Intracranial dissections commonly present as ischemic stroke and as hemorrhagic stroke. In general, while either ischemic stroke or hemorrhagic stroke may develop, the simultaneous onset of both may also occasionally occur. In this report, we present a case of simultaneous development of ischemic stroke and hemorrhagic stroke due to an intracranial artery dissection.
Aneurysm, Dissecting ; Arteries* ; Carotid Artery, Internal ; Stroke*

Treatment of giant intracranial aneurysms, via either surgical or endovascular approaches, is associated with a high level of technical difficulty as well as a high rate of treatment-related morbidity and mortality. Flow-diverting stents, such as the Pipeline embolization device (PED), have drastically altered the therapeutic strategies for the treatment of giant aneurysms. Gaining endovascular access using a microcatheter to the portion of the parent artery distal to the aneurysm neck is requisite for safe and effective stent deployment. Giant aneurysms are often associated with vascular tortuosity, which necessitates significant catheter support systems to enable maneuvering of PEDs across the aneurysm neck. This is also required in order to reduce the probability of stent herniation within giant aneurysms. We report on a case of a giant supraclinoid internal carotid artery (ICA) aneurysm which was treated successfully with a PED utilizing a balloon anchor technique to facilitate direct microcatheter access across the aneurysm neck.
Aneurysm ; Arteries ; Carotid Artery, Internal ; Catheters ; Endovascular Procedures ; Humans ; Intracranial Aneurysm* ; Mortality ; Neck* ; Parents ; Stents ; Stroke ; Subarachnoid Hemorrhage

Spontaneous anterior cerebral artery (ACA) dissection, although extremely rare, is often associated with severe morbidity and mortality. It could lead to cerebral hemorrhage, ischemic stroke, or, rarely, combination of hemorrhage and ischemia due to hemodynamic changes. Prompt and accurate diagnosis is essential for determining the appropriate management. However, the optimal treatment for ACA dissection remains controversial. Herein, we report on two rare cases of subarachnoid hemorrhage (SAH) caused by ACA dissection; a case presenting with simultaneous SAH and infarction without aneurysmal formation and another case presenting with SAH with fusiform aneurysmal formation. A review of the related literature is provided, and optimal treatments for each type of dissection are suggested.
Aneurysm* ; Anterior Cerebral Artery* ; Cerebral Hemorrhage ; Diagnosis ; Hemodynamics ; Hemorrhage* ; Infarction ; Ischemia* ; Mortality ; Stroke ; Subarachnoid Hemorrhage*

The pipeline(TM) embolization device (PED) is a braided, tubular, bimetallic endoluminal implant used for occlusion of intracranial aneurysms through flow disruption along the aneurysm neck. The authors report on two cases of giant internal carotid artery aneurysm treated with the PED. In the first case, an aneurysm measuring 26.4 mm was observed at the C3-C4 portion of the left internal carotid artery in a 64-year-old woman who underwent magnetic resonance imaging (MRI) for dizziness and diplopia. In the second case, MRI showed an aneurysm measuring 25 mm at the C4-C5 portion of the right internal carotid artery in a 39-year-old woman with right ptosis and diplopia. Each giant aneurysm was treated with deployment of a PED (3.75 mm diameter/20 mm length and 4.5 mm diameter/25 mm length, respectively). Nine months later, both cases showed complete radiological occlusion of the giant intracranial aneurysm and sac shrinkage. We suggest that use of the PED can be a therapeutic option for giant intracranial aneurysms.
Adult ; Aneurysm* ; Carotid Artery, Internal* ; Diplopia ; Dizziness ; Female ; Follow-Up Studies* ; Humans ; Intracranial Aneurysm ; Magnetic Resonance Imaging ; Middle Aged ; Neck

