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The authors present a case of giant serpentine aneurysm (a partially thrombosed aneurysm containing tortuous vascular channels with a separate entrance and outflow pathway). Giant serpentine aneurysms form a subgroup of giant intracranial aneurysms, distinct from saccular and fusiform varieties, and in this case, too, the clinical presentation and radiographic features of CT, MR imaging and angiography were distinct.

Ehlers-Danlos syndrome (EDS) type IV is characterized by its clinical manifestations, which are easy bruising, thin skin with visible veins, and rupture of arteries, uterus, or intestines. Arterial complications are the leading cause of death in vascular EDS because they are unpredictable and surgical repair is difficult due to tissue fragility. The authors report a case presented with cervical radiculopathy due to a segmental fusiform aneurysm of the cervical vertebral artery. Transfemoral cerebral angiography (TFCA) was done to verify the aneurysmal dilatation. However, during TFCA, bleeding at the puncture site was not controlled, skin and underlying muscle was disrupted and profound bleeding occurred during manual compression after femoral catheter removal. Accordingly, surgical repair of the injured femoral artery was performed. At this time it was possible to diagnose it as an EDS with fusiform aneurysm on cervical vertebral artery. Particularly, cervical fusiform aneurysm is rare condition, and therefore, connective tissue disorder must be considered in such cases. If connective tissue disorder is suspected, the authors suggest that a noninvasive imaging modality, such as, high quality computed tomography angiography, be used to evaluate the vascular lesion to avoid potential arterial complications.

Internal carotid artery (ICA) trapping can be used for the treatment of giant intracranial aneurysms, blood blister-like aneurysms, and fusiform dissecting aneurysms. Fusiform dissecting aneurysms are challenging to treat surgically and endovascularly because of no definite neck and critical perforators. Surgical or endovascular trapping of the ICA with or without an extracranial-intracranial bypass has commonly been used as an effective method to treat these lesions, but balloon test occlusion (BTO) must be performed. Here, we report a case of a ruptured fusiform dissecting aneurysm of the distal ICA, which was successfully treated using an endovascular ICA trapping with a manual ICA compression test instead of BTO.

Intracranial pial arteriovenous fistulas (AVFs) are rare vascular lesions of the brain. These lesions consist of one or more arterial connection to a single venous channel without true intervening nidus. A 24-year-old woman visited to our hospital because of headache, vomiting, dizziness and memory disturbance that persisted for three days. She complained several times of drop attack because of sudden weakness on both leg. Cerebral angiograms demonstrated a giant venous aneurysm on right frontal lobe beyond the genu of corpus callosum, multiple varices on both frontal lobes fed by azygos anterior cerebral artery, and markedly dilated draining vein into superior sagittal sinus, suggesting single channel pial AVF with multiple varices. Transarterial coil embolization of giant aneurysm and fistulous portion resulted in complete disappearance of pial AVF without complication.

Giant serpentine aneurysms are rare and have distinct angiographic findings. The rarity, large size, complex anatomy and hemodynamic characteristics of giant serpentine aneurysms make treatment difficult. We report a case of a giant serpentine aneurysm of the right middle cerebral artery (MCA) that presented as headache. Treatment involved a superficial temporal artery (STA)-MCA bypass followed by aneurysm resection. The patient was discharged without neurological deficits, and early and late follow-up angiography disclosed successful removal of the aneurysm and a patent bypass graft. We conclude that STA-MCA bypass and aneurysm excision is a successful treatment method for a giant serpentine aneurysm.

Neurofibromatosis type 1 (NF-1) has a variety of localized or systemic manifestations. Among them, Cerebrovascular dysplasia can be very rare finding of neurofibromatosis which can be very rarely seen. Here we report a case of 17-year-old boy representing bilateral giant fusiform aneurysms of extracranial internal carotid arteries and intracranial aneurysms of left middle cerebral artery. He showed no related symptoms at all, but screening for vascular lesions and close monitoring is warranted in NF-1 patients considering that it can be symptomatic unexpectedly.

Objective

Complex aneurysms such as fusiform and very small aneurysms (< 3 mm) are challenging in neurovascular and endovascular surgery. Author reports follow-up results of 9 cases treated by sole stent technique with pertinent literature review.

