Warning Signs in the Era of Unruptured Intracranial Aneurysms: Report on 2 Cases of Fatal Aneurysmal Hemorrhage

Abstract

<b><i>Introduction:</i></b> The timing of treatment remains unresolved for patients with unruptured intracranial aneurysms (UIAs) and headaches, particularly when the pain is short term, localized, and related to the aneurysm site. We lack evidence to support the notion that when a headache accompanies an aneurysm, it elevates the risk of rupture. <b><i>Results:</i></b> We describe 2 cases of fatal subarachnoid hemorrhage in patients with a history of headache and known aneurysms. Both of these patients had good indications for treatment: a young age and an aneurysm >7 mm, and both were qualified for elective surgery. However, both patients died of fatal aneurysm ruptures before the planned surgery. <b><i>Conclusion:</i></b> These cases suggested that treatment should be started as soon as possible, when a UIA is diagnosed based on a short-term period of severe headaches or when a UIA is observed and then severe headaches appear. There is no straightforward guideline for treatment timing in these patients. However, in this era of UIAs, the significance of sentinel headaches should be reevaluated. Given the incidence of headaches in the general population and the very low risk of aneurysm rupture, there may be a tendency to neglect the role of headache as a possible warning sign.

Acute hemicranial pain accompanied with a pearl and string type dissection of intracranial vertebral artery: Consideration for the time when to finish the medical observation

“…[ 20 ] Hemorrhage or infarction due to ICVAD usually occurs concurrently with headache or neurological symptoms, but headache may sometimes precede vascular events. [ 8 , 9 ] Therefore, if some of the typical features of ICVAD, such as pain on occipito-nuchal region, unilateral, severe, acute, are accompanied by initial headache, angiographic studies using CTA or MRA can easily provide early detection of ICVAD. [ 16 , 21 ]…”

“…However, there are reports supporting evidence that conservatively managed ICVADs have a potential risk of delayed hemorrhage or infarction. [ 8 , 9 ] Currently, owing to advances in endovascular treatment technology, more unruptured ICVADs are being treated prophylactically because of uncertainties about prognosis. [ 7 , 10 ] In order to prevent subsequent bleeding that may occur due to the progression of dissection, ICVADs which are thought to be prone to bleeding should be recognized early.…”

“…Headache can be a warning sign that rupture is imminent, but neither pain intensity nor angiographic characteristics are reliable predictors of dissection progression. [ 9 , 14 , 15 ] Headache relief is not necessarily a sign of a cure; therefore, if pearl and string type ICVADs are found in patients with acute headache, a decision should be made whether to treat it immediately or simply to perform follow-up imaging studies until stabilization of the dissection is confirmed.…”