Mimicking aneurysm in a patient with chronic occlusion of the left middle cerebral artery

The chronic occlusion of intracranial arteries generally has no or mild clinical symptoms,and the clinical symptoms of acute cerebral artery occlusion are mostly manifested as severe cerebral infarction symptoms,which often make early diagnosis difficult,thus losing the best treatment opportunity.Once cerebral infarction occurs,the consequences are difficult to recover.This is also an important reason for the high misdiagnosis rate and mortality of this disease.In this paper,the characteristics of the disease were analyzed to provide clinical reference.

Prenatal Diagnosis of an Apically Located Congenital Left Ventricular Aneurysm: A Rare Case

Congenital ventricular aneurysm is a very rare cardiac anomaly.A diagnosis can be made during the prenatal period using fetal echocardiography.This study presents a very rare apically located left ventricular aneurysm case,and the relevant literature was reviewed and discussed.In this case,a 35-year-old,gravida 2,parity 1 preg-nant woman at 24 weeks of gestation,displayed a wide aneurysmal image in the left ventricular apical wall on fetal echocardiography.There was a 1.79 mm muscular ventricular septal defect at the apical region of the interven-tricular septum.In the course of the color Doppler ultrasonography examination,an aberrantfibrous band within the left ventricle and consequent turbulentflow during systole were observed.The baby,born via cesarean section at 37 weeks of gestation,is now in its postnatal seventh month.However,during echocardiographic follow-ups,changes have been observed,including mild to moderate mitral insufficiency and a decrease in systolic function.Despite thesefindings,the clinical condition remains asymptomatic.It is of great importance to use a multidis-ciplinary approach in managing these rare cases that could lead to potential adverse outcomes during the antena-tal or postnatal periods.

Neuroimaging diagnosis for cerebral infarction An 8-year bibliometric analysis

OBJECTIVE： To identify global research trends in neuroimaging diagnosis for cerebral infarction using a bibliometric analysis of the Web of Science. DATA RETRIEVAL： We performed a bibliometric analysis of data retrieval for neuroimaging diagnosis for cerebral infarction containing the key words ＂CT, magnetic resonance imaging, MRI, transcranial Doppler, transvaginal color Doppler, digital subtraction angiography, and cerebral infarction＂ using the Web of Science. SELECTION CRITERIA： Inclusion criteria were： （a） peer-reviewed articles on neuroimaging diagnosis for cerebral infarction which were published and indexed in the Web of Science; （b） original research articles and reviews; and （c） publication between 2004-2011. Exclusion criteria were： （a） articles that required manual searching or telephone access; and （b） corrected papers or book chapters. MAIN OUTCOME MEASURES： （1）Annual publication output; （2） distribution according to country; （3） distribution according to institution; （4） top cited publications; （5） distribution according to journals; and （6） comparison of study results on neuroimaging diagnosis for cerebral infarction. RESULTS： Imaging has become the predominant method used in diagnosing cerebral infarction. The most frequently used clinical imaging methods were digital subtraction angiography, CT, MRI, and transcranial color Doppler examination. Digital subtraction angiography is used as the gold standard. However, it is a costly and time-consuming invasive diagnosis that requires some radiation exposure, and is poorly accepted by patients. As such, it is mostly adopted in interventional therapy in the clinic. CT is now accepted as a rapid, simple, and reliable non-invasive method for use in diagnosis of cerebrovascular disease and preoperative appraisal. Ultrasonic Doppler can be used to reflect the hardness of the vascular wall and the nature of the plaque more clearly than CT and MRI. CONCLUSION： At present, there is no unified standard of classification of cerebral infarction imaging. Detection of clinical super-acute cerebral infarction remains controversial due to its changes on imaging, lack of specificity, and its similarity to a space-occupying lesion. Neuroimaging diagnosis for cerebral infarction remains a highly active area of research and development.

