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Case Reports
. 2021 Apr 2;8(1):7-12.
doi: 10.2176/nmccrj.cr.2020-0004. eCollection 2021 Apr.

Characteristics and Management of Ruptured Aneurysms Originating from the Penetrating Artery of the Distal Middle Cerebral Artery

Yu Iida  1 , Kentaro Mori  1 , Yosuke Kawahara  1 , Issei Fukui  1 , Katsuya Abe  2 , Mutsuki Takeda  2 , Tatsu Nakano  2 , Kunio Yanagimoto  3 , Motohiro Nomura  1
Affiliations
Case Reports

Characteristics and Management of Ruptured Aneurysms Originating from the Penetrating Artery of the Distal Middle Cerebral Artery

Yu Iida et al. NMC Case Rep J. .

Abstract

We report a rare case of an aneurysm originating from the penetrating artery of the distal middle cerebral artery (MCA). A 76-year-old man without a notable past history presented with sudden-onset severe headache, left hemiparesis, and a decreased level of consciousness. Computed tomography (CT) revealed subarachnoid hemorrhage (SAH) with intracerebral hemorrhage (ICH) in the right temporal lobe extending into the ventricle. Contrast-enhanced CT (CE-CT) demonstrated a focus of contrast enhancement (CE) adjacent to the hematoma in the right frontal lobe. An aneurysm fed by a penetrating artery branching off from the right distal MCA was found on angiography. The patient underwent emergency resection of the aneurysm and hematoma evacuation. Histological analysis revealed that arterial dissection may be an associated factor in the pathogenesis of this peripheral aneurysm formation. A focus of CE within or adjacent to the hematoma may be useful for diagnosing this peripheral aneurysm. ICH can result in a life-threatening situation. Therefore, microsurgery may be the first treatment choice for aneurysms in this location.

Keywords: aneurysm; dissection; distal middle cerebral artery; intracerebral hemorrhage; penetrating artery.

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Conflict of interest statement

Conflicts of Interest Disclosure The authors have no personal financial or institutional interests in any of the drugs, materials, or devices in the article.

Figures

Fig. 1
Fig. 1
(A) CT showing SAH and ICH in the right temporal lobe extending into the ventricle. (B) Contrast-enhanced CT demonstrating a focus of CE adjacent to the hematoma in the right frontal lobe (arrow). (C) Angiography showing an aneurysm fed by a penetrating artery branching off from the right distal MCA (arrowheads). Left panel: conventional image, right: maximum intensity projection image. CE: contrast enhancement, CT: computed tomography, ICH: intracerebral hemorrhage, MCA: middle cerebral artery, SAH: subarachnoid hemorrhage.
Fig. 2
Fig. 2
An intraoperative photograph (A) and the illustrative drawing (B) demonstrating the aneurysm originating from the M2 penetrating artery. Photomicrograph of histopathological examination corresponding to the intraoperative photograph (C) showing disruption of the aneurysm wall and the thrombus.
Fig. 3
Fig. 3
Close-up view of aneurysm wall of Fig. 2C showing disrupted ends of the IEL and media (arrows) of the parent artery (arrowhead). The aneurysm wall is lack of the IEL and covered by the neointima (asterisks) with the thin adventitia (double arrowheads). The neointima attached on the fresh thrombus (double asterisks) is relatively thin. Left: Elastica van Gieson staining, right: Masson Trichrome staining, IEL: internal elastic lamina.
Fig. 4
Fig. 4
Postoperative angiography showing disappearance of the aneurysm. Left panel: conventional image, right: maximum intensity projection image.
Fig. 5
Fig. 5
Illustration of the aneurysm formation from arterial dissection to aneurysm rupture of the penetrating artery.
See this image and copyright information in PMC

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