Virginia Research Day 2021

RUPTURED GIANT INTERNAL CAROTID ARERTY ANEURYSM Jacob LaGrone, DO & James Rixey, DO Sovah Health Internal Medicine Residency Program, Danville, VA

RC-255

Background: Intracerebral hemorrhage accounts for about 10% of all strokes and has very high morbidity and mortality. Cerebral artery aneurysm rupture accounts for only a small portion of these and have devastating consequences. Chief Complaint & History : A 73-year-old Caucasian female presented to the emergency department (ED) with aphasia and right-sided paralysis. In 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. Figure 11 Past Medical History: Hypertension, coronary artery disease and MI, ,hyperlipidemia & partial Thyroidectomy. Medications : diltiazem, atorvastatin calciferol, montelukast, potassium chloride, Metoprolol tartrate, ramipril and aspirin: Allergies: None Family History : Father died from heart failure; Mother and paternal grandmother died of cerebral hemorrhage. Social History: Lives at home with husband. Completes all activities of daily living independently. No history of tobacco, alcohol or illicit drug use. Vital Signs: Temp: 101.0 F; Pulse: 111; BP: 158/112; Resp 22; Oxygen sat 93% on non-rebreather mask. Pertinent Physical Findings : Unresponsive frail- elderly appearing Caucasian female, symmetrical 2 mm fixed pupils and NIH stroke scale of 24, right periorbital swelling, agonal breathing and decerebrate posturing, right-sided contracted extremities with withdrawal to noxious stimuli and a Foley catheter in place Review of Systems : Unable to be obtained.

Clinical Course : Patient was admitted and given anti- platelet therapy with rectal aspirin. Duke Telestroke Program advised that surgical and/or intervascular treatment of the aneurysm was not feasible due to the extent of cerebral necrosis around the aneurysm. Due to persistent dysphagia a PEG tube was placed and statin therapy and clopidogrel were initiated. On hospital day 3, the patient had worsening right periorbital swelling, decreased responsiveness and labored breathing leading to intubation. A repeat non-contrast CT of head demonstrated a new acute right parasellar lobulated area (2.1 x 1.6 cm) consistent with a giant intra carotid artery aneurysm and right temporal/ intraventricular hemorrhage consistent with aneurysm rupture. Figure 2 Ultimately, patient’s family decided on comfort measures only and shortly thereafter patient expired. Discussion: This was an atypical presentation of acute intracranial hemorrhage from a ruptured aneurysm which was initially seen on imaging and not amendable to surgical intervention due to a concomitant acute cerebral infarct in an area away from the intracranial aneurysm. Conclusion: C erebral aneurysm 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 intervascular treatment techniques.

Pertinent Diagnostic Studies: WBC: 23.26, Ammonia 96, SGPT 27, SGOT 23, T. Bili 0.4, Arterial Blood Gas: pH 7.33, pCO2 65.8, PO2 73.6, HCO3 33.8 , Abdominal Ultrasound was normal, and hepatitis panel was negative. Awake and sleep EEGs were negative for seizures.

Figure 1 : ED Head CT Angiogram: Aneurysm on Right Side Anterior Communicating Artery

Figure 2 : Hospital Day 3 Head CT without contrast with ruptured Aneurysm

References: • Etminan N, Rinkel GJ. Unruptured intracranial aneurysms: development, rupture and preventive management. Nat Rev Neurology 2016: 12:699. • Rinkel GJE. Management of patients with unruptured intracranial aneurysms . Current Opin Neurology 2019; 32:49 • Ellis, JA, Nossek E, Kronenburg A, et al. Intracranial Aneurysm: Diagnostic Monitoring, Current Interventional Practices and Advances . Current Treatment Options Cardiovascular Medicine 2018; 20:94.

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