Intracranial Arterial Aneurysms

Abstract

Case 1. A young white male, 30 years of age, whose past medical history was entirely irrelevant to the present condition, was hospitalized in a state of extreme nervousness, complaining of frontal headache, nausea, and vomiting. On the evening prior to the day of admission, while fixing a radio aerial on the roof of his home, he suddenly became dizzy and apparently was unconscious for about fifteen minutes. When he finally recovered consciousness, he was able to make his way to his apartment downstairs, where he complained of a rightsided pounding headache and a sense of exhaustion. His wife noticed him to be extremely pale. Within the next hour he vomited several times. Late that night he had a chill, or at least felt chilly. Within a few hours after admission to the hospital he became semi-stuporous. His rectal temperature was 100 degrees; pulse 84 per minute; blood pressure 160/90. Physical examination failed to reveal any evidence of trauma, and the entire physical examination did not disclose any abnormalities. A tentative diagnosis of an acute gastrointestinal disturbance was made. The eyegrounds were clear. There was no evidence of cranial nerve palsies, and all reflexes were of normal activity. The pupils were regular and equal and reacted smartly to light. The following day he became irrational. His respirations were labored. The blood pressure was now 142/76, pulse 70, temperature 99.4 degrees, and respirations 22. He vomited frequently. There appeared to be signs of meningeal irritation, since he now complained of pain and stiffness in the neck. Kernig's sign was not present. On the following day there was extreme restlessness, irritability, and periods of disorientation and irrationalism. Some stiffness of the neck was still present. During this day the blood pressure ranged from 120 to 140 systolic and 60 diastolic. The rectal temperature ranged just below 100 degrees. On the third day after admission to the hospital, he was somewhat more rational and coherent, complaining of stiffness of the neck. The left pupil was now noted to be slightly larger than the right and reacted better to light. No abnormal reflexes were observed but normal reflexes were not obtained. Biceps and triceps reflexes were diminished. Areas of anesthesia or paresthesia were not found. On the fourth day after admission to the hospital, the right pupil was definitely smaller than the left, and there was a paralysis of the right external rectus muscle. He now complained of some diplopia. Fundus exam-