Rupture of De Novo Anterior Communicating Artery Aneurysm 8 Days after the Clipping of Ruptured Middle Cerebral Artery Aneurysm
A 47-year-old man with subarachnoid hemorrhage in Hunt & Hess grade III was admitted via emergency room. The initial brain CT revealed a thick subarachnoid blood clot around basal cistern and left sylvian fissure (). A 64-detector 3D-CT angiography showed a saccular aneurysm on the left M1 portion of middle cerebral artery and no additional aneurysms (). Considering the distribution of the hemorrhage on CT scans and 3D-CT angiography, we concluded that the cause of the hemorrhage was rupture of the left M1 aneurysm. Immediately, we underwent pterional approach and aneurysmal clipping. On the microsurgical view, M1 aneurysm was surrounded with clots and we confirmed the obliteration of the aneurysm. The patient's mentality was improved to Hunt & Hess grade II. On the next day, right side hemiparesis was developed and the diffusion weighted magnetic resonance images showed ischemic change on the left posterior limb of the internal capsule (). We performed digital subtraction angiography (DSA) which revealed mild vasospasm and performed intra-arterial nimodipine injections. There was no abnormal finding in the anterior communicating artery ().\nAt eight days after the clipping, sudden deterioration of mentality appeared and the follow-up brain CT showed an intraparenchymal hematoma on the right frontal lobe (). We performed the DSA again, which revealed severe vasospasm on the left M1 and A1 portion and the left anterior communicating artery aneurysm that was not found in the previous 3D CT angiography and DSA (). Simultaneously, coil-embolization was performed for the anterior communicating artery aneurysm with Target coils (4×10, 3×6, 2×4, and 2×2) (Boston scientific, Stryker) and it was obliterated completely on the final angiography. We injected intra-arterial nimodipine for the vasospasm (). After the coil embolization, the patient was kept in confused mentality status. However, one month-follow up CT scan showed left cerebral hemisphere ischemia due to vasospasm and hemorraghic transformation (). He was cooperative but was discharged with moderately severe disability due to right hemiplegia (mRS 4).