无蛛网膜下腔出血的大脑中动脉动脉瘤破裂

目的总结无蛛网膜下腔出血（SAH）的大脑中动脉（MCA）动脉瘤破裂的临床特点。方法对6例在首次CT扫描上表现为脑内出血（ICH），或壁内出血（IMH）而无SAH的MCA动脉瘤破裂患者的临床表现、影像学检查、治疗方法和预后进行回顾性总结。结果本组首次CT扫描时间为起病后0—2d，表现为单纯ICH者4例，IMH者2例。DSA和手术证实为MCA动脉瘤破裂。开颅动脉瘤切除1例，夹闭5例，其中4例同时行血肿清除术。术后无死亡。结论MCA动脉瘤破裂首次CT扫描可仅表现为ICH或IMH而无SAH，与动脉瘤的部位、出血量以及CT扫描时间相关。     

Usefulness of CT angiography for demonstrating cerebral aneurysms

We report the usefulness of computed cerebral angiotomography (CT angiography) for demonstrating cerebral aneurysm and the clinical significance of CT angiography for ruptured cerebral aneurysm. Our modified method of CT angiography was easy and less time-consuming. Fifteen seconds after starting a single bolus injection, 1 ml/kg/25 seconds via cubital vein, of contrast medium (60% urograffin), 5 serial 5 mm thick-CT slices were scanned in every 6.5 seconds including 2 seconds of interval, beginning from an axial level 20 mm above the orbitomeatal line and ending at a level 40 mm. A total of 103 patients were examined in this report, consisting of 70 unruptured asymptomatic, 8 unruptured symptomatic (oculomotor nerve palsy) and 25 subarachnoid hemorrhage (SAH). Seven unruptured aneurysms in 4 asymptomatic cases, 2 unruptured aneurysms in 2 symptomatic cases 27 aneurysms in 24 SAH cases were suspected by CT angiography. Of these 36 aneurysms suspected by CT angiography 32 aneurysms were confirmed by cerebral angiography. The detection rate of CT angiography in this report was 89%, higher than those of previous reports. Thirteen aneurysms were located at internal carotid-posterior communicating artery (ICPC) junction. 11 at anterior communicating artery (Acom), 7 at middle cerebral artery (MCA). CT angiography showed a false positive findings in 4 cases, which were all located at Acom. Four aneurysms were not detected in CT angiography, which were all located at MCA and were very small (2-3 mm) in diameter. There were no deteriorated cases during and after CT angiography. We suggest that CT angiography is a useful and safe method for predicting the location of not only unruptured but ruptured aneurysms.     

Computed tomography in the diagnosis of hemorrhage secondary to intracranial aneurysm. (author's transl)

In 168 patients with ruptured intracranial aneurysms, the pathology of intracranial hemorrhage visualized on CT was analyzed. Blood in the subarachnoid space could be visualized in 95% of cases within three days after SAH and 75% of 106 cases within two weeks after SAH. In one case blood clot in the subarachnoid space visible up to 13 days after SAH. Concerning the cases within two weeks after the bleeding, intracerebral hematomas were observed in 36% of anterior cerebral aneurysms and middle cerebral aneurysms, 16% of internal carotid aneurysms and none of vetebro-basilar aneurysms. The incidence of the intraventricular hemorrhage was as follows; vertebro-basilar, 44%; anterior cerebral, 38%; internal carotid, 28%; middle cerebral, 12%. On the basis of the pattern of distribution of extravasated blood the location of the ruptured aneurysm was properly predicted in 58% of anterior cerebral, 81% of middle cerebral, 58% of internal carotid and 30% of vertebro-basilar. Especially CT could contribute to predict which aneurysm has ruptured in patients with multiple aneurysms. It was possible to localize the site of bleeding in 11 out of 12 CT positive cases. The development of intracranial hemorrhage demonstrated by CT well correlated with the clinical grading of the patients and the clinical outcome. Patients merely showing subarachnoid hemorrhage were more likely to have good neurological grades, but ones showing complicated intracerebral hematomas and intraventricular hemorrhage had poor neurological grades at the time of the scan. The findings of extensive subarachnoid clot, which were followed by severe vasospasm, and marked intraventricular hemorrhage, usually correlated with poor prognosis. These pathology recognizable on CT was very helpful in determination of the timing of surgery and management of such patients. In conclusion CT is of great value in the examination of SAH when performed in the acute stage and should be the initial examination followed by angiography.     

