A 50-year-old woman reported to the emergency department with thunderclap headache and vomiting. Non-enhanced brain computed tomography (CT) showed a subarachnoid hemorrhage of Hunt-Hess Grade II and Fisher Grade III. Brain angiography CT and transfemoral cerebral angiography (TFCA) revealed an aneurysm of the anterior communicating artery. A direct neck clipping was performed using the pterional approach. The post-operation CT was uneventful. Six days postoperatively, the patient became lethargic. The mean velocity (cm/s) of the middle cerebral artery peaked at 173 cm/s on the right side and 167 cm/s on the left. A TFCA revealed decreased perfusion in both recurrent arteries of Heubner (RAH), but no occlusion in either. Intra-arterial nimodipine injection was administered. On the 7th postoperative day, CT demonstrated a newly developed low-density lesion in the RAH territory bilaterally. The cause of the infarction was attributed to decreased perfusion caused by cerebral vasospasm. The patient was discharged with no definite neurologic deficit except for mild cognitive disorder.
Aneurysm ; Angiography ; Arteries* ; Brain ; Cerebral Angiography ; Emergency Service, Hospital ; Female ; Headache Disorders, Primary ; Humans ; Infarction* ; Infarction, Anterior Cerebral Artery ; Intracranial Aneurysm* ; Middle Aged ; Middle Cerebral Artery ; Neck ; Neurologic Manifestations ; Nimodipine ; Perfusion ; Subarachnoid Hemorrhage ; Vasospasm, Intracranial ; Vomiting

Intracranial arterial stenosis usually occurs due to atherosclerosis and is considered the most common cause of stroke worldwide. Although the effectiveness of bypass surgery for ischemic stroke is controversial, the superficial temporal artery to the middle cerebral artery bypass for ischemic stroke is a common procedure. In our report, a 50-year-old man presented with sudden-onset left side weakness and dysarthria. An angiogram showed significant stenosis in the junction of the right cavernous-supraclinoid internal carotid artery and right pericallosal artery. Symptoms altered between improvement and deterioration. Magnetic resonance imaging showed a repeated progression of anterior cerebral artery (ACA) infarction despite maximal medical therapy. We performed a STA-ACA bypass with contralateral STA interposition. Postoperative course was uneventful with no further progression of symptoms. Thus, bypass surgery may be considered in patients with symptomatic stenosis or occlusion of the ACA, especially when patients present progressive symptoms despite maximal medical therapy.
Anterior Cerebral Artery ; Arteries ; Atherosclerosis ; Carotid Artery, Internal ; Cerebral Revascularization ; Constriction, Pathologic* ; Dysarthria ; Humans ; Infarction ; Magnetic Resonance Imaging ; Middle Aged ; Middle Cerebral Artery ; Stroke ; Temporal Arteries ; Transplants*

The artery of Percheron (AOP) is an uncommon variant of the paramedian artery, a solitary trunk branching off from the posterior cerebral arteries, supplying both paramedian thalami, and also often the rostral midbrain and the anterior thalamus. The typical clinical manifestations of the AOP infarction include altered mental status, cognitive impairment, and oculomotor dysfunction. We report a rare case with AOP infarction, and the clinical characteristics and rehabilitation courses for alertness disorder, cognitive dysfunction, and other accompanied symptoms.
Anterior Thalamic Nuclei ; Arteries* ; Cognition ; Cognition Disorders ; Infarction* ; Mesencephalon ; Ophthalmoplegia ; Posterior Cerebral Artery ; Rehabilitation ; Thalamus

