PMC9282736_01
(a and b) Computed tomography (CT) scans showed subarachnoid hemorrhage in the posterior fossa and left Sylvian fissure, intraventricular hemorrhage with slight ventriculomegaly, and contusion of the left temporal lobe. (c) Three-dimensional CT image showed fractures of the right temporal bone and zygoma. (d and e) A cerebral CT angiogram revealed no vascular abnormalities or aneurysms. (d) Three-dimensional CT angiography, (e) sagittal view of CT angiography.
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F1
Computed tomography (CT) showed SAH in the posterior fossa and left Sylvian fissure, IVH with slight ventriculomegaly, and contusion of the left temporal lobe [Figures 1a and b]. Fractures of the right temporal bone and zygoma were also observed [Figure 1c]. CT angiogram revealed no aneurysm and vascular abnormalities without right dominant PICA [Figures 1d and e]. Chest and abdominal CT showed pneumothorax and multiple rib fractures on the right side.
(a) One hour later cerebral computed tomography (CT) images showed increased subarachnoid hemorrhage, intraventricular hemorrhage, and ventricular enlargement. (b) A right vertebral artery (VA) angiography three-dimensional image revealed an 11 mm aneurysm in the right posterior inferior cerebellar artery (PICA) anterior medullary segment (AMS). (c) The enlarged view of B. Green line is 11 mm and the orange line is 9 mm. It was considered a pseudoaneurysm because of its small and unclear aneurysmal neck. (d) The Marathon microcatheter (Medtronic, Minneapolis, Minnesota, USA) was approached to the aneurysm from the right VA using the Tenrou 1014 (Kaneka Medics, Kanagawa, Japan). However, with this approach, it was difficult to guide the microcatheter because the direction of the microcatheter and the aneurysm neck was almost at 180  with each other. (e) A Marathon catheter was approached to the aneurysm from the left VA beyond the union using the Tenrou 1014. (f) Microcatheter angiography revealed an aneurysm and backflow to the VA and PICA. The diameter of the small space at the entrance of the aneurysm where the Marathon microcatheter could be placed was approximately 1.5 mm. G: n-butyl-2-cyanoacrylate (NBCA) (12.5%) was injected into the aneurysm while blocking the proximal part of the right VA with a SHOURYU HR balloon (7 mm x 7 mm) (Kaneka Medics, Kanagawa, Japan) and suppressing the backflow to the VA. (h) Using NBCA, we were able to embolize a small part of the aneurysm neck. Although the Marathon microcatheter was carefully removed, its removal from the aneurysm caused NBCA to scatter into the PICA. (i) The right VA angiography revealed that the aneurysm had disappeared, but blood flow in the PICA was very slow.
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F2
Cerebral CT showed increased SAH, IVH, and ventricular enlargement [Figure 2a]. It was considered a pseudoaneurysm because of its small and unclear aneurysmal neck [Figures 2b and c]. However, with this approach, it was difficult to guide the microcatheter because the direction of the microcatheter and the aneurysm neck was almost at 180  with each other [Figure 2d]. A Marathon catheter and a Tenrou 1014 were inserted into the 5-Fr JB2 125 cm catheter in the left VA and guided beyond the union to the right PICA [Figure 2e]. Tenrou 1014 to the entrance of the aneurysm but were unable to guide them into the aneurysm. Microcatheter angiography revealed an aneurysm and backflow to the VA and PICA [Figure 2f]. The diameter of the small space at the entrance of the aneurysm where the Marathon microcatheter could be placed was approximately 1.5 mm. NBCA (12.5%) was injected into the aneurysm while blocking the proximal part of the right VA with a SHOURYU HR balloon (7 mm x 7 mm) (Kaneka Medics, Kanagawa, Japan) and suppressing the backflow to the VA [Figure 2g]. The Marathon microcatheter was carefully removed, but its removal from the aneurysm caused NBCA to scatter into the PICA [Figure 2h]. An angiogram revealed that the aneurysm had disappeared, but blood flow in the PICA was extremely slow [Figure 2i].
(a) Postoperative cerebral computed tomography (CT) image revealed a contusive hemorrhage in the left temporal lobe with uncal herniation. (b and c) External decompression and hematoma removal were performed, but a postoperative CT image showed an enlarged contusive hemorrhage and uncal herniation. (b) 3D image, (c) axial view.
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F3
Cerebral CT revealed dilated ventricles and contusive hemorrhage in the left temporal lobe with uncal herniation [Figure 3a]. Although decompression craniectomy and hematoma removal were performed, postoperative CT showed an enlarged contusion hemorrhage and uncal herniation [Figures 3b and c].