Methods

A retrospective study was made of 9 patients who were treated by sole stenting technique for cerebral aneurysm between January 2003 and January 2009. Two of them had fusiform aneurysm, 5 had very small aneurysm, and 2 had small saccular aneurysm. Five patients had ruptured aneurysms and four had unruptured aneurysms. Seven aneurysms were located in the internal carotid artery (ICA), 1 in the middle cerebral artery (MCA) and 1 in the basilar artery. Follow-up cerebral angiography was performed at post-procedure 3 months, 6 months, and 12 months. Mean follow-up period is 30 months (ranged from 3 days to 30 months).

Results

Aneurysm size was decreased in 6 of 9 cases on follow-up images and was not changed in 3 cases. Although total occlusion was not seen, patients had stable neurological condition and angiographic result. The procedural complication occurred in 2 cases. One was coil migration and the other was suboptimal deployment of stent, and both were asymptomatic. Re-bleeding and thromboembolic complication had not been occurred.

Conclusion

Sole stenting technique is relatively effective and safe as an alternative treatment for fusiform and very small aneurysms.

Summary

Typical treatment of intracranial aneurysm includes: surgical clipping, intrasacular packing, and parent artery occlusion. The treatment of a fusiform aneurysm is often parent artery occlusion, and keeping patency of the parent artery is difficult. We report our experience in the treatment of 3 cases of intracranial fusiform aneurysm with stent placement inside the parent artery only, without coil packing of the aneurysm lumen. All 3 patients had a non-hemorrhagic dissecting aneurysm in the vertebral artery. They were treated with 2 Helistents, 3 Neuroform stents, and 2 Neuroform stents, respectively. These aneurysms disappeared after treatment at their follow-up angiograms. Treatment with a bare stent may induce obliteration or reduction in the size of some aneurysms. This technique is useful in the treatment of non-hemorrhagic fusiform-shaped aneurysms or non-hemorrhagic dissecting aneurysms to preserve the patency of these parent arteries.

Takayasu aortoarteritis (TA) rarely affects the nervous system, but when it does, it usually manifests as cerebral ischemia or stroke. These strokes have mainly been attributed to stenotic extracranial vessels. Stenoses of intracranial vessels, although rare in TA, can occur due to either embolization into the vessel or because of the vasculitic process itself. Intracranial aneurysms are very rare in patients with TA. Bilateral cavernous internal carotid artery (ICA) aneurysms are rarer. They have been reported following radiation therapy and in association with fibromuscular dysplasia and juvenile Paget disease. Bilateral mycotic intracavernous aneurysms also occur. Bilateral giant cavernous ICA aneurysms with carotid-cavernous fistula (CCF) consequent to rupture into the cavernous sinus in a case of TA are extremely unusual. We report a case that fulfilled both American College of Rheumatology and European League against Rheumatology criteria for TA. The patient had bilateral cavernous sinus giant aneurysms and CCF because the right-sided aneurysm had ruptured and was leaking into the cavernous sinus.

Partial thrombosis of giant aneurysms is not uncommon however, complete angiographic occlusion occurs less frequently. In the case of non-giant aneurysms, complete thrombosis and recanalization has been rarely reported. A 31-year-old man presented to the emergency department with sudden bursting headache. Brain computed tomography (CT) revealed diffuse subarachnoid hemorrhage on the left side. Both CT angiography (CTA) and digital subtraction angiography showed suspicion of small left anterior choroidal artery aneurysm. We performed surgical exploration. In the operation field, anterior choroidal artery aneurysm of 2 × 2 mm with broad neck and friable appearance was observed. Because we could not clip without sacrificing the anterior choroidal artery, we performed wrapping only. Follow up CTA after 7 months demonstrated 4 mm right internal carotid artery bifurcation aneurysm. The patient underwent aneurismal neck clipping. During the operation, 9 × 13 mm sized thrombosed aneurysm was detected and completely clipped. We initially thought this aneurysm to be a de novo aneurysm however, it was an aneurysm that had recanalized from a completely thrombosed aneurysm. This case report provides an insight into the potential for complete thrombosis and recanalization of non-giant aneurysms.