BACKGROUND AND PURPOSE: The outcomes of acute internal carotid artery (ICA) terminus occlusions are poor. We classified ICA terminus occlusions into 2 groups according to the occlusion pattern of the circle of Willis and hypothesized that clinical outcomes would significantly differ between them. METHODS: Consecutive patients with acute ICA terminus occlusions evaluated by baseline computed tomographic angiography were enrolled. We investigated the occlusion patterns in the circle of Willis, retrospectively classified patients into simple ICA terminus occlusion (STO; with good Willisian collaterals from neighboring cerebral circulation) and complex ICA terminus occlusion (CTO; with one or more of A2 anterior cerebral artery, fetal posterior cerebral artery occlusion, or hypoplastic/absent contralateral A1; or with poor collaterals from anterior communicating artery) groups, and compared their baseline characteristics and outcomes. RESULTS: The STO group (n=58) showed smaller infarct volumes at 72 hours than the CTO group (n=34) (median, 81 mL [interquartile range, 38-192] vs. 414 mL [193-540], P<0.001) and more favorable outcomes (3-month modified Rankin Scale 0-3, 44.8% vs. 8.8%, P<0.001; 3-month mortality, 24.1% vs. 67.6%, P<0.001). In multivariable analyses, STO remained an independent predictor for favorable outcomes (odds ratio 6.1, P=0.010). CONCLUSIONS: Favorable outcomes in STO group suggested that the outcomes of acute ICA terminus occlusions depend on Willisian collateral status. Documenting the subtypes on computed tomographic angiography would help predict patient outcome.
Angiography ; Anterior Cerebral Artery ; Carotid Artery Thrombosis ; Carotid Artery, Internal ; Cerebral Infarction ; Circle of Willis ; Collateral Circulation ; Endovascular Procedures ; Humans ; Mortality ; Posterior Cerebral Artery ; Retrospective Studies

We report a patient with a severe limitation of function in the right hand resulting from grasp reflex following a stroke affecting the left anterior cerebral artery region. We describe, using diffusion tensor tractography (DTT), a disconnection between the bilateral frontal lobes via the corpus callosum. The patient could not control his right hand at all, even though his bilateral corticospinal tracts were intact. We noted that over the infarcted lesion on DTT, the white matter was invisible from the corpus callosum to the prefrontal cortex. These findings reflected a unique pattern of white-matter disconnection between the ipsilateral medial frontal lobe and ipsilateral and contralateral frontal cortex causing hand function deterioration in the form of severe grasp reflex.
Anterior Cerebral Artery ; Corpus Callosum ; Diffusion ; Frontal Lobe* ; Hand ; Hand Strength* ; Humans ; Infarction* ; Prefrontal Cortex ; Pyramidal Tracts ; Reflex* ; Stroke

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*

There are several documented cases of coexistence of Graves' disease and Moyamoya disease, but an association between thyrotoxicosis and Moyamoya disease is largely unknown. A 32-year-old woman presented with impaired consciousness and left hemiparesis. Brain magnetic resonance imaging revealed acute infarction in the territory of the bilateral anterior cerebral arteries and occlusion of both internal carotid arteries. Antithyroid medication improved the patient's consciousness. Thyrotoxicosis could be a cause of acute infarction in patients with Moyamoya disease.
Adult ; Anterior Cerebral Artery ; Brain ; Carotid Artery, Internal ; Cerebral Infarction ; Consciousness ; Female ; Graves Disease ; Humans ; Infarction ; Magnetic Resonance Imaging ; Moyamoya Disease* ; Paresis ; Stroke* ; Thyroid Crisis* ; Thyrotoxicosis

Cardiac myxoma is the most common primary tumor of the heart and development of a cerebral aneurysm is rare in cardiac myxoma patients. We present the case of a 57-year-old asymptomatic male with multiple aneurysms in the cerebral and coronary arteries complicated by cardiac myxoma. Multiple cerebral aneurysms were fusiform shaped and located in the right middle cerebral artery, right anterior cerebral artery, right anterior choroidal artery, and left anterior cerebral artery. A coronary artery aneurysm was also located in the distal left circumflex artery with subendocardial myocardial infarction seen by cardiac magnetic resonance imaging (MRI). The cardiac myxoma was surgically removed and 1 month after surgical resection, there was no progression of the aneurysms on follow-up brain MRI.
Aneurysm* ; Anterior Cerebral Artery ; Arteries ; Brain ; Choroid ; Coronary Aneurysm* ; Coronary Vessels ; Follow-Up Studies ; Heart ; Humans ; Intracranial Aneurysm ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Middle Cerebral Artery ; Myocardial Infarction ; Myxoma*

