Cerebral aneurysm with rupture

Case contributed by A.Prof Frank Gaillard

Presentation

Headache for investigation

Patient Data

Age: 90
Gender: Female
CT

CT and CTA brain

Brain (non-contrast):

Sliver of high attenuation material within the dependent portion of the left circular sulcus likely represents a small amount of subarachnoid blood. No other intracranial haemorrhage identified.

Hyperdensity seen within the suprasellar cistern corresponds to the large left terminal MCA aneurysm described below.

Bilateral periventricular and deep white matter hypoattenuation is likely in keeping with chronic small vessel ischaemia. Large calcified pineal gland. Ventricles and sulcal pattern are age appropriate.

CTA COW:

The left common carotid artery arises from the brachiocephalic trunk. The left vertebral artery arises directly from the aortic arch, between the origins of the brachiocephalic trunk and left subclavian artery. Right dominant vertebral artery. Tortuous bilateral common carotid arteries near their origins.

There is a large, lobulated, anteriorly directed 11 x 4 x 14 mm aneurysm arising from the terminal left ICA, with a 3 mm neck. Further 2 mm aneurysm at the right M1 bifurcation. Left PCOM infundibulum.

DSA (angiography)

DSA

After informed consent, with aseptic technique, via right CFA uphill, bilateral CCA and vertebral angiograms performed, demonstrating:

Large left carotid terminus aneurysm measuring 14 x 6 mm in perpendicular dimensions.

During the procedure patient developed severe left sided headache with moderate confusion, with suspicion for acute rupture ( treating team was notified). Angiographic extravasation was identified. Groin was closed with a 6Fr angioseal and patient was transferred for an urgent CT.

Conclusion:

On table rupture of aneurysm. Large left carotid terminus saccular aneurysm as described. The aortic arch anatomy was of bovine with significant carotid tortuosity making stable position of the catheter impossible even for a SIM catheter, therefore due to likely endovascular access difficulty, the aneurysm was considered unsuitable for coil embolisation.

CT

CT brain post DSA

Marked bilateral extensive subarachnoid haemorrhage admixed with contrast (in keeping with rupture during DSA) is demonstrated overlying each cerebral cortex also within the basal cisterns. There is some haemorrhage present within the fourth ventricle. There is some large amount of blood lying anterior to the brainstem. There is a large aneurysm on the left side. This lies medial to or adjacent to the origin of the left middle cerebral artery and approximates 11 mm in size.

CONCLUSION:

Extensive massive bilateral subarachnoid haemorrhage. Aneurysm is present as described.

Case Discussion

Went on to have a clipping and survived.

PlayAdd to Share

Case information

rID: 29933
Case created: 4th Jul 2014
Last edited: 28th Oct 2015
Inclusion in quiz mode: Included

Updating… Please wait.
Loadinganimation

Alert accept

Error Unable to process the form. Check for errors and try again.

Alert accept Thank you for updating your details.