A coronary artery aneurysm is an uncommon disorder and is seen as a characteristic dilatation of a localized portion of the coronary artery. Clinical manifestation of a coronary artery aneurysm varies from an asymptomatic presentation to sudden death of a patient. Although coronary aneurysms are typically diagnosed by the use of coronary angiography, a new generation of coronary 64-slice multidetector computed tomography (64-MDCT) scanners have successfully been used for evaluating this abnormality in a noninvasive manner. In the present case, we performed coronary 64-MDCT scanning preoperatively and postoperatively on a patient with multiple giant coronary aneurysms. The use of coronary 64-MDCT may provide an evaluation technique not only for diagnosis but also for follow-up after surgery for this condition.

Background

While hemodynamic stress can result in aneurysm formation, it rarely contributes to the development of peripheral aneurysms in collateral pathways. We report two patients with ruptured distal aneurysms in a collateral pathway associated with stenosis of a major cerebral artery.

Case Description

A 67-year-old man presented with intracerebral hemorrhage in the right frontal lobe. Digital subtraction angiography (DSA) revealed severe stenosis of the right middle cerebral artery and two aneurysms in the collateral pathway of the right anterior cerebral artery. The ruptured aneurysm was trapped and resected; histologically, it was a true saccular aneurysm. The unruptured aneurysm was clipped and the patient was discharged without additional neurological deficits. The second patient was a 73-year-old woman with subarachnoid hemorrhage. DSA revealed three arterial dilations. On the 7th day of hospitalization, one of the aneurysms in a posterior inferior cerebellar artery–anterior inferior cerebellar artery anastomosis that functioned as a collateral pathway in the presence of severe basilar artery stenosis was found to be enlarged. It was treated by selective aneurysmal coil embolization with parent artery preservation. Her postoperative course was uneventful and she was discharged without any neurological deficits.

Conclusion

We document the successful treatment of two patients with ruptured aneurysms in the peripheral portion of a collateral pathway. We discuss the histology of peripheral aneurysms and present a review of the literature.

Background:

Primitive trigeminal artery variants (PTAVs) are one of the rare persistent fetal anastomoses between the carotid and vertebrobasilar circulations. They originate from the internal carotid artery and join one of the cerebellar arteries instead of the basilar artery.

Case Description:

We present an 82-year-old woman with subarachnoid hemorrhage due to a ruptured aneurysm originating at a PTAV. Three-dimensional computed tomography angiogram and cerebral angiography revealed bilateral PTAV and two aneurysms originating at the left PTAV. The proximal and distal aneurysms were saccular and fusiform, respectively. She underwent surgical treatment and her postoperative course was uneventful.

Conclusion:

Our case demonstrates that extremely rare cerebral aneurysms associated with PTAV can be addressed successfully by surgical intervention.

Aneurysms of the coronary sinuses of Valsalva and coronary artery aneurysms are uncommon cardiac anomalies, and cases in which these two uncommon lesions occur at the same time are extremely rare. A case of a woman with unstable angina who had a giant aneurysm of the left coronary sinus and multiple coronary artery aneurysms associated with an idiopathic hypereosinophilic syndrome is presented. Her sustained eosinophilia, elevated eosinophilic cationic protein concentration, and pathological findings of eosinophil infiltration of the aortic wall suggested the association of eosinophilia induced vascular injury as the cause of these aneurysms. This is the first such case to survive following surgical treatment.


Keywords: aneurysm; arteritis; coronary sinus; eosinophilia

We report the case of an 87-year-old female who died following coil embolization of an intracerebral giant aneurysm. Guglielmi Detachable and Matrix2 Coils were utilized during the procedure to occlude the surgically untreatable left supraclinoid carotid artery aneurysm. Postprocedure imaging studies showed scattered areas of acute infarct involving multiple bilateral vascular territories. Autopsy confirmed widespread infarction due to embolized foreign material, morphologically consistent with hydrophilic polymer originating from the coated Matrix coil and Terumo Glidewire. Polymer gel is now widely used on several medical devices for interventional procedures worldwide, and we suspect that risks associated with iatrogenic embolization of this substance are under-recognized.

