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Multiple fusiform aneurysms of the distal middle cerebral artery showing different radiological courses: A case report
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 8–10
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com
Case report
Multiple fusiform aneurysms of the distal middle cerebral artery showing different radiological courses: A case report Masatoshi Takagaki ⁎, Yuki Togami, Akira Murasawa, Kazutami Nakao Department of Neurosurgery, Kawachi General Hospital, Higashi-Osaka City, Osaka, Japan
a r t i c l e
i n f o
Article history: Received 6 February 2017 Accepted 30 April 2017 Available online xxxx Keywords: fusiform aneurysm middle cerebral artery dissecting aneurysm
a b s t r a c t Middle cerebral artery (MCA) fusiform aneurysms may occur in the proximal MCA, and distal MCA fusiform aneurysms are rare. Here we present a rare case of subarachnoid hemorrhage (SAH) with multiple fusiform aneurysms in the M3 portion, which showed different morphological changes. A 43-year-old left-handed man with sudden aphasia and left-side hemiparesis had SAH with intraparenchymal hemorrhage in the right parietal lobe. Digital subtraction angiography (DSA) revealed multiple fusiform aneurysms in the M3 portion. Repeat DSA performed on day 29 demonstrated morphological changes in one fusiform aneurysm. We performed aneurysm trapping, and pathological examination indicated a dissecting aneurysm. Three-dimensional computed tomography angiography performed 4 months after onset revealed a decrease in other fusiform aneurysmal dilatations. This case showed two different clinical courses of fusiform aneurysms (regrowth and reduction). Frequent and close radiological examinations are necessary for ruptured multiple fusiform aneurysms. © 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Fusiform aneurysms of the middle cerebral artery (MCA) are rare; however, the number of cases is increasing [1–3]. These aneurysms may occur in proximal MCA; the rate of these aneurysms in distal MCA is approximately 10% [1]. MCA fusiform aneurysms cause hemorrhage and infarct; the natural course is unclear [3]. Although surgical management is reported for these cases, the strategy remains unclear because of anatomical features and necessity of preserving the distal blood flow [2]. We present a case of subarachnoid hemorrhage (SAH) with multiple fusiform aneurysms in the M3 portion showing different morphological changes. 2. Case presentation A 43-year-old left-handed man developed convulsive seizure for several minutes and was admitted to Kawachi General Hospital, Osaka, Japan. Two days later, he developed sudden aphasia and leftside hemiparesis. Emergency computed tomography (CT) demonstrated SAH with intraparenchymal hemorrhage at the right parietal lobe (Fig. 1A, B). Three-dimensional CT angiography (3D–CTA) showed slight irregular dilatation in the M3 portion of the anterior parietal and angular arteries, no saccular aneurysm, and vascular malformation.
⁎ Corresponding author at: Department of Neurosurgery, Kawachi General Hospital, 1-31, Yokomakura, Higashi-osaka city, Osaka 578-0954, Japan. E-mail address: [email protected] (M. Takagaki).
(Fig. 1E). Digital subtraction angiography (DSA) performed on the same day revealed similar findings (Fig. 1C). We planned conservative therapy because the two dilated vessel diameter was small (approximately 4 mm). Follow-up 3D–CTA (day 14) revealed no morphological changes in aneurysms. Repeat DSA (day 29) demonstrated an obvious increase in anterior parietal artery dilatation (Fig. 1D). Conversely, angular artery dilatation did not change. SAH was caused by rupture of the fusiform aneurysm of the anterior parietal artery; therefore, we performed trapping using an aneurysmal clip and resected the aneurysm (day 34). Postoperative CT and magnetic resonance imaging showed no ischemic lesion because of aneurysm resection (Fig. 2A, B). Resected lesion examination showed a disconnected internal elastic lamina along the wall and thickened intima (Fig. 2C, D). Follow-up 3D–CTA (day 42) showed no morphological change in the aneurysm of the angular artery. 3D– CTA (4 months after onset) revealed a decrease in angular artery dilatation (Fig. 1F).
