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We experienced a case of unruptured internal carotid artery aneurysm improved endocrinological function after the treatment. A 68-year-old woman was admitted to our hospital complaining of general fatigue, dizziness, and decreased visual acuity. Radiological examination revealed unruptured large aneurysm at the right anterior carotid artery compressing on the pituitary gland. We underwent right STA-MCA bypass and trapping of right internal carotid artery. Post-operative course was uneventful. Although visual function was not improved, her endocrinological function was improved 8 months after surgery by thrombosed and shrunken aneurysm. The mechanism of panhypopituitarism due to aneurysm has been suggested to involve mechanical compression on the pituitary gland, pituitary stalk, or hypophyseal artery. Although it was unclear about the improvement of endocrine function after the treatment of aneurysm, some cases could recover the hypopituitarism after enough follow-up period.

Intracranial pseudoaneurysms arising after radiotherapy for brain tumors are a relatively rare occurrence and associated with high-volume radiotherapy such as stereotactic radiosurgery. Herein, the authors report a rare case of intracranial pseudoaneurysm after conventional radiotherapy for oligodendroglioma. Case:A 46-year-old female incidentally presented with an intracranial hemorrhage from a middle temporal artery aneurysm. Four years earlier, she underwent surgical resection and conventional radiation therapy for oligodendroglioma. The aneurysm was successfully treated with middle cerebral artery(MCA)aneurysm trapping, in conjunction with a parietal branch superficial temporal artery-MCA bypass, to prevent re-rupture. Formation of intracranial pseudoaneurysm after conventional radiotherapy is extremely rare. However, the occurrence of cerebral aneurysm(s), as well as vascular stenosis during follow-up for brain tumors treated with radiotherapy, should be considered.

Recent advances in digital subtraction angiography(DSA)and 3D-CT angiography(3D-CTA)have enabled the identification of tiny intracranial aneurysms. However, the imaging of blood blister-like aneurysms(BBAs)in the internal carotid artery(ICA)is still challenging. We report the case of a subarachnoid hemorrhage(SAH)with a ruptured BBA in the ICA that was revealed by magnetic resonance vessel wall imaging(MR-VWI). A 68-year-old woman presented with SAH. CT showed diffuse SAH(Fisher group 3). 3D-CTA and DSA showed a small bulge in the right ICA. MR-VWI with gadolinium showed thick wall enhancement in the supraclinoid portion of the right ICA; hence, we diagnosed SAH because of the ruptured BBA of the right ICA. Trapping combined with high-flow bypass was performed for the ruptured BBA. We concluded that MR-VWI may be useful for diagnosing ruptured BBAs under strict blood pressure management.

We report a case of subarachnoid hemorrhage(SAH)with multiple cerebral aneurysms, in which magnetic resonance vessel wall imaging(MR-VWI)revealed the rupture site. A 68-year-old woman presented with SAH. Computed tomography(CT)showed diffuse SAH(Fisher group 3). 3D-CT angiography revealed two intracranial aneurysms:a 4.2-mm anterior communicating artery aneurysm(Acom An)and a 5.8-mm basilar tip aneurysm(BAtip An). As the BAtip An was the larger of the two, it was deemed the most likely site of rupture;however, high-resolution MR-VWI with gadolinium showed thick wall enhancement in the Acom An and no enhancement in the BAtip An. Thus, we performed a craniotomy for the Acom An. Intraoperative findings confirmed the rupture site at the Acom An. We concluded that high resolution MR-VWI may be useful for identifying the rupture site in patients with spontaneous SAH and multiple cerebral aneurysms.

