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.

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?

Age is another crucial point to be taken into consideration

for a decision-making process. Although increasing age

after 50 does not substantially impact the risk of rupture,

preventive surgical intervention brings an additional benet

to morbidity and lethality rates, regardless of whether one

chooses to endovascular or open surgery.

In Table 1 are listed meta-analysis studies that evaluated

different conditions that may modify the risk of rupture of

a still unruptured intracranial aneurysm.

Table 1. Published meta-analyses on risk factors for aneurysm growth

Risk factor for aneurysm growth Studies

Smoking Jin

et al.

; Backes

et al.

; Wermer

et al.

Age >70-years-old Brinjikji

et al.

Arterial hypertension Backes

et al.

; Wermer

et al.

Woman Jin

et al.

; Backes

et al.

; Brinjikji

et al.

; Wermer

et al.

Aneurysm size >7 mm Brinjikji

et al.

; Wermer

et al.

Middle cerebral artery aneurysm Brinjikji

et al.

; Wermer

et al.

Using longitudinal analysis of the aneurysm volume, Liu and

coworkers

demonstrated in a series of 112 aneurysms in

95 patients (the mean follow-up time was 4.0 years.) with

UIA that there was evident growth at one year of follow-up

in 8% of cases. 36/112 (32%) of the aneurysms exhibited

noticeable growth during the study, and 11/36 (31%) an-

eurysms with noticeable change had an episode of abrupt

growth (only 11 of the 112 aneurysms (9.8%) presented an

episode of sudden growth).

The relative growth rate was

dependent on age and the location of the aneurysm, with

aneurysms of the anterior cerebral artery showing the fastest

growth rate of 4.07% per year. In this study, aneurysms of

the middle cerebral artery presented an annual growth

rate of 1.41%.

A recent study

evaluated the role of statins in unruptured

intracranial aneurysm growth and rupture, observing wheth-

er atorvastatin (20 mg daily) was associated with aneurysm

growth or rupture in patients with less than 7 mm aneu-

rysms. Among the 1.087 enrolled patients, 489 (45%)

took atorvastatin (mean follow-up duration of 33.0 ± 12.5

months). Current smoker and uncontrolled hypertension

were associated with aneurysm rupture, whereas atorvas-

tatin use was not. The authors concluded that unruptured

aneurysms sized 5 to <7 mm and uncontrolled hypertension

both were associated with a high growth rate, whereas

atorvastatin was associated with a reduced growth rate.

In another study

, chosen aneurysm locations (i.e., anterior

communicating artery, posterior communicating artery, and

middle cerebral artery) and an aneurysm size of 5 to <7

mm were associated with a high risk of aneurysm growth,

whereas aspirin and well-controlled blood pressure were

associated with a low risk of growth. However, in high-risk

patients (>1 risk factor), the cumulative annual growth rates

were as high as 40.0 and 53.3 per 100 person-years.

It is worth remembering the headaches associated with

aneurysmatic rupture with subarachnoid hemorrhage due

to the risk of death due to the lack of an accurate and

immediate diagnosis. Headache associate with aneurysm

rupture or aneurysm expansion presents as a sudden-onset,

high-intensity explosive thunderclap headache, usually

occurring during physical exertion. Intracranial aneurysms

can simulate a primary headache as well, such as cluster

headache. In this context, it is recalled that every patient

with cluster headache should be investigated by imaging,

including an MRA and cerebral digital subtraction angi-

ography.

Regarding the choice of a conservative management of

UIA, results from two studies support this decision. Lawson

and colleagues

built a methodological model to compare

the probability of poor outcomes from intervention (clipping

and endovascular) compared to the natural history of the

aneurysm, as a function of age and aneurysm size, using

data from previous studies. Poor outcomes included dis-

charge to a skilled nursing facility, long-term care facility,

Figure 2. Lobulation is observed in the aneurismal wall.

