Neurointervention.  2021 Jul;16(2):180-184. 10.5469/neuroint.2021.00017.

Unrecognized Ruptured Intracranial Aneurysm Presenting as Cerebral Vasospasm-Induced Ischemic Stroke: A Case Report

• Kim JG
• Kang CH
• Choi JC
• Rhim JK

• KMID: 2517745
• DOI: http://doi.org/10.5469/neuroint.2021.00017

Abstract

A 44-year-old woman presented with acute confusion, apparently due to a clinically silent subarachnoid hemorrhage followed by vasospasm, which in turn led to an ischemic stroke. During the initial evaluation, an acute ischemic stroke in the left middle cerebral artery territory was observed. Magnetic resonance imaging revealed a late subacute hemorrhage in the left basal cistern. Digital subtraction angiography indicated the presence of a small saccular aneurysm that had recently ruptured, as well as vasospasm in the left circle of Willis. Balloon angioplasty and balloon-assisted coil embolization were performed for the vasospasm and saccular aneurysm, respectively. This case demonstrates that clinically silent subarachnoid hemorrhages resulting in ipsilateral vasospasm and infarction can occur as complications of a ruptured aneurysm.

Keyword

Cerebral aneurysm; Stroke; Angioplasty; Intracranial vasospasm; Magnetic resonance imaging

Figure

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  Fig. 1. (A) There is a subtle high density within the basal cistern—just lateral to the medial temporal lobe (white arrowhead). There is minimal, if any localized edema within the region of hemorrhage. No further evidence of blood spread out from the basal cistern. (B) High signal intensity on diffusion-weighted images indicated an acute ischemic stroke in the left middle cerebral artery territory (white arrowheads). (C) Three-dimensional time-of-flight magnetic resonance angiography revealed stenosis of the middle cerebral artery (white arrowhead). (D) Axial T1 weighted imaging shows conspicuous bright lesions, including the neighboring area of the left basal cistern (white arrowheads). (E) T2-weighted imaging shows high signal intensity in the left basal cistern, implying a late subacute hemorrhage (white arrowheads). (F) Subarachnoid hemorrhage was detected on the gradient echo T2 image as an area of low signal (white arrowheads). (G) The digital subtraction angiography revealed severe stenosis (white arrowhead), indicating vasospasm of the left middle cerebral artery. (H) Lateral angiography confirmed the presence of a left posterior communicating artery aneurysm (white arrowhead) along with parent artery narrowing. (I) The saccular aneurysm was treated using a balloon-assisted coil embolization technique (white arrowhead).

Reference

1. Heros RC. Intracranial aneurysms. A review. Minn Med. 1990; 73:27–32.

2. Kowalski RG, Claassen J, Kreiter KT, Bates JE, Ostapkovich ND, Connolly ES, et al. Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA. 2004; 291:866–869.

3. Leblanc R. The minor leak preceding subarachnoid hemorrhage. J Neurosurg. 1987; 66:35–39.

4. Oda S, Shimoda M, Hirayama A, Imai M, Komatsu F, Shigematsu H, et al. Neuroradiologic diagnosis of minor leak prior to major SAH: diagnosis by T1-FLAIR mismatch. AJNR Am J Neuroradiol. 2015; 36:1616–1622.

5. Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the cooperative aneurysm study. Neurosurgery. 1983; 13:479–481.

6. de Oliveira Manoel AL, Mansur A, Murphy A, Turkel-Parrella D, Macdonald M, Macdonald RL, et al. Aneurysmal subarachnoid haemorrhage from a neuroimaging perspective. Crit Care. 2014; 18:557.

7. Davis KR, Kistler JP, Heros RC, Davis JM. A neuroradiologic approach to the patient with a diagnosis of subarachnoid hemorrhage. Radiol Clin North Am. 1982; 20:87–94.

8. Nussbaum ES, Sebring LA, Wen DY. Intracranial aneurysm rupture presenting as delayed stroke secondary to cerebral vasospasm. Stroke. 1997; 28:2078–2080.

9. Adams HP Jr, Jergenson DD, Kassell NF, Sahs AL. Pitfalls in the recognition of subarachnoid hemorrhage. JAMA. 1980; 244:794–796.

10. Bauer AM, Rasmussen PA. Treatment of intracranial vasospasm following subarachnoid hemorrhage. Front Neurol. 2014; 5:72.

11. Wiesmann M, Brückmann H. [Magnetic resonance imaging of subarachnoid hemorrhage]. Rofo. 2004; 176:500–505. German.

12. Li MH, Li YD, Gu BX, Cheng YS, Wang W, Tan HQ, et al. Accurate diagnosis of small cerebral aneurysms ≤5 mm in diameter with 3.0-T MR angiography. Radiology. 2014; 271:553–560.

13. Nishikawa H, Shimizu S, Nakajima H, Kitano Y, Sano T, Mouri G, et al. Characteristics of blood blister-like aneurysms with a saccular-shape appearance. World Neurosurg. 2017; 108:595–602.