Case report: The case report details the admission of an 81 year old Caucasian woman who presented with a history of sudden onset of a severe occipital headache. The headache was associated with photophobia. History revealed that she had suffered similar headaches in the past 2 months. However, this particular episode was the most severe and had continued overnight.
Past medical history: She had suffered a right hemisphere lacunar infarct 2 years previously and made a good recovery. She has a history of ischemic heat disease and and angina. She also suffered from hypertension, atrial fibrillation for which she was on Clopidrogel.
Social History: She is an independent woman and lives alone. She self cares and uses one stick to walk. She is fully mobile and cognitively intact. Clinical examination: She was fully intact and had no obvious focal deficit. The GCS was 15/15.
Radiological investigations: CT did not reveal SAH though there was evidence of the previous lacunar infarct. The CT revealed evidence of a enhancing lesion in the interhemispheric fissure. This was highly suggestive of an aneurysm. MRI and MRA were performed and confirmed the 5mm aneurysm of the anterior communicating artery.
Clinical course: We required evidence that this aneurysm had indeed ruptured so a Lumbar Puncture was performed. There was no xanthochromia and 55, 70 red blood cells in the first and second bottles.
So we have presented a case of an elderly patient with a possibly unruptured but symptomatic aneurysm in he anterior communicating artery complex. She is neurologically intact and has a reasonable good quality of life prior to admission. However, she has significant co-morbidity.
Comments: The elderly constitute a significant and increasing proportion of the population. Elderly patients with subarachnoid hemorrhage can be treated successfully, and results are improving. The decision to treat an intracranial aneurysm however remains difficult whether it is ruptured or unruptured. Despite recent controversy regarding aneurysmal hemorrhage rates, symptomatic unruptured aneurysms should probably be treated even in older patients.
