Acute Aneurysm Rupture

A 57-year-old man complained of a severe headache of sudden onset while he was lifting heavy boxes. Within minutes, he collapsed and became unconscious.

On arrival at the emergency department, the patient was deeply comatose. His pupils were 7 mm, fixed, and unreactive to light; brainstem reflexes were absent, and he was unresponsive to noxious stimulation. His blood pressure was 210/120 mm Hg; he had no known history of hypertension.

Dr Roman Kesler of Ocean Springs, Miss, writes that the CT scans of the brain revealed complete filling of the entire ventricular system-including the third and fourth ventricles-with hyperdense material (blood). Blood also was seen in the prepontine and suprasellar cisterns. A degree of hydrocephalus had set in secondary to obstruction of cerebrospinal fluid circulation pathways. The CT images are unique in that the blood from this presumed left-sided ruptured aneurysm is almost exclusively in the ventricular system; only a relatively small amount of blood is outside the ventricular system.

Based on the results of the examination (Hunt and Hess grade IV to V), the patient's prognosis was dismal. Despite supportive care, he died within 24 hours of hospitalization.

Surgery for acute aneurysm rupture is indicated for patients with less severe clinical deficits on presentation (Hunt and Hess grades 0 to III); however, surgery is not useful and may be detrimental for those with higher-grade subarachnoid hemorrhages, which have a very high morbidity and mortality rate.