Headache Medicine 2021, 12(1) p-ISSN 2178-7468, e-ISSN 2763-6178

ASAA

DOI: 10.48208/HeadacheMed.2021.13

Headache Medicine

Case Report

Incidental intracranial saccular aneurysm in a patient with post-

Covid-19 headache: What to do with the incidentaloma?

Marcelo Moraes Valença

Alberto Henrique Torres Trindade da Silva

Renan Furtado de Almeida

Mendes

Pedro Henrique Pereira de Andrade

Ubiratan Alves Viturino da Silva

Déborah Emmily

de Carvalho

Laécio Leitão Batista

Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.

Universidade de Pernambuco, Recife, Pernambuco, Brazil.

Universidade Federal da Paraíba, João Pessoa, Paraíba, Brazil.

Marcelo Moraes Valença

mmvalenca@yahoo.com.br

Edited by:

Mario Fernando Prieto Peres

Received: July 30, 2021

Accepted: August 20, 2021

Introduction

n the last decades, there was a growing increase in inci-

dentalomas.

1-6

In the radiological investigation of patients

with headaches, it is not infrequent to nd incidentalomas.

7-8

Incidentaloma is classically dened when, during a radio-

logical investigation, a tumoral lesion is identied, and such

lesion is not related to the clinical condition that justied

the request for the examination. In other words, it was an

incidental nding,

i.e

., a lesion found by coincidence without

any clinical symptoms or suspicion.

The term incidentaloma also serves to designate other

lesions found incidentally, such as in the case of an aneu-

rysm. Unruptured intracranial saccular aneurysms develop

in cerebral arteries over months or years and are rarely

symptomatic.

10-14

Eventually, during an imaging evaluation,

these brain aneurysms are discovered. For many of these

aneurysms, the chosen approach is conservative, depend-

ing on the size, location, associated diseases, risk of bleed-

ing, family history, among other factors that modify the risk

of rupture.

13,15

If the approach is conservative, it is essential

to follow up with serial reassessment by angiography (e.g.,

MR angiography).

Approximately 2–4% of the population harbours an unrup-

tured intracranial aneurysm

16-21

, and up to 30% and 42% of

these patients may have multiple aneurysms in imaging or

autopsy studies, respectively.

22-23

With increased utilization

of noninvasive imaging, the detection of these aneurysms

has become very common, the so-called incidentaloma.

The discovery of an incidental unruptured intracranial

saccular aneurysm implies decision-making strategy about

its treatment, either conservative or surgical (open or an

endovascular approach), depending on the size, location,

angioarchitecture of the aneurismal sac, associated dis

eases, age, risk of bleeding, family history, among other

factors that may modify the risk of rupture.

13,15

If the approach

ASAA

Valença MM, Silva AHTT, Mendes RFA, Andrade PHP, Silva UAV, Batista LL

Incidental intracranial saccular aneurysm in a patient with post-Covid-19 headache: What to do with the incidentaloma?

is conservative, following up the aneurysm with a serial

reassessment by magnetic resonance angiography (MRA)

is essential. This article will discuss the best management of

an elderly patient with an incidentally discovered saccular

aneurysm originated in the left middle cerebral artery (MCA).

Case report

An 83-year-old woman in January 2021 developed per-

sistent headache and decline in cognitive functions that

appeared after the acute onset of Covid-19. She is a regular

smoker and has hypertension treated with bisoprolol, oral

anticoagulants (rivaroxaban) to control cardiac arrhythmia,

and oral rosuvastatin to control dyslipidemia. She denied

a family history of a brain aneurysm. She was evaluated

with computed tomography (CT), magnetic resonance im-

aging (MRI), and digital angiography to investigate the

causes of symptoms (Figures 1 and 2). CT scan showed

an image compatible with aneurysmal dilatation in the left

middle cerebral artery bifurcation, conrmed by contrast

magnetic resonance angiography (Figure 1). According

to digital angiography, the saccular dilatation had the

following dimensions: 7.7 x 4.7 x 3.5 mm, with a neck

measuring 2.5 x 2.4 mm (Figure 2). In this case, after eval-

uating the advantages and disadvantages of conservative

versus preventive surgical intervention (clipping or coiling),

considering the patient's advanced age and expectations,

associated morbid conditions, we decided on a non-surgi-

cal approach, with conservative measures such as blood

pressure control, use of beta-blockers, statin, and follow-up

by CE-MRA.

Comments

Despite advancements in the management of subarachnoid

hemorrhage (SAH) due to aneurysmal rupture, overall case

fatality is quiet high. (40-60%).

Perhaps, for this reason,

patients harboring unruptured intracranial aneurysms have

performed preventive surgical intervention for many de-

cades to eliminate any conceivable aneurysm rupture.

Accordingly, managing of the patient with unruptured in-

tracranial aneurysms

remains a challenge with medical,

ethical, and legal implications. Some key questions remain:

what is the risk of rupture for a specic aneurysm in a pa-

tient in which specic risk factors can be identied? So, we

should consider important clinical and morphological points

before deciding when and how an accidental aneurysm

should be treated.

The prospective arm of the ISUIA

, one of the most exten-

sive studies examining rupture risk of unruptured asymptom-

atic intracerebral aneurysms, examined especially patients

with no previous history of subarachnoid hemorrhage that

location and size are the major key points to consider in

terms of rupture risk. A majority of ruptured aneurysm

shows diameter less than 7 mm, coming up the theory that

faster the aneurysm grows, soon will be ruptured. Recent-

ly, Liu and coworkers

monitoring unruptured intracranial

aneurysms based on a volumetric analysis found that a

group of the aneurysm can present with accelerated growth

rate mainly depending on the location, suggesting that

linear measurements could be fallible in predict a warning

aneurysm behavior.

Figure 1. (A) Brain axial CT scan revealed a saccular hyperdensity on the distal left middle cerebral artery

(MCA) (arrow); (B) 3D CE-MRA reconstruction on frontal and (C) oblique views showing a 7.1 mm lobula-

ted saccular aneurysm (arrows) on the bifurcation of the MCA. Lobulation on the aneurismal wall is seen.