Multiple

Intracranial

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DAVID

J. ZACKS’

About 20% of intracranial aneurysms are multiple [1-3]. This paper describes a unique case with 13 intracranial aneurysms. The literature is reviewed and management discussed. Case

If the tion

confused,

and

Report

vomited.

The

following

day

she

was

taken to a district hospital where she was found to have no localizing signs, but lumbar puncture revealed uniformly bloodstained cerebrospinal fluid. She was transferred to Atkinson Morley’s Hospital 5 days later; she was fully conscious and exhibited no neurological deficit. She did have some neck discomfort on fiexion. Bilateral carotid and subclavian angiognams demonstrated left and right carotid, left vertebral, and basilar circulations. The right vertebral artery was not visualized, presumably because it arose from the aorta (6% of cases [4]) or was absent. Thirteen aneurysms were demonstrated: four in the left carotid circulation, three in the right carotid circulation, and six in the posterior

circulation.

from the left middle middle

cerebral

Specifically,

cerebral

artery

(fig.

four

aneurysms

one

aneurysm

from

investigation,

arose the

right

callosomarginal artery (fig. 16), three from the left posterior cerebral artery, two from the right anterior inferior cerebellar artery, and one from the left posterior inferior cerebellar artery (figs. 1C and 10). The middle cerebral lesions.

largest aneurysm It was associated

was one of the left with marked sun-

rounding vascular narrowing (fig. 1A). A CT scan showed a small localized hematoma in the anterior portion of the left sylvian fissure, consistent with hemorrhage from a left middle cerebral artery aneurysm. The patient was treated with an antispasmodic agent on a trial

program

and

bed

rest

for

10 days.

She

remained

fairly

well, developing no focal neurologic signs. On the tenth day, left common carotid artery ligation was performed under local anesthesia.

Following

ligation,

she was gradually

mobilized

for

a 1 week period with no ill effects. The patient was discharged and has remained well for a follow-up period of 18 months. Discussion

Multiple aneurysms comprise approximately 20% of intracranial aneurysms [1-3]. In the cooperative study of 1958-1965 [2], 95% of cases with multiple intracranial aneurysms showed two lesions and S% had three on more (3.5% had three aneurysms and only 1 .4% had four on more). It is clear that the present case is indeed uncommon; a thorough search of the literature has revealed only a few others, including Eppingen’s report [5] of a patient with nine aneurysms and Stebben’s account [6] of a case of seven aneurysms. Received April 14, 1977; accepted after revision August ‘ Atkinson Morley’s Hospital, Wimbledon, St. George’s Alberta

Hospital,

Edmonton,

Am J Ro.ntg.nol

130:180-182,

© 1978 American

Roentgen

Alberta,

incidence

is of the

of aneurysms

order

of 1%-2%

in the [7, 8],

popula-

it is possible

and

the

relative

number

of

angiognaphic

and postmortem examinations. Theme were approximately twice as many female as male patients with multiple aneurysms, which agrees with the studies of Paterson and Bond [10] and McKissock et al . [1 1]. The most common age mange was 40-49 years [10, 12]. The patient reported here bled from the largest left middle cerebral artery aneurysm, which was the largest of all hen aneurysms. Although it is sometimes difficult to determine which aneurysm has bled, valid angiographic indices of the actual bleeding focus include: largest aneurysm, displacement of vessels indicating a hematoma, presence of adjacentvasospasm, and, namely, the actual display of extravasated contrast during active bleeding [13, 14]. In cases of subamachnoid hemorrhage, it may be difficult to plan the angiogmaphic sequence and to determine the extent of the study in view of patient age and clinical status. The advent of CT has eased this problem so that the extent and site of hematomas, whether intracemebnal , intraventriculan, or subarachnoid , may now be delineated. In the cooperative study [2], the chances of multiple aneurysms occurring on the same side were 21%, on opposite sides 47%, and other combinations 32%. The overall chance of aneurysms being situated on opposite sides was 2:1 . Multiple aneurysms are often seen in a strikingly symmetrical bilateral location, the middle cemebmal bifurcation and internal carotid arteries being the commor.est sites [15]. Therefore, in a one vessel (carotid) angiogmam, the diagnosis of multiple aneurysms is made in only 20%30% of cases, while in adequate bilateral carotid angiography, the diagnosis of multiple aneurysms could be made in 92% of cases. Theoretically, four-vessel angiography should show 100% of lesions. Statistically, the incidence of missed double aneurysms in adequate bilateral carotid studies is about 2% [2]. Several authors [12, 16-19] are strong advocates of a surgical approach and, if possible, a direct intracranial

