We assess the usefulness of serial three-dimensional CT angiography (CTA) in the diagnosis of cerebral vasospasm (VS), and evaluate the contribution of VS to symptomatic vasospasm (SVS), cerebral infarction, and modified Rankin scale (mRS) in patients with aneurysmal subarachnoid hemorrhage (SAH). Within 3 hours after the onset of symptoms, CTA was performed in 48 patients with SAH. CTA was repeated on Day 5-8 (median 7) and Day 12-15 (median 14) to assess VS. Vasospasm was defined as ≥25% vascular narrowing, and rated with the following criteria (degree of VS): moderate spasm (25-50% decrease in vessel diameter), and severe spasm (≥50% decrease). Vasospasm was also categorized as follows (CTA grade): no VS, local VS, and diffuse VS. By local VS we mean an area of narrowing of the vessel in continuity with an aneurysm and not extending more than 2 cm to the aneurysm, or limited to the A-1, A -2 portion (≤2 cm). Diffuse VS means any stenosis affecting either a long segment of vessel or distal segments of cerebral arteries.Aggressive treatments for the VS including triple H therapy were started, when either SVS was revealed or Diffuse VS was detected on CTA. We statistically investigate correlations of Hunt and Kosnik grade, Fisher CT group, degree of VS, and CTA grade, with SVS, cerebral infarction, and mRS. Of the 48 patients, 32 (67%) showed VS and 19 (40%) revealed SVS by the 3rd CTA.Cerebral infarction on CT was detected in 13 (27%) patients. With logistic regression analysis, CTA grade significantly correlated with SVS and infarction, while Hunt and Kosnik grade and age of the patients significantly correlated with mRS.Prospective evaluation of CTA following SAH might allow early recognition of VS and promote aggressive treatment and improved neurological outcomes.
We describe a case of 58-year-old man who presented with a right internal carotid artery-anterior choroidal artery aneurysm. The patient hoped for the operation of clipping the unruptured aneurysm. His profound ischemia due to temporary occlusion of the anterior choroidal artery was clearly detected during surgery for the internal carotid artery-anterior choroidal artery aneurysm using motor-evoked potential (MEP). Reopening the anterior choroidal artery immediately recovered the MEP amplitude. Because the MEP would have disappeared due to clipping, only wrapping and coating was performed. The normal wrapping and coating material, Bemsheet ® , was used. Therefore, the postoperative course was good, and he left the hospital one week after the operation. However, about two months after the operation, he complained of a fever and staggering. A cerebral infarction in the anterior choroidal artery area was detected using MR imaging, and a right internal carotid artery stricture was detected using MRA. After he was hospitalized, the edema around the right basal ganglia infarction increased, and he developed left hemiparesis, sensory neglect, and disorientation. Vasculitis due to the Bemsheet ® was suspected. A steroid was administered. The fever was alleviated one week after the administration of the steroid, and the inflammation was improved. However, he did not recover from the left hemiparesis, and was transferred to a rehabilitation hospital. This case suggests that Bemsheet ® used when operating can cause an arterial occlusive lesion that is observed following aneurysm surgery, and a safer wrapping and coating material is necessary in the future.
Summary: Ruptured vertebral artery dissecting aneurysm (VADA) requires urgent treatment because of the high incidence of re-bleeding, especially during the first 24 hours. Among such cases lesions involving the origin of the posterior inferior cerebellar artery (PICA) are formidable because it is difficult to prevent rebleeding and preserve blood flow of the PICA in the acute stage.We report a representative case in which we tried a simple and effective therapeutic method for these cases. A 38-year-old man was admitted to our hospital suffering severe headache, vomiting, and loss of consciousness. CT scan revealed subarachnoid hemorrhage, but soon after, rebleeding occurred and he fell into a deep coma. After waiting until the chronic stage when he recovered, we performed cerebral angiography. A left vertebral angiogram demonstrated a dissecting aneurysm involving the origin of the PICA. We occluded the affected vertebral artery (VA) near its root with platinum coils, intending to introduce collateral blood flow from the deep cervical artery into the VA trunk. We thought the controlled antegrade VA flow and retrograde flow from the contralateral VA would make a watershed at the dissecting aneurysm, which promotes thrombosis of the pseudolumen while preserving the antegrade flow of the PICA. After treatment, the dissecting aneurysm disappeared on angiogram and the patient recovered without rebleeding or ischemic complication.This method should be considered as the treatment of choice in cases with VADA involving PICA.
A 65-year-old female presented with right oculomotor nerve palsy due to a large internal carotid artery (ICA) cavernous aneurysm. She underwent ligation of the right ICA with an external carotid artery to middle cerebral artery high-flow bypass (HFB). Although her postoperative course was uneventful, she developed a cerebral infarction at the right internal capsule 5 months after surgery. Cerebral angiography revealed a filling defect at the origin of the anterior choroidal artery. We sus
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