Fatal recurrent subarachnoid hemorrhage after complete endovascular aneurysm occlusion

Abstract

Endovascular treatment of aneurysms has become an alternative to the neurosurgical approach. Here, we describe a patient presenting with a subarachnoid hemorrhage (SAH) due to a basilar tip aneurysm, which was completely occluded with coils. Fourteen days later the patient died due to massive recurrent SAH. Histologic evaluation showed aneurysm rerupture with coil dislocation in the subarachnoid space. This is a rare histologically documented case of fatal recurrent hemorrhage early after coil embolization of cerebral aneurysms.

Fig 1.

Preinterventional angiogram of the basilar tip aneurysm. Anteroposterior (A) and 3D view (B) demonstrate a basilar tip aneurysm, which is directed posteriorly.

Fig 2.

Postinterventional angiogram of the basilar tip aneurysm. Unsubtracted (A) and corresponding subtracted (B) anteroposterior view after endovascular treatment shows complete angiographic occlusion of the aneurysm. The coils are located inside the aneurysm.

Fig 3.

Control angiogram 4 days after coiling for suspected vasospasm. The coil package is in identical shape and position. The aneurysm is still completely occluded, and there is no evidence of vasospasm. This projection is slightly different from that shown in Fig 2.

Fig 4.

Postmortem changes of the brain and aneurysm. On autopsy, massive acute subarachnoid hemorrhage was present in the basal cisterns (A). Moreover, massive brain swelling was found. There is no evidence for basilar artery thrombosis. Histologic presentation of plastic-embedded toluidine-stained sections of the aneurysm (B) shows the basal artery (arrow) running into the sac of the aneurysm (dotted arrows), which is partially occluded by coils. The lumen of the aneurysm between the coils is filled by a fibrin meshwork and erythrocytes. No signs of organization or absorption, like macrophages, fibroblasts, or capillaries, are present. Note the discontinuity of the anterior wall of the aneurysm (arrowhead). The basal artery and aneurysm are shown at a parasagittal level in 4 C. At the top left the sac of the aneurysm, (arrow), at the top right (ie, anterior to the basilar artery, dotted arrows), a fresh coagulum with longitudinally and perpendicularly oriented coils is located outside the aneurysm ventral to the basilar tip. Close view of 1 of the coils outside of the aneurysm, (D) surrounded by fresh coagulum, shows the nylon guide within the coil in polarized light.