A rare case of bilateral third cranial nerve palsy due to a ruptured anterior communicating artery aneurysm is presented. A 68-yr-old woman was semicomatose with bilaterally fixed dilated pupil, abducted eyes, and ptosis. A computed tomography demonstrated extensive hemorrhage spreading around the both Sylvian and interhemisheric fissure without focal mass effect. Intracranial pressure via extraventricular drainage before surgery was 15-50 mmHg. Three months later, brain MRI showed infarction of left posterior cerebral artery territory and lacuna infarction of the pons. Eleven months after aneurysm repair, nerve palsy improved slowly and recovered partially. The patient communicated well with simple words. The author reviewed and discussed the possible mechanism of this rare neuro-ophthalmological manifestation in view of a false localizing sign.
Rupture, Spontaneous ; Oculomotor Nerve Diseases/*etiology ; Magnetic Resonance Imaging ; Intracranial Aneurysm/*complications/surgery ; Humans ; Female ; Aged

Direct Microsurgical intracranial approach is a standard technic for the treatment of ruptured intracranial aneurysms. Nevertheless aneurysms of the anterior communicating artery present particular difficulties because of their critical location, their various projections, the serious circulatory disturbances that may follow their rupture or vasospasm, the prevalence of local vascular anomalies, and their tendency for fatal recurrent hemorrhage. The authors analyzed 102 cases of anterior communicating artery aneurysms, surgically treated at Yonsei University Hospital in the Department of Neurosurgery from 1971 through August 1981. The operative mortality of the microsurgical pterional approach was 4.8% and the morbidity was 5.9% as compared to a mortality of 16.7% and a morbidity of 44.4% seen before the advent of microsurgery.
Adult ; Aged ; Female ; Human ; Intracranial Aneurysm/diagnosis ; Intracranial Aneurysm/surgery* ; Male ; Microsurgery/methods ; Middle Age ; Postoperative Complications ; Tomography, X-Ray Computed

The authors have reviewed and analyzed 105 cases of unruptured cerebral aneurysms in 94 patients from the medical records of 407 patients who had aneurysm sugery consecutively since the advent of microsurgery at the Department of Neurosurgery of Yonsei University. This study was done to define the clinical characteristics of intact intracranial aneurysms and to determine the principles of their management. There was no surgical mortality among 75 cases of intact intracranial aneurysms in 68 patients. Two cases of morbidity were not directly related to the surgery of intact aneurysms. As a result of the analysis of the cases, it was concluded that all symptomatic aneurysms should be treated immediately after the diagnosis, because they tend to be large in size and prone to rupture. If asymptomatic multiple unruptured aneurysms are accessible during surgery for a ruptured aneurysm, they should be treated at the same time. The decision for the treatment of unruptured aneurysms located opposite to ruptured ones or detected incidentally, should be made at the surgeon's discretion. The authors' belief is that intact intracranial aneurysms should be corrected regardless of their size when detected in young patients, in hypertensive patients, in hypertensive patients, or in patients with such high flow lesions as arteriovenous malformation.
Adult ; Aged ; Female ; Human ; Intracranial Aneurysm/surgery* ; Male ; Middle Age ; Postoperative Complications/etiology ; Prognosis ; Subarachnoid Hemorrhage/surgery

BACKGROUNDOculomotor palsy is a common complication in patients with posterior communicating aneurysm. This study was conducted to investigate the postoperative recovery of patients with posterior communicating aneurysm complicated with oculomotor palsy and to analyze the factors influencing length of recovery.

METHODSFrom 2000 to 2006, 148 patients with posterior communicating aneurysm were treated at our hospital, with 74 of them having concurrent unilateral oculomotor palsy. All of the patients underwent craniotomy after the diagnosis by means of whole-brain digital subtraction angiography (DSA). The patients were divided into two groups for observation of postoperative recovery during the follow-up period. Patients in group A were treated with simple pedicle clipping of the aneurysm while patients in group B were treated with pedicle clipping of the aneurysm and decompression of the oculomotor nerve.

RESULTSOf the 40 patients in group A, 20 underwent surgery within 14 days and completely recovered from oculomotor palsy in 10 - 40 days. Fourteen patients underwent surgery within 14 - 30 days, of whom 12 completely recovered within 30 - 90 days and 2 cases recovered incompletely. The remaining six patients underwent surgery after more than 30 days; of these, four patients recovered completely and two recovered incompletely. Of the 34 cases in group B, 15 underwent surgery within 14 days and completely recovered from oculomotor palsy in 10 - 40 days. Sixteen patients underwent surgery in 14 - 30 days, of whom 14 completely recovered in 30 - 90 days and 2 recovered incompletely. The remaining three patients underwent surgery after more than 30 days, of whom two patients recovered completely and one recovered incompletely.

