occlusion of the aneurysm (Video 1). Patient underwent craniotomy and hematoma evacuation 1 day after the procedure in view of his rapidly deteriorating neurological status. He was later discharged with Modified Rankin Scale of 3. Follow up angiography after 3 months showed completely occluded aneurysm (Video 2).

Post-thrombolysis rupture of small lenticulostriate aneurysms: A report of 2 consecutive cases.

The 2018 American Heart Association/American Stroke Association (AHA/ASA) guidelines stated that the administration of intravenous recombinant tissue-type plasminogen activator (rTPA) for acute ischaemic stroke is probably safe for patients with small (i.e. <10 mm) unruptured intracranial aneurysms. We present 2 cases of small (2 and 5 mm) lenticulostriate artery (LSA) aneurysms which ruptured immediately following rtPA infusion. The ensuing acute intracranial haemorrhages resulted in the death of one patient and severe functional impairment for the other. Given the limited literature available, the natural history of LSA aneurysms is largely unknown. This report suggests that LSA aneurysms, regardless of size, be considered separately from other conventional aneurysms as "high-risk" lesions and a contraindication to thrombolysis.

Embolization of Ruptured Distal Lenticulostriate Artery Aneurysms.

OBJECTIVE: To describe the critical role of endovascular treatment and safety for the patients who presented with intraventricular hemorrhage owing to rupture of the distal lenticulostriate artery aneurysms. METHODS: Three patients who underwent endovascular treatment for distal lenticulostriate artery aneurysms related to intraventricular hemorrhage were selected and retrospectively reviewed. RESULTS: Patients were treated successfully using endovascular embolization without any complications. CONCLUSIONS: Endovascular therapy is available and safe as a treatment option for distal lateral lenticulostriate artery aneurysms.

The "Spot Sign" secondary to a ruptured lenticulostriate artery aneurysm.

The "Spot Sign" is a well-recognized radiographic predictor for hematoma expansion in patients with intracerebral hemorrhages. Although the exact underlying pathophysiology is unknown, it is generally assumed to be the site of blood vessel rupture and contrast extravasation. We report a case of an 81-year-old man who presented with right basal ganglia hemorrhage and the "Spot Sign" on computed tomography angiography. Conventional angiography subsequently revealed a lenticulostriate artery aneurysm within the hematoma, which was treated with surgical clipping. This case demonstrates that rare entities such as lenticulostriate aneurysms must be kept in the differential diagnoses in order to optimize patient management and improve clinical outcome.