Demographic and clinical predictors of multiple intracranial aneurysms in patients with subarachnoid hemorrhage

OBJECTIVEPathophysiological differences that underlie the development and subsequent growth of multiple aneurysms may exist. In this study, the authors assessed the factors associated with the occurrence of multiple aneurysms in patients presenting with aneurysmal subarachnoid hemorrhage (SAH).METHODSConsecutive patients presenting with aneurysmal SAH between 1996 and 2012 were prospectively enrolled in the Subarachnoid Hemorrhage Outcome Project. Patients harboring 1, 2, or 3 or more aneurysms were stratified into groups, and the clinical and radiological characteristics of each group were compared using multivariate logistic regression.RESULTSOf 1277 patients with ruptured intracranial aneurysms, 890 had 1 aneurysm, 267 had 2 aneurysms, and 120 had 3 or more aneurysms. On multinomial regression using the single-aneurysm cohort as base case, risk factors for patients presenting with 2 aneurysms were female sex (relative risk ratio [RRR] 1.80, p < 0.001), higher body mass index (BMI) (RRR 1.02, p = 0.003), more years of smoking (RRR = 1.01, p = 0.004), and black race (RRR 1.83, p = 0.001). The risk factors for patients presenting with 3 or more aneurysms were female sex (RRR 3.10, p < 0.001), higher BMI (RRR 1.03, p < 0.001), aneurysm in the posterior circulation (RRR 2.59, p < 0.001), and black race (RRR 2.15, p = 0.001). Female sex, longer smoking history, aneurysms in the posterior circulation, BMI, and black race were independently associated with the development of multiple aneurysms in our adjusted multivariate multinomial model.CONCLUSIONSSignificant demographic and clinical differences are found between patients presenting with single and multiple aneurysms in the setting of aneurysmal SAH. These predictors of multiple aneurysms likely reflect a predisposition toward inflammation and endothelial injury.

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Detection rates and sites of unruptured intracranial aneurysms according to sex and age: an analysis of MR angiography–based brain examinations of 4070 healthy Japanese adults

Journal of Neurosurgery ◽

10.3171/2017.9.jns171191 ◽

2019 ◽

Vol 130 (2) ◽

pp. 573-578 ◽

Cited By ~ 7

Author(s):

Yohichi Imaizumi ◽

Tohru Mizutani ◽

Katsuyoshi Shimizu ◽

Yosuke Sato ◽

Junichi Taguchi

Keyword(s):

