[Case of ruptured multiple cerebral aneurysms associated with primary aldosteronism]

Primary aldosteronism (PA) has been recognized as a relatively benign form of hypertension associated with a low incidence of vascular complications. Recent reports, however, indicate that cerebrovascular accidents are common in PA. We report a case of multiple aneurysms with PA in a middle-aged woman who presented with subarachnoid hemorrhage. A 47-year-old woman with a history of untreated hypertension was referred to our hospital for subarachnoid hemorrhage. Cerebral angiography showed multiple small aneurysms. The initial intervention was aneurysm clipping for a ruptured aneurysm at the bifurcation of the right middle cerebral artery. Despite medication, she continued to suffer from uncontrolled hypertension and hypokalemia. She was diagnosed with PA on the basis of elevated plasma aldosterone, suppressed plasma rennin, and a right adrenal tumor detected by abdominal CT scanning. She underwent several more neck clippings for the remaining aneurysms (unruptured), followed by a total right adrenectomy. Histological examination revealed an adrenal adenoma. After the operation, her blood pressure returned to normal without any vasodepressors. Recent studies have demonstrated that hyperaldosteronism might have direct vasculo-toxic actions, including remodeling, fibrosis, and proliferation. Cerebrovascular accidents caused by PA are reported to have high rates of mortality and recurrence when the PA is overlooked or untreated. Physicians must be alert to the possibility of PA in patients with hypertension and persistent hypokalemia, especially in those who are young or middle-aged. We also recommend screening for intracranial aneurysms by low-invasive magnetic resonance angiography.