Virginia Research Day 2021

Medical Resident Research Case Reports

25 Ruptured Giant Internal Carotid Artery Aneurysm

Jacob LaGrone, DO; James Rixey, DO Corresponding author: michael.moore1@LPNT.net

SOVAH Health Internal Medicine Residency Program

Context: Intracerebral hemorrhage accounts for about 10% of all US strokes and has a high morbidity and mortality. Cerebral artery aneurysmal rupture accounts typically for only a small portion of these and has devastating consequences. Case Report: A 73-year-old Caucasian female presented to the Emergency Department (ED) with aphasia and right-sided paralysis. An ED, head CT demonstrated an evolving infarct in the left middle cerebral artery (MCA) distribution with edema and sulci effacement. A Head CT angiogram demonstrated 100% occlusion of the left MCA and left Internal carotid artery (ICA) and a 1.8 cm right anterior communicating artery aneurysm. Review of Systems: Unavailable. Past Medical & Surgical History (Hx): Hypertension, hyperlipidemia, and partial thyroidectomy. Outpatient meds: atorvastatin, metoprolol, and aspirin. Social and Family Hx: Lived at home with spouse. No tobacco, alcohol, or illicit drug use. Mother had cerebral hemorrhage.

Pertinent Admission Physical Exam: BP 158/112, pulse 111, Resp 22, Temp 101.0°F, pulse ox 93% on non-rebreather mask. Unresponsive-frail elderly female with symmetrical 2 mm fixed pupils and a NIH stroke score of 24. Right periorbital swelling, agonal breathing, decerebrate posturing, right side contracted extremities with withdrawal to noxious stimuli, and a Foley. Treatment: Contact was made with the Duke University Telestroke program which after examining the patient and her CT studies advised that no intervention was possible due to the extent of cerebral tissue necrosis. She was admitted and given rectal aspirin. Surgical and/or endovascular treatment of the cerebral aneurysm was not feasible due to the extent of cerebral necrosis around the aneurysm. Due to persistent dysphagia, a PEG tube was placed and a statin and clopidogrel were begun. On hospital day 3, she had worsening right periorbital swelling, decreased responsiveness, and labored breathing leading to intubation. A non-contrasted head CT demonstrated a new acute right parasellar lobulated area (2.1 x 1.6 cm) consistent with a giant internal carotid artery aneurysm and right temporal/

intraventricular hemorrhage consistent with aneurysm rupture. The patient’s family decided on comfort measures only and shortly afterwards she expired. Diagnosis: Acute right temporal hemorrhage with intraventricular and subarachnoid extension secondary to anterior cerebral artery ruptured aneurysm. Comments: This case was an atypical presentation of an acute intercranial hemorrhage from a ruptured aneurysm which was previously seen on imaging and not amendable to surgical intervention due to a concomitant acute cerebral infarct in an area away from the intercranial aneurysm. It illustrates how devastating an intercranial hemorrhage can be. Conclusion: Cerebral aneurysmal rupture is associated with significant morbidity and mortality. Up to 50% of individuals do not survive an aneurysm rupture and most survivors suffer a neurologic deficit. This case demonstrates the importance of prompt management of a cerebral artery aneurysm rupture with strategies that often can combine operative and/ or endovascular treatment techniques.

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