Rete mirabile (or carotid rete) is a normal structure that plays physiological roles in the lower mammals. However, the rete does not exist in the normal carotid circulation of humans. Carotid rete mirabile (CRM) is a rare condition compensating for congenital dysplastic internal carotid artery. Arterial plexus at the cavernous region, which supplies intradural internal carotid artery instead of the aplastic cavernous portion of internal carotid artery, looks like the "rete mirabile" seen in the lower mammals, and is a characteristic angiographical finding of CRM. In addition to the CRM, existence of segmental occlusion and tortuous collaterals of vertebral artery, so-called carotid and vertebral rete mirabile (CVRM), is a very rare condition. We report a 70-year-old female patient with bilateral CVRM presenting with subarachnoid hemorrhage (SAH) caused by the rupture of a cervical spinal artery aneurysm. Our patient is the oldest, compared with the previously reported four patients with CVRM. Moreover, this is the first report of ruptured spinal artery aneurysm as a cause of SAH associated with CRM/CVRM. To avoid rebleeding in the patient, we successfully treated the patients by performing coil embolization of the remaining spinal aneurysms. In patients with CVRM, aneurysm formation of the cervical spinal artery may be a reasonable consequence because of the hemodynamic stress on the spinal artery as a collateral pathway. Detailed evaluation of the cervical spinal arteries should be performed to detect or to rule out ruptured aneurysm in patients with SAH associated with CVRM.

Objective: Patients with subarachnoid hemorrhage and multiple intracranial aneurysms present a unique challenge to the neurosurgeon. Unless all aneurysms can be clipped through a single craniotomy, the surgeon must accurately determine which aneurysm has ruptured. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true ruptured lesion. We assessed the risk of false localization of the rupture site and subsequent rebleeding and documented the problems in predicting the true rupture site when patients have multiple intracranial aneurysms., Method: We reviewed the records of a consecutive series of 93 patients treated over a period of 12 years who presented with their first subarachnoid hemorrhage and who had multiple intracranial aneurysms. The rupture site was determined on the basis of computed tomographic and angiographic findings, and the supposed ruptured aneurysm was clipped within 2 days of hemorrhage in each patient. Additional aneurysms that could not be accessed in the same surgical session were operated on at a later stage. All patients' records were reviewed, and all computed tomographic scans and angiograms, including repeat studies performed in some patients, were retrospectively reevaluated by the authors, who had no knowledge of the patients' clinical information., Results: The location of the aneurysm that ruptured was verified at the time of surgery or during the autopsy in 76 patients (82%). The aneurysm that ruptured was the one predicted as ruptured by the surgeon before surgery in 69 patients (91%) and in retrospect in 72 patients (95%). Five of the 6 patients in whom the ruptured aneurysm was not correctly identified were thought to have only a single aneurysm. Four patients rebled after surgery, and 2 patients died as a result of the rebleeding., Conclusion: In the reported series, the most common cause of rebleeding soon after aneurysm surgery was failure to obliterate the ruptured aneurysm, usually because it was missed on the initial angiogram. The results support not only meticulous radiological investigation of all intracranial arteries before surgery but also thorough surgical inspection of the target aneurysm in all cases of subarachnoid hemorrhage even after one candidate lesion has been discovered.

BACKGROUND Multiple aneurysms, associated with distal anterior cerebral artery (ACA) aneurysm, are not rare; therefore, it is important to examine multiplicity of the aneurysms preoperatively. CASE REPORT A case of ruptured distal ACA aneurysm, associated with another one in a mirror position, is reported. A 43-year-old woman suffered subarachnoid hemorrhage. Conventional angiography demonstrated a saccular aneurysm on the bifurcation of the right or left distal ACA; however, magnetic resonance angiography (MRA) revealed two mirror-image aneurysms on both bifurcations. CONCLUSION MRA was useful for preoperative diagnosis of kissing aneurysms on distal ACAs.

Acute intracranial hemorrhages can be caused by cerebrovascular disease or head injury. Diagnostic imaging is in both cases sometimes similar, so it is difficult to make an exact diagnosis. We report a case of acute subdural hematoma due to head injury after loss of consciousness due to an aneurysmal rupture. A 52-year-old male was found out fallen on the floor in a state of unconsciousness and was brought to the nearest hospital. CT scan showed subarachnoid hemorrhage with left acute subdural hematoma and he was transported to our hospital. Angiography revealed a left MCA aneurysm. The next day, a clipping operation was performed but brain contusion was observed in the left frontal lobe. Postoperative CT scan showed contusional hematoma at the left frontal lobe and plain skull X-ray films demonstrated a diastatic fracture of the right lambdoid suture. Acute subdural hematoma due to the rupture of a cerebral aneurysm is sometimes recognized, but the first CT findings are similar to those observed after head injury. When the clinical course of onset is unclear, we must keep in mind that the cause of acute subdural hematoma may be head injury, even if angiography demonstrates abnormal vessels.

