Cases reported "Subarachnoid Hemorrhage"

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1/124. Recanalization and rupture of a giant vertebral artery aneurysm after hunterian ligation: case report.

    OBJECTIVE AND IMPORTANCE: Recanalization and subsequent rupture of giant aneurysms of the posterior circulation after Hunterian ligation is an extremely rare event that has been noted to occur with basilar apex, basilar trunk, and vertebrobasilar junction aneurysms. We report the case of a giant, previously unruptured right vertebral artery aneurysm, which recanalized from the contralateral vertebral artery and subsequently ruptured after previously performed angiography showed complete thrombosis of the aneurysm. CLINICAL PRESENTATION: A 72-year-old woman presented with headaches, ataxia, and lower extremity weakness. A giant 3-cm right vertebral artery aneurysm was found during the patient evaluation. INTERVENTION: Because of the size of the aneurysm and the absence of a discrete neck, Hunterian ligation was performed. After treatment, angiograms showed no filling of the aneurysm from either the right or left vertebral artery. Nine days later, after the patient developed lethargy and nausea, repeat angiography showed that a small portion of the aneurysmal base had recanalized. The next day, the patient had a massive subarachnoid hemorrhage and subsequently died. CONCLUSION: We think that this is a previously undescribed complication associated with direct arterial ligation of giant vertebral artery aneurysms. patients with aneurysms treated using Hunterian ligation need to be followed up closely. Even aneurysms that have minimal recanalization are at risk for subarachnoid hemorrhage.
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2/124. Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients.

    OBJECT: To enhance visual confirmation of regional anatomy, endoscopy was introduced during microsurgery for cerebral aneurysms. The risks and benefits are analyzed in the present study. methods: The endoscopic technique was used during microsurgery for 54 aneurysms in 48 patients. Forty-three aneurysms were located in the anterior circulation and 11 were in the posterior circulation. Thirty-eight aneurysms (70.4%) had not ruptured. All ruptured aneurysms in the present series produced Hunt and Hess Grade I or II subarachnoid hemorrhage. After initial exposure achieved with the aid of a microscope, the rigid endoscope was introduced to confirm the regional anatomy, including the aneurysm neck and adjacent structures. The necks of 43 aneurysms were clipped using microscopic control or simultaneous microscopic/endoscopic control. After clipping, the positions of the clip and nearby structures were inspected using the endoscope. Use of the neuroendoscope provided useful information that further clarified the regional anatomy in 44 cases (81.5%) either before or after neck clipping. In nine cases (16.7%), these details were available only with the use of the endoscope. In five cases (9.3%), the surgeons reapplied the clip on the basis of endoscopic information obtained after the initial clipping. There were two cases in which surgical complications were possibly related to the endoscopic procedures (one patient with asymptomatic cerebral contusion and another with transient oculomotor palsy). CONCLUSIONS: It is the authors' impression that the use of the endoscope in the microsurgical management of cerebral aneurysms enhanced the safety and reliability of the surgery. However, there is a prerequisite for the surgeon to be familiar with this instrumentation and fully prepared for the risks and inconveniences of endoscopic procedures.
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3/124. Ballonn-assisted Guglielmi detachable coiling of wide-necked aneurysma: Part II--clinical results.

