Super-selective Wada test for pre-surgical leg motor function assessment: A case report.

Background: Pituitary apoplexy is a life-threatening condition in which there is a hemorrhage or infarction of the pituitary gland. It can be characterized by the sudden onset of headaches, vomiting, visual impairment, endocrine deficits, and changes in consciousness. There are very few cases of pituitary apoplexy presenting as strokes in children. We report a rare occurrence of an ischemic stroke in the left anterior and middle cerebral artery territories, caused by pituitary apoplexy from a prolactinoma in a 13-year-old male which was managed medically. Case Presentation: He presented with worsening headaches and visual acuity and later developed left oculomotor nerve palsy, right hemiplegia, and dysarthria. MRI and CT imaging confirmed an apoplectic pituitary macroadenoma with internal carotid artery encasement and infarction in the territory of the left middle and anterior cerebral arteries. The patient was treated using dopamine agonists, which led to a decrease in tumor size and serum prolactin levels without surgery. Conclusion: This report emphasizes the need to promptly recognize pituitary apoplexy as a potential cause of stroke in children. It also illustrates successful medical management in these cases, which could be especially important in areas with limited resources

Multiple vascular anomalies in a 22-year-old patient who had signs and symptoms of vestibulocochlear dysfunction are reported. Angiography revealed a fenestration of the proximal segment of the left anterior cerebral artery, an ectasia of the left anterior and posterior cerebral arteries, and a persistence of the right trigeminal artery. The rarity of the association is documented, and the clinical significance is discussed.

We report a rare case with a ruptured aneurysm of the bihemispheric anterior cerebral artery(ACA), a rare anomaly of the ACA. A 50-year-old female experienced a sudden onset of severe posterior cervical pain. CT revealed diffuse subarachnoid hemorrhage(SAH)and intra cerebral hemorrhage of the left rectal gyrus. Cerebral angiography showed the left bihemispheric ACA and hypoplasia of the right ACA. A saccular aneurysm was indicated at the A1-A2 junction of the left bihemispheric ACA. A neck clipping was performed completely through the right transsylvian approach. There are several reports of an aneurysm with bihemispheric ACA, but all cases are distal ACA aneurysms. In this case, the aneurysm was proximal to the bihemispheric ACA and such aneurysms have not been reported.

Contralateral reperfusion injury after carotid endarterectomy

The clinical case of simultaneous endovascular bloodstream exclusion of arteriovenous malformation and saccular aneurysm in parturient woman is presented. Onyx liquid adhesive composition and monospiral aneurysm occlusion technique were used. Patient X., 31, was hospitalized to the clinic on the 10th day of the postpartum period. From the anamnesis: twice (at 20th and 27th weeks of pregnancy) patient suffered intraventricular hemorrhage due to the rupture of arteriovenous malformation in the posterior third of the corpus callosum, left lateral ventricle and left parietal lobe of the brain. After the first hemorrhage a conservative treatment tactic was determined, given the high risk of complications associated with the surgical intervention for the mother and fetus. After the second hemorrhage endovascular embolization of malformation was suggested, however, the patient and her husband refused surgery, preferring conservative therapy with subsequent surgical treatment after delivery. In addition to the malformation, according to the data of selective cerebral subtraction angiography multiple cerebral saccular aneurysms of the left Anterior Cerebral – Anterior Communicating Artery and 2 Anterior Cerebral Artery aneurysms (A2-A2, A3-A4-segments) on the right side were diagnosed. Endovascular subtotal embolization of arteriovenous malformation and occlusion of the right Anterior Cerebral Artery (A2-A3-segment) saccular aneurysm were performed during the operation. A control angiographic examination after 3 months showed a complete exclusion of these arteriovenous malformation and saccular aneurysm and disappearance of all aneurysms of the left Anterior Cerebral Artery – Anterior Communicating Artery and right Anterior Cerebral Artery (A3-A4-segment).

Here, we describe a case of a woman suspected to have an anterior cerebral artery (ACA) aneurysm that was ultimately found to have an azygous ACA shield. This benign entity highlights the importance of thorough investigation with cerebral digital subtraction angiography (DSA). This 73-year-old female initially presented with dyspnea and dizziness. CT angiogram of the head suggested an incidental 5mm ACA aneurysm. Subsequent DSA demonstrated a Type I azygos ACA supplied by the left A1 segment. Also noted was a focal dilatation of the azygos trunk as it gave rise to the bilateral pericallosal and callosomarginal arteries. Three-dimensional visualization demonstrated a benign dilatation secondary to the four vessels branching; no aneurysm was noted. Incidence of aneurysms at the distal dividing point of an azygos ACA ranges from 13% to 71%. However, careful anatomical examination is imperative as findings may be a benign dilatation for which case intervention is not indicated.

