J Cerebrovasc Endovasc Neurosurg.  2015 Jun;17(2):113-119. 10.7461/jcen.2015.17.2.113.

Seven Intracranial Aneurysms in One Patient: Treatment and Review of Literature

• Ahmed O
• Kalakoti P
• Hefner M
• Cuellar H
• Guthikonda B

• KMID: 1879343
• DOI: http://doi.org/10.7461/jcen.2015.17.2.113

Abstract

Before the advent of endovascular coiling, patients with multiple intracranial aneurysms were treated with surgical clipping; however, with the advancements in endovascular technology, intracranial aneurysms can be treated with surgical clipping and/or endovascular coiling. We describe a case of subarachnoid hemorrhage in a patient with 7 intracranial aneurysms. A 45-year-old female developed a sudden headache and left sided hemiparesis. Initial workup showed a subarachnoid hemorrhage in the right Sylvian fissure. Further angiographic workup showed 7 intracranial aneurysms (left and right middle cerebral artery bifurcation, right middle cerebral artery, anterior communicating artery, left posterior communicating artery, right posterior inferior cerebellar artery, and left superior cerebellar artery). The patient underwent two craniotomies for surgical clipping of the anterior circulation aneurysms and endovascular stent-assisted coils for the posterior circulation aneurysms. The need for anti-platelet agents for endovascular treatment of the posterior circulation aneurysms and clinical presentation warranted surgical clipping of the anterior circulation aneurysms prior to endovascular therapy. We describe a case report and decision making for a patient with multiple intracranial aneurysms treated with surgical clipping and endovascular coiling.

Keyword

Aneurysm; Coiling; Clipping; Subarachnoid hemorrhage; Intracranial

MeSH Terms

Aneurysm
Arteries
Craniotomy
Decision Making
Female
Headache
Humans
Intracranial Aneurysm*
Middle Aged
Middle Cerebral Artery
Paresis
Subarachnoid Hemorrhage
Surgical Instruments

Figure

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  Fig. 1 CT head without contrast showing a hyperdensity in the right Sylvian fissure.

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  Fig. 2 Anterior-posterior view of a right carotid injection angiogram. From right to left, the first arrow indicates a right-filling anterior communicating artery aneurysm. The second arrow indicates a M1 aneurysm. The third arrow indicates a middle cerebral artery (MCA) bifurcation aneurysm. The MCA bifurcation aneurysm was the suspected ruptured aneurysm based on the clinical presentation.

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  Fig. 3 Anterior-posterior view of a left carotid injection angiogram. The arrow indicates a middle cerebral artery bifurcation aneurysm.

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  Fig. 4 Lateral view of a left carotid injection angiogram identifying the posterior communicating artery aneurysm.

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  Fig. 5 Anterior-posterior view of a right vertebral injection angiogram showing a right posterior inferior cerebellar artery aneurysm and a left superior cerebellar artery aneurysm.

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  Fig. 6 3D reconstruction of the right carotid artery.

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  Fig. 7 3D reconstruction of the left carotid artery.

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  Fig. 8 3D reconstruction of the right vertebral artery. The left superior cerebellar artery has a wide neck, which required a stent-assisted coil and use of anti-platelet agents.

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  Fig. 9 Angiogram showing obliteration of the left posterior communicating, left middle cerebral, and anterior communicating artery aneurysms.

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  Fig. 10 Angiogram showing obliteration of the posterior circulation aneurysms with endovascular therapy.

Reference

1. Baumann F, Khan N, Yonekawa Y. Patient and aneurysm characteristics in multiple intracranial aneurysms. Acta Neurochir Suppl. 2008; 103:19–28. PMID: 18496941.

2. Bederson JB, Awad IA, Wiebers DO, Piepgras D, Haley EC Jr, Brott T, et al. Recommendations for the management of patients with unruptured intracranial aneurysms: A Statement for healthcare professionals from the Stroke Council of the American Heart Association. Stroke. 2000; 11. 31(11):2742–2750. PMID: 11062304.

3. Chyatte D, Fode NC, Sundt TM Jr. Early versus late intracranial aneurysm surgery in subarachnoid hemorrhage. J Neurosurg. 1988; 9. 69(3):326–331. PMID: 3404227.

4. de Gans K, Nieuwkamp DJ, Rinkel GJ, Algra A. Timing of aneurysm surgery in subarachnoid hemorrhage: a systematic review of the literature. Neurosurgery. 2002; 2. 50(2):336–342. discussion 340-2PMID: 11844269.

5. Ellamushi HE, Grieve JP, Jager HR, Kitchen ND. Risk factors for the formation of multiple intracranial aneurysms. J Neurosurg. 2001; 5. 94(5):728–732. PMID: 11354403.

6. Findlay JM. Current management of aneurysmal subarachnoid hemorrhage guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci. 1997; 5. 24(2):161–170. PMID: 9164696.

7. Heiskanen O. Risk of rebleeding from unruptured aneurysm in cases with multiple intracranial aneurysms. J Neurosurg. 1981; 10. 55(4):524–526. PMID: 7277000.

