American Journal of Neuroradiology 24:709-710, April 2003
© 2003 American Society of Neuroradiology
Case Report
BRAIN
Development of De Novo Intracranial Aneurysm in Three Months: Case Report and Literature Review
M. Gisele Matheusa and
Mauricio Castilloa
a From the Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, NC
Address reprint requests to Mauricio Castillo, MD, University of North Carolina, Department of Radiology, Campus Box 7510, Chapel Hill, NC 27599-7510
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Abstract
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Summary: Formation of de novo intracranial aneurysms is rare.
Their etiology is not known, but they are seen in patients with
inherited collagen disorders, polycystic kidney disease, and
familial history of aneurysms. Most de novo intracranial aneurysms
are found 3–20 years after diagnosis of the initial aneurysm.
We report the imaging findings in a 46-year-old man who developed
a de novo intracranial aneurysm only 3 months after surgical
clipping of another aneurysm.
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Introduction
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Development of a de novo aneurysm is rare, with a frequency
of 0.84–1.8% per year (
1–
6). De novo aneurysms most
commonly appear in the anterior circulation (
7). Risk factors
involved in the development of these aneurysms are unclear.
Sex, inherited factors, hemodynamic changes, hypertension, and
cigarette smoking correlate with the higher prevalence of de
novo aneurysms, but how each factor contributes to the physiopathology
and how they interact are unknown. To exclude the development
of new aneurysms, follow-up angiography 6 months to 5 years
after aneurysm treatment is recommended (
1–
6,
8). We present
the imaging findings in a patient who developed a de novo aneurysm
in the anterior circulation after clip placement in another
aneurysm. We believe that the short period in which this aneurysm
developed is very unusual.
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Case Report
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A 46-year-old man had an acute onset of slurred speech and altered
behavior. A few hours later, he developed right hemiparesis,
and a CT scan revealed an acute hemorrhage in the left basal
ganglia. The patient was transferred to our hospital for further
evaluation and treatment. Physical examination revealed a right
lateral gaze, right-central seventh cranial nerve palsy, mild
right hemiparesis, slurred speech, and confusion. The patient
smoked a pack of cigarettes a day and had a history of hypertension
but no familial history of aneurysms. An MR image showed the
acute hemorrhage in the left basal ganglia and blood in the
laterals and fourth ventricle. Three-dimensional time-of-flight
MR angiography of the circle of Willis revealed a saccular aneurysm
measuring approximately 1.5 cm in diameter arising from the
anterior communicating artery. Angiographic findings confirmed
the aneurysm (
Fig 1), and the patient was taken to the operating
room, where an uneventful clip-placement procedure was performed.
Three months after surgery, follow-up digital subtraction angiography
revealed no evidence of a neck remnant or aneurysm at the site
of the clip but a well-defined, new 1–2-mm de novo saccular
aneurysm at the origin of the left ophthalmic artery (
Fig 2).
Treatment of this new aneurysm is pending.
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FIG 1. Preoperative digital subtraction angiogram after injection of the left internal carotid artery, confirming the presence of the saccular aneurysm of the anterior communicating artery. No other aneurysms are seen.
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FIG 2. Follow-up digital subtraction angiogram of the left internal carotid artery, obtained 3 months after the preoperative angiogram. There is a well-defined sacular de novo aneurysm (arrow) in the origin of the left ophthalmic artery. A clip had been placed in the previous anterior communicating aneurysm.
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Discussion
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In 1964, Graf and Hamby (
9) reported the formation of a new
aneurysm and introduced the term "de novo" aneurysm. Since then,
the formation of new aneurysms remains one of the concerns in
the post-treatment follow-up of patients treated for intracranial
aneurysms. The pathophysiology of aneurysm formation involves
changes in the vascular connective tissue such as the presence
or formation of "loci minoris resistantial" and hemodynamic
stress. A defect in the arterial media or injury to the elastic
lamina (loci minoris resistantial) correlates with a failure
of embryonic vessels or acquired changes in vessel walls, resulting
from degenerative processes, trauma, hormonal changes, and connective-tissue
diseases (
10,
11). Hemodynamic stress such as that induced by
carotid artery ligation, hypertension, or anatomic variations
in the circle of Willis also correlates with aneurysm formation.
Aneurysm formation may also be related to hereditary factors.
There is a high prevalence of aneurysm formation in some heritable
connective disorders. For example, patients with Ehlers-Danlos
syndrome type IV, Marfan syndrome, neurofibromatosis type I,
autosomal dominant polycystic kidney disease, and other disorders
are known to develop aneurysms. Overall, these disorders are
found in approximately 5% of patients with intracranial aneurysms
(
6). In the familial form of intracranial aneurysms, members
of a family demonstrate a tendency toward aneurysm formation
when no associated disorders are present. Between 7% and 20%
of patients with aneurysmal subarachnoid hemorrhage have a first-
or second-degree relative with a history of an intracranial
aneurysm (
6,
12,
13). Some familial lines support an autosomal
dominant inheritance, and others support autosomal recessive
or multifactorial transmission, and thus the inheritance pattern
responsible for the aneurysm formation is still unclear (
6,
12). Other factors that appear to correlate with aneurysm formation
are hypertension, female sex, middle age, and cigarette smoking
(
2,
3,
6,
8,
10,
14–
16). Risk factors that correlate with
de novo aneurysm formation appear to be similar to those described
above, in addition to a history of multiple intracranial aneurysms
(
1,
4,
5,
12,
14,
15,
17–
22).
Although all the factors described above correlate with a higher prevalence of de novo aneurysm in several studies, no consistent pattern has been described. The only common significant risk factor that has been observed is cigarette smoking (2–4, 6, 8, 12, 15, 16, 19). The risk factors for rupture are the same for both types of aneurysms (ie, familial vs non-familial) (8, 11, 21). In reality, the incidence of de novo aneurysms may be higher than accepted, because many patients may die before the diagnosis is established.
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Conclusion
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Development of de novo aneurysms is rare; they are found most
commonly 3–20 years after the first aneurysm. In our patient,
the de novo aneurysm grew in 3 months, an occurrence seldom
reported in the literature (
1,
21). This observation suggests
that at least some patients, even after successful aneurysm
treatment, need routine angiographic follow-up studies. In addition,
a new subarachnoid hemorrhage in a patient with a previously
treated aneurysm dictates the need for a search of a de novo
aneurysm and not only detailed evaluation of the original aneurysm.
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Received June 5, 2003;
accepted after revision July 8, 2003.
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Abstract
Introduction