Risk Factors ◽

Intracranial Aneurysms ◽

Mr Angiography ◽

Detection Rate ◽

Smoking History ◽

Maximum Diameter ◽

Detection Rates ◽

Female Sex ◽

Unruptured Intracranial Aneurysms ◽

Aneurysm Detection

OBJECTIVEThe purpose of this study was to evaluate the detection rate and occurrence site according to patient sex and age of unruptured intracranial aneurysms detected through MRI and MR angiography (MRA).METHODSA total of 4070 healthy adults 22 years or older (mean age [± SD] 50.6 ± 11.0 years; 41.9% women) who underwent a brain examination known as “Brain Dock” in the central Tokyo area between April 2014 and March 2015 were checked for unruptured saccular aneurysm using 3-T MRI/MRA. The following types of cases were excluded: 1) protrusions with a maximum diameter < 2 mm at locations other than arterial bifurcations, 2) conical protrusions at arterial bifurcations with a diameter < 3 mm, and 3) cases of suspected aneurysms with unclear imaging of the involved artery. When an aneurysm was definitively diagnosed, the case was included in the aneurysm group. The authors also investigated the relationship between aneurysm occurrence and risk factors (age, sex, smoking history, hypertension, diabetes, and hyperlipidemia).RESULTSOne hundred eighty-eight aneurysms were identified in 176 individuals (detection rate 4.32%), with the detection rate for women being significantly higher (6.2% vs 3.0%, p < 0.001). The average age in the aneurysm group was significantly higher than in the patients in whom aneurysms were not detected (53.0 ± 11.1 vs 50.5 ± 11.0 years). The detection rate tended to increase with age. The detection rates were 3.6% for people in their 30s, 3.5% for those in their 40s, 4.1% for those in their 50s, 6.9% for those in their 60s, and 6.8% for those in their 70s. Excluding persons in their 20s and 80s—age groups in which no aneurysms were discovered—the detection rate in women was higher in all age ranges. Of the individuals with aneurysms, 12 (6.81%) had multiple cerebral aneurysms; no sex difference was observed with respect to the prevalence of multiple aneurysms. Regarding aneurysm size, 2.0–2.9 mm was the most common size range, with 87 occurrences (46.3%), followed by 3.0–3.9 mm (67 [35.6%]) and 4.0–4.9 mm (20 [10.6%]). The largest aneurysm was 13 mm. Regarding location, the internal carotid artery (ICA) was the most common aneurysm site, with 148 (78.7%) occurrences. Within the ICA, C1 was the site of 46 aneurysms (24.5%); C2, 57 (30.3%); and C3, 29 (15.4%). The aneurysm detection rates for C2, C3, and C4 were 2.23%, 1.23%, and 0.64%, respectively, for women and 0.68%, 0.34%, and 0.21%, respectively, for men; ICA aneurysms were significantly more common in women than in men (5.27% vs 2.20%, p < 0.001). Multivariate logistic regression analysis revealed that age (p < 0.001, OR 1.03, 95% CI 1.01–1.04), female sex (p < 0.001, OR 2.28, 95% CI 1.64–3.16), and smoking history (p = 0.011, OR 1.52, 95% CI 1.10–2.11) were significant risk factors for aneurysm occurrenceCONCLUSIONSIn this study, both female sex and older age were independently associated with an increased aneurysm detection rate. Aneurysms were most common in the ICA, and the frequency of aneurysms in ICA sites was markedly higher in women.

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Enlargement of small, asymptomatic, unruptured intracranial aneurysms in patients with no history of subarachnoid hemorrhage: the different factors related to the growth of single and multiple aneurysms

Journal of Neurosurgery ◽

10.3171/2013.3.jns121469 ◽

2013 ◽

Vol 119 (1) ◽

pp. 190-197 ◽

Cited By ~ 38

Author(s):

Aichi Chien ◽

Feng Liang ◽

James Sayre ◽

Noriko Salamon ◽

Pablo Villablanca ◽

...

Keyword(s):

Risk Factors ◽

Intracranial Aneurysms ◽

Posterior Circulation ◽

Unruptured Aneurysms ◽

Multiple Aneurysms ◽

Unruptured Intracranial Aneurysms ◽

History Of ◽

Aneurysm Growth ◽

Small Aneurysms

Object This study was performed to investigate the risk factors related to the growth of small, asymptomatic, unruptured aneurysms in patients with no history of subarachnoid hemorrhage (SAH). Methods Between January 2005 and December 2010, a total of 508 patients in whom unruptured intracranial aneurysms were diagnosed at the University of California, Los Angeles medical center did not receive treatment to prevent rupture. Of these, 235 patients with no history of SAH who had asymptomatic, small, unruptured aneurysms (< 7 mm) were monitored with 3D CT angiography images. Follow-up images of the lesions were used to measure aneurysm size changes. Patient medical history, family history of SAH, aneurysm size, and location were studied to find the risk factors associated with small aneurysm growth. Results A total of 319 small aneurysms were included, with follow-up durations of 29.2 ± 20.6 months. Forty-two aneurysms increased in size during the follow-up; 5 aneurysms grew to become ≥ 7 mm within 38.2 ± 18.3 months. A trend of higher growth rates was found in single aneurysms than in multiple aneurysms (p = 0.07). A history of stroke was the only factor associated with single aneurysm growth (p = 0.03). The number of aneurysms (p = 0.011), number of aneurysms located within the posterior circulation (p = 0.030), and patient history of transient ischemic attack (p = 0.044) were related to multiple aneurysm growth. Conclusions Multiple small aneurysms are more likely to grow, and multiple aneurysms located in the posterior circulation may require additional attention. Although single aneurysms have a lower risk of growth, a trend of higher growth rates in single aneurysms was found.