3. Discussion Day et al. reviewed 102 MCA fusiform aneurysm cases with more frequent M1 or M2 lesions; M3 or M4 lesions were approximately 10% of all fusiform aneurysms [1]. Multiple fusiform aneurysms in the anterior circulation are rare [4]. Park et al. reported on pathological features of MCA dissecting aneurysms, with focal loss of the internal elastic lamina with or without marked thickening of the intima [2]. Here similar pathological features were noted; the aneurysm was diagnosed as a dissection.
http://dx.doi.org/10.1016/j.inat.2017.04.007 2214-7519/© 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Takagaki et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 8–10
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Fig. 1. Computed tomogramphy (CT) shows massive subarachnoid hemorrhage in the basal cistern with right parietal intraparenchymal hemorrhage (A, B). Admission digital subtraction angiography (DSA) demonstrates multiple aneurysmal dilatations of the M3 portion (C). Repeated DSA on day 29 shows morphological change in the fusiform aneurysm (D, arrow). 3D– CTA performed at onset and after 4 months (D, F) shows a decrease in remaining aneurysmal dilatation (arrowhead).
The natural course of MCA dissecting aneurysms is still unclear; therefore, appropriate management of these aneurysms remains controversial [2]. For ruptured VA dissecting aneurysms, urgent surgical treatment is recommended because of a high re-rupture rate [5]. Ohkuma et al. presented a series of MCA dissecting aneurysm rupture cases with re-bleeding in 50% cases [3]. Conversely, unruptured dissecting vertebrobasilar artery aneurysms remain morphologically unchanged in approximately 80% cases; therefore, close follow-up is recommended [6]. Asymptomatic MCA dissecting aneurysms should be conservatively treated unless serial neuroimaging assessments indicate significant enlargement over time [1]. Here during the first diagnostic imaging, it was not clear which aneurysm located in the M3 portion had ruptured. We selected conservative therapy with repetitive image analysis. Surgery was performed for the ruptured aneurysm. Saito et al. reported a case
with two MCA dissecting aneurysms that were resected. Pathological examination confirmed that both were dissecting aneurysms and one aneurysm had ruptured [7]. MCA dissecting aneurysms are treated by trapping with or without STA-MCA anastmosis and clipping [2,4]. To determine the risk of neurological worsening, somatosensitive and motor-evoked potentials were used when deciding on aneurysm trapping [8]. Recently, endovascular treatment for proximal MCA dissection was reported, in which a stentassisted coil technique was used to reserve distal blood flow [9]. We selected simple trapping of the M3 fusiform aneurysm. Endovascular surgery has been established as a treatment for VA dissecting aneurysms with coil embolization for distal MCA mycotic aneurysms [10]. Therefore, coil embolization could be possible for M3 dissecting aneurysms without bypass surgery.
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M. Takagaki et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 8–10
Fig. 2. Postoperative CT and MRI show no ischemic lesion (A, B). Pathological findings of the resected lesion show a disconnected internal elastic lamina along the wall and a thickened intima (C: HE staining, D: Elastica van Gieson staining).
4. Conclusion We reported a case of SAH with multiple fusiform aneurysms originating from the M3 portion. Different morphological changes in the fusiform aneurysms were observed under repeated radiological imaging. Frequent and close radiological examinations are necessary for multiple fusiform aneurysms. References [1] A.L. Day, C.G. Gaposchkin, C.J. Yu, D.J. Rivet, R.G. Dacey Jr., Spontaneous fusiform middle cerebral artery aneurysms: characteristics and a proposed mechanism of formation, J. Neurosurg. 99 (2003) 228–240. [2] S.-H. Park, M.-B. Yim, C.-Y. Lee, E. Kim, E.-I. Son, Intracranial fusiform aneurysms: it's pathogenesis, clinical characteristics and managements, J. Korean Neurosurg. Soc. 44 (2008) 116–123. [3] H. Ohkuma, S. Suzuki, N. Shimamura, T. Nakano, Dissecting aneurysms of the middle cerebral artery: neuroradiological and clinical features, Neuroradiology 45 (2003) 143–148. [4] M. Kurino, S. Yoshioka, Y. Ushio, Spontaneous dissecting aneurysm of aterior and middle cerebral artery associated with brain infarction: a case report with review of the literature, Surg. Neurol. 46 (2003) 357–360.
