Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report
- Department of Neurosurgery, Suzuka General Hospital, Suzuka,
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan.
Hideki Nakajima, Department of Neurosurgery, Suzuka General Hospital, Suzuka, Mie, Japan.
DOI:10.25259/SNI_713_2021Copyright: © 2021 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Hideki Nakajima1, Takuro Tsuchiya1, Shigetoshi Shimizu1, Hidenori Suzuki2. Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report. 06-Oct-2021;12:498
How to cite this URL: Hideki Nakajima1, Takuro Tsuchiya1, Shigetoshi Shimizu1, Hidenori Suzuki2. Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report. 06-Oct-2021;12:498. Available from: https://surgicalneurologyint.com/surgicalint-articles/11163/
Background: The causes of angiogram-negative subarachnoid hemorrhage (SAH) on initial angiography, which accounts for 10–30% of spontaneous SAH, are heterogeneous and still unclear. We report a case of nonaneurysmal SAH, in which initial computed tomographic angiography (CTA) showed no source of bleeding, but the subsequent digital subtraction angiography (DSA) revealed contrast extravasation from the basilar artery without aneurysms.
Case Description: A 67-year-old woman with a medical history of hypertension presented as SAH of World Federation of Neurological Surgeons Grade II. CTA on admission did not show any cause of bleeding and DSA was subsequently performed to show contrast extravasation from a perforator of the middle third of the basilar artery without aneurysms during the subsequent DSA, resulting in profound deterioration SAH and neurological status. The patient was conservatively treated. Follow-up DSAs on days 2 and 16 showed no source of bleeding as well.
Conclusion: Although the precise cause of bleeding in this case is uncertain, SAH might be caused by local dissection of the basilar artery perforator, and the bleeding site might heal spontaneously without forming of a pseudoaneurysm.
Keywords: Basilar artery perforator aneurysm, Contrast extravasation, Subarachnoid hemorrhage, Unknown etiology
Approximately 10–30% of spontaneous subarachnoid hemorrhage (SAH) patients have unknown origin on initial angiographic imaging.[
A 67-year-old woman with a medical history of hypertension presented to our hospital after sudden onset of headache with vomiting. On admission, she was drowsy, but there were no neurological deficits. The blood pressure and pulse rate were 197/111 mmHg and 84 beats/min, respectively. She was clinically judged World Federation of Neurological Surgeons Grade II. CT of the head showed SAH of Fisher Group 3, especially in the prepontine cistern, and CTA showed no source of bleeding [
Right vertebral artery angiography on days 2 (a, anteroposterior view; b, lateral view) and 16 (c, anteroposterior view; d, lateral view). (a and b) No source of hemorrhage is shown, and the wall of the basilar artery is smooth. (c and d) No cause of hemorrhage is revealed, but vasospasm of the basilar artery (arrow) is shown.
Spontaneous SAH is caused by rupture of a cerebral aneurysm in 80–90% of patients.[
Possible sources of angiogram-negative SAH include vascular malformations, tumors, vasculitides, infections, venous thromboses, and nonvisualized aneurysms.[
DSA is the gold standard in terms of diagnosing the source of bleeding. However, CTA is more rapid and less invasive than DSA.[
Because there was no treatable aneurysm and it is difficult to explore the middle third basilar artery in a direct surgery, we performed conservative therapy in this case. DSA on days 2 and 16 showed neither contrast extravasation nor the source of bleeding, and no rebleeding occurred during the hospitalization. To the best of our knowledge, there were no cases of SAH in which there was only contrast extravasation without aneurysm shown on DSA following negative findings on CTA as in the present case. However, we found four cases of SAH in which there were negative findings on DSA following contrast extravasation without aneurysm on CTA.[
Although the precise cause of bleeding in this case is uncertain, the possibility of basilar artery perforator aneurysms (BAPAs) should be considered: BAPAs can cause angiogram-negative SAH and spontaneously disappear.[
SAH with no visualization of bleeding sources on CTA and contrast extravasation from a perforator of the basilar artery on DSA is extremely rare. Although thrombosis developed immediately after the initial bleeding, rebleeding occurred during the subsequent DSA and contrast extravasation from a perforator of the middle third of the basilar artery was observed, suggesting that the mechanism of bleeding might include a localized dissection like BAPAs. The present case suggests that there may be a group of diseases which cause the localized dissection of a perforator of the basilar artery and result in SAH without forming aneurysms.
The authors certify that they have obtained all appropriate patient consent.
There are no conflicts of interest.
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