Division of Neurosurgery, The University of Rochester School of Medicine and Dentistry and Strong Memorial Hospital, Rochester, New York Neurosurgery 31; 129-131, 1992 ABSTRACT: A 74-YEAR-OLD woman sought treatment after an initial subarachnoid hemorrhage verified on computed tomographic scan with no focal neurological deficit. Shortly after admission, she sustained a second subarachnoid hemorrhage with acute neurological decompensation. A repeat computed tomographic scan revealed increased blood along the right medial temporal region, as well as in the interhemispheric fissure and bilateral sylvian cisterns. Also evident was a right hemispheric acute subdural hematoma. The patient's rapidly deteriorating neurological status precluded a cerebral angiogram; therefore, a double-dose infusion computed tomographic scan was performed. This revealed a cerebral artery aneurysm adjacent to the right medial temporal hematoma. She was taken to the operating room on the basis of this study. After evacuation of the right hemispheric subdural hematoma and clipping of the right posterior communicating artery aneurysm, the patient made a rapid, full neurological recovery. KEY WORDS: Aneurysm; Doubledose infusion computed tomographic scan; Subdural hematoma; Subarachnoid hemorrhage The patient, a 74-year-old woman, was admitted to a local hospital after an acute onset of an excruciating headache. After an initial transient lethargy, she improved rapidly. She had a computed tomographic (CT) scan at a local hospital, with findings consistent with a subarachnoid hemorrhage. These included a right medial temporal hematoma and blood in the sylvian cisterns bilaterally and the interhemispheric fissure (Fig. 1). She was immediately transferred to the Emergency Department of Strong Memorial Hospital. An examination revealed her to be alert and oriented with no focal neurological deficit. After approximately 10 minutes, the patient acutely deteriorated with a sudden loss of consciousness. She was immediately intubated and noted to be deeply comatose with decerebrate posturing, hypoactive corneal reflexes. Her pupils were 2 mm bilaterally and reactive. An immediate head CT scan was

DISCUSSION Brandt et al. (4) described 4 patients with intracerebral hematoma secondary to a ruptured middle cerebral artery aneurysm who were taken to the operating room suite on the basis of a head CT scan without cerebral angiograms. Three of these patients had a good outcome after aneurysmal clipping. Batjer and Samson (3) also described 4 patients who had emergent aneurysmal surgery without cerebral angiogram who were also in a comatose state preoperatively. In each case, the patient underwent emergent craniotomy for intracerebral hematoma evacuation as well as definitive aneurysmal clipping on the basis of CT correlation alone. In both reports, the authors believed that the delay imposed for diagnostic angiography needed to be avoided in an attempt to save vital minutes in those severely neurologically compromised patients. In those patients who were neurologically stable, even with large intracerebral hematomas, the authors again reiterated the fact that they did not advocate routine performance of acute aneurysmal surgery without definitive angiographic verification. Asari et al. (2) described the delineation of

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AUTHOR(S): Rusyniak, W. George, M.D.; Peterson, Paul C., M.D.; Okawara, ShigeHisa, M.D., Ph.D.; Pilcher, Webster H., M.D., Ph.D.; George, Eugene D., M.D.

obtained and showed an enlargement of her right medial temporal hematoma, more blood in the right sylvian cistern, and an acute subdural hematoma on the right hemisphere (Fig. 2). After this CT scan, a double-dose intravenous contrast infusion (200 ml of Omnipaque 240 [Winthrop-Breon Laboratories, New York, NY]) was given and dynamic CT scanning was started at the level of her sella turcica. After 1.5-mm slices were obtained, a right internal carotid posterior communicating artery aneurysm was evident (Fig. 3). It appeared as a dilation around the origin of the right internal carotid artery. She was taken to the operating room immediately for a craniotomy. The acute subdural hematoma was removed, and then the carotid artery was exposed in the subarachnoid blood. A bilobular right posterior communicating artery aneurysm was found and upon attempted clipping, it initially bled briefly, which necessitated temporary clipping of the internal carotid artery for approximately 5 minutes to control the bleeding. The aneurysm was meanwhile successfully clipped with apparent preservation of both the posterior communicating and the anterior choroidal arteries. Dissection was then carried out distally along the middle cerebral artery. No other aneurysm was found. After the operation, the patient (still under general anesthesia) was taken to neuroradiology for an immediate cerebral angiogram to rule out another aneurysm. Her cerebral angiogram showed clipping of the posterior communicating artery aneurysm with preservation of the right posterior communicating and choroidal arteries (Fig. 4). No other cerebral aneurysm was shown on this study. Several hours later, the patient started to follow simple verbal commands. She showed mild hemiparesis on her left side, with her arm more hemiparetic than her leg. This hemiparesis resolved over the next several days.