8. Hong T, Wang Y. Unilateral approach to clip bilateral multiple intracranial aneurysms. Surg Neurol. 2009; 8. 72(Suppl 1):S23–S28. PMID: 18514280.

9. Imhof HG, Yonekawa Y. Management of ruptured aneurysms combined with coexisting aneurysms. Acta Neurochir Suppl. 2005; 94:93–96. PMID: 16060246.

10. Inagawa T, Hirano A. Autopsy study of unruptured incidental intracranial aneurysms. Surg Neurol. 1990; 12. 34(6):361–365. PMID: 2244298.

11. Inagawa T. Surgical treatment of multiple intracranial aneurysms. Acta Neurochir (Wien). 1991; Jan-Feb. 108(1-2):22–29. PMID: 2058422.

12. Isaksen J, Egge A, Waterloo K, Romner B, Ingebrigtsen T. Risk factors for aneurysmal subarachnoid hemorrhage: the Tromso study. J Neurol Neurosurg Psychiatry. 2002; 8. 73(2):185–187. PMID: 12122180.

13. Jeon P, Kim BM, Kim DJ, Kim DI, Suh SH. Treatment of multiple intracranial aneurysms with 1-stage coiling. AJNR Am J Neuroradiol. 2014; 6. 35(6):1170–1173. PMID: 24371032.

14. Juvela S, Porras M, Heiskanen O. Natural history of unruptured intracranial aneurysms: a long-term follow-up study. J Neurosurg. 1993; 8. 79(2):174–182. PMID: 8331397.

15. Juvela S. Prevalence of risk factors in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage. Arch Neurol. 1996; 8. 53(8):734–740. PMID: 8759979.

16. Kassell NF, Torner JC, Jane JA, Haley EC Jr, Adams HP. The international cooperative study on the timing of aneurysm surgery. Part 2: surgical results. J Neurosurg. 1990; 7. 73(1):37–47. PMID: 2191091.

17. Laidlaw JD, Siu KH. Ultra-early surgery for aneurysmal subarachnoid hemorrhage: outcomes for a consecutive series of 391 patients not selected by grade or age. J Neurosurg. 2002; 8. 97(2):250–258. PMID: 12186450.

18. Lawton MT, Quinones-Hinojosa A, Sanai N, Malek JY, Dowd CF. Combined Microsurgical and Endovascular Management of Complex Intracranial Aneurysms. Neurosurgery. 2003; 2. 52(2):263–274. discussion 274-5PMID: 12535354.

19. McCormick WF, Acosta-Rua GJ. The size of intracranial saccular aneurysms. An autopsy study. J Neurosurg. 1970; 10. 33(4):422–427. PMID: 5471931.

20. Mizoi K, Suzuki J, Yoshimoto T. Surgical treatment of multiple aneurysms: review of experience with 372 cases. Acta Neurochir (Wien). 1989; Jan-Feb. 96(1-2):8–14. PMID: 2929394.

21. Mount LA, Brisma R. Treatment of multiple intracranial aneurysms. J Neurosurg. 1971; 12. 35(6):728–730. PMID: 5117224.

22. Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid hemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol. 2009; 7. 8(7):635–642. PMID: 19501022.

23. Qureshi AI, Suarez JI, Parekh PD, Sung G, Geocadin R, Bhardwaj A, et al. Risk factors for multiple intracranial aneurysms. Neurosurgery. 1998; 7. 43(1):22–27. PMID: 9657184.

24. Rinne J, Hernesniemi J, Puranen M, Saari T. Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study. Neurosurgery. 1994; 11. 35(5):803–808. PMID: 7838326.

25. Solander S, Ulhoa A, Vinuela F, Duckwiler GR, Gobin YP, Martin NA, et al. Endovascular treatment of multiple intracranial aneurysms by using Guglielmi detachable coils. J Neurosurg. 1999; 5. 90(5):857–864. PMID: 10223451.

26. Stehbens WE. Etiology of intracranial berry aneurysms. J Neurosurg. 1989; 6. 70(6):823–831. PMID: 2654334.

27. Vajda J. Multiple intracranial aneurysms: a high risk condition. Acta Neurochir (Wien). 1992; Jan-Feb. 118(1-2):59–75. PMID: 1414531.

28. Whitfield PC, Kirkpatrick PJ. Timing of surgery for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2001; (2):CD001697. PMID: 11405999.

29. Winn HR, Almaani WS, Berga SL, Jane JA, Richardson AE. The long-term outcome in patients with multiple aneurysms. Incidence of late hemorrhage and implications for treatment of incidental aneurysms. J Neurosurg. 1983; 10. 59(4):642–651. PMID: 6886785.

30. Xavier AR, Rayes M, Pandey P, Tiwara A, Kansara A, Guthikonda M. The safety and efficacy of coiling multiple aneurysms in the same session. J Neurointerv Surg. 2012; 1. 4(1):27–30. PMID: 21990433.