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Subarachnoid hemorrhage after surgical treatment of unruptured intracranial aneurysms

Journal of Neurosurgery ◽

10.3171/2017.3.jns162984 ◽

2018 ◽

Vol 129 (2) ◽

pp. 490-497

Author(s):

Hidetoshi Matsukawa ◽

Hiroyasu Kamiyama ◽

Toshiyuki Tsuboi ◽

Kosumo Noda ◽

Nakao Ota ◽

...

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Surgical Treatment ◽

Incidence Rate ◽

Intracranial Aneurysms ◽

Annual Incidence ◽

Annual Incidence Rate ◽

Excellent Outcome ◽

Unruptured Intracranial Aneurysms ◽

Average Annual Incidence

OBJECTIVEOnly a few previous studies have investigated subarachnoid hemorrhage (SAH) after surgical treatment in patients with unruptured intracranial aneurysms (UIAs). Given the improvement in long-term outcomes of embolization, more extensive data are needed concerning the true rupture rates after microsurgery in order to provide reliable information for treatment decisions. The purpose of this study was to investigate the incidence of and risk factors for postoperative SAH in patients with surgically treated UIAs.METHODSData from 702 consecutive patients harboring 852 surgically treated UIAs were evaluated. Surgical treatments included neck clipping (complete or incomplete), coating/wrapping, trapping, proximal occlusion, and bypass surgery. Clippable UIAs were defined as UIAs treated by complete neck clipping. The annual incidence of postoperative SAH and risk factors for SAH were studied using Kaplan-Meier survival analysis and Cox proportional hazards regression models.RESULTSThe patients’ median age was 64 years (interquartile range [IQR] 56–71 years). Of 852 UIAs, 767 were clippable and 85 were not. The mean duration of follow-up was 731 days (SD 380 days). During 1708 aneurysm years, there were 4 episodes of SAH, giving an overall average annual incidence rate of 0.23% (95% CI 0.12%–0.59%) and an average annual incidence rate of 0.065% (95% CI 0.0017%–0.37%) for clippable UIAs (1 episode of SAH, 1552 aneurysm-years). Basilar artery location (adjusted hazard ratio [HR] 23, 95% CI 2.0–255, p = 0.0012) and unclippable UIA status (adjusted HR 15, 95% CI 1.1–215, p = 0.046) were significantly related to postoperative SAH. An excellent outcome (modified Rankin Scale score of 0 or 1) was achieved in 816 (95.7%) of 852 cases overall and in 748 (98%) of 767 clippable UIAs at 12 months.CONCLUSIONSIn this large case series, microsurgical treatment of UIAs was found to be safe and effective. Aneurysm location and unclippable morphologies were related to postoperative SAH in patients with surgically treated UIAs.

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Small (< 10-mm) incidentally found intracranial aneurysms, Part 1: reasons for detection, demographics, location, and risk factors in 212 consecutive patients

Neurosurgical FOCUS ◽

10.3171/2011.9.focus11234 ◽

2011 ◽

Vol 31 (6) ◽

pp. E3 ◽

Cited By ~ 18

Author(s):

