Neurosurgical Review

, Volume 39, Issue 4, pp 711–716 | Cite as

A 54-year-old man with 12 intracranial aneurysms and familial subarachnoid hemorrhage: case report

  • Sayied Abdol Mohieb HosaineyEmail author
  • Torstein R. Meling
Case Report


Unruptured intracranial aneurysms occur in 1–3 % of the general population, and the risk of rupture is generally considered to be low. However, patients with multiple aneurysms and familial predisposition carry a particular risk of subarachnoid hemorrhage (SAH). A 54-year-old hypertensive man underwent screening with a head CT angiography (CTA) because of his comorbidities. CTA revealed multiple bilateral aneurysms around the circle of Willis. At first surgery, seven aneurysms were clipped (BA, ACOM, ICA ×2, and MCA ×3), two of which were detected intraoperatively only. During the second surgery, another three aneurysms were surgically clipped (PCOM and MCA ×2), one of which was detected intraoperatively. Follow-up angiography revealed another two aneurysms. A PCOM aneurysm was treated by coil embolization and a VA aneurysm clipped surgically during a third admission. The patient made an uneventful recovery. However, 4 months after his second surgery, his daughter underwent surgical clipping of a right-sided ICA aneurysm. This case report highlights both the importance of screening of high risk patients with family history of SAH, as well as its limitations, as our patient developed two de novo aneurysms during 6-month follow-up and CTA preoperatively missed three small aneurysms.


Endovascular coil embolization Familial subarachnoid hemorrhage Unruptured intracranial aneurysm Multiple aneurysms Subarachnoid hemorrhage Surgical clipping 



Anterior cerebral artery


Anterior communicating artery


Anterior choroidal artery


Basilar artery


Familial intracranial aneurysm


Internal carotid artery


Intracranial aneurysm


International Study of Unruptured Intracranial Aneurysms


Middle cerebral artery


Odds ratio


Posterior communicating artery


Subarachnoid hemorrhage


Vertebral artery


Compliance with ethical standards

Written informed consent was obtained from the patient.

