Rare Cause Of Subarachnoid Hemorrhage Research Articles

Cervical intradural extramedullary cavernous malformation as a rare cause of subarachnoid hemorrhage without spinal dysfunction: illustrative case

BACKGROUNDIntradural extramedullary cavernoma is a very rare lesion of the spinal cord, especially of the cervical spine. Its clinical presentation can vary with symptoms of sensory or motor deficits and even with symptoms of subarachnoid hemorrhage (SAH).OBSERVATIONSThe authors present a case of a 45-year-old man with SAH with prolonged neck pain and increasing headache confirmed by lumbar puncture. Head computed tomography revealed only discrete blood deposits in the right frontal and biparietal lobes. The finding of pan-cerebral angiography was negative for the cause of bleeding. Spinal magnetic resonance imaging revealed an intradural extramedullary mass lesion at cervical level C5–6. The finding of subsequent cervical angiography was negative. The diagnosis of a cavernous malformation was confirmed histopathologically after surgery. The cavernoma was completely removed, and full recovery of the initial symptoms was achieved.LESSONSSpinal lesions should be considered in the diagnostic work-up for SAH with excluded origin of bleeding in cranial neuroimaging. An intradural extramedullary cavernous malformation is an extremely rare entity in the differential diagnosis of SAH, and surgical resection is the treatment of choice to prevent further bleeding and neurological deficits.

Flow Diverter Treatment of Ruptured Basilar Artery Perforator Aneurysms

PurposeRuptured basilar artery perforator aneurysms (BAPAs) represent a very rare cause of subarachnoid hemorrhage and an under-reported subtype of cerebral aneurysm. There is no consensus for the optimal treatment strategy (conservative vs. surgical vs. various endovascular approaches). We aim to present a multicenter experience of BAPA treatment using flow-diverter (FD) stents.MethodsAt five tertiary neurovascular centers, all cases of ruptured BAPAs treated by FD were retrospectively collected. Baseline imaging and clinical characteristics, complications, as well as early and long-term angiographic and clinical outcome (mRS) were analyzed.ResultsEighteen patients (mean age, 57 years; SD, ±10.7 years) with acute SAH related to a BAPA were treated using 18 FD stents. Aneurysms were detected on initial imaging study in 28%; delayed diagnosis was triggered by clinical deterioration due to rebleeding in 15%. No rebleeding after FD was seen, 28% developed FD-related ischemic complications. At long term (n = 16), overall mortality was 13% (2/16), and favorable outcome (mRS 0–2) was 81% (13/16). All BAPAs (n = 13) were completely occluded at long-term angiographic follow-up.ConclusionIn our multicenter experience, FD treatment of ruptured BAPAs appears to have comparable safety and efficacy outcomes to FD treatment of other ruptured posterior circulation aneurysms as well as to the conservative management of BAPAs. This treatment strategy for a ruptured BAPA achieved a high rate of angiographic occlusion and favorable clinical outcome; however, as the conservative management also seems to offer similar clinical outcomes an individualized treatment decision is warranted. Future prospective studies comparing both approaches are required.

Repeated Retching and Vomiting in the Pathophysiology of Isolated Spinal Aneurysms

Rupture of spinal aneurysms is a rare cause of subarachnoid hemorrhage. These aneurysms are often associated with a variety of vascular malformations that increase blood flow in the spinal circulation or with disorders that compromise the vessel wall. However, spinal aneurysms may be isolated, not associated with any known predisposing condition. The objective of this study is to explore the possible mechanisms associated with the formation and rupture of isolated spinal aneurysms (ISAs). We conducted a retrospective review of a series of consecutive patients admitted for a ruptured ISA. In all cases, spinal angiography confirmed the presence of a spinal aneurysm responsible for the bleeding. Particular attention was paid to medical history and symptoms before bleeding, for potential factors predisposing to their formation and rupture. Between 2008 and 2020, ten cases of spinal aneurysms were seen at our institution including 4 cases of ISA. All patients with ISA were female, and in 3 cases the aneurysm involved the territory of the posterior spinal artery. In 3 of these 4 (75%) ISA cases, there was a strikingly similar history of retching and vomiting preceding the thunderclap headache. In 1 patient, the aneurysm was surgically resected; pathologic analysis revealed a fusiform dissecting aneurysm. All 4 patients had a favorable outcome. We suggest that the straining during prolonged retching and vomiting plays a role in the formation and rupture of some ISAs, possibly because of pressure spikes, increased transmural arterial pressure, and increased wall shear stress during straining.

Functional Outcomes After Treatment of Posterior Inferior Cerebellar Artery Aneurysms.

