• History and Examination:

    • A woman in her 60s presents with the worst headache of her life.

    • Smoker, but no other medical history.

    • Awake, alert, fluent, and neurologically intact.

     

    Figure 1 Noncontrast Head CT

    Figure 2 Right Common Carotid Artery DSA

    Figure 3 Left Common Carotid Artery DSA

    1. Which cerebral aneurysm most likely ruptured?

    2. How would you manage this patient?

    3. If the patient develops cerebral vasospasm later in her hospitalization, would you treat her with induced hypertension ("Triple-H")?

    4. Which of the following describes you?

    5. I practice in one of the following locations.

    6. Comments
     
    • Good case
    • Both aneurysm should be dealt with simultanously.
    • I would treat firt the suspect rupture anerism. That seem to me a2 . If you do it as craniotomy i would cnoice interhemispheric approach. And few month later clip the acomp aneurism. But if there isendovascular treatment available. Iwould choice to treat allof them.
       Im mycountry is notpossible in all cente to do endovascular procedure. I would ask all of you what would you do if there is no endovascular ?
    • Interesting case
    • Angiogram DSA although shows multiple bulges, a 3D reconstruction and a neuro-radiology opinion to rule out multiple aneurysm would have been my priority, before touching this well preserved patient.
    • There is one more possibility to treat surgical both aneurysms.
       Bifrontal craniotomy 1-Go Interhemisferic to clip the A2-A3 ruptured aneurysm, and 2- to open left silvian fissure to clip the left M1 aneurysm.
       After, proceed with the haemodinamic control for the cerebral vasospasm.
       ( the triple H is an old concept)

       Prof. Dr. Leonidas M. Quintana M.D. FAANS.
       Valparaíso University -Chile

    • I am not a student or Neurologist, just a Chiari patient that studies my disorder.

    • I might consider clipping of the biggest aneusysm in the case endovascular treatment is less indicated to the aneurusm geometry (the quality of the pictures does not allow me definitive conclusions about this issue)

     

     

     

    References:

    Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment.

    Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O'Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC; International Study of Unruptured Intracranial Aneurysms Investigators.

    Lancet. 2003 Jul 12;362(9378):103-10.

    Bottleneck factor and height-width ratio: association with ruptured aneurysms in patients with multiple cerebral aneurysms.

    Hoh BL, Sistrom CL, Firment CS, Fautheree GL, Velat GJ, Whiting JH, Reavey-Cantwell JF, Lewis SB.

    Neurosurgery. 2007 Oct;61(4):716-22; discussion 722-3.

    PMID: 17986932

     

    International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion.

    Molyneux AJ, Kerr RS, Yu LM, Clarke M, Sneade M, Yarnold JA, Sandercock P; International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group.

    Lancet. 2005 Sep 3-9;366(9488):809-17.

    The Barrow Ruptured Aneurysm Trial.

    McDougall CG, Spetzler RF, Zabramski JM, Partovi S, Hills NK, Nakaji P, Albuquerque FC.

    J Neurosurg. 2012 Jan;116(1):135-44. doi: 10.3171/2011.8.JNS101767. Epub 2011 Nov 4.

    PMID: 22054213

    The Barrow Ruptured Aneurysm Trial: 3-year results.

    Spetzler RF, McDougall CG, Albuquerque FC, Zabramski JM, Hills NK, Partovi S, Nakaji P, Wallace RC.

    J Neurosurg. 2013 Jul;119(1):146-57. doi: 10.3171/2013.3.JNS12683. Epub 2013 Apr 26. Erratum in: J Neurosurg. 2014 Feb;120(2):581.

    PMID: 23621600

    The Barrow Ruptured Aneurysm Trial: 6-year results.

    Spetzler RF, McDougall CG, Zabramski JM, Albuquerque FC, Hills NK, Russin JJ, Partovi S, Nakaji P, Wallace RC.

    J Neurosurg. 2015 Sep;123(3):609-17. doi: 10.3171/2014.9.JNS141749. Epub 2015 Jun 26.

    PMID: 26115467

    Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association.

    Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology.

    Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3.

    PMID: 22556195

    The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms.

    Reynolds MR, Buckley RT, Indrakanti SS, Turkmani AH, Oh G, Crobeddu E, Fargen KM, El Ahmadieh TY, Naidech AM, Amin-Hanjani S, Lanzino G, Hoh BL, Bendok BR, Zipfel GJ.

    J Neurosurg. 2015 Oct;123(4):862-71. doi: 10.3171/2014.12.JNS141201. Epub 2015 Jul 24.

    PMID: 26207606

    Risk of hemorrhage from unsecured, unruptured aneurysms during and after hypertensive hypervolemic therapy.

    Hoh BL, Carter BS, Ogilvy CS.

    Neurosurgery. 2002 Jun;50(6):1207-11; discussion 1211-2.

    PMID: 12015837

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