PMC6057701_01
(a) Presenting computed tomography head demonstrating diffuse subarachnoid hemorrhage eccentric to the left with hydrocephalus. (b) Preoperative anteroposterior angiogram demonstrating seemingly normal vasculature. (c) Magnified left anterior oblique view angiogram demonstrating small mid A1 blister aneurysm
BC-4-19-g001.jpg
PMC6057701_01_BC-4-19-g001.jpg
F1
She was found to have Fisher Grade 3 SAH and acute hydrocephalus on computed tomography (CT) [Figure 1a]. Digital subtraction angiography (DSA) revealed very small left mid A 1 1.5 mm x 1.3 mm aneurysm [Figure 1c].
(a) Intraoperative image demonstrating the left internal carotid artery and proximal A1 segment. The hemorrhagic adventitia of the A1 is visible; the blister aneurysm is within the clot on the posterior side of the vessel. During dissection in this area, intraoperative rupture occurred. (b) Intraoperative image with stacked mini permanent clips across the diseased A1 segment. Lateral (c) and anteriorposterior (d) right internatl carotid artery intraoperative runs demonstrating good bilateral flow through anterior cerebral artery territories from R A1, and no residual aneurysm or left A1 filling on left internal carotid artery run (white arrow)
BC-4-19-g002.jpg
PMC6057701_01_BC-4-19-g002.jpg
F2
The left optic nerve and ICA [Figure 2a white triangle] were identified as well as the M1, anterior choroidal artery, and proximal left A1 disappearing into clot [Figure 2a white arrow]. At this point, another area in the vessel distal to the previous bleeding was found to be ruptured. As the whole A1 was likely dysplastic, the A1 was sacrificed with sequential stacking of clips up to the A1/anterior communicating artery (AComm) junction [Figure 2b]. Intraoperative angiography revealed bilateral filling of the ACA territory from the right A1/AComm as well as no angiographic filling of the left A1 or blister aneurysm [Figure 2d].