[5] C. Kitanaka, T. Sasaki, T. Eguchi, A. Teraoka, M. Nakane, K. Hoya, Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations, Neurosurgery 34 (1994) 620–627. [6] N. Kobayashi, Y. Murayama, I. Yuki, T. Ishibashi, M. Ebara, H. Arakawa, et al., Natural course of dissecting vertebrobasilar artery aneurysms without stroke, Am. J. Neuroradiol. 35 (2014) 1371–1375. [7] A. Saito, M. Fujimura, T. Inoue, H. Shimizu, T. Tominaga, Lectin-like oxidized lowdensity lipoprotein receptor 1 and matrix metalloproteinase expression in ruptured and unruptured multiple dissections of distal middle cerebral artery: case report, Acta Neurochir. 152 (2010) 1235–1240. [8] D.A. Gripp, F.J. Nakasone, M. Vinícius, C. Maldaun, P. Henrique, P. De Aguiar, Giant pseudoaneurysm originated from distal middle cerebral artery dissection treated by trapping under sensitive evoked potential and motor evoked potential monitoring: case report and discussion, Surg. Neurol. Int. 7 (2016) S214. [9] D.H. Nam, S.K. Park, Endovascular treatment in ruptured middle cerebral artery dissection preservation of arterial continuity, J. Cerebrovasc. Endovasc. Neurosurg. 17 (2015) 108. [10] J.Y. Chun, W. Smith, V. Van Halbach, R.T. Higashida, C.B. Wilson, M.T. Lawton, Current multimodality management of infectious intracranial aneurysms, Neurosurgery 48 (2001) 1203–1214.
Contents lists available at ScienceDirect
Interdisciplinary Neurosurgery: Advanced Techniques and Case Management journal homepage: www.inat-journal.com
Case report
Multiple fusiform aneurysms of the distal middle cerebral artery showing different radiological courses: A case report Masatoshi Takagaki ⁎, Yuki Togami, Akira Murasawa, Kazutami Nakao Department of Neurosurgery, Kawachi General Hospital, Higashi-Osaka City, Osaka, Japan
a r t i c l e
i n f o
Article history: Received 6 February 2017 Accepted 30 April 2017 Available online xxxx Keywords: fusiform aneurysm middle cerebral artery dissecting aneurysm
a b s t r a c t Middle cerebral artery (MCA) fusiform aneurysms may occur in the proximal MCA, and distal MCA fusiform aneurysms are rare. Here we present a rare case of subarachnoid hemorrhage (SAH) with multiple fusiform aneurysms in the M3 portion, which showed different morphological changes. A 43-year-old left-handed man with sudden aphasia and left-side hemiparesis had SAH with intraparenchymal hemorrhage in the right parietal lobe. Digital subtraction angiography (DSA) revealed multiple fusiform aneurysms in the M3 portion. Repeat DSA performed on day 29 demonstrated morphological changes in one fusiform aneurysm. We performed aneurysm trapping, and pathological examination indicated a dissecting aneurysm. Three-dimensional computed tomography angiography performed 4 months after onset revealed a decrease in other fusiform aneurysmal dilatations. This case showed two different clinical courses of fusiform aneurysms (regrowth and reduction). Frequent and close radiological examinations are necessary for ruptured multiple fusiform aneurysms. © 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http:// creativecommons.org/licenses/by-nc-nd/4.0/).
