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J. P. Segundo, E. Balea and R. Arana

procedures (5 cases), by operation (34 cases) or by autopsy (4 cases). Most of these patients had tumors (34 cases) but 3 had hydatid cysts, 1 a giant and partially thrombosed aneurysm of the temporal fossa, 1 a spontaneous intracerebral hematoma, 2 platybasia with modifications of the cervical vertebrae, and 2 cervical spinal cord traumatic injuries. Group II consisted of 7 leucotomized schizophrenics, 2 cingulectomized idiots, and a patient who, because of a large oligodendroglioma, was subjected to a right temporal lobectomy; this patient was included in Group II

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C. G. Drake and A. L. Amacher

palsy disappeared, and the patient has remained well for 6 years. In the six cases operated on, there was one death (Case 4) of a patient who was moribund with temporal lobe and intraventricular clot after a fourth hemorrhage and in whom a fusiform aneurysm had to be excised. Of the five survivors, four are perfectly well except that one (Case 7) has an incomplete hemisensory defect which is of little concern to him. This probably resulted from dissection of the large partially thrombosed aneurysm from its bed in the thalamus. The hemiplegia and third nerve

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Charles G. Drake

three aneurysms and there was evidence of relief of brain-stem compression, paradoxical in view of the unlikely change in the size of the sacs. It is perhaps significant in Case 1, where postoperatively the opposite vertebral artery filled well the partially thrombosed aneurysm, that the relief was short-lived, and the sac again enlarged, ultimately producing a fatal hemorrhage. In retrospect, ligation of the second vertebral artery should have been attempted. Extracranial Bilateral Vertebral Artery Ligation In this group, a bilateral ligation of the

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Giant serpentine aneurysm

Report of two cases

Harold D. Segal and Robert L. McLaurin

C ontemporary literature on cerebral aneurysms tends to categorize a group of lesions identified as “giant aneurysms” on the basis of size alone (greater than 2.5 cm in diameter). 6 However, within this group, a subgroup exists consisting of large partially thrombosed aneurysms with a persistent serpentine vascular channel. Case reports of lesions within this subgroup have been scattered throughout the recent literature. 3, 7, 10 This paper attempts to clearly identify the subgroup on clinical and pathological grounds and to report successful total excision

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Göran Edner, David M. C. Forster, Ladislau Steiner and Ulf Bergvall

will spontaneously thrombose completely. Furthermore, such a thrombosis must be complete to provide a cure, and the fact that partially thrombosed aneurysms may rebleed is well documented. 9 A review of the literature has revealed only six cases in which complete thrombosis of an intracranial arterial aneurysm has been established during life following SAH, without surgical interference with the aneurysm or its parent artery, locally or in the neck. 19, 23, 27, 28 In these six cases, an aneurysm was demonstrated radiologically following SAH, but failed to fill

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Yoshio Hosobuchi

of the aneurysm. 8 During the past 8 years the author has managed 40 cases of large intracranial aneurysms that were classified as “giant” (greatest dimension > 2.5 cm) on the basis of either radiological measurement or, in cases of partially thrombosed aneurysms, actual measurement intraoperatively. 23 This paper reviews the clinical features of these aneurysms, the surgical techniques used, and the outcomes. Giant intracavernous carotid aneurysms are excluded from this series since they rarely require direct surgical obliteration. 9 Summary of Cases

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Surgical approach to giant intracranial aneurysms

Operative experience with 80 cases

Thoralf M. Sundt Jr. and David G. Piepgras

roofing contractor. Postoperative angiograms have demonstrated good filling of the left MCA complex through the bypass graft ( Fig. 5 ). Fig. 3. Case 3. Preoperative angiogram showing a giant partially thrombosed aneurysm of the middle cerebral artery. Fig. 4. Case 3. Preoperative computerized tomograms. The aneurysm is much larger than it appears on the angiogram. This is commonly the case with giant aneurysms. Fig. 5. Case 3. Postoperative angiograms. The aneurysm has been excised, and the middle cerebral artery fills from a

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Robert F. Spetzler, Richard A. Roski, Robert S. Rhodes and Michael T. Modic

squamous cell carcinoma of the tongue. Methotrexate was infused into the lingual artery via a temporal artery catheter, and he then underwent radical neck surgery. The patient did well until the present admission. Emergency arteriography confirmed the clinical diagnosis of a common carotid artery aneurysm ( Fig. 1 left ). A polytetrafluoroethylene graft was used to connect the common carotid artery to the internal carotid artery after resection of a large, partially thrombosed aneurysm at the bifurcation ( Fig. 1 right ). However, the oral cavity was entered when a

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Eugenio Pozzati, Leo Fagioli, Franco Servadei and Giulio Gaist

not thrombosed. On plain CT scan, aneurysms that are not thrombosed appear as sharply delineated round or oval masses with a slightly increased homogeneous density compared to nearby brain. Partially thrombosed aneurysms appear as areas of mixed density, where the vascular lumen and the thrombosed part may be difficult to differentiate due to the protean density of the thrombus. A completely thrombosed aneurysm presents as a roundish area with mottled appearance, the well or ill defined limits depending on the presence of a calcified wall. These aneurysms may

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Garnette R. Sutherland, Martin E. King, S. J. Peerless, William C. Vezina, G. William Brown and Mike J. Chamberlain

episodic right lower extremity weakness. Her CT scan revealed a partially calcified nonhomogeneous lesion that distorted and elevated the left cerebral peduncle and thalamus. With contrast injection, both ring and central enhancement were seen, in keeping with a partially thrombosed aneurysm. On angiography, a left carotid bifurcation aneurysm was found involving the origin of the left middle cerebral artery and displacing the pericallosal artery to the right. Her initial radionuclide study demonstrated platelet aggregation, with an In(D)/In(BP) ratio of 0.79 ± 0