Table of Contents
Washington University Experience | VASCULAR | Aneurysm - Saccular | 13A0 Case 13 History
Case 13 History ---- The patient is a 45 year old right handed female in good health until age 29, when she was found semi-conscious with dysarthria. She was hospitalized for "nervous breakdown”, and returned to her baseline. At age 31 she had the acute onset of extremely severe headache and was again hospitalized for a nervous breakdown. She was thereafter asymptomatic until July 1979, when she developed bi-frontal .headaches. Head CT scan revealed ring-like calcifications in the region of the trigone of the right middle cerebral artery. There was also lucency in the right frontal lobes suggesting previous infarction. Intense staining with contrast was seen in the region of the suprasellar cistern and anterior 3rd ventricle. A four vessel cerebral angiography was performed and revealed enlarged intracranial aneurysm at the neck of the right middle cerebral artery, a second 1 cm diameter aneurysm at the origin of the right posterior communicating artery, a 2 cm multi-lobulated aneurysm at the tip of the basilar artery, another aneurysm was seen at the bifurcation of the left middle cerebral artery. Because outside neurosurgical advice was to be obtained the patient was sent home for 2 weeks. She apparently did well until 10/11/79, when the patients husband heard the patient fall to the floor and found her not breathing with blood coming from her nose. He resuscitated her until she gradually developed gasping respirations. She was otherwise unresponsive. Periorbital ecchymoses were found involving in the left eye and chin. Blood was seen behind the left ear drum and in the nose. The pupils were 4/3 RRL, although sluggish on the right. The patient had a partial left 3rd nerve palsy with a right medial rectus weakness. Visual fields were full. A subhyaloid hemorrhage was seen in the right fundus. Sensation, motor strength, and coordination were normal. The patient was diffusely hyperreflexic with ankle clonus and bilateral Babinski’s. Head and CT scan revealed blood along the falx consistent with subarachnoid hemorrhage. Lumbar puncture showed grossly bloody CSF with an opening pressure of 310 mms. The patient was treated with Dilantin, Amicar, sedation and steroids. Mental status gradually improved over the next few days. On 10/23 the patient underwent repeat cerebral angiography. Multiple aneurysms were as previously described except for a change in the right internal carotid aneurysm which was felt to be the aneurysm which had bled. Mild diffuse spasm was seen both in the anterior and posterior circulations. Two days post-angiogram the patient became considerably more lethargic. A repeat heat CT s revealed no major hydrocephalus. Because the patient had a persistent increase intracranial pressure a ventriculostomy was placed on 10/28. On 10/30 a VA shunt was performed. On 11/1 frontal craniectomy was done with clipping of the right internal carotid aneurysm. Post -operatively the patient had a mild to moderate left hemiparesis which resolved over the next week. She was intermittently lethargic and disoriented. On 11/11 (10 days post-surgery) the patient suddenly deteriorated. At that time she was comatose with deep slow respirations. Ice water calorics were negative. Gag reflex was present. The patient was bilaterally decerebrate to deep pain with bilateral clonus and Babinski reflexes. Head and CT scan revealed marked edema of the right hemisphere with right to left shift and obliteration of the right lateral ventricle. On 11/12 the patient had no spontaneous respiration and was maintained on the ventilator. She remained in this state until death on 11/27/79.
