PMC4123257_01
(a-h) Multiple views of a four vessels cerebral angiogram and 3D reconstructions taken 6 years prior to presentation, demonstrating no intracranial aneurysm or significant vascular lesion
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F1
This prompted a cerebral angiogram, which demonstrated normal intracranial vasculature without evidence of an aneurysm or other abnormality [Figure 1].
(a-e) Admission angiographic views of the left and right internal carotid arteries demonstrating multiple fusiform aneurysms involving the anterior and posterior divisions of both MCA M2-M3 segments.; (f-i) 3D reconstructions showing multiple fusiform aneurysms affecting all major intracranial arteries
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F2
The patient was transferred to our facility and underwent catheter angiography, which revealed at least 20 fusiform aneurysms involving bilateral middle, anterior, and posterior cerebral arteries [Figure 2].
(a-i) Multiple MRI images, T1 and T2, confirming multiple fusiform aneurysm dilatations involving the anterior circulation. Of interest, there is no evidence of ischemic injury on the diffusion-weighted imaging
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F3
The patient underwent numerous investigations including MRI [Figure 3], and testing for/of human immunodeficiency virus (HIV), dobutamine stress echocardiogram, Epstein-Barr virus, erythrocyte sedimentation rate, syphilis, C-reactive protein, antinuclear antibodies, antineutrophil cytoplasmic antibody, complement and immunoglobulins testing, skin biopsy, transthoracic and transesophageal echocardiograms.
Intraoperative angiography following surgical clippings of the right MCA posterior division (saccular component) and the fusiform dilatation of the anterior temporal artery; showing complete obliteration of the aneurysm without evidence of parent artery compromise
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F4
MCA branch aneurysm was confirmed as the source of bleeding and was clipped successfully [Figure 4]. Multiple nearby fusiform lesions were wrapped and/or clipped, and a fusiform aneurysm of the anterior temporal artery was clipped allowing us to biopsy the "clipped" portion of the aneurysmal wall.
(a) Hematoxylin and eosin. Original magnification x100. Significant inflammation is absent. Well-developed distinction between intima, media and adventitia is not apparent. (b) Alcian blue (pH 2.5) Original magnification x100. Alcian blue highlights acid mucosubstances and acetic mucins. Small amounts of staining are normal in blood vessel walls but increases in early lesions of atherosclerosis. The illustrated sample is essentially normal or mildly increased. (c) Verhoeff van Giesen elastic stain. Original magnification x100. Note that no distinctive internal elastic lamina is visible within the sample
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F5
The biopsy demonstrated nonspecific intimal hyperplasia and all histological biomarkers were negative [Figure 5].