Unexpected intraabdominal hemorrhage due to segmental arterial mediolysis following subarachnoid hemorrhage: A case of ruptured intracranial and intraabdominal aneurysms

Abstract

Background:Segmental arterial mediolysis (SAM) is an uncommon vascular disease, which manifests as catastrophic intraabdominal hemorrhage caused by rupture of visceral dissecting aneurysms in most cases. The etiology of SAM is still unclear, but SAM may be a vasospastic disorder and the responsible pressor agent is norepinephrine. Recently, abdominal SAM coexisting with intracranial dissecting aneurysms has been reported, but the relationship between intraabdominal and intracranial aneurysms in SAM remains unclear, as no cases of concomitant abdominal SAM and ruptured intracranial saccular aneurysm have been reported.Case Description:A 49-year-old woman underwent emergent clipping for a ruptured saccular aneurysm at the left C1 portion of the internal carotid artery. Intraoperatively, norepinephrine was continuously administered intravenously under general anesthesia. Four days after the subarachnoid hemorrhage (SAH), the patient suddenly developed shock due to massive hematoma in the abdominal cavity. Imaging showed multiple aneurysms involving the splenic artery, gastroduodenal artery, common hepatic artery, and superior mesenteric artery. Coil embolization of the splenic artery was performed immediately to prevent bleeding. Subsequent treatment for cerebral vasospasm following SAH was performed with prevention of hypertension, and the patient recovered with left temporal lobe infarction. The diagnosis was abdominal SAM based on the clinical, imaging, and laboratory findings.Conclusion:Norepinephrine release induced by SAH and/or iatrogenic administration of norepinephrine may have promoted abdominal SAM in this case. Abdominal SAM may occur subsequent to rupture of ordinary saccular aneurysm, and may provoke catastrophic abdominal hemorrhage in the spasm stage after SAH.

A Case of Segmental Arterial Mediolysis: Hemoperitoneum with Hemorrhagic Shock due to Rupture of a Visceral Artery Aneurysm Following Subarachnoid Hemorrhage

“…Regarding aneurysm morphology, dissecting aneurysms are frequently reported, but saccular aneurysms may also be formed. 3,4,11) The anterior communicating artery aneurysm in this patient was small and irregularly shaped and no finding clearly suggested dissection in the intraoperative observation. Moreover, as SAM was not originally considered, histopathological tissue was not evaluated.…”

“…These may have been a cause of visceral artery aneurysm rupture or promoted hemoperitoneum. Many SAM cases in which hemoperitoneum developed in the acute phase of SAH were reported from Japan, 3,4,[6][7][8][9][10]12) suggesting a racial difference concerning onset. However, are the internal carotid artery and vertebral artery.…”

“…Several SAM cases with hemoperitoneum that developed in the acute phase of SAH from intracranial aneurysm rupture were recently reported. [3][4][5][6][7][8][9][10][11][12] Case reports of SAM with hemoperitoneum that developed in the acute phase of SAH are presented in Table 1. Based on analysis of the present case and previously reported cases, hemoperitoneum the accumulation and investigation of patients are necessary.…”

“…Moreover, induction of subarachnoid and hemoperitoneum by the rupture of SAM-induced intracranial and visceral artery aneurysms within a short time has been reported, although it is rare. [2][3][4][5][6][7][8][9][10][11][12] We report a patient in whom an aneurysm ruptured in a visceral artery 6 days after the onset of SAH induced by rupture of an anterior communicating artery aneurysm, causing hemorrhagic shock.…”

Rare Mesenteric Arterial Diseases: Fibromuscular Dysplasia and Segmental Arterial Mediolysis and Literature Review

“…To improve our understanding of these diseases, we recently reviewed the reported cases of FMD and SAM in the gastroenterologic regions (3,9,11,15-29) and reported the characteristics of imaging studies. For a further understanding of the clinical characteristics, we updated the information, focusing on cases reported within the past 20 years, since imaging modalities have shown significant advances in this time period (30-78). Based on the obtained information, CT revealed stenosis and aneurysmal changes in 33 cases (77%) of FMD and aneurysm, dissection, occlusion, and stenosis in 28 cases (88%) of SAM.…”