Financial disclosure



  1. 1.
    Alfano JM, Kolega J, Natarajan SK, Xiang J, Paluch RA, Levy EI, Siddiqui AH, Meng H (2013) Intracranial aneurysms occur more frequently at bifurcation sites that typically experience higher hemodynamic stresses. Neurosurgery 73:497–505. doi: 10.1227/NEU.0000000000000016 CrossRefPubMedGoogle Scholar
  2. 2.
    Blane G (1800) History of some cases of disease in the brain, with an account of the appearance upon examination after death, and some general observations on complaints of the head. Trans Soc Improv Med Chir Knowl 192–198Google Scholar
  3. 3.
    Bor AS, Koffijberg H, Wermer MJ, Rinkel GJ (2010) Optimal screening strategy for familial intracranial aneurysms: a cost-effectiveness analysis. Neurology 74:1671–1679. doi: 10.1212/WNL.0b013e3181e04297 CrossRefPubMedGoogle Scholar
  4. 4.
    Bor AS, Rinkel GJ, van Norden J, Wermer MJ (2014) Long-term, serial screening for intracranial aneurysms in individuals with a family history of aneurysmal subarachnoid haemorrhage: a cohort study. Lancet Neurol 13:385–392. doi: 10.1016/S1474-4422(14)70021-3 CrossRefPubMedGoogle Scholar
  5. 5.
    Broderick JP, Brown RD Jr, Sauerbeck L, Hornung R, Huston J 3rd, Woo D, Anderson C, Rouleau G, Kleindorfer D, Flaherty ML, Meissner I, Foroud T, Moomaw EC, Connolly ES, Investigators FIAS (2009) Greater rupture risk for familial as compared to sporadic unruptured intracranial aneurysms. Stroke 40:1952–1957. doi: 10.1161/STROKEAHA.108.542571 CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Chapman AB, Rubinstein D, Hughes R, Stears JC, Earnest MP, Johnson AM, Gabow PA, Kaehny WD (1992) Intracranial aneurysms in autosomal dominant polycystic kidney disease. N Engl J Med 327:916–920. doi: 10.1056/NEJM199209243271303 CrossRefPubMedGoogle Scholar
  7. 7.
    Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P, American Heart Association Stroke C, Council on Cardiovascular R, Intervention, Council on Cardiovascular N, Council on Cardiovascular S, Anesthesia, Council on Clinical C (2012) Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 43:1711–1737. doi: 10.1161/STR.0b013e3182587839 CrossRefPubMedGoogle Scholar
  8. 8.
    Connolly HM, Huston J 3rd, Brown RD Jr, Warnes CA, Ammash NM, Tajik AJ (2003) Intracranial aneurysms in patients with coarctation of the aorta: a prospective magnetic resonance angiographic study of 100 patients. Mayo Clin Proc 78:1491–1499. doi: 10.4065/78.12.1491 CrossRefPubMedGoogle Scholar
  9. 9.
    Ellamushi HE, Grieve JP, Jager HR, Kitchen ND (2001) Risk factors for the formation of multiple intracranial aneurysms. J Neurosurg 94:728–732. doi: 10.3171/jns.2001.94.5.0728 CrossRefPubMedGoogle Scholar
  10. 10.
    Huttunen T, von und zu Fraunberg M, Frosen J, Lehecka M, Tromp G, Helin K, Koivisto T, Rinne J, Ronkainen A, Hernesniemi J, Jaaskelainen JE (2010) Saccular intracranial aneurysm disease: distribution of site, size, and age suggests different etiologies for aneurysm formation and rupture in 316 familial and 1454 sporadic eastern Finnish patients. Neurosurgery 66:631–638. doi: 10.1227/01.NEU.0000367634.89384.4B, discussion 638CrossRefPubMedGoogle Scholar
  11. 11.
    Investigators UJ, Morita A, Kirino T, Hashi K, Aoki N, Fukuhara S, Hashimoto N, Nakayama T, Sakai M, Teramoto A, Tominari S, Yoshimoto T (2012) The natural course of unruptured cerebral aneurysms in a Japanese cohort. N Engl J Med 366:2474–2482. doi: 10.1056/NEJMoa1113260 CrossRefGoogle Scholar
  12. 12.
