PMC10365113_01
Axial T2 weighted image obtained on the day of transfer shows low signal intensity (arrowhead) adjacent to the right middle cerebral artery (MCA) and an aneurysm at the left distal ICA (arrow) suggesting subarachnoid hemorrhage resulted from aneurysmal rupture.
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The brain MRI on the day of transfer showed acute hemorrhage around the distal internal carotid artery (ICA) and right middle cerebral artery (MCA) obliterating the basal cistern and narrowing of both distal ICA and aneurysm at the left distal ICA (Figure 1).
Diffusion weighted image obtained at the time of onset (A,B) shows high signal intensity lesions at both parasagittal areas (arrowheads), and apparent diffusion coefficient (ADC) map (C) shows low signal intensity (arrows) suggesting acute cytotoxic edema. The brain magnetic resonance angiography (MRA) demonstrates diffuse narrowing of the cerebral arteries and small aneurysms (red arrows) at both distal internal carotid arteries (D).
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ICAs, as well as small aneurysms at both distal ICAs (Figure 2D). In addition to the persistent SAH in the basal cistern and prepontine cistern, multifocal parasagittal acute infarctions were found (Figures 2A-C).
Transfemoral cerebro-arteriography and subsequent coiling of the aneurysms. There are diffuse narrowing of both distal internal carotid arteries, middle cerebral arteries, and anterior cerebral arteries, as well as and multiple unruptured aneurysms in both anterior choroidal artery and the left middle cerebral artery on angiography in anteroposterior (A,F), lateral (B,G) views, which is better demonstrated on 3D reconstruction images (C,H). The first endovascular coil embolization for aneurysms on the right anterior choroidal artery on anteroposterior (D) and sagittal views (E), respectively. Secondary coiling was performed on left anterior choroidal artery aneurysm in the angiography on anteroposterior (I) and sagittal views (J).
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Transfemoral cerebral angiography (TFCA) was performed on the sixth hospitalization day, revealing three unruptured aneurysms in both anterior choroidal arteries and left MCA and posthemorrhagic vasospasm involving both distal ICAs, MCAs, and ACAs (Figures 3A,F). On the seventh hospitalization day, after confirming that the vessels were widened enough to perform the intervention, we executed the first endovascular coil embolization for obliteration of unruptured aneurysms on the right anterior choroidal artery (Figures 3B-E). On the seventeenth hospitalization day, we performed the second endovascular coil embolization for obliterating the left anterior choroidal artery aneurysm (Figures 3G-J).
Follow-up axial T2 weighted images (A) demonstrate the high signal intensity in both parasagittal areas suggesting the watershed injury (arrows). The MRA (B) shows improved narrowing of both MCAs and ACAs suggesting improved diffuse spasm of the arteries. There are remaining multifocal stenosis of the vessels at both distal internal carotid arteries, proximal middle cerebral arteries, and proximal anterior cerebral arteries.
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The brain MRI and MRA performed 10 months after discharge demonstrated encephalomalacia in both parasagittal areas especially in the left frontal lobe (Figure 4).