PMC6193347_01
Imaging study upon patient's arrival at the hospital in 2012. (a) CT head without contrast showing diffuse subarachnoid hemorrhage that originated from an aneurysm identified by (b) Cerebral angiogram. (c) Cerebral angiogram imaging after coiling of an aneurysm.
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CT demonstrated left frontal intraparenchymal hemorrhage (IPH) measuring 1.2 x 2.6 cm with bilateral frontal and Sylvian fissure subarachnoid hemorrhage (Figure 1(a)) with hemorrhagic extension into the fourth ventricle; Fisher grade: IV. CT-A demonstrated a left distal anterior cerebral artery aneurysm measuring 3.7 x 3.4 mm pointing in a superior-medial direction. After coiling the ruptured aneurysm, postcoiling images were also obtained (Figure 1(c)).
Imaging upon hospitalization in 2016. (a) CT head without contrast in 2016 showing intracerebral hemorrhage adjacent to the previously coiled aneurysm. (b and c) Cerebral angiogram of the anterior and posterior circulations showing the development of multiple new aneurysms.
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The patient was assessed as Hunt and Hess grade II + 1 and a GCS of 15 with no focal deficits. There was a left medial frontal intracerebral hemorrhage adjacent to an aneurysm that was coiled previously on head CT (Figure 2(a)). Additionally, three neoaneurysms that were found include a periophthalmic aneurysm of the right internal carotid artery, approximately 5 mm, a fusiform dilation aneurysm at the pericallosal and callosomarginal bifurcation, and a basilar tip aneurysm, approximately 1.5-2 mm and 4 mm, respectively (Figures 2(b) and 2(c)) and were assessed as Fisher grade IV. Postoperative formal angiogram, less than 3 weeks from her previous cerebral angiogram, showed that the previously identified fusiform dilations associated with the right pericallosal and callosomarginal bifurcation segment now had a small saccular component with a neck of 5 mm and a height of 7 mm (Figure 2(b)).
(a) 5 days after discharge in 2016: CT head shows large intracerebral hematoma. (b) A diagnostic cerebral angiogram less than 3 weeks from previous imaging demonstrating interval development of a saccular aneurysm at the callosomarginal and pericallosal bifurcation. (c) Cerebral angiogram postcoiling.
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Five days after discharge in 2016, the patient again presented to the hospital as a transfer from an outside hospital, intubated, with a head CT demonstrating a 3.7 x 5.2 x 5 cm left frontal intracerebral hemorrhage (ICH) with extension into the bilateral lateral ventricles, third and fourth ventricles (Figure 3(a)). She subsequently underwent angiography assisted coiling of the right pericallosal and callosomarginal bifurcation aneurysm (Figure 3(c)).