Presentation
Right weakness and aphasia.
Patient Data
There is a large volume of acute subarachnoid blood within the suprasellar, ambient, interpeduncular and prepontine cisterns as well as the sylvian fissures and cerebral sulci bilaterally.
Large, amount of blood is centered upon the left sylvian fissure, with possible intraparenchymal component.
No intraventricular blood.
No hydrocephalus.
Grey-white matter differentiation at the left insula cortex is difficult to assess due to adjacent hyperdense blood.
Grey-white matter differentiation is preserved elsewhere.
CTA COW:
There is a 4.8 x 9.4 mm bilobed saccular aneurysm at the bifurcation of the left MCA, with a 2 mm neck.
There is also a 4.5 x 3.6 mm saccular aneurysm at the bifurcation of the right MCA, with a 1.5 mm neck.
The rest of the intracranial arteries opacify normally.
Conventional aortic arch branching morphology.
No significant neck artery stenosis.
Conclusion:
Bilateral MCA bifurcation aneurysms, larger on the left.
Large amount of subarachnoid blood is in keeping with aneurysm rupture, likely from the left, given most of the blood is centered there.
A left pterional decompressive craniectomy has been performed with clips in the region of the left MCA bifurcation. Stable large volume of subarachnoid hemorrhage with hematoma filling and expanding the left sylvian fissure. There is progressive surrounding hypodensity involving the adjacent insular cortex, temporal lobe and posterior left frontal lobe. Mass effect continues to distort the left lateral ventricle and cause uncal herniation. The right temporal horn is more prominent than on the previous study in keeping with developing hydrocephalus. Blood continues to pool in the occipital horns of the lateral ventricles, within the third and the fourth ventricles as well as the basal cisterns.
No residual filling of the previously demonstrated left MCA bifurcation aneurysm identified. Anterior pointing right MCA bifurcation 4.5 x 3.5 mm aneurysm again demonstrated.
3D reconstructions spotting the bilateral MCA aneurysms (red circle).
Case Discussion
Berry aneurysms form 97% of aneurysms of the central nervous system. The rupture of an intracranial aneurysm is a medical emergency with a high mortality index.
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