A Case of Aneurysmal Subarachnoid Hemorrhage with Middle Cerebral Artery Aplasia at 30 Weeks of Pregnancy

AbstractPurpose: Computed tomography perfusion (CTP) has been performed to predict which patients with aneurysmal subarachnoid hemorrhage are at risk of developing delayed cerebral ischemia (DCI). Patients with severe arterial narrowing may have significant reduction in perfusion. However, many patients have less severe arterial narrowing. There is a paucity of literature evaluating perfusion changes which occur with mild to moderate narrowing. The purpose of our study was to investigate serial whole-brain CTP/computed tomography angiography in aneurysm-related subarachnoid hemorrhage (aSAH) patients with mild to moderate angiographic narrowing. Methods: We retrospectively studied 18 aSAH patients who had baseline and follow-up whole-brain CTP/computed tomography angiography. Thirty-one regions of interest/hemisphere at six levels were grouped by vascular territory. Arterial diameters were measured at the circle of Willis. The correlation between arterial diameter and change in CTP values, change in CTP in with and without DCI, and response to intra-arterial vasodilator therapy in DCI patients was evaluated. Results: There was correlation among the overall average cerebral blood flow (CBF; R=0.49, p<0.04), mean transit time (R=–0.48, p=0.04), and angiographic narrowing. In individual arterial territories, there was correlation between changes in CBF and arterial diameter in the middle cerebral artery (R=0.53, p=0.03), posterior cerebral artery (R=0.5, p=0.03), and anterior cerebral artery (R=0.54, p=0.02) territories. Prolonged mean transit time was correlated with arterial diameter narrowing in the middle cerebral artery territory (R=0.52, p=0.03). Patients with DCI tended to have serial worsening of CBF compared with those without DCI (p=0.055). Conclusions: Our preliminary study demonstrates there is a correlation between mild to moderate angiographic narrowing and serial changes in perfusion in patients with aSAH. Patients developing DCI tended to have progressively worsening CBF compared with those not developing DCI.

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THE IMPACT OF BALLOON ANGIOPLASTY ON THE EVOLUTION OF VASOSPASM-RELATED INFARCTION AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000311351.32904.8b ◽

2008 ◽

Vol 62 (3) ◽

pp. 610-617 ◽

Cited By ~ 47

Author(s):

Leonie Jestaedt ◽

Mirko Pham ◽

Andreas J. Bartsch ◽

Ekkehard Kunze ◽

Klaus Roosen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Balloon Angioplasty ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Fisher Exact Test ◽

Computed Tomographic ◽

Fisher Grade ◽

The Impact

Abstract OBJECTIVE Vasospasm of the cerebral vessels remains a major source for morbidity and mortality after aneurysmal subarachnoid hemorrhage. The purpose of this study was to evaluate the frequency of infarction after transluminal balloon angioplasty (TBA) in patients with severe subarachnoid hemorrhage-related vasospasm. METHODS We studied 38 patients (median Hunt and Hess Grade II and median Fisher Grade 4) with angiographically confirmed severe vasospasm (>70% vessel narrowing). A total of 118 vessels with severe vasospasm in the anterior circulation were analyzed. Only the middle cerebral artery, including the terminal internal carotid artery, was treated with TBA (n = 57 vessel segments), whereas the anterior cerebral artery was not treated (n = 61 vessel segments). For both the treated and the untreated vessel territories, infarction on unenhanced computed tomographic scan was assessed as a marker for adverse outcome. RESULTS Infarction after TBA occurred in four middle cerebral artery territories (four out of 57 [7%]), whereas the infarction rate was 23 out of 61 (38%) in the anterior cerebral artery territories not subjected to TBA (P < 0.001, Fisher exact test). Three procedure-related complications occurred during TBA (dissection, n = 1; temporary vessel occlusions, n = 2). One of these remained asymptomatic, whereas this may have contributed to the development of infarction on follow-up computed tomographic scans in two cases. CONCLUSION In a population of patients with a high risk of infarction resulting from vasospasm after subarachnoid hemorrhage, the frequency of infarction in the distribution of vessels undergoing TBA amounts to 7% and is significantly lower than in vessels not undergoing TBA despite some risk inherent to the procedure.