Progressive change in cerebral blood flow during the first three weeks after subarachnoid hemorrhage

Cerebral blood flow (CBF) was estimated from each cerebral hemisphere by the 133Xe inhalation method. Daily estimates were made during the first 3 weeks after subarachnoid hemorrhage (1265 studies in 116 patients). Some of the patients were taking adrenergic blocking drugs (propranolol and phentolamine), others were taking tranexamic acid, and the rest were taking no drugs. CBF was also studied in 67 normal subjects. The resting CBF was related inversely to age not only for normal subjects but also for patients after subarachnoid hemorrhage (SAH). The CBF fell progressively during the first 2 weeks after SAH and was abnormally low throughout the 3 weeks after hemorrhage. For any 1 day after SAH, those patients who were fully alert had the smallest reduction in CBF. The progressive changes in CBF occurred whether or not an aneurysm was present on angiograms. For aneurysms situated to one side of the midline, the changes in CBF affected both sides of the brain. The progressive decline in CBF was least in those patients who subsequently made the best clinical recovery. Arterial pCO2 seemed to influence CBF throughout the 3 weeks after SAH. During the 2nd week, CBF was especially low in SAH patients treated with tranexamic acid. The serial changes in CBF are discussed in relation to current views concerning the timing of operation for ruptured aneurysms.     

Ruptured internal carotid artery bifurcation aneurysm presenting with only intracerebral hemorrhage without subarachnoid hemorrhage--case report

A 55-year-old man presented with intracerebral hemorrhage (ICH) without subarachnoid hemorrhage (SAH) manifesting as acute onset of consciousness disturbance and right hemiparesis. Computed tomography showed ICH mainly localized in the left putamen, but no evidence of SAH. Magnetic resonance angiography demonstrated a cerebral aneurysm originating from the bifurcation of the left internal carotid artery, which was considered to be responsible for the ICH. The patient underwent emergent intravascular surgery for coil embolization of the aneurysm, and his neurological symptoms gradually recovered with rehabilitation after surgery. Although ICH without SAH is a rare presentation of cerebral aneurysm, ruptured cerebral aneurysm should be considered as a potential cause of ICH. The localization and extent of ICH may be suggestive of latent cerebral aneurysm in such cases.     

A rare case of cerebral aspergillus aneurysm at the site of temporary clip application

Anterior communicating artery aneurysm was shown in a 48-year-old man who had suffered from subarachnoid hemorrhage (SAH) by cerebral angiography. Right pterional approach was performed on the 40th day after SAH. Premature ruptured occurred during aneurysmal manipulation and temporary clip (Scoville clip) was placed at the middle of the right A1 segment for fifteen minutes. the anterior communicating artery aneurysm was successfully clipped and postoperative course was uneventful. But, four days after the operation, the patient fell into coma following generalized tonic convulsion. Lumbar puncture showed fresh SAH. Consciousness recovered gradually to a lethargic state. A newly formed berry aneurysm was revealed on the righ A1 segment at the site of the temporary clip application by cerebral angiography performed on the seventh day after aneurysmal surgery. Second attack occurred on the 12th postoperative day and the patient died on the 16th day after the operation. Postmortem findings disclosed massive subarachnoid and intraventricular hemorrhage from the ruptured aneurysm at the right A1 segment. Microscopic examination of the aneurysm and the right A1 segment. microscopic examination of the aneurysm and the right A1 segment showed the extensive destruction of the artery and massive proliferation of aspergillus in the arterial wall which was prominent of its outer layer. The mechanism of the formation of the new aneurysm in this case was considered as follows: the arterial wall was primarily damaged by the temporary clip and was weakened rapidly by the invasion of aspergillus, probably producing thrombosis of the vast vasorum, hemorrhage, and necrosis in it.     

Use of spiral computerized tomography angiography in patients with subarachnoid hemorrhage in whom subtraction angiography did not reveal cerebral aneurysms

