Presentation
Day 7 post cardiac surgery. Presents with sudden collapse and facial weakness. INR 3.0
Patient Data
There is extensive infra and supratentorial subarachnoid hemorrhage demonstrated centered at the suprasellar cistern and extending into the premedullary cistern, cerebellopontine cistern, into bilateral Sylvian fissures, along the floor of the middle cranial fossa and falx cerebri anteriorly.
There is also widespread sulci hemorrhage seen in bilateral frontal, anterior temporal and parietal as well as right anterior occipital lobe.
An area of ill-defined hypodensity is shown in the right frontal lobe appears suspicious for an area of established infarction.
No intraventricular blood. No midline shift. No focal mass identified.
CT angiogram (not shown) demonstrate peripheral right MCA dilatation, suspicious for an aneurysm.
In the periphery of the right middle cerebral artery is a slow to fill and slow to empty aneurysm.
Post surgical clipping DSA to confirm exclusion of the aneurysm.
Case Discussion
Although INR 3.0, other causes of intraparenchymal and subarachnoid hemorrhage need to be considered. Review of history indicated the thoracic surgery was performed on background of bacterial endocarditis.
CTA source images (not shown) did reveal the aneurysm immediately deep to the cranial vault, at an unusual site for typical aneurysms, and with artefact from skull vault potentially leading to missed diagnosis.
The DSA shows an aneurysm at an atypical site - on these images alone a mycotic (infective) aneurysm would be proposed without additional history. Once the additional history was known, the diagnosis was almost certain and was subsequently surgically confirmed.
In this case the very distal location, tortuous cervical ICA access led to the consensus decision to manage with surgical clipping. Once thought a relative contraindication to endovascular treatment, infective aneurysms have now been treated with coil embolization.
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