Multiple Intracranial Aneurysms Presented with Subarachnoid Hemorrhage; Which to Secure and How?

Abstract

BACKGROUND: Dealing with multiple intracranial aneurysms (MIA) presenting with subarachnoid hemorrhage (SAH) is challenging.OBJECT: To make a proposal for the decision-making regarding which aneurysm to secure and how, as the most challenging part in the management of MIA. METHODS: This descriptive study included 25 patients presenting with SAH and having multiple intracranial aneurysms. All patients had a brain computed tomography (CT) scan, CT angiography (CTA), and digital subtraction angiography (DSA). Patients were treated in our institution using microsurgical clipping and/or endovascular embolization according to the clinical and radiological situation. Functional outcome was assessed by modified Rankin scale. RESULTS: Fifteen females and 10 males with average age of 48 years were included. All patients (100%) presented with hemorrhage. Ten patients (40%) were hunt and Hess (H&H) grade I, seven patients (28%) grade II, 3 patients (12%) grade III, 3 patients (12%) grade V and 2 patients (8%) grade IV. Fisher scale was grade II in 11 patients (44%), grade IV in 9 patients (36%) and 5 patients (20%) were grade III. Criteria for the suspected ruptured aneurysm were aneurysm wall irregularity in 24 patients (96%) and the largest size in 23 cases (92%). The epicenter of hemorrhage was a satisfactory localizing sign on CT in only 10 cases (40%). Fifty-six aneurysms were encountered in the 25 patients; 19 patients (76%) had 2 aneurysms and 6 patients (24%) had 3 aneurysms. Clipping was done for 40 aneurysms (71%), wrapping for 2 aneurysms (3%), 4 aneurysms (7%) were followed up, 8 aneurysms (14%) were coiled, and 2 aneurysms (3%) were treated by flow diverters. Twenty patients (80%) had a good outcome on the modified Rankin scale, 4 patients (16%) had mental changes and one patient (4%) had residual neurological deficit. CONCLUSION: The ruptured one in multiple intracranial aneurysms can be suspected by its size and wall irregularity especially in the absence of localizing sign in the CT scan. High-resolution CTA and/or 3D DSA are highly helpful. These cases should be managed in specialized centers where the surgical and endovascular treatment modalities are available.