The Neuroradiology Journal 21: 717-720 2008
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Intraventricular Hemorrhage Caused by Peripheral Anterior Choroidal Artery Aneurysm Rupture A Case Report G. PAVESI, P. AMISTÀ*, M. MUNARI **, M.P. GARDIMAN*** Neurosurgery, * Neuroradiology, ** Neuroanesthesia, *** Pathology, Padua City Hospital; Padua Italy
Key words: subarachnoid hemorrhage, hydrocephalus, intracranial aneurysm
SUMMARY – Intraventricular hemorrhage is a severe ictal event secondary to several pathological conditions (anticoagulation therapies, hypertension, post-surgical, traumatic, neoplastic, vascular malformations), leading to blockage of CSF flow and possible hydrocephalus, often justifying surgical intervention. We describe an uncommon source of intraventricular hemorrhage in a 54-year-old woman caused by a peripheral anterior choroidal artery aneurysm rupture.
Introduction Among hemorrhagic strokes intraventricular hemorrhage is a relatively common feature, especially if associated with other pathological findings such as intracerebral hemorrhage and/or subarachnoid hemorrhage. Whenever the hemorrhagic pattern is exclusively confined in the ventricles, and surgical and traumatic causes are ruled out, the most frequent sources are found in anticoagulation therapies, arterial hypertension, AVMs, moyamoya disease and, rarely, bleeding tumors. Aneurysms arising from the wall of the intraventricular segment of the anterior choroidal artery are an even rarer source of intraventricular hemorrhage, with only seven previously reported cases of intraventricular hemorrhage caused by rupture of these aneurysms 1-7. The present report describes the clinical and therapeutical features of this unusual aneurysm location. Case Report A 54-year-old woman had an abrupt onset of headache and vomiting, rapidly followed by loss of consciousness. On admission she showed an H&H grade IV. CT scan disclosed a diffuse
intraventricular hematoma without intracerebral and subarachnoid hemorrhage (figure 1). Clotting function was normal and there was no history of trauma. Cerebral angiography was performed before any surgical procedure of ventricular drainage and disclosed a saccular aneurysm in the distal segment of the anterior choroidal artery at its plexal point (figure 2). The patient underwent emergency surgery: a left frontotemporal caraniotomy was performed and through a small anterior temporal corticotomy in the middle temporal gyrus access to the temporal horn was rapidly gained. Clot evacuation was followed by aneurysm identification, trapping and removal, since neck clipping was not feasible due to the fusiform appearance of the aneurysm. Histological examination of the surgical specimen, stained with H&E and elastica van Gieson, showed a small relatively preserved portion of aneurysm wall with medial fibrotic thickening as well as loss of the elastica merging with ectatic segments of vessel wall completely replaced by a homogeneous hyaline tissue. An extensive organized laminated mural thrombus was evident in the lumen of the aneurysm. Further clot removal and positioning of a frontal ventricular catheter relieved intracranial pressure. Two weeks later a ventriculo-peritoneal shunt was implanted. MRI 717
Intraventricular Hemorrhage Caused by Peripheral Anterior Choroidal Artery Aneurysm Rupture
G. Pavesi
Figure 1 Axial CT scans on admission showing a diffuse intraventricular hematoma with acute hydrocephalus.
showed no deep ischemic areas linked to distal anterior choroidal artery interruption (figure 3). The patient was then transferred to a rehabilitation care institution where she showed a progressive neurological improvement with a GOS of 4 at four months follow-up. Discussion Intraventricular hemorrhage in adults usually occurs as a severe aspect of aneurysmal subarachnoid hemorrhage or hypertensive in718
tracerebral hemorrhage. Less frequently IVH may occur separately, linked to dyscoagulopathy conditions or caused by bleeding of intraventricular or paraventricular lesions. For these reasons, and since ventricular drainage is often required to treat acute obstructive hydrocephalus, the underlying cause of IVH should be always looked for with imaging studies and clotting function evaluation. Few cases are reported of IVH caused by rupture of distal anterior choroidal artery aneurysm 1-7, since this aneurysmal site is very uncommon, and with a preponderance of reported cases associ-
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Figure 2 Left carotid DSA, lateral projection, showing a truncal aneurysm on the distal part of the anterior choroidal artery.
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Figure 3 Axial T2-weighted MR images obtained three weeks after hemorrhage showing no ischemia in the territory of anterior choroidal artery supply.
