J Cerebrovasc Endovasc Neurosurg.  2015 Sep;17(3):234-238. 10.7461/jcen.2015.17.3.234.

Huge Intramural Hematoma in a Thrombosed Middle Cerebral Artery Aneurysm: A Case Report

• Kim HJ
• Lee SW
• Lee TH
• Kim YS

• KMID: 2069249
• DOI: http://doi.org/10.7461/jcen.2015.17.3.234

Abstract

We describe a case of a huge intramural hematoma in a thrombosed middle cerebral artery aneurysm. A 47-year-old female patient with liver cirrhosis and thrombocytopenia presented to the neurosurgical unit with a 5-day history of headache and cognitive dysfunction. Magnetic resonance imaging and computed tomography of the brain showed a thrombosed aneurysm located in the right middle cerebral artery with a posteriorly located huge intramural hematoma mimicking an intracerebral hematoma. Imaging studies and cerebrospinal fluid analysis showed no evidence of subarachnoid hemorrhage. Angiography showed a partially thrombosed aneurysm at the origin of the right anterior temporal artery and an incidental aneurysm at the bifurcation of the right middle cerebral artery. Both aneurysms were embolized by coiling. After embolization, the thrombosed aneurysmal sac and intramural hematoma had decreased in size 4 days later and almost completely disappeared 8 months later. This is the first reported case of a nondissecting, nonfusiform aneurysm with a huge intramural hematoma, unlike that of a dissecting aneurysm.

Keyword

Hematoma; Cerebral aneurysm; Therapeutic embolization; Dissection; Middle cerebral artery

MeSH Terms

Aneurysm
Aneurysm, Dissecting
Angiography
Brain
Cerebrospinal Fluid
Embolization, Therapeutic
Female
Headache
Hematoma*
Humans
Intracranial Aneurysm*
Liver Cirrhosis
Magnetic Resonance Imaging
Middle Aged
Middle Cerebral Artery*
Subarachnoid Hemorrhage
Temporal Arteries
Thrombocytopenia

Figure

• 

  Fig. 1 Initial T1-weighted axial image shows the target-like thrombosed aneurysm in the right anterior sylvian fissure (B). Another ovoid high signal intensity suggests hematoma surrounded by the posterior aspect of the aneurysm. T2-weighted axial image also shows the thrombosed aneurysm and posteriorly located hematoma with a surrounding dark line (A). The posteriorly located hematoma differs in signal intensity from the thrombosed aneurysm on T1- and T2-weighted images, i.e., the posterior hematoma shows homogeneous high signal intensity, whereas the thrombosed portion of the aneurysm shows intermediate and inhomogeneous high signal intensity on T1- and T2-weighted images (A, B). Gd-enhanced axial image shows no definite enhancement of the lesions (C). After one year, MR of the brain shows almost resorption state of the hematoma in the right temporal lobe.(D-F).

• 

  Fig. 2 Digital subtraction angiography was performed and two unruptured aneurysms were found in the right middle cerebral artery. (A, B) Surgical intervention was not performed due to continued thrombocytopenia. Instead, coil embolization followed immediately. After embolization of two aneurysms, follow-up angiography shows faint staining of the contrast

• 

  Fig. 3 On precontrast CT scan (A), the thrombosed aneurysm shows a high attenuating wall. The posteriorly located hematoma abuts the aneurysm sac. The hematoma also differs from the high attenuating aneurysm wall in density. Follow-up brain CT was performed immediately after coil embolization. Capsular enhancement is seen not only in the aneurysm sac but also in the posterior hematoma (B). (C-E) and F are CT images of the brain at POD 4 days, 11 days, 1 month, and 5 months. The aneurysm sac and hematoma had decreased in size 4 days after coil embolization (C-E) and almost disappeared 4 months later (F).

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