PMC9357451_01
A-D Preoperative images obtained at the first hospital. The paranasal sinus. CT returned no abnormal finding at the maxillary (A) and the sphenoid sinus (B). MRI scans (C-D): T2 axial view (C), T1 sagittal view after contrast medium injection (D). Neither image shows abnormal finding at the sphenoid sinus.
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E-M Preoperative images obtained at our hospital at the time of craniopharyngioma recurrence. CT shows an iso-dense lesion and no bone destruction at the sphenoid sinus (E). MRI (T2, axial view) (F) at the sphenoid sinus detected a mixed intensity lesion. MRI (T1, coronal view) (G) shows an iso- and high-density lesion. Contrast-enhanced T1 (coronal view) (H) and sagittal (I) images showing homogenous mucosal enhancement. MRI (T2 coronal view) (J) and the contrast-enhanced (T1 coronal view) (K) scans reveal a tumor encasing the left internal carotid artery. The fused image with venography (L) and the CTA scan (M) reveal no aneurysm at the laterally pushed left internal carotid artery.
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Preoperative computed tomography (CT) and magnetic resonance imaging (MRI) studies performed at the other hospital had detected no paranasal sinus anomalies (Fig. 1A-D). These observations indicated postoperative changes (Fig. 1E-I). No aneurysmal changes were noted (Fig. 1J-M).
Post-endoscopic endonasal surgery images.
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A CT performed on the 1st postoperative day shows no hemorrhage.
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B CT scan obtained on the 5th postoperative day reveals massive SAH with intraventricular hemorrhage.
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C CTA performed immediately shows a paraclinoid aneurysm on the left internal carotid artery.
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D Digital subtraction angiogram acquired approximately 10 hours thereafter shows occlusion of the irregularly shaped aneurysm on the left internal carotid artery.
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ICA, and subsequent intra-arterial digital subtraction angiography revealed an occluding left ICA pseudoaneurysm whose wall was irregular (Fig. 2). It was trapped, and a high-flow bypass from the left external to the left middle cerebral artery was placed using a radial artery graft.
Images of the left internal carotid artery (ICA).
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A-C The wall of the left ICA is disrupted.
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A The H&E-stained section shows severe infiltration by acute and chronic inflammatory cells in all layers of the ICA (x40).
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B EVG stain (x40). The internal elastic lamina is disrupted by inflammatory infiltrates.
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C Grocott stain (x40). Mycotic colonies invading the vascular wall.
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D H&E stain (x200). Note the severe infiltration of acute and chronic inflammatory cells in all ICA layers and the vascular lumen.
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E Grocott stain (x200). Mycotic colonies invading the vascular wall. Characteristically branching Aspergillus hyphae suggest Aspergillus infection.
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F Grocott stain (x200). Aspergillus hyphae invade the cerebrum. The invading colonies are smaller than in the ICA wall.
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There was an invasion into the cerebrum by fungal colonies smaller than in the vessel wall, suggesting that Aspergillus hyphae had primarily invaded and then disrupted the vessels, leading to the spread of colonies into the cerebrum (Fig. 3).