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Involvement of the anterior inferior cerebellar artery is the rarest form of posterior fossa aneurysm. A case is presented in which such a lesion was demonstrated angiographically by use of the submental-vertex view.A NEURYSMS of the anterior inferior cerebellar artery (AICA) ..t1.. are extremely rare; only 2 were discovered in a series of 7,933 intracranial aneurysms (4). Preoperative angiographic demonstration of the lesion has been described only once previously (8). The purpose of this report is to describe a second case and stress the importance of the base view in the angiographic localization of posterior fossa aneurysms. CASE REPORT R. B., a 41-year-old Caucasian woman had been in good health until the day of admission to Barnes Hospital. Her husband returned from work to find her semicomatose in bed with evidence of recent vomiting. At a local hospital a lumbar puncture examination revealed an opening pressure of 300 mm Hg and grossly bloody cerebrospinal fluid. NeuroradiologyOn admission, fundoscopic examination revealed bilateral papilledema with flame-shape hemorrhages. There was marked nucchal rigidity and the patient was lethargic and confused. Blood pressure was elevated to 170/90. Extensive right-side cranial nerve involvement was noted, with the right sixth through twelfth nerves affected. The deep tendon reflexes were diffusely hyperactive. Electrolytes and blood profile were normal as were the chest and skull radiographs.Right brachial angiography was performed with simultaneous anteroposterior (Fig. 1) and lateral (Fig. 2) filming. These views revealed an aneurysm lateral and posterior to the right vertebral artery but its origin could not be determined with certainty. A submental-vertex view was then obtained (Fig. 3), but the aneurysm was crossed by both the right anterior inferior cerebellar artery (AICA) and right posterior inferior cerebellar artery (PICA). For this reason, left brachial angiography was performed in the submental-vertex position (Fig. 4). Filling of the aneurysm was from the basilar artery and right AICA with no filling of the right PICA. Right cerebellar craniotomy was performed and a 0.5 X 0.3 X 0.5-cm aneurysm was discovered immediately below the origins of the right ninth and tenth cranial nerves with a thick dot surrounding the eleventh and twelfth nerves. The aneurysm was excised and the right AICA dipped, but not all of the adherent dot could be removed.A postoperative angiogram showed failure of the previous aneurysm to fill, with opacification of only the proximal 8 mm of the right AICA. Occlusion of the vessel at the point of dipping with retrograde propagation of clot was considered present. DISCUSSIONThe incidence of posterior fossa aneurysms has been reported as 8-12% of all intracranial aneurysms (l, 5, 8). Involvement of the AICA is the rarest of all posterior fossa aneurysms (1). Locksley's review of 7,933 aneurysms in 5,484 patients (4) in a cooperative study revealed only 2 in- Fig. 1. Anteroposterior view of the right brachial angiogram demonstrates a l...

insipidus complicating acute leukemia has been reported but rarely. In a comprehensive review Rosensweig and Kendall1 found 12 such cases, only one of which was in a child. The patient was recorded to have had acute granulocytic leukemia.2 Of the remaining 11 adult patients, only one had acute lymphocytic leukemia.3 This report presents the first well-documented case of diabetes insipidus complicating acute lymphocytic leukemia in a child. following one month of polyuria and polydipsia.She had first presented ten months earlier with fever, dyspnea, and chest pain at which time a left pleural effusion was noted radiographically. Thoracentesis followed by biopsy and examination of scalene and anterior mediastinal lymph nodes established a diagnosis of lymphocytic lymphoma. Other abnormal physical findings were lacking and there was no evidence of leukemic involvement in peripheral blood or bone marrow.Following local radiotherapy and intravenous¬ ly administered vincristine sulfate (0.05 mg/kg/ week, three doses), there was a therapy-free Adelbert Rd, Cleveland 44106 (Dr. Gross). remission lasting three months. She returned with left leg pain and a left abducens paresis. Bone marrow and cerebrospinal fluid (CSF) examinations revealed leukemic changes, but no abnormal cells were seen in the peripheral blood. An intravenous pyelogram showed bi¬ lateral renal cortical enlargement consistent with the presence of leukemic infiltrate. Exces¬ sive thirst and polyuria were not noted at that time. She was given a single dose of metho¬ trexate intrathecally (0.9 mg/kg) and eight weekly doses of methotrexate intravenously (30 mg/sq m body surface area), following which her symptoms resolved, although the CSF con¬ tinued to contain blast cells. Two months later, blast cells appeared in the peripheral blood, and oral treatment with mercaptopurine and predni¬ sone was begun (3 and 1 mg/kg/day respec¬ tively) . Two months later, excessive thirst, polydipsia, and polyuria were noted by her parents. Nocturia and nocturnal enuresis became prominent. Just prior to the child's admission to the Re¬ search Center, one 24-hour urine volume ex¬ ceeded 10 liters. Blast cells were again seen in the CSF and radiotherapy to the skull was be¬ gun. Radiographie examination of the skull re¬ vealed no distortion of the sella turcica. She remained on prednisone therapy, but vincristine sulfate (0.05 mg/kg/week) was substituted for mercaptopurine.At that time, she appeared slim and felt well. Pulse was 120 beats per minute, respiratory rate, 32 breaths per minute; and weight, 25 kg (55 lb 3 ounces). Her skin and mucous membranes were dry and skin turgor was moderately de¬ creased. Lymph nodes and spleen were not palpable, and the liver was not enlarged. Ab¬ normal neurological findings included a mild left abducens paresis, absence of the left ankle Downloaded From: http://archpedi.jamanetwork.com/ by a University of Pennsylvania User on 06/20/2015

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