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A misleading distal anterior cerebral artery aneurysm.

Weil AG, McLaughlin N, Lessard-Bonaventure P, Bojanowski MW - Surg Neurol Int (2010)

Bottom Line: Following the procedure, the patient's neurological and functional status gradually improved.Quantity and distribution of isolated aSDH can be misleading and is not always a reliable predictor of aneurysm location.Misinterpretation of the aneurysm as an incidental finding would lead to improper management with potentially serious consequences.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Neurosurgery, Department of Surgery, Notre Dame Hospital, University of Montreal Hospital Centre, Montreal, Quebec, Canada.

ABSTRACT

Background: Aneurysmal rupture causing pure acute subdural hematoma (aSDH) is rare. In the four previously reported cases of distal anterior cerebral artery (ACA) aneurysm resulting in pure aSDH, blood distribution in the interhemispheric (IH) space has systematically incriminated the distal ACA as the source of rupture. We present a misleading case of a distal ACA rupture resulting in convexity aSDH with minimal IH blood.

Case description: A 51-year-old patient presented in coma with decerebrate posturing and a blown left pupil from a left convexity acute hemispheric subdural hematoma. She underwent urgent left craniectomy and subdural hematoma evacuation. Given the absence of identifiable etiology, including trauma, we performed an immediate postoperative Computed tomography-angiography (CTA) in order to rule out an underlying cause. The CTA revealed an aneurysm originating from the callosomarginal artery branch of the ACA. Although the minimal amount of IH blood and the remote distance of convexity blood from the aneurysm suggested that it may be a fortuitous finding, we considered the possibility that the two might be related. The patient underwent surgical aneurysm clipping, confirming that it had ruptured and allowing complete aneurysm obliteration. Following the procedure, the patient's neurological and functional status gradually improved.

Conclusion: Ruptured distal ACA aneurysms may present with convexity isolated aSDH with minimal IH blood. Quantity and distribution of isolated aSDH can be misleading and is not always a reliable predictor of aneurysm location. Misinterpretation of the aneurysm as an incidental finding would lead to improper management with potentially serious consequences.

No MeSH data available.


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a) CT scan following aneurysm clipping through a frontal transcallosal approach; b) conventional cerebral angiogram through the left internal carotid artery shows complete aneurysm obliteration with preservation of the parent artery
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Figure 0004: a) CT scan following aneurysm clipping through a frontal transcallosal approach; b) conventional cerebral angiogram through the left internal carotid artery shows complete aneurysm obliteration with preservation of the parent artery

Mentions: A 51-year-old female patient with no previous past medical history presented with acute headache followed by rapid deterioration of her level of consciousness to coma with decerebrate posturing and a blown left pupil. There was no history of trauma or coagulopathy. Computed tomography (CT) showed a left convexity acute hemispheric subdural hematoma without intraparenchymal or intraventricular hemorrhage. There was doubtful subarachnoid hemorrhage [Figure 1]. She underwent an urgent left craniectomy, subdural hematoma drainage and insertion of an intracranial pressure (ICP) monitor. Given the absence of etiology, including trauma, we performed an immediate postoperative CT-angiography (CTA) in order to rule out an underlying cause. This study revealed an aneurysm of the callosomarginal artery branch of the ACA [Figure 2]. Although we could have interpreted this aneurysm as being fortuitous because of the minimal amount of IH blood combined with its remote distance from the convexity subdural hematoma, we considered the possibility that the two might be related. The patient underwent surgical aneurysm clipping through a frontal IH approach, confirming that it had ruptured [Figure 3] and allowing complete aneurysm obliteration [Figure 4]. Following the procedure, the patient’s neurological and functional status gradually improved.


A misleading distal anterior cerebral artery aneurysm.

Weil AG, McLaughlin N, Lessard-Bonaventure P, Bojanowski MW - Surg Neurol Int (2010)

a) CT scan following aneurysm clipping through a frontal transcallosal approach; b) conventional cerebral angiogram through the left internal carotid artery shows complete aneurysm obliteration with preservation of the parent artery
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2958328&req=5

Figure 0004: a) CT scan following aneurysm clipping through a frontal transcallosal approach; b) conventional cerebral angiogram through the left internal carotid artery shows complete aneurysm obliteration with preservation of the parent artery
Mentions: A 51-year-old female patient with no previous past medical history presented with acute headache followed by rapid deterioration of her level of consciousness to coma with decerebrate posturing and a blown left pupil. There was no history of trauma or coagulopathy. Computed tomography (CT) showed a left convexity acute hemispheric subdural hematoma without intraparenchymal or intraventricular hemorrhage. There was doubtful subarachnoid hemorrhage [Figure 1]. She underwent an urgent left craniectomy, subdural hematoma drainage and insertion of an intracranial pressure (ICP) monitor. Given the absence of etiology, including trauma, we performed an immediate postoperative CT-angiography (CTA) in order to rule out an underlying cause. This study revealed an aneurysm of the callosomarginal artery branch of the ACA [Figure 2]. Although we could have interpreted this aneurysm as being fortuitous because of the minimal amount of IH blood combined with its remote distance from the convexity subdural hematoma, we considered the possibility that the two might be related. The patient underwent surgical aneurysm clipping through a frontal IH approach, confirming that it had ruptured [Figure 3] and allowing complete aneurysm obliteration [Figure 4]. Following the procedure, the patient’s neurological and functional status gradually improved.

Bottom Line: Following the procedure, the patient's neurological and functional status gradually improved.Quantity and distribution of isolated aSDH can be misleading and is not always a reliable predictor of aneurysm location.Misinterpretation of the aneurysm as an incidental finding would lead to improper management with potentially serious consequences.

View Article: PubMed Central - HTML - PubMed

Affiliation: Division of Neurosurgery, Department of Surgery, Notre Dame Hospital, University of Montreal Hospital Centre, Montreal, Quebec, Canada.

ABSTRACT

Background: Aneurysmal rupture causing pure acute subdural hematoma (aSDH) is rare. In the four previously reported cases of distal anterior cerebral artery (ACA) aneurysm resulting in pure aSDH, blood distribution in the interhemispheric (IH) space has systematically incriminated the distal ACA as the source of rupture. We present a misleading case of a distal ACA rupture resulting in convexity aSDH with minimal IH blood.

Case description: A 51-year-old patient presented in coma with decerebrate posturing and a blown left pupil from a left convexity acute hemispheric subdural hematoma. She underwent urgent left craniectomy and subdural hematoma evacuation. Given the absence of identifiable etiology, including trauma, we performed an immediate postoperative Computed tomography-angiography (CTA) in order to rule out an underlying cause. The CTA revealed an aneurysm originating from the callosomarginal artery branch of the ACA. Although the minimal amount of IH blood and the remote distance of convexity blood from the aneurysm suggested that it may be a fortuitous finding, we considered the possibility that the two might be related. The patient underwent surgical aneurysm clipping, confirming that it had ruptured and allowing complete aneurysm obliteration. Following the procedure, the patient's neurological and functional status gradually improved.

Conclusion: Ruptured distal ACA aneurysms may present with convexity isolated aSDH with minimal IH blood. Quantity and distribution of isolated aSDH can be misleading and is not always a reliable predictor of aneurysm location. Misinterpretation of the aneurysm as an incidental finding would lead to improper management with potentially serious consequences.

No MeSH data available.


Related in: MedlinePlus