Ruptured Cerebral Aneurysm without Subarachnoid Hemorrhage: Who needs angiography?

Hue, Yun Hee; Chun, Hyoung Joon; Im, Tai Ho; Yi, Hyeong Joong; Ko, Yong; Kim, Jae Min

Abstract

OBJECTIVE
Ruptured intracranial aneurysms usually present as a subarachnoid hemorrhage (SAH), but are sometimes associated with intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), or subdural hematoma (SDH). However, the presentation of a ruptured aneurysm without a SAH is quite unusual. We describe nine such cases and highlight some easily overlooked, but important clinical features.
METHODS
Among 341 patients diagnosed with ruptured cerebral aneurysms during the past 4 years, 9 patients exhibited non-SAH bleeding on admission, as revealed by brain computed tomograms (CT). On these 9 patients, the characteristic features were reviewed using medical charts, emergency room notes, and radiographic findings.
RESULTS
The incidence of aneurysmal rupture without SAH was 2.6%. Eight patients exhibited ICH, and among them, an IVH occurred in one patient and a SDH in two patients. The initial clinical grade was grave in 8 patients, and a favorable outcome occurred in 4 patients. All of these aneurysms arose from the anterior circulation (the circle of Willis in two patients, and distal aneurysms in seven patients). The causes of the aneurysms were spontaneous in four patients, trauma in two patients, infective endocarditis in two patients, and moyamoya syndrome with a history of craniotomy and clipping in one patient. In three patients, additional intervention was required because the initial radiographic images did not reveal a ruptured aneurysm.
CONCLUSION
Ruptured aneurysms should be suspected in cases of unexplained intracranial bleeding, even if SAH is not present on the initial CT scan, because most patients exhibit a poor neurologic grade. Therefore, careful interpretation of the clinical and radiologic culprits and timely management should be provided to achieve total occlusion.