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Usefulness of Enhanced Three-dimensional T1 Fast Spin-echo in the Treatment of Subarachnoid Hemorrhage with Multiple Intracerebral Aneurysms in Elderly Patients: A Report of Two Cases

In the treatment of subarachnoid hemorrhage, identifying the ruptured aneurysm is sometimes difficult when the patients have multiple intracerebral aneurysms (MIAs). In a recent study, circumferential enhancement along the aneurysmal wall is reported to be associated with ruptured aneurysm. We report two cases of subarachnoid hemorrhage with MIAs in which magnetic resonance imaging three-dimensional (3-D) T1 fast spin-echo (FSE) was useful for estimating the rupture site. Case 1: An 87-year-old woman developed subarachnoid hemorrhage (SAH), and magnetic resonance angiography (MRA) detected bilateral internal carotid artery-posterior communicating artery (IC-PC) aneurysms. The right IC-PC aneurysm was large and broad-necked, suggesting difficulties in endovascular treatment. The left aneurysm was smaller; however, it had an irregular-shaped bleb on its wall. Bilateral craniotomies were thought to be exceedingly invasive because of her advanced age. On the 3-D FSE, stronger enhancement was observed along the left IC-PC aneurysm wall than along the right IC-PC aneurysm. The left IC-PC aneurysm was estimated as the ruptured aneurysm, and selective embolization was performed. Her postoperative course was uneventful. Case 2: An 80-year-old woman developed SAH and was transferred to our hospital 7 days after onset. MRA detected anterior communicating artery (AcomA) and left middle cerebral artery (MCA) aneurysms. The AcomA aneurysm had a bleb on its wall and was likely to be the rupture site. The MCA aneurysm had a broad neck and was unsuitable for endovascular treatment. Craniotomy was thought to be risky because of her advanced age and her admission in the period of cerebral vasospasm. We performed 3-D FSE subsequently to the MRA. Significant enhancement was observed along the bleb of the AcomA; on the other hand, the wall of the MCA aneurysm was not enhanced. We determined the AcomA aneurysm as the rupture site and performed endovascular coil embolization, leaving the MCA aneurysm untreated. Her postoperative course was uneventful and rebleeding was not observed. Identification of the ruptured aneurysm is the most important problem in the treatment of SAH. However, especially in elderly patients who are intolerant for surgical procedures, radical treatment can lead to a worse outcome. Enhancement of the aneurysmal wall on 3-D FSE can provide a useful finding in the decision of treatment strategies for SAH.