[Rupture of previously documented asymptomatic saccular intracranial aneurysms]

The authors report four cases of patients with documented asymptomatic intact aneurysms that subsequently ruptured. Case 1 involves a 64-year-old woman who had two unruptured aneurysms, i.e., an anterior communicating artery aneurysm and a posterior inferior cerebellar aneurysm, both were discovered during evaluation of cerebral ischemic symptoms. At that time, only the posterior inferior cerebellar aneurysm was clipped. Seven years later, the patient bled fatally from a 5-mm untreated anterior communicating artery aneurysm that had measured approximately 3 mm on an angiogram obtained 7 years earlier. Case 2 is that of a 50-year-old woman who bled from an anterior communicating artery aneurysm that had been discovered 6 years earlier when she suffered subarachnoid hemorrhage (SAH) from a left middle cerebral artery aneurysm. At that time, she had refused surgery for the anterior communicating artery aneurysm. She recovered well from the second SAH. Case 3 is that of a 74-year-old woman who bled from a left paraclinoid internal carotid artery aneurysm that had been discovered incidentally 3 years earlier during evaluation of vertigo. She had not agreed to have a clipping at that time the aneurysm was first discovered because of her age and the difficult location of the aneurysm. She eventually made an uneventful recovery. In the fourth case, during evaluation of cerebral ischemic symptoms, a 59-year-old man was discovered to have a large basilar bifurcation aneurysm. He underwent a craniotomy for clipping of the aneurysm. The aneurysm, however, was unclippable and was instead coated with Bemsheet. Four months later, the patient bled from the aneurysm and entered a vegetative state. The indications for surgery on unruptured asymptomatic cerebral aneurysms are still unclear. The cases reported herein show that asymptomatic aneurysms, especially anterior communicating aneurysms and aneurysms once exposed surgically, do carry a certain risk for future hemorrhage and should not be dismissed as innocuous. Neurosurgeons have recognized the importance of considering life expectancy in managing patients with asymptomatic, unruptured, intracranial aneurysms. With the rapid aging of the population, withholding aneurysm surgery merely because a patient is elderly may not necessarily be the most appropriate decision.