PMC6417339_01
Magnetic resonance imaging angiography of the brain on April 12, 2017, showing a basilar tip saccular aneurysm
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F1
Incidentally, a 6.5 mm basilar tip saccular aneurysm was found [Figure 1].
Three-dimensional computed tomography angiography of the brain and a computational fluid dynamics study on May 2, 2017. (a) Posterior view of three-dimensional computed tomography angiography of the brain; (b) Left view of three-dimensional computed tomography angiography of the brain; (c) Computational fluid dynamic study showing high wall pressure with low WSS pressure and WSS vector and the streamline within the basilar tip aneurysm sac. WSS: Wall stream stress
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F2
A two-dimensional and three-dimensional computed tomography angiography of the brain and a computational fluid dynamics study were performed on May 2, 2017, before the surgery [Figure 2].
Intraoperative dual-image videoangiography. (a) Initial unnoticed filling defect (solid arrow) in the internal carotid artery when the motor evoked potential recording was normal (dotted arrow showing basilar tip aneurysm); (b) Occlusion also noted within a branch of middle cerebral artery (dotted-dash arrow); (c) Obvious filling defect within ICA when the signal of the motor evoked potential recording was lost; (d) Good flow within both internal carotid artery and a branch of the middle cerebral artery
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F3
The video showed a small intraluminal filling defect in the cisternal segment of the ICA which was not recognized earlier during surgery [Figure 3a]. ICA and a branch of middle cerebral artery (MCA) [Figure 3b and c]. Intravenous edaravone was administrated. A repeat DIVA was performed which demonstrating good blood flow in the ICA [Figure 3d].
Motor evoked potential recordings. Loss of motor evokes potential recordings form the abductor pollicis brevis using transcranial motor evoke potential from 14:11H, signal returned at 14:49H
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F4
At 1411H, there was a sudden loss of MEP recording at the left APB [Figure 4].
(a-e) Magnetic resonance imaging done on May 31, 2017; (f) Magnetic resonance angiography done on May 31, 2017; (g): Commuted tomography scan of the brain done on October 10, 2017; (h) Commuted tomography scan of the brain done on October 11, 2017. (a) T1-weighted; (b) T2-weighted, (c) fluid-attenuated inversion recovery; (d) Diffusion weighted Imaging; (e) Apparent diffusion coefficient - No other all the different sequences of magnetic resonance imaging of the brain suggestive of any acute ischemic changes; (f) Magnetic resonance imaging showing no residual aneurysm at the basilar tip with both right internal carotid artery and middle cerebral artery are well seen; (g) Commuted tomography scan of the brain (plain) showing right frontoparietal hypo- to isodense subdural collection suggestive of chronic subdural hematoma; (h) Commuted tomography scan of the brain showing no residual subdural collection
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F5
MRI and MRA of the brain were performed the same day of surgery showed no ischemic changes and good flow in all major intracranial arteries [Figure 5a-f]. He was readmitted on October 10, 2017, with a complaint of a mild headache and CT scan of the brain showed right frontoparietal chronic subdural hematoma [Figure 5g]. The surgery was uneventful, and a repeat CT scan brain showed no residual hematoma [Figure 5h].