Lethal Ultra-Early Subarachnoid Hemorrhage Due to Rupture of De Novo Aneurysm 5 Months After Primary Aneurysmatic Subarachnoid Hemorrhage

Highlights

• Secondary SAH from a de novo aneurysm is a rare event affecting only ≈1% of SAH patients who are often affiliated with poor outcome.

• Young age and male sex predict a favorable outcome after secondary SAH.

• Five months after complete obliteration of an ACOM aneurysm, the patient was subjected to a fatal SAH from a de novo aneurysm.

• Despite the patient’s young age in this case, secondary SAH from a de novo aneurysm ended fatally.

Background

Approximately 1% of all patients surviving rupture of a cerebral aneurysm suffer from a second aneurysmatic subarachnoid hemorrhage later in their lives, 61% of which are caused by rupture of a de novo aneurysm. Latency between bleedings is usually many years, and younger patients tend to achieve better outcomes from a second subarachnoid hemorrhage.

Case Description

We report an unusual case of lethal ultra-early rupture of a de novo aneurysm of the anterior communicating artery only 5 months after the initial subarachnoid hemorrhage and complete coiling in a young, healthy male patient.

Conclusion

Despite complete aneurysm obliteration, young age, and good recovery, patients may be subjected to secondary subarachnoid hemorrhages from de novo aneurysms after only a few months of the initial bleeding. Early-control magnetic resonance angiography might hence be advisable.

Introduction

Approximately only 1% of all patients surviving an aneurysmatic subarachnoid hemorrhage (SAH) will suffer from another one later in their lives.¹ While one third of those secondary SAHs are caused by rerupture of the initial aneurysm and in 6% of all cases no source of bleeding can be found, the vast majority of secondary SAHs is caused by rupture of a de novo aneurysm that had not been detected during initial work-up or follow-up examinations.¹ Those de novo aneurysms tend to be small in size (<10 mm) and pose a higher risk of bleeding than initially discovered aneurysms of equal size.² Risk factors for ruptures of de novo aneurysms after an initial aneurysmatic SAH include female sex, higher age, and time between initial SAH and discovery of the de novo aneurysm.² Rebleeding usually occurs 7 to 10 years after the first hemorrhage and is afflicted with worse outcomes compared with initial SAH.1, 2 While only approximately 40% of patients suffering from secondary SAH reach a favorable neurologic outcome, younger age seems to be a predictor of favorable outcome.¹ In this report we present the case of a young patient who suffered from lethal ultra-early secondary SAH caused by rupture of a de novo aneurysm only 5 months after initial SAH from an anterior communicating artery aneurysm.