OBJECT: Patients with subarachnoid hemorrhage (SAH) in whom angiography does not demonstrate diagnostic findings sometimes suffer recurrent disease and actually harbor undetected cerebral aneurysms. The management strategy for such cases remains controversial, but technological advances in spiral computerized tomography (CT) angiography are changing the picture. The purpose of this prospective study was to examine how spiral CT angiography can contribute to the detection of cerebral aneurysms that cannot be visualized on angiography. METHODS: In 134 consecutive patients with SAH, a prospective search for the source of bleeding was performed using digital subtraction (DS) and spiral CT angiography. In 21 patients in whom initial DS angiography yielded no diagnostic findings, spiral CT angiography was performed within 3 days. Patients in whom CT angiography provided no diagnostic results underwent second and third DS angiography sessions after approximately 2 weeks and 6 months, respectively. Six patients with perimesencephalic SAH were included in the 21 cases. Six of the other 15 patients had small cerebral aneurysms detectable by spiral CT angiography, five involving the anterior communicating artery and one the middle cerebral artery. Two patients in whom initial angiograms did not demonstrate diagnostic findings proved to have a ruptured dissecting aneurysm of the vertebral artery; in one case this was revealed at autopsy and in the other during the second DS angiography session. A third DS angiography session revealed no diagnostic results in 13 patients. CONCLUSIONS: Spiral CT angiography was useful in the detection of cerebral aneurysms in patients with SAH in whom angiography revealed no diagnostic findings. Anterior communicating artery aneurysms are generally well hidden in these types of SAH cases. A repeated angiography session was warranted in patients with nonperimesencephalic SAH and in whom initial angiography revealed no diagnostic findings, although a third session was thought to be superfluous.     

Experimental subarachnoid hemorrhage: cerebral blood flow and brain metabolism during the acute phase in three different models in the rat

OBJECTIVE: To study the cerebral metabolism and its relationship to cerebral blood flow (CBF) acutely after subarachnoid hemorrhage (SAH). METHODS: SAH was induced in rats by endovascular perforation of the internal carotid artery, blood injection into the prechiasmatic cistern or the cisterna magna. CBF (measured by laser Doppler flowmetry), cerebral perfusion pressure, O(2) tension, and extracellular levels of glucose, lactate, and pyruvate were monitored during 90 minutes after SAH. CBF (assessed by (125)I-antipyrine autoradiography), arteriovenous O(2) difference, and cerebral metabolic rate of O(2) were calculated at 15 or 90 minutes after SAH. RESULTS: After a transient reduction, cerebral perfusion pressure normalized within 5 minutes after SAH in all groups. There was a transient global decrease in CBF after SAH: its duration depended on the severity of the hemorrhage. CBF of less than 20% of baseline was observed for at least 15 minutes in 25% and 14% of the animals after perforation and prechiasmatic SAH, respectively. In all SAH groups, O(2) tension was suddenly reduced to approximately 40% of baseline and gradually increased, reaching 70 to 90% of baseline 90 minutes after SAH. The cerebral metabolic rate of O(2) was reduced only at 15 minutes after perforation and prechiasmatic SAH, but arteriovenous O(2) difference was normal in all groups. During 30 minutes after perforation SAH, a 50% decrease in glucose and a threefold increase in lactate and pyruvate levels were observed. CONCLUSION: The data suggest that SAH induced an acute global decrease in CBF together with a depression in the cerebral metabolism. The degree of the changes was related to the severity of the hemorrhage. The metabolic derangements were not always explained by ischemic episodes.     

Long-term follow-up of cerebral blood flow in patients with ruptured cerebral aneurysm.

The xenon-133 inhalation technique was used to make three measurements of regional cerebral blood flow (CBF) in 34 patients with ruptured cerebral aneurysm: in the acute period (less than 14 days) after subarachnoid hemorrhage, in the subacute period (15-30 days), and in the chronic period (12-24 months). The hemispheric mean value of initial slope index was used as the mean CBF. The clinical outcomes were classified into good recovery (GR) (24 cases), moderate disability (MD) (5), and severe disability (SD) (5) on the Glasgow Outcome Scale. In all periods, the mean CBF significantly correlated with the outcome. GR patients had the highest mean CBF, MD patients the intermediate mean CBF, and SD patients the lowest mean CBF. GR patients had a near-normal mean CBF by the chronic period, while SD patients showed no significant CBF recovery throughout the course.     

