Ruptured vertebral artery-posterior inferior cerebellar artery aneurysm associated with facial nerve paresis successfully treated with interlocking detachable coils--case report

Subarachnoid haemorrhage due to intracranial vertebral artery dissection presenting with atypical cauda equina syndrome features: case report

Background

Failing to recognise the signs and symptoms of subarachnoid haemorrhage (SAH) causes diagnostic delay and may result in poorer outcomes. We report a rare case of SAH secondary to a vertebral artery dissection (VAD) that initially presented with cauda equina-like features, followed by symptoms more typical of SAH.

Case presentation

A 55-year-old man developed severe lower back pain after sudden movement. Over the next 5 days he developed paraesthesiaes in the feet, progressing to the torso gradually, and reported constipation and reduced sensation when passing urine. On day six he developed left facial palsy, and later gradual-onset headache and intermittent confusion.

Magnetic resonance imaging of the brain showed diffuse subarachnoid FLAIR hyperintensity, concerning for blood, including a focus of cortical/subcortical high signal in the left superior parietal lobule, which was confirmed by computed tomography. Digital subtraction angiography demonstrated a left VAD with a fusiform aneurysm.

Conclusion

We present a very rare case of intracranial VAD with SAH initially presenting with spinal symptoms. The majority of subsequent clinical features were consistent with a parietal focus of cortical subarachnoid blood, as observed on neuroimaging.

Congenital aneurysm presenting as peripheral facial paresis

The incidence of intracranial aneurysms in infancy is relatively rare. They are infrequent in children less than 1 year old, and are an exception in the neonatal period. They usually originate in the internal carotid artery bifurcation, posterior circulation and seldom in the territory of the distal middle cerebral artery distribution. Infants often present with nonspecific symptoms: irritability, lethargy, vomiting, seizures and coma. Sometimes, they may present with unexpected clinical symptoms such as peripheral facial palsy. Subarachnoid hemorrhage is the most frequent presentation in this kind of aneurysms. Intracerebral hematoma is unusual. We present the case of a 10-week-old child harboring a middle cerebral artery aneurysm. To our knowledge, this is the first case of an aneurysm presenting as a peripheral facial paresis in a pediatric patient.

Early resolution of third nerve palsy following endovascular treatment of a posterior communicating artery aneurysm

A 69-year-old man underwent successful endovascular treatment of a posterior communicating artery aneurysm that had caused a third nerve palsy. Pupil size became normal within 10 days and ptosis and ocular ductions became normal within 3 weeks of the procedure. Based on the reported recovery rates of third nerve palsy after aneurysmal clipping, recovery may occur more rapidly in patients who undergo endovascular treatment. Further data are necessary to substantiate this hypothesis.