Ioannis Loumiotis ◽

Anne Wagenbach ◽

Robert D. Brown ◽

Giuseppe Lanzino

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

Imaging Techniques ◽

Imaging Study ◽

Consecutive Series ◽

Common Location ◽

Unruptured Intracranial Aneurysms ◽

Paraclinoid Aneurysms ◽

History Of

Object The widespread use of imaging techniques for evaluating nonspecific symptoms (vertigo, dizziness, memory concerns, unsteadiness, and the like) and focal neurological symptoms related to cerebrovascular disease has led to increased identification of asymptomatic incidentally discovered unruptured intracranial aneurysms (UIAs). The management of these incidental aneurysms is controversial and many factors need to be considered. The authors describe reasons leading to diagnosis, demographics, and risk factors in a large consecutive series of patients with small incidentally found UIAs. Methods The authors prospectively evaluated 335 patients harboring 478 small (< 10-mm) UIAs between January 2008 and May 2011. Patients with known aneurysms, possibly symptomatic aneurysms, arteriovenous malformation–related aneurysms, patients with a history of subarachnoid hemorrhage from another aneurysm, and patients harboring extradural aneurysms were excluded from the analysis. Only truly incidental small aneurysms (272 aneurysms in 212 patients) were considered for the present analysis. Data regarding the reason for detection, demographics, location, and presence of potential risk factors for aneurysm formation were prospectively collected. Results There were 158 female (74.5%) and 54 male (25.5%) patients whose mean age was 60.6 years (median 62 years). The most common reason for undergoing the imaging study that led to a diagnosis of the aneurysms was evaluation for nonspecific spells and symptoms related to focal cerebrovascular ischemia (43.4%), known/possible intracranial or neck pathology (24%), and headache (16%). The most common location (27%) of the aneurysm was the middle cerebral artery; the second most common (22%) was the paraclinoid internal carotid artery (excluding cavernous sinus aneurysms). Sixty-nine percent of patients were current or prior smokers, 60% had a diagnosis of hypertension, and 23% had one or more relatives with a history of intracranial aneurysms with or without subarachnoid hemorrhage. Conclusions Small incidental UIAs are more commonly diagnosed in elderly individuals during imaging performed to investigate ill-defined spells or focal cerebrovascular ischemic symptoms, or during the evaluation of known or probable unrelated intracranial/neck pathology. Hypertension, smoking, and family history of aneurysms are common in this patient population, and the presence of these risk factors has important implications for treatment recommendations. Although paraclinoid aneurysms (excluding intracavernous aneurysms) are uncommon in patients with ruptured intracranial aneurysms, this location is very common in patients with small incidental UIAs.

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Impact of Young Age on the Presentation of Saccular Intracranial Aneurysms: Population-Based Analysis of 4082 Patients

Neurosurgery ◽

10.1093/neuros/nyx305 ◽

2017 ◽

Vol 82 (6) ◽

pp. 815-823 ◽

Cited By ~ 5

Author(s):

Sari Räisänen ◽

Juhana Frösen ◽

Mitja I Kurki ◽

Terhi Huttunen ◽

Jukka Huttunen ◽

...

Keyword(s):

Risk Factors ◽

Family History ◽

Intracranial Aneurysms ◽

De Novo ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Population Based ◽

Young Age ◽

Smoking History ◽

Old Patients ◽

First Diagnosis

Abstract BACKGROUND Formation and rupture of saccular intracranial aneurysms (sIAs) may have different pathobiologies in patients with younger age at first diagnosis of sIA disease. OBJECTIVE To study the phenotype of sIA disease and formation of new (de novo) sIAs in patients below 40 yr. METHODS A population-based cohort study was conducted in 613 young (<40 yr) sIA patients with first diagnosis between 1980 and 2014 and total angiographic follow-up of 3768 yr. RESULTS Of the 613 sIA patients <40 yr, 508 had aneurysmal subarachnoid hemorrhage (sIA-SAH) and 105 unruptured sIA(s) at first sIA diagnosis. Hypertension was 2 times less common among <40 than >40-yr-old patients (unruptured and ruptured). Smoking was very prevalent in <40-yr-old patients (33% in SAH, 68% unruptured). SAH patients <40 yr more often had family history of sIA, and lower PHASES scores (age omitted, P < .001). Ruptured sIAs were small (<7 mm) in 33% of 39 to 30 yr patients, in 44% of 29 to 20 yr patients, and 57% of <19 yr patients. Their shape was irregular in 90%, 94%, and 95%, respectively. Smoking history (hazard ratio [HR] 2.8, 95% confidence interval [CI] 1.2-7.0), family history for sIAs (HR 3.1, 95% CI 1.3-7.7), and age at presentation (HR .91 per year, 95% CI .85-.98) were risk factors for de novo sIA formation, diagnosed in 4% even after 20 yr (median 11.8 yr). CONCLUSION Smoking and family history are risk factors for sIA formation and aneurysmal SAH at young age. Young aneurysmal SAH patients had lower PHASES scores and often rupture from a small sIA, suggesting need for more aggressive management.