artery (fig. 1A), two from the right 1B),

general

at large

that fewer aneurysms actually rupture than commonly believed, since the percentage of subanachnoid hemonrhage in the general population is not of this magnitude [9]. The cooperative study [2] estimated that approximately 19% of aneurysms were multiple, compared to 22% found at autopsy. The difference is probably related to the quantity and quality of angiography, timing of the

M. L. , a 49-year-old right-handed woman, had been well until she suddenly experienced pain on the left side of her face, became

Aneurysms

12. 1977. Hospital Group,

London,

England.

Present

address:

Department

of Radiology,

0361

-803X/78/01

00-01

University

Canada.

January Ray Society

1978

180

80 $02.00

of

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CASE

181

REPORTS

Left carotid arteniogram demonstrating four aneurysms (arrowheads) arising from left middle cerebral artery. Largest aneurysm (large lesion which ruptured. Note adjacent vasospasm. B, Right carotid arteriogram demonstrating two right middle cerebral artery aneurysms (arrowheads) and aneurysm of callosomarginal artery (arrow). Lesions were confirmed on additional projections. C, Left vertebral arteriogram demonstrating multiple aneurysms arising from left posterior cerebral artery (three arrows) and right anterior inferior cerebellar artery (two arrows). Oblique views confirmed lesions. 0, Left vertebral arteriogram demonstrating multiple aneurysms of posterior circulation (arrows). Note aneurysm arising from left posterior inferior cerebellar artery. Fig.

1 -A,

arrowhead)

was

procedure. They argue that untreated aneurysms show a strong tendency to enlarge and rupture and that surgery has less risk than a conservative approach. On the other hand, authorities such as McKissock et al. [20] and others [10, 21] point out that there has been no significant difference in overall morbidity and mortality between patients treated medically or surgically. Nishioka [22] found little evidence to suggest that more than one aneurysm would rupture within a 6 month follow-up time of the cooperative study. Paterson and

Bond

[10]

concluded

that

attempts to treat all rather than in staged significantly treatment. treatment tional benefit. mortality 10%.

higher Others of choice

craniotomies

surgery

the aneurysms procedures,

within at were

7 days

and

one operation, associated with

mortality rates than other forms of [23, 24] believe that surgery is the for ruptured aneurysms, but addifor

Heiskanen and of 9% compared

unruptuned

lesions

Marttila [24] reported to a nonsurgical

were

of

little

a surgical mortality of

182

CASE

Patients morbidity Recurrent

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ways

with multiple and mortality hemorrhage

from

the

same

aneurysms do have a higher than those with single lesions. occurs earlier and is almost alaneurysm

[11].

Many

aneurysms

(25%-30%) bleed again, more than half within 14 days of the initial hemorrhage. In the opinion of Alvond et. al. [21], the probability of survival depends on the clinical status of the patient after the first hemorrhage and the time

since

the

the better

last

hemorrhage.

the prognosis,

The

regardless

longer

the

REPORTS subarachnoid 10. 11.

Dr. James Dreger

Ambrose

for typing

for

sion

15.

