[Magnetic resonance vessel wall imaging reveals rupture site in subarachnoid hemorrhage with multiple cerebral aneurysms].

We report a case of subarachnoid hemorrhage(SAH)with multiple cerebral aneurysms, in which magnetic resonance vessel wall imaging(MR-VWI)revealed the rupture site. A 68-year-old woman presented with SAH. Computed tomography(CT)showed diffuse SAH(Fisher group 3). 3D-CT angiography revealed two intracranial aneurysms:a 4.2-mm anterior communicating artery aneurysm(Acom An)and a 5.8-mm basilar tip aneurysm(BAtip An). As the BAtip An was the larger of the two, it was deemed the most likely site of rupture;however, high-resolution MR-VWI with gadolinium showed thick wall enhancement in the Acom An and no enhancement in the BAtip An. Thus, we performed a craniotomy for the Acom An. Intraoperative findings confirmed the rupture site at the Acom An. We concluded that high resolution MR-VWI may be useful for identifying the rupture site in patients with spontaneous SAH and multiple cerebral aneurysms.

Bilateral carotid and vertebral rete mirabile presenting with subarachnoid hemorrhage caused by the rupture of spinal artery aneurysm.

Rete mirabile (or carotid rete) is a normal structure that plays physiological roles in the lower mammals. However, the rete does not exist in the normal carotid circulation of humans. Carotid rete mirabile (CRM) is a rare condition compensating for congenital dysplastic internal carotid artery. Arterial plexus at the cavernous region, which supplies intradural internal carotid artery instead of the aplastic cavernous portion of internal carotid artery, looks like the "rete mirabile" seen in the lower mammals, and is a characteristic angiographical finding of CRM. In addition to the CRM, existence of segmental occlusion and tortuous collaterals of vertebral artery, so-called carotid and vertebral rete mirabile (CVRM), is a very rare condition. We report a 70-year-old female patient with bilateral CVRM presenting with subarachnoid hemorrhage (SAH) caused by the rupture of a cervical spinal artery aneurysm. Our patient is the oldest, compared with the previously reported four patients with CVRM. Moreover, this is the first report of ruptured spinal artery aneurysm as a cause of SAH associated with CRM/CVRM. To avoid rebleeding in the patient, we successfully treated the patients by performing coil embolization of the remaining spinal aneurysms. In patients with CVRM, aneurysm formation of the cervical spinal artery may be a reasonable consequence because of the hemodynamic stress on the spinal artery as a collateral pathway. Detailed evaluation of the cervical spinal arteries should be performed to detect or to rule out ruptured aneurysm in patients with SAH associated with CVRM.