- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
Muhammad Omar Chohan
Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
DOI:10.4103/2152-7806.129615Copyright: © 2014 Chohan MO. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Chohan MO, Westhout FD, Taylor CL. Delayed rebleeding of a spontaneously thrombosed aneurysm after subarachnoid hemorrhage. Surg Neurol Int 28-Mar-2014;5:42
How to cite this URL: Chohan MO, Westhout FD, Taylor CL. Delayed rebleeding of a spontaneously thrombosed aneurysm after subarachnoid hemorrhage. Surg Neurol Int 28-Mar-2014;5:42. Available from: http://sni.wpengine.com/surgicalint_articles/delayed-rebleeding-of-a-spontaneously-thrombosed-aneurysm-after-subarachnoid-hemorrhage/
Background:This report provides a rare documentation of spontaneous thrombosis of a ruptured aneurysm followed by delayed recanalization and subsequent rerupture.
Case Description:A 47-year-old female presented with spontaneous subarachnoid hemorrhage (SAH). Four aneurysms were identified on CT angiogram including a basilar apex aneurysm, considered source of bleeding. Cerebral angiogram on postbleed day (PBD) #1 showed spontaneous thrombosis of basilar apex aneurysm. The patient was discharged to a nursing home on PBD #18 after two subsequent studies showed no recanalization of the basilar aneurysm. The patient returned on PBD #26 with a second episode of spontaneous SAH. The previously thrombosed basilar aneurysm had recanalized and reruptured, which was now treated with coil embolization.
Conclusion:We are not aware of a previous report of saccular cerebral aneurysm documenting spontaneous thrombosis after SAH and recanalization with second hemorrhage. This occurrence presents a dilemma regarding the timing and frequency of subsequent cerebrovascular imaging and treatment.
Keywords: Aneurysm, embolization, recanalization, subarachnoid hemorrhage, thrombosis
Spontaneous thrombosis of cerebral aneurysms is known to occur.[
A 47-year-old female presented with spontaneous SAH. Computed tomography angiography (CTA) demonstrated diffuse SAH and intraventricular haemorrhage [
Catheter angiography on postbleed day (PBD) #1 showed irregularity at the basilar apex with no filling of the dome of the basilar aneurysm, consistent with spontaneous thrombosis [Figure
Postbleed day 1 (PBD#1) catheter angiogram demonstrating irregular basilar apex without evidence of aneurysm filling indicating spontaneous thrombosis (a: AP and b: lateral views; c and d 3D reconstructions in AP and lateral views). PBD#8 catheter angiogram again did not show aneurysm filling (e and f). Note significant vasospasm of basilar trunk in (e). Lateral view is magnified to show persistent thrombosis of basilar apex aneurysm (f)
CTA on PBD #2 showed no filling of the basilar aneurysm. Catheter angiography on PBD #8 showed moderate vasospasm of the basilar artery, fullness of the basilar apex with less irregularity of the apex, but no filling of the dome or neck of the aneurysm [Figure
Second presentation and intervention
A rapid decline in her neurologic functioning occurred on PBD #26. Head CT showed new acute SAH in the fourth ventricle and in the prepontine cistern, extending inferiorly along the medulla [
Rapid decline of patient on PBD#26 demonstrated new SAH on CT scan (a) and redemonstration of previously thrombosed basilar apex aneurysm on catheter angiography (b: 3D reconstruction; c: AP and d: lateral views), which was subsequently coil embolized (e: AP, f: lateral views). Arrowheads demonstrate coil mass in e and f.
We are not aware of a previous report of saccular cerebral aneurysm documenting spontaneous thrombosis after SAH and recanalization with second hemorrhage. We performed a PubMed database search with the following key words: “intracranial aneurysm”, “rupture”, “spontaneous thrombosis”, “rerupture”, and “recanalization”. Spontaneous thrombosis is uncommon but well documented.[
More recently, hemorrhage after apparent “complete” thrombosis has been reported with endovascular flow-diversion treatment.[
Our practice in patients with SAH (exceeding the perimesencephalic cistern) and negative CTA has been to perform catheter angiography immediately, and at one week and four weeks as needed. Patients with negative immediate angiography are screened for spinal pathology with magnetic resonance imaging (MRI). We intended to follow the same protocol with this patient, however, the basilar aneurysm recanalized and reruptured prior to the delayed study. The likelihood of this sequence of events is too low to justify a more aggressive imaging protocol. However, if faced again with the same situation, we will likely screen weekly with CTA or MRA for at least the first month and less frequently thereafter.
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