case_images: PMC4228499_01
case_images: Small hemorrhage within the Sylvian fissure and intraventricular hemorrhage in the right lateral and third ventricles associated with mild hydrocephalus
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case_images: PMC4228499_01_SNI-5-152-g002.jpg
case_images: F1
case_images: Preliminary workups were all negative and brain computed tomography scan (CTS) showed a small left frontal opercular intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) accompanied with mild hydrocephalus [Figure 1].
case_images: Second CT scan showing normal sized ventricles, but expanded left opercular ICH
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case_images: F2
case_images: Brain CTS showed a left frontal opercular ICH [Figure 2].
case_images: AP view of the DSA showing distal MCA aneurysm
case_images: SNI-5-152-g004.jpg
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case_images: F3
case_images: Four-vessel digital subtraction angiography (DSA) showed a left distal middle cerebral artery (MCA) aneurysm that was 12 x 9 mm in diameter and without an identifiable neck [Figure 3].
case_images: Lateral view DSA showing the larger distal MCA aneurysm (black arrow) and two other smaller aneurysms located more proximally on the Sylvian arterial branches (white arrows)
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case_images: PMC4228499_01_SNI-5-152-g005.jpg
case_images: F4
case_images: These two blebs were located along the more proximal branches of M3 segment of left MCA [Figure 4].
case_images: The good-quality CTA demonstrating all three aneurysms in AP and lateral views
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case_images: F5
case_images: The other two ill-defined aneurysms noted in the previous DSA were well elucidated in the new CTA [Figure 5].
case_images: (a) Intraoperative image of second MCA aneurysm clipped and (b) the second mid-size aneurysm resected
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case_images: F6
case_images: The clip could be removed after micro-coagulation of the parent artery [Figure 6a and b].
case_images: (a) H&E staining x40 showing portions of vessel wall with necrotic (ring 1), fibrotic (ring 2), and thrombotic (ring 3) changes. Scale bar is 2 mm. (b) H and E, x100 fibro-necrotic wall containing hemosiderin-laden macrophages (ring 2) admixed with many RBCs (ring 1). Scale bar is 1 mm. (c) H and E, x400 showing white small rings encircling few foreign body type giant cells and inflammatory cells, interposed by thrombotic material. Periodic acid Schiff (PAS) staining (for fungi) and acid-fast bacillus (AFB) staining for mycobacteria show no specific microorganism. All these findings are compatible with "necrotizing vasculitis." Scale bar is 100 mum
case_images: SNI-5-152-g008.jpg
case_images: PMC4228499_01_SNI-5-152-g008.jpg
case_images: F7
case_images: The histopathological examination of the resected aneurysms was compatible with "mycotic aneurysm" [Figure 7a-c].
case_images: (a-d) The CTA performed after 14 months showing the course of MCA along the Sylvian fissure without aneurysmal dilatation
case_images: SNI-5-152-g009.jpg
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case_images: F8
case_images: The postoperative CTA performed after 1 year confirmed no aneurysmal dilatation along the course of MCA [Figure 8].