The early hemorrhage and development of a bacterial aneurysm after a cerebral ischemic attack caused by a septic embolism--a case report]

A 71-year-old female was admitted with the complaints of dysarthria and right hemiparesis. CT scan revealed subarachnoid hemorrhage in the left cerebral sulcus. The first angiography was performed 3 days after the onset and left carotid angiography revealed a small aneurysm arising from the left middle cerebral artery. After 3 weeks of antibiotic therapy, the second angiography showed the aneurysm to be clearly enlarged, so it was resected. The patient complained of marked dysarthria a day after the operation and CT scan revealed a new infarction in the right frontal lobe. The third angiography showed an aneurysm arising from the right middle cerebral artery and the fact that two peripheral arteries of the aneurysm had disappeared 3 weeks after the first operation. The second operation was performed and a bacterial aneurysm was resected. The patient left the hospital without any neurological deficits. Septic embolism is the most important complication of infective endocarditis and it is usually presented with subarachnoid hemorrhage and intracerebral hemorrhage caused by ruptured bacterial aneurysms. In this case the septic embolism occurred two times. At each time cerebral ischemic attacks were presented. The reason why this case presented with ischemic symptoms was suspected to be that embolisms occurred at the trifurcation of the distal middle cerebral arteries. We were able to detect a bacterial aneurysm angiographically 3 days after the ischemic attack and we suspected that a bacterial aneurysm had been able to develop within 3 days after the septic embolism.     

Cerebral circulation and metabolism in the acute stage of subarachnoid hemorrhage

OBJECT: The mechanism of reduction of cerebral circulation and metabolism in patients in the acute stage of aneurysmal subarachnoid hemorrhage (SAH) has not yet been fully clarified. The goal of this study was to elucidate this mechanism further. METHODS: The authors estimated cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), O2 extraction fraction (OEF), and cerebral blood volume (CBV) preoperatively in eight patients with aneurysmal SAH (one man and seven women, mean age 63.5 years) within 40 hours of onset by using positron emission tomography (PET). The patients' CBF, CMRO2, and CBF/CBV were significantly lower than those in normal control volunteers. However, OEF and CBV did not differ significantly from those in control volunteers. The significant decrease in CBF/CBV, which indicates reduced cerebral perfusion pressure, was believed to be caused by impaired cerebral circulation due to elevated intracranial pressure (ICP) after rupture of the aneurysm. In two of the eight patients, uncoupling between CBF and CMRO2 was shown, strongly suggesting the presence of cerebral ischemia. CONCLUSIONS: The initial reduction in CBF due to elevated ICP, followed by reduction in CMRO, at the time of aneurysm rupture may play a role in the disturbance of CBF and cerebral metabolism in the acute stage of aneurysmal SAH.     

Urgent treatment of severe subarachnoid hemorrhage caused by ruptured traumatic aneurysm of the cavernous internal carotid artery using coil embolization followed by superficial temporal artery-middle cerebral artery anastomosis: a case report

BACKGROUND: Traumatic aneurysm of the cavernous internal carotid artery (ICA) with extension into the subarachnoid space is associated with increased risk of fatality especially when it is accompanied by severe subarachnoid hemorrhage (SAH). Only cases of patients who survived the acute stage and who were treated in a delayed setting have been reported. There has been no successfully treated case immediately after an injury. CASE DESCRIPTION: We encountered a 48-year-old man who presented with dense SAH immediately after being involved in a motor vehicle accident. Emergent angiography revealed traumatic aneurysm of the left cavernous ICA with extension beyond the superior wall of the cavernous sinus into the subarachnoid space and concomitant direct high-flow carotid cavernous fistula. Detachable platinum coil occlusion of the cavernous ICA followed by superficial temporal artery-middle cerebral artery anastomosis on day 0 and aggressive therapy to SAH, including ventriculocisternal irrigation and drainage, was performed. The patient eventually made a good recovery. CONCLUSION: Considering the extremely poor prognosis and unstable nature of a ruptured traumatic aneurysm with extensive SAH in the acute stage, definitive and immediate prevention of rebleeding in conjunction with proper revascularization would be warranted, such as in the present case.     

A ruptured aneurysm in the bifurcation of the proximal anterior cerebral artery and the frontopolar artery: case report

We report a case of ruptured aneurysm in the bifurcation of the proximal anterior cerebral artery and the frontopolar artery. A 49-year-old woman complained of sudden onset of severe headache on December 24, 2000. She was admitted to our hospital and CT scan revealed subarachnoid hemorrhage. Cerebral angiography on the next day revealed an aneurysm in the bifurcation of the frontopolar artery and the proximal anterior cerebral artery. She was operated on using the left pterional approach and complete neck clipping was performed. The post-operative course was uneventful. She was discharged with no neurological deficit two months after the operation.     