EXECUTIVE SUMMARY

The Medical Advisory Secretariat conducted a systematic review of the evidence on the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysm in comparison to open surgical repair. An abdominal aortic aneurysm [AAA] is the enlargement and weakening of the aorta (major blood artery) that may rupture and result in stroke and death. Endovascular abdominal aortic aneurysm repair [EVAR] is a procedure for repairing abdominal aortic aneurysms from within the blood vessel without open surgery. In this procedure, an aneurysm is excluded from blood circulation by an endograft (a device) delivered to the site of the aneurysm via a catheter inserted into an artery in the groin. The Medical Advisory Secretariat conducted a review of the evidence on the effectiveness and cost-effectiveness of this technology. The review included 44 eligible articles out of 489 citations identified through a systematic literature search. Most of the research evidence is based on non-randomized comparative studies and case series. In the short-term, EVAR appears to be safe and comparable to open surgical repair in terms of survival. It is associated with less severe hemodynamic changes, less blood transfusion and shorter stay in the intensive care and hospital. However, there is concern about a high incidence of endoleak, requiring secondary interventions, and in some cases, conversion to open surgical repair. Current evidence does not support the use of EVAR in all patients. EVAR might benefit individuals who are not fit for surgical repair of abdominal aortic aneurysm and whose risk of rupture of the aneurysm outweighs the risk of death from EVAR. The long-term effectiveness and cost-effectiveness of EVAR cannot be determined at this time. Further evaluation of this technology is required.

OBJECTIVE

The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysms (EVAR) in comparison to open surgical repair (OSR).

BACKGROUND

Clinical Need

An abdominal aortic aneurysm (AAA) is a localized, abnormal dilatation of the aorta greater than 3 cm or 50% of the aortic diameter at the diaphragm. (1) A true AAA involves all 3 layers of the vessel wall. If left untreated, the continuing extension and thinning of the vessel wall may eventually result in rupture of the AAA. The risk of death from ruptured AAA is 80% to 90%. (61) Heller et al. (44) analyzed information from a national hospital database in the United States. They found no significant change in the incidence rate of elective AAA repair or ruptured AAA presented to the nation’s hospitals. The investigators concluded that technologic and treatment advances over the past 19 years have not affected the outcomes of patients with AAAs, and the ability to identify and to treat patients with AAAs has not improved.

Classification of Abdominal Aortic Aneurysms

At least 90% of the AAAs are affected by atherosclerosis, and most of these aneurysms are below the level of the renal arteries.(1)

An abdominal aortic aneurysm may be symptomatic or asymptomatic. An AAA may be classified according to their sizes:(7)

Small aneurysms: less than 5 cm in diameter.

Medium aneurysms: 5-7cm.

Large aneurysms: more than 7 cm in diameter.

Small aneurysms account for approximately 50% of all clinically recognized aneurysms.(7)

Aortic aneurysms may be classified according to their gross appearance as follows (1):

Fusiform aneurysms affect the entire circumference of a vessel, resulting in a diffusely dilated lesion

Saccular aneurysms involve only a portion of the circumference, resulting in an outpouching (protrusion) in the vessel wall.

Prevalence of Abdominal Aortic Aneurysms

In community surveys, the prevalence of AAA is reported to be between 1% and 5.4%. (61) The prevalence is related to age and vascular risk factors. It is more common in men and in those with a positive family history.

In Canada, Abdominal aortic aneurysms are the 10th leading cause of death in men 65 years of age or older. (60) Naylor (60) reported that the rate of AAA repair in Ontario has increased from 38 per 100,000 population in 1981/1982 to 54 per 100,000 population in 1991/1992. For the period of 1989/90 to 1991/92, the rate of AAA repair in Ontarians age 45 years and over was 53 per 100,000. (60) In the United States, about 200,000 new cases are diagnosed each year, and 50,000 to 60,000 surgical AAA repairs are performed. (2) Ruptured AAAs are responsible for about 15,000 deaths in the United States annually. One in 10 men older than 80 years has some aneurysmal change in his aorta. (2)

Symptoms of Abdominal Aortic Aneurysms

AAAs usually do not produce symptoms. However, as they expand, they may become painful. Compression or erosion of adjacent tissue by aneurysms also may cause symptoms. The formation of mural thrombi, a type of blood clots, within the aneurysm may predispose people to peripheral embolization, where blood vessels become blocked. Occasionally, an aneurysm may leak into the vessel wall and the periadventitial area, causing pain and local tenderness. More often, acute rupture occurs without any prior warning, causing acute pain and hypotension. This complication is always life-threatening and requires an emergency operation.

