Presentation
Worst headache ever.
Patient Data
There is dense subarachnoid blood, predominantly in the anterior interhemispheric fissure, also in both sylvian fissures, and in the suprasellar cistern extending to the left side of the interpeduncular cistern. No intraparenchymal or intraventricular extension.
Ventricles and cortical sulci within normal limits for a patient of this age. No evidence of hydrocephalus.
No evidence of acute vascular territory infarct.
Visualized paranasal sinuses and mastoid air cells are well-aerated. No concerning bone lesion.
CTA COW (aortic arch to vertex)
There is a 1.1 x 0.8.x 0.8 cm lobulated aneurysm arising from the anterior communicating artery. This has a wide - 5 mm - neck. It fills from supply via the left A1 segment.
The right A1 segment is hypoplastic.
Both the left and right A2 segments arise from the base of the aneurysm.
No other aneurysm is demonstrated.
Conclusion:
Lobulated wide neck anterior commuting artery aneurysm.
Acute subarachnoid hemorrhage with distribution of blood compatible with rupture of the ACom aneurysm.
Anterior communicating artery aneurysm Endovascular Treatment
Diagnostic angiography 11 x 7 x 4 mm, daughter aneurysms, broad necked, arising from dominant left A1 segment. Right A1 segment is aplastic. Questionable area involving the right P1 of either dysplastic segment versus very small bleb aneurysm, worthy of follow up.
Case Discussion
Berry cerebral aneurysms occur in ~90% in the anterior circulation, and the ACA/ACoA complex accounts for ~30-40% of those.
Treatment of large or symptomatic aneurysms should be considered, with either endovascular coiling or surgical clipping. This case illustrates a ruptured aneurysm treated by coiling.