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Detection of Microemboli by Transcranial Doppler Ultrasonography in Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1097/00006123-200205000-00016 ◽

2002 ◽

Vol 50 (5) ◽

pp. 1026-1031 ◽

Cited By ~ 8

Author(s):

Jose G. Romano ◽

Alejandro M. Forteza ◽

Mauricio Concha ◽

Sebastian Koch ◽

Roberto C. Heros ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Transcranial Doppler ◽

Doppler Ultrasonography ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Statistical Significance ◽

Cerebral Arteries ◽

Transcranial Doppler Ultrasonography ◽

Control Subjects

Abstract OBJECTIVE: To determine the frequency and characteristics of microembolic signals (MES) in subarachnoid hemorrhage (SAH). METHODS: Twenty-three patients with aneurysmal SAH were monitored with transcranial Doppler ultrasonography for the presence of MES and vasospasm. Each middle cerebral artery was monitored for 30 minutes three times each week. Patients were excluded if they had traumatic SAH or cardiac or arterial sources of emboli. Monitoring was initiated 6.3 days (1–16 d) after SAH and lasted 6.6 days (1–13 d). Eleven individuals without SAH or other cerebrovascular diseases who were treated in the same unit served as control subjects. Each patient underwent monitoring of both middle cerebral arteries a mean of three times; therefore, 46 vessels were studied (a total of 138 observations). Control subjects underwent assessment of each middle cerebral artery once, for a total of 22 control vessels. RESULTS: MES were detected for 16 of 23 patients (70%) and 44 of 138 patient vessels (32%) monitored, compared with 2 of 11 control subjects (18%) and 2 of 22 control vessels (9%) (P < 0.05). MES were observed for 83% of patients with clinical vasospasm and 54% of those without clinical vasospasm. Ultrasonographic vasospasm was observed for 71 of 138 vessels monitored; MES were observed for 28% of vessels with vasospasm and 36% of those without vasospasm. Aneurysms proximal to the monitored artery were identified in 38 of 138 vessels, of which 34% exhibited MES, which is similar to the frequency for vessels without proximal aneurysms (31%). Coiled, clipped, and unsecured aneurysms exhibited similar frequencies of MES. CONCLUSION: MES were common in SAH, occurring in 70% of cases of SAH and one-third of all vessels monitored. Although MES were more frequent among patients with clinical vasospasm, this difference did not reach statistical significance. We were unable to demonstrate a relationship between ultrasonographic vasospasm and MES, and the presence of a proximal secured or unsecured aneurysm did not alter the chance of detection of MES. Further studies are required to determine the origin and clinical relevance of MES in SAH.

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Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

Neurocritical Care ◽

10.1007/s12028-013-9927-x ◽

2013 ◽

Vol 20 (2) ◽

pp. 255-262 ◽

Cited By ~ 14

Author(s):

M. Seule ◽

C. Muroi ◽

C. Sikorski ◽

M. Hugelshofer ◽

K. Winkler ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Flow Velocity ◽

Therapeutic Hypothermia ◽

Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Artery Flow

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Proposed Use of Prophylactic Decompressive Craniectomy in Poor-grade Aneurysmal Subarachnoid Hemorrhage Patients Presenting with Associated Large Sylvian Hematomas

Neurosurgery ◽

10.1097/00006123-200207000-00018 ◽

2002 ◽

Vol 51 (1) ◽

pp. 117-124 ◽

Cited By ~ 123

Author(s):

Edward R. Smith ◽

Bob S. Carter ◽

Christopher S. Ogilvy

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Decompressive Craniectomy ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Artery Aneurysm ◽