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Intracranial Aneurysms in Children with Sickle-Cell Anemia

Blood ◽

10.1182/blood.v120.21.4756.4756 ◽

2012 ◽

Vol 120 (21) ◽

pp. 4756-4756

Author(s):

Manoelle Kossorotoff ◽

Valentine Brousse ◽

David Grevent ◽

Michel Zerah ◽

Olivier Naggara ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Sickle Cell ◽

Sickle Cell Anemia ◽

Coil Embolization ◽

Intracranial Aneurysms ◽

Brain Mri ◽

Posterior Circulation ◽

Moyamoya Syndrome ◽

Stenotic Lesion ◽

Concurrent Development

Abstract Abstract 4756 Background: Intracranial aneurysms in sickle-cell anemia (SCA) have been reported in about 50 adult patients, mostly presenting with subarachnoid hemorrhage (SAH). Aneurysms in those patients tend to be multiple (50%), to involve the posterior circulation more frequently than in the general population (33% vs 14%) and to be diagnosed at a younger age. In pediatric SCA patients, SAH has scarcely been reported, without evident link with stenotic cerebral vasculopathy. An associated intracranial aneurysm has only been demonstrated once in a teenager. Case reports: We report the cases of 2 children with sickle-cell anemia (HbSS) with intracranial aneurysms. The first patient was a 5-year old girl with abnormal transcranial Doppler (TCD) screening for cerebral vasculopathy: left middle cerebral artery time-averaged mean velocity (MCA TAMV) 208cm/sec, right MCA TAMV 196cm/sec. She had normal neurological assessment. On her brain MRA, no stenotic lesion was found within the Circle of Willis and the Internal Carotid arteries. A 6mm distal left posterior cerebral artery unruptured saccular aneurysm was observed. The brain MRI revealed a left thalamic lacunar infarction likely due to asymptomatic embolic infarction from the aneurysm. Longitudinal MR imaging showed spontaneous but incomplete thrombotic aneurysm occlusion. The second patient, an 11 year-old boy with slight cognitive delay and normal annual TCD procedures, presented with a non-traumatic SAH. Brain MRI showed several small silent cerebral infarctions in the white matter watershed territories. Brain MRA revealed multiple aneurysms without any stenotic lesion. A ruptured aneurysm was located on the basilar artery termination. Four unruptured aneurysms were found: 3 on the posterior cerebral arteries (1 right, 2 left) and 1 on the ophthalmic artery ostium. Endovascular coil embolization resulted in angiographic occlusion of the 2 accessible aneurysms. Clinical outcome was excellent. Discussion: Hemorrhagic strokes are more frequent than ischemic strokes in young adult SCA patients. Two main mechanisms are described: intracerebral or intraventricular hemorrhage due to major occlusive vasculopathy (moyamoya syndrome) or subarachnoid hemorrhage due to aneurysm rupture or leak. Our pediatric patients have no evidence for moyamoya syndrome. Their intracranial aneurysms bear similar characteristics with adult SCA patients': possibility of multiple aneurysms and posterior circulation involvement. They are observed at a very young age and are associated with mild cerebral vasculopathy: abnormal TCD without MRA stenosis in one case, silent cerebral infarcts without MRA stenosis in the other case. These findings plead for a possible concurrent development of vascular lesions leading either to ischemic or hemorrhagic stroke. This hypothesis is supported by similar histopathological findings in both aneurysms and cerebrovascular occlusive lesions in SCA: intimal hyperplasia, smooth-muscle layer hyalinization and elastic lamina fragmentation. This challenges the supposedly sequential pathophysiology of strokes in SCA, based on the high prevalence of infarctive strokes in children and hemorrhagic strokes in young adults. Conclusion: This report of pediatric intracranial aneurysms, associated with mild cerebral vasculopathy in both patients, supports the hypothesis of a common pathophysiological mechanism and the possible concurrent development of stenotic lesions and dilatations. This is also the first report of successful coil embolization in a pediatric SCA patient. Disclosures: No relevant conflicts of interest to declare.

