Subarachnoid hemorrhage (SAH) following intracranial aneurysmal rupture is a major cause of morbidity and mortality.2 Several factors may affect the probability of rupture, such as use of tobacco or alcohol; size, shape, and location of the aneurysm; presence of intraluminal thrombus; and even the sex of the patient. 1,2However, few data correlate such findings with the timing of aneurysmal rupture.2 Hiu et al. 5 highlighted the role of surrounding brain edema as an early manifestation in the course to aneurysmal rupture. We report 2 similar cases, suggesting that perianeurysmal parenchymal edema is a marker preceding acute aneurysmal rupture, and discuss pertinent hypotheses. Case Report Case 1A 37-year-old woman presented for neuroradiological investigation of a 3-month history of progressively worsening pulsatile headache. Her medical history was negative for smoking, alcohol intake, and medication use. She denied any family history of intracranial aneurysms. Her clinical and neurological examinations were unremarkable. Brain MRI revealed a saccular aneurysm of approximately 5 mm at the anterior communicating artery complex (Fig. 1A). It also showed vasogenic edema surrounding the aneurysm, characterized by hypointensity on T1-weighted and hyperintensity on T2-weighted and FLAIR sequences (Fig. 1A).The patient was referred for neurological follow-up. At 2-month follow-up, her headache persisted and was progressively worsening, and another MRI study was obtained. Imaging now revealed increased edema and an aneurysm bleb (Fig. 1B). Six days after the second MRI, the patient presented with "the worst headache of her life" followed by impairment of consciousness. Urgent head CT revealed a Fisher Grade 4 SAH with an intraparenchymal hemorrhage (IPH) in the right gyrus rectus, adjacent to the aneurysm (Fig. 1C).The patient was evaluated by the neurosurgical team and underwent aneurysm clipping (Fig. 1D). She recovered well and was discharged with a Glasgow Outcome Scale score of 5. Case 2A 45-year-old woman presented with dizziness lasting 2 weeks. Her medical history was negative for smoking, alcohol intake, and medication use, and she denied any family history of intracranial aneurysms. Subarachnoid hemorrhage following intracranial aneurysmal rupture is a major cause of morbidity and mortality. Several factors may affect the probability of rupture, such as tobacco and alcohol use; size, shape, and location of the aneurysm; presence of intraluminal thrombus; and even the sex of the patient. However, few data correlate such findings with the timing of aneurysmal rupture. The authors report 2 cases of middle-age women with headache and MRI findings of incidental aneurysms. Magnetic resonance imaging showed evidence of surrounding parenchymal edema, and in one case there was a clear increase in edema during follow-up, suggesting a progressive inflammatory process that culminated with rupture. These findings raise the possibility that bleb formation and an enlargement of a cerebral aneurysm might be associated with a...
Eight patients with life-threatening hemobilia were treated by percutaneous transcatheter occlusive therapy. The bleeding was caused by a traumatic pseudoaneurysm of the hepatic artery in 6 cases (auto accident in 4, surgery in 1, biliary drainage in 1) and a true aneurysm of the hepatic artery in 2 (unknown etiology in 1 and mycotic in 1). Arterial catheterization was used in all cases except for one in which a direct percutaneous puncture was performed. Gelfoam alone was used as embolic material in 3 patients. In 1 patient each, the material used was gelfoam plus coils, coils alone, blood clot, n-butyl-cyanoacrylate and an occluding balloon catheter. In all cases the bleeding stopped and did not recur during the follow-up period which ranged from 9 months to 14 years. This experience indicates that transcatheter occlusive therapy is an effective method for the treatment of severe hemobilia.
-We report the case of a 27 year old man who presented to the emergency room of a hospital with headache, vomiting and an episode of loss of conciousness. A cranial CT scan was normal and the patient discharged. Ten hours later he came to the emergency room of our hospital with the same complaints. A technically difficult cisternal puncture in an anxious patient who moved during the needle introduction was done. The CSF sample showed 1600 intact red blood cells without other alterations. His headache worsened and after 6 hours he became drowsy, numb and exhibited decerebration signs. A new CT scan showed diffuse subarachnoid and intraventricular blood. An emergency angiogram demonstrated laceration of a left posterior-inferior cerebellar artery in its retrobulbar loop with a pseudoaneurysm. He was succesfully treated by surgical clipping without injury. Sixteen days later he was discharged with a normal neurological exam.KEY WORDS: CSF, suboccipital puncture, angiogram, posterior inferior cerebellar artery, pseudoaneurysm, laceration.Laceração da artéria cerebelar póstero-inferior causada por punção suboccipital: relato de caso RESUMO -Relatamos o caso de um homem de 27 anos que procurou o pronto atendimento de um hospital com cefaléia intensa, vômitos e um episódio de perda de consciência. Uma tomografia de crânio foi normal e o paciente foi dispensado. Dez horas após, o paciente procurou o setor de emergência do nosso hospital com as mesmas queixas. Uma punção suboccipital tecnicamente dificultada pela ansiedade do paciente que se movimentou durante a coleta foi realizada evidenciando amostra de LCR levemente hemorrágico. A análise do LCR mostrou presença de 1600 hemácias íntegras sem aumento de leucócitos nem alterações bioquímicas. Houve piora acentuada da cefaléia e após 6 horas apresentou sonolência, torpor e sinais de descerebração. Nova tomografia mostrou sangue no espaço subaracnóideo e nos ventrículos. Uma angiografia realizada de emergência demonstrou laceração da artéria cerebelar póstero-inferior esquerda com a formação de um pseudoaneurisma. O paciente foi de imediato operado tendo sido realizada a clipagem do pseudoaneurisma com sucesso. Dezesseis dias após o paciente teve alta com exame neurológico normal. PALAVRAS-CHAVE: LCR, punção suboccipital, artéria cerebelar póstero-inferior, angiografia, pseudoaneurisma, laceração.Suboccipital puncture for cerebrospinal fluid (CSF) collection is known to present increased risk for vascular injury when compared with lumbar puncture. However, since easier to perform by experienced hands and without risk of post-puncture headache, it is still favoured by many.We report the laceration of a posterior-inferior cerebellar artery by suboccipital puncture, successfully treated by surgical clipping, without permanent injury. CASEA 27 years old man presented to the emergency room complaining of headache, vomiting and an episode
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