PMC4756250_01
A: Axial FLAIR image showing an isointense lesion (arrow) in the right side of the sphenoid sinus extending to the orbital apex and the cavernous portion of the ICA. B: Axial FLAIR image showing a high-intensity lesion (arrow) at the base of the bilateral frontal lobes, suggesting meningoencephalitis due to intracranial extension of sphenoid sinusitis. C: MRA image, right anterior oblique view, showing an aneurysm (arrow) projecting anteriorly at the C3 portion of the right ICA. D: 3D-CT angiography, right anterior oblique view, showing rapid growth of the aneurysm (arrow). Note that bilateral anterior cerebral arteries distal to the anterior communicating artery are not opacified, suggesting the presence of a stenosis caused by frontal base meningoencephalitis. E: Pre-operative single photon emission computed tomography showing a hypoperfusion area in the anterior cerebral artery distribution. FLAIR: fluid attenuated inversion recovery, ICA: internal carotid artery, MRA: magnetic resonance angiogram, 3D-CT: three-dimensional computed tomography.
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ICA aneurysm projecting anteriorly into the sphenoid sinus at the C3 portion (Fig. 1C). It was noted that bilateral anterior cerebral arteries (ACAs) distal to the anterior communicating artery (AcoA) were pooly visualized, suggesting the presence of arterial stenosis caused by frontal base meningoencephalitis. Because a three-dimensional computed tomography (3D-CT) angiogram taken 5 days later showed rapid growth of this fungal aneurysm (from 9 mm x 3 mm to 11 mm x 10 mm) (Fig. 1D), we planned an emergency operation to prevent the aneurysm rupturing, which might have resulted in fatal epistaxis. Pre-operative single photon emission computed tomogram (SPECT) showed presence of a hypoperfusion area in the anterior cerebral artery distribution (Fig. 1E).
A: MRI image taken 4 days after the operation showing patency of both the radial artery graft and the frontal branch of the right superficial temporal artery. The right ICA has been obliterated, and the aneurysm is not visualized. B: Post-operative single photon emission computed tomogram showing improved perfusion in the right anterior cerebral artery distribution. ICA: internal carotid artery, MRI: magnetic resonance imaging.
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MRI taken 4 days after the operation showed patency of both the radial artery graft and the frontal branch of the right STA (Fig. 2A). Post-operative SPECT taken 2 weeks after the operation showed improved perfusion in the right anterior cerebral artery distribution (Fig. 2B).