    Juvela S, Porras M, Heiskanen O (1993) Natural history of unruptured intracranial aneurysms: a long-term follow-up study. J Neurosurg 79:174–182. doi: 10.3171/jns.1993.79.2.0174 CrossRefPubMedGoogle Scholar
  13. 13.
    Juvela S, Porras M, Poussa K (2008) Natural history of unruptured intracranial aneurysms: probability of and risk factors for aneurysm rupture. J Neurosurg 108:1052–1060. doi: 10.3171/JNS/2008/108/5/1052 CrossRefPubMedGoogle Scholar
  14. 14.
    Juvela S, Poussa K, Lehto H, Porras M (2013) Natural history of unruptured intracranial aneurysms: a long-term follow-up study. Stroke 44:2414–2421. doi: 10.1161/STROKEAHA.113.001838 CrossRefPubMedGoogle Scholar
  15. 15.
    Krischek B, Inoue I (2006) The genetics of intracranial aneurysms. J Hum Genet 51:587–594. doi: 10.1007/s10038-006-0407-4 CrossRefPubMedGoogle Scholar
  16. 16.
    Krisht AF, Gomez J, Partington S (2006) Outcome of surgical clipping of unruptured aneurysms as it compares with a 10-year nonclipping survival period. Neurosurgery 58:207–216. doi: 10.1227/01.NEU.0000194638.61073.FC, discussion 207-216CrossRefPubMedGoogle Scholar
  17. 17.
    Leblanc R (1996) Familial cerebral aneurysms. A bias for women. Stroke 27:1050–1054CrossRefPubMedGoogle Scholar
  18. 18.
    Li MH, Chen SW, Li YD, Chen YC, Cheng YS, Hu DJ, Tan HQ, Wu Q, Wang W, Sun ZK, Wei XE, Zhang JY, Qiao RH, Zong WH, Zhang Y, Lou W, Chen ZY, Zhu Y, Peng DR, Ding SX, Xu XF, Hou XH, Jia WP (2013) Prevalence of unruptured cerebral aneurysms in Chinese adults aged 35 to 75 years: a cross-sectional study. Ann Intern Med 159:514–521. doi: 10.7326/0003-4819-159-8-201310150-00004 CrossRefPubMedGoogle Scholar
  19. 19.
    Lovelock CE, Rinkel GJ, Rothwell PM (2010) Time trends in outcome of subarachnoid hemorrhage: population-based study and systematic review. Neurology 74:1494–1501. doi: 10.1212/WNL.0b013e3181dd42b3 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Mackey J, Brown RD Jr, Moomaw CJ, Sauerbeck L, Hornung R, Gandhi D, Woo D, Kleindorfer D, Flaherty ML, Meissner I, Anderson C, Connolly ES, Rouleau G, Kallmes DF, Torner J, Huston J 3rd, Broderick JP, Fia II (2012) Unruptured intracranial aneurysms in the Familial Intracranial Aneurysm and International Study of Unruptured Intracranial Aneurysms cohorts: differences in multiplicity and location. J Neurosurg 117:60–64. doi: 10.3171/2012.4.JNS111822 CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Magnetic Resonance Angiography in Relatives of Patients with Subarachnoid Hemorrhage Study G (1999) Risks and benefits of screening for intracranial aneurysms in first-degree relatives of patients with sporadic subarachnoid hemorrhage. N Engl J Med 341:1344–1350. doi: 10.1056/NEJM199910283411803 CrossRefGoogle Scholar
  22. 22.
    Mahindu A, Koivisto T, Ronkainen A, Rinne J, Assaad N, Morgan MK (2008) Similarities and differences in aneurysmal subarachnoid haemorrhage between eastern Finland and northern Sydney. J Clin Neurosci 15:617–621. doi: 10.1016/j.jocn.2007.08.018 CrossRefPubMedGoogle Scholar
  23. 23.
    Morita A, Fujiwara S, Hashi K, Ohtsu H, Kirino T (2005) Risk of rupture associated with intact cerebral aneurysms in the Japanese population: a systematic review of the literature from Japan. J Neurosurg 102:601–606. doi: 10.3171/jns.2005.102.4.0601 CrossRefPubMedGoogle Scholar
  24. 24.
    Muller TB, Sandvei MS, Kvistad KA, Rydland J, Haberg A, Vik A, Garseth M, Stovner LJ (2013) Unruptured intracranial aneurysms in the Norwegian Nord-Trondelag Health Study (HUNT): risk of rupture calculated from data in a population-based cohort study. Neurosurgery 73:256–261. doi: 10.1227/01.neu.0000430295.23799.16, discussion 260CrossRefPubMedGoogle Scholar