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Analysis of intracranial aneurysms treated at a University Hospital in Curitiba

Arquivos Brasileiros de Neurocirurgia Brazilian Neurosurgery ◽

10.1055/s-0038-1625660 ◽

2012 ◽

Vol 31 (02) ◽

pp. 55-60

Author(s):

Johnni Oswaldo Zamponi Junior ◽

Paulo Eduardo Carneiro da Silva ◽

Guilherme Zandavalli Ramos ◽

Guilherme Mailio Buchaim ◽

Lucas Cunha de Andrade ◽

...

Keyword(s):

Diabetes Mellitus ◽

Risk Factors ◽

Treatment Outcome ◽

Subarachnoid Hemorrhage ◽

Hospital Admission ◽

Intracranial Aneurysms ◽

Smoking Habit ◽

University Hospital ◽

Anterior Circulation ◽

History Of

Abstract Objective: The aim of this paper is analyze the population and the types of intracranial aneurysms treated in the neurosurgery service of the Hospital Universitário Evangélico of Curitiba (HUEC), checking possible relations of this pathology with some risk factors and analyzing also the result of the treatment of this patients. Method: We reviewed the hospital files, surgical and out-patient notes of all patients operated on for the treatment of intracranial aneurysms from January 2006 to December 2010, composing a sample of 93 patients. The variables analyzed were gender, age, history of hypertension, smoking habit, diabetes mellitus, site of aneurysm, score scales Hunt-Hess and Fisher at hospital admission and treatment outcome of aneurysms using the Glasgow Outcome Scale (GOS). Results: The patients studied were predominantly women (73%), ranging in age from 51 to 60 years (38%), with a history of hypertension (61%). At admission, the grade 1 in a Hunt-Hess scale was most frequent (31%), while grade 4 on a scale of Fisher was more prevalent (26%). Aneurysms were more frequent in the anterior circulation, mainly affecting the middle cerebral artery. The most frequent score in GOS was 5 (40%). Conclusion: Subarachnoid hemorrhage is an event that may worsen the outcome of treatment of patients with intracranial aneurysms, so there is a correlation between the amount of bleeding identified on CT and prognostic evolution.

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The case for family screening for intracranial aneurysms

Neurosurgical FOCUS ◽

10.3171/2011.9.focus11210 ◽

2011 ◽

Vol 31 (6) ◽

pp. E8 ◽

Cited By ~ 7

Author(s):

Nohra Chalouhi ◽

Rohan Chitale ◽

Pascal Jabbour ◽

Stavropoula Tjoumakaris ◽

Aaron S. Dumont ◽

...

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Natural History ◽

Intracranial Aneurysms ◽

Family Screening ◽

Multiple Factors ◽

History Of ◽

The Cost ◽

Familial Aneurysms ◽

Risk Of Treatment

Given that relatives of patients with intracranial aneurysms (IAs) or subarachnoid hemorrhage have a greater risk of harboring an aneurysm, family screening has become a common practice in neurosurgery. Unclear data exist regarding who should be screened and at what age and interval screening should occur. Multiple factors including the natural history of IAs, the risk of treatment, the cost of screening, and the psychosocial impact of finding an aneurysm should be taken into account when family screening is considered. In this paper, the authors review the current literature regarding risk factors and natural history of sporadic and familial aneurysms. Based on these data the authors assess current recommendations for screening and propose their own recommendations.

