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LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 1  |  Page : 128-129

Subarachnoid hemorrhage from a ruptured proximal lenticulostriate artery aneurysm


Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India

Date of Submission16-Nov-2011
Date of Decision17-Nov-2011
Date of Acceptance25-Dec-2011
Date of Web Publication7-Mar-2012

Correspondence Address:
Dhananjaya I Bhat
Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.93621

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How to cite this article:
Bhat DI, Shukla DP, Somanna S. Subarachnoid hemorrhage from a ruptured proximal lenticulostriate artery aneurysm. Neurol India 2012;60:128-9

How to cite this URL:
Bhat DI, Shukla DP, Somanna S. Subarachnoid hemorrhage from a ruptured proximal lenticulostriate artery aneurysm. Neurol India [serial online] 2012 [cited 2019 Oct 22];60:128-9. Available from: http://www.neurologyindia.com/text.asp?2012/60/1/128/93621


Sir,

Aneurysms arising from lenticulostriate arteries (LSAs) distal to their origin from the middle cerebral artery (MCA) are rare and commonly present with basal ganglia hemorrhage. [1],[2],[3] We report a case of pure subarachnoid hemorrhage (SAH) resulting from rupture of a fusiform aneurysm arising from the proximal part of a lateral LSA.

A 39-year-old gentleman presented five days following sudden-onset severe headache with no deficits. Computed tomography (CT) scan brain showed a left sylvian fissure bleed [Figure 1]a. Digital subtraction angiogram (DSA) with three-dimensional (3-D) reconstruction revealed a fusiform aneurysm arising from a left lateral LSA [Figure 1]b. He underwent a left pterional craniotomy, the LSA was arising from the posterosuperior surface of the distal M1 segment and took an acute bend backwards along the M1 segment before entering the aneurysm, which was then trapped and excised [Figure 1]c. The postoperative period was uneventful. A routine CT on postoperative Day 3 revealed a moderate-sized infarct in the left basal ganglia sparing the posterior limb of the internal capsule [Figure 1]d. He was discharged on postoperative Day 8 with no neurologic deficits.
Figure 1: (a) CT scan showing left sylvian fissure bleed (arrow), (b) 3-D reconstructed angiogram image showing the aneurysm, (c) intraoperative photograph of the aneurysm, (d) postoperative CT scan shows a well-developed infarct in the left basal ganglia

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Till date only 29 cases of aneurysms arising from the LSA beyond its origin have been reported [2],[3],[4],[5],[6],[7] and mostly present with intraparenchymal hemorrhage. Only two cases of such aneurysms presenting with pure SAH have been reported. [1],[6] LSA aneurysms are usually associated with conditions like moyamoya disease, hypertension, vasculitis, systemic lupus erythematosus, infections, arteriovenous malformations and tumors. [1],[2],[3],[4],[8] These aneurysms may either be sacular or fusiform. [2] Due to the fragile and small nature of parent arteries and deep location of aneurysms, trapping of the aneurysm may be the only option in many cases. [2] LSAs are endarteries, small and fragile, which do not anastomose with each other. They supply the basal ganglia and internal capsule. Due to multiple branches and variation in the dominance of each of the groups of arteries it is not possible to predict the clinical outcome following sacrifice of an LSA. [1],[2] As there is a risk of rebleed many authors have treated these aneurysms with parent vessel occlusion with favorable outcomes. [1],[2]

As our patient had a fusiform aneurysm we decided to sacrifice the parent vessel. Postoperative CT scan showed basal ganglia infarct without clinical deficits. Though endovascular obliteration of the parent vessel is an attractive option for fusiform aneurysms we did not consider it because of technical difficulty. LSA takes an acute bend after its origin to retrace its path on the M1 segment making catheterization of these vessels difficult. Due to the fragile and small nature of these vessels there is also a high risk of damage while catheterizing them. Hence surgical sacrifice of the vessel seems to be a better option than endovascular treatment. [1],[2],[3] LSA aneurysms are uncommon and can rarely present with SAH. Because of the anatomical complexity of an LSA aneurysm, parent vessel sacrifice may be the only treatment option and can be done safely with unpredictable clinical outcome.

 
 » References Top

1.Eddleman CS, Surdell D, Pollock G, Batjer HH, Bendok BR. Ruptured proximal lenticulostriate artery fusiform aneurysm presenting with subarachnoid hemorrhage: Case report. Neurosurgery 2007;60: E949; discussion E949.  Back to cited text no. 1
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2.Gandhi CD, Gilad R, Patel AB, Haridas A, Bederson JB. Treatment of ruptured lenticulostriate artery aneurysms. J Neurosurg 2008;109:28-37.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Narayan P, Workman MJ, Barrow DL. Surgical treatment of a lenticulostriate artery aneurysm. Case report. J Neurosurg 2004;100:340-2.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Ahn JY, Cho JH, Lee JW. Distal lenticulostriate artery aneurysm in deep intracerebral hemorrhage. J Neurol Neurosurg Psychiatry 2007;78:1401-3.  Back to cited text no. 4
[PUBMED]    
5.Binning M, Duhon B, Couldwell WT. Partially thrombosed lateral lenticulostriate aneurysm presenting with embolic stroke. J Neurosurg Pediatr 2010;5:190.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Kochar PS, Morrish WF, Hudon ME, Wong JH, Goyal M. Fusiform lenticulostriate artery aneurysm with subarachnoid hemorrhage: The role for superselective angiography in treatment planning. Interv Neuroradiol 2010;16:259-63.  Back to cited text no. 6
[PUBMED]    
7.Matushita H, Amorim RL, Paiva WS, Cardeal DD, Pinto FC. Idiopathic distal lenticulostriate artery aneurysm in a child. Case report and review of the literature. J Neurosurg 2007;107(Suppl 5):1419-24.  Back to cited text no. 7
    
8.Takeuchi S, Takasato Y, Masaoka H, Hayakawa T, Otani N, Yoshino Y, et al. Bilateral lenticulostriate artery aneurysms. Br J Neurosurg 2009;23:543-4.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  


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