A 69-year-old female underwent surgery for subarachnoid hemorrhage due to a ruptured intracranial aneurysm. Nine additional aneurysms were found. Four of the latter nine aneurysms were clipped in a second operation, and two were wrapped.

Diurnal changes in vasopressin and oxytocin levels in cerebrospinal fluid were investigated under normal diurnal conditions. The patients examined had ruptured intracranial aneurysms, and underwent neck-clipping operations and continuous drainage from the basal cistern. All of the patients recovered consciousness without signs of neurological deficit. The investigations were conducted for 2 days starting 5-9 days after the neck-clipping operations were performed. The oxytocin concentration decreased as night fell, remained low during this period and then increased during the day. The vasopressin level demonstrated no definite rhythmic tendency. No correlation was revealed between the changes in the concentrations of either vasopressin or oxytocin in the cerebrospinal fluid and the osmolality.

The authors report a case of giant aneurysm in which extravasation of contrast medium was demonstrated during cerebral angiography and confirmed by computed tomography. A 33-year-old man suddenly lost consciousness and vomited frequently. Three hours later, he was admitted to our hospital in semicomatose state with left hemiplegia. Within two hours after admission, plain CT scan, enhanced CT scan, left carotid angiography and post-angiographic CT scan were performed. CT scan showed marked subarachnoid hemorrhage, left temporal intracerebral hematoma and oval mass which was remarkably enhanced in the left Sylvian fissure. First left carotid angiogram demonstrated a giant aneurysm of the middle cerebral artery which was measured 4.5 cm in maximum diameter. Second left carotid angiogram demonstrated an extravasation of contrast medium around the aneurysm. The patient immediately underwent CT scan, which showed enlargement of intracerebral hematoma and intraventricular high density area as added lesion. By regulation of window level, the presence of contrast medium due to intra-angiographic rupture of the aneurysm was confirmed. The patient expired fifteen hours after admission. At autopsy, the thrombus in the aneurysmal sac was hardly present and the wall of the sac was made mainly of collagen fibers. From the following two points this case was very interesting. However this aneurysm was very large, the thrombus in the aneurysmal sac was hardly present. Extravasation of contrast medium was clearly demonstrated during cerebral angiography with confirmation by computed tomography in the giant aneurysm.

A rare case of rapidly growing intracranial aneurysm is reported. The enlarged aneurysmal wall was extirpated and studied histologically. The cause of the rapid growth of the aneurysm is discussed.

The authors described a case with a saccular aneurysm of the persistent trigeminal artery (PTA) treated with intra- and extracranial proximal obliteration of the feeding arteries. PTA aneurysm is a rare disorder found only 14 cases in the literature. There have been only 4 cases treated by surgical procedure; 2 underwent direct surgery and the remaining 2 had carotid ligation. Both of the cases treated by direct obliteration of the aneurysm sustained diplopia and sensory disturbance around the orbit as postoperative neurological deficits. We thought another choice of treatment to reduce the risk of rupture of the aneurysm avoiding postoperative complications. Clinical presentation of the present case was rt-oculomotor palsy, which disappeared before the operation. Cerebral angiography disclosed an intracavernous sinus aneurysm with a broad neck arising from the rt-internal carotid-PTA junction. Bilateral posterior cerebral arteries were perfused by the rt-internal carotid artery was compressed manually, lt-vertebral angiography showed the aneurysm and the internal carotid artery simultaneously via the PTA as retrograde filling. Because the direct surgery might cause damage to the cranial nerves passing through the cavernous sinus, we employed proximal obliteration of the feeding vessels. The operation was done by the following steps: ligation of the cervical portion of the rt-internal carotid artery, rt-superficial temporal artery-middle cerebral artery anastomosis, clipping of the PTA at the basilar side.(ABSTRACT TRUNCATED AT 250 WORDS)