Subacute ruptured intracranial aneurysm complicated by vasospasm and stroke

Case contributed by Dr Henry Knipe

Presentation

One week of headache followed by right arm tingling.

Patient Data

Age: 55 years
Gender: Male

Right anterior temporal pole intraparenchymal hematoma and is of a density suggestive of a non-acute bleed. Hypodensity surrounding the bleed is likely vasogenic edema, however, there is possible loss of grey-white differentiation in the right frontal lobe suggestive of superimposed ischemia. 

Large broad-based inferiorly projecting aneurysm arising from the right MCA bifurcation. Proximal right M1 is of reduced caliber compared to the left. M2 branches and the mid-to-distal left A1 segment is also markedly asymmetrically narrowed. Mild caliber irregularity of the terminal right ICA.

On the current study, this MCA aneurysm does not demonstrate internal flow signal, likely due to slow flow, given that there is luminal contrast enhancement. Adjacent to the patent lumen there is a larger rounded region of T1 hyperintensity with peripheral enhancement, which may represent mural thrombus in a partially thrombosed aneurysm sac rather than a hematoma.

However, there has been a recent bleed, with a thin subdural hematoma extending over the right convexity.

Abnormal T2 hyperintensity and diffusion restriction through the right frontal operculum and insular cortex, and to a lesser extent involving right temporal cortex in keeping with infarct.

Elsewhere in the brain there are patchy foci of white matter T2 hyperintensity compatible with chronic small vessel ischemia. No hydrocephalus.

Case Discussion

This is an example of a subacute ruptured aneurysm with largely intra-parenchymal hemorrhage complicated by vasospasm and subsequent infarct. The patient was managed with craniotomy and clipping of the large right MCA bifurcation aneurysm. 

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Case information

rID: 56750
Published: 22nd Nov 2017
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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