American Journal of Neuroradiology 26:1370-1371, June-July 2005
© 2005 American Society of Neuroradiology
Case Report
INTERVENTIONAL
Extravasation from Rupturing Aneurysm Demonstrated by 3D Digital Subtraction Angiography
Hiroshi Manabea,
Atsuhito Takemuraa,
Seiko Hasegawaa,
Morio Nagahatab and
Yoshiki Ikoa
a Department of Neurosurgery, Kuroishi City Hospital, Kuroishi Aomori, Japan
b Department of Radiology, Kuroishi City Hospital, Kuroishi Aomori, Japan
Address correspondence to Hiroshi Manabe, MD, Department of Neurosurgery, Kuroishi City Hospital, 70, Kitami-cho Kuroishi Aomori, 036-0541, Japan
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Abstract
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Summary: We describe the 3D digital subtraction angiography
(3D-DSA) image of extravasation from a rupturing aneurysm. This
image clearly showed that the extravasation was coming from
a pseudoaneurysm on an aneurysmal wall. To the best of our knowledge,
this is the first demonstration of a 3D-DSA image of a rupturing
aneurysm.
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Introduction
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Although it is known that a fragile pseudoaneurysm forms at
the rupture site on a ruptured irregularly shaped aneurysm (
1),
to the best of our knowledge clear angiographic demonstration
of a rupture from the fragile pseudoaneurysm has not been reported.
Recent development of 3D radiologic images makes it possible
to demonstrate the fine structure of the cerebral arteries.
We report here the first demonstration of a 3D rotational digital
subtraction angiography (3D-DSA) image of extravasation from
a pseudoaneurysm on an aneurysmal wall.
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Case Report
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A 49-year-old woman was admitted to our department after complaining
of severe headache, the cause of which was diagnosed as subarachnoid
hemorrhage by CT scan. She was well oriented and showed no focal
neurologic deficit. Angiography was performed following the
CT scan. Angiography of the left internal carotid artery revealed
an anterior communicating artery aneurysm, which had a small
daughter aneurysm on its anterior wall (
Fig 1). To clarify the
exact anatomic relationship between the aneurysm neck and bilateral
anterior cerebral arteries, which was thought to be useful preoperative
or preembolization information, 3D-DSA (Integris Allura; Philips,
Best, the Netherlands) was performed. During rotation of the
C-arm, rebleeding of the aneurysm occurred. An extravasation
of the contrast media from the daughter aneurysm was visible
on the 3D-DSA image (
Fig 2). The 3D-DSA image also revealed
that the daughter aneurysm had a connection to the aneurysm
dome with very narrow lumen (
Fig 3). This finding suggested
that the daughter aneurysm was not a true aneurysm, but a pseudoaneurysm
located on the rupture site. After the rebleeding, the patient
was in a comatose state. Therefore, she underwent emergency
aneurysmal neck clipping and hematoma removal, and this was
followed by ventricle-peritoneal shunt 5 weeks after the operation.
She showed good postoperative recovery and returned to her home
on foot with only slight mental impairment 8 weeks after the
operation.
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FIG 1. Lateral view of the left internal carotid angiogram taken immediately before the rerupture shows a small daughter aneurysm on its anterior wall (arrow).
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FIG 2. 3D-DSA image of the left internal carotid angiography during the rerupture of the aneurysm clearly demonstrates a jet of blood flow (small arrows) coming from the daughter aneurysm (large arrow).
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FIG 3. 3D-DSA image of waters view reveals that the daughter aneurysm (small arrow) has connection to the aneurysm dome with very narrow space (large arrow). The asterisk indicates the extravasation.
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Discussion
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This is the first demonstration of an extravasation from rupturing
aneurysm imaged by 3D-DSA. The jet of blood flow coming from
the pseudoaneurysm was clearly shown. Nomura et al. suggested
that a ruptured, irregularly shaped aneurysms might be accompanied
by a fragile pseudo-aneurysm-like cavity located at the rupture
point (
1). This 3D-DSA image supported this hypothesis and clearly
demonstrated that the fragile pseudoaneurysm was formed at a
rupture site on the irregularly shaped aneurysm.
To ensure a clear image, greater volume of contrast media should be injected for a longer duration (3–4 mL/s for 5 seconds, for a total volume of 15–20 mL) for cerebral 3D-DSA than for usual cerebral angiography. It is well known that rebleeding in the acute stage is predominant within 6 hours from the initial subarachnoid hemorrhage (2, 3). The rebleeding rate during angiography within 6 hours after initial bleeding has been reported as 3.1–3.3% (4, 5), which is higher than the rebleeding rate during angiography beyond 6 hours. As the pressure wave of the injected contrast media may overcome the weak wall of the rupture site even during normal cerebral angiography (6), we should keep it mind that the rebleeding rate might be higher during cerebral 3D-DSA than during ordinary cerebral DSA for acutely ruptured aneurysms.
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References
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- Nomura H, Kida S, Uhiyama N, et al. Ruptured irregularly shaped aneurysms: pseudoaneurysm formation in a thrombus located at the rupture site. J Neurosurg 2000;93:998–1002[Medline]
- Inagawa T, Kamiya K, Ogasawra H, et al. Rebleeding of ruptured intracranial aneurysms in the acute stage. Surg Neurol 1987;28:93–99[Medline]
- Yasui N, Suzuki A, Ohta H, et al. Rebleeding attack of the cerebral aneurysm: clinical significance of the early aneurysmal rebleeding. No Shinkei Geka 1985;13:61–68[Medline]
- Komiyama M, Tamura K, Nagata Y, et al. Aneurysmal rupture during angiography. Neurosurgery 1993;33:798–803[Medline]
- Sampei T, Yasui N, Mizuno M, et al. Contrast medium extravasation during cerebral angiography for ruptured intracranial aneurysm: clinical analysis of 26 cases. Neurol Med Chir (Tokyo) 1990;30:1011–1015[Medline]
- Saitoh H, Hayakawa K, Nishimura K, et al. Intracranial blood pressure change during contrast medium injection. AJNR Am J Neuroradiol 1996;17:51–54[Abstract]
Received June 28, 2004;
accepted after revision August 24, 2004.
TOP
Abstract
Introduction