Simultaneous occurrence of intracerebral hemorrhage (ICH) in different arterial territories is an uncommon event. We report on two cases of multiple spontaneous simultaneous ICH for which we could find no specific cause. A 73-year-old man, with no related medical history, was admitted to the hospital with simultaneous bithalamic ICH, and subsequently died of recurrent pneumonia. Second patient was a 60-year-old man who presented with simultaneous ICH in the pons and thalamus; he died of recurrent bleeding. We review the possible pathological mechanisms, clinical and radiologic features of simultaneous multiple ICH.
Aged ; Cerebral Hemorrhage* ; Hemorrhage ; Humans ; Hypertension ; Middle Aged ; Pneumonia ; Pons ; Thalamus

Pial arteriovenous fistulas (pAVF) are rare vascular lesions consisting of one or more arterial connections to a single venous channel without any intervening nidus of vessels or capillaries. Case 1: A 65-year-old woman with a complaint of headache and left hand paresthesia was referred to us. Magnetic resonance imaging showed a large saccular lesion with signal void in the posterior part of the right sylvian fissure and catheter angiography showed a giant venous aneurysm fed by one branch of the middle cerebral artery (MCA) and draining into the vein of Trolard. Case 2: A 12-year-old boy was transferred to our hospital with a history of sudden loss of consciousness and hemiplegia. Brain computed tomography revealed a massive hemorrhagic mass in the right hemisphere and cerebral angiography showed a pAVF with a large aneurysmal varix, which was fed by multiple branches of the right MCA and draining into the superior sagittal sinus. Both patients underwent craniotomy and after ligation of vascular connections, aneurysmal varices were removed completely. Surgical resection can be a safe method for treatment of pAVFs, particularly in those with large varices.
Aged ; Aneurysm ; Angiography ; Arteriovenous Fistula* ; Brain ; Capillaries ; Catheters ; Cerebral Angiography ; Child ; Craniotomy ; Female ; Hand ; Headache ; Hemiplegia ; Humans ; Ligation ; Magnetic Resonance Imaging ; Male ; Microsurgery ; Middle Cerebral Artery ; Paresthesia ; Superior Sagittal Sinus ; Unconsciousness ; Varicose Veins* ; Veins

Symptomatic cerebral air embolism during cerebral angiography is extremely rare. We report on the case of a 69-year-old woman undergoing elective stent-assisted coiling of an unruptured right middle cerebral artery (MCA) bifurcation aneurysm, who was found to have severe attenuation of somatosensory evoked potential (SSEP) and electroencephalography (EEG) during the procedure. Intra-operative DynaCT showed hypodense cortical vessels consistent with cerebral air embolism. Diagnostic and management strategies for this rare complication are reviewed.
Aged ; Aneurysm ; Cerebral Angiography ; Diagnosis* ; Electroencephalography ; Embolism, Air* ; Evoked Potentials, Somatosensory ; Female ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery

OBJECTIVE: The T2*-weighted gradient echo image susceptibility vessel sign (GRE SVS) is a well-known indicator of intraluminal thrombi in acute cerebral infarction. The purpose of this study was to evaluate the relationships between thrombus size on GRE SVS and recanalization after intravenous administration of tissue plasminogen activator (IV-tPA). MATERIALS AND METHODS: Fifty five patients with GRE SVSs on the M1 were enrolled. Examination of magnetic resonance image (MRI), including diffusion weighted imaging and MR angiography, was performed within 20 minutes of admission. Thrombus size on GRE was calculated using the Picture Archiving and Communication System upon initial MRI. Recanalization was assessed with follow-up MRI or transfemoral cerebral angiography within 24 hours of treatment. RESULTS: The patient group consisted of 37 males and 18 females with an average age of 63.74 +/- 10.28 years (range: 43 - 77 years). The median NIHSS score was 13. Fifteen of these patients achieved recanalization (27.3%). The average thrombus cross-sectional area in the recanalization group was 38.54 +/- 20.27 mm2, and the corresponding size of the non-recanalization group was 53.38 +/- 24.77 mm2 (p = 0.043). In the receiver operator characteristic curve for thrombus cross-sectional area in relation to recanalization, the cut-off point was 47.28 mm2. The sensitivity at this cut-off point was 73.3%, the specificity was 60%, and the area under the curve was 0.687. CONCLUSION: Thrombus size on GRE is a simple diagnostic tool that can be easily measured, and thrombus size on GRE SVS was found to be associated with recanalization after IV-tPA.
Administration, Intravenous ; Angiography ; Cerebral Angiography ; Cerebral Infarction ; Diffusion ; Female ; Follow-Up Studies ; Humans ; Infarction, Middle Cerebral Artery* ; Magnetic Resonance Imaging ; Male ; Sensitivity and Specificity ; Thrombosis* ; Tissue Plasminogen Activator

