Subarachnoid hemorrhage caused by a ruptured anterior spinal artery aneurysm

A 51-year-old man presented with an extremely rare case of intracranial subarachnoid hemorrhage caused by rupture of an anterior spinal artery aneurysm manifesting as disturbance of consciousness following sudden onset of neck pain and numbness of the extremities. Cranial computed tomography revealed subarachnoid hemorrhage, mainly in the posterior fossa. Cerebral angiography studies on admission and on the 4th day demonstrated no definite abnormality as a bleeding source. A ventricular catheter was inserted to treat the acute hydrocephalus, and conservative management was continued during the acute period. Third angiography on the 18th day demonstrated an anterior spinal artery aneurysm at the C1 level which was considered to be the bleeding site. After conservative treatment, the patient was discharged without neurological deficits. Fourth angiography on the 108 th day disclosed spontaneous disappearance of the aneurysm, which was confirmed by the fifth angiography on the 269 th day. If subarachnoid hemorrhage of unknown etiology is encountered, spinal artery aneurysm should be considered as the bleeding source. Despite the controversy concerning the treatment strategy, ruptured spinal artery aneurysms can be treated conservatively because of the possibility of spontaneous regression. Follow-up angiography is required to evaluate the natural course of the lesion.     

Subarachnoid hemorrhage from a dissecting aneurysm of the middle cerebral artery. Case report

A case of subarachnoid hemorrhage (SAH) from a dissecting aneurysm of the inferior limb of the middle cerebral artery is reported. The patient's clinical status and the initial and follow-up angiographic appearance of the aneurysm are presented. Diagnosis and treatment are briefly discussed. It is suggested that, if angiography demonstrates luminal narrowing or vascular occlusion in a patient with unexplained SAH, a dissecting aneurysm of the carotid system should be considered as a cause of the hemorrhage.     

Subarachnoid hemorrhage possibly caused by a saccular carotid artery aneurysm within the cavernous sinus. Case report

Aneurysms arising from the intracavernous portion of the internal carotid artery very rarely rupture. A patient is presented in whom rupture of an aneurysm wholly within the cavernous sinus caused a subarachnoid hemorrhage. The aneurysm was successfully clipped via a direct surgical approach. The possible mechanism by which subarachnoid hemorrhage occurred is briefly discussed.     

Subarachnoid hemorrhage caused by a fungal aneurysm of the vertebral artery as a complication of intracranial aneurysm clipping. Case report

Intracranial aneurysms are an uncommon manifestation of fungal infection. A case is described in which the formation of an aneurysm followed an intracranial intraoperative Aspergillus infection attributable to a long period of preoperative antibiotic medication and immunosuppressive therapy with steroids.     

Subarachnoid hemorrhage due to ruptured posterior cerebral artery aneurysm simultaneously associated with multiple remote intracerebral hemorrhages--case report

A 61-year-old woman presented with aneurysmal subarachnoid hemorrhage (SAH) associated with multiple remote intracerebral hemorrhages (ICHs). She had undergone microsurgical neck clipping for ruptured right middle cerebral artery aneurysm and ventriculo-peritoneal shunting 16 years previously. Computed tomography revealed SAH predominantly in the basal cistern and ambient cistern, in association with multiple ICHs in the bilateral tegmentum of the brain stem and right caudate nucleus. Digital subtraction angiography revealed an aneurysm at the P(1) segment of the left posterior cerebral artery. The ruptured aneurysm was microsurgically clipped via a left subtemporal approach without complications. Simultaneous occurrence of aneurysmal SAH and multiple remote ICHs is rare. The spatial pattern of the ICHs in the present case is apparently unique.     

Terson's syndrome as the initial symptom of subarachnoid hemorrhage caused by ruptured vertebral artery aneurysm. Case report

A 61-year-old male initially presented to the ophthalmology department complaining of sudden visual loss. Fundus photography and ultrasonography followed by computed tomography identified Terson's syndrome caused by subarachnoid hemorrhage (SAH). Cerebral angiography revealed a dissecting aneurysm of the left vertebral artery. Other than obtunded visual acuity, his neurological examination was normal and he denied any headache. He was treated conservatively with pain and blood pressure control. He complained of headache associated with rerupture of the aneurysm on day 5. The patient died of rerupture on day 14. The clinical course of this patient indicates that Terson's syndrome may occur without sudden increase of intracranial pressure. Terson's syndrome may occur as a rare initial clinical sign of SAH caused by ruptured cerebral aneurysm.     

Subarachnoid hemorrhage caused by ruptured posterior inferior cerebellar artery aneurysm arising from the extracranial portion of an anomalous vertebral artery

A 42-year-old woman presented with subarachnoid hemorrhage caused by a ruptured posterior inferior cerebellar artery aneurysm arising from the extracranial portion of an anomalous vertebral artery. We speculated that the aneurysm formed by dissection of the media because of its shape and location. Therefore, the aneurysm was isolated by trapping and excised, with occipital artery to posterior inferior cerebellar artery bypass. Histological examination showed a typical true aneurysm without evidence of dissection. This case suggests that an aneurysm of an anomalous artery is caused by hemodynamic stress and is a true aneurysm, not a dissection.     

