Congenital Absence of Internal Carotid Artery with Rare Type of Intercavernous Anastamosis and Ruptured Cerebral Aneurysm.

Congenital absence of Internal Carotid Artery (ICA) is a rare anomaly seen in <0.01% of the population. Various collateral circulations develop in these cases to maintain adequate cerebral perfusion. High incidence of aneurysms is reported in these cases. Complete evaluation is required to detect other abnormalities usually seen in these patients. We report a case of congenital absence of right ICA in a 39-year-old female who presented with Subarachnoid Haemorrhage (SAH) and had a Middle Cerebral Artery Aneurysm (MCA). The right MCA got supply from the intercavernous communication from the left internal carotid artery. Skull base Computed Tomogram (CT) confirmed the congenital absence of right ICA. She underwent successful surgical clipping for the aneurysm. The high incidence of aneurysms, collateral circulations, embryological development and postulated mechanisms of this anomaly were discussed. The exact aetiology behind the absence of ICA remains unclear. It is important to differentiate this condition from acquired stenosis/occlusion due to atherosclerosis and carotid dissection. Recognising the anomaly is important and gains even more significance during surgical planning in cases of direct aneurysm clipping, carotid endarterectomy and transphenoidal surgeries.

Endovascular treatment of fusiform A2 aneurysm with parent artery occlusion.

BACKGROUND: A2 aneurysms are rare with a reported incidence of <1% of the intracranial aneurysms. These aneurysms are located between the anterior communicating artery and genu of the corpus callosum. Fusiform aneurysms in this location are even rarer and we present one such case of fusiform A2 aneurysm treated with endovascular technique. CASE DESCRIPTION: In this report, we present a case of ruptured fusiform A2 or proximal pericallosal artery aneurysm in a middle-aged female who presented with subarachnoid hemorrhage. She subsequently underwent endovascular parent artery occlusion, and post-procedure angiogram showed good pial collaterals filling the distal territory. She developed transient lower limb weakness which improved over the next 24 h with supportive inotrope management to maintain adequate cerebral flow. CONCLUSION: We report a rare unique case of ruptured fusiform proximal pericallosal artery aneurysm. Endovascular treatment of this type of aneurysm is a feasible method and can be considered as an effective alternative to surgical technique.

Endovascular treatment of basilar artery stenosis due to cerebral vasculopathy related to neurofibromatosis (NF1).

BACKGROUND: Cerebrovascular lesions are uncommon in neurofibromatosis type 1 (NF1). CASE DESCRIPTION: We report a case of 34-year-old man with NF1 who developed posterior circulation stroke. Diffusion-weighted imaging showed acute infarcts in the right vertebra basilar artery territory. Digital subtraction angiography demonstrated significant stenosis of the basilar artery in the mid segment that was identified as the etiology of the symptoms. The vertebral arteries were tortuous and the basilar artery was ectatic. Subsequently endeavour resolute stent was placed across the lesion and post-procedure angiogram showed resolution of stenosis. CONCLUSION: Selective stenotic involvement of the basilar artery with ectatic vertebrobasilar circulation associated with NF1, which was successfully treated with endovascular method, was not been reported previously to our knowledge.

Role of balloon-expandable stents in intracranial atherosclerotic disease in a series of 182 patients.

BACKGROUND AND PURPOSE: To demonstrate the safety and efficacy of balloon-expandable intracranial stents in patients with intracranial atherosclerotic lesions (>70% stenosis) who were symptomatic despite being on optimum medical therapy. METHODS: Between April 2004 and May 2012, 182 patients underwent intracranial stenting in our institution. All patients had symptoms despite being on optimum medical therapy. Clinical follow-up was done at 1, 3, 6, and 12 months. Angiographic follow-up was done at 1 year in 121 patients. RESULTS: Technical success was achieved in 97.44% of the cases. The incidence of all strokes at 1 month after procedure was 11 (5.64%), of which 2 (1.02%) were major, both related to stent thrombosis not responding to tirofiban, and 9 (4.61%) were minor. Periprocedural minor stroke was seen in 9 patients. There were 2 deaths in our study (mortality=1.09%). CONCLUSIONS: Treatment of intracranial atherosclerotic disease with balloon-expandable intracranial stents is a safe and effective method with acceptable adverse events, especially in patients who failed medical therapy and were symptomatic despite being on optimum medical therapy.

Stent-assisted coiling in ruptured wide-necked aneurysms: A single-center analysis.

BACKGROUND: To evaluate the safety and efficacy of stent-assisted coiling of ruptured intracranial wide-necked aneurysms in a setting of acute subarachnoid hemorrhage, without compromising on the antiplatelet regimen. METHODS: Forty-two consecutive patients who underwent stent-assisted coiling for ruptured wide-necked intracranial aneurysms from August 2008 to May 2012 were studied. Demographic data like age, sex, Hunt & Hess grade, Fischer scale, and location, and size of the aneurysms were noted. Complications such as aneurysmal rupture, bleeding complications, thromboembolic events, etc. were documented. Also, 30-day and 1-year outcome was measured using modified Rankin scale (mRS). RESULTS: Forty-four wide-necked aneurysms were treated in 42 patients with stent-assisted coiling from August 2008 to May 2012 in our institution, out of a total of 248 aneurysms treated endovascularly in the same period. All these patients presented with subarachnoid hemorrhage (SAH) with varying grades and were treated in the acute phase, i.e. within 1 week of the ictus. There were 24 males and 18 females in the age group ranging from 12 to 78 years, with a mean of 45 years. Technical success was achieved in 39 patients with complete angiographic cure (93%). Intraprocedural stent thrombosis was seen in two patients, which resolved with intra-arterial bolus of tirofiban, and both the patients did not have any neurological deficit. Rebleed occurred in two patients of which one patient succumbed. Six patients required external ventricular drain because of worsening hydrocephalus on computed tomography (CT) scan with clinical deterioration. There was one death in our series due to rebleed. Three other patients died in a period of 1 month due to complications not related to the coiling procedure which include vasospasm, pulmonary embolism, and respiratory infection. All the patients were clinically followed up at 1 month, 3 months, 6 months, and 1 year. Also, angiographic follow- up was done at 1 year in 25 patients (72%). All the patients were maintained on clopidogrel 75 mg per day and ecospirin 150 mg per day for a period of 1 year and were advised to continue ecospirin 150 mg per day lifelong. CONCLUSION: Even in a setting of acute SAH, stent-assisted coiling can be an effective and safe treatment option with acceptable risks in experienced hands.

