Objective : The anatomy of middle cerebral artery (MCA) bifurcation aneurysms has been noted to be unfavorable for endovascular treatment. Our purpose was to analyze the clinical and angiographic results of coiling of the MCA bifurcation aneurysms. Methods : From January 2004 to April 2007, 26 patients harboring 29 MCA bifurcation aneurysms were treated with coils. Of these patients, 16 had subarachnoid hemorrhages (SAH). The bleeding source was a ruptured MCA bifurcation aneurysm in 11 patients and a ruptured aneurysm in a different location in 5 patients, respectively. Treatment-related complications, clinical outcomes, and postprocedural and follow-up angiography results were retrospectively evaluated. Results : 29 MCA bifurcation aneurysms (11 ruptured, 18 unruptured) were occluded with coils in 26 patients. Occlusion was complete for 24 (82.8%) of the 29 aneurysms, incomplete for 3 (10.3%), and partial for 2 (6.9%) aneurysms. Procedural complications included thromboembolism in 6, a small nonocclusive thrombus formation in 1, and intraprocedural aneurysmal rupture in 1. All of symptomatic complications were thromboembolic events that occurred 3 patients with unruptured aneurysm and they discharged with moderate disability state. Follow-up angiograms were available on 16 patients with 18 aneurysms and 1 patient with an initial complete occlusion had a slight neck recanalization. Conclusion : Coiling of MCA bifurcation aneurysm could be achieved without treatment-induced neurologic deficit in 88.5% (23/26) of the patients while at the same time obtaining favorable anatomic results. Improvements in device technology and technique will certainly greatly increase the safety of coiling of MCA bifurcation aneurysm, widening its indications.

Objective : This study was conducted to evaluate the prognostic factors of primary intraventricular hemorrhage. Methods : We retrospectively reviewed 26 patients who suffered from primary intraventricular hemorrhage between 2003 and 2007. We analyzed the various factors that might influence the prognosis and these included the patient age, the disease etiology, the initial Glasgow Coma Scale(GCS) score, the pupil reflex, Evan's ratio, Graeb' score, the ventriculocranial ratio (VCR) and dilatation of the fourth ventricle. The clinical outcomes were evaluated for each patient by using the Glasgow Outcome Scale (GOS) three months after the hemorrhage. Results : The overall mortality rate was 38.5%. The factors correlated with a poor clinical outcome are an initial GCS score below 12 (p<0.05), the absence of a pupil reflex (p<0.05), a Graeb' score above 9 (p<0.05), a VCR above 0.23 (p<0.05) and the presence of obstructive hydrocephalus (p<0.05). The etiology didn' influence the clinical outcome (p>0.05). Dilatation of the fourth ventricle showed a poor outcome in 10 patients (83.3%), but this was without clinical significance (p>0.05). Conclusion : A low initial GCS score, a high Graeb's score, the absence of a pupil reflex, a high VCR and the presence of obstructive hydrocephalus are associated with a poor outcome in patients with primary intraventricular hemorrhage.

Objective : This study compare outcomes in patients with laparoscopic guided ventriculo-peritoneal shunt placement with the nonlaparoscopic approach (conventional mini-laparotomy technique) in patients with hydrocephalus. Methods : The study enrolled 102 adult patients who had undergone surgery between August 2005 and May 2008 for the treatment of hydrocephalus at our department. Seventy-six patients (38 men and 38 women) received laparoscopy-assisted distal catheter placement, and 26 patients (14 men and 12 women) received shunt surgery by a conventional mini-laparotomy approach. The median follow-up period of the non-laparoscopic group was 26 months (14- 33 months) and laparoscopic group was 12 months (1-30 months). We analyzed age, sex, cause of hydrocephalus, type of shunt valve, operation time, shunt infection rate, and shunt distal catheter malfunction during follow-up. Results : There was no statistically significant difference in age, sex, cause of hydrocephalus, or type of shunt valve. Shunt infections were observed in 10 cases (13.2%) in the laparoscopic group and in 4 cases (15.4%) in the mini-laparotomy group, which was not statistically significant. Distal shunt malfunction rates were significantly lower in the laparoscopic group (1.3%) compared to the mini-laparotomy group (11.5%, P<0.05). The mean operation time was also shorter in the laparoscopic group (108 min, 45-190 min) than of the mini-laparotomy group (146 min, 75-255 min, P<0.005). Conclusion : Laparoscopic guided placement of the VP shunt in hydrocephalus patients reduces shunt distal catheter malfunction and operation time.