Terson syndrome is a vitreous hemorrhage associated with subarachnoid hemorrhage. This can be caused by spontaneous, aneurysmal rupture or traumatic subarachnoid hemorrhage, but never has been reported as a consequence of hemorrhage due to thrombolysis and thrombectomy treatments of acute ischemic stroke patient. A 48-year-old man presented with left sided weakness was diagnosed as cerebral infarction on right middle cerebral artery territory due to complete occlusion of right distal internal carotid, middle cerebral, and anterior cerebral artery. He underwent thrombolysis and mechanical thrombectomy, and subarachnoid hemorrhage developed. Later, visual disturbance on right eye occurred so he was consulted to ophthalmology. Vitreous hemorrhage was found and surgery was recommended after two weeks of observation. After pars planar vitrectomy, visual acuity improved, along with functional ability. Therefore, possibilities of Terson syndrome in patients with subarachnoid hemorrhage have to be kept in mind to improve not only visual acuity but also rehabilitation outcome.
Aneurysm ; Anterior Cerebral Artery ; Cerebral Infarction ; Hemorrhage ; Humans ; Middle Aged ; Middle Cerebral Artery ; Ophthalmology ; Rupture ; Stroke* ; Subarachnoid Hemorrhage* ; Subarachnoid Hemorrhage, Traumatic ; Thrombectomy* ; Treatment Outcome ; Visual Acuity ; Vitrectomy ; Vitreous Hemorrhage

Moyamoya disease is a cerebrovascular disease of unknown etiology, which is characterized by bilateral stenosis or occlusion at terminal portion of internal carotid artery and at proximal portion of anterior cerebral artery and/or middle cerebral artery and abnormal vascular network in the vicinity of the arterial occlusions. It occurs frequently in Asian countries, particularly in Korea and Japan, but is rare in Western countries. To establish the etiology of moyamoya disease, much about the pathology from autopsies, factors involved in its pathogenesis, and its genetics have been studied. It may occur at any age from childhood to adulthood and in general, initial manifestation is cerebral ischemic symptoms in children and intracranial hemorrhage symptoms in adults. Because it progress and cause recurrent stroke, early diagnosis and proper management has been recognized. Cerebral angiography is essential for definitive diagnosis and treatment plan. Magnetic resonance imaging/magnetic resonance angiography is useful for diagnosis and follow-up tools after revascularization. Evaluation of the cerebral hemodynamics by single photon emission computed tomography and positron emission tomography is useful for diagnosis and assessment of the severity of cerebral ischemia in moyamoya patients. Surgical revascularization is effective for moyamoya disease manifesting as ischemic symptoms, to prevent further ischemia and infarction. In hemorrhagic type moyamoya disease, revascularization can be considered. Direct bypass, indirect synangiosis and combined methods are used. Outcomes of revascularization are excellent in preventing transient ischemic attacks in most patients.
Adult ; Angiography ; Anterior Cerebral Artery ; Asian Continental Ancestry Group ; Autopsy ; Brain Ischemia ; Carotid Artery, Internal ; Cerebral Angiography ; Cerebral Hemorrhage ; Child ; Constriction, Pathologic ; Early Diagnosis ; Follow-Up Studies ; Hemodynamics ; Humans ; Infarction ; Intracranial Hemorrhages ; Ischemia ; Ischemic Attack, Transient ; Japan ; Korea ; Magnetic Resonance Spectroscopy ; Middle Cerebral Artery ; Moyamoya Disease ; Positron-Emission Tomography ; Stroke ; Tomography, Emission-Computed, Single-Photon