A 47-year-old female presented with spontaneous SAH. Computed tomography angiography (CTA) demonstrated diffuse SAH and intraventricular haemorrhage [Figure 1a]. Four aneurysms were identified including an 8 mm basilar apex aneurysm, a 7 mm anterior communicating artery (AComm) aneurysm, and smaller bilateral middle cerebral artery aneurysms [Figure 1b]. Based on the pattern of bleeding and the size of the aneurysms, the basilar apex aneurysm was identified as the source of bleeding.
Catheter angiography on postbleed day (PBD) #1 showed irregularity at the basilar apex with no filling of the dome of the basilar aneurysm, consistent with spontaneous thrombosis [Figure 2a-d]. The AComm aneurysm was treated with coil embolization. No anticoagulation was given.
CTA on PBD #2 showed no filling of the basilar aneurysm. Catheter angiography on PBD #8 showed moderate vasospasm of the basilar artery, fullness of the basilar apex with less irregularity of the apex, but no filling of the dome or neck of the aneurysm [Figure 2e-f]. Routine CT imaging showed progressive resolution of SAH and the neurological exam improved. The patient was transferred to a long-term acute care facility after an 18-day hospital stay. At the time of discharge she was arousable to voice and following simple commands with a mild paresis of the left upper extremity and paralysis in the right upper extremity.
A rapid decline in her neurologic functioning occurred on PBD #26. Head CT showed new acute SAH in the fourth ventricle and in the prepontine cistern, extending inferiorly along the medulla [Figure 3a]. Catheter angiography on PBD #27 showed recanalization of the basilar apex aneurysm [Figure 3b-d]. There was no filling of the anterior communicating artery aneurysm. The basilar artery aneurysm was treated with coil embolization [Figure 3e and f].