A molecular probe carrying anti-tropomyosin 4 for early diagnosis of cerebral ischemia/reperfusion injury

In vivo imaging of cerebral ischemia/reperfusion injury remains an important challenge.We injected porous Ag/Au@SiO_(2) bimetallic hollow nanoshells carrying anti-tropomyosin 4 as a molecular probe into mice with cerebral ischemia/reperfusion injury and observed microvascular changes in the brain using photoacoustic imaging with ultrasonography.At each measured time point,the total photoacoustic signal was significantly higher on the affected side than on the healthy side.Twelve hours after reperfusion,cerebral perfusion on the affected side increased,cerebrovascular injury worsened,and anti-tropomyosin 4 expression increased.Twenty-four hours after reperfusion and later,perfusion on the affected side declined slowly and stabilized after 1 week;brain injury was also alleviated.Histopathological and immunohistochemical examinations confirmed the brain injury tissue changes.The nanoshell molecular probe carrying anti-tropomyosin 4 has potential for use in early diagnosis of cerebral ischemia/reperfusion injury and evaluating its progression.

Differentiation and diagnosis of migrating cerebral sparganosis: 2 case reports from China

Human cerebral sparganosis is a rare but neglected parasitic disease. We present details of the diagnosis of two cases of migrating cerebral sparganosis from China based on computed tomography and magnetic resonance imaging combined with epidemiological information and serology. Its differentiatial diagnosis from other parasitic diseases, tuberculoma and brain tumor by neuroimaging is briefly discribed.

Study on the role of Cathepsin B and JNK signaling pathway in the development of cerebral aneurysm

Objective: To investigate the correlation between JNK signal and the apoptosis of VSMC as well as the expression of Cathepsin B and to explore the role of JNK signal in the development of cerebral aneurysm. Methods: Rat models of cerebral aneurysm were established and histopathologic changes of cerebral aneurysm and the apoptosis of VSMC were analyzed. Rat models were respectively subject to subcutaneous injection of Cathepsin B si RNA and JNK inhibitor SP600125. Western blot technique was used to detect the expression of proteins like Cathepsin B, Caspase-3, and p-JNK. Spearman's rho was used to examine the correlation between p-JNK and Cathepsin B, as well as the expression of relevant proteins. Results:The success rate of modeling rats with cerebral aneurysm was 88.75%. After the respective injection of Cathepsin B si RNA, SP600125 and their combination, the cell densities of VSMC of rats with cerebral aneurysm all increased significantly(P<0.05 or P<0.01), but the apoptosis rate of VSMC decreased significantly(P<0.01). Compared with normal rats, the expression of Cathepsin B, Caspase-3 and p-JNK in cerebral aneurysm models increased significantly. Effectively intervening Cathepsin B genes with Cathepsin B si RNA could significantly inhibit the expression of Cathepsin B and Caspase-3, but hardly influence the expression of p-JNK. JNK inhibitor SP600125 had no influence on the expression of Cathepsin B and Caspase-3, but effectively inhibited the expression of p-JNK. In cerebral aneurysm tissues, positive correlation was observed between the expression of p-JNK and Cathepsin B, the correlation coefficient was r=0.640. Conclusion: After the attack of cerebral aneurysm, proteins like Cathepsin B, Caspase-3 and p-JNK are all involved in the apoptosis of VSMCs. This process may be realized by Cathepsin B which activates the apoptosis mechanism of Caspase-3 and mediate the apoptosis of VSMC through the JNK signaling pathway. Therefore, silencing Cathepsin B gene or inhibiting the conduction through JNK signaling pathway can mitigate the apoptosis of vascular smooth muscle cells in cerebral aneurysm.

Surgical Treatment of Poor Grade Middle Cerebral Artery Aneurysms Associated with Large Sylvian Hematomas Following Prophylactic Hinged Craniectomy