Objective : Spontaneous intracerebral hemorrhage (sICH) is a leading cause of morbidity and mortality, especially in Asian countries. Nevertheless, few reports of sICH in young people have been published. This study investigates the clinical features of sICH in young people. Methods Between February 1999 and December 2007, we retrospectively reviewed the medical records of patients aged ${\leq}$45 years diagnosed with sICH at our institute. We analyzed the causes, locations, risk factors, and final outcomes of sICH in these patients. Results : Twenty-one patients (14.5%) were younger than 25 years, while 27 patients (18.6%) were 25~34 years old. Ninety-seven patients (66.9%) were between the ages of 35~45. The most common cause of sICH was hypertension (57.9%). The most common location of sICH was in the lobar region (35.2%). Vascular anomaly was the main cause in both the <25 age group (76.2%) and the 25~34 age group (70.4%). The diagnostic rate of angiography was 75% for the under 25 age group and 80% in the 25~34 age group. Conclusions : Hypertension is the most common cause of sICH in people between 35 and 45, and vascular anomaly is the main cause in people under 35 years of age. Thus, angiography should be mandatory for people under 35 with sICH, and for people with lobar hemorrhage. For young people, early diagnosis of hypertension and strict blood pressure control is recommended.

Objectives : Serial changes of focal ischemic lesions as seen on magnetic resonance (MR) images and triphenyltetrazolium chloride (TTC)-stained samples of transient middle cerebral artery occlusion in a rat model were evaluated to investigate the natural course of the lesions and the feasibility of the use of each method as a monitoring tool. Methods : Transient middle cerebral artery occlusion (MCAO) was induced in fifteen adult female Sprague Dawley rats using the method of intraluminal vascular occlusion. Two hours after MCAO was induced, reperfusion was performed. Serial MR images were obtained and the volume of the brain infarct was estimated. For macroscopic and microscopic evaluation of the ischemic lesions, the ten animals were sacrificed at different times after MCAO. The rat brains were then removed and six coronal sections were made. Each section was incubated at $37^{\circ}C$ in 2% TTC solution for 15 minutes. Results : Postischemic injury evaluations that were made periodically for eight weeks revealed that the lesion volume as determined from T2 maps had reached a peak on the second day after ischemic injury and the volume decreased afterwards for one week; by the fourth week, the lesion volume again increased to stabilize initial lesion development. There were considerable discrepancies between the infarct area of the samples determined by TTC staining and the in vivo infarct area estimated from the MR images, especially for late stages. Conclusion : T2 map MR images, with a careful consideration of the natural course of infarction development, can provide an adequate and noninvasive means to evaluate the degree of ischemic injury under diverse experimental circumstances.

Objective : We evaluated whether serum total bilirubin levels were related to large artery atherosclerosis (LAA), classified by the Trial of Org 10172 in Acute Stroke Treatment (TOAST) classification, and stroke severity at admission in acute ischemic stroke. Methods : We analyzed clinical features, laboratory tests, and radiologic findings such as brain MRI and MR angiography of patients admitted to our hospital within 24 hours of the onset of ischemic stroke between January 2004 and June 2007. By TOAST classification, 237 patients [115 with LAA and 122 with small artery occlusion (SAO)] were selected. We divided serum total bilirubin levels into three groups: Low (<0.6 mg/dL), Middle (0.6~0.9 mg/dL), and High (1.0~1.2 mg/dL). Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) at admission. We divided NIHSS scores into three groups: Mild (0-6), Moderate (7-15), and Severe group (>15). Results : Total bilirubin levels were significantly higher in the Mild group than other groups, and high-sensitivity C reactive protein (hsCRP) levels were significantly higher in the Severe group than other groups in LAA. There were no differences for these factors in SAO. We found a significant correlation between total bilirubin levels and stroke severity in LAA (p=0.005). Conclusion : Higher serum total bilirubin levels were associated with lower stroke severity at admission in LAA but not SAO.

