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Abstract
Introduction This case of SAH alongside dual imaging findings of MCA aneurysm and AVM, underscores the intricate nature of managing complex intracranial vascular pathologies.
Case Description We present a 38 year old, left-handed GCS 15 male presenting with sudden-onset frontal headache with dizziness, nausea, photophobia and ataxia. Non-contrast CT demonstrated subarachnoid haemorrhage (SAH). CTA revealed a wide-necked aneurysm at right M1 bifurcation with a concurrent right frontoparietal arteriovenous malformation (AVM), indicating two potential SAH contributors, introducing ambiguity regarding optimal management
Given aneurysmal SAH’s higher threat of rebleeding and mortality compared to AVM-related SAH, it was prioritized for clipping via standard pterional approach. After a 41-day recovery period, the AVM was addressed (1, 2).
The AVM was located posterior to the postcentral gyrus with arterial feeders from MCA branches and drainage into the vein of Labbé and superior sagittal sinus. Proximity to the motor strip, language, and speech areas was of great concern due to the patient’s left-handedness and a WADA test demonstrating ambiguous bihemispheric response.
Right parietal craniotomy with trans-sulcal approach was chosen for resection of the Speltzer-Martin 5 AVM. Post-operative CTA confirmed complete resection, on examination patient had right upper limb dysdiadokinesia and minor proprioception impairment. Patient was transferred out of ICU two days post-op and discharged day 7 post-op.
Results From prompt diagnosis to navigating uncertainty, selecting the most likely culprit in an emergent scenario is paramount to mitigating complications and reducing mortality risks. Finally, this case invites multidisciplinary dialogue regarding optimal intervention, whether endovascular or open.