Disappearance and reappearance of a cerebral aneurysm

Abstract

A 42-year-old male was hospitalized with acute-onset
aphasia and right hemiparesis due to acute middle cerebral artery (MCA) superior division infarction. A computerized tomography angiography (CTA), obtained for
evaluation of stroke etiology and vessel status, revealed
a partially thrombosed unruptured saccular aneurysm on
left MCA bifurcation (figure a, b). Following fractional

neurological recovery, he developed sudden onset global
aphasia and right hemiplegia on the sixth day of hospitalization. A second CTA, obtained for evaluating the
possibility of an endovascular intervention to achieve
acute recanalization, showed complete disappearance of
the aneurysm along with thrombosis of the distal M1
segment of the left MCA (figure c,d). In addition, disseminated thrombosis of the great arteries including
ascending and descending aorta, bilateral subclavian and
iliac arteries were noted. Interventional treatment was
then not attempted and intravenous heparin was initiated.
There was evidence for systemic hypotension, significant leukocytosis (36,500/mm3) and liver dysfunction
that was considered to be secondary to systemic inflammatory response syndrome in the setting of severe hospital-acquired aspiration pneumonia. No acquired or
hereditary thrombophilia could be demonstrated albeit
an extensive work-up. While the patient remained clinically stable, a follow-up CTA obtained on nineteenth
day showed reappearance of the aneurysm in addition to
complete recanalization of MCA and other arteries (figure e,f).
Because of the clinical severity of infarction and denial
of the patient for a surgical clipping of the aneurysm, he
was transferred to a rehabilitation facility on subcutaneous low-molecular weight heparin treatment. Unfortunately, the patient was lost on follow-up after discharge
from this facility, and we could not get in contact with
him against our best effort.
Spontaneous disappearance and reappearance of a ruptured cerebral aneurysm is rarely documented, and is