The clinical characteristics of patients who presented in poor clinical grade due to ruptured middle cerebral artery aneurysms （MCAAs） associated with large sylvian hematomas （SylH） were ana- lyzed and an ingenious designed prophylactic hinged craniectomy was introduced. Twenty-eight pa- tients were graded into Hunt-Hess grades IV-V and emergency standard micro-neurosurgeries （aneu- rysm clipping, hematoma evacuation and prophylactic hinged craniectomy） were performed, and their clinical data were retrospectively analyzed. 46.43% of the patients reached encouraged favorable out- comes on discharge. The favorable outcome group and the poor outcome group significantly differed in terms of patients＇ anisocoria, Hunt-Hess grade before surgery, extent of the midline shift and time to the surgery after bleeding （P〈0.05）. There were no significant differences in age, sex, volume and location of the hematoma, size of aneurysm between the favorable and poor groups （P〉0.05）. However, ingen- ious designed prophylactic hinged craniectomy efficiently reduced the patients＇ intracranial pressure （ICP） after surgery. It was suggested that preoperative conditions such as Hunt-Hess grading, extent of the midline shift and the occurrence of cerebral hernia affect the prognosis of patients, but time to the surgery after bleeding and prophylactic hinged craniectomy are of significant importance for optimizing the prognosis ofMCAA oatients 19resenting with large SylH.

Impact of Intraoperative Blood Pressure Control and Temporary Parent Artery Blocking on Prognosis in Cerebral Aneurysms Surgery

Objective In cerebral aneurysm clipping and embolization, blood pressure control and temporaryparent artery blocking are common methods to prevent aneurysm rupture. Their influence on the prognosis isuncertain. In this study, we try to find out the association between methods above and prognostic indicators.

Preoperative diagnosis and operative effect of intracranial aneurysm with three-dimensional computed tomography angiography

BACKGROUND ： Digital subtraction angiography （DSA） is always regarded as the golden standard for diagnosis of intracranial aneurysm; however, the procedure is complex, traumatic, expensive and easy to induce vascular complication. Three-dimensional computed tomography angiography （3D-CTA） can make up deficiencies of DSA; therefore, it is used in clinical therapy wider and wider. OBJECTIVE ： To evaluate the clinical effect of 3D-CTA on disruption and hemorrhage of intracranial aneurysm pre- and post-operation and compare with the effect of DSA. DESIGN ： Auto-control contrast observation SETTING ： Department of Neurosurgery, Shengjing Hospital of China Medical University PARTICIPANTS ： A number of 106 patients with disruption and hemorrhage of intracranial aneurysm were selected from the Department of Neurosurgery, Shengjing Hospital of China Medical University from January 2003 to April 2006. All patients were diagnosed with cranial operation and consent. There were 47 males and 59 females aged from 3-76 years with the mean age of （47±13） years. Among them, 82 patients had extensive subarachnoid hemorrhage （SAH）, 7 had hemorrhage at longitudinal fissure, and 17 had hemorrhage at ambiens cistema and lateral fissure. Moreover, intraventricular hematocele was accompanied on 13 patients and hematom on 9 patients. METHODS： （1） 3D-CTA examination： Siemens SOMATOM Sensation 64 CT was used in this study. The thickness was 1 mm and interval of reconstruction was 0.8 mm. Localizing section was plainly scanned as the standard of canthus line. Scan ranged from 30 mm below sella to 50 mm above sella. Non-ion contrast medium of Omnipaque 350 （concentration of iodine was 350 g/L） was inserted into anterior vein of elbow with 18G trochar retained with high-pressured injectoc pum. The speed was 4.5 mL/s and the total volume was 80-100 mL with the means of 90 mL. Scan started at 10-20 s after injection of contrast medium. Original image was dealt with Leonardo workstation and retreated with Syngo software. Volume rendering and maximum intensity projection were used to reconstructed images, （2） All 106 patients suffered from occlusion of aneurysm clamp. Before operation, 3D-CTA was undertaken and DSA was followed. After operation, patients were rechecked with 3D-CTA. MAIN OUTCOME MEASURES： Comparisons between 3D-CTA and DSA. RESULTS ： All 106 patients were involved in the final analysis. （1） Examination of 3D-CTA and DSA： Among 118 patients with aneurysm, 110 were checked with 3D-CTA and the detected rate was 93.2% （110/118）. Among other 8 cases, 3 were negative and checked again with DSA; 1 had pericallosal aneurysm, 1 ophthalmic aneurysm, and 1 anterior choroidal artery of aneurysm. 3D-CTA results of other 5 cases were suspicious, and then, they were regarded as having aneurysm with DSA. Before operation, correlation among site, body, neck of aneurysm and peripheral anatomic structure were shown sufficiently. After operation, 82 patients were rechecked with 3D-CTA, which was complete occlusion, precise, unobvious constriction, emphraxis or remains as compared with 3D-CTA those pre-operation. （2） Characteristics of 3D-CTA： With multiple vessels and angles, 3D-CTA observed the relationship between aneurysm neck and carried artery and showed thrombosis in cavity of aneurysm, calcification of aneurysm wall and peripheral structure of vessel at the same time. However, DSA could not detect the reactions mentioned above. It could delete image of cranium, simulate image of operative route, eliminate artifact induced by metal, but not distinguish blood stream direction. Meanwhile, posterior communicating artery was always poor during circle of Willis artery showing. CONCLUSION： （1） 3D-CTA is characterized by simple operation and non-invasive showing vascular stereo structure and correlation. Therefore, it is significant for diagnosis and designing plan of operative approach and focal location pre-operation and evaluating effect post-operation. （2） 3D-CTA does not completely replace DSA on the diagnosis of intracranial aneurysm.