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?

hospice, or in-hospital death. They demonstrated a poor

outcome for both clipping or coiling beyond the age of 80

years. Considering the patient's characteristics reported

here, an advantage in intervention chose is observed in only

one of the four comparisons made, in which endovascular

treatment would show benet up to 86 years old.

Additionally, at the PHASES score study

, many of patients

with an unruptured intracranial aneurysm derived from six

extensive cohort studies, and information was included

in a pooled database. They built a model indicating the

probability of rupture based on well-known risk factors for

aneurysm rupture. The PHASES study incorporated in the

evaluation other risk factors, such as age, the maximal

diameter and the previous history of subarachnoid hemor-

rhage. Considering the PHASES score, we calculate a risk of

rupture of 2.4% per year (95% CI; 1.6-3.3), considering the

sum total of 7 points from a population, hypertension, age,

aneurysm size and site, and absence of a history of SAH.

Both studies include the patient's history of hypertension and

the rst includes the history of smoking. As for limitations,

the PHASES score considers populations that do not belong

to the reality of the case, making the risk of rupture with the

application of the score an estimate.

We conclude by commenting on the signicant chance

to encounter an asymptomatic intracranial lesion during

a patient's headache investigation.

Thus, the physician

must decide how to treat this incidental nding, which may

increase the risk of death.

Conflict of interests: No

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

Alberto Henrique Torres Trindade da Silva

https://orcid.org/0000-0003-2356-4426

Renan Furtado de Almeida Mendes

https://orcid.org/0000-0002-9433-7020

Pedro Henrique Pereira de Andrade

https://orcid.org/0000-0002-7701-983X

Ubiratan Alves Viturino da Silva

https://orcid.org/0000-0002-7715-8258

Laécio Leitão Batista

https://orcid.org/0000-0001-5081-2689

Déborah Emmily de Carvalho

https://orcid.org/0000-0002-8068-3598

References

1. Kebebew E. Adrenal Incidentaloma.

N Engl J

Med

2021;384(16):1542-1551 Doi:10.1056/

NEJMcp2031112

2. Fujikawa H and Hinata M. Splenic incidentaloma

on routine chest radiography before admission to

a nursing home.

BMJ Case Rep

2021;14:e243031

Doi:10.1136/bcr-2021-243031

3. Gokce A, Hatipoglu M, Kandemir NO and Akkas

Y. Thoracic incidentaloma in a chest computed

tomography scan of a patient with COVID-19.

Br J

Hosp Med (Lond)

2021;82(6):1-3 Doi:10.12968/

hmed.2021.0295

4. Kim YJ and Lee KA. Unusual case of adrenal incidentaloma:

pheochromocytoma with acute adrenal hemorrhage.

m J Med Sci

2021;S0002-9629(21):00239-1 Doi:

10.1016/j.amjms.2021.06.008

5. Wang J, Yan H, Huang G, Sun R, Cheng Y, Tian S and

Ma Y. Hormone silent giant adrenal incidentaloma-

adrenal ganglioneuroma: case report and literature

review.

Rofo

2021;Doi:10.1055/a-1487-6740

6. Sherlock M, Scarsbrook A, Abbas A, Fraser S,

Limumpornpetch P, Dineen R and Stewart PM. Adrenal

Incidentaloma.

Endocr Rev

2020;41(6):bnaa008

Doi:10.1210/endrev/bnaa008

7. Valenca MM, Valenca LP and Menezes TL. Computed

tomography scan of the head in patients with migraine

or tension-type headache.

Arq Neuropsiquiatr

2002; 60(3-A):542-547 Doi: 10.1590/S0004-

282X2002000400005

8. Valença MM. "Incidentalomas" in the investigation

of a patient with headache.

Headache Medicine

2014;5(1):4-6 Doi:10.48208/HeadacheMed.2014.1

9. Stip E, Miron JP, Nolin M, Letourneau G, Bernazzani O,

Chamelian L, . . .Lungu O. Incidentaloma Discoveries

in the Course of Neuroimaging Research.