The microanatomy features of cerebral arteries may be variable and may be different in different ethnic groups. To study the anterior cerebral artery (ACA) anatomy in North-West Indian cadavers. Microanatomy features of the ACA were studied in 15 formalin fixed human cadaveric brains under microscope. The outer diameter, length, and number of perforating branches with respective anomalies were measured for each of the following vessels: ACA (proximal A1 segment to distal A2 segment), anterior communicating artery (ACoA), Recurrent artery of Heubner (RAH), and callosomarginal artery and photographed for documentation. The mean length and external diameter of right and left A1 segment was 12.09 mm and 12.0 mm and 2.32 mm and 2.36 mm respectively. Narrowing, duplication, and median ACA were seen in 6.6%, 3.3% and 6.6% of the vessels respectively. Complex ACoA type was seen in 40% cadavers. RAH originated at an average point of 0.2 mm distal to ACoA, but in one cadaver it arose 5 mm proximal to ACoA. Double RAH was found in 26.6%. The course of RAH in relation to A1 was superiorly in 60%, in anteriorly 30% and posteriorly in 10% of cadavers. The orbitofrontal artery (OFA) and frontopolar artery (FPA) arose from A2 in 83.3% to 40% respectively. The mean distance of OFA and FPA from ACoA was 4.17 mm and 8.5 mm respectively. After giving rise to central, callosal and cortical branches, pericallosal artery terminated near the splenium of the corpus callosum or on the precuneus as the inferomedial parietal artery. Knowledge of the microvascular anatomy is indispensable and it is mandatory to be aware of the possible variations in the anomalies to minimize morbidity.

An 85-year-old man with essential hypertension and diabetes mellitus abruptly developed right-sided isolated shoulder palsy (ISP). Cranial magnetic resonance imaging demonstrated infarction of the cortical branch of the left anterior cerebral artery (ACA), which involved the left precentral gyrus. In the primary motor cortex, the corresponding area to the shoulder is very small. Consequently, there have been only five reported cases of ISP due to a cortical infarction, and its vascular supply remains uncertain. Our present case denotes that the corresponding area to the shoulder in the primary motor cortex receives its blood from the cortical branch of the ACA. J Med Cases. 2014;5(1):49-51 doi: http://dx.doi.org/10.4021/jmc1634w

Carotid-anterior cerebral artery anastomosis (carotid-ACA anastomosis) is described as infrequent vascular connections between the pre-ophthalmic segment of the internal carotid artery (ICA) and the A1 segment of the anterior cerebral artery (ACA). The embryological origin of these variant is still unclear and they are often associated to other vascular anomalies of the circle of Willis, as well as to the presence of aneurysms. Carotid-ACA anastomosis is often right-sided although left and bilateral cases have also been described. We report a rare case by MR angiography of a carotid-ACA anastomosis in which the abnormal vessel arises from the right ICA and takes an infraoptic course to join the A2 segment of the contralateral ACA, making this vascular anomaly function as a ‘left ACA with an origin at the right ICA’. The A1 segment of the left ACA is absent and both A2 segments of the ACAs present fenestration. To our knowledge, no similar cases have been reported in English literature so far.

Objective To investigate the effect ofbuflomedil hydrochlorde on regional cerebral blood flow in different subtypes of schizophrenia.Methods Two hundred and eighty-six patient met the diagnostic criteria of CCMD-3 for schizophrenia,admitted to our hospital from February 2007 to February 2009,were chosen in our study; patients of type Ⅰ (n=86),type Ⅱ (n=63) and type Ⅲ (n=137)were randomly divided into treatment group of type Ⅰ (n=46),placebo treatment group of type Ⅰ (n=40),treatment group of type Ⅱ (n=34),placebo treatment group of type Ⅱ (n=29),treatment group of type Ⅲ(n=72) and placebo treatment group of type Ⅲ (n=65).Patients from the treatment groups were treated with antipsychotics with buflomedil hydrochloride and those from placebo treatment groups were given antipsychotics with saline for 4 weeks.On the 1st day and at the end of the 4th week of treatment,cerebral blood flows of bilateral anterior cerebral artery,middle cerebral artery,posterior cerebral artery,vertebral artery and basilar arterywere were measured by transcranial Doppler (TCD).Results No statistically significant difference of cerebral blood flow was noted between the two groups of type Ⅰ before/after treatment,neither between before and after treatment in one of the groups (P＞0.05).For type Ⅱ schizophrenia,no statistically significant difference of cerebral blood flow was noted between the two groups on the 1st day of treatment (P＞0.05); however,at the end of 4th week of treatment,cerebral blood flow in the bilateral anterior cerebral artery,middle cerebral artery,posterior cerebral artery blood of the treatment group were significant greater than that in the placebo treatment group (P＜0.05); the cerebral blood flow in the bilateral anterior cerebral artery,middle cerebral artery,posterior cerebral artery blood of the treatment group at the end of 4th week of treatment was significantly higher than that on the 1 st day of treatment (P＜0.05),while no significant difference was noted in the placebo treatment group (P＞0.05).For type Ⅲ schizophrenia,at the end of 4th week of treatment,the cerebral blood flow in the treatment group in the left anterior cerebral artery,the left middle cerebral artery and right middle cerebral artery were significant greater than that in the placebo treatment group (P＜0.05); and that of the bilateral anterior cerebral artery and middle cerebral artery in the treatment group at the end of 4th week of treatment was significantly greater than that on the 1st day of treatment (P＜0.05).Conclusions Different subtypes of schizophrenia enjoys different cerebral blood flows:most significant decline in cerebral blood flow and largest number of cerebral arteries of type Ⅱ schizophrenia are noted,followed by type Ⅲ schizophrenia;cerebral blood flow of schizophrenia maybe have an order to decline and the left middle cerebral artery maybe the first; the changes of cerebral blood flow between before and after treatment show that the decline of cerebral blood flow can be inverted with drugs. Key words: Schizophrenia; Buflomedil hydrochloride; Transcranial Doppler; Cerebral blood flow

