2 cases of aneurysm in the brain that were completely thrombosis.

!---- thrombotic aneurysm accounts for about 40% of the large cystic aneurysm in the skull, which can be secondary to the occupatic effect or cause stroke.however, completely spontaneous thrombosis is rare for intracranial non-massive aneurysms., neurosurgery at Huashan Hospital, affiliated with Fudan University, admitted two patients with a completethrombod editing of aneurysms in the brain in 2017.is now the clinical diagnosis and treatment of its clinical treatment after a summary analysis, and combined with the relevant literature review, to explore the complete thrombosis of intracranial aneurysms clinical characteristics, imaging performance, differential diagnosis and treatment methods.1. Clinical data 1.1 cases 1 female, 58 years of age.was admitted to hospital in July 2017 for "more than two months of headaches."two months ago, the patient had no obvious cause of headache, for bloating pain, pain is not severe, no vomiting, twitching limbs, size incontinence.a CT examination of the head at a local hospital, a circular, slightly dense shadow of a type of circular density shadow (Figure 1A) in the left side fissure;admission: blood pressure 135/80mmHg, clear consciousness, answer-to-answer questions, double pupils and other large isometric circles, light reflection sensitive, limb muscle force V-grade, pathological reflection negative.Glasgow coma scale, GCS) with a score of 15.line of high-resolution skull MRI enhancement scan show, left island leaf-like circular lesions, and visible openings connected to the left brain artery;DSA tests did not show an intracranial aneurysm development (Figures 1D, E).conservative treatment and follow-up.follow-up after one year of discharge from hospital, the patient had no symptoms of discomfort, the examination of the skull MRI showed slightly larger lesions than before (Figure 1H, I);continues to follow up.imaging examination of patients in Case 1 of Figure 1.A: 2 months before admission to the skull CT, left side fissure area of a kind of circular slightly dense shadow lesions; B: 2 months before admission to the skull MRIT1WI, lesions show a high signal; C: MRIT2WI, lesions show low signal; D, E: DSA after admission, no obvious abnormalities; F: MRIT1WI, the main body of the disease is obvious after admission High signal, clear boundary, peripheral see uniform low signal ring, peripheral and other signal tumor wall uniform ring thickening; G: MRI-enhanced scan, lesions did not see significant lying strengthening; H, I: 1 year after discharge MRI review, lesions slightly increased; J: 1 year after discharge DSA review, no aneurysm development 1.2 cases 2 patients, 54 years old.was admitted to hospital in October 2017 due to "intermittent seizure dizziness for more than half a year".six months ago, patients had no obvious trigger for seizure dizziness, every 2 to 3d seizures, each lasting from minutes to hours;a cranial CT examination showed a circular iso-density shadow in the left side fissure (Figure 2A);admission: blood pressure 130/75mmHg, clear consciousness, fluent speech, answer-to-answer questions, double pupils and other large circles, light reflection sensitive, limb muscle force V.class, Romberg negative, finger nasal test negative.GCS score of 15.line of high-resolution MRI-enhanced scanning, left outer cracking circular lesions, T1WI is uneven and other low signals, the boundary is clear, the tumor wall thickens, the inner and lower tumor wall is significantly strengthened, the surrounding can be seen low density cerebrospinal fluid ring (Figure 2B, C, D).line DSA check and no obvious anomalies (Figures 2E, F).conservative treatment and follow-up.follow-up after 1 year of discharge from the hospital, the patient has no symptoms of discomfort.imaging examination of patients in Case 2 in Figure 2.A: pre-admission skull CT, left side fissure area of a circular and other density shadow lesions; B: after admission to the skull MRIT1WI, lesions are uneven and other low signals, boundary clear, tumor wall thickening; C: MRI-enhanced scan, the inner tumor wall significantly strengthened, the surrounding low density cerebrospinal fluid ring; D: MRIT2WI, lesions show a high signal; E, F: DSA after admission, no obvious abnormality 2. Discussion 2.1 clinical characteristics review completethrombotic intracranial aneurysm related literature found that the majority of patients in women, the ratio of male to female incidence is 1:2; the site of theaneurysm has the largest number of arteries in the brain, followed by the lower artery behind the cerebellum, the pre-cerebellum artery, the front altre artery of the brain, etc.;clinical manifestations of headache as the first symptoms, rare seizures, a small number of patients show tinnitus, deafness and so on.2.2 imaging performance of blood clot-free aneurysm CT flat sweep for equidistant or slightly high density shadow, lesions around no or mild edema, enhance the obvious uniformity of tube cavity-like reinforcement.aneurysm with some thrombosis can be shown as a slightly high density shadow, enhanced scanning tumor cavity partial strengthening, blood clots partially not strengthened.if the blood clot is located in the vicinity of the vascular cavity, the tumor cavity and outer sac wall at the center of the enhanced scanning are strengthened, forming the central high density and peripheral high density ring, the middle interval is equal density belt; complete thrombosis CT flat sweep is often a slightly high density shadow, the inside can