Downloaded from www.ajronline.org by Gazi Universitesi on 05/05/15 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved Case Report Cerebral Aneurysms Associated with Seizures but Without Clinical Signs of Rupture: Seemingly Distinctive MR Imaging Findings inTwo Patients James M. Provenzale1, John P. Gorecki2, Joseph the I L Koen2 finding of MR perianeurysmal signal noid hemorrhage. Less commonly, aneu- abnormality should raise the possibility that an aneurysm has caused structural changes in the adjacent brain and serve as evidence to rysms can with headache in ntracraniala clinical aneurysms typically of have presentation symptoms related to subarach- the support the role of an aneurysm absence of aneurysm rupture opathy secondary to cranial or cranial neurnerve compres- seizures in individual sion. an present Because seizures presenting feature aneurysm is generally differential diagnosis are lesions in the causing sei- We two I 1-3]. hemorrhage present patients the MR with imaging cerebral seizures in the absence aneurysm rupture. abnormal perianeurysmal findings in aneurysms of clinical In both features of we saw cases. MR and signal within Report A 65-year-old ened from sleep man in good and experienced seizure. Neurologic later had nonfocal health awaka generalized examination findings. MR a few hours imaging per- IA and IB). On Tl-weighted weighted images, abnormal signal a circumferential of the aneurysm and T2was seen in pattern around the periphery lumen, consistent with partial In one of found out- region of hypointense abnormal signal on Ti-weighted that images side the abnormal hyperintense on MR signal of the aneurysm. We the therefore Received November 2, 1995: accepted 1 Department of Radiology, 2Department of Neurosurgery, leakage suggest that after revision December Duke University Medical Duke University region extended lobe (Figs. ‘U-weighted through much 1A and I B). found was subarachnoid of hemor- within space the or sur- adjacent brain to indicate prior rupture. The medial left temporal lobe was seen to have a yellowish hue and abnormally firm texture secondary to gliosis, which we supposed to be a was and images. This of the temporal MR angiography ing. within The the temporal patient, who lobe on MR imagplaced was on anticon- vulsants at the time of hospital admission, has experienced no seizures during a 6month follow-up. Similar findings of abnormal perianeurysmal MR signal were found in another patient with seizures cerebral that aneurysm were (Fig. associated with a 2). Discussion Seizures presenting are an uncommon, feature but not rare, of intracranial aneurysms. 7, i995. Center Box 3808, Durham, NC 27710. Address Medical A 1-cm No evidence signal lobe on all pulse sequences, conthe lumen of an aneurysm (Figs. at surgery of gliotic brain tissue. these patients, who had thrombus subclinical products clipping approach. left temporal sistent with we noted a marginated at surgery. aneurysm reaction to the aneurysm. We thought the gliosis most likely was the cause of abnormal thrombosis of the aneurysm. Also, more peripheral and irregularly also indicated from formed the same day showed a small rounded region of hypointense signal within the medial the adjacent temporal lobe, and the MR signal abnormality was associated with findings aneurysm underwent was found. rounding laterally of the left internal (Fig. lC). This projection was by catheter angiography. patient rhagic Case zures. Aneurysms can produce seizures by a number of mechanisms. including compression or infarction of adjacent brain tissue as well as irritation by blood products from subclinical The to project segment the next day by a pterional aneurysm aneurysms, not considered of the aneurysm the supraclinoid carotid artery later confirmed in producing patients. uncommon of intracranial showed correspondence to J. M. Provenzale. Center, Durham, NC 27710. AJR 1996:167:230-2320361-803X196/1671-230 © American Roentgen Ray Society 230 AJR:167, July 1996 Downloaded from www.ajronline.org by Gazi Universitesi on 05/05/15 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved Cerebral Aneurysms Associated with Seizures Fig. 1.-MR imaging in 65-year-old man who had recently suffered first seizure. A, Unenhanced Ti-weighted axial image (500/li/i ITR/TE/excitationsl) shows rounded region of hypointense signal representing patent lumen of aneurysm (straight arrow). Extensive region of abnormal signal (curved arrow) extends through much of left temporal lobe. B, 12-weighted axial image (2500/80/0.75) shows lumen of aneurysm surrounded by rim of abnormal signal (arrow) that is hypointense to brain, representing intraaneurysmal thrombus. At surgery, actual size of aneurysm correlated with external diameter of rim of hypointense signal. That correlation was taken as evidence that aneurysm was, indeed, partially thrombosed. Hyperintense signal abnormality (curved arrow) extends through much of medial left temporal lobe, which was correlated with gliosis at surgery. C, Three-dimensional time-of-flight MR angiogram (48/5.6/i; flip angle, 30) shows aneurysm (arrowhead) arising from supraclinoid segment of left internal carotid artery and projecting laterally. of the proximity of such temporal lobe ( I 1. The likelihood rysm’s causing with the seizures size of of patients aneurysms. 5C/ seizures all the and 4]. the aneurysm giant (>2.5 of patients had aneurysms Seizures can by cm) Fig. 2.