1. Introduction Fusiform aneurysms of the middle cerebral artery (MCA) are rare; however, the number of cases is increasing [1–3]. These aneurysms may occur in proximal MCA; the rate of these aneurysms in distal MCA is approximately 10% [1]. MCA fusiform aneurysms cause hemorrhage and infarct; the natural course is unclear [3]. Although surgical management is reported for these cases, the strategy remains unclear because of anatomical features and necessity of preserving the distal blood flow [2]. We present a case of subarachnoid hemorrhage (SAH) with multiple fusiform aneurysms in the M3 portion showing different morphological changes. 2. Case presentation A 43-year-old left-handed man developed convulsive seizure for several minutes and was admitted to Kawachi General Hospital, Osaka, Japan. Two days later, he developed sudden aphasia and leftside hemiparesis. Emergency computed tomography (CT) demonstrated SAH with intraparenchymal hemorrhage at the right parietal lobe (Fig. 1A, B). Three-dimensional CT angiography (3D–CTA) showed slight irregular dilatation in the M3 portion of the anterior parietal and angular arteries, no saccular aneurysm, and vascular malformation.
⁎ Corresponding author at: Department of Neurosurgery, Kawachi General Hospital, 1-31, Yokomakura, Higashi-osaka city, Osaka 578-0954, Japan. E-mail address: [email protected] (M. Takagaki).
(Fig. 1E). Digital subtraction angiography (DSA) performed on the same day revealed similar findings (Fig. 1C). We planned conservative therapy because the two dilated vessel diameter was small (approximately 4 mm). Follow-up 3D–CTA (day 14) revealed no morphological changes in aneurysms. Repeat DSA (day 29) demonstrated an obvious increase in anterior parietal artery dilatation (Fig. 1D). Conversely, angular artery dilatation did not change. SAH was caused by rupture of the fusiform aneurysm of the anterior parietal artery; therefore, we performed trapping using an aneurysmal clip and resected the aneurysm (day 34). Postoperative CT and magnetic resonance imaging showed no ischemic lesion because of aneurysm resection (Fig. 2A, B). Resected lesion examination showed a disconnected internal elastic lamina along the wall and thickened intima (Fig. 2C, D). Follow-up 3D–CTA (day 42) showed no morphological change in the aneurysm of the angular artery. 3D– CTA (4 months after onset) revealed a decrease in angular artery dilatation (Fig. 1F).
3. Discussion Day et al. reviewed 102 MCA fusiform aneurysm cases with more frequent M1 or M2 lesions; M3 or M4 lesions were approximately 10% of all fusiform aneurysms [1]. Multiple fusiform aneurysms in the anterior circulation are rare [4]. Park et al. reported on pathological features of MCA dissecting aneurysms, with focal loss of the internal elastic lamina with or without marked thickening of the intima [2]. Here similar pathological features were noted; the aneurysm was diagnosed as a dissection.
http://dx.doi.org/10.1016/j.inat.2017.04.007 2214-7519/© 2017 The Authors. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
M. Takagaki et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 8–10
9
Fig. 1. Computed tomogramphy (CT) shows massive subarachnoid hemorrhage in the basal cistern with right parietal intraparenchymal hemorrhage (A, B). Admission digital subtraction angiography (DSA) demonstrates multiple aneurysmal dilatations of the M3 portion (C). Repeated DSA on day 29 shows morphological change in the fusiform aneurysm (D, arrow). 3D– CTA performed at onset and after 4 months (D, F) shows a decrease in remaining aneurysmal dilatation (arrowhead).
The natural course of MCA dissecting aneurysms is still unclear; therefore, appropriate management of these aneurysms remains controversial [2]. For ruptured VA dissecting aneurysms, urgent surgical treatment is recommended because of a high re-rupture rate [5]. Ohkuma et al. presented a series of MCA dissecting aneurysm rupture cases with re-bleeding in 50% cases [3]. Conversely, unruptured dissecting vertebrobasilar artery aneurysms remain morphologically unchanged in approximately 80% cases; therefore, close follow-up is recommended [6]. Asymptomatic MCA dissecting aneurysms should be conservatively treated unless serial neuroimaging assessments indicate significant enlargement over time [1]. Here during the first diagnostic imaging, it was not clear which aneurysm located in the M3 portion had ruptured. We selected conservative therapy with repetitive image analysis. Surgery was performed for the ruptured aneurysm. Saito et al. reported a case
with two MCA dissecting aneurysms that were resected. Pathological examination confirmed that both were dissecting aneurysms and one aneurysm had ruptured [7]. MCA dissecting aneurysms are treated by trapping with or without STA-MCA anastmosis and clipping [2,4]. To determine the risk of neurological worsening, somatosensitive and motor-evoked potentials were used when deciding on aneurysm trapping [8]. Recently, endovascular treatment for proximal MCA dissection was reported, in which a stentassisted coil technique was used to reserve distal blood flow [9]. We selected simple trapping of the M3 fusiform aneurysm. Endovascular surgery has been established as a treatment for VA dissecting aneurysms with coil embolization for distal MCA mycotic aneurysms [10]. Therefore, coil embolization could be possible for M3 dissecting aneurysms without bypass surgery.
