ARC Journal of Radiology and Medical Imaging

AUTHOR DETAILS

Culleton S^a, KokHK^a,*, Looby S^a, Brennan P^a, O’Hare A^a, Javadpour M^b, Thornton J^a, Asadi H ^a,c

a Neurointerventional and Interventional Radiology Service,Department of Radiology, Beaumont Hospital, Dublin 9, Ireland.
b Department of Neurosurgery, Beaumont Hospital, Dublin 9, Ireland.
c School of Medicine, Faculty of Health, Deakin University, Pigdons Road,Waurn Ponds, VIC 3216, Australia.
*[email protected]

INTRODUCTION

The successful management of a ruptured intracranial aneurysm requires exclusion of the aneurysm from the intracranial circulation, thereby preventing future risk of haemorrhage. Endovascular tech-niques are associated with lower morbidity and mortality compared with open surgery [1]. Despite many advances in the management of ruptured aneurysms and endovascular treatments, there still re-mains significant morbidity and mortality as a consequence of an acute subarachnoid haemorrhage, and cases can vary in complexity depending on the size, number and location of aneurysms.

This case highlights how the management of multiple intracranial aneurysms can pose challenges to the clinician and interventionist. Not only did the acutely ruptured aneurysm require immediate coil-ing but for each remaining aneurysm, a specific treatment plan had to be defined, requiring a combi-nation of endovascular and open neurosurgical techniques.

CASE REPORT

A 58 year-old right-handed woman presented with a one-day history of acute onset severe frontal headache and confusion. She had no prior medical or surgical history. Her Glasgow Coma Scale was 14 at arrival to the Emergency Department and she had no focal neurologic deficit on clinical exami-nation.

Non-contrast computed tomography (CT) scan of the brain at presentation showed acute subarachnoid haemorrhage in the interhemispheric fissure and a left frontal lobe intraparenchymalhaematoma with extension into the ventricular system (Figure 1) consistent with a Fisher grade 4 subarachnoid hae-morrhage.

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Figure1. CT brain shows subarachnoid along the interhemispheric fissure (white arrow) with extension into the third and left lateral ventricle.

A catheter cerebral angiogram was subsequently performed under general anaesthesia to assess and treat the suspected ruptured aneurysm, showing an irregularly lobulated anterior communicating ar-tery (ACOM) aneurysm (Figure 2), concordant with the pattern of haemorrhage on CT, accounting for the acute presentation. However, it also revealed 9 further intracranial aneurysms throughout the cir-cle of Willis (Figure 2).

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Figure2. Right and left ICA as well as left vertebral catheter angiograms (A, B & C respectively) demonstrating multiple intracranial aneurysms, including the multiloculated ruptured anterior communicating artery aneu-rysm:

1 & 9 – MCA bifurcation, 2 & 8 – Anterior temporal, 3 – PCOM, 4 – ACOM, 5 – Pericallosal, 6 – Supraoph-thalmic, 7 – Transitional, 10 – Basilar.

MANAGEMENT STRATEGY

The ACOM aneurysm was treated successfully by endovascular coiling (Figure 3). She recovered well from the acute episode with no post-procedural complications or neurological deficit. The basilar tip aneurysm was also coil embolised during the recovery period in hospital (Figure 3). The treatment decision regarding the remaining 8 aneurysms is challenging and a combination of en-dovascular and neurosurgical techniques will be required.

The two right middle cerebral artery (MCA) and two paraclinoid internal carotid artery (ICA) aneu-rysms are likely amenable to balloon assisted coil embolisation. Next, the two left MCA aneurysms demonstrate wide necks and will be treated with surgical clipping, and finally with full antiplatelet premedication on board, the two remaining left sided transitional and paraclinoid wide neck ICA aneurysms are to be stented for flow diversion.

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Figure3. Cerebral angiogram showing the ruptured anterior communicating artery aneurysm, successfully se-cured (A), and balloon assisted (B) coiling of the basilar aneurysm (C).

DISCUSSION

Cerebral aneurysms and subarachnoid haemorrhage have a complex clinical course. The majority of aneurysms have an annual rupture risk of less than 1% [2,3]. However, rupture carries a high mortali-ty rate of approximately 40% [4,5]. Multiple intracranial aneurysms have been shown to have a worse outcome compared to single aneurysms after subarachnoid haemorrhage [6,7], and up to 20-34% of patients may have multiple intracranial aneurysms [6,8].

Endovascular intervention is now considered first line treatment for intracranial aneurysms. The In-ternational Subarachnoid Aneurysm Trial demonstrated that endovascular coiling was associated with lower mortality and morbidity rates compared to open neurosurgical clipping [1]. Advances in both equipment and techniques have made endovascular treatment of even dissecting and wide neck aneu-rysms possible [9,10]. Such advances include three dimensional coils, micro-stents and balloons, flow diverting stents and the introduction of balloon and stent assisted coiling [9,10]. Almost the entire spectrum of these advanced endovascular techniques will be used in managing the various aneurysms encountered in this case.

This case highlights the need for a meticulous, multidisciplinary management strategy for each aneu-rysm, taking into consideration the urgency of treatment and suitability to different therapeutic tech-niques. Although not unreported, multiple aneurysms of this number in a signal individual is very rare and a combined endovascular and surgical approach is often required in a timely fashion for treatment.