Neurointervention.  2024 Jul;19(2):118-122. 10.5469/neuroint.2024.00185.

Vessel Wall Imaging in Angiogram-Negative Diffuse Subarachnoid Hemorrhage Reveals a Ruptured Lenticulostriate Aneurysm

• Phi HQ
• Alkhatib SG
• Raymond SB
• Choudhri OA
• Song JW

• KMID: 2556664
• DOI: http://doi.org/10.5469/neuroint.2024.00185

Abstract

A patient presented with acute onset headache and subsequent unconsciousness. The neurologic exam showed left-sided myoclonic jerking and right flaccid hemiparalysis. Noncontrast computed tomography revealed diffuse subarachnoid hemorrhage (SAH) with acute hydrocephalus. Initial digital subtraction angiography (DSA) showed no culprit source for SAH. Repeat DSA on day 7 after initial presentation raised suspicion for left internal carotid artery ophthalmic segment and left lateral lenticulostriate artery (LSA) aneurysms. A magnetic resonance vessel wall imaging (VWI) exam was performed given the presence of multiple potential culprit aneurysms. Vessel wall enhancement around the dome of the left LSA aneurysm suggested rupture, which then facilitated treatment with surgical clipping. LSA aneurysms are exceedingly rare and challenging to treat. Given the associated high degree of morbidity, expedient diagnosis is critical to direct management. VWI could be a valuable tool for detecting ruptured aneurysms in the setting of angiogram-negative SAH.

Keyword

Magnetic resonance imaging; Circle of Willis; Aneurysm; Basal ganglia cerebrovascular disease; Subarachnoid hemorrhage; Cerebrovascular imaging

Figure

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  Fig. 1. (A) Unenhanced head computed tomography (CT) shows diffuse subarachnoid hemorrhage (SAH) in the basal cisterns, Sylvian fissures and sulci, and acute hydrocephalus with enlargement of the ventricles. (B) Sagittal, (C) axial, and (D) coronal views of the initial computed tomography angiography (CTA) show no saccular aneurysm or sources for SAH. (E) Lateral views of repeat digital subtraction angiography (DSA) on day 7 showing an aneurysm (arrowhead) of the left lenticulostriate artery (LSA). (F) Three-dimensional (3D) volume rendering of the left LSA aneurysm (arrowhead). (G) Lateral view of repeat DSA on day 7 visualizing aneurysm of the ophthalmic segment of the left internal carotid artery (ICA) (arrowhead). (H) 3D volume rendering of the left ICA ophthalmic segment aneurysm (arrowhead). (I) Pre-contrast T1-weighted vessel wall imaging (VWI) showing focal irregularity at the origin of the left LSA (arrowhead). Inset shows the time-of-flight magnetic resonance angiography (TOF MRA) of the left LSA (arrowhead). (J) Post-contrast T1-weighted VWI shows a rim of enhancement around the LSA aneurysm dome (arrowhead), suggesting rupture. (K) Pre-contrast T1-weighted VWI showing aneurysm at the left ICA ophthalmic segment (arrowhead). Inset shows the TOF MRA of the left ICA ophthalmic segment (arrowhead). (L) Post-contrast T1-weighted VWI of the left ICA ophthalmic segment aneurysm reveals no wall enhancement (arrowhead).

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