Background: Anterior communication artery is a collateral channel that connects the right and left anterior cerebral arteries in the circle of Willis. This helps in stabilizing the cerebral blood flow. Different types of variations of this artery were reported in the previous studies. The hemodynamic changes in the blood flow produced by variations induce strain at the sites of bifurcation, which may result in the formation of aneurysms. This commonly occurs at the meeting point of anterior communicating artery (ACoA) with the anterior cerebral artery. The anatomical variations in this portion may complicate the planning and performance of surgery which in turn will lead to postoperative complications. Methodology: The study was conducted in 60 specimens of the brain in the department of anatomy, Government Medical college, Calicut. The artery was carefully dissected and observed. Photographs were taken. The observations were tabulated. Results: Variations were noted in 15 specimens (25%). Duplication of the artery was noted in 6 specimens (10%), hypoplasia in 3 specimens (5%), V-type artery in 1 specimen, and X-type in 6 specimens (10%). There was no triplication or plexiform type noted. An accessory anterior cerebral artery was noted in 3 specimens (5%). Conclusions: As the ACoA acts a collateral channel that stabilizes the cerebral blood flow, when there is any vascular occlusion in any components of the circle, the knowledge of these anatomical variations becomes significant. As the radiological and neurosurgical interventions are increasingly performed, nowadays, the surgeons and radiologists should be aware of these variations in the cerebral arteries.

Akinetic Mutism Following Unilateral Anterior Cerebral Artery Occlusion

Segmental duplications (also termed 'fenestrations') of the fetal anterior cerebral artery are a relatively rare anomaly. Their occurrence was studied in 200 fetuses at 20-40 wk gestational age. Duplications were found in 21 of the 200 fetuses, i.e. 10.5%. In 2 fetuses, i.e. 1%, the duplications were bilateral. In 1 case, i.e. 0.5%, 2 duplications were found on the left anterior cerebral artery. There were 15 segmental duplications on the left anterior cerebral artery, i.e. 62.5% of all duplications, and 9 on the right, i.e. 37.5%. The duplications were located in the distal part of the A1 segment in 45.7%, at the level of the anterior communicating artery (A1-A2) in 37.7%, and in the initial part of the A2 segment in 16.6%. The duplications had 4 different forms namely oviform, fissured, triangular and punctate.

Symptomatic Cerebral Vasospasm and Delayed Cerebral Ischemia Following Transsphenoidal Resection of a Craniopharyngioma

Objective: Primary anterior cerebral artery (ACA) occlusion is a rare condition and sometimes leads to significant neurological deficits. We herein report on the efficacy of mechanical thrombectomy (MT) in treating the distal ACA occlusion in a clinical setting. Case Presentation: A 76-year-old woman presented with a sudden onset of right hemiparesis. Computed tomographic angiography and perfusion imaging and subsequent analysis with RAPID software revealed acute left ACA occlusion with salvageable penumbra. The patient obtained a score of 11 on the National Institutes of Health Stroke Scale. MT was performed for occlusion of the left ACA (A4), and successful reperfusion (Thrombolysis in Cerebral Infarction score of 3) was achieved on the first attempt using a stent retriever. The patient’s recovery progressed well, and she was discharged 13 days after admission with a modified Rankin Scale score of 1. Conclusion: This case report demonstrates the clinical efficacy, safety, and favorable clinical outcome of treating a primary distal ACA occlusion with MT.