-MR 4 A4 .. imaging study of 39-year-old man who suf- fered olfactory hallucinations due to temporal lobe seizures and had long-standing history of right-sided headache. Long TR/short TE axial image (2500/30/i) shows partially thrombosed aneurysm (arrow) with hyperintense signal within adjacent mesial temporal lobe (arrowheads). At surgery, i.2-cm posterior communi- cating artery aneurysm that was densely adherent to medial right temporal lobe was found. Organized throm- bus was also seen outside dome of aneurysm in right temporal lobe, indicating previous subclinical aneurysm and images attributed aneurysms that the mesial be responsible cause of the temporal ond patient attributed complex of the middle AJR:i67, Ju)y i996 partial seizures cerebral artery and clearly and temporal the irritative effects perhaps, noid blood previous from of an aneurysm. aneu- surgery because aneurysms seizures mesial seizure rysms lobe Also. with begun that common have that secondarily event. cases. be poral lobe rupture of rupture been reported presented nal in as lobe the to a superior Another adjacent a adjacent at a total with includ- within on medial hemorrhage that at the artery to our similar an one temporal cerebellar patient. aneurysm In T2-weighted who had was caused two a tem- by bifurcation of cerebral artery. had abnormal to the hemorrhage but signone of the aneurysm by hemorrhage. that was Neither patient had seizures. None of the 41 unruptured aneurysms in this group of patients had a complex patients seizures. signal around the portion not surrounded first findings seen rupture. in a pattern the middle generalized. Various imaging other the tonic-clonic as patients, clinical aneurysmal was at MR sec- in our found in two aneurysm of subarach- We of period and The gliosis a 5-year other a total had lobe lobe over 32 had parenchyma may reasonably (who seen reviewed of signal of whom adjacent we abnormal lobe likely related to tetnporal having aneurysms structural subclinical at surgery. with [2]. of abnor- signal, examinations hyperintense at the importance imaging patient, images in our the seizure MR of abnormality. can partial between that the per- was loss and gliosis MR findings findings temporal to right and. relatively indicate the signal for probably be reported patients found to been within assess both T2- neuronal perianeurysmal efTect has previously in our severe 43 aneurysms) our institution. within brain on [51. The amygdalohippocampectomy mal of indicative I I ]; and, in one case in formed, patients especially signal changes seizure appears of hyperintense surgery gliosis association discovery years. to edema of temporal experienced strongest 1 occasional products hemorrhage To further than compression; blood which with larger to clinical attention because of mass rather than aneurysmal rupture I I I. patient is most The series presented many lobe subclinical increase intracranial precede temporal to come weighted ing perianeurysmal often leak. Moderate gliosis was also noted at surgery in part lobe that exhibited abnormal signal. Patient no further seizures following surgery. to the of an aneuIn one unruptured Perianeurysmal .*,. appears aneurysm. with cm aneurysms abnormal MR imaging trated MR of 43 unruptured earlier). studies only signal. Therefore, aneurysms (including two had of seen on the two illusabnormal peri- 231 Provenzale Downloaded from www.ajronline.org by Gazi Universitesi on 05/05/15 from IP address 194.27.18.18. Copyright ARRS. For personal use only; all rights reserved aneurysmal MR signal. and both were aneurysms that lack such frequency with which abnormal MR signal is correlated associated with seizures. We suggest that the MR imaging examina- tions a cerebral subclinical for important link. which eurysmal MR of patients with seizures aneurysm should abnormal perianeurysmal may indicate dental inspected signal, MR that the aneurysm finding but related seizures. However, abnormal perianeurysmal the true only of cases have been analyzed. that patients rysmal MR rupture different signal when mal mciof the signal a larger that signal ing such abnormality, rupture Surg an earlier complex cerebral also suffer seizures in patients in which lack- case this MR might be an indication for earlier, aggressive, anticonvulsant therapy. or of patients with EMT. and treatment. Rosemberg partial S. da E. de Assis seizures Silva LM. associated HCA, Intractable with posterior artery giant aneurysm: a case report. Epilepsia 1994:35:I 317-1320 3. Sengupta RP, Saunders M, Clarke PR. Unruptured intracranial aneurysms: an unusual source of epilepsy. Aetti Neurochir 1978:40:45-53 4. Solomon RA, Fink ME, Pile-Spellman management of rysms. J Neuro.surg unruptured intracranial J. Surgical aneu- 1994;80:44()-446 5. Atlas References I . Whittle history 1985:24:533-540 Jorge CL, de Olivera be an more perianeu- 2. Yacubian perian- than on the natural Neural will finding it is comments with abnormal may frequency with of have a risk of aneurysmal from at a different Patients The perianeurys- number For instance, with abnormal aneutysmal abnormality. will significance MR apparent possible is not an to the cause become 232 and be carefully et al. SW, Grossman RI, Goldberg HI. Hackney Bilaniuk LI, Zimmerman RA. Partially thrombosed giant intracranial aneurysms: correlaDB, IR, Allsop JL, Halmagyi zures: an unusual presentation nial a report aneurysms: GM. Focal sei- of giant intracraof four cases with tion of MR and pathologic findings. Radiolog AJR:167, July 1996 1987:162:111-114