Posterior Communicating Artery Aneurysm: Unrecognized Previous Aneurysm Rupture, Acute Ischemic Stroke Symptoms Due to Post-Hemorrhagic Vasospasm, Emergent Balloon-Assisted Coil Occlusion, and Repeated Intra-arterial Vasospasmolysis with Acceptable Clinical Outcome

Abstract

A patient with acute hemiparesis on the left-hand side and acute dysarthria and suffering from headaches for the past week presented at the emergency department of the referring hospital. Based on a non-contrast CT examination within normal limits, his symptoms were misdiagnosed as an acute ischemic stroke with an assumed large vessel occlusion. As a result of the stroke work-up in our hospital, however, a profound vasospasm and a large PcomA aneurysm on the right-hand side were identified. The aneurysmal subarachnoid hemorrhage (SAH) was responsible for the post-hemorrhagic vasospasm, which in turn caused the clinical signs and symptoms. The aneurysm was subsequently treated by balloon-assisted coil occlusion, and the patient underwent multiple endovascular treatments with intra-arterial vasospasmolysis during the following days. The patient’s outcome was acceptable although minor infarction caused by the vasospasm could not be prevented. The sufficient occlusion of the aneurysm was confirmed by a follow-up DSA after 3 months. This case history illustrates that the clinical symptoms and the imaging results of a patient with an SAH are sometimes misleading. Despite rapid and uneventful treatment of the ruptured aneurysm, post-hemorrhagic vasospasm is frequently the key reason for a poor clinical outcome.