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Ruptured posterior communicating artery aneurysm complicated by vasospasm

Case contributed by Stefan Tigges
Diagnosis certain

Presentation

Worst headache of life, altered level of consciousness.

Patient Data

Age: 25 years.
Gender: Female

Right anterior Sylvian and uncal hematomas. Extensive subarachnoid hemorrhage extending into the Sylvian fissures, small amount of intraventricular blood. Mild hydrocephalus. Preserved gray-white differentiation.

The first 4 images show a right posterior communicating artery aneurysm, the next 6 images were obtained after successful aneurysm coiling. Mild narrowing of the right internal carotid, middle cerebral, and anterior cerebral arteries due to vasospasm.

Right internal carotid injection shows severe narrowing distal internal carotid, middle cerebral and anterior cerebral arteries due to vasospasm. Left vertebral injection shows severe moderate narrowing distal basilar arteriy due to vasospasm.

Left internal carotid injection shows severe narrowing distal internal carotid, middle cerebral and anterior cerebral arteries due to vasospasm.

Right posterior communicating artery aneurysm coils and left ventriculostomy tube tip in place. Evolving right anterior Sylvian and uncal hematomas. Essentially unchanged subarachnoid/intraventricular blood. New diffuse low attenuation of brain parenchyma and loss of gray-white differentiation.

Cerebral perfusion scintigraphy shows no blood flow above the circle of Willis, compatible with brain death.

Case Discussion

Vasospasm is a potentially devastating complication of subarachnoid hemorrhage due to a ruptured aneurysm. The likelihood of vasospasm can be calculated using the modified Fisher scale. Grades from 0 to 4 are calculated based on the presence/amount of subarachnoid and intraventricular blood: the higher the grade, the more likely the patient is to have vasospasm. In our case, the presence of "thick" SAH and intraventricular hemorrhage results in a grade of 4, which corresponds to a 40% risk of symptomatic vasospasm.

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