PMC4228499_01
Small hemorrhage within the Sylvian fissure and intraventricular hemorrhage in the right lateral and third ventricles associated with mild hydrocephalus
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F1
Preliminary workups were all negative and brain computed tomography scan (CTS) showed a small left frontal opercular intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) accompanied with mild hydrocephalus [Figure 1].
Second CT scan showing normal sized ventricles, but expanded left opercular ICH
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F2
Brain CTS showed a left frontal opercular ICH [Figure 2].
AP view of the DSA showing distal MCA aneurysm
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F3
Four-vessel digital subtraction angiography (DSA) showed a left distal middle cerebral artery (MCA) aneurysm that was 12 x 9 mm in diameter and without an identifiable neck [Figure 3].
Lateral view DSA showing the larger distal MCA aneurysm (black arrow) and two other smaller aneurysms located more proximally on the Sylvian arterial branches (white arrows)
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F4
These two blebs were located along the more proximal branches of M3 segment of left MCA [Figure 4].
The good-quality CTA demonstrating all three aneurysms in AP and lateral views
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F5
The other two ill-defined aneurysms noted in the previous DSA were well elucidated in the new CTA [Figure 5].
(a) Intraoperative image of second MCA aneurysm clipped and (b) the second mid-size aneurysm resected
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F6
The clip could be removed after micro-coagulation of the parent artery [Figure 6a and b].
(a) H&E staining x40 showing portions of vessel wall with necrotic (ring 1), fibrotic (ring 2), and thrombotic (ring 3) changes. Scale bar is 2 mm. (b) H and E, x100 fibro-necrotic wall containing hemosiderin-laden macrophages (ring 2) admixed with many RBCs (ring 1). Scale bar is 1 mm. (c) H and E, x400 showing white small rings encircling few foreign body type giant cells and inflammatory cells, interposed by thrombotic material. Periodic acid Schiff (PAS) staining (for fungi) and acid-fast bacillus (AFB) staining for mycobacteria show no specific microorganism. All these findings are compatible with "necrotizing vasculitis." Scale bar is 100 mum
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F7
The histopathological examination of the resected aneurysms was compatible with "mycotic aneurysm" [Figure 7a-c].
(a-d) The CTA performed after 14 months showing the course of MCA along the Sylvian fissure without aneurysmal dilatation
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F8
The postoperative CTA performed after 1 year confirmed no aneurysmal dilatation along the course of MCA [Figure 8].