Abstract
A 43 year old male presented with a sudden onset of gait disturbance and urinary incontinence. An emergency CT scan revealed a subarachnoid hemorrhage and a spherical calcification on the right side of the foramen magnum. He was admitted to the hospital with generalized deterioration (bradycardia and irregular respiration).
The patient's general condition stabilized after 2 weeks and a contrast enhanced CT scan and a cerebral angiogram were carried out. Aneurysms were noted at the trifurcation of the right middle cerebral artery, A2 portion of the anterior cerebral artery and the M2-M3 portion of the left middle cerebral artery supratentorially. Infratentorially, the right vertebral artery was hypoplastic and no contrast material entered the spherical calcified lesion observed by CT.
Based on these findings, the subarachnoid hemorrhage was thought to be due to a rupture of a supratentorial aneurysm. These supratentorial aneurysms were therefore surgically clipped. Unfortunately, after the 2 month uneventful postoperative course, death occurred secondary to hemorrhage from the posterior surface of the aneurysm at the M2-M3 portion of the left middle cerebral artery.
The 9 prior cases of aneurysms of the central side of the VA-PICA bifurcation have been identified in the literature. The present case describes hemorrhage from the trunk of the M2 portion of the left middle cerebral artey in the posterior surfase of the aneurysm treated with clipping. Hemodynamic changes before and after the clipping were the most likely cause of the fatal hemorrhage.