  25. 25.
    Nehls DG, Flom RA, Carter LP, Spetzler RF (1985) Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg 63:342–348. doi: 10.3171/jns.1985.63.3.0342 CrossRefPubMedGoogle Scholar
  26. 26.
    Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ (2009) Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol 8:635–642. doi: 10.1016/S1474-4422(09)70126-7 CrossRefPubMedGoogle Scholar
  27. 27.
    Olsson C, Thelin S, Stahle E, Ekbom A, Granath F (2006) Thoracic aortic aneurysm and dissection: increasing prevalence and improved outcomes reported in a nationwide population-based study of more than 14,000 cases from 1987 to 2002. Circulation 114:2611–2618. doi: 10.1161/CIRCULATIONAHA.106.630400 CrossRefPubMedGoogle Scholar
  28. 28.
    Qureshi AI, Suarez JI, Parekh PD, Sung G, Geocadin R, Bhardwaj A, Tamargo RJ, Ulatowski JA (1998) Risk factors for multiple intracranial aneurysms. Neurosurgery 43:22–26, discussion 26-27CrossRefPubMedGoogle Scholar
  29. 29.
    Rasing I, Nieuwkamp DJ, Algra A, Rinkel GJ (2012) Additional risk of hypertension and smoking for aneurysms in people with a family history of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 83:541–542. doi: 10.1136/jnnp-2011-301147 CrossRefPubMedGoogle Scholar
  30. 30.
    Regalado E, Medrek S, Tran-Fadulu V, Guo DC, Pannu H, Golabbakhsh H, Smart S, Chen JH, Shete S, Kim DH, Stern R, Braverman AC, Milewicz DM (2011) Autosomal dominant inheritance of a predisposition to thoracic aortic aneurysms and dissections and intracranial saccular aneurysms. Am J Med Genet A 155A:2125–2130. doi: 10.1002/ajmg.a.34050 CrossRefPubMedGoogle Scholar
  31. 31.
    Regalado ES, Guo DC, Villamizar C, Avidan N, Gilchrist D, McGillivray B, Clarke L, Bernier F, Santos-Cortez RL, Leal SM, Bertoli-Avella AM, Shendure J, Rieder MJ, Nickerson DA, Project NGES, Milewicz DM (2011) Exome sequencing identifies SMAD3 mutations as a cause of familial thoracic aortic aneurysm and dissection with intracranial and other arterial aneurysms. Circ Res 109:680–686. doi: 10.1161/CIRCRESAHA.111.248161 CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Rinne J, Hernesniemi J, Niskanen M, Vapalahti M (1995) Management outcome for multiple intracranial aneurysms. Neurosurgery 36:31–37, discussion 37-38CrossRefPubMedGoogle Scholar
  33. 33.
    Rinne J, Hernesniemi J, Puranen M, Saari T (1994) Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study. Neurosurgery 35:803–808CrossRefPubMedGoogle Scholar
  34. 34.
    Ronkainen A, Hernesniemi J, Ryynanen M (1993) Familial subarachnoid hemorrhage in east Finland, 1977-1990. Neurosurgery 33:787–796, discussion 796-797CrossRefPubMedGoogle Scholar
  35. 35.
    Ruigrok YM, Buskens E, Rinkel GJ (2001) Attributable risk of common and rare determinants of subarachnoid hemorrhage. Stroke 32:1173–1175CrossRefPubMedGoogle Scholar
  36. 36.
    Ruigrok YM, Rinkel GJ, Algra A, Raaymakers TW, Van Gijn J (2004) Characteristics of intracranial aneurysms in patients with familial subarachnoid hemorrhage. Neurology 62:891–894CrossRefPubMedGoogle Scholar
  37. 37.
    Sawyer B, Sawyer PH (1993) Medieval Scandinavia: from conversion to reformation, Circa 800-1500. University of Minnesota PressGoogle Scholar
  38. 38.
    Sonobe M, Yamazaki T, Yonekura M, Kikuchi H (2010) Small unruptured intracranial aneurysm verification study: SUAVe study, Japan. Stroke 41:1969–1977. doi: 10.1161/STROKEAHA.110.585059 CrossRefPubMedGoogle Scholar
  39. 39.
