Background: Initial three-dimensional computed tomography angiography and cerebral angiography fail to identify any aneurysm in 20% of cases of subarachnoid hemorrhage. Basilar artery (BA) perforator aneurysm is rare and about 30-60% were not identi ed by initial angiography.Case presentation: A 71-year-old male was transferred with sudden onset of headache and loss of consciousness. Computed tomography demonstrated subarachnoid hemorrhage, but no ruptured aneurysm was detected. Repeat preoperative cerebral angiography indicated bifurcation aneurysm of the circum ex branch of the superior cerebellar artery perforator but microsurgical observation identi ed BA perforator aneurysm.Conclusions: If the location of the BA perforator aneurysm cannot be clearly identi ed, as in this case, repeat angiography should be considered, and the treatment strategy should be decided based on detailed consideration of the site of the aneurysm. BackgroundSubarachnoid hemorrhage (SAH) of unknown etiology is classi ed into perimesencephalic and non-perimesencephalic types based on the ndings of computed tomography (CT). Since non-perimesencephalic SAH is often caused by rupture of a cerebral aneurysm and carries a poor prognosis due to rebleeding, identifying the rupture point is important. No aneurysm is detected in about 20% of cases of SAH by the initial threedimensional CT angiography (3DCTA) or cerebral angiography [1]. In particular, aneurysms of the perforator of the basilar artery (BA) are di cult to diagnose because of the small size and the shape may undergo changes caused by thrombosis [2]. We experienced a rare case of SAH in which repeat preoperative angiography showed aneurysm of the superior cerebellar artery (SCA) perforator, but the actual aneurysm location was on the BA perforator in the intraoperative ndings. Case PresentationA 71-year-old male was transferred to our hospital after sudden onset of headache and loss of consciousness. Consciousness level was Glasgow Coma Scale (GCS) 12 (E3V4M5) and blood pressure was 210/120 mmHg on admission. Laboratory evaluations did not show any abnormalities. He had a medical history of hypertension and angina after percutaneous coronary intervention. Head CT demonstrated SAH (Hunt and Kosnik grade IV, World Federation of Neurosurgical Societies grade IV) extending from the premedullary cisterns superiorly into the bilateral sylvian ssures and interhemispheric ssure (Fisher group 3) (Fig. 1a). However, 3DCTA of the cerebral vessels demonstrated no clear evidence of ruptured cerebral aneurysm.Digital subtraction angiography (DSA) performed on the day after admission found no cerebral aneurysm (Fig. 1b). Repeat conventional angiography showed no obvious aneurysm on day 5, but multi-planar reconstruction (MPR) angiography showed a tiny aneurysm between the BA and the left SCA (Fig. 1c). However, since the origin of the aneurysm was not clear, no treatment strategy could be established. MPR angiography on day 14 showed an aneurysm with a neck on the SCA, which was slightly different...
Background: Initial three-dimensional computed tomography angiography and cerebral angiography fail to identify any aneurysm in 20% of cases of subarachnoid hemorrhage. Basilar artery (BA) perforator aneurysm is rare and about 30–60% were not identified by initial angiography.Case presentation: A 71-year-old male was transferred with sudden onset of headache and loss of consciousness. Computed tomography demonstrated subarachnoid hemorrhage, but no ruptured aneurysm was detected. Repeat preoperative cerebral angiography indicated bifurcation aneurysm of the circumflex branch of the superior cerebellar artery perforator but microsurgical observation identified BA perforator aneurysm.Conclusions: If the location of the BA perforator aneurysm cannot be clearly identified, as in this case, repeat angiography should be considered, and the treatment strategy should be decided based on detailed consideration of the site of the aneurysm.
We herein show a case of symptomatic common carotid artery occlusion that underwent bonnet bypass (contralateral superficial temporal artery (STA) -saphenous vein (SV) -cortical segment (M4) of the middle cerebral artery (MCA) bypass) using an SV graft. STA-MCA bypass surgery has been established for the prevention of secondary cerebral infarction of symptomatic internal carotid artery occlusion. On the other hand, there has been no standard surgical treatment for symptomatic common carotid artery occlusion. It has been reported that bonnet bypass using donor grafts is effective for these pathological conditions. We herein performed bonnet bypass surgery using an SV graft as a donor graft. The vascular reserve was improved in quantitative single photon emission computed tomography, the bypass patency was also spared, and the postoperative course was uneventful.
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