Ipsilateral hemiparesis caused by subarachnoid hemorrhage in a patient with a ruptured middle cerebral artery aneurysm: a case report

The authors report a patient with a ruptured middle cerebral artery (MCA) aneurysm who presented with ipsilateral hemiparesis. A computed tomographic (CT) scan and cerebral angiograms suggested that the ipsilateral hemiparesis was most likely due to compression by hematoma of the secondary motor area in the island of Reil. Two other cases that demonstrated ipsilateral motor weakness after rupture of MCA aneurysms have been reported. We emphasize not only the importance of considering dysfunction of the secondary motor area in patients with hemiparesis, but also the difficulty in differentiating ipsilateral secondary motor area dysfunction from contralateral primary motor area dysfunction in certain cases without CT scanning and angiography.     

Subarachnoid hemorrhage caused by ruptured intracranial fusiform aneurysm associated with microscopic polyangiitis

A 44-year-old woman with microscopic polyangiitis (MPA) presented with a ruptured cerebral aneurysm. She was admitted to our hospital for further examination of progressive renal failure. She was found lying on the ward floor. Computed tomography showed subarachnoid hemorrhage, and digital subtraction angiography revealed a saccular-like aneurysm arising from the right distal posterior inferior cerebellar artery (PICA) at the non-branching site. We performed neck clipping of the right distal PICA aneurysm, which recurred 5 days after the operation. Second angiography demonstrated a right distal PICA aneurysm just above the site of the clip. Therefore, we performed trapping of the affected lesion with emergent bypass of the contralateral occipital artery to the ipsilateral PICA. Her postoperative course was uneventful until she coughed up blood and had gross hematuria 3 days after the second surgery. Histological examination of a renal biopsy specimen revealed crescentic glomerulonephritis. MPA was diagnosed on the basis of the cardinal symptoms, including progressive glomerular nephritis and the lung abnormality, as well as the presence of myeloperoxidase-antineutrophil cytoplasmic antibodies. After intensive treatment, she was discharged for rehabilitation without neurological deficit. MPA commonly affects small-sized vessels mainly in the kidneys and lungs and may lead to crescentic glomerulonephritis and pulmonary hemorrhage. MPA is rarely associated with aneurysms of medium-sized muscular vessels. Cerebral aneurysm is extremely rare in patients with MPA, but rupture of an intracranial fusiform aneurysm can be lethal, so screening of the intracranial vessels should be performed by magnetic resonance imaging in patients with MPA.     

Subarachnoid hemorrhage caused by a dissecting aneurysm of the internal carotid artery

OBJECT: Subarachnoid hemorrhage (SAH) caused by the rupture of a dissecting aneurysm of the internal carotid artery (ICA) has been considered rare. Based on data from cooperatively collected cases, the clinical features of patients with dissecting aneurysms of the ICA who presented with SAH were examined. METHODS: Data from 18 patients with dissecting aneurysms of the ICA who presented with SAH diagnosed on the basis of clinical signs, neuroradiological findings, and intraoperative findings from 41 institutions were collected during a 5-year period between 1995 and 1999. The authors found that 0.3% of all cases of SAH and 3.1% of cases of SAH of unverified cause were attributable to a dissecting aneurysm of the ICA. Eleven patients (61%) were middle-aged women, and eight patients (44%) had hypertension. Rebleeding before admission was demonstrated in 13 patients (72%), and intraoperative bleeding was exhibited in half of the patients who underwent surgery during the acute stage. Postoperative growth of an aneurysm bulge or recurrent SAH was seen in five of 10 patients who had undergone wrapping or clipping of the aneurysm bulge in the acute phase. Trapping with or without bypass, which resulted in no postoperative recurrence, was performed in three patients in the acute stage and in two patients in the chronic stage. Twelve patients (67%) had a poor prognosis, primarily attributed to intraoperative bleeding and postoperative recurrence. CONCLUSIONS: Generally, dissecting aneurysms of the ICA are not thought of as frequent causes of SAH. Nonetheless. the presence of these aneurysms should be considered when dealing with SAH because they have a susceptibility to bleeding that can lead to a poor prognosis. Careful surgical planning is necessary to decrease intraoperative bleeding and to avoid postoperative recurrence.     

Subdural hemorrhage in the posterior fossa caused by a ruptured cavernous carotid artery aneurysm after a balloon occlusion test. Case report

Given the relatively benign natural history of cavernous carotid artery aneurysms and based on anecdotal reports in the literature of subarachnoid hemorrhage (SAH) or subdural hemorrhage (SDH) from these aneurysms, observation is warranted and typically recommended. In this case report, the authors describe a woman who harbored a partially thrombosed, giant cavernous aneurysm that ruptured after she underwent a balloon occlusion test (BOT) and predominately led to an SDH. The authors believe that this occurrence is the first such report in the English literature. They discuss possible mechanisms for this event and the literature related to SAH or SDH from cavernous aneurysms, including why cavernous aneurysms cause such hemorrhages. The authors also recommend that attention be paid to such lesions regarding the possibility of aneurysmal rupture following a BOT.     