ObjectiveAneurysms of the posterior inferior cerebellar artery (PICA) are a rare cause of subarachnoid hemorrhage. Treatment for this type of aneurysm may be microsurgical clipping or endovascular. This decision is based on patient characteristics, aneurysm location and dimensions, along with surgeon and institutional experience. In this study we aim to assess the outcomes of surgical and endovascular treatment of PICA aneurysms.MethodsWe retrospectively reviewed the charts of 52 patients who were admitted to Vancouver General Hospital for ruptured or symptomatic PICA aneurysms between 2005 and 2015. Modified Rankin scores were assigned at the time of discharge and at two subsequent follow-up time points. The mean short-term follow-up period post-operatively was 11.1 months and the mean long-term follow-up period was 19.3 months. Clinical and radiological characteristics were collected for all patients.ResultsOf the 52 patients, two died prior to obtaining treatment. Of the 50 patients who were treated for their PICA aneurysm, 39 presented with subarachnoid hemorrhage while 11 had symptomatic unruptured PICA aneurysms. Overall, 11 patients had endovascular treatment (coil embolization) while 39 patients underwent microsurgical clipping/trapping of the aneurysm. At the time of hospital discharge, patients in the microsurgical group trended towards a better the modified Rankin Scale score (2.3) compared to the endovascular group, though this did not reach significance (3.0) (p=0.20). The long-term score in the endovascular group (1.6) was also comparable to the microsurgical group (1.9) (p=0.55).ConclusionWhile the early outcomes in patients treated endovascularly appear better, there is no statistically significant difference in outcomes between the microsurgical and endovascular treatment groups at short- and long-term follow-up.

The Use of Flow Diverter in Ruptured, Dissecting Intracranial Aneurysms of the Posterior Circulation.

Acute dissecting aneurysms of the posterior circulation are a rare cause of subarachnoid hemorrhage. Established endovascular treatment options include parent artery occlusion and stent-assisted coiling, but appear to be associated with an increased risk of ischemic stroke. Vessel reconstruction with flow diverters is an alternative treatment option; however, its safety and efficacy in the acute stage remains unclear. This is a multicentric retrospective analysis of 15 consecutive acutely ruptured dissecting posterior circulation aneurysms treated with flow diverters. The primary end point was favorable aneurysm occlusion, defined as OKM C1-3 and D (O'Kelly Marotta scale). Secondary end points were procedure-related complications and clinical outcome. Nine of 15 aneurysms (60%) arose from the intradural portion of the vertebral artery, 3 were located on the posterior inferior cerebellar artery and 1 each on the anterior inferior cerebellar artery, posterior cerebral artery, and basilar artery. Flow diverter placement was technically successful in 14 of 15 cases (93%). After endovascular treatment, none of the ruptured aneurysms rebled. Median clinical follow-up was 217 days and median angiographic follow-up was 203 days. Favorable occlusion was observed in 7 of 14 aneurysms (50%) directly after flow diverter placement; of those, 5 were completely occluded (36%). Seven patients (47%) with poor-grade subarachnoid hemorrhage died in the acute phase. Favorable clinical outcome (modified Rankin scale ≤2) was observed in 4 of 15 patients (27%) and a moderate outcome (modified Rankin scale 3/4) was observed in 5 of 15 patients (33%). All aneurysms showed complete occlusion at follow-up. Flow diverters might be a feasible, alternative treatment option for acutely ruptured dissecting posterior circulation aneurysms and may effectively prevent rebleeding. Larger cohort studies are required to validate these results.

Carotid-ophthalmic aneurysms – protective features making them a rare cause of subarachnoid hemorrhage

Abstract Objective: To review the rate of carotid-ophthalmic aneurysm (COA) rupture and to identify protective features that may contribute to their low rupture rate. Methods: We reviewed the records of 790 patients with 773 aneurysms greater than 2 mm treated by endovascular routes between 2002 and 2012 at our institution. Seventy five carotid-ophthalmic aneurysms were identified in 72 patients. Three injected human cadaver heads were studied to evaluate the perianeurysmal environment of the carotid-ophthalmic region. Results: Only 2 (2.8%) of these 72 patients presented with acute SAH due to a ruptured carotid-ophthalmic aneurysm. The average size of ruptured COA was 11.3 mm versus 7 mm for unruptured aneurysms. Most of the aneurysms were discovered in patients who were asymptomatic. The most common presenting symptom was headache. In this study, we also provide cadaveric anatomic illustrations of the perianeurysmal environment in order to investigate the low rate of COA rupture. Additionally, we highlight the existence of a double arachnoid layer consisting of the arachnoid on the inferior aspect of the optic nerve and surrounding the internal carotid artery (ICA), which could further contribute to the low rupture rate of these aneurysms. Conclusions: Carotid-ophthalmic aneurysms are uncommon sources of subarachnoid hemorrhage. The perianeurysmal environment surrounding these aneurysms may provide protection, lending these aneurysms to a relatively benign natural history.

Posterior spinal artery aneurysm rupture after ‘Ecstasy’ abuse

Posterior spinal artery (PSA) aneurysms are a rare cause of subarachnoid hemorrhage (SAH). The commonly abused street drug 3,4-methylenedioxymethamphetamine (MDMA) or ‘Ecstasy’ has been linked to both systemic and neurological...

