Abstract
INTRODUCTION: A 49‐year‐old lady presented to hospital with a WFNS 3 aneurysmal subarachnoid haemorrhage. Her symptomatology included sudden onset headache, vomiting, neck stiffness and mild left‐sided weakness. Her past medical history comprised discoid lupus, scleroderma and hypertension. Plain CT imaging demonstrated a significant blood load distributed primarily around the right Sylvian fissure. CT angiography confirmed two right‐sided middle cerebral artery (MCA) aneurysms. The proximal aneurysm appeared smooth and unruptured. The distal aneurysm appeared irregular and was therefore believed to be the ruptured lesion. The anatomy of this aneurysm precluded endovascular coiling as it was fully incorporated into the inferior MCA M2 branch. METHODS: Following interdisciplinary discussion, the patient proceeded to open surgical clipping of both aneurysms. A clip was placed across the rupture point of the distal aneurysm but a significant neck was left to permit filling of the distal branches. Post‐operative angiography accordingly showed a small residual component to the aneurysm. On follow‐up angiography one week later, this remnant appeared to have increased in size. The decision was therefore made to endovascularly place a contour device to reduce flow to the persistent portion of the aneurysm. This combined treatment approach resulted in excellent clinical and angiographic outcome. RESULTS: The patient was eventually discharged home with a modified Rankin scale score of 1 and had no residual neurological deficit at 1‐year outpatient follow‐up. Similarly, follow‐up catheter angiography at 1‐year demonstrated continued satisfactory appearances with the combination of clip and contour device. CONCLUSIONS: This case highlights the successful clinical and radiological outcomes of a combined surgical and endovascular approach in aneurysmal subarachnoid haemorrhage ‐ despite an anatomically difficult vascular abnormality ‐ due to good interdisciplinary cooperation and careful patient follow‐up. It furthermore demonstrates the effective use of a relatively novel endovascular device following acute haemorrhage and open surgery which avoided the need for long‐term antiplatelet medication.