Subarachnoid hemorrhage in a case of segmental arterial mediolysis with coexisting intracranial and intraabdominal aneurysms

Abstract

The authors report the rare case of a 58-year-old man with segmental arterial mediolysis (SAM) with associated intracranial and intraabdominal aneurysms, who suffered subarachnoid hemorrhage (SAH) due to rupture of an intracranial aneurysm. This disease primarily involves the intraabdominal arterial system, resulting in intraabdominal and retroperitoneal hemorrhage in most cases. The patient presented with severe headache and vomiting. The CT scans of the head revealed SAH. Cerebral angiography revealed 3 aneurysms: 1 in the right distal anterior cerebral artery (ACA), 1 in the distal portion of the A(1) segment of the right ACA, and 1 in the left vertebral artery. The patient had a history of multiple intraabdominal aneurysms involving the splenic, gastroepiploic, gastroduodenal, and bilateral renal arteries. He underwent a right frontotemporal craniotomy and fibrin coating of the dissecting aneurysm in the distal portion of the A(1) segment of the right ACA, which was the cause of the hemorrhage. Follow-up revealed no significant changes in the residual intracranial and intraabdominal aneurysms. An SAH due to SAM with associated multiple intraabdominal aneurysms is extremely rare. The authors describe their particular case and review the literature pertaining to SAM with associated intracranial and intraabdominal aneurysms.

Pathomorphometry of ruptured intracranial vertebral arterial dissection: adventitial rupture, dilated lesion, intimal tear, and medial defect

“…11,12 Segmental arterial mediolysis is usually found in abdominal arteries; 14 however, recently, segmental arterial mediolysis has been reported in intracranial arterial dissections with and without small arterial dissections in abdominal arteries. 4,13,18 We reported on cases of segmental arterial mediolysis affecting both the intraabdominal and intracranial VAs. 12 In the well-known case report of intracranial VA dissection from Yonas et al, 20 which first shed light on this disease, the cause of death of the patients was not SAH but sudden abdominal hemorrhage.…”

Unexpected intraabdominal hemorrhage due to segmental arterial mediolysis following subarachnoid hemorrhage: A case of ruptured intracranial and intraabdominal aneurysms

“…Locations of the intracranial aneurysm included the ICA, basilar artery, vertebral artery (VA), and anterior cerebral artery. [ 2 4 8 10 12 14 ] An autopsy case of SAM with both intraabdominal and intracranial VA dissections indicated that medial defects, which resemble the vascular lesions found in patients with SAM, are very important in the occurrence of intracranial VA dissections. [ 10 11 ] However, pathological findings of intracranial aneurysm are difficult to obtain except for autopsy cases, so the relationship between intraabdominal and intracranial lesions in SAM is unclear, especially whether the intracranial aneurysm is caused by SAM or not.…”

“…[ 5 7 ] The etiology of SAM is still unclear, but SAM may be a vasospastic disorder and the responsible pressor agent may be norepinephrine. [ 17 18 19 ] Recently, abdominal SAM coexisting with intracranial dissecting aneurysms has been reported in a few cases, [ 2 4 8 10 12 14 ] but the relationship between intraabdominal and intracranial aneurysms in SAM remains unclear. Moreover, concomitant abdominal SAM and ruptured intracranial saccular aneurysm have not been reported previously.…”

Challenging Mimickers of Primary Systemic Vasculitis

“…Other manifestations of SAM include hematochezia, lumbar or flank pain, gross hematuria, acute coronary syndrome, pancreatitis, subarachnoid hemorrhage, and stroke. [47][48][49] Catastrophic presentations caused by arterial rupture, resulting in hemoperitoneum or retroperitoneal bleeding, occur in less than 30% of patients but are associated with high mortality. 50,51 In addition, SAM can also be subclinical and is sometimes identified incidentally when subjects are imaged for other reasons.…”