PMC9062925_01
Computed tomography (CT) (a and b) and CT angiography (c) scans performed on admission (a) Brain window image showing an intracerebral hemorrhage in the left occipital lobe and an intraventricular hemorrhage (b) Bone window image showing no bone destruction or fluid storage in the paranasal sinus (c) CT angiography showed a cerebral aneurysm (arrow) in the distal left posterior cerebral artery.
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F1
Brain computed tomography (CT) revealed a subcortical hemorrhage in the left occipital lobe and acute hydrocephalus due to intraventricular hemorrhaging [Figure 1a]. No fluid or bone destruction was seen in the paranasal sinuses [Figure 1b]. 3DCT angiography revealed a cerebral aneurysm in the distal left PCA [Figure 1c].
Anteroposterior (a) and lateral (b) left vertebral angiograms showing a cerebral aneurysm in segment P4 of the left posterior cerebral artery (arrow).
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F2
The left vertebral angiography revealed a wide-necked aneurysm in the left parietooccipital artery (POA) [Figures 2a and b].
Intraoperative photographs. (a) Left occipital craniotomy and corticotomy in the superior occipital gyrus were performed. (b) The proximal (arrow) and distal (arrowhead) posterior occipital artery were exposed. Intra-aneurysmal thrombosis was found (asterisk). (c) The aneurysm was removed, and end-to-end anastomosis of the normal sections of the proximal and distal POA was performed. (d) Indocyanine green video angiography confirmed the patency of the bypass.
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F3
A corticotomy was made in the superior occipital gyrus and the hematoma was approached [Figure 3a]. The proximal and distal portion of parent artery were exposed and the location of the neck of the aneurysm was confirmed [Figure 3b]. As neck clipping would have been difficult due to the fragility of the neck of the aneurysm, the aneurysm was removed, and end-to-end anastomosis of the normal parts of the proximal and distal POA was performed [Figures 3c and d].
Hematoxylin and eosin staining. (a and b) Photomicrographs showing that the elastic fibers had disappeared from the aneurysm wall and only fibrotic tissue was present. (c) Photomicrograph of the outside of the aneurysm showing the accumulation of neutrophils and lymphocytes, and coenocytic hyphae in the necrotic tissue. (d) Photomicrograph obtained after staining using Grocott's method showing coenocytic hyphae, which varied in width and exhibited right-angled branching. These findings are characteristic of zygomycetes. Original magnification: (a) x20, (b) x100, (c) x400, and (d) x400.
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F4
A histopathological examination revealed that the elastic fibers had disappeared from the aneurysm wall and only fibrotic tissue was seen [Figures 4a and b]. On the outside of the aneurysm, neutrophils and lymphocytes gathered and necrotic tissue was seen [Figure 4c]. Immunohistochemical analysis performed with Grocott's stain revealed that the coenocytic hyphae varied in width and exhibited right-angled branching, which are characteristics of zygomycetes [Figure 4d].