Case 18 - Posterior Communicating Artery Aneurysm, Leading to IPH: CT, Arteriogram

Dr. Yousem has provided the following report as a sample report for your reference. It does not match the case reviewed in the video.

Hematoma from PCOM aneurysm

Indication: Patient found unresponsive by neighbor. Posturing.

Technique: Axial CT scan images were performed from the foramen magnum to the vertex without administration of intravenous contrast.

Findings:
These images demonstrate a large rounded area of hyperintense blood products seen emanating from the supraclinoid left side. This measures approximately 3.1 x 3.1 cm in size. There is subarachnoid hemorrhage. There is also subdural hematoma overlying the left hemispheric measuring approximately 8 mm in greatest dimension. There is subfalcine herniation and uncal herniation with shift of midline
at the level of the septum pellucidum measuring 9 mm. Blood products also extend into the interhemispheric fissure and along the tentorium. There is dilatation of the temporal horn of the right lateral ventricle likely from mass effect and entrapment. The midbrain is deviated by the hematoma.
The calvarium is unremarkable. Mastoid air cells and paranasal sinuses are clear.

IMPRESSION:
Rounded hematoma in the medial aspect of the left temporal lobe affecting being the uncus and communicating with the supraclinoid left side of the brain likely on the basis of aneurysm formation with hematoma. Extension into the subdural space of the left hemisphere and tentorium and interhemispheric parafalcine region raises the possibility of trauma.

Subfalcian and uncal herniation and right temporal horn dilatation.

Recommend CTA to assess for aneurysm versus conventional arteriography.

Angiography

HISTORY:58-year-old female who presented with headaches and loss of consciousness found to have a subarachnoid hemorrhage, left temporal clot, and left-sided subdural hematoma with angiogram demonstrating 5 mm left posterior communicating artery aneurysm

VESSELS CATHETERIZED:
Right common femoral artery
Left internal carotid artery
Left middle cerebral artery (highest order)

VESSELS STUDIED:
Left internal carotid artery: Head: Magnified AP and lateral
(pre-embolization)
Left internal carotid artery: Head: Magnified AP and lateral
(pre-detachment first coil)
Left internal carotid artery: Head: Magnified AP and lateral (post 5 coil)
Left internal carotid artery: Head: AP and lateral (final control)

INTERPRETATION:
Left internal carotid artery: Head: Magnified AP and lateral
(pre-embolization): Injection reveals the presence of a widely patent ICA that leads to a patent ACA and MCA. There is a 5 mm cerebral aneurysm in the region of the left posterior communicating artery. The aneurysm is bilobed and "snowman" shaped. This is the source the patient's subarachnoid hemorrhage. The visualized portions of the capillary and venous phases are unremarkable. No contrast extravasation.

Left internal carotid artery: Head: Magnified AP and lateral (pre-detachment first coil): Coil mass attached to delivery device visualized within the aneurysm. No contrast extravasation. No coil prolapses into the parent vessel. There is aneurysm filling.

Left internal carotid artery: Head: Magnified AP and lateral (post 5 coils): Additional coil mass visualized within the aneurysm. No contrast extravasation. No coil prolapses into the parent vessel. There is complete occlusion of the aneurysm dome.  

Left internal carotid artery: Head: AP and lateral (final control): Injection reveals the presence of a widely patent left ICA that leads to a patent ACA and MCA. Coil mass visualized within the left posterior
communicating artery aneurysm. There is complete occlusion of the aneurysm dome. No contrast extravasation. No coil prolapses into the parent vessel. The parenchymal and venous phases are otherwise unremarkable.

IMPRESSION:
1. Successful coil embolization of left posterior communicating artery aneurysm as described above.
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Indication: Postop aneurysm treatment

Technique: Axial CT scan images were performed from the foramen magnum to the vertex without administration of intravenous contrast.

Findings:

These images demonstrate a left temporal craniectomy defect as well as coils in the left supraclinoid aneurysm. The hematoma in the medial aspect of the left temporal lobe persists. There is enlargement of the lateral ventricles in the interval since the prior examination earlier in the day. There is blood products layering along the tentorial edge and there is pneumocephalus over the left frontal lobe. The craniectomy has resulted in removal of the subdural hematoma. The left cerebrum is swollen. There is midline shift measuring approximately 7 mm currently. Intraventricular hemorrhage is present.

IMPRESSION:

Interval coiling of the left supraclinoid aneurysm with left craniectomy resulting in removal of left-sided subdural hematoma.

Interval enlargement of the lateral ventricles. Reduction in midline shift from 9 mm to 7 mm from left to right. Persistent subdural hematomas along the tentorium.