Neurological Surgery No Shinkei Geka Volume 44, Issue 8 (August 2016)

Repeated Rupture of Bilateral Internal Carotid Artery Aneurysms in a Short Period in Association with Polyarteritis Nodosa:A Case Report Takanori MIURA 1 , Jun MARUYA 1 , Jun WATANABE 1 , Ryuta SATO 2 , Takashi HATAKEYAMA 2 , Keiichi NISHIMAKI 1 1Department of Neurosurgery, Akita Red Cross Hospital 2Department of Nephrology, Akita Red Cross Hospital Keyword: polyarteritis nodosa , aneurysmal subarachnoid hemorrhage , takotsubo cardiomyopathy , clipping , coil embolization pp.661-668
Published Date 2016/8/10
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 Cerebral involvement is rare in polyarteritis nodosa(PAN);furthermore, secondary intracranial hemorrhage due to cerebral aneurysm is extremely rare. We describe an unusual case of repeated subarachnoid hemorrhage(SAH)in a 64-year-old woman with a history of PAN. Initially, she developed severe headache(probable first SAH, day 0), and presented at our hospital with second severe headache with disturbed consciousness on day 6. Computed tomography(CT)revealed that SAH was mainly distributed in the right basal cistern and sylvian fissure(second SAH). Three aneurysms were detected using CT angiography on the bilateral internal carotid arteries. An intentionally delayed surgery was planned because of the high risk period of cerebral vasospasm and takotsubo cardiomyopathy. On day 15, she complained of headache and had a convulsion. CT revealed a third SAH in the left sylvian fissure;cerebral angiography revealed enlargement of the left internal carotid-posterior communicating artery(IC-PC)aneurysm. Coil embolization of the aneurysm was performed on day 16, and she was treated using prednisolone(20mg/day)for PAN. However, on day 20, the patient became comatose, and CT revealed a fourth SAH in the right sylvian fissure. Cerebral angiography revealed enlargement of the right IC-PC aneurysm. Clipping of the aneurysm was successfully performed in spite of ventricular dysfunction, and the dose of prednisolone was increased to 40mg/day. After treatment, the ventricular dysfunction gradually resolved. Cerebral aneurysms with PAN are candidates for intervention because of their strong tendency to rupture. In our case, takotsubo cardiomyopathy might have been associated with impairment of the coronary microcirculation due to PAN. We suggest that aggressive immunosuppressive treatment for PAN and curative treatments for cerebral aneurysms should be considered with careful radiological examination and follow-up monitoring.

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Neurological Surgery 脳神経外科
44巻8号 (2016年8月)
電子版ISSN 1882-1251 印刷版ISSN 0301-2603 医学書院