Acute disappearance of ruptured aneurysm located near the origin of the superior cerebellar artery - case report -

A 63-year-old woman presented with a ruptured aneurysm which apparently spontaneously thrombosed. She was admitted after sudden onset of severe headache. Computed tomography (CT) demonstrated subarachnoid hemorrhage (SAH) in the pontine and interpeduncular cisterns. Initial three-dimensional CT (3D-CT) angiography revealed an aneurysm (diameter, 9 mm) near the origin of the left superior cerebellar artery. However, angiography 3 hours later failed to show the aneurysm. Total thrombosis was thought to have occurred in the aneurysm. The patient returned home with no deficit 1 month after admission. T(1)- and T(2)-weighted magnetic resonance imaging 75 days after the SAH demonstrated the thrombosed aneurysm as an isointense mass lesion. 3D-CT angiography showed no recanalization of the aneurysm 9 months after the SAH.     

Flow dynamics analysis in patients with a ruptured middle cerebral artery aneurysm. A case report

Despite advancement of diagnostic and treatment modalities, subarachnoid hemorrhage (SAH) is still an entity of neurosurgical emergency with poor outcome. Recent reports indicated that hemodynamic stress might play an important role in rupture or the growth of cerebral aneurysms, but there is no consensus about how or which hemodynamic factor contribute to this phenomenon. In this report, magnetic resonance (MR)-based flow dynamics analysis was performed for a patient with SAH and the data obtained were directly compared with intraoperative findings. This 74-year-old woman was admitted for sudden onset headache. Head computed tomography scan showed SAH on the right sylvian fissure and intracerebral hematoma on the right temporal tip. Digital subtraction angiography showed a right middle cerebral artery aneurysm, which was considered to be the ruptured one. The aneurysm had two blebs, and the bleb around the aneurysm tip was exposed to low magnitude and high oscillation of wall shear stress (WSS). On the other hand, another bleb was exposed to high magnitude and low oscillation of WSS. Next day, the patient underwent open surgery and intraoperative findings showed the aneurysm tip was the ruptured point. MR-based flow dynamics analysis might be a useful diagnostic modality for patients with SAH. Although low magnitude and high oscillation of WSS might contribute to the aneurysm rupture, further case accumulation is necessary to reach a conclusion whether or not this is so.     

Fatal subarachnoid hemorrhage, with brainstem and cerebellar infarction, caused by Aspergillus infection after cerebral aneurysm surgery: case report

OBJECTIVE AND IMPORTANCE: Intracranial aspergillosis has been reported to cause subarachnoid hemorrhage (SAH) attributable to ruptured mycotic aneurysms. We describe a case of Aspergillus arteritis that caused SAH without aneurysm formation, followed by successive brainstem and cerebellar infarction. CLINICAL PRESENTATION: A 50-year-old woman experienced a sudden onset of headache. Computed tomography demonstrated SAH. After angiography revealed an aneurysm of the anterior communicating artery, a complete neck-clipping operation was performed, without neurological deterioration. However, the patient experienced another episode of SAH on the 26th postoperative day. INTERVENTION: We repeated the craniotomy and confirmed that the clip was still intact. A second angiographic evaluation did not reveal an aneurysm or any other cause of hemorrhage. On the 30th postoperative day, magnetic resonance imaging demonstrated cerebellar infarction in the territory of the anteroinferior cerebellar artery. The patient died on the 40th postoperative day, after another episode of SAH and progressive cerebellar and brainstem infarction. The postmortem examination revealed destruction of the basilar artery and occlusion of the basilar and vertebral arteries attributable to Aspergillus arteritis. CONCLUSION: When a patient presents with SAH of unknown origin followed by cerebral infarction, Aspergillus arteritis should be included in the differential diagnosis. Earlier recognition of this fungal infection improves the prognosis.     

Early cerebral circulatory disturbance in patients suffering subarachnoid hemorrhage prior to the delayed cerebral vasospasm stage: xenon computed tomography and perfusion computed tomography study

