Motor aphasia after acute surgery for

ruptured proximal middle cerebral artery

aneurysm: case report

Leite MJ, Camelo Pinto A.

Service of Neurosurgery and PRM (Unit of brain lesions), Centro Hospitalar do Porto, Hospital Santo António, Porto, Portugal

Introduction:

The word aneurysm comes from the Latin word aneurysma, wich means dilatation. Aneurysm is an abnormal dilatation in the wall of blood vessels, due to a defect, disease, or injury.

The true incidence of intracranial aneurysm is estimated at 1-6 % of the population, typically becoming symptomatic in people aged 40-60 years. Aneurysms can be true or false. A

false aneurysm is a cavity lined by blood clot. The 3 major types of true intracranial aneurysms are saccular, fusiform, and dissecting. Saccular aneurysms are rounded outpouchings

that arise from arterial bifurcation, most commonly in the circle of Willis. Aneurysms of the middle cerebral artery (MCA) account for 18-22 % of all aneurysms.

The common causes of intracranial aneurysm include hemodynamically induced or degenerative vascular injury, atherosclerosis (typically leading to fusiform aneurysms), underlying

vasculopathy (eg, fibromuscular dysplasia), and high-flow states, as in arteriovenous malformation (MAV) and fistula.

Case report:

The authors describe a case of a 40 years old woman, without cardiovascular risk factors, smoking or alcohol habits, with history of headaches with 2 weeks of evolution that

suddenly begins an acute confusional state. At admission she was lethargic, without verbal response, not localizing pain and with Babinski sign at right; GCS score of 9 and Hunt and

Hess grade of 3.

Cerebral CT (fig.1) revealed insular hematoma in apparent continuity with subarachnoid hemorrhage filling the sylvian fissure. Cerebral CT angiography (fig.2 and 3) showed 2

aneurysms in the M1 (projected inferiorly) and M2 (projected superiorly) bifurcation. The patient was treated surgically (transsylvian approach) to prevent the risk of repeated

hemorrhage and vasospasm on the day after admission. The proximal aneurysm was clipped and the distal was wrapped. Postoperative cranial CT revealed sylvian hematoma without

apparent rebleeding and basal ganglia infarction.

Six months after surgery and rehabilitation she had no motor deficits and Broca aphasia.

Discussion:

The risk of rupture among aneurysms that have not bled is unknown. A study (International Study of Unruptured Intracranial Aneurysms –ISUIA) published in 1998 (rectrospective)

and 2003 (prospective) outlined to determine natural history risk of rupture, found that for aneurysms smaller than 7 mm and those located at the anterior circulation the risk of

rupture was 0,05 % per year.Thus, small and asymptomatic aneurysms are managed in a conservative way. Cigarette smoking, female sex, younger age and hypertension have

recently been shown to correlate with aneurysm growth and rupture.

During the past 15 years, endovascular methods have been developed and refined to treat intracraneal aneurysms. At this time there is much controversy with the obliteration of an

aneurysm (ruptured or unruptured) with coiling and clipping. Current data suggest that coiling is safer at least in the acute perioperative period, whereas clipping is slightly more

durable.

The major causes of morbidity and mortality associated with ruptured aneurysms include misdiagnosis, rebleeding, hydrocefhalus and vasospasm. Early referral to a hospital with

experienced physicians, early treatment and agressive treatment of vasospasm are 3 factors that have been correlated with improved outcomes. Administration of calcium channel

blockers shoud be possible to all patients to prevent vasospasm. Triple “H” therapy (hypertension, hemodilution, and hypervolemia) remains the most important medical management

of vasospasm, but, in refractory cases in wich medical management fails, it is used endovascular methods. Peaks incidence are between days 6 and 8 after subarachnoid hemorrhage

(rarely before day 3) . Clinically is diagnosed as deterioration in mental status or focal neurologic deficits. Transcranial Doppler is frequently used as a noninvasive diagnostic tool

and is sensitive to changes in the vessel caliber of the larger vessels of the circle of Willis.

Controversy exist between early (within 48-96h) and late (>10-14d) surgery, with the first advocated to reduce the risk of rebleeding and vasospasm (lavage of spasmogenic agents,

allowing induction of arterial hypertension and volume expansion without danger of aneurysmal rerupture); and the second one proclaming the inflammation and brain edema

following subarachnoid hemorrhages, complicating brain retraction; with an incidence of vasospasm due to mechanotrauma to vessels increased. The advent of endovascular coiling

as a less invasive modality of treatment that does not require brain manipulation is expected to continue the ability to treat patients in the early period

This patient in particular, without cardiovascular risk factors, smoking or alcohol habits, despite the critical care, presented a postoperative infarctation in the lenticulostriate

territory, possibly related to retraction injury

Conclusion:

As reported in the literature this case suggests that critical care should be taken in the management of M1 artery aneurysms; thus, preventing surgical complications, such as

retraction injury, which may result in neurologic deficits.

Bibliography:

1. Jonathan L Brisman et al; Cerebral Aneurysm; www.emedicine.com; May 22, 2009.

2. Dong-Hyuk Park et al, Angiographic features, surgical management and outcomes of proximal middle cerebral artery aneurysms; Clinical Neurology and Neurosurgery; 2008; 110:

544–551

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