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Neurosurgery 1992-98 July 1992, Volume 31, Number 1 129 Acute Subdural Hematoma after Aneurysmal Rupture; Evacuation with Aneurysmal Clipping after Emergent Infusion Computed Tomography: Case Report Case Report

which accurately identified the offending posterior communicating artery aneurysm and facilitated operative intervention. We believe that this technique of double-contrast infusion CT scanning must be considered as a diagnostic option in rapidly deteriorating patients with a space-occupying hematoma secondary to probable aneurysmal rupture. A cerebral angiogram can result in a delay before surgery is undertaken. ACKNOWLEDGMENT We thank Wendy A. Reed for her technical assistance in preparation of the manuscript. Received, November 8, 1991. Accepted, January 8, 1992. Reprint requests: W. George Rusyniak, M.D., 601 Elmwood Avenue-Box 670, Rochester, NY 14642.

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Adams HP, Kassell NF, Torner JC, Sahs AL: CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: A preliminary report of the cooperative aneurysm study. Neurology 33:981-988, 1983. Asari S, Satoh T, Sakurai M, Yamamoto Y, Sadamoto K: Delineation of unruptured cerebral aneurysms by computerized angiotomography. J Neurosurg 57:527- 534, 1982. Batjer HH, Samson DS: Emergent aneurysm surgery without cerebral angiography for the comatose patient. Neurosurgery 28:283-287, 1991. Brandt L, Sonesson B, Ljunggren B, Saveland H: Ruptured middle cerebral artery aneurysm with intracerebral hemorrhage in younger patients appearing moribund: Emergency operation? Neurosurgery 20:925-929, 1987. Newell DW, LeRoux PD, Dacey RG, Stimac GK, Winn HR: CT infusion scanning for the detection of cerebral aneurysms. J Neurosurg 71:175-179, 1989. Schmid UD, Steiger HJ, Huber P: Accuracy of high resolution computed tomography in direct diagnosis of cerebral aneurysms. Neuroradiology 29:152-159, 1987. Weir B, Myles T, Kahn M, Maroun F, Malloy D, Benoit B, McDermott M, Cochrane D, Mohr G, Ferguson G, Durity F: Management of acute subdural hematomas from aneurysmal rupture. Can J Neurol Sci 11:371376, 1984. Winn HR, Newell DW, Mayberg MR, Grady MS, Dacey RG, Eskridge J: Early surgical management of poor-grade patients with intracranial aneurysms. Clin Neurosurg 36:289-298, 1990.

COMMENTS The authors present the case of an elderly patient

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REFERENCES: (1-8)

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unruptured cerebral aneurysms by the method of computerized angiotomography, which consisted of injecting 1 ml/kg of 60% meglumine iothalmate intravenously at a speed of 2 ml/s. The iodine level rose promptly to over 15 mg/ml at 20 seconds after the injection was started and was maintained at higher than 15 mg/ml for the next 20 seconds by the intravenous bolus injection of contrast material (1 ml/kg) at a rate of 2 ml/sec. By maintaining this infusion rate during the high resolution CT scan, they were able to obtain clear images of the cerebral vessels and to delineate 15 unruptured cerebral aneurysms in 86 patients. Most of the aneurysms discovered in the series were more than 5 mm in diameter. Schmid et al. (6) demonstrated that in 102 consecutive patients with 76 angiographically or autopsy-verified cerebral aneurysms as small as 3 mm in diameter, 74 (97.4%) aneurysms were detected. They used a similar high-resolution intravenous contrast scanning technique but with 1.5 mm slices. By using this technique in a neurologically deteriorating patient with a spaceoccupying hematoma, they believed that it could be used to identify an aneurysm of either the middle cerebral artery or the posterior communicating artery. Overall, in this consecutive series of 102 patients with suspected ruptured or unruptured aneurysms who were examined by the infusion CT scanning technique, the false-negative rate was 2.6% and the false-positive rate turned out to be 3%. Newell et al. (5) also tested the sensitivity of this method by examining a group of 39 patients with suspected aneurysmal rupture by using this technique before angiography. Of aneurysms that were 5 mm in size or greater, 97% were detected, whereas 69% of the aneurysms between 2 and 5 mm were visualized by this CT scanning technique. None of the aneurysms less than 2 mm in size were identified. The false-positive rate was reported to be 8.1%. Winn et al. (8) studied 8 patients who sought treatment for spontaneous intracerebral hemorrhage by using this technique. In 5 patients, the CT scan showed an aneurysm that was then confirmed by angiography in 4 patients. In one case, surgery was performed on the basis of the infusion CT scan alone in a rapidly deteriorating patient (8). In this patient, successful clipping of a middle cerebral artery aneurysm was performed, with a postoperative angiogram showing no other evidence of cerebral aneurysms. Whether an individual in a poor neurological condition after a subarachnoid hemorrhage may benefit from early operative intervention still remains controversial among neurosurgeons. Few neurosurgeons, however, would delay surgical intervention in a deteriorating patient with an acute subdural hematoma, which occurs in 1 to 2% of patients with subarachnoid hemorrhage (1,7). In this case, the patient's acute subdural hematoma and neurological decline seemed to be precipitated by her second aneurysmal bleeding, mandating prompt operative intervention. Valuable time was saved in proceeding with a double-dose infusion CT scan,

