J Cerebrovasc Endovasc Neurosurg.  2016 Sep;18(3):253-257. 10.7461/jcen.2016.18.3.253.

Delayed Rebleeding of Cerebral Aneurysm Misdiagnosed as Traumatic Subarachnoid Hemorrhage

• Song SY
• Kim DW
• Park JT
• Kang SD

• KMID: 2355650
• DOI: http://doi.org/10.7461/jcen.2016.18.3.253

Abstract

An intracranial saccular aneurysm is uncommonly diagnosed in a patient with closed head trauma. We herein present a patient with delayed rebleeding of a cerebral aneurysm misdiagnosed as traumatic subarachnoid hemorrhage (SAH). A 26-year-old female visited our emergency department because of headache after a motorcycle accident. Brain computed tomography (CT) showed a right-side dominant SAH in Sylvian fissure. Although traumatic SAH was strongly suggested because of the history of head trauma, we performed a CT angiogram to exclude any vascular abnormalities. The CT angiogram showed no vascular abnormality. She was discharged after conservative treatment. One day after discharge, she returned to the emergency department because of mental deterioration. Brain CT showed diffuse SAH, which was dominant in the right Sylvian fissure. The CT angiogram revealed a right middle cerebral artery bifurcation aneurysm. During operation, a non-traumatic true saccular aneurysm was found. The patient recovered fully after successful clipping of the aneurysm and was discharged without neurologic deficit. Normal findings on a CT angiogram do not always exclude aneurysmal SAH. Follow-up vascular study should be considered in trauma patients who are highly suspicious of aneurysmal rupture.

Keyword

Cerebral aneurysm; Subarachnoid hemorrhage; Head trauma

MeSH Terms

Adult
Aneurysm
Brain
Craniocerebral Trauma
Emergency Service, Hospital
Female
Follow-Up Studies
Head Injuries, Closed
Headache
Humans
Intracranial Aneurysm*
Middle Cerebral Artery
Motorcycles
Neurologic Manifestations
Rupture
Subarachnoid Hemorrhage
Subarachnoid Hemorrhage, Traumatic*

Figure

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  Fig. 1 Brain CT on initial admission shows focal SAH in the right Sylvian fissure. CT = computed tomography; SAH = subarachnoid hemorrhage.

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  Fig. 2 Bone window setting view: skull fracture and scalp swelling found at frontal area.

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  Fig. 3 CT angiogram on admission reveals no abnormal vascular lesion. CT = computed tomography.

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  Fig. 4 Brain CT on readmission demonstrates SAH which dominant in the right Sylvian fissure. CT = computed tomography; SAH = subarachnoid hemorrhage.

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  Fig. 5 CT angiogram on readmission shows a 4 × 4 mm right MCA bifurcation aneurysm (white arrow). CT = computed tomography; MCA = middle cerebral artery.

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  Fig. 6 Intraoperative photographs. (A) Aneurysm with narrow neck (star) located at right MCA bifurcation. Arrow: frontal branch of MCA, Open arrow: temporal branch of MCA. (B) After aneurysmal clipping, transcranial Doppler reflected violation of the MCA by the clip. (C) Another clip was applied above the first clip. (D) Frontal and temporal branch of MCA are patent after removal of the first clip. MCA = middle cerebral artery.

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