CONCLUSIONSEarly diagnosis and surgical treatment of patients with unilateral oculomotor palsy induced by posterior communicating aneurysm are important to full postoperative recovery of the oculomotor nerve. No correlation was found, however, between decompression of the oculomotor nerve, such as excision or puncture of the aneurysm, and postoperative recovery time.

Adult ; Aged ; Female ; Humans ; Intracranial Aneurysm ; complications ; pathology ; surgery ; Male ; Middle Aged ; Ophthalmoplegia ; etiology ; pathology ; surgery ; Treatment Outcome

OBJECTIVETo evaluate clinical strategy and effect of early-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm.

METHODSSeventy-five patients presenting with anterior circulating aneurysmal subarachnoid hemorrhage (SAH) underwent early-mid-phase (within 3 days or 3-10 days) microsurgical clipping at Huashan Hospital between January 2001 and August 2004. Glasgow outcome scale (GOS) was conducted to evaluate patients' outcomes.

RESULTSOf 81 intracranial aneurysms, 77 lesions were clipped successfully, and 4 were wrapped. Good outcome was achieved in 53 cases, mild disability in 9 cases, severe disability in 7 cases, persistent vegetative state in 3 cases, and 3 patients (4%) died after surgery. The difference of GOS was statistically significant between patients in Hunt and Hess Grade I-III and Grade IV-V. However, there was no significant difference between early surgery and metaphase surgery.

CONCLUSIONSEarly-mid-phase microsurgery for ruptured cerebral anterior circulating aneurysm is considered the feasible opinion.

Acute Disease ; Adolescent ; Adult ; Aged ; Aged, 80 and over ; Aneurysm, Ruptured ; complications ; surgery ; Female ; Humans ; Intracranial Aneurysm ; complications ; surgery ; Male ; Microsurgery ; methods ; Middle Aged ; Neurosurgical Procedures ; methods ; Retrospective Studies ; Rupture, Spontaneous ; complications ; surgery ; Subarachnoid Hemorrhage ; etiology ; surgery ; Treatment Outcome

Simultaneous occurrence of aneurysmal subarachnoid hemorrhage (SAH) and hypertensive intracerebral hemorrhage (ICH) is very rare and only two cases have been previously reported in the literatures. We present a case of 68-yr-old man with a history of untreated hypertension, who suffered from sudden onset of headache followed by right hemiparesis. Computed tomographic (CT) scan revealed SAH in the basal cistern and remote ICH at the left putamen. Cerebral angiography showed a saccular aneurysm at the anterior communicating artery. No other vascular anomaly could be found at left putaminal area. Nine days after the ictal attack of SAH, the neck of aneurysm was clipped via the left frontotemporal craniotomy. Because of the ICH at the left frontal lobe and intraventricular hematoma on postoperative CT, we performed hematoma removal and external ventricular drainage 3 hours after the first operation. Postoperative neurological status had been improved to be drowsy and he was discharged in a severely disabled state 4 weeks after surgery. We suggest that the rupture of aneurysm possibly caused a rapid increase in blood pressure and subsequently resulted in hypertensive ICH.
Aged ; Aneurysm, Ruptured/*complications/radiography/surgery ; Carotid Arteries/radiography ; Humans ; Intracranial Hemorrhage, Hypertensive/*complications/radiography/surgery ; Male ; Putaminal Hemorrhage/*complications/radiography/surgery ; Subarachnoid Hemorrhage/*etiology/radiography/surgery ; Tomography, X-Ray Computed

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 analyzed and an ingenious designed prophylactic hinged craniectomy was introduced. Twenty-eight patients were graded into Hunt-Hess grades IV-V and emergency standard micro-neurosurgeries (aneurysm clipping, hematoma evacuation and prophylactic hinged craniectomy) were performed, and their clinical data were retrospectively analyzed. 46.43% of the patients reached encouraged favorable outcomes 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, ingenious 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 of MCAA patients presenting with large SylH.
Adult ; Aged ; Cerebral Aqueduct ; pathology ; Craniotomy ; methods ; Female ; Hematoma ; complications ; Humans ; Intracranial Aneurysm ; complications ; surgery ; Male ; Middle Aged ; Retrospective Studies ; Tomography, X-Ray Computed ; Treatment Outcome

OBJECTIVETo investigate risk factors for the occurrence of shunt-dependent hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODSA cohort of 136 consecutive patients who were treated for ruptured aneurysms within 72 h after onset of aSAH from January 2011 to January 2013 were retrospectively analyzed. Lumbar drainage was performed during the surgery in all patients. The risk factors of shunt-dependent hydrocephalus were analyzed.

