Multimodal Endovascular Management of Aneurysmal Subarachnoid Hemorrhage Associated with Three Intracranial Aneurysms: A Case Report

Abstract

Aneurysmal subarachnoid hemorrhage (aSAH) is a neurological emergency in which prompt aneurysm identification and definitive exclusion are central to preventing rebleeding. The presence of multiple intracranial aneurysms creates an additional diagnostic problem because the hemorrhage pattern may not reliably identify the ruptured lesion, while aneurysm morphology and parent-vessel anatomy may require different endovascular strategies.A 63-year-old woman presented after an episode of giddiness followed by a fall in the restroom, headache, and three episodes of vomiting. Non-contrast computed tomography performed at an outside facility demonstrated acute subarachnoid hemorrhage involving the bilateral Sylvian fissures, basal cisterns, bilateral temporofrontoparietal cortical sulci, and prepontine cistern, without hydrocephalus, midline shift, or significant mass effect. Cerebral digital subtraction angiography identified three intracranial aneurysms: a 3 × 2 mm wide-neck right supraclinoid internal carotid artery aneurysm with an adjacent blister aneurysm, a 6.1 × 5.2 mm left posterior communicating artery aneurysm with twin daughter sacs and a narrow neck, and a 2 × 2 mm wide-neck basilar apex aneurysm. During the same hospitalization, the right supraclinoid lesion was treated with coil embolization followed by Silk Vista flow-diverter deployment, the left posterior communicating artery aneurysm with detachable coils, and the basilar apex aneurysm with a Leo braided stent. Periprocedural and neurocritical care included antiplatelet therapy, nimodipine, neurological and hemodynamic monitoring, levetiracetam, intravenous fluids, supportive treatment, and packed red-cell transfusion for microcytic hypochromic anemia.Completion angiography showed marked reduction in filling of the right supraclinoid aneurysm with satisfactory flow-diverter apposition and reconstruction of the adjacent blister lesion, complete angiographic occlusion of the left posterior communicating artery aneurysm with preservation of the parent internal carotid artery, and marked flow stasis within the basilar apex aneurysm with preservation of posterior circulation branches. No thromboembolism, dissection, contrast extravasation, or distal embolization was documented. The patient was successfully extubated, remained neurologically stable without a newly documented focal deficit, and was discharged hemodynamically stable.This case illustrates the value of lesion-specific endovascular planning in aSAH with multiple aneurysms. The combination of simple coiling, flow-diverter-assisted coiling, and braided-stent reconstruction allowed treatment of three anatomically and morphologically different aneurysms during one hospitalization. The case also emphasizes the need for multidisciplinary neurocritical care and continued imaging surveillance after treatment.