Spontaneous thrombosis of basilar tip aneurysm: Role of neuroimaging and follow-up with review of literature.

The incidence of pediatric aneurysms is rare compared to that of the adults. The natural history and the course of these aneurysms were not well understood. We present a rare case of spontaneously thrombosed basillar tip nongiant aneurysm in a 9-year-old male child who presented with symptoms of mass effect and subsequently followed up by imaging over a period of 1 year.

Corkscrew angiopathy of intracranial vessels in a young stroke patient: a case report.

INTRODUCTION: We present a rare finding of a 'corkscrew appearance' of the distal cerebral vessels in a young Asian woman who presented with acute stroke. CASE PRESENTATION: A 32-year-old Asian woman presented with a 3-month history of recurrent right-sided transient ischemic attacks. Her clinical workup and brain imaging results were normal. A digital subtraction angiogram revealed an abnormal corkscrew appearance of all intracranial distal vessels. She was discharged on a single antiplatelet drug. She had no further transient ischemic attacks on clinical follow-up. A digital subtraction angiogram performed 1 year later revealed no changes in the appearance of these vessels. CONCLUSION: To the best of our knowledge no similar previous reports exist in the literature. The present report describes a unique case of an unusual corkscrew appearance of the distal intracranial vessels. However, the underlying etiology in the present case remains unknown.

Endovascular management of fusiform superior cerebellar artery aneurysms: a series of three cases with review of literature.

Distal superior cerebellar artery (SCA) aneurysms are rare. Fusiform aneurysms of SCA are rarer and more challenging to treat. Parent artery occlusion by endovascular coiling is the treatment option for these cases. Presence of good collateral circulation and paucity of perforators from S1 and S2 segments makes this a feasible option. From 2007 to 2010, we treated three patients (two men and one woman between the ages of 42 to 64 years) with distal fusiform SCA aneurysms using endovascular coiling. All the patients presented with symptoms of rupture and were treated in the acute phase. Informed and written high-risk consent was given by all patients prior to the procedure. Successful angiographic and clinical outcome was achieved in all three patients. Endovascular treatment of fusiform SCA aneurysms with coils is a safe and feasible option in the management of this rare entity.

Idiopathic thrombus in the common carotid artery on digital subtraction angiography.

In the present study, we discuss the accuracy of digital subtraction angiography (DSA) in diagnosis of thrombus in the common carotid artery and its role in the medical management of this disorder. Between 2006 and 2011, four patients (age group ranging from 26 to 48 years) presented to our institution with symptoms of stroke. DSA in all these patients showed cigar-shaped filling defect in the common carotid artery. All the patients were managed successfully with anticoagulation treatment. Follow-up Duplex scan was done in all the patients. DSA is the gold standard to diagnose free floating thrombus in the common carotid artery. Medical management can be effective in these patients but a multidisciplinary team approach is needed for appropriate management.

Simultaneous bilateral carotid stenting in a series of 9 patients: a single-center experience with review of literature.

OBJECTIVES: Simultaneous bilateral carotid artery stenting (SBCAS) is a challenging procedure, and selection criteria play an important role in determining the final outcome. The aim of the present study was to determine the efficacy and safety of the SBCAS in a series of 9 patients with significant bilateral carotid artery disease (>50% on the symptomatic side and >60% on the asymptomatic side). MATERIALS AND METHODS: The present study is a retrospective study of 9 patients from January 2005 to December 2012 in a tertiary care center. There were 8 males and 1 female in the age range 50 to 75 years and an average mean age of 63 years. Inclusion criteria of the present study were patients with bilateral internal carotid artery stenosis >50% (50 - 99%) in the symptomatic side and >60% in the asymptomatic side as seen on digital subtraction angiography (DSA). SBCAS with use of distal protection device (Spider device, ev3), to prevent intra-procedural embolic migration, was done in all the patients. RESULTS: Technical success was achieved in all patients (100%). Post-procedural events in the form of hypotension and bradycardia occurred in 3 patients after the placement of stent on both the sides, in 2 patients after the placement of the first stent, and in 1 patient after the placement of the second stent. We did not encounter any cases of hyperperfusion, which was a concern in these patients. There were no deaths, major or minor strokes, or myocardial infarction either in the post-procedural period (up to 1 month) or on clinical follow-up 3 and 6 months post-treatment. CONCLUSION: SBCAS was an effective and safe alternative treatment method in a select group of patients with bilateral carotid artery disease. It can be considered as a feasible treatment option with acceptable risks.

Role of endovascular treatment in pediatric cerebral aneurysms: a series of two case reports.

Aneurysms in the pediatric age group are rare and have preponderance for the posterior circulation. These aneurysms are more commonly large, giant, and complex. We present two case reports of saccular aneurysms in pediatric patients who were treated successfully by endovascular technique.