Ruptured MCA aneurysm

Case contributed by Daniel Toth
Diagnosis certain

Presentation

Found unconscious in hospital bathroom some hours after last seen in an out-patient clinic waiting room.

Patient Data

Age: 50 years
Gender: Female
ct

Large intraparenchymal hemorrhage in the right frontal lobe, extending near the basal nuclei with narrow zone of surrounding hypodensity, most likely representing edema.

Large volume subarachnoid hematoma in most sulci and all cisterns.

Intraventricular hematomas in both lateral ventricles, the third and fourth ventricle.

Widening and hydrocephalic configuration of supratentorial ventricles, indicative of obstructive hydrocephalus due to blood in the aqueduct. 

ct

Aneurysm extending from the middle cerebral artery (MCA) bifurcation of about 5 mm extending in a latero-antero-caudate direction.

DSA pre & post coils

dsa

First series shows aneurysm at MCA bifurcation, in accordance with previous CTA findings.

Second image shows successful coiling of aneurysm with no residual contrast enhancement of aneurysm.

Single-shot non-contrast image shows coils for better visualization.

ct

CCT two weeks after treatment shows interval placement of external ventricular drainage and coiling of MCA aneurysm.

There is interval resolution of the intraparenchymal hematoma in the frontal lobe with residual cystic-gliotic changes noted.

Partial resolution of most subarachnoid hemorrhage, with some residual blood in the sulci near the vertex (high frontal and parietal lobes).

Partial resolution of most intraventricular hemorrhage, with some residual blood in both lateral ventricles.

Resolution of hydrocephalus with normalization of configuration and width of both lateral ventricles and the third ventricle.

 

CTA shows strong metal artefacts near the coils, any possible residual perfusion of the aneurysm cannot be fully assessed.

Case Discussion

Typical presentation of a ruptured aneurysm of the middle cerebral artery (MCA) with large-volume intracerebral bleeds of different types (subarachnoid, intraparenchymal, intraventricular) and resulting obstructive hydrocephalus.

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