Ruptured dissecting aneurysm as a cause of subarachnoid hemorrhage of unverified etiology

The clinical features of "aneurysmal" subarachnoid hemorrhage (SAH) of angiographically unverified etiology were reviewed to clarify the incidence and natural history of dissecting aneurysms as the hemorrhagic source of SAH.

We reviewed 30 patients with SAH of unverified etiology in whom initial CT scan showed a diffuse or anteriorly distributed subarachnoid blood clot. Ten of the patients had stenotic or occlusive lesions (SOCL) on initial angiography, and these were the main focus of this study.

Among the 10 patients with SOCL on initial angiography, the lesions were located on the anterior circulation in 6 and on the posterior circulation in 4. Ruptured dissecting aneurysms were confirmed by exploratory surgery or autopsy in 6 patients. Subsequent rupture occurred in 6 of the 10 patients (60%), and all 6 of these patients died as a result.

The incidence (6/30) of dissecting aneurysms as the cause of SAH of unverified etiology was unexpectedly high, especially when initial angiography disclosed SOCL (6/10). The moribund patients with SOCL showed a high rate of rebleeding, and the untreated recurrent hemorrhages were fatal. Further MRI study is indicated for these patients to demonstrate the intramural hematoma. Compared with the devastating mortality caused by the subsequent ruptures, the extent of surgical morbidity was minor. Surgical intervention could therefore be justified when the following neuroradiological findings are present: (1) SOCL evident on angiography, (2) distribution of SAH on CT compatible with the location of the SOCL, and (3) intramural hematoma on MRI in the same region as the SOCL.