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with acute worsening of neurological deficit after subarachnoid hemorrhage and subsequent hemorrhage. An aneurysm was demonstrated on computed tomographic (CT) scan by an infusion technique with double dosing and thin (1.5-mm) slices. The patient then underwent emergency surgery with clipping of a posterior communicating artery aneurysm. To the authors' credit, the patient had an extremely good outcome. The technique of double-dose "infusion CT" scanning has been reported by others (2). It should be emphasized that the technique can be performed rapidly (with an additional 10-15 min in scan-length time), that the study should concentrate on the lower cuts (from the floor of the sella turcica to the point just above the anterior communicating artery), and that the scan should be imaged with intermediate window settings (level 80 window, 400 Hounsfield units). The technique sensitivity is directly related to the size of the aneurysm(s) present (2). In the last 65 aneurysms that I have done, only 2 patients have been taken to surgery without the benefit of angiography. Each of these patients had a CT scan before surgery, but neither was an infusion study. Radiological "estimation" of the aneurysm location was correlated with large expansion in perianeurysmal clot found on our CT scans. Unfortunately, the diagnosis of an anterior communicating aneurysm and giant middle cerebral aneurysm were made intraoperatively. Both elderly patients were in poor grades (Hunt and Hess grade IV) (1) before decompensation. I have not been as fortunate as the authors, because one patient died from severe vasospasm and the other has remained neurologically devastated. The additional information of "infusion CT" may not have helped with my two patients and their poor outcomes, because surgery went quite smoothly in both cases. Certainly, clinical grade before the subsequent hemorrhage, coupled with the CT grade, from this time, patient age, and whether the subsequent hemorrhage represents an additional mass effect or just worsening of the subarachnoid hemorrhage, plays a larger role in my mind to outcome than not knowing the precise location and projection of the aneurysm. The exception is that of the posterior circulation aneurysms. Although I am a firm believer in performing angiography in every aneurysm case when feasible, I am not sure that the information gained plays as great a role in outcome as one may believe. More important outcome factors are the time of day the subsequent hemorrhage occurs, whether an experienced team can be gathered together, and the length of time before proceeding with the case. An extra 15 minutes spent in the scanner may make a difference to the patient's eventual recovery. The authors describe a technique that, if time permits, can confirm suspicions regarding the location of the offending aneurysm in these rare cases. Whether infusion scanning improves outcome or only lessens the surgeon's anxiety factor is yet to be proven.

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Figure 2. CT scan after second subarachnoid hemorrhage showing a right mesial temporal hematoma. Also noted is the bottom of the acute right hemispheric subdural hematoma.

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Figure 1. CT scan after initial subarachnoid hemorrhage showing blood in the interhemispheric tissue and bilateral sylvian cisterns. Increased amount of blood noted in right proximal sylvian cistern.

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Figure 4. Postoperative cerebral angiogram showing a clipped right posterior communicating artery aneurysm with the preservation of blood flow in the posterior communicating artery. No other cerebral aneurysms are evident.

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Figure 3. Double-dose infusion CT scan showing apparent abnormal vessel dilation at the proximal right internal carotid artery.

Acute subdural hematoma after aneurysmal rupture; evacuation with aneurysmal clipping after emergent infusion computed tomography: case report.

A 74-year-old woman sought treatment after an initial subarachnoid hemorrhage verified on computed tomographic scan with no focal neurological deficit...
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