PMC9894615_01
a: Head CT scan demonstrated diffuse SAH in the perimesencephalic cistern (Fisher group 3). b: DSA showing no cerebral aneurysm on day 1. c: MPR angiogram on day 5 showed a tiny aneurysm (arrow) between the BA and the left SCA. d: MPR angiogram on day 14 showed an aneurysm (arrow) with a neck on the SCA, which was slightly different from the finding on day 5. e: Selective angiogram (MIP axial view) using a microcatheter on day 21 revealed the aneurysm (arrow) between the SCA (small arrow) and the circumflex branch of the SCA perforator (arrowhead). f: The aneurysm (arrow) was below the posterior clinoid process (red arrowhead).
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Head CT demonstrated SAH (Hunt and Kosnik Grade IV; World Federation of Neurosurgical Societies Grade IV) extending from the premedullary cisterns superiorly into the bilateral sylvian fissures and interhemispheric fissure (Fisher Group 3) (Fig. 1a). A digital subtraction angiography (DSA) performed on the day after admission found no cerebral aneurysm (Fig. 1b). Repeat conventional angiography showed no obvious aneurysm on day 5, but multiplanar reconstruction (MPR) angiography showed a tiny aneurysm between the BA and the left SCA (Fig. 1c). SCA, which was slightly different from the findings on day 5 (Fig. 1d). Sedative and analgesic care was performed for 14 days after the onset. These findings suggested a diagnosis of a bifurcation aneurysm between the SCA and the circumflex branch of the SCA perforator (Fig. 1e). A subtemporal transtentorial approach was planned based on the height relationship between the aneurysm and the posterior clinoid process (Fig. 1f).
a, b: Pre-clipping surgical views showing that the neck of the aneurysm was located on the basilar artery perforator. c, d: Post-clipping surgical views showing that only the rupture point was clipped.
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The location of the aneurysm was different from that of the bifurcation aneurysm of the circumflex branch of the SCA perforator detected by preoperative cerebral angiography (Fig. 2a, b). Consequently, the rupture point was clipped (Fig. 2c, d).