A 79-year-old woman presented with a subarachnoid hemorrhage. Angiography revealed pseudoaneurysm formation due to rupture of a true saccular anterior communicating artery aneurysm. Coil embolization, limited to the true aneurysm, was performed successfully with a favorable clinical outcome. This procedure can be considered as an alternative treatment option for similar aneurysms in cases where surgical clipping is contraindicated.

Background:We report a case of steroid-resistant Tolosa–Hunt syndrome (THS) with recurrent bilateral painful ophthalmoplegia, accompanied with sphenoid sinusitis, pituitary abscess, and an aneurysm arising from the cavernous portion of the internal carotid artery.Case Description:A 53-year-old woman suffered severe left painful ophthalmoplegia. A magnetic resonance image (MRI) revealed thickness of the left cavernous sinus (CS). Steroid was administrated under the diagnosis of THS, and the symptom transiently diminished. However, painful ophthalmoplegia fluctuated bilaterally after tapering the steroid. An MRI showed development of bilateral cavernous lesions associated with sphenoid sinusitis, pituitary abscess, and an aneurysm in the left C4 segment. Biopsy and drainage of the lesions were performed with an endoscopic transsphenoidal procedure. The histological examination showed nonspecific granulomatous inflammation. The methotrexate (MTX) was effective to reduce the CS and pituitary lesions; however, the aneurysm slightly increased and remained unchanged in size thereafter.Conclusions:To our knowledge, this is the first report of a growing de novo C4 aneurysm in THS. Surgical intervention and administration of MTX should be attempted in steroid-resistant THS. Careful observation with serial MRI and MR angiography is important to manage the complicated THS.

We report three cases of scalp rupture after cranioplasty using titanium plates ． Case l is a 68 − year

Anterior communicating artery (ACoA) aneurysms have a complex architecture and many variations, making endovascular therapy more difficult in some cases. The aim of this study was to investigate whether the neck position of an aneurysm was identifiable for determining the immediate angiographic success and procedural complications in the coiling of the ACoA aneurysms. We conducted a retrospective case review of 40 patients with ACoA aneurysms treated by endovascular therapy from 2008 to 2015. The mean age was 66.8 years. Thirty-five aneurysms were ruptured; five were unruptured. For the analysis, the patients were divided into two groups according to the neck position of aneurysms: the true ACoA group, 9 patients with the neck located on the ACoA itself; and the other ACoA group, 31 patients with the neck at the junction of the A1 and A2 portions of an anterior cerebral artery. Morphological characteristics (dome size, dome direction, rate of wide neck, and angulation of aneurysms in relation to the parent artery) were analyzed along with immediate angiographic results, volume embolization ratio (VER), and procedural complications. Small aneurysms with superior dome projection and acute angulation of the aneurysm direction occurred more often in the true ACoA group. The rates of complete obliteration, VER, and procedural complications were 33.3%, 32.3%, and 22.2% in the true ACoA group and 54.8%, 36.3%, and 6.5% in the other ACoA group, respectively. True ACoA aneurysms could present an anatomical difficulty in endovascular coiling. Aneurysmal neck position should be accurately assessed to achieve successful embolization of the ACoA aneurysms.

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