A 75-year-old woman underwent Gamma Knife surgery (GKS) for a vestibular schwannoma. Eight years after GKS, she suffered sudden onset of headache. Computed tomography revealed diffuse subarachnoid hemorrhage around the cisterns of the posterior fossa. Right vertebral artery angiography showed an aneurysm arising from the lateral pontomedullary segment of the left anterior inferior cerebellar artery. The aneurysm was not located at a branching site. Trapping of the distal anterior inferior cerebellar artery aneurysm was performed, and the aneurysm was removed. The pathological features of this aneurysm are discussed. This aneurysm was diagnosed as a pseudoaneurysm pathologically. This is the first report of aneurysm formation with pathological findings following GKS for a vestibular schwannoma.
The clinical characteristics of intrasylvian and subpial hematomas caused by rupture of middle cerebral artery (MCA) aneurysm were examined in 86 patients admitted to our department with subarachnoid hemorrhage (SAH) caused by ruptured MCA aneurysms. A retrospective study of 26 patients with a large hematoma associated with SAH treated surgically within 48 hours evaluated clinical grade at admission, secondary development of cerebral swelling, ratio of hematoma removal, and incidence of symptomatic vasospasm. Clinical grade on admission, age, and sex showed no significant differences. Ratio of cerebral swelling against the initial hematoma volume (p = 0.005), and incidence of symptomatic vasospasm (p = 0.041) were significantly lower, and the ratio of hematoma was significantly higher (p = 0.01) in the subpial hematoma group. Removal of hematoma was more difficult and symptomatic vasospasm was more frequent in the intrasylvian hematoma group. The clinical features of subpial and intrasylvian hematomas caused by rupture of MCA aneurysm should be considered for the better management of associated SAH.
A 32-year-old man presented with subependymoma in the lateral ventricle causing intraventricular hemorrhage and manifesting as severe headache and disturbance of consciousness. Computed tomography on admission showed a massive intraventricular hemorrhage and acute obstructive hydrocephalus. Cerebral angiography revealed no abnormal findings. Emergency external ventricular drainage was performed, and his neurological deficits gradually improved. Magnetic resonance imaging at 5 weeks after admission showed a tumor arising from the septum pellucidum or the floor of the right lateral ventricle, appearing as a mixed-intensity solid tumor, which was partially enhanced following gadolinium administration. The tumor had arisen from the septum pellucidum and was totally removed via an interhemispheric anterior transcallosal approach. Histological examination found typical subependymoma, with little vascularity. Intraventricular hemorrhage from cerebral neoplasms is usually due to highly vascular tumors. Since subependymomas are quite benign and show poor vascularity, intraventricular or subarachnoid hemorrhages are very rare, but do occasionally occur.
Pial arteriovenous fistulas (AVFs) are known as rare cerebrovascular lesions. They are composed of >/= 1 arterial feeding vessels and a single draining vein that usually has high perfusion pressure and generally occur in infants. Cases involving adults are very rare and the developmental mechanisms and natural history of these lesions remain unknown. The authors present a case of multiple pial AVFs in an adult in whom the lesions developed after radiosurgical treatment of dural AVFs. Direct disconnection of pial arterial supplies was performed, and the abnormal shunts were successfully eliminated. The authors report the clinical course of this case and discuss the characteristics of and treatment strategy for multiple pial AVFs, reviewing the published literature.
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