1. Neurosurg. / Volume 31 / October, 1969

Radiological Demonstration of Rupture of a Carotid Aneurysm
During Cerebral Angiography
Case Report
GIUSEPPE FERRARI, M.D., AND MARA Wlo, M.D.
lnstituto di Clinica dette Malattie Nervose e Mentali, Universita" di Cagliari, Cagliari, Italy

HAT cerebral arteriography can carry
certain hazards has been repeatedly
recognized. 6,1~
The complications are usually due to the trauma of puncturing the vessel, the toxic action of the contrast medium itself, or hydrodynamic disturbances.
The rupture of an intracranial aneurysm
during an arteriographic procedure has seldom been visualized radiographically.7,',~,~z
The case we are reporting is the only one
observed in the last 10 years among the
many carotid arteriographies performed in
the Radiological Department of the Institutes of Neurosurgery and Neurology of the
University of Padua and the Institute of
Neurology of the University of Cagliari.

T

Case Report
This 38-year-old woman had always been
in perfect health until 1957 when she contracted typhoid fever; at the same time she
started having fits that recurred once every 4
to 10 months and were characterized by vertigo, sweating, and sudden loss of consciousness. Headache and drowsiness were a constant aftermath. The most recent seizure
took place 4 days before admission in 1967
and was marked by especially severe headache and repeated vomiting. The patient had
never been studied or treated.
Examination. On admission on July 31,
1967, the patient showed slight increase of
the tendon reflexes on the right side, moderate anisochoria (left side greater than right),
and left anosmia. Urine examination and
routine blood tests were negative. X-ray
films of the skull were normal with the exception of a faint pea-sized opacity which in
the lateral view coincided with the anterior
clinoid process and in the anteroposterior
Received for publication August 28, 1968.
Revision received March I0, 1969.

view was located to the left of these processes. The electroencephalogram showed
moderate irritative abnormalities in the anterior and middle left temporal leads.
Angiography. We considered suprasellar
meningioma as a possible diagnosis, and left
carotid angiography was performed using
Conray 60%. The patient showed no unfavorable reactions to two consecutive 8 ml
doses, but at the end of a third dose became
unconscious, with deviation of the head and
eyes to the left, apnea, hypotension, and mcreased pulse rate. These symptoms were
caused by extravasation of the contrast medium from the aneurysm into the subarachnoid space, which was fully documented by
Figs. 1 and 2. After cessation of the tonic
phase, respiration started again, at first periodic, then normal. The patient was comatose
with loss of tendon reflexes; there were bilateral Babinski's signs and anisochoria (right
side greater than the left).
In the following days consciousness gradually returned. There was, however, a right
hemiplegia and aphasia. In the left fundus
oculi, there were hemorrhages around the
papilla. Seven months after admission the
patient still had flaccid hemiplegia but was
able to pronounce some words, although not
fluently. The electroencephalogram then
showed almost complete absence of cortical
activity on the left side.

Discussion

The rupture of an intracranial aneurysm
during carotid or vertebral angiography is a
rare but possible occurrence. In most cases
of subarachnoid hemorrhage, however, angiographic procedures are necessary to diagnose the precise anatomical conditions underlying the hemorrhage s or to clarify a
doubtful case such as our own, in which a
meningioma was suspected. Decker says, in
fact, that a calcification in the wall of an aneurysm is quite rare. 5
462

Rupture of Aneurysm During Angiography

463

FIG. 1. Left carotid angiograms. Left: First injection. The image of the aneurysm is projected on
the bifurcation of the siphon. Center: Second injection. The aneurysm now appears half filled with
contrast medium. Above the anterior clinoid processes there is an oblong image not anatomically definable. Right: Third injection, first film. The aneurysm appears completely filled and bears a concave
imprint anteriorly; the size is unchanged. At the posterior pole a diffusion of the contrast medium
descends towards the clivus.
W e are discussing this case to evaluate the
possible factors in the r u p t u r e of the aneur y s m during a n g i o g r a p h y and to eliminate
the easy e x p l a n a t i o n of an accidental relationship between two coincidental o c c u r rences. L a c k i n g precise m e a s u r a b l e a n a t o m i c
evidence and data because of the dramatic
suddenness of the accident, we m u s t m a k e a
circumstantial d e d u c t i o n based on previous
experience.
T h e contrast m e d i u m used ( C o n r a y

6 0 % ) is considered one of the safest for cerebral angiography. T h e technique was the
same we had followed in several t h o u s a n d
other carotid or vertebral angiographies with
n o m a j o r complications. T h e c o m m o n carotid artery was p u n c t u r e d p e r c u t a n e o u s l y ;
during each injection, 8 cc of contrast m e dium were introduced b y m a n u a l pressure
over a period of 2 to 3 seconds. Pressure
was not applied to the contralateral carotid;
this, if prolonged, leads to a considerable in-

FIG. 2. Left carotid angiograms. Left: Third injection, second film. A veil of opacity goes around
the aneurysm showing this to be very probably vilobate. The contrast medium can be followed around
the brain stem in the cisternae. Right: Third injection, third film. The contrast medium is now
recognizable in the interhemispheric and basal cisternae.

464

Giuseppe Ferrari and Mara Vio

crease in the systolic pressure. 19 The patient
was a young woman with a normal heart and
no arteriosclerosis.
In uncomplicated angiography the lack of
precise information concerning the time
elapsed between arteriography and hemorrhage makes difficult any estimation of the
risk of angiographic procedures performed
too quickly. The number of injections and
the briefness of the intervals between them
might be important in determining the complications. T6rma and Fogelholm 16 tend to
minimize these factors. Most cases of rupture of aneurysm during angiography, however, received doses of contrast medium and
a number of injections higher than those required for a normal procedure. Broman and
Olsson 3 believe that a summation effect
might develop if the injections are given too
close to each other. As far as Diodrast is
concerned, the reaction with the vascular
wall was directly related to the concentration
of the contrast medium and the duration of
its contact with the endothelial lining. Chemical toxic action on the vascular walls demonstrated for U r o k o n 70% 2 and Diodrast ~s
cannot be ruled out in the case of Conray
6 0 % . I n our patient, retention of the contrast medium in the sac for a relatively long
time could have damaged the aneurysmal
wall which was undergoing reparative phenomena.
A t the same time, the contrast medium
caused segmental spasm of the vessels, also
shown in the radiographs. We consider it a
reasonable hypothesis that these segmental
contractions and the accompanying hemodynamic imbalance, with local pressure increase
and possible formation of a functional valve
mechanism, might have resulted in an increase of pressure within the aneurysm leading to its rupture.

Summary
A case of rupture of an intracranial aneurysm during carotid arteriography has been
reported. The patient, a 38-year-old woman,
survived but still has severe aphasia and flaccid hemiplegia 7 months later.
The possible factors in the production of
this infrequent complication have been discussed with a special emphasis on the chemical toxic action by the contrast medium on
the wall of the aneurysm, and hemodynamic
imbalance with segmental increase in the intra~umi~a~ ~ e s s u r e .

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