Objective : The use of decompressive craniectomy for treating massive cerebral infarction is attracting much attention because conventional medical treatment is associated with high mortality. The aim of this retrospective study was to evaluate the surgical treatment results and prognostic factors for patients suffering with malignant cerebral infarction. Methods : We analyzed 9 consecutive patients who underwent decompressive craniectomy with or without temporal lobectomy after malignant cerebral infarction from 2000 to 2008. We reviewed the medical records, the radiological finding and the pre-operative clinical assessment using the Glasgow Coma scale (GCS). The postoperative functional outcome was assessed as the Barthel-Index (BI) and the modified Rankin scale (mRS). Results : The male to female ratio was 3.5:1. The mean age was 50 years (range: 36-68). Eight patients (89%) showed involvement of the entire middle cerebral artery (MCA) territory and the concomitant anterior cerebral artery (ACA) or posterior cerebral artery (PCA) territory. The preoperative mean GCS was 8.3 (range: 5-12) and the mean time to surgery after the onset of symptoms was 47.7 hours (range: 4-168 hours). All the patients underwent decompressive craniectomy and duroplasty. Among them, four patients (45%) underwent temporal lobectomy. The mean followup period was 7.3 months (range: 1-26 months) and five patients died within this period. Conclusion : Decompressive craniectomy with or without lobectomy for patients with malignant cerebral infarction decreases the mortality rate and it improves the functional outcome. In the survived group, comparison of the two surgical modalities didn' show any statistically significant difference. However, the decompressive craniectomy with lobectomy group demonstrated a high survival rate (75%). Future studies are needed to investigate the proper treatment modalities for malignant cerebral infarction.

We report here on 2 cases of remote cerebellar hemorrhage (RCH) that developed after surgery for supratentorial unruptured aneurysm. In both cases, cerebral angiography was performed to diagnose the aneurysms and then screening was conducted for determining if there were any previous bleeding tendencies and comorbidities. After surgery, computed tomography (CT) was immediately performed to check for postoperative hemorrhage or infarction, and the images showed cerebellar hemorrhage that was relatively far away from the surgical site. We present the similarities of the 2 patients' preoperative angiography and CT and their perioperative blood pressure, and we discuss these findings to illuminate the pathophysiology of RCH.

Giant fusiform aneurysms at the basilar trunk tend to have a poor natural history and surgical management for these aneurysms remains controversial. For these aneurysms, basilar trunk occlusion with endovascular coiling is difficult when the collateral supply from the carotid circulation is relatively poor. Interestingly, we herein present a successfully treated case of a partially thrombosed giant fusiform aneurysm at the basilar trunk with relatively poor collateral supply using endovascular coil occlusion following bypass surgery (superficial temporal artery-radial artery-superior cerebellar artery anastomosis).

Objective : This study was designed to determine the clinical characteristics of patients with aneurysms that are located at the distal posterior inferior cerebellar artery (dPICA). Patients & Methods : From September 1976 to June 2007, 54 consecutive patients with PICA aneurysms were treated at our institute. Among them, 19 patients had PICA aneurysms distal to the junction of the vertebral artery-PICA. We retrospectively reviewed the database and imaging studies as sources of information for analysis. Results : Five patients were male and 14 patients were female. The mean age was 44.6 years old (range: 23-70). Sixteen patients had ruptured lesions: 1 patient was Hunt and Hess Grade I, 4 were Grade II, 5 were Grade III, 4 were Grade IV and 2 were Grade V. Intraventricular hemorrhage or intracerebral hemorrhage was identified in 5 patients on the initial computed tomography (CT). Three patients had unruptured lesions. The locations of aneurysm were the lateral medullary segment in 10 patients, the tonsillomedullary segment in 1 patient, the telovelotonsillar segment in 5 patients and the cortical segment in 3 patients. Most aneurysms (17) were the saccular shape. Seventeen aneurysms were small and 2 were large or giant. The mean diameter of aneurysm was 6.5 mm (range: 2.0-28.0) and the mean diameter of the ruptured aneurysm was 4.8 mm (range: 2.0-12.0). Two patients had mirror aneurysms. Post-hemorrhagic hydrocephalus was identified in 10 patients on the initial CT and shunt surgery was performed on 3 patients. The obliteration methods of the aneurysms were microsurgery in 15 patients (midline suboccipital approach: 9, lateral suboccipital approach: 6) and endovascular surgery in 4 patients (therapeutic distal PICA occlusion: 3, intra-aneurysmal coiling: 1). Early surgery was performed on 2 patients, intermediate surgery (days between rupture: 4-10) was performed on 4 patients and delayed surgery was performed on 10 patients. The mean post-treatment follow up period was 49.5 months (range: 7-156). The clinical outcome was assessed using the modified Glasgow Outcome Scale. All the patients showed favorable outcomes. Five patients suffered from treatmentrelated complications (a CSF collection requiring wound revision for dura repair: 2, shunt surgery: 1 and transient hemiparesis due to impairment of the blood flow distal to the aneurysm: 2).Conclusions : In our series, distal PICA aneurysms had the characteristics of a female predominance, they more often presented with intraventricular hemorrhage and the rupture was of a relatively small size. Both microsurgery and endovascular surgery can be troublesome due to the small size, wide neck and tortuosity of the proximal parent artery and the location of aneurysms at a branching site. The surgeons should be careful for preserving vessel patency and insuring watertight dura repair.