Subarachnoid hemorrhage (SAH) causes dynamic changes in cerebral blood flow (CBF), and results in delayed ischemia due to vasospasm, and early perfusion deficits before delayed cerebral vasospasm (CVS). The present study examined the severity of cerebral circulatory disturbance during the early phase before delayed CVS and whether it can be used to predict patient outcome. A total of 94 patients with SAH underwent simultaneous xenon computed tomography (CT) and perfusion CT to evaluate cerebral circulation on Days 1-3. Cerebral blood flow (CBF) was measured using xenon CT and the mean transit time (MTT) using perfusion CT and calculated cerebral blood volume (CBV). Outcome was evaluated with the Glasgow Outcome Scale (good recovery [GR], moderate disability [MD], severe disability [SD], vegetative state [VS], or death [D]). Hunt and Hess (HH) grade II patients displayed significantly higher CBF and lower MTT than HH grade IV and V patients. HH grade III patients displayed significantly higher CBF and lower MTT than HH grade IV and V patients. Patients with favorable outcome (GR or MD) had significantly higher CBF and lower MTT than those with unfavorable outcome (SD, VS, or D). Discriminant analysis of these parameters could predict patient outcome with a probability of 74.5%. Higher HH grade on admission was associated with decreased CBF and CBV and prolonged MTT. CBF reduction and MTT prolongation before the onset of delayed CVS might influence the clinical outcome of SAH. These parameters are helpful for evaluating the severity of SAH and predicting the outcomes of SAH patients.     

Evaluation of CT-guided stereotaxic aspiration for thalamic hemorrhage by single photon emission CT

Sixteen patients with thalamic hemorrhage (hematoma volume greater than or equal to 10 ml and CT classification greater than or equal to IIa) were included in this study. In sixteen patients, ten were treated conservatively (conservative group) and six were subjected to CT-guided stereotaxic aspiration (aspiration group). Stereotaxic aspiration was performed at the acute stage within five days after the onset. We measured cerebral blood flow (CBF) using Single Photon Emission CT (Tomomatic 64) and 133-Xe inhalation method. In both groups, CBF was measured at the onset (day 1-5), acute stage (day 7-13), subacute stage (1 month from the onset) and chronic stage (2-4 months from the onset). In this study, mean hemispheric cerebral blood flow (mCBF) was calculated from the middle slice 2, positioned 5cm above the orbitomeatal line. Regional devision of slice 2 in the hematoma side was made as follows. rCBF-A: regional cerebral blood flow in the anterior area of the hematoma. rCBF-L: regional cerebral blood flow in the lateral area of the hematoma. rCBF-P: regional cerebral blood flow in the posterior area of the hematoma. In both groups, age, neurological grading, CT classification and hematoma volume had no significance. In the conservative group, mCBF of the hematoma side in the subacute stage was 68 +/- 7%, and in the aspiration group it was 85 +/- 17%. This difference was statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)     

A ruptured aneurysm in the hypoplastic proximal anterior cerebral artery (A1 portion); case report

A case of ruptured aneurysm in the hypoplastic proximal anterior cerebral artery (A1 portion) is reported. This 25-years old man complained of the sudden onset of severe headache and vomiting on January 11, 1989. He was referred to our hospital on the same day, and CT scan revealed subarachnoid hemorrhage. Cerebral angiography on the next day revealed an aneurysm in the hypoplastic A1 portion of the right anterior cerebral artery, and no branch was present at the site of the aneurysmal neck. He was operated on using the right pterional approach. The A1 portion was trapped and the aneurysm was removed successfully. The histology of the aneurysm was that of the usual type of the saccular aneurysm. The post-operative course was uneventful. He was discharged with no neurological deficit two months after the operation. As far as we know, there has been no report on a ruptured aneurysm in the hypoplastic A1 portion. We also reviewed the 55 aneurysms in the A1 portion that have been reported in the literature.     

Simultaneous occurrence of subarachnoid hemorrhage and epistaxis due to ruptured petrous internal carotid artery aneurysm: association with transsphenoidal surgery and radiation therapy: case report

A 62-year-old woman presented with simultaneous subarachnoid hemorrhage (SAH) and massive epistaxis. The patient had been treated for pituitary prolactinoma by two transsphenoidal surgeries, gamma knife radiosurgery, and conventional radiation therapy since age 43 years. Cerebral angiography showed left petrous internal carotid artery (ICA) aneurysm with slight stenosis on the adjacent left petrous ICA. She underwent superficial temporal artery-middle cerebral artery (STA-MCA) double anastomosis with endovascular internal trapping without complication the day after onset. Postoperative course was uneventful; the patient did not develop symptomatic vasospasm, recurrent epistaxis, or cerebrospinal fluid rhinorrhea. Postoperative angiography demonstrated complete disappearance of the aneurysm with patent STA-MCA anastomosis. The patient was discharged 2 months after surgery without neurological deficit. The present case is extremely rare with simultaneous onset of SAH and epistaxis caused by ruptured petrous ICA aneurysm. The transsphenoidal surgeries and radiation therapies might have been critical in the formation of the petrous ICA aneurysm.