The Neuroradiology Journal 21: 717-720, 2008
719
Intraventricular Hemorrhage Caused by Peripheral Anterior Choroidal Artery Aneurysm Rupture
ated with moyamoya disease 6,8. Its anatomical location, just proximal to the ending of anterior choroidal artery into the choroid plexus clarifies the entire intraventricular pattern of hemorrhage. We believe that in this case early surgery was the most appropriate therapeutic approach to obtain prompt closure of the bleeding malformation and at the same time a satisfactory cerebral relaxation by means of external ventricular drainage preceded by intraventricular surgical clot removal. Although there is no clear evidence of increased risk of rebleeding after treatment of acute hydrocephalus in the setting of aneurysmal subarachnoid hemorrhage 9,10, in the present case the immediate insertion of a ventricular cathether appeared more hazardous, since the source of bleeding may be mechanically injured in addition to an increased transmural pressure gradient effect. Due to the massive intraventricular hematoma, further clot evacuation with subsequent cerebral decompression was achieved through a small frontal corticotomy along the ventricular catheter trajectory. Direct evacuation of intraventricular clot is a useful manoeuvre to obtain immediate relief of elevated intracranial pressure otherwise difficult to reduce with external ventricular drainage alone 11. In addition, it is a common observation that external ventricu-
G. Pavesi
lar drainage may obstruct in the presence of a massive intraventricular clot. With respect to aneurysm securing procedure peripheral aneurysms are nonsaccular aneurysms arising along the arterial trunk, unrelated to branching sites 12, and without a recognizable neck, thus forcing the surgeon to perform an aneurysmectomy procedure rather than aneurysm clipping. As other authors have pointed out 4,5, the surgical approach to the distal part of the anterior choroidal artery is gained through a small cortical incision in the anterior third of the middle temporal gyrus, thus reaching the temporal horn of the lateral ventricle deep in the white matter. In our case sacrifice of the most distal portion of the anterior choroidal artery was necessary to eliminate the aneurysm from cerebral circulation. Anatomic studies and surgical observations 4,13,14 suggest that the intraventricular tract of the anterior choroidal artery is not involved in the arterial supply of the posterior limb of the internal capsule and cerebral peduncle, since its perforating branches arise from the more proximal cisternal segment of the basal cistern. Our patient did not show any motor impairment and MRI confirmed the absence of ischemia in the territory of anterior choroidal artery supply.
References 1 Ahn JY, Han IB, Hong CK et Al: Ruptured distal anterior choroidal artery aneurysm. J Clin Neurosci 13: 872-875, 2006. 2 Inagawa T, Matsuda Y, Kamiya K et Al: Saccular aneurysm of the distal anterior choroidal artery-case report. Neurol Med Chir 30: 498-502, 1990. 3 Yanaka K, Tsuboi K, Fujita K et Al: Distal choroidal artery neurysm associated with an arteriovenous malformation. Intraoperative localization and treatment. Surg Neurol 53: 546-551, 2000. 4 Nishihara J, Kumon Y, Matsuo Y et Al: A case of distal anterior choroidal artery aneurysm; case report and review of the literature. Neurosurgery 32: 834-837, 1993. 5 Knuckey NW, Epstein MH, Haas R et Al: Distal choroidal artery aneurysm. Intraoperative localization and treatment. Neurosurgery 22: 1084-1087, 1988. 6 Tanaka Y, Takeuchi K, Ogashiwa M et Al: Moyamoya phenomenon combined with cerebral aneurysm. Brain Nerve 30: 687-695, 1978. 7 Papo I, Salvolini U, Caruselli G: Aneurysm of the anterior choroidal artery with intraventricular hematoma and hydrocephalus. Case report. J Neurosurg 39: 255260, 1973. 8 Konishi Y, Kadowaki C, Hara M et Al: Aneurysms associated with moyamoya disease. Neurosurgery 16: 484-491, 1985. 9 Fountas KN, Kapsalaki EZ, Machinis T et Al: Review of the literature regarding the relationship of rebleeding and external ventricular drainage in patients with
720
10
11
12 13 14
subarachnoid hemorrhage of aneurysmal origin. Neurosurg Rev 29:14-18, 2006. Hellingman CA, van den Bergh WM, Beijer IS et Al: Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 38: 96-99, 2007. Lagares A, Putman CM, Ogilvy CS: Posterior fossa decompression and clot evacuation for fourth ventricle hemorrhage after aneurismal rupture: case report. Neurosurgery 49: 208-211 Biondi A: Truncal intracranial aneurysms: dissecting and fusiform aneurysms. Neuroimaging Clin N Am 16: 453-465, 2006. Marinkovic S, Gibo H, Brigante L et Al: The surgical anatomy of the perforating branches of the anterior choroidal artery. Surg Neurol 52: 30-36, 1999. Rhoton AL Jr, Fujii K, Fradd B: Microsurgical anatomy of the anterior choroidal artery. Surg Neurol 12: 171-187, 1979.