16.

in Intracranial edited by III., Thomas, 1965, pp 2-

Fields WL, Sahs AL, Springfield, 24 2. Sahs AL, Penret GE, Locksley HB, Nishioka of Intracranial

H: Report

Aneurysms

and

on Sub-

Philadelphia, Lippincott, 1969 NH: Multiple intracranial arterial aneurysms. An of their significance. Arch Neurol Psychiatr 73 : 76-

3. Bigelow analysis 99, 1955 4. Aadner S: Vertebral angiography by catheterization. Acta Radio! (Supp!J (Stockh) 87, 1951 5. Eppinger H: Pathogenesis den Aneurysmen einschleisslich des Aneurysma Equi Verminosum. Arch KIm Chir 35:1563,

1887

6. Stebbens

WE: Intracranial

Med3:214-218,

7. Housepian aneurysms

arterial

aneurysms.

Aust

Ann

1954

EM, Pool J: A systematic from

the autopsy tal,1914-1956. J Neuropathol

in patients

with

multiple

cerebral

analysis

of intracranial

file of the Presbyterian HospiExp Neurol 17 :409-423, 1958

8. Zacks DJ, Russell DB, Miller JDR: Fortuitously intracranial aneurysms. In preparation 9. Pakarinen S: Incidence, aetiology and prognosis

discovered

surg 21 :182-198, 1964 Heiskanen 0: The identification

Hassler

0:

Walton

ston, 17.

multiple Morphological

JN: Subarachnoid

aneurysms.

le-

of ruptured aneurysms in Neurochirurgie 8 : 102-

studies

on

the

Hemorrhage.

large

cerebral

of subarachnoid 51 4 : 1 -1 45, 1961 Edinburgh,

Living-

1956

Poppen JL, Fager CA: Neurosurg 16:581-589,

Multiple 1959

intracranial

aneurysms.

J

18. Pool JL: Timing and techniques in the intracranial surgery of ruptured aneurysms of the anterior communicating antery.JNeurosurg 19:378-388, 1962 19. Moyes PD: Surgical treatment of multiple aneurysms and incidentally-d iscovered unruptured aneurysms . J Neurosurg 35:291-296,

1971

20. McKissock N, Richardson A, cating artery aneurysms: a trial treatment. Lancet 1 :873-876, 21 . Alvord EC, Loeser JD, Bailey noid

hemorrhage

Walsh L: Anterior communiof conservative and surgical 1965

WL, Copass

due to ruptured

aneurysms.

MK: SubarachArch

Neuro!

27:273-283, 1972 22. Nishioka H: Evaluation of conservative management of ruptured intracranial aneurysms (cooperative study, sec. 7, pt. 1).JNeurosurg 25:574-592, 1966 23. Bjorkesten G, Troupp H: Multiple intracranial arterial aneuChirScand

rysms.Acta

24. Heiskanen nysm

of primary

N

J Neuro-

aneurysms.

arteries with reference to the aetiology hemorrhage. Acta Psychiatr Scand [Suppl]

REFERENCES

the Cooperative Study arachnoid Hemorrhage.

L, Bnisman A: Multiple intracranial aneurysms. 281 : 1307, 1969 EH: Angiographic identification of the ruptured

patients with 107, 1965

guidance

1 . Alpens BJ: Aneurysms of the circle of Willis, Aneurysms and Subarachnoid Hemorrhage,

43, supp!.

A, Bond MA: Treatment of multiple intracranial Lancet 1 : 1302-1304, 1973 McKissock W, Richardson A, Walsh L, Owen E: Multiple intracranial aneurysms. Lancet 1 :623-626, 1964

13. Wood

of therapy.

neuroradiologic

Scand

EngI J Med

interval,

assistance.

Neuro!

Paterson

12. Mount

ACKNOWLEDGMENT I thank

Acta

aneurysms.

14.

and Darlene

hemorrhage.

29:1-28, 1967

in

118:387,

1960

0, Marttila I: Risk of rupture of a second aneupatients with multiple aneurysms. J Neurosurg

32 :295-303,

1970