Intraoperative hemodynamic parameters of middle cerebral artery and other artery aneurysms utilizing transcranial Doppler ultrasonography

BACKGROUND： Hemodynamic changes accompany the initiation, development and rupture of middle cerebral artery （MCA） aneurysms. The complexity of the intraaneurysmal hemodynamic factors has not been completely clarified by the indirect measures and methods used in previous studies. OBJECTIVE： To evaluate correlations of intraoperative hemodynamic factors to initiation and rupture of MCA aneurysms. DESIGN, TIME AND SETTING： A case-control study was performed at the Department of Neurosurgery, Tiantan Hospital Affiliated to Capital Medical University, China between March and October 2008. PARTICIPANTS： A total of 12 consecutive patients diagnosed with MCA aneurysms （MCA aneurysms group） and five patients without middle cerebral artery aneurysms （with aneurysms located at other arteries, control group） were enrolled at the Department of Neurosurgery, Tiantan Hospital Affiliated to Capital Medical University, China. METHODS： The proximal and distal arteries of MCA aneurysms were exposed visibly in the MCA aneurysm group. The M1 segment of MCA without the aneurysm and the aneurysm on other arteries were also exposed visibly in the control group. Hemodynamic indices were then measured using an intraoperative 16 MHz probe installed in a Multi-Dop TCD8X4 device. MAIN OUTCOME MEASURES： Mean （time-averaged velocity） difference, maximum mean, pulsatility index difference, maximum pulsatility index, resistance index difference, maximum resistance index; correlation of development and rupture of MCA aneurysms to intraoperative hemodynamic factors of the parent artery. RESULTS： A total of 12 patients underwent microsurgery for treatment to occlude 15 MCA aneurysms. Of the 15 MCA aneurysms, 12 were located at the bifurcation, two at the M1 segment and one at the M3 segment; eight of the aneurysms were unruptured and seven were ruptured. The whole indices with combination mean difference, maximum mean, and maximum pulsatility index of the aneurysms were important factors influencing the rupture of MCA aneurysms （t = 2.92, P = 0.03, constant）. A higher velocity intraaneurismal flow at the bifurcation was identified （t = 3.48, P = 0.01, constant）. After the aneurysm was completely occluded, global high-velocity flow could not be detected in the parent arteries （t = 2.57, P=0.03, constant）. CONCLUSION： When short-term high-velocity blood flow is present, aneurysms can be easily initiated and ruptured at the bifurcation of MCA.

Outcomes of early physiotherapy in patients with cerebral aneurysms treated by surgical clipping or endovascular embolization