    OBJECTIVE: To demonstrate the indications and efficacy of balloon-assisted Guglielmi detachable coiling (BAGDC). methods: BAGDC was used for 23 patients (19 women and 4 men; mean age, 55 yr) (17%) of a series of 136 consecutive patients who underwent Guglielmi detachable coiling of aneurysms. Every aneurysm had a wide neck, and 57% were large (11-25 mm in diameter). In each case, a nondetachable silicone balloon was advanced in the parent artery and inflated to occlude the neck of the aneurysm and stabilize the Guglielmi detachable coil delivery microcatheter at the aneurysm neck. Guglielmi detachable coils were then deposited. The balloon was then deflated to verify appropriate coil placement and stability, and finally, the Guglielmi detachable coils were detached. This process was repeated until the aneurysm was suitably embolized. RESULTS: One hundred percent aneurysm embolization was achieved in 19 patients (83%), and 95 to 100% embolization was achieved in 4 patients (17%). Twenty-two patients (96%) were at their preprocedure neurological baseline after the procedure. There were three complications in the study. One patient died after sustaining subarachnoid hemorrhage-induced vasospasm followed by a hemorrhagic infarction. She had undergone an unsuccessful clip ligation of her aneurysm. A second patient developed an intra-arterial thrombus at the site of balloon deployment. She sustained ischemic events that were treated with thrombolysis and anticoagulation. She made a complete recovery. A third patient developed an intra-arterial thrombus that was noted during the procedure. She was treated with intra-arterial thrombolysis and experienced no clinical sequelae. No permanent complications could be attributed to the BAGDC technique. The median clinical follow-up time was 10 months. No patient required additional treatment or developed a recurrent aneurysm neck or lumen. CONCLUSION: BAGDC is a promising adjunct to the treatment of wide-necked aneurysms. The balloon serves two purposes: it stabilizes the microcatheter in the aneurysm during coil delivery, and it forces the coil to assume the three-dimensional shape of the aneurysm without impinging on the parent artery.
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4/124. Anaesthesia for caesarean section in a patient with recent subarachnoid haemorrhage and severe pre-eclampsia.

    Subarachnoid haemorrhage is a leading 'indirect' cause of maternal death in the UK. We describe the case of a 43-year-old woman who presented with headache, photophobia and neck stiffness of sudden onset at 32 weeks' gestation. Cerebral computed tomography demonstrated subarachnoid blood in the cisterns around the midbrain, and oral nimodipine was started to prevent vasospasm. Preparations were made for endovascular coil embolisation in the event of identification of a posterior circulation aneurysm. However, angiography under general anaesthesia failed to reveal any vascular abnormality. On emergence from anaesthesia, headache persisted, and over the next 24 h severe pre-eclampsia developed. magnesium sulphate was started, and urgent Caesarean section performed under general anaesthesia without incident. The rationale for the neuroradiological, obstetric and anaesthetic management is discussed.
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5/124. Cervical subarachnoid hematoma of unknown origin: case report.

    OBJECTIVE AND IMPORTANCE: Spontaneous spinal subarachnoid hematoma is rare, having been reported in the English literature in only seven other cases. We describe the first case of spontaneous subarachnoid hematoma located in the cervical spinal cord of a 43-year-old man. The pathologic examination showed no apparent source of bleeding, but there was evidence of cervical spondylotic myelopathy. CLINICAL PRESENTATION: The patient presented with a 10-day history of severe neck pain, followed by the onset of quadriparesis that was more evident on the left side, urinary retention, and sensory loss below C5. His medical history included hypertension. magnetic resonance imaging showed a massive hemorrhage in the cervical spinal canal. INTERVENTION: A C4-C5 subarachnoid hematoma was removed. The patient died due to respiratory distress and uncontrollable hypotension on day 6 after surgery. Surgical exploration, neuroradiologic examinations, and autopsy showed no evidence of vascular malformations, tumors, or other possible sources of bleeding. CONCLUSION: After excluding more common causes of spontaneous subarachnoid hematoma in this patient, we suggest that chronic spinal cord compression (spondylotic myelopathy) and arterial hypertension in this patient may have caused the pathogenesis of this rare clinical entity. Experimental data supporting this hypothesis are discussed.
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6/124. Traumatic basal subarachnoid hemorrhage due to rupture of the posterior inferior cerebellar artery--case report.

    A 20-year-old male presented with traumatic basal subarachnoid hemorrhage after being involved in a fight. Antemortem clinical examinations could not exclude the possibility of rupture of abnormal blood vessels because of the absence of external injuries. Careful postmortem examination of the head and neck regions and histological examination of the intracranial arteries demonstrated traumatic rupture of the left posterior inferior cerebellar artery due to a fist blow to the jaw. This case indicates the need for careful autopsy examination for the differentiation of traumatic and non-traumatic basal subarachnoid hemorrhages.
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7/124. Clinical study on recurrent intracranial aneurysms.