Subarachnoid hemorrhage due to a ruptured intracranial vertebral artery aneurysm associated with cerebrovascular fibromuscular dysplasia: case report

Fibromuscular dysplasia (FMD) is comprised of a group of nonatherosclerotic and noninflammatory arterial diseases. Cerebrovascular FMD occurs more frequently in women, and the mean age at which it is diagnosed is 50 years. The most common angiographic pattern of cerebrovascular FMD is the "string-of-beads" deformity at the extracranial internal carotid artery. We report the case of a 52-year-old woman who presented with a sudden severe headache and went into a deep coma. She had been complaining of headaches for 2 weeks, but no specific imaging findings were obtained. A computed tomography scan obtained on admission showed a diffuse subarachnoid hemorrhage (SAH) from the cerebellomedullary cistern to the basal cistern with evidence of clot in the fourth and third ventricles. We performed digital subtraction angiography and made the diagnosis of cerebrovascular FMD. Right carotid angiography and left vertebral angiography showed the classic "string-of-beads" pattern with multiple constrictions of the lumen. Left carotid angiography showed a long segment of tubular stenosis. Right vertebral angiography also revealed the "string-of-beads" pattern and a ruptured aneurysm at the intracranial segment, which presented as a diverticulum-like outpouching. The patient was treated with conservative measures but passed away on the 23rd day of hospitalization. An autopsy was not performed. To our knowledge, during the last three decades, there are only four previous reports which showed intracerebral ruptured aneurysms of the vertebral artery or its branch in adults with cerebrovascular FMD. We demonstrate and discuss the radiologic findings here.     

Subarachnoid hemorrhage due to ruptured dissecting aneurysm of peripheral superior cerebellar artery

The peripheral superior cerebellar artery (SCA) dissecting aneurysm (DA) is extremely rare, with only 4 cases (including our case) having been reported. Here we report a case of subarachnoid hemorrhage due to ruptured DA of peripheral SCA and summarize the 23 cases of the DA of peripheral arteries in the posterior fossa. A 64-year-old woman was found unconscious at home and was admitted to our hospital on December 12, 1998. A computed tomography scan revealed a diffuse subarachnoid hemorrhage (Fisher's classification Group 3), mainly in the prepontine cistern. Her neurological state on admission was Hunt and Kosnik grade III. A cerebral angiogram was performed on admission, and revealed a slightly enlarged lesion at the anterior pontine segment of the left SCA. The day after admission, a second angiogram was performed and revealed that the lesion was not well-defined. She was treated conservatively, with no change in condition. On the 16th day after admission, a third angiogram was performed and revealed a saccular aneurysm-like lesion arising at that region with intra luminal pooling sign. She was treated, using the left subtemporal approach. In the operation, organized clots and hemosiderin were identified in the prepontine cistern. However, saccular aneurysm was not found at all and only the arterial wall was thin and discolored. These serial angiogram and operative findings revealed a DA of peripheral SCA. In this case, serial angiogram showed singular change of findings within a short period. We emphasize the need to repeat the angiogram taking due timing into account.     

Acute subdural hematoma without subarachnoid hemorrhage caused by ruptured A1-A2 junction aneurysm. Case report

A 54-year-old man was admitted to our hospital with complaint of sudden headache. The patient had suffered two episodes of transient headache before admission. Computed tomography (CT) revealed acute subdural hematoma (ASDH) on the right side of the cerebral convexity with bilateral extension along the tentorium cerebelli without signs of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH). Three-dimensional CT angiography and conventional cerebral angiography revealed a left A1-A2 junction aneurysm. Neck clipping of the aneurysm was performed. The aneurysm extended inferiorly, with the dome embedded in the chiasmatic cistern and tightly adhered to the arachnoid membrane. There was no evidence of hematoma in the subarachnoid space. The patient was discharged without neurological deficit. Ruptured aneurysms resulting in ASDH without SAH or ICH are very rare. Radiological investigation such as three-dimensional CT angiography should be performed to find the causative aneurysm in a patient with ASDH with a history of repeated headaches and without traumatic signs or episodes, and the appropriate treatment should be planned with expediency.     

Successful treatment of a ruptured dissecting basilar artery aneurysm. Case report

Dissecting basilar artery (BA) aneurysms in patients presenting with subarachnoid hemorrhage are life threatening, especially in those who experience subsequent bleeding or progressive dissection, and immediate surgical or endovascular intervention may be necessary. The authors report on a 52-year-old woman whose dissecting BA aneurysm was treated successfully with proximal occlusion and flow reversal. Clipping of the proximal BA above the level of the anterior inferior cerebellar arteries facilitated retrograde flow from a radial artery graft placed between the left vertebral artery and the left posterior cerebral artery, thereby providing continuous perfusion of the BA and its branches. Postoperative angiograms obtained 1 year later revealed good retrograde flow through the BA and dilation of the radial arterial graft. There were no episodes of recurrent hemorrhage.