Early physiotherapy was given to 124 patients with ruptured or unruptured cerebral aneurysms who were treated by surgical clipping or endovascular embolization.Patients were divided into four groups according to their Hunt and Hess grade at admission and aneurysm treatment modality： Group 1,Hunt and Hess grade≤II and surgical clipping;Group 2,Hunt and Hess grade≤II and endovascular embolization;Group 3,Hunt and Hess grade≥III and surgical clipping;Group 4,Hunt and Hess grade≥III and endovascular embolization.Level of consciousness was evaluated using the Glasgow Coma Scale,functional status using the Glasgow Outcome Scale,level of the mobility using the Mobility Scale for acute stroke patients,and independence in activities of daily living using the Barthel Index.After early physiotherapy,the level of consciousness and functional status improved significantly in Groups 1,3,and 4;mobility improved significantly in all groups;and independence in activities of daily living improved significantly in Groups 1 and 3.At discharge, Groups 1 and 2 had better functional status than Groups 3 and 4.Level of consciousness,functional status,mobility and independence in activities of daily living improved after early physiotherapy. These findings suggest that early physiotherapy improved the prognosis of patients with cerebral aneurysms who were treated by surgical clipping or endovascular embolization.Patients with a worse clinical status at presentation had a poorer functional status at discharge.The outcome of physiotherapy was not affected by whether surgical clipping or endovascular embolization was chosen for treatment of the aneurysm.

Recurrent Transient Ischemic Attacks Revealing Cerebral Amyloid Angiopathy: A Comprehensive Case

This case report investigates the manifestation of cerebral amyloid angiopathy (CAA) through recurrent Transient Ischemic Attacks (TIAs) in an 82-year-old patient. Despite initial diagnostic complexities, cerebral angiography-MRI revealed features indicative of CAA. Symptomatic treatment resulted in improvement, but the patient later developed a fatal hematoma. The discussion navigates the intricate therapeutic landscape of repetitive TIAs in the elderly with cardiovascular risk factors, emphasizing the pivotal role of cerebral MRI and meticulous bleeding risk management. The conclusion stresses the importance of incorporating SWI sequences, specifically when suspecting a cardioembolic TIA, as a diagnostic measure to explore and exclude CAA in the differential diagnosis. This case report provides valuable insights into these challenges, highlighting the need to consider CAA in relevant cases.

Diagnosis and management of extrahepatic portal vein aneurysm:a case report

BACKGROUND: Extrahepatic portal vein aneurysm is a rare clinical entity with no more than 50 reported cases in the English literature. This study was to elucidate the procedures used in the diagnosis and management of portal vein aneurysm. METHOD: The clinical data of a patient with extrahepatic portal vein aneurysm were analyzed. RESULTS: Extrahepatic portal vein aneurysm associated with portal hypertension and splenomegaly was diagnosed by color Doppler ultrasonography (US), computed tomography (CT), magnetic resonance angiography (MRA) and angiography (indirect portography). Splenectomy and surgical shunt (splenorenal shunt) were performed. No hepatic encephalopathy and variceal bleeding occurred after the operation except mild pancreatic leakage caused by partial pancreatic tail resection. The patient recovered well. CONCLUSIONS: Extrahepatic portal vein aneurysm can be evaluated by US, CT, MRA, and angiography for optimum conservative or surgical management.

Angiographic follow-up of cerebral aneurysms treated with Guglielmi detachable coils(GDCs): An analysis of 162 cases of 173 aneurysms

Objective To evaluate the mid- and long-term radiological outcomes of cerebral aneurysms with GDCs embolization.Methods One hundred and sixty-two patients with 173 aneurysms embolized with GDCs underwent angiographic follow-up from 1 to 54 months post-operatively and were retrospectively reviewed. Three neuro-radiologists reviewed each angiogram and made a comparison between initial and follow-up angiograms. Morphological outcomes were evaluated as follows: unchanged; progressive thrombosis; and re-opening or re-growth. Results Of 173 aneurysms with GDC embolization, 142 aneutysms had total or nearly total occlusion, 23 subtotal occlusion and 8 partial occlusion shown on initial angiograms. The incidence of re-opening was 17.1% (13/76) in less than 3 months, and 6.2% (6/97) between 3 and 6 months postoperatively. Four aneurysms showed recurrency(2.3%) on second follow-up angiography in one year after procedure and one-year cumulative recurrent rate was 13.3% of 56 aneurysms with the third follow-up angiography in the post-operation period of 12 to 54 months, four showed a little enlargement and the cmnulative recurrent rate so far was 20.2% (35/173). Conclusions The direct and main causes for aneurysmal recurrence are incomplete and loosening packing. The first angiographic follow-up is recommended to be performed at 3 months or earlier after the procedure, especially in aneurysms with initial incomplete occlusion. Re-treatment with balloon- or stent-assisted coil embolization is recommended in re-opening aneurysms.