Diagnosis of Abdominal Aortic Aneurysms

An AAA is usually detected on routine examination as a palpable, pulsatile, and non-tender mass. (1)

Abdominal radiography may show the calcified outline of the aneurysms; however, about 25% of aneurysms are not calcified and cannot be visualized by plain x-ray. (1) An abdominal ultrasound provides more accurate detection, can delineate the traverse and longitudinal dimensions of the aneurysm, and is useful for serial documentation of aneurysm size. Computed tomography and magnetic resonance have also been used for follow-up of aortic aneurysms. These technologies, particularly contrast-enhanced computer tomography, provide higher resolution than ultrasound.

Abdominal aortography remains the gold standard to evaluate patients with aneurysms for surgery. This technique helps document the extent of the aneurysms, especially their upper and lower limits. It also helps show the extent of associated athereosclerotic vascular disease. However, the procedure carries a small risk of complications, such as bleeding, allergic reactions, and atheroembolism. (1)

Prognosis of Abdominal Aortic Aneurysms

The risk of rupture of an untreated AAA is a continuous function of aneurysm size as represented by the maximal diameter of the AAA. The annual rupture rate is near zero for aneurysms less than 4 cm in diameter. The risk is about 1% per year for aneurysms 4 to 4.9 cm, 11% per year for aneurysms 5 to 5.9 cm, and 25% per year or more for aneurysms greater than 6 cm. (7)

The 1-year mortality rate of patients with AAAs who do not undergo surgical treatment is about 25% if the aneurysms are 4 to 6 cm in diameter. This increases to 50% for aneurysms exceeding 6 cm. Other major causes of mortality for people with AAAs include coronary heart disease and stroke.

Treatment of Abdominal Aortic Aneurysms

Treatment of an aneurysm is indicated under any one of the following conditions:

The AAA is greater than 6 cm in diameter.

The patient is symptomatic.

The AAA is rapidly expanding irrespective of the absolute diameter.

Open surgical repair of AAA is still the gold standard. It is a major operation involving the excision of dilated area and placement of a sutured woven graft. The surgery may be performed under emergent situation following the rupture of an AAA, or it may be performed electively.

Elective OSR is generally considered appropriate for healthy patients with aneurysms 5 to 6 cm in diameter. (7) Coronary artery disease is the major underlying illness contributing to morbidity and mortality in OSR. Other medical comorbidities, such as chronic renal failure, chronic lung disease, and liver cirrhosis with portal hypertension, may double or triple the usual risk of OSR.

Serial noninvasive follow-up of small aneurysms (less than 5 cm) is an alternative to immediate surgery.

Endovascular repair of AAA is the third treatment option and is the topic of this review.

Twelve patients in a series of 22 with giant intracranial aneurysms demonstrated neuroradiological features of partial or total spontaneous intra-aneurysmal thrombosis. The presence of this intra-aneurysmal clot significantly altered the computed tomographic appearance of the giant aneurysm. Massive intra-aneurysmal thrombosis did not protect against subarachnoid haemorrhage and the likelihood of rupture of a clot containing giant aneurysm was not significantly different from that of a non-thrombosed giant aneurysm. Although parent artery occlusion from a thrombosed giant aneurysm, and massive aneurysmal thrombosis leading to the formation of giant serpentine aneurysm were documented, these are rare epiphenomena. The risk of embolisation from a partially thrombosed giant aneurysm, which was documented in one case, would appear to be greater than that from a non-thrombosed giant aneurysm. The findings in this series, and a review of literature, suggest that the presence of intra-aneurysmal clot in giant intracranial aneurysms has little prognostic significance and does not alter the management or outcome after treatment.

