Endovascular treatment for recurrent subarachnoid hemorrhage from the ruptured small aneurysm not clearly seen at the first rupture

Abstract

We present a case of recurrent subarachnoid hemorrhage (SAH) attributed to rupture of an aneurysm which was not treated because it was not clearly seen on angiography at the first SAH. A 67-year-old woman presented with consciousness disturbance (Hunt & Kosnik grade IV) and left hemiparesis. A CT scan revealed massive SAH (Fisher group 3). Angiography showed a 5mm right carotid cave aneurysm and a bulging at the posterior communicating artery origin which was thought to be an infundibular dilatation. Emblization for the carotid cave aneurysm was successfully performed. Sudden consciousness disturbance occurred 7 days after embolization, and CT scan revealed recurrent SAH. Because of severe brain swelling due to vasospasm, the patient was treated conservatively. After a ventricle - peritoneal shunt was performed for normal pressure hydrocephalus, the patient recovered but had a left hemiparesis. Angiography obtained two months after embolozation showed complete occlusion of the previously embolized aneurysm, and the enlarged aneurysm thought to be an infundibular dilatation, previously. Both episodes of SAH were considered to be attributed to this aneurysm. Because it was a very small aneurysm, endovascular treatment was considered extremely difficult and dangerous. But at the request of her family, we performed endovascular embolization of aneurysm successfully. Postoperative course of the patient was uneventful. We stressed that early follow-up angiography is very important even after successeful occlusion of small carotid cave aneurysms because small carotid cave aneurysms tend not to rupture and another aneurysm which was unclear at the first angiography may appear clearly, after a while as in to our case.