Stent-Assisted Coil Embolization and Computational Fluid Dynamics Simulations of Bilateral Vertebral Artery Dissecting Aneurysms Presenting With Subarachnoid Hemorrhage

A vertebral artery dissecting aneurysm (VADA) is a relatively rare cause of subarachnoid hemorrhage. Bilateral VADAs are even rarer, and management strategies are controversial. We report a case of bilateral VADAs presenting with subarachnoid hemorrhage. We treated the patient by stent-assisted coil embolization of both aneurysms at a single session on the basis of results of preoperative computational fluid dynamic simulations. A 48-year-old man presented with subarachnoid hemorrhage resulting from bilateral VADAs. We treated the patient by stent-assisted coil embolization of both aneurysms at a single session. Before the treatment, we performed computational fluid dynamics simulations to predict the ruptured side. We also estimated the increase in wall shear stress on an aneurysm in case of trapping of another aneurysm, which might cause enlargement and rupture of the aneurysm. The treatment was performed successfully. The patient remains neurologically intact at 14 months from the onset. Stent-assisted coil embolization of subarachnoid hemorrhage with bilateral VADAs for both sides is a reasonable treatment because it prevents rebleeding and preserves bilateral vertebral arteries without increasing hemodynamic stress. To the best of our knowledge, this is the first report to describe this type of treatment for bilateral VADAs with subarachnoid hemorrhage. Computational fluid dynamics simulations may be useful for developing treatment strategies for aneurysms.

Report of two cases of a rare cause of subarachnoid hemorrhage including unusual presentation and an emerging and effective treatment option

PurposeTo report two cases of a rare cause of subarachnoid hemorrhage (SAH), including unusual presentation and an emerging and effective treatment option.Case reportsRuptured basilar perforator artery aneurysm is a rare...

Successful Treatment of Bilateral Vertebral Artery Dissecting Aneurysms with Subarachnoid Hemorrhage: Report of Three Cases

Vertebral artery dissecting aneurysm (VADA) is a relatively rare cause of subarachnoid hemorrhage (SAH). Bilateral VADAs are even rare, and management strategies for this type of VADAs are still controversial. Here, we report 3 cases of bilateral VADAs with SAH. All 3 patients were treated conservatively under strict sedation and blood pressure control during the acute stage. During the course, rebleeding was not observed in any case. One patient underwent trapping of the ruptured VADA on day 28, because this lesion was considered to have a high tendency to rebleed, even in the chronic stage. In the other 2 patients, after conservative treatment, the VADAs spontaneously resolved on the both sides. As for the therapeutic strategy for bilateral VADAs presenting with SAH, at the acute stage, considering the difficulty of bypass surgery, we recommend conservative treatment with sedation and strict control of blood pressure. At the chronic stage, however, when the VADA is still large and growing in size, surgical treatment such as proximal occlusion or trapping of the affected VA with or without distal revascularization should be considered to avoid rebleeding.

Spinal cord arteriovenous malformation in a toddler presenting with altered mental status and fever

Central nervous system arteriovenous malformations (AVMs) are a rare cause of subarachnoid hemorrhage and neurologic deficits. About 90% of these lesions are supratentorial, with a smaller percentage occurring in the posterior fossa and an even smaller number found throughout the spine. Although spinal AVMs are uncommon, these disorders represent a treatable cause of significant morbidity in a young age group. We report a case of a T11-T12 spinal AVM in a 14-month-old girl presenting with low-grade fever and lethargy who was found to have subarachnoid hemorrhage on evaluation and describe a reasonable stepwise approach to these patients in the emergency department utilizing computed tomography, lumbar puncture, magnetic resonance imaging, and angiography.

Vertebrobasilar dolichoectasia associated with Marfan syndrome

We report a 37-year-old woman with Marfan syndrome (MFS) who presented with acute myelopathy secondary to a subdural spinal hematoma. The patient died of a subarachnoid hemorrhage 4 days later. Autopsy showed a markedly ectatic vertebrobasilar system with fragmentation of the internal elastic lamina. Microscopic examination of the aorta similarly showed a fragmented internal elastic lamina. We discuss the implications of our patient's early onset vertebrobasilar dolichoectasia; this intracranial disease represents a rare cause of subarachnoid hemorrhage in MFS.

Ruptured Cerebral Aneurysms Caused by Micro-Organisms

RUPTURE of a cerebral aneurysm caused by a mycotic organism is a rare cause of subarachnoid hemorrhage. Published descriptions are few and meager and do not emphasize the importance of making the clinical diagnosis. Bacterial endocarditis may be indolent and not recognized for long periods until the unheralded rupture of a cerebral aneurysm. Even then the diagnosis may not be suspected in the turmoil associated with a serious neurologic illness. However, the site and appearance of these aneurysms are usually quite different from the typical berry aneurysm, and this fact should lead to vigorous attempts to establish the presence of . . .