Images

Background:

To describe the use of a short segment cortical intracranial–intracranial (IC–IC) bypass for the treatment of a distal middle cerebral artery (MCA) aneurysm.

Case Description:

A 54-year-old woman presented with a loss of consciousness followed by multiple seizures and was found to have a partially thrombosed distal MCA aneurysm. This possibly mycotic aneurysm was treated by creating a short segment jump graft between a normal cortical artery and a nearby cortical branch arising from the aneurysmal M3 arterial segment. The bypass allowed for subsequent occlusion of the aneurysmal vessel without ischemic consequence. At surgery, the anterior division of the superficial temporal artery (STA) was exposed and dissected. Intraoperative angiography was utilized to localize a cortical artery arising from the involved segment as well as a nearby cortical artery arising from a distinct, uninvolved MCA branch. A segment of the STA was harvested, and then 10-0 suture was utilized to anastomose this short segment, to both the involved and normal cortical arteries. This created a short jump graft allowing for subsequent sacrifice of the diseased artery. Following surgery, the patient immediately underwent coil embolization of the aneurysm back into the parent artery resulting in local vascular sacrifice. The remainder of the patient's hospital course was uneventful. She was discharged home in good condition.

Conclusions:

We suggest that cortical IC–IC bypass followed by endovascular arterial sacrifice as performed in our case represents a simple and safe option for treating unclippable distal MCA aneurysms including mycotic lesions.

Hemifacial spasm induced by intracranial aneurysm is a rare clinical condition. A 45-year-old male patient presented with a 3-year history of progressive involuntary twitching movement on right face. On radiological study, a dilated vascular lesion compressing the brain stem was found at the junction of vertebral artery and posterior inferior cerebellar artery. On operative field, we found the posterior inferior cerebellar artery and the fusiform aneurysm compressing root exit zone of facial nerve. Microvascular decompression was performed and the facial symptom was relieved without complications.

The unilateral suboccipital craniotomy is the commonly performed approach to aneurysms of the vertebrobasilar junction, the vertebral artery, and the posterior inferior cerebellar artery (PICA). Many of these aneurysms are placed anterior or anterolateral to the brain stem, necessitating brain stem retraction for adequate exposure. Small dorsolateral enlargement of the foramen magnum, partial resection of the occipital condyle, and removal of the jugular tubercle allow access to the neurovascular structures ventral to the medulla without retraction of the neuroaxis. This extreme lateral transcondylar approach was performed in 20 patients with aneurysms of the vertebrobasilar junction, the vertebral artery, and the PICA; intraoperatively, two suspected aneurysms proved to be vascular malformations. Occlusion of the aneurysm and vascular malformation was successfully performed in 16 patients, resection of the vascular malformation was achieved in 1 patient, and the vertebral artery was clipped in 3 patients with fusiform aneurysms without complications related to the extreme lateral transcondylar approach. Unobstructed exposure of the aneurysm, parent artery, and neural structures without retraction of the sensitive lower brain stem are the major advantages of the extreme lateral transcondylar approach.

Images

Objective

The objective of this study is to investigate clinical characteristics, management methods and possible causes of intracranial fusiform aneurysm.

Methods

Out of a series of 2,458 intracranial aneurysms treated surgically or endovascularly, 22 patients were identified who had discrete fusiform aneurysms. Clinical presentations, locations, treatment methods and possible causes of these aneurysms were analyzed.

Results

Ten patients of fusiform aneurysm were presented with hemorrhage, 5 patients with dizziness with/without headache, 4 with ischemic neurologic deficit, and 1 with 6th nerve palsy from mass effect of aneurysm. Two aneurysms were discovered incidentally. Seventeen aneurysms were located in the anterior circulation, other five in the posterior circulation. The most frequent site of fusiform aneurysm was a middle cerebral artery. The aneurysms were treated with clip, and/or wrapping in 7, resection with/without extracranial-intracranial (EC-IC) bypass in 6, proximal occlusion with coils with/without EC-IC bypass in 5, EC-IC bypass only in 1 and conservative treatment in 3 patient. We obtained good outcome in 20 out of 22 patients. The possible causes of fusiform aneurysms were regard as dissection in 16, atherosclerosis in 4 and collagen disease or uncertain in 2 cases.