Effects of Elasticity on Wall Shear Stress in Patient-Specific Aneurysm of Cerebral Artery

The behavior of wall shear stress (WSS) was previously reported in a deformable aneurysm model using fluid-structure interactions. However, these findings have not been validated. In the present study, we examined the effect of elasticity (i.e., deformation) on wall shear stress inside a cerebral aneurysm at the apex of a bifurcation using particle image velocimetry in vitro. The flow model simulated a human patient-specific aneurysm at the apex of the bifurcation of the middle cerebral artery. Flow characteristics by wall elasticity were examined for both elastic and non-deformable aneurysm models with pulsatile blood flow. The absolute temporally- and spatially-averaged WSS along the bleb wall was smaller in the elastic model than that in the non-deformable model. This small WSS may be related to attenuation of the WSS. Further, the WSS gradient had a finite value near the stagnation point of the aneurysm dome. Finally, the WSS gradient near the stagnation point was slightly smaller in the elastic model than that in the non-deformable model. These data suggest that elasticity of the aneurysm wall can affect the progression and rupture of aneurysms via hemodynamic stress.

Ruptured intracranial aneurysm presenting as cerebral circulation insufficiency:A case report

BACKGROUND Rupture of an intracranial aneurysm is a type of acute stroke that is a serious threat to human health.Misdiagnosis of ruptured intracranial aneurysms is a serious clinical event that may have disastrous consequences in some patients.To date,ruptured intracranial aneurysms have been misdiagnosed as meningitis,tumors,stroke,or trauma,among other conditions.Here,we report what appears to be the first case of a ruptured intracranial aneurysm that presented as cerebral circulation insufficiency.CASE SUMMARY A middle-aged man was admitted to our hospital because of a parasellar lesion identified on a noncontrast computed tomography(CT)image after a mild traffic accident that was caused by a brief loss of consciousness.Notably,he was diagnosed with cerebral circulation insufficiency after two unexplained episodes of a transient loss of consciousness within the past 8 mo.The patient was diagnosed with right internal carotid artery aneurysm based on CT angiography and completely recovered after a craniotomy at our hospital.A few clots and severe adhesions around the aneurysm were observed in the subarachnoid space during the operation,suggesting that the aneurysm had ruptured and may had been misdiagnosed as cerebral circulation insufficiency.CONCLUSION Ruptured intracranial aneurysms may show negative imaging results and present as cerebral circulation insufficiency,which should be recognized as soon as possible to ensure timely management.

Biomechanical Considerations in the Unruptured Cerebral Aneurysm Study (UCAS Japan): Rupture Risk and True Stress of Wall

When an unruptured aneurysm is found, deciding whether to operate or follow up is one of the most important issues. There are guidelines for making the best final decision on treatment, taking into account the effectiveness of diagnostic and therapeutic devices and the risk-benefit ratio of patients, caregivers, and healthcare professionals. The guidelines evidence-based of large clinical data for this purpose are presented by national medical societies. As one of the rupture risk indicators, there is the hazard risk ratio derived by the UCAS Japan research group based on the statistical method of 6697 aneurysms in 5720 patients with cerebral aneurysms of 3 mm or more. Therefore, we investigated the biomechanical significance of this hazard risk ratio using a spherical aneurysm model. It was revealed that 1) the reason why the frequency of aneurysm rupture is relatively high up to about 10 mm, 2) the UCAS hazard risk ratio corresponds to stress of the aneurysm wall, and the true stress can be calculated by multiplying the patient’s blood pressure, and 3) the factors that cause the daughter’s sac (irregular protrusion of the aneurysm wall). In addition, our two methods for measuring the strength of the blood vessel wall of an individual patient were described.