be a bit calcification, the tumor wall can be seen eggshell-like arc calcification; thrombotic aneurysm MRI flat sweep visible flow effect, accompanied by thrombosis performance mixed signals. the performance of MRI T1WI and T2WI of complete thrombosis aneurysm is non-specific, the intrasome aneurysm thrombosis can be high, low, equivalent or mixed signals, difficult to diagnose; 2.3 Differential Diagnosis (1) intracranial spongiform hemangioma: Several cases of complete thrombosis aneurysm in the lower arteries of the hypochony or the arteries in the brain have been misdiagnosed as spongiform hemangiomas prior to surgery. intracranial spongiform hemangioma is an giomort that occurs in the central nervous system, and CT is less sensitive to the diagnosis of spongiform hemangioma if the lesions are not accompanied by bleeding or calcification. intrabrain spongiform hemangioma is an isometric signal in T1WI, a mixed signal is presented in the core of the T2WI lesions, and there is a ring low signal band around the lesions. this low-signal ring is an image change of iron hemoglobin, and it is an important basis for diagnosing intracranial spongiform hemangioma. also has low signal rings around the T2WI for complete thrombosis aneurysms, which can be easily confused; (2) intra-brain tumor: intra-axis lesions refer to the brain's physical intrapathy, such as gliomas, neurocytoblastomas, lymphomas, metastases, etc. that develop directly from the neural tube. complete thrombosis of aneurysm MRI enhanced scanning lesions on the edge of the lesions, the surrounding white matter FLAIR has abnormal edema signals, often mistaken for intra-axis tumors, and the aneurysm around often no or accompanied by mild edema. the fullthrombotic intracranial aneurysms can also be confused with the later cranial nest tumor when they are affected by the post-cycle. (3) vestibular neurorhyma: A completely thrombosis of the cerebellum pre-brain aneurysm is easily misdiagnosed as a vestibular neuroblastoma in the inner hearing canal. CT scans can see an expansion of the inner hearing, and the MRI T1WI enhancement scan shows a ring-reinforced strengthening of the pre-brain artery into the inner hearing section, suggesting possible vascular lesions that originate in the lower arteries of the pre-cerebellum. , thehigh-resolution MRI examination of the corners of the bridge's cerebellum is therefore a necessary preoperative examination. (4) intracranial epithelial cysts: cerebral artery A2 thrombosis aneurysm is easily misdiagnosed as an intracranial epithelial-like cyst, an intracranial epithelial cyst is a rare congenital benign tumor, especially in the middle line. the CT of a typical cranial endothelial-like cyst is shown as a circular or circular low-density occupaposition lesions, with irregular high density shadows (calcification or intracystic bleeding). MRI examination, the contents of the sac in T1WI, T2WI are often high signal, the sac wall is low signal, T1WI shows a high signal of the sac fat composition, in the fat inhibition image is low signal, in DWI more high signal; (5) intracranial epidermis-like cysts: Lan and other reports, a completethrombod edema of the hypotheric post-brain aneurysm patients misdiagnosed before surgery as intracranial epidermal cysts. epidermis-like cysts, also known as bile lioma or pearl tumors, grow slowly, grow along the cobweb membrane under the gap-like growth, showing the characteristics of "see seam sewing". imaging performance is mainly related to the composition of cystic contents. cysts on MRI T1WI are more low signal, a few are equally high mixed signal, T2WI is more high signal, DWI high signal is its characteristic performance; 2.4 Treatment Lawton and others divided thrombosis aneurysms into 6 types: concentric, eccentric, leaf-splitting, complete thrombosis, pipe type and spring-ring embolism. for concentric and conjugal type, thrombosis and tumor neck, suitable for aneurysm isolation and vascular reconstruction; eccentric type, leaf type and spring ring embolism type, aneurysm neck generally no thrombosis, suitable for direct clamping; the two patients with completethrombotic aneurysm in the brain who had no rupture and no occupancy effect in the study, the treatment strategy was chosen for observation and regular follow-up. however, the walls of aneurysms that are completely thrombosis obtain blood supplies through the new blood vessels formed on the surface of the surrounding brain, and MRI-enhanced scans show tumor wall strengthening. intratumor thrombosis can also be through the hemolytic mechanism to achieve tumor cavity re-access, resulting in new blood vessels and normal pressure blood flow, resulting in the rupture of aneurysm. therefore, spontaneous thrombosis of aneurysm can not be equated with aneurysm self-healing, it still has the risk of rupture bleeding, is the clinical significance of regular follow-up review. misdiagnosed as thrombosis aneurysms such as spongiform hemangiomas, brain tumors or dermal cysts, the literature was treated with surgery such as isolation plus excision, excision and vascular reconstruction, or intra-hypertensive decompression. , complete thrombosis intracranial aneurysms are clinically rare, imaging examination appears around the lesions ring low signal belt, as well as enhanced scanning appears ring-like strengthening and so on, easy to be misdiagnosed as intracranial spongiform hemangioma or intra-axis tumor; if the aneurysm with complete thrombosis has no occupatic effect, it should be observed and reviewed by regular follow-up. .