RESULTSOf 136 patients, 23 (16.91%) underwent shunt operation to treat shunt-dependent hydrocephalus. Univariate analysis showed that Hunt-Hess grade at admission (P<0.01), Fisher grade (P<0.01), the presence of intraventricular hemorrhage (P<0.01), location of ruptured aneurysm (P=0.001), and the average daily volume of cerebrospinal fluid drainage (CSF) (P=0.047) were associated with shunt-dependent hydrocephalus.

CONCLUSIONThe aSAH patients with poor Hunt-Hess grade at admission, high Fisher grade, the presence of intraventricular hemorrhage, ruptured aneurysm in posterior circulation, and abnormal average daily volume of CSF are more likely to develop shunt-depended hydrocephalus.

Adult ; Aged ; Aneurysm, Ruptured ; complications ; Arteriovenous Shunt, Surgical ; adverse effects ; Female ; Humans ; Hydrocephalus ; etiology ; prevention & control ; Intracranial Aneurysm ; complications ; Male ; Middle Aged ; Retrospective Studies ; Risk Factors ; Subarachnoid Hemorrhage ; etiology ; surgery

OBJECTIVETo observe the improvement of acupuncture in cerebral vasospasm (CVS) after embolization of ruptured aneurysms.

METHODSSixty cases were randomly divided into two groups, an acupuncture-medication group and a conventional treatment group, 30 cases in each one. The cases of CVS in conventional treatment group were treated with Nimodipine. In acupuncture-medication group, on the basis of the treatment as conventional treatment group, Baihui (GV 20) and Fengchi (GB 20) were selected as the main acupoints in the treatment of CVS. The treatment lasted for 3 weeks. Hunt-Hess scale for the standard assessment was adopted to determine the severity of disease before and after treatment and compare the efficacy between two groups. The transcranial Doppler (TCD) was conducted on the 1st, 4th, 7th, 10th, 14th and 21st days successively after operation, and the average flow velocity of 3 pairs of vessels (ACA, MCA, and PCA) was recorded. CT perfusion (CTP) was taken to test cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) on the 1st, 7th, 14th and 21st days successively.

RESULTSThe improvement of Hunt-Hess scale in acupuncture-medication group was superior to that in conventional treatment group (P < 0.05). The analysis of variance (ANOVA) was adopted in the comparison of ACA, MCA, PCA, CBF, CBV and MTT between two groups. The results showed that the therapy in either group achieved the effect on CVS (all P < 0.05). But, the improvements in the above mentioned indices in acupuncture-medication group were superior to those in conventional treatment group (all P < 0.05).

CONCLUSIONAcupuncture at Baihui (GV 20) and Fengchi (GB 20) down-regulates the peak values or upregulates the valley values. It releases the peak of CVS effectively, improves the clinical prognosis significantly and is the effective therapy for CVS after subarachnoid hemorrhage.

Acupuncture Therapy ; Adult ; Aged ; Aneurysm, Ruptured ; complications ; surgery ; therapy ; Balloon Occlusion ; Female ; Humans ; Male ; Middle Aged ; Treatment Outcome ; Vasospasm, Intracranial ; etiology ; therapy

OBJECTIVETo study and analyze the factors affecting the recovery of posterior communicating artery aneurysm-induced oculomotor nerve palsy (ONP).

METHODSThe clinical and follow-up data of posterior communicating artery aneurysm-induced ONP in 23 patients from May 2005 to May 2009 were retrospectively compared. There were 7 male and 16 female with a mean age of 50.4 years. Among the 23 patients, 13 patients underwent endovascular coiling (endovascular group) and 10 patients underwent surgical clipping (surgical group).

RESULTSOf the patients with 2 year of follow-up, 6 patients recovered completely and 7 patients recovered partially in the endovascular group, compared with 6 patients recovered completely and 4 patients recovered partially in the surgical group (P = 0.407). Compared to the patients with preoperative complete ONP, the rate of complete recovery was higher in the patients with preoperative partial ONP, while the results did not reach the significance (P = 0.095). Patients accepted treatment in 14 days since the onset of symptoms recovered significantly than who accepted treatment after 14 days since the onset of symptoms (P = 0.045).

CONCLUSIONSThere is no significant difference in recovery from ONP between endovascular coiling and surgical clipping as treatment for posterior communicating artery aneurysm patients with ONP. Timing of treatment after onset of symptoms is a factor affects the recovery of ONP.

Adult ; Aged ; Embolization, Therapeutic ; Female ; Follow-Up Studies ; Humans ; Intracranial Aneurysm ; complications ; surgery ; therapy ; Male ; Middle Aged ; Oculomotor Nerve Diseases ; etiology ; Retrospective Studies ; Treatment Outcome