Delayed rupture of pre-existing cerebral aneurysm in a young patient with minor head trauma

Ruptured intracranial aneurysm presenting as cerebral circulation insufficiency: A case report

BACKGROUND

Rupture of an intracranial aneurysm is a type of acute stroke that is a serious threat to human health. Misdiagnosis of ruptured intracranial aneurysms is a serious clinical event that may have disastrous consequences in some patients. To date, ruptured intracranial aneurysms have been misdiagnosed as meningitis, tumors, stroke, or trauma, among other conditions. Here, we report what appears to be the first case of a ruptured intracranial aneurysm that presented as cerebral circulation insufficiency.

CASE SUMMARY

A middle-aged man was admitted to our hospital because of a parasellar lesion identified on a noncontrast computed tomography (CT) image after a mild traffic accident that was caused by a brief loss of consciousness. Notably, he was diagnosed with cerebral circulation insufficiency after two unexplained episodes of a transient loss of consciousness within the past 8 mo. The patient was diagnosed with right internal carotid artery aneurysm based on CT angiography and completely recovered after a craniotomy at our hospital. A few clots and severe adhesions around the aneurysm were observed in the subarachnoid space during the operation, suggesting that the aneurysm had ruptured and may had been misdiagnosed as cerebral circulation insufficiency.

CONCLUSION

Ruptured intracranial aneurysms may show negative imaging results and present as cerebral circulation insufficiency, which should be recognized as soon as possible to ensure timely management.

Surgical treatment of traumatic distal anterior cerebral artery aneurysm: a report of nine cases from a single centre

BACKGROUND

Traumatic distal anterior cerebral artery (dACA) aneurysm is rare and can be easily neglected and misdiagnosed in patients with trauma. The aim of this study was to explore the radiologic characteristics of and therapeutic strategies for traumatic dACA aneurysm and to improve our understanding of unusual complications after trauma.

METHODS

The clinical data of nine cases of traumatic dACA aneurysm from our neurosurgical department from July 1, 2010, to July 1, 2018, were retrospectively analysed.

RESULTS

All 9 patients had a history of brain trauma. The initial computed tomography scan immediately after trauma showed subarachnoid haemorrhage in 8 cases. Among these cases, delayed intracranial haemorrhage occurred in 7 cases. The average interval between injury and diagnosis was 13.67 ± 9.43 days. All 9 cases were confirmed as traumatic dACA aneurysm by computed tomography angiography (CTA) and/or digital subtraction angiography. According to Lehecka's classification system, traumatic dACA aneurysm located in the A3 and A4 segment was found in 3 and 6 cases, respectively. Surgical treatment was performed in 8 cases, including neck clipping, with or without wrapping in 3 cases, trapping in 4 cases, aneurysm excision and suturing in 1 case and conservative treatment in 1 case. Three patients required a ventriculoperitoneal shunt due to severe hydrocephalus. According to the Glasgow Outcome Scale scoring system, good recovery was achieved in 4 cases, moderate disability in 2 cases, severe disability in 1 case, and death in 2 cases.

CONCLUSION

Traumatic dACA aneurysm is a rare complication of brain trauma. Delayed intracranial haemorrhage and the sudden deterioration of neurologic function were the typical characteristics in patients with traumatic dACA aneurysm. CTA is the first-line screening modality for patients who present with intracerebral haemorrhage in the corpus callosum after trauma, particularly for patients who are older, in a poorer or critical condition. When the aneurysm is located in the A4 segment or involves a small branch, surgical trapping is the preferred definitive therapy to prevent further growth and disastrous bleeding. Early diagnosis and prompt treatment could help to improve clinical outcomes.

Delayed Rebleeding of Cerebral Aneurysm Misdiagnosed as Traumatic Subarachnoid Hemorrhage

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.

Surgical repair of lacerated anterior cerebral artery presented with massive intracerebral hemorrhage

OBJECTIVE AND IMPORTANCE

Traumatic intracranial aneurysms present diagnostic and therapeutic challenges. Owing to their fragile nature, endovascular intervention has become the first-line treatment; however, direct surgery has an advantage in certain cases.

CLINICAL PRESENTATION

A 34-year-old man in coma was admitted after a motor vehicle accident. Brain computed tomographic scans revealed deep bifrontal, left intraventricular, and subarachnoid hemorrhages. Three-dimensional computed tomographic angiography and digital subtraction angiography revealed an aneurysm arising from the left pericallosal artery.

INTERVENTION

A massive intracerebral hematoma prompted us to perform emergency surgical intervention. We immediately removed the hematoma and extirpated the aneurysm. After hematoma evacuation via the interhemispheric approach, a pulsating red sphere projecting from the pericallosal artery, with no obvious solid wall or neck, was encountered. While retracting the frontal lobe, it suddenly ruptured. Under temporary trapping of the parent artery, the point of bleeding was identified. No aneurysm wall or fibrous tissue was present, whereas a 1.5-mm laceration was observed at the pericallosal artery close to its branching point. The laceration was sutured with 10-0 nylon. Postoperative digital subtraction angiography confirmed patency of the pericallosal artery.

CONCLUSIONS

Although recent technologic advances of intravascular surgery have enabled successful treatment of traumatic pseudoaneurysms, open surgical intervention still has some advantages of providing definitive hemostasis, allowing for parent artery reconstruction, and facilitating mass reduction. The case in the current study was quite unusual in that angiographic aneurysm had disrupted easily, leaving arterial laceration. This finding implies the probability of unavoidable parent artery occlusion when endovascular treatment is applied.