V.S. Panuntsev, V.A. Pak, L.V. Rozhchenko
(Polenov Research Neurosurgical Institute, Saint Petersburg)
Male patient S., aged 53, was admitted with complaints of bursting headaches, reduction of vision acuity, marked hypomnesia, unsteady gait, weakness in the left arm and leg. Before admission he had suffered repeated cerebral-subarachnoid-ventricular hemorrhages (2005).
On admission neurological symptoms were represented by gross intellectual-mnemic disorders, left-side pyramidal insufficiency, moderate static and dynamic cerebellar ataxia. Ophthalmologic examination revealed resolving hemorrhage into the vitreous body of the right eye. MRI was indicative of a round formation with an irregular structure, spreading into the interpeduncular cistern and anterior segments of the IIIrd ventricle; besides, there was considerable dilation of lateral ventricles. CT and computed angiography demonstrated dilation of the ventricular system (D=S=21 mm). There was a hyperdense irregular formation with heterogenic density (35.8x17.1 mm), located in the interpeduncular cistern in the area of oral segments of the stem and anterior segments of the IIIrd ventricle. It partially blocked Monro’s foramen, spread into the body of the left lateral ventricle and compressed chiasm cisterns (thrombosed aneurysm). According to angiographic data, a size of aneurysm, located in the area of bifurcation of the basilar artery and near branching of the superior cerebellar artery, was 14.9´7.3 mm. Examination by a therapist revealed the third stage of hypertension with signs of marked chronic coronary insufficiency. There was an attempt to perform endovasal occlusion of aneurysm (4.10.05); but it failed because of inability to ensure adequate catheterization of the vertebral artery. There was no augmentation of focal neurological symptoms after intervention. The patient was transferred to the resuscitation unit, where he suddenly lost consciousness and stopped breathing. Examination, carried out after effective resuscitative measures, was indicative of subarachnoid hemorrhage. There was marked psychomotor excitement, watched in the patient during the next three weeks, then his state became stable. The second attempt to catheterize the basilar artery with a microcatheter was made on October 26, 2005 (22 days after hemorrhage); however, it was impossible to introduce a coil into aneurysm. A postoperative course was uneventful. Superselective embolization of aneurysm with two detachable platinum coils was made on November 2, 2005. Control angiography revealed no filling of aneurysm. Postoperatively one could watch symptoms of damage of frontal lobes and Hakim-Adams syndrome. There were no signs of congestion in the eye fundus. Ventriculoperitoneal shunting was made with the purpose of hydrocephalus correction. Its symptoms regressed.
The demonstration goal was to show possibility of achieving good clinical results in complex treatment of giant aneurysm, complicated by hydrocephalus development.