A 19-year-old male presented with sudden onset of right hemiparesis caused by left cerebral hemorrhage. Cerebral angiography demonstrated no vascular abnormality, and the hematoma was removed surgically. At operation, no abnormal vascular lesion was found in the brain adjoining the hematoma. Two years later, magnetic resonance (MR) imaging demonstrated a few foci of flow voids adjacent to the hematoma cavity. Four years after the hemorrhage, MR imaging showed more extensive flow-void abnormalities that indicated growth of an occult arteriovenous malformation (AVM). Cerebral angiography indicated a definite AVM supplied mainly by branches of the middle cerebral artery. Total resection of this lesion was performed. The histological diagnosis was typical AVM. Immunohistochemistry with vascular endothelial growth factor showed staining in the walls of the abnormal vessels. Serial MR imaging is very useful for the diagnosis and management of occult AVMs.

A 30-year-old man presented with an aneurysm of the left posterior inferior cerebellar artery manifesting as subarachnoid hemorrhage and cerebellar infarction. Angiography demonstrated string-of-beads sign typical of fibromuscular dysplasia (FMD) in the extracranial carotid and vertebral arteries. The aneurysm and the parent artery were successfully embolized with Guglielmi detachable coils. Severe vasospasm developed 1 week after admission, and was treated several times by selective injection of vasodilator. A new aneurysm of the left external carotid artery became evident 1 month later, whereas only slight dilation had previously been apparent. This angiographic sequence demonstrated a new arterial dissection. Despite the possibility of damage to the artery during multiple catheterizations, arterial wall changes caused by FMD appear to have been primarily responsible. This case emphasizes the need for particular care in performing vascular interventional procedures in the presence of FMD.

A 35-year-old man developed osteosarcoma of the left parietal and occipital bones 16 years after radiotherapy for glioma in the right occipital lobe. Radiotherapy of the primary neoplasm used 50 Gy administered to a localized field through two lateral ports. The secondary neoplasm arose contralateral to the primary lesion but within the irradiated field. The tumor had a multilocular cyst with considerable intracranial extension, and symptoms of elevated intracranial pressure were prominent early in the course. After a short-lived initial remission following surgical intervention and chemotherapy, the patient deteriorated because of tumor recurrence and died 18 months after the diagnosis. Radiationinduced osteosarcoma is a well-known but rare complication of radiotherapy for brain neoplasms with a poor prognosis.

A 61-year-old male with hypertension presented with sudden onset of headache and nausea due to subarachnoid hemorrhage (SAH). He had two siblings with history of SAH due to ruptured intracranial aneurysms. Right carotid angiography on admission showed an anterior communicating artery aneurysm. At that time, the extracranial arteries were not examined. The aneurysm was clipped with no complications. A pulsating mass was palpable in the abdomen 37 days after the onset. Ultrasonography and computed tomography showed an abdominal aortic aneurysm with intraluminal thrombus, measuring 8 × 9 × 8 cm. Normal pressure hydrocephalus had already developed. The patient underwent elective abdominal aortic aneurysm resection before ventriculoperitoneal shunting. After shunting, he recovered fully. The present case indicates that unpredictable sudden enlargement of associated abdominal aortic aneurysm is possible in patients with ruptured intracranial aneurysms.

No abstract

No abstract

Background and purpose: Endovascular coil embolization is an acceptable first-line treatment modality for ruptured anterior communicating artery (AcoA) aneurysms. The management varies among institutions because the causes for selection of coil embolization include not only aneurysm morphology but also institutional factors. We assess our experience with a "coil first" policy and determine predictors of complications. In addition, we report our institutional factors. Materials and methods: We retrospectively analyzed 27 consecutive patients with a ruptured AcoA aneurysm who underwent coil embolization at our institution between August 2013 and July 2016. During this period, none of the patients had a crossover to clipping. More than half of the neurosurgeons at our institution had much more experience with coils than with clips.Results: Of the patients, 11 were women (40.7%). The mean age of the patients was 58.0 years. The overall clinical outcome was modified Rankin scale (mRS) score of 0-2 in 16 patients (59.3%), 3 or 4 in 4 (14.8%), and 5 or 6 in 7 (25.9%). Intraprocedural rupture (IPR) occurred in 4 patients whose aspect ratios (ARs) were <1.5. Of the 4 patients, 1 had a small basal outpouching (SBO) associated with IPR.Delayed rebleeding occurred 3 years after the initial coil embolization. Three patients underwent additional treatment without procedure-related complications. One of the recurrent aneurysms with a SBO was treated with clipping in the chronic stage.Conclusion: As worse outcomes are associated with IPR and delayed rebleeding, crossover to clipping in the case of AR of <1.5 or SBO may allow a safer obliteration in the acute stage. Intentional partial coil embolization followed with additional clipping in the chronic stage, however, may improve procedural safety.

An 84-year-old woman visited our hospital with gastrointestinal bleeding and was hospitalized for suspected colon cancer by abdominal CT. She had a history of atrial fibrillation and she had undergone aortic valve replacement. Warfarin was stopped because PT-INR was excessively prolonged. On the third day of hospitalization, she developed unconsciousness and left hemiplegia, and Magnetic resonance (MR) showed ischemia in the right putamen and corona radiata on diffusion-weighted imaging. MR angiography revealed occlusion of the right middle cerebral artery. T 2weighted imaging showed no susceptibility vessel sign (SVS). She underwent endovascular thrombectomy. As a result, complete recanalization was achieved and white thrombus was retrieved. The pathological diagnosis of the retrieved white thrombus proved that the clump was gram-positive cocci. The pathological examination disclosed the final diagnosis of the embolic stroke due to infective endocarditis, but not atrial fibrillation or malignancy. It is important to predict the characteristics of thrombus from SVS, and if white thrombus is collected, it need to be submitted for pathology.