Whole-brain CT Perfusion at Admission and During Delayed Time-window Detects the Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage

Objective To evaluate the utility of computed tomography perfusion(CTP)both at admission and during delayed cerebral ischemia time-window(DCITW)in the detection of delayed cerebral ischemia(DCI)and the change in CTP parameters from admission to DCITW following aneurysmal subarachnoid hemorrhage.Methods Eighty patients underwent CTP at admission and during DCITW.The mean and extreme values of all CTP parameters at admission and during DCITW were compared between the DCI group and non-DCI group,and comparisons were also made between admission and DCITW within each group.The qualitative color-coded perfusion maps were recorded.Finally,the relationship between CTP parameters and DCI was assessed by receiver operating characteristic(ROC)analyses.Results With the exception of cerebral blood volume(P=0.295,admission;P=0.682,DCITW),there were significant differences in the mean quantitative CTP parameters between DCI and non-DCI patients both at admission and during DCITW.In the DCI group,the extreme parameters were significantly different between admission and DCITW.The DCI group also showed a deteriorative trend in the qualitative color-coded perfusion maps.For the detection of DCI,mean transit time to the center of the impulse response function(Tmax)at admission and mean time to start(TTS)during DCITW had the largest area under curve(AUC),0.698 and 0.789,respectively.Conclusion Whole-brain CTP can predict the occurrence of DCI at admission and diagnose DCI during DCITW.The extreme quantitative parameters and qualitative color-coded perfusion maps can better reflect the perfusion changes of patients with DCI from admission to DCITW.

Superficial Temporal Artery to Middle Cerebral Artery Bypass and Endovascular Parent Artery Occlusion in the Treatment of Giant Intracranial Aneurysms

The authors are reporting on a study drawn from unpublished dissertation done by the corresponding author when he completed his neurosurgical training in Paris, France in 2004, few years before the advent of flow diverters. The study was a retrospective review of giant intracranial aneurysms treated by superficial temporal artery to middle cerebral artery bypass combined with endovascular occlusion of the parent artery. From 1990 to 2003, 29 consecutive cases of giant cerebral aneurysms, not suitable to selective treatment were managed in that way. Twenty-one medical records had enough data to allow objective evaluation. Sixteen female and five male patients bearing 21 giant aneurysms were involved. Their mean age was 46 years. The aneurysm was revealed by mass effect in 13 cases and subarachnoid hemorrhage in one case. On admission 19 patients presented with unruptured aneurysms and two have sustained a subarachnoid hemorrhage. The balloon occlusion test before the bypass operation was not tolerated in 18 patients. The treatment was completed in 19 patients and 17 of them had parent artery occlusion with latex detachable balloons. The only death of the series occurred before the endovascular treatment. The mean follow-up period was 30 months. After completion of the treatment, 16 (84%) patients had no symptom. Aneurysm recanalization or rupture was not observed after the parent artery occlusion. With the combination of superficial temporal artery to middle cerebral artery bypass + endovascular parent artery occlusion, 90% of giant intracranial aneurysms untreatable selectively were permanently excluded with a good outcome in 95%.

Saccular trilobed aneurysm of azygos anterior cerebral artery

Multiple saccular or giant aneurysms of azygos anteriorcerebral artery(AACA) at the distal segments A2-A5 are very rarely reported. Distal anterior cerebral artery(DACA) aneurysms represent approximately 2%-7% of all cerebral aneurysms. We present the case of an Albanian 62-year-old male, admitted at our service after sudden onset of severe headache and vomiting. Computerized tomography(CT) of the head showed hemorrhage in the front of corpus callosum. CT angiography followed by digitally subtracted angiography(DSA) documented a large necked aneurysm with three lobes at the origin of calloso-marginal artery and a single DACA, also known as AACA. A frontal parasagittal craniotomy was performed. Obliteration of the aneurysm was done only by separate clipping of each three lobes at the respective neck. Postoperative DSA demonstrated complete exclusion of the aneurysm and a regular flow of AACA. The patient recovered uneventfully. Despite it is a rare occurrence, an aneurysm of distal segments of anterior cerebral artery A2-A5, concomitant to AACA should be studied with DSA. In the era of embolization, conserving good microsurgical skills is fundamental for dealing with multilobar cerebral aneurysms, associated with rare anatomical variations.