G. Pavesi, MD Neurosurgery Deparment Padua Hospital Via Giustiniani 1 35100 Padua, Italy Tel.: 0039498213645 Fax: 0039498213672 E-mail: [email protected]
www. centauro. it
Intraventricular Hemorrhage Caused by Peripheral Anterior Choroidal Artery Aneurysm Rupture A Case Report G. PAVESI, P. AMISTÀ*, M. MUNARI **, M.P. GARDIMAN*** Neurosurgery, * Neuroradiology, ** Neuroanesthesia, *** Pathology, Padua City Hospital; Padua Italy
Key words: subarachnoid hemorrhage, hydrocephalus, intracranial aneurysm
SUMMARY – Intraventricular hemorrhage is a severe ictal event secondary to several pathological conditions (anticoagulation therapies, hypertension, post-surgical, traumatic, neoplastic, vascular malformations), leading to blockage of CSF flow and possible hydrocephalus, often justifying surgical intervention. We describe an uncommon source of intraventricular hemorrhage in a 54-year-old woman caused by a peripheral anterior choroidal artery aneurysm rupture.
Introduction Among hemorrhagic strokes intraventricular hemorrhage is a relatively common feature, especially if associated with other pathological findings such as intracerebral hemorrhage and/or subarachnoid hemorrhage. Whenever the hemorrhagic pattern is exclusively confined in the ventricles, and surgical and traumatic causes are ruled out, the most frequent sources are found in anticoagulation therapies, arterial hypertension, AVMs, moyamoya disease and, rarely, bleeding tumors. Aneurysms arising from the wall of the intraventricular segment of the anterior choroidal artery are an even rarer source of intraventricular hemorrhage, with only seven previously reported cases of intraventricular hemorrhage caused by rupture of these aneurysms 1-7. The present report describes the clinical and therapeutical features of this unusual aneurysm location. Case Report A 54-year-old woman had an abrupt onset of headache and vomiting, rapidly followed by loss of consciousness. On admission she showed an H&H grade IV. CT scan disclosed a diffuse
intraventricular hematoma without intracerebral and subarachnoid hemorrhage (figure 1). Clotting function was normal and there was no history of trauma. Cerebral angiography was performed before any surgical procedure of ventricular drainage and disclosed a saccular aneurysm in the distal segment of the anterior choroidal artery at its plexal point (figure 2). The patient underwent emergency surgery: a left frontotemporal caraniotomy was performed and through a small anterior temporal corticotomy in the middle temporal gyrus access to the temporal horn was rapidly gained. Clot evacuation was followed by aneurysm identification, trapping and removal, since neck clipping was not feasible due to the fusiform appearance of the aneurysm. Histological examination of the surgical specimen, stained with H&E and elastica van Gieson, showed a small relatively preserved portion of aneurysm wall with medial fibrotic thickening as well as loss of the elastica merging with ectatic segments of vessel wall completely replaced by a homogeneous hyaline tissue. An extensive organized laminated mural thrombus was evident in the lumen of the aneurysm. Further clot removal and positioning of a frontal ventricular catheter relieved intracranial pressure. Two weeks later a ventriculo-peritoneal shunt was implanted. MRI 717
Intraventricular Hemorrhage Caused by Peripheral Anterior Choroidal Artery Aneurysm Rupture
G. Pavesi
Figure 1 Axial CT scans on admission showing a diffuse intraventricular hematoma with acute hydrocephalus.
showed no deep ischemic areas linked to distal anterior choroidal artery interruption (figure 3). The patient was then transferred to a rehabilitation care institution where she showed a progressive neurological improvement with a GOS of 4 at four months follow-up. Discussion Intraventricular hemorrhage in adults usually occurs as a severe aspect of aneurysmal subarachnoid hemorrhage or hypertensive in718
tracerebral hemorrhage. Less frequently IVH may occur separately, linked to dyscoagulopathy conditions or caused by bleeding of intraventricular or paraventricular lesions. For these reasons, and since ventricular drainage is often required to treat acute obstructive hydrocephalus, the underlying cause of IVH should be always looked for with imaging studies and clotting function evaluation. Few cases are reported of IVH caused by rupture of distal anterior choroidal artery aneurysm 1-7, since this aneurysmal site is very uncommon, and with a preponderance of reported cases associ-
www. centauro. it
Figure 2 Left carotid DSA, lateral projection, showing a truncal aneurysm on the distal part of the anterior choroidal artery.
➜
➜
Figure 3 Axial T2-weighted MR images obtained three weeks after hemorrhage showing no ischemia in the territory of anterior choroidal artery supply.
