Rebleeding of ruptured cerebral aneurysms during three-dimensional computed tomographic angiography: report of two cases and literature review

Abstract

Although three-dimensional computed tomographic angiography (3D-CTA) is less complicated and time-consuming than conventional cerebral angiography (CCA) and represents a reliable alternative for evaluating cerebral aneurysms, some patients experience aneurysmal rerupture during 3D-CTA. Two women, 79 and 71 years old, who presented with severe subarachnoid hemorrhage (SAH) underwent 3D-CTA within 3 h after SAH onset. Their images clearly indicated extravasation from their aneurysms. Neither patient recovered from deep coma, and both died within 2 days. We reviewed the literature with special reference to the condition of SAH patients at admission and the interval between SAH onset and 3D-CTA, and discuss serious complications of 3D-CTA study. Although aneurysmal rerupture may reflect the natural course, rerupture during 3D-CTA, especially in SAH patients who are in poor clinical condition during the acute stage, should be recognized as a potentially fatal complication. Their blood pressure must be strictly controlled and factors such as their clinical condition and the interval from the ictus must be considered.

Aneurysmal Rebleeding : Factors Associated with Clinical Outcome in the Rebleeding Patients

“…This discrepancy may be due to the difference of emergency medical delivery system. Consistent with previous reports [3][4][5][6]10,11,15) , we experienced rebleeding during angiogram (4 cases) and anesthesia (5 cases). Thus, more careful attention will be necessary while performing these procedures.…”

Active Bleeding in Acute Subarachnoid Hemorrhage Observed by Multiphase Dynamic-Enhanced CT

“…20 Thus, even slight enhancement in the subarachnoid space can be observed more easily on a thick-slab maximum-intensity-projection image than on a volume-rendered image (Fig 3), because volume-rendering is an operator-dependent technique. Although string-shaped extravasation in SAH often mimics vascular structures, [20][21][22][23] multiphase CT imaging is superior to routine CTA, differentiating between extravasation and vascular structures, including aneurysms, because extravasated contrast medium is not washed out in the delayed phase (Fig 4).…”

“…[21][22][23][24][25] In addition, active bleeding from an aneurysm was recently visualized with 4D time-resolved CT angiography. 5 Use of multiphase dynamic enhancement can increase the time window for hemodynamic observation, and the evolution of bleeding Extravasation had a vessel-like shape at the interhemispheric cistern (A, arrow), and spreading contrast extravasation was observed in the left ventricle (B, arrow).…”

Rebleeding from Cerebral Aneurysms during 3DCT Angiography

“…The capacity of CTA for the detection of cerebral aneurysm is reportedly equivalent to that of angiography, and this modality provides more information for performing surgical procedures, and can be performed non-invasively within a short period of time, making it useful for the diagnosis of cerebral aneurysm [13,14]. Nakatsuka et al performed CTA on 28 patients with subarachnoid hemorrhage and reported a rebleeding rate of 17.9% [15], while Hashiguchi et al reported rebleeding in 2 of 61 patients (3.3%) [16]. As rebleeding also occurred in 4 patients (6.7%) in our own series, occurrence during CTA is far from infrequent.…”

“…Table 2 shows a summary of reported cases [16][17][18][19][20][21] Rebleeding was more common in patients with severe subarachnoid hemorrhage and tended to be more frequent in those who underwent CTA within 3 h of initial bleeding, but no consistent findings were seen with respect to aneurysm location. Outcomes were poor for patients who experienced rebleeding.…”