    Stegmayr B, Eriksson M, Asplund K (2004) Declining mortality from subarachnoid hemorrhage: changes in incidence and case fatality from 1985 through 2000. Stroke 35:2059–2063. doi: 10.1161/01.STR.0000138451.07853.b6 CrossRefPubMedGoogle Scholar
  40. 40.
    Takeuchi S, Karino T (2010) Flow patterns and distributions of fluid velocity and wall shear stress in the human internal carotid and middle cerebral arteries. World Neurosurg 73:174–185. doi: 10.1016/j.surneu.2009.03.030, discussion e127CrossRefPubMedGoogle Scholar
  41. 41.
    Teasdale GM, Wardlaw JM, White PM, Murray G, Teasdale EM, Easton V (2005) The familial risk of subarachnoid haemorrhage. Brain 128:1677–1685. doi: 10.1093/brain/awh497 CrossRefPubMedGoogle Scholar
  42. 42.
    Tsutsumi K, Ueki K, Morita A, Kirino T (2000) Risk of rupture from incidental cerebral aneurysms. J Neurosurg 93:550–553. doi: 10.3171/jns.2000.93.4.0550 CrossRefPubMedGoogle Scholar
  43. 43.
    International Study of Unruptured Intracranial Aneurysms Investigators (1998) Unruptured intracranial aneurysms—risk of rupture and risks of surgical intervention. N Engl J Med 339:1725–1733. doi: 10.1056/NEJM199812103392401 CrossRefGoogle Scholar
  44. 44.
    Vernooij MW, Ikram MA, Tanghe HL, Vincent AJ, Hofman A, Krestin GP, Niessen WJ, Breteler MM, van der Lugt A (2007) Incidental findings on brain MRI in the general population. N Engl J Med 357:1821–1828. doi: 10.1056/NEJMoa070972 CrossRefPubMedGoogle Scholar
  45. 45.
    Vlak MH, Algra A, Brandenburg R, Rinkel GJ (2011) Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 10:626–636. doi: 10.1016/S1474-4422(11)70109-0 CrossRefPubMedGoogle Scholar
  46. 46.
    Wachter D, Kreitschmann-Andermahr I, Gilsbach JM, Rohde V (2011) Early surgery of multiple versus single aneurysms after subarachnoid hemorrhage: an increased risk for cerebral vasospasm? J Neurosurg 114:935–941. doi: 10.3171/2010.10.JNS10186 CrossRefPubMedGoogle Scholar
  47. 47.
    White PM, Teasdale EM, Wardlaw JM, Easton V (2001) Intracranial aneurysms: CT angiography and MR angiography for detection prospective blinded comparison in a large patient cohort. Radiology 219:739–749. doi: 10.1148/radiology.219.3.r01ma16739 CrossRefPubMedGoogle Scholar
  48. 48.
    Wiebers DO, Whisnant JP, Huston J 3rd, Meissner I, Brown RD Jr, Piepgras DG, Forbes GS, Thielen K, Nichols D, O'Fallon WM, Peacock J, Jaeger L, Kassell NF, Kongable-Beckman GL, Torner JC, International Study of Unruptured Intracranial Aneurysms I (2003) Unruptured intracranial aneurysms: natural history, clinical outcome, and risks of surgical and endovascular treatment. Lancet 362:103–110CrossRefPubMedGoogle Scholar
  49. 49.
    Wills S, Ronkainen A, van der Voet M, Kuivaniemi H, Helin K, Leinonen E, Frosen J, Niemela M, Jaaskelainen J, Hernesniemi J, Tromp G (2003) Familial intracranial aneurysms: an analysis of 346 multiplex Finnish families. Stroke 34:1370–1374. doi: 10.1161/01.STR.0000072822.35605.8B CrossRefPubMedGoogle Scholar
  50. 50.
    Woo D, Khoury J, Haverbusch MM, Sekar P, Flaherty ML, Kleindorfer DO, Kissela BM, Moomaw CJ, Deka R, Broderick JP (2009) Smoking and family history and risk of aneurysmal subarachnoid hemorrhage. Neurology 72:69–72. doi: 10.1212/01.wnl.0000338567.90260.46 CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Zacks DJ (1978) Multiple intracranial aneurysms. AJR Am J Roentgenol 130:180–182. doi: 10.2214/ajr.130.1.180 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Sayied Abdol Mohieb Hosainey
    • 1
    Email author
  • Torstein R. Meling
    • 1
  1. 1.Department of NeurosurgeryOslo University HospitalOsloNorway

Personalised recommendations