OBJECTIVE: The objective of this study was to compare the incidence of ventricular shunt placement for shunt-dependent hydrocephalus (SDHC) after clipping versus coiling of ruptured aneurysms. MATERIALS AND METHODS: A retrospective review was conducted in 215 patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent surgical clipping or endovascular coiling during the period from May 2008 to December 2011. Relevant clinical and radiographic data were analyzed with regard to the incidence of hydrocephalus and ventriculo-peritoneal shunt (VPS). Patients treated with clipping were assigned to Group A, while those treated with coiling were assigned to Group B. RESULTS: Of 215 patients (157 clipping, 58 coiling), no significant difference in the incidence of final VPS was observed between treatment modalities (15.3% vs. 10.3%) (p = 0.35). Independent risk factors for VPS for treatment of chronic hydrocephalus were as follows: (1) older than 65 years, (2) poorer Hunt-Hess grade IV and V, (3) Fisher grade III and IV, and (4) particularly initial presence of an intraventricular hemorrhage. CONCLUSION: In this study comparing two modalities for treatment of aneurysm, there was no difference in the incidence of chronic hydrocephalus requiring VPS. A significantly higher rate of shunt dependency was observed for age older than 65 years, poor initial neurological status, and thick SAH with presence of initial intraventricular hemorrhage. By understanding these factors related to development of SDHC and results, it is expected that management of aneurysmal SAH will result in a better prognosis.
Aneurysm ; Aneurysm, Ruptured ; Hemorrhage ; Humans ; Hydrocephalus* ; Incidence* ; Prognosis ; Retrospective Studies ; Risk Factors* ; Subarachnoid Hemorrhage* ; Surgical Instruments ; Ventriculoperitoneal Shunt

OBJECTIVE: Water-tight closure of the dura in extracranial-intracranial (EC-IC) bypass is impossible because the superficial temporal artery (STA) must run through the dural defect. Consequently, subdural hygroma and subcutaneous cerebrospinal fluid (CSF) collection frequently occur postoperatively. To reduce these complications, we prospectively performed suturing of the arachnoid membrane after STA-middle cerebral artery (STA-MCA) and evaluated the clinical usefulness. MATERIALS AND METHODS: Between Mar. 2005 and Oct. 2010, extracranial-intracranial arterial bypass (EIAB) with/without encephalo-myo-synangiosis was performed in 88 cases (male : female = 53 : 35). As a control group, 51 patients (57 sides) underwent conventional bypass surgery without closure of the arachnoid membrane. Postoperative computed tomography (CT) scan was performed twice in three days and seven days later, respectively, for evaluation of the presence of subdural fluid collection and other mass lesions. RESULTS: The surgical result was excellent, with no newly developing ischemic event until recent follow-up. The additional time needed for arachnoid suture was five to ten minutes, when three to eight sutures were required. Post-operative subdural fluid collection was not seen on follow-up computed tomography scans in all patients. CONCLUSION: Arachnoid suturing is simple, safe, and effective for prevention of subdural fluid collection in EC-IC bypass surgery, especially the vulnerable ischemic hemisphere.
Arachnoid* ; Cerebral Arteries ; Cerebral Revascularization ; Cerebrospinal Fluid ; Female ; Follow-Up Studies ; Humans ; Membranes* ; Prospective Studies ; Subdural Effusion ; Sutures ; Temporal Arteries