    The authors report 11 cases who underwent reoperations upon for recurrent aneurysms. The initial operations were performed on average 10.1 years earlier for subarachnoid hemorrhage (SAH). The patients' mean age at the first surgery was 39.7 years. The locations were 9 internal carotid (IC)-posterior communicating artery (PC) and 2 anterior communicating artery (A-com) aneurysms. A residual aneurysmal neck after the first operation was observed in 3 of 10 cases confirmed by postoperative angiography. The primitive-type PC artery was seen in 8 of 9 recurrent IC-PC aneurysms. The recurrent manifestations were SAH in 9 cases. Clipping operations were conducted in 10 and ligation of the IC artery together with extracranial-intracranial bypass in 1 large IC-PC aneurysm. The present study demonstrated two risk factors for aneurysm recurrence, namely, young age and IC-PC aneurysms with a primitive-type PC. Furthermore, direct operation for recurrent aneurysm is often embarrassing due to adhesions to the surrounding tissue as a sequela of the previous operation, hence understanding of the anatomical correlation between the old clip and the recurrent portion is important.
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8/124. Spontaneous disappearance and reappearance of a ruptured cerebral aneurysm: one case found in a group of 33 consecutive patients with subarachnoid hemorrhage who underwent repeat angiography.

    The spontaneous disappearance and reappearance of a ruptured cerebral aneurysm is generally assumed to be a rare phenomenon although the actual incidence is unknown. Among 39 consecutive cases of acute subarachnoid hemorrhage (SAH), 33 were studied by three-dimensional computed tomographic angiography (CTA) within 6 h after the onset of SAH, followed by digital subtraction angiography (DSA) within 24 h after the ictus. Of those patients, one, a 58-year-old woman, had a saccular aneurysm at the distal anterior cerebral artery; the aneurysm was clearly demonstrated by CTA 2.5 h after the SAH onset, but was not shown by a subsequent DSA performed 8.5 h after the ictus. A follow-up DSA detected the neck of aneurysm on day 11, and the whole aneurysm was visualized on day 19. The observations in this particular case suggest that the spontaneous disappearance of a ruptured cerebral aneurysm may occur during the ultra-early stage of SAH and that reappearance may follow during the next few weeks. The patient did not suffer complications such as vasospasm or systemic hypotension nor was she treated with antifibrinolytic agents. The aneurysmal shape and the surrounding clot are considered as putative factors possibly related to the intermittent appearance of the aneurysm.
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9/124. Surgery of basilar aneurysms associated with unexpected rupture of an internal carotid artery aneurysm.

    During a surgery of basilar aneurysms via the trans-sylvian approach, we encountered an arterial bleeding caused by rupture of an internal carotid artery aneurysm that had been difficult to diagnose before surgery, as it was a small and brood-neck aneurysm and mimicked arteriosclerosis. In spite of several surgical procedures, the surgical path at the basilar aneurysms became narrow, and we had to abandon the clipping of the aneurysms. Consideration of radiological and intraoperative findings was made for this case, demonstrating a pitfall that neurosurgeons may encounter during surgery.
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10/124. Analysis of slipstream flow in a wide-necked basilar artery aneurysm: evaluation of potential treatment regimens.

    SUMMARY: A replica of a lethal wide-necked basilar artery aneurysm was created by casting a deceased patient's brain vessels and then placing the replica in a circuit of pulsating optically clear non-Newtonian fluid. Individual fluid slipstreams were opacified with isobaric dyes, and images were recorded on film. Studies were completed on the vascular replica, then were repeated, first after placement of a stent across the aneurysm neck and then after placement of Guglielmi detachable coils into the aneurysm sac through the stent. The slipstreams entered the untreated aneurysm via the distal aneurysm neck (the inflow zone), impacting against the distal lateral aneurysm wall. When the stent was placed across the aneurysm neck, the slipstreams lost coherence and did not strike the aneurysm sidewall. Placing the coils further disturbed and reduced aneurysmal flow, especially when the coils filled the inflow zone at the distal lateral aneurysm sac.
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