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Association of single and multiple aneurysms with tobacco abuse: an @neurIST risk analysis

Neurosurgical FOCUS ◽

10.3171/2019.4.focus19130 ◽

2019 ◽

Vol 47 (1) ◽

pp. E9 ◽

Cited By ~ 2

Author(s):

Bawarjan Schatlo ◽

Oliver P. Gautschi ◽

Christoph M. Friedrich ◽

Christian Ebeling ◽

Max Jägersberg ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

General Population ◽

Risk Analysis ◽

Intracranial Aneurysms ◽

Lifestyle Modification ◽

Smoking Status ◽

Reference Population ◽

Multiple Aneurysms ◽

Risk Of Rupture ◽

Tobacco Abuse

OBJECTIVEAlthough several studies have suggested that the incidence of intracranial aneurysms (IAs) is higher in smokers, the higher prevalence of subarachnoid hemorrhage (SAH) in smokers remains uncertain. It is unclear whether smoking additionally contributes to the formation of multiple aneurysms and the risk of rupture. The aim of this study was to determine whether smoking is associated with IA formation, multiplicity, or rupture.METHODSPatients from the prospective multicenter @neurIST database (n = 1410; 985 females [69.9%]) were reviewed for the presence of SAH, multiple aneurysms, and smoking status. The prevalence of smokers in the population of patients diagnosed with at least one IA was compared with that of smokers in the general population.RESULTSThe proportion of smokers was higher in patients with IAs (56.2%) than in the reference population (51.4%; p < 0.001). A significant association of smoking with the presence of an IA was found throughout group comparisons (p = 0.01). The presence of multiple IAs was also significantly associated with smoking (p = 0.003). A trend was found between duration of smoking and the presence of multiple IAs (p = 0.057). However, the proportion of smokers among patients suffering SAH was similar to that of smokers among patients diagnosed with unruptured IAs (p = 0.48).CONCLUSIONSSmoking is strongly associated with IA formation. Once an IA is present, however, smoking does not appear to increase the risk of rupture compared with IAs in the nonsmoking population. The trend toward an association between duration of smoking and the presence of multiple IAs stresses the need for counseling patients with IAs regarding lifestyle modification.

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Coccidioidal meningitis with multiple aneurysms presenting with pseudo–subarachnoid hemorrhage: illustrative case

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21424 ◽

2021 ◽

Vol 2 (15) ◽

Author(s):

Rohin Singh ◽

Visish M. Srinivasan ◽

Joshua S. Catapano ◽

Joseph D. DiDomenico ◽

Jacob F. Baranoski ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Aneurysms ◽

External Ventricular Drain ◽

Severe Case ◽

Western United States ◽

Illustrative Case ◽

Basal Cistern ◽

Aneurysmal Rupture ◽

Multiple Aneurysms ◽

Prompt Treatment

BACKGROUND Coccidioidomycosis is a primarily self-limiting fungal disease endemic to the western United States and South America. However, severe disseminated infection can occur. The authors report a severe case of coccidioidal meningitis that appeared to be a subarachnoid hemorrhage (SAH) on initial inspection. OBSERVATIONS A man in his early 40s was diagnosed with coccidioidal pneumonia after presenting with pulmonary symptoms. After meningeal spread characterized by declining mental status and hydrocephalus, coccidioidal meningitis was diagnosed. The uniquely difficult aspect of this case was the deceptive appearance of SAH due to the presence of multiple aneurysms and blood draining from the patient’s external ventricular drain. LESSONS Coccidioidal infection likely led to the formation of multiple intracranial aneurysms in this patient. Although few reports exist of coccidioidal meningitis progressing to aneurysm formation, patients should be closely monitored for this complication because outcomes are poor. The presence of basal cistern hyperdensities from a coccidioidal infection mimicking SAH makes interpreting imaging difficult. Surgical management of SAH can be considered safe and viable, especially when the index of suspicion is high, such as in the presence of multiple aneurysms. Even if it is unclear whether aneurysmal rupture has occurred, prompt treatment is advisable.

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