10
M. Takagaki et al. / Interdisciplinary Neurosurgery: Advanced Techniques and Case Management 10 (2017) 8–10
Fig. 2. Postoperative CT and MRI show no ischemic lesion (A, B). Pathological findings of the resected lesion show a disconnected internal elastic lamina along the wall and a thickened intima (C: HE staining, D: Elastica van Gieson staining).
4. Conclusion We reported a case of SAH with multiple fusiform aneurysms originating from the M3 portion. Different morphological changes in the fusiform aneurysms were observed under repeated radiological imaging. Frequent and close radiological examinations are necessary for multiple fusiform aneurysms. References [1] A.L. Day, C.G. Gaposchkin, C.J. Yu, D.J. Rivet, R.G. Dacey Jr., Spontaneous fusiform middle cerebral artery aneurysms: characteristics and a proposed mechanism of formation, J. Neurosurg. 99 (2003) 228–240. [2] S.-H. Park, M.-B. Yim, C.-Y. Lee, E. Kim, E.-I. Son, Intracranial fusiform aneurysms: it's pathogenesis, clinical characteristics and managements, J. Korean Neurosurg. Soc. 44 (2008) 116–123. [3] H. Ohkuma, S. Suzuki, N. Shimamura, T. Nakano, Dissecting aneurysms of the middle cerebral artery: neuroradiological and clinical features, Neuroradiology 45 (2003) 143–148. [4] M. Kurino, S. Yoshioka, Y. Ushio, Spontaneous dissecting aneurysm of aterior and middle cerebral artery associated with brain infarction: a case report with review of the literature, Surg. Neurol. 46 (2003) 357–360.
[5] C. Kitanaka, T. Sasaki, T. Eguchi, A. Teraoka, M. Nakane, K. Hoya, Intracranial vertebral artery dissections: clinical, radiological features, and surgical considerations, Neurosurgery 34 (1994) 620–627. [6] N. Kobayashi, Y. Murayama, I. Yuki, T. Ishibashi, M. Ebara, H. Arakawa, et al., Natural course of dissecting vertebrobasilar artery aneurysms without stroke, Am. J. Neuroradiol. 35 (2014) 1371–1375. [7] A. Saito, M. Fujimura, T. Inoue, H. Shimizu, T. Tominaga, Lectin-like oxidized lowdensity lipoprotein receptor 1 and matrix metalloproteinase expression in ruptured and unruptured multiple dissections of distal middle cerebral artery: case report, Acta Neurochir. 152 (2010) 1235–1240. [8] D.A. Gripp, F.J. Nakasone, M. Vinícius, C. Maldaun, P. Henrique, P. De Aguiar, Giant pseudoaneurysm originated from distal middle cerebral artery dissection treated by trapping under sensitive evoked potential and motor evoked potential monitoring: case report and discussion, Surg. Neurol. Int. 7 (2016) S214. [9] D.H. Nam, S.K. Park, Endovascular treatment in ruptured middle cerebral artery dissection preservation of arterial continuity, J. Cerebrovasc. Endovasc. Neurosurg. 17 (2015) 108. [10] J.Y. Chun, W. Smith, V. Van Halbach, R.T. Higashida, C.B. Wilson, M.T. Lawton, Current multimodality management of infectious intracranial aneurysms, Neurosurgery 48 (2001) 1203–1214.