Vasospasm has been known as one of the most potent causes of delayed ischemic neurologic deficits (DINDs) after aneurysmal subarachnoid hemorrhage (SAH). An established effective therapy for vasospasm has been used in preventing cerebral ischemia. Nevertheless, several reports suggested the possibility that there may be other causes of DINDs from the cases which couldn' be explained by hemodynamic vasospasm. Authors experienced two cases of thromboembolic infarction as a cause of DINDs after aneurysmal SAH. We propose that thromboembolism can be a considerable cause of DINDs independent of hemodynamic vasospasm.

Objective : We evaluated the relationship between transcranial Doppler sonography (TCD) and three-dimensional computerized tomography angiography (3D-CTA) under delayed ischemic neurologic deficit (DIND) with angioplasty following vasospasm. Materials & Methods : Twenty consecutive patients with DIND following vasospasm who received sequential TCD and CTA were analyzed. On TCD, vasospasm was defined as anterior circulation peak mean velocity>120 cm/s, daily increases of 50cm/s, and a Lindegaard ratio $(LG)^\circ\sqrt[]{3}$. On 3D-CTA data were subdivided into local and combined types according to the position where vasospasm occurred, and into mild, moderate, and severe by the blood vessel diameter. Results : Among the 20 consecutive patients with DIND, 13 of them received angioplasty. On TCD, the angioplasty group had more frequent vasospasm and tended to have an LR higher than 3. The mean blood flow velocity of MCA in the angioplasty group was 40 cm/sec higher than the group without angioplasty. On CTA, the angioplasty group showed combined, moderate types more frequently. After 3D-CTA evaluation, TCD sensitivity, specificity, positive predictive value and negative predictive value, analyzed with the index of diminished vessel diameter that was more than moderate, were 92.6%, 83.3%, 72.2% and 50.0%, respectively. Conclusion : TCD and 3D-CTA could be useful tools for evaluation and management planning of critical patients suspected of having DIND by vasospasm.

We present a patient with moyamoya disease and a ruptured superior cerebellar artery aneurysm that was managed by endovascular embolization. A 53-year-old man with sudden onset severe headache and altered mental status was referred to our hospital. Computed tomography revealed a subarachnoid hemorrhage. Cerebral angiography showed evidence of moyamoya disease and a 7 mm saccular aneurysm at the origin of the right superior cerebellar artery. Endovascular coil embolization was performed successfully without posterior cerebral artery and superior cerebellar artery obliteration. Endovascular treatment with microcoils appear particularly safe for moyamoya patients with cerebral saccular aneurysms.

Objective : Perfusion-computed tomography (CT) is useful and quick diagnostic tool for evaluating ischemic stroke patients. We evaluated three measurement maps, cerebral blood flow (CBF), cerebral blood volume (CBV) and time to peak (TTP) for their usefulness in deciding on revascularization surgery using CT parameters after single photon emission computed tomography (SPECT) findings in chronic steno-occlusive disease patients. Methods : We retrospectively investigated 47 patients with unilateral internal carotid artery (ICA) or middle cerebral artery (MCA) steno-occlusive disease . All patients underwent digital subtraction angiography (DSA) as well as an acetazolamide challenge with SPECT and perfusion CT. Patients who showed decreased reserve capacity with a Diamox challenge were classified in the positive group, whereas patients who had no difference in reserve capacity were placed in the negative group. Results : Thirty-one patients were positive and the remaining 16 were negative. Differences in rCBV and rCBF parameters between normal cerebral hemispheres and cerebral hemispheres with steno-occlusive disease did not correlate with SPECT results, but TTP values did. SPECT results seemed relevant when TTP differences between hemispheres with normal and steno-occlusive disease were more than 1.55 times. Conclusion : Perfusion CT is a useful tool for the rapid, adequate diagnosis of large territorial infarcts, and the TTP map of perfusion CT is a sensitive and reliable parameter to show the status of collateral circulation in chronic cerebrovascular ischemic disease.