Conclusion

There is a subset of cerebral aneurysms with discrete fusiform morphology. Although the dissection or injury of internal elastic lamina of the cerebral vessel is proposed as the underlying cause for most of fusiform aneurysm, more study about pathogenesis of these lesions is required.

Summary

We describe a case of a ruptured basilar bifurcation aneurysm that thrombosed during preparation for endovascular therapy as a complication of diagnostic angiogaphy, and showed a favorable evolution during long-term follow-up.

Endogenous thrombosis of ruptured, non giant aneurysms is uncommon. The persistence of occlusion over time in such cases is not well established.

Two weeks after rupture, a 6 x 8 mm basilar bifurcation aneurysm was referred for endovascular treatment. During preparation for endovascular coil occlusion, without having any endovascular material at the level of the basilar artery, a complete thrombotic occlusion of the basilar bifurcation and aneurysm was observed. Given the good collateral circulation for both posterior cerebral arteries no thrombolysis was undertaken. The early follow-up of seven days, three and six months showed a complete recanalization of the basilar artery and remodeling of the basilar bifurcation. The 20 months imaging follow-up demonstrated a small aneurysm regrowth at the prevoius location that remained stable during the follow-up of seven years. Unchanged biological and hemodynamic characteristics. however, may pose an elevated risk of a new aneurysm formation over time, making long-term imaging follow-up, and in case of progression, aneurysm occlusion necessary for the patient.

True aneurysm of the brachial artery is a rare disease entity. The mechanism of aneurysm formation is considered to be compression of the arterial wall, producing contusion of the media and subsequent weakness of the wall and fusiform dilatation. It can be caused by arteriosclerotic, congenital, and metabolic disorders, and can be associated with diseases such as Kawasaki's disease. Doppler ultrasonography, computed tomography, arteriography, and selective upper extremity angiography may be performed for establishing the diagnosis of aneurysm. The best therapeutic option is operative repair, and it should be performed without any delay, in order to prevent upper extremity ischemic or thrombotic sequelae. Here, we report a case of recurrent brachial artery aneurysm with review of the literature.

We report an exceptional case of a de novo giant fusiform aneurysm of the basilar trunk, which developed shortly after the therapeutic occlusion of the right internal carotid artery for a fusiform carotid aneurysm. It would appear to be appropriate to call this entity a sequential giant fusiform aneurysm. The patient was successfully treated with endovascular occlusion of the giant basilar trunk aneurysm following bypass surgery.

BACKGROUND AND PURPOSE

A comprehensive evaluation of aneurysmal morphometry requires appreciation of both the vascular lumen and the intraluminal thrombus. MR imaging methods can both evaluate the lumen and directly image the vessel wall. We investigated the ability of T1-weighted, T2-weighted, and steady-state MR imaging techniques to delineate thrombus morphology and reveal changes with time.

MATERIALS AND METHODS

Nine patients with fusiform basilar or intracranial vertebral artery aneurysms that contained intraluminal thrombus were studied with MR imaging. All patients underwent at least 2 imaging sessions, which were separated by 4–22 months. Analysis of signal intensity to determine the mean signal intensity from thrombus, blood, CSF, and brain in matched regions was performed. Aneurysm maximal diameter and cross-sectional area were determined with and without thrombus.

RESULTS

Thrombus was identified on all image sequences, and its general appearance was consistent between imaging sessions. Thrombus produced the highest and most consistent signal intensities with T1-weighted and steady-state techniques, though the latter showed superior contrast between luminal blood and thrombus. Heterogeneity within clot was evident in 4/9 of patients, with peripheral hyperintensity being a common feature.

CONCLUSIONS

Steady-state imaging was found to be superior to T1- and T2-weighted imaging for delineating and characterizing intraluminal thrombus within aneurysms. The imaging characteristics of intraluminal thrombus proved to be very consistent for long periods. Assessment of overall aneurysm size, including thrombosed portions, permits more accurate evaluation of aneurysm growth and concomitantly may permit more informed clinical decision-making with regard to the timing and need for aneurysm treatment.