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      Dissecting Aneurysm at the Proximal Segment of the Anterior Cerebral Artery Associated with Infraoptic Course Anterior Cerebral Artery

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          Abstract

          A 48-year-old man presented a subarachnoid hemorrhage caused by a rupture of a dissecting aneurysm at the proximal segment (A1 segment) of the right anterior cerebral artery (ACA). He also had an anomalous artery named infraoptic course ACA and an agenesis of the contralateral ACA A1 segment. Balloon occlusion test at the bifurcation of the right internal carotid artery demonstrated that the distal segments of the bilateral ACAs were perfused through the infraoptic course ACA. Therefore, we surgically trapped the A1 segment including the aneurysm. The patient got discharged without any neurological deficit. Natural course of ACA dissecting aneurysms is unclear because of rarity of the disease and treatment strategy is still controversial. Most of the dissecting aneurysms in the A1 segment are surgically treated, because they often present with massive hemorrhage and poor prognosis. In the present case, the contralateral A1 segment was absent but trapping of the dissecting aneurysm could be achieved without vascular reconstruction (e.g., bypass surgery) because of the presence of the infraoptic course ACA.

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          Most cited references 18

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          Recurrent subarachnoid hemorrhage from untreated ruptured vertebrobasilar dissecting aneurysms.

          The clinical characteristics of vertebrobasilar dissecting aneurysms occurring with subarachnoid hemorrhage (SAH) were reviewed in 42 patients, with particular focus on the time, incidence, and outcome in association with subsequent rupture. Twenty-nine patients underwent 31 surgical procedures, and the remaining 13 patients were managed without surgery. Surgical details included 19 proximal vertebral artery obliterations (including 1 case of endovascular surgery using balloon occlusion), 9 trappings, 1 wrapping, 1 bleb clipping, and 1 bleb clipping combined with wrapping. Surprisingly, subsequent rupture occurred in 30 (71.4%) of the 42 patients. Excluding one patient with postoperative rupture, 29 patients suffered a subsequent rupture in the unsecured stage. Of these 29 patients, 19 were operated on after the subsequent rupture and 10 were not operated on because of deteriorated clinical condition (9 patients) or anatomic considerations (1 patient). Of the 30 patients that suffered a subsequent rupture, 14 died. Twelve of the deaths were directly related to the second episode of rupture. Of the 12 patients who did not suffer a subsequent rupture, 10 underwent operations and there were no operative deaths. Only one patient died as the result of the initial critical SAH. The mortality (46.7%) of the patients with subsequent rupture was significantly higher (P < 0.05) than that (8.3%) of the patients without subsequent rupture. Seventeen (56.7%) of the 30 subsequent ruptures occurred within 24 hours after the first SAH, and 24 (80%) occurred within the first week. Six (66.7%) of the 9 patients operated on within 24 hours after the first SAH and 11 (68.8%) of the 16 patients operated on within a week suffered preoperative subsequent ruptures.(ABSTRACT TRUNCATED AT 250 WORDS)
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            Dissecting aneurysms of intracranial carotid circulation.

            Clinical features of nontraumatic dissecting aneurysms of intracranial carotid circulation remain unclear because investigation of this disease has been limited to case reports. The aim of this study was to investigate the clinical features of this disease through the use of cooperatively collected cases. The cases diagnosed as dissecting aneurysms of intracranial carotid circulation on the basis of clinical signs and neuroradiological findings in 46 stroke centers from 1995 through 1999 were collected, and their clinical features were analyzed. Forty-nine cases of dissecting aneurysms of intracranial carotid circulation were collected. Thirty-two patients presented with subarachnoid hemorrhage (SAH), and 17 presented with cerebral ischemia. The ratio of this disease to all intracranial dissecting aneurysms treated in the same institutes for the same period was 19.1%, and the ratio of SAH resulting from this disease to SAH of unverified origin treated in the same institutes for the same period was 6.2%. The predominant site of lesion was the internal carotid artery in 18 of 32 patients (56%) with SAH and the anterior cerebral artery in 13 of 17 patients (76%) with cerebral ischemia. The predominant angiographic findings were that stenosis with dilatation occurred in 20 of 32 patients (63%) with SAH and stenosis without dilatation was seen in 11 of 17 patients (65%) with cerebral ischemia. Poor prognosis was seen in 21 of 32 patients (66%) with SAH, which was due largely to rebleeding seen preoperatively, during operation, and even postoperatively when clipping or wrapping of the aneurysmal bulge was performed. Nontraumatic dissecting aneurysm of intracranial carotid circulation is not as rare as expected. It seems to be one of the important causes of SAH of unverified origin.
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              Neuroradiologic and clinical features of arterial dissection of the anterior cerebral artery.

              Case reports of nontraumatic arterial dissection of the anterior cerebral artery (ACA) have recently increased. The aim of this study was to investigate the neuroradiologic and clinical features of ACA dissection based on a series of collected cases. The cases of 18 patients with a diagnosis of ACA dissection based on clinical signs and neuroradiologic findings from 46 stroke centers during a 5-year period were collected. The neuroradiologic and clinical records were analyzed. The mean patient age was 52.8 +/- 9.8 years. Five cases presented with subarachnoid hemorrhage, nine with cerebral ischemia, and four with both ischemic symptoms and subarachnoid hemorrhage. In cases presenting with ischemia, the main site of the lesion was the A2 portion and the main angiographic finding was stenosis with or without dilation. Follow-up angiography showed progression of the stenosis in the acute stage and resolution of the stenosis in the chronic stage. Hyperintensity around the flow void due to intramural hematoma on T1-weighted MR images was often seen during the second week. In all cases, the findings of MR angiography corresponded to the findings of cerebral angiography. Eight of nine cases showed a good prognosis. In three of the patients with bleeding, in whom the site of the lesion was at the A1 portion, a diffuse thick subarachnoid hemorrhage was present and surgical treatment was required but resulted in a poor prognosis. In the other patients with bleeding, in whom the site of the lesion was at the distal ACA, the prognosis was good and no rebleeding or need for surgical treatment occurred. ACA dissection presenting with ischemia has several identifiable neuroradiologic and clinical characteristics, which suggests that it may be classified as a unique clinical entity.
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                Author and article information

                Journal
                NMC Case Rep J
                NMC Case Rep J
                NMCCRJ
                NMC Case Report Journal
                The Japan Neurosurgical Society
                2188-4226
                October 2014
                19 June 2014
                : 1
                : 1
                : 12-15
                Affiliations
                Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka
                Author notes
                Corresponding author: Hiroki Namba, MD, Department of Neurosurgery, Hamamatsu University School of Medicine, 1-20-1 Handayama, Higashi-ku, Hamamatsu, Shizuoka 431-3192, Japan. hnamba@ 123456hama-med.ac.jp
                Article
                nmccrj-1-012
                10.2176/nmccrj.2013-0351
                5364937
                28663945
                © 2014 The Japan Neurosurgical Society

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/4.0/

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                Case Report

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