Objectives : This report was designed to study the prognostic factors that affect the therapeutic results of dural arteriovenous fistula (DAVF). Methods : We retrospectively reviewed 97 patients who were treated for DAVF at our institute from January, 2000 to August, 2008. The DAVFs were usually located in four sites (cavernous sinus, transverse-sigmoid sinus, superior sagittal sinus and others). The diagnosis and the results of treatment were obtained by performing cerebral angiography. Results : The most common location of DAVF was the cavernous sinus (59.4%) and the next most common location was the transverse-sigmoid sinus (30.2%). Borden classification type II (72.2%) was most common and the next most common was type I (18.6%). Cortical venous reflux was abundant in the transverse-sigmoid sinus DAVFs and superior sagittal sinus DAVFs. Complete obliteration was achieved in 52 cases (55.3%) of all the 94 treated cases and incomplete obliteration was achieved in 42 cases (44.7%). Complete obliteration of the DAVF was achieved for 66.7% of the cavernous sinus lesions and in 41.4% of the transverse-sigmoid sinus lesions. Repeated treatments due to partial obliteration or recanalization were done in 18 cases. Conclusion : Transverse-sigmoid sinus lesion and cortical venous reflux in a DAVF are closely related to the aggressive clinical features. Active treatment should be considered to treat these lesions. (ED note: some of this abstract was not clear and you need to check the revised abstract.)

Objective : Life-threatening middle cerebral artery infarction may be accompanied by severe post-ischemic brain swelling due to cytotoxic vasogenic edema. The resultant progressive mass effect may prove fatal, owing to increased intracranial pressure and herniation. Recent studies have shown that early decompressive craniectomy decreases mortality, but no comparison has been performed between the outcomes achieved with simple craniectomy and those achieved with craniectomy combined with lesionectomy. This study was performed to compare the outcomes achieved after simple craniectomy and after craniectomy combined with lesionectomy. Materials and Methods : We prospectively reviewed the records of 59 patients who presented with acute middle cerebral infarction between January 2001 and October 2007. Thirty-one patients (Group A) underwent simple decompressive craniectomy, and 28 patients (Group B) underwent lesionectomy with craniectomy. In all patients, lesion volume and mid-line shift were measured radiologically. Outcomes were quantified using the Glasgow Outcome Scale. Result : Patient factors (age, sex), Glasgow Coma Scale, radiologic findings, and lobe involvement were the same for the two groups. However, the outcomes for the two groups were different. At 6 months after surgery, the mean Glasgow Outcome Scale for Group A was 2.71 and that for Group B was 3.39 (p<0.05). Conclusion : Surgical treatment, especially decompressive craniectomy combined with lesionectomy, was beneficial in the setting of malignant cerebral infarction.

Objective : Middle cerebral artery (MCA) aneurysm is a common source of aneurysmal subarachnoid hemorrhage, but distal MCA aneurysms are rare. This present study was conducted to evaluate the clinical characteristics of the distal MCA aneurysms and the optimal treatment for a good outcome. Methods : Among 3323 patients underwent aneurysmal surgery from 1975 to 2007, 21 patients with distal MCA aneurysm was identified. The clinical, radiological and operative records of 21 patients with distal MCA aneurysms who underwent surgical management were reviewed retrospectively. The clinical outcomes were evaluated according to the Glasgow Outcome Scale. Results : The clinical analyses of 21 patients with distal MCA aneurysms has following characteristics. (1) Mean aneurysm size of 5.3mm (range 2~8mm). (2) All lesions were considered to be saccular except one case. (3) The location being M2 in one patient, M2-3 junction in 12, M3 in 3, and M4 in 5 patients. (4) In 7 of 21 patients, initial CT scan revealed intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). (5) All patients underwent surgical treatment for aneurysm; the procedures were clipping in 17 patients, trapping in 2 patients, trapping and end-to-end anastomosis in 1 patient, and direct vessel suture in 1 patient. (6) All patients without ICH had a good recovery. However, the patient with ICH had a different prognosis. Of the 7 patients with ICH, 4 patients had a good recovery and 2 patients had a moderate disability. 1 patient died due to severe brain swelling. Conclusion : The patients with distal MCA aneurysm were relatively young, and there was no female predominance. The aneurysms have high rates of cardiac problems such as infective endocarditis or mitral valve prolapse, attributing to be developed infectious aneurysm. Ruptured distal MCA aneurysms are rare and can cause life-threatening ICH with SAH. However, the appropriate surgical treatments can obtain a favorable outcome.