Pathological Process ◽

Sylvian Fissure ◽

Excellent Outcome ◽

Number Of Patients

Abstract OBJECTIVE As a group, patients who present in poor neurological grade after aneurysmal subarachnoid hemorrhage (SAH) often have poor outcomes. There may be subgroups of these patients, however, in which one pathological process predominates and for which the initiation of specific therapeutic interventions that target the predominant pathological process may result in improved outcome. We report the use of prophylactic decompressive craniectomy in patients presenting in poor neurological condition after SAH from middle cerebral artery aneurysms with associated large sylvian fissure hematomas. Craniectomy allowed significant parenchymal swelling in the posthemorrhagic period without increased intracranial pressure (ICP) or herniation syndrome. METHODS Eight patients (mean age, 56.5 yr; age range, 42–66 yr) presented comatose with SAH (five Hunt and Hess Grade IV, three Hunt and Hess Grade V). Radiographic evaluations demonstrated middle cerebral artery aneurysm and associated large sylvian fissure hematoma (mean clot volume, 121 ml; range, 30–175 ml). Patients were brought emergently to the operating room and treated with a modification of the pterional craniotomy and aneurysm clipping that included a planned craniectomy and duraplasty. A large, reverse question mark scalp flap was created, followed by bone removal with the following margins: anterior, frontal to the midpupillary line; posterior at least 2 cm behind the external auditory meatus; superior up to 2 cm lateral to the superior sagittal sinus; and inferior to the floor of the middle cranial fossa. Generous duraplasty was performed using either pericranium or suitable, commercially available dural substitutes. RESULTS All of the eight patients tolerated the craniectomy without operative complications. Postoperatively, all patients experienced immediate decreases in ICP to levels at or below 20 mm Hg (presentation mean ICP, 31.6 mm Hg; postoperative mean ICP, 13.1 mm Hg). ICP control was sustained in seven of eight patients, with the one exception being due to a massive hemispheric infarction secondary to refractory vasospasm. Follow-up (≥1 yr, except for one patient who died during the hospital stay) demonstrated that the craniectomy patients had a remarkably high number of good or excellent outcomes. The outcomes in the hemicraniectomy group were five good or excellent, one fair, and two poor or dead. CONCLUSION The data gathered in this study demonstrate that decompressive craniectomy can be performed safely as part of initial management for a subcategory of patients with SAH who present with large sylvian fissure hematomas. In addition, the performance of decompressive craniectomy in the patients described in this article seemed to be associated with rapid and sustained control of ICP. Although the number of patients in this study is small, the data lend support to the hypothesis that decompressive craniectomy may be associated with good or excellent outcome in a carefully selected subset of patients with SAH.

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Watershed subarachnoid hemorrhage after middle cerebral artery rescue stenting in patients with acute ischemic stroke

Neuroradiology ◽

10.1007/s00234-021-02692-0 ◽

2021 ◽

Author(s):

Francesco Diana ◽

Maria Di Gregorio ◽

Giulia Frauenfelder ◽

Renato Saponiero ◽

Daniele Giuseppe Romano

Keyword(s):

Ischemic Stroke ◽

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Carotid Stenting ◽

Endovascular Interventions ◽

Rescue Treatment ◽

Middle Cerebral Artery Stenosis

AbstractCortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal subarachnoid hemorrhage, rarely reported in watershed territories (wSAH) after carotid stenting. It has never been reported after treatment of middle cerebral artery stenosis (MCAS) that is increasingly used in selected patients, as rescue treatment of failed mechanical thrombectomy, due to recent advancements in endovascular interventions. We present a series of patients with MCAS that developed a wSAH after stenting.

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Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS)

Journal of Neurosurgery ◽

10.3171/2019.9.jns192055 ◽

2020 ◽

Vol 133 (6) ◽

pp. 1811-1820 ◽

Cited By ~ 2

Author(s):

Nicolai Maldaner ◽

Valentin K. Steinsiepe ◽

Johannes Goldberg ◽

Christian Fung ◽

David Bervini ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Surgical Treatment ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Patterns Of Care ◽

Favorable Outcome ◽

National Database ◽

Control Group

OBJECTIVEThe objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort.METHODSThe authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009–2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined.RESULTSAmong 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74–1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89–12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23–2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30–0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676).CONCLUSIONSMicrosurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.

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A Rare Case of Pediatric Cortical Aneurysm Rupture in an Eight-Year-Old Boy

Indian Journal of Neurosurgery ◽

10.1055/s-0041-1731251 ◽

2021 ◽

Author(s):

Anooja Abdul Salam ◽

Imogen Ibbett ◽

Nova Thani

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracerebral Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Rare Case ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Pediatric Population ◽

Rare Condition ◽

Aneurysm Rupture ◽

Acute Intracerebral Hemorrhage

AbstractAneurysmal subarachnoid hemorrhage in the pediatric population is an extremely rare condition. We present an acute intracerebral hemorrhage in an 8-year-old boy, secondary to a ruptured middle cerebral artery cortical branch (M4 segment) aneurysm. There have been very few cases of cortical aneurysm reported in adults and we did not identify any pediatric cases in the literature to date.

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