The Neuroradiology Journal 21: 717-720, 2008
719
Intraventricular Hemorrhage Caused by Peripheral Anterior Choroidal Artery Aneurysm Rupture
ated with moyamoya disease 6,8. Its anatomical location, just proximal to the ending of anterior choroidal artery into the choroid plexus clarifies the entire intraventricular pattern of hemorrhage. We believe that in this case early surgery was the most appropriate therapeutic approach to obtain prompt closure of the bleeding malformation and at the same time a satisfactory cerebral relaxation by means of external ventricular drainage preceded by intraventricular surgical clot removal. Although there is no clear evidence of increased risk of rebleeding after treatment of acute hydrocephalus in the setting of aneurysmal subarachnoid hemorrhage 9,10, in the present case the immediate insertion of a ventricular cathether appeared more hazardous, since the source of bleeding may be mechanically injured in addition to an increased transmural pressure gradient effect. Due to the massive intraventricular hematoma, further clot evacuation with subsequent cerebral decompression was achieved through a small frontal corticotomy along the ventricular catheter trajectory. Direct evacuation of intraventricular clot is a useful manoeuvre to obtain immediate relief of elevated intracranial pressure otherwise difficult to reduce with external ventricular drainage alone 11. In addition, it is a common observation that external ventricu-
G. Pavesi
lar drainage may obstruct in the presence of a massive intraventricular clot. With respect to aneurysm securing procedure peripheral aneurysms are nonsaccular aneurysms arising along the arterial trunk, unrelated to branching sites 12, and without a recognizable neck, thus forcing the surgeon to perform an aneurysmectomy procedure rather than aneurysm clipping. As other authors have pointed out 4,5, the surgical approach to the distal part of the anterior choroidal artery is gained through a small cortical incision in the anterior third of the middle temporal gyrus, thus reaching the temporal horn of the lateral ventricle deep in the white matter. In our case sacrifice of the most distal portion of the anterior choroidal artery was necessary to eliminate the aneurysm from cerebral circulation. Anatomic studies and surgical observations 4,13,14 suggest that the intraventricular tract of the anterior choroidal artery is not involved in the arterial supply of the posterior limb of the internal capsule and cerebral peduncle, since its perforating branches arise from the more proximal cisternal segment of the basal cistern. Our patient did not show any motor impairment and MRI confirmed the absence of ischemia in the territory of anterior choroidal artery supply.
References 1 Ahn JY, Han IB, Hong CK et Al: Ruptured distal anterior choroidal artery aneurysm. J Clin Neurosci 13: 872-875, 2006. 2 Inagawa T, Matsuda Y, Kamiya K et Al: Saccular aneurysm of the distal anterior choroidal artery-case report. Neurol Med Chir 30: 498-502, 1990. 3 Yanaka K, Tsuboi K, Fujita K et Al: Distal choroidal artery neurysm associated with an arteriovenous malformation. Intraoperative localization and treatment. Surg Neurol 53: 546-551, 2000. 4 Nishihara J, Kumon Y, Matsuo Y et Al: A case of distal anterior choroidal artery aneurysm; case report and review of the literature. Neurosurgery 32: 834-837, 1993. 5 Knuckey NW, Epstein MH, Haas R et Al: Distal choroidal artery aneurysm. Intraoperative localization and treatment. Neurosurgery 22: 1084-1087, 1988. 6 Tanaka Y, Takeuchi K, Ogashiwa M et Al: Moyamoya phenomenon combined with cerebral aneurysm. Brain Nerve 30: 687-695, 1978. 7 Papo I, Salvolini U, Caruselli G: Aneurysm of the anterior choroidal artery with intraventricular hematoma and hydrocephalus. Case report. J Neurosurg 39: 255260, 1973. 8 Konishi Y, Kadowaki C, Hara M et Al: Aneurysms associated with moyamoya disease. Neurosurgery 16: 484-491, 1985. 9 Fountas KN, Kapsalaki EZ, Machinis T et Al: Review of the literature regarding the relationship of rebleeding and external ventricular drainage in patients with
720
10
11
12 13 14
subarachnoid hemorrhage of aneurysmal origin. Neurosurg Rev 29:14-18, 2006. Hellingman CA, van den Bergh WM, Beijer IS et Al: Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage. Stroke 38: 96-99, 2007. Lagares A, Putman CM, Ogilvy CS: Posterior fossa decompression and clot evacuation for fourth ventricle hemorrhage after aneurismal rupture: case report. Neurosurgery 49: 208-211 Biondi A: Truncal intracranial aneurysms: dissecting and fusiform aneurysms. Neuroimaging Clin N Am 16: 453-465, 2006. Marinkovic S, Gibo H, Brigante L et Al: The surgical anatomy of the perforating branches of the anterior choroidal artery. Surg Neurol 52: 30-36, 1999. Rhoton AL Jr, Fujii K, Fradd B: Microsurgical anatomy of the anterior choroidal artery. Surg Neurol 12: 171-187, 1979.
G. Pavesi, MD Neurosurgery Deparment Padua Hospital Via Giustiniani 1 35100 Padua, Italy Tel.: 0039498213645 Fax: 0039498213672 E-mail: [email protected]