Objective : Unruptured intracranial aneurysms (UIA) accompanied by ischemic cerebrovascular disease (CVD), will be an increasing problem for neurosurgeons in the future, as the population ages. These patients are a high-risk group of treatment. UIA associated with ischemic CVD in seventeen patients were analyzed and their managements are discussed. Methods : In the past four years, one hundred seventy seven cases of UIAs were treated in our hospital. Among them, seventeen patients suffered from ischemic CVD before treatment of aneurysm. The age of patients varied from 40 to 78 (mean 63.2) years old. The associated ischemic CVD was that transient ischemic attack (TIA) was nine, minor completed stroke in eight patients. There was permanent neurological deficit in two patients. Microsurgical treatment underwent for ten patients and seven patients were treated with endovascular technique. Results : Fourteen patients were fully recovered from surgical and endovascular management. In clipping group, hemiparesis event occurred in one patient after the surgery. The patient suffered from ischemia-related permanent neurological worsening. There were two patients who developed neurological deficit following endovascular treatment for UIA in seven patients of coiling group. One patient was recovered after rehabilitation but the other patient didn' improve left hemiparesis until discharge. This patient had bilateral paraclinoid aneurysms. We treated these lesions simultaneously and coil embolization for the aneurysm was uneventful. However, left side weakness developed after the procedure. Angiography revealed occlusion of cortical branches of middle cerebral artery and MRI scan showed hyperintense areas in the right motor cortex. Conclusion : Our results suggest that surgical treatment of unruptured cerebral aneurysm is not contraindicated in patients with CVD. However, the treatment of UIA accompanied by CVD should be performed only after careful examination of the factors involved in the particular ischemic episodes. Careful case selection and perioperative management are mandatory for preventing surgical complications.

Coiling of intracranial aneurysms is a generally safe treatment. However, despite increasing clinical experience and technological improvements, endovascular treatment still has inherent risks of morbidity and mortality. Recently, we have experienced two cases of delayed complications that developed after uneventful coil embolization of unruptured aneurysms.

Anterior choroidal artery (AChA) syndrome is widely known to be composed of a triad of hemiparesis, hemisensory loss and homonymous hemianopia. AChA syndrome is an unusual complication of aneurysmal treatment. This report documents two cases of AChA syndrome that occurred after an endovascular aneurysmal coiling procedure. Both cases showed complete recovery of the neurologic deficit at the time of discharge. To avoid this complication, meticulous caution is required to preserve the posterior communicating artery, the AChA and the various perforators during an endovascular procedure. When AChA syndrome occurs, immediate treatment is necessary, including vasodilators, thrombolytics and close observation of the patient' clinical status.

Computerized tomography angiography (CTA) and magnetic resonance angiography (MRA) have been frequently used as non-invasive methods for the evaluation of cerebral vessels. The use of an invasive therapeutic method, transfemoral carotid angiography (TFCA), has also recently increased. The complication rate after TFCA is reported to be 0.9 % to 4%, and it is continuously decreasing. We experienced 2 patients who underwent TFCA as a diagnostic tool. The embolic type of cerebral infarction, which occurred within 30 hours, was diagnosed with performing diffusion weighted MRI (DW-MRI). One patient developed temporary dysphasia and motor weakness, but the patient improved after 2 days. The other patient presented with an altered mentality and motor weakness with some permanent deficits. TFCA is a less invasive method for treating cerebral vessels, and because this is a popular therapeutic modality, the frequency of complications will increase. Clinicians should bear in mind that complications may occur when performing TFCA and so they should be prepared to deal with them.

The azygous anterior cerebral artery (ACA) is a rare type of ACA anomaly. In the conventional angiography, cognition of its realm is difficult without considerable reading. Clinically, misreading its nature causes confusion during the surgical approach to its associated cerebral aneurysm. We report this rare clinical experience with an angiographic and surgical review.

A 22-month-old male infant visited at our hospital with stuporous mentality. Brain CT angiography revealed right M1 aneurysm with subarachnoid hemorrhage and intraventricular hemorrhage. After one month from ictus, aneurysmectomy and neck clipping was done. We report here on an extremely rare case of ruptured intracranial aneurysm under the age of 5 years.