Can J Neurol

Sci

2019;46(3):275-279 Doi:10.1017/cjn.2018.397

10. Liu X, Haraldsson H, Wang Y, Kao E, Ballweber M, Martin

AJ, . . .Saloner D. A Volumetric Metric for Monitoring

Intracranial Aneurysms: Repeatability and Growth

Criteria in a Longitudinal MR Imaging Study.

AJNR Am J

Neuroradiol

2021;Doi:10.3174/ajnr.A7190

11. Wang J, Weng J, Li H, Jiao Y, Fu W, Huo R,

...Zhao J. Atorvastatin and growth, rupture

of small unruptured intracranial aneurysm:

results of a prospective cohort study.

Ther Adv

Neurol Disord

2021;14(1756286420987939

Doi:10.1177/1756286420987939

12. Weng JC, Wang J, Li H, Jiao YM, Fu WL, Huo R, . .

.Zhao JZ. Aspirin and Growth of Small Unruptured

Intracranial Aneurysm: Results of a Prospective

Cohort Study.

Stroke

2020;51(10):3045-3054

Doi:10.1161/STROKEAHA.120.029967

13. Brinjikji W, Pereira VM, Khumtong R, Kostensky A,

Tymianski M, Krings T and Radovanovich I. PHASES

and ELAPSS Scores Are Associated with Aneurysm

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?

Growth: A Study of 431 Unruptured Intracranial

Aneurysms.

World Neurosurg

2018;114:e425-e432

Doi:10.1016/j.wneu.2018.03.003

14. Juvela S. Natural history of unruptured intracranial

aneurysms: risks for aneurysm formation, growth,

and rupture.

Acta Neurochir Suppl

2002;82:27-30

Doi:10.1007/978-3-7091-6736-6_5

15. Valenca MM. "Sit back, observe, and wait." Or is

there a pharmacologic preventive treatment for

cerebral aneurysms?

Neurosurg Rev

2013;36(1):1-9;

discussion 9-10 Doi:10.1007/s10143-012-0429-7

16. Abi-Aad KR, Rahme RJ, Syal A, Patra DP, Hudson M,

Richter KR, . . .Bendok BR. Quality of Life of Patients

with Unruptured Intracranial Aneurysms Before and

After Endovascular Coiling: A HEAT Trial Secondary

Study and Systematic Review of the Literature.

World

Neurosurg

2021;146:e492-e500 Doi:10.1016/j.

wneu.2020.10.120

17. Akimoto J, Ichimasu N, Haraoka R, Fukami S and Kohno

M. A case of unruptured aneurysm of the internal carotid

artery presenting as olfactory hallucinations.

Surg

Neurol Int

2017;8:197 Doi:10.4103/sni.sni_134_17

18. Ben-Israel D, Belanger BL, Adibi A, Eesa M, Mitha

AP and Spackman E. Innovation in unruptured

intracranial aneurysm coiling: At which price or

efficacy are new technologies cost-effective? P

LoS

One

2021;16(8):e0255870 Doi:10.1371/journal.

pone.0255870

19. Boulouis G, Rodriguez-Regent C, Rasolonjatovo EC, Ben

Hassen W, Trystram D, Edjlali-Goujon M, . . .Naggara

O. Unruptured intracranial aneurysms: An updated

review of current concepts for risk factors, detection and

management.

Rev Neurol (Paris)

2017;173(9):542-

551 Doi:10.1016/j.neurol.2017.05.004

20. Chien A, Callender RA, Yokota H, Salamon N, Colby

GP, Wang AC, . . .Hildebrandt MAT. Unruptured

intracranial aneurysm growth trajectory: occurrence

and rate of enlargement in 520 longitudinally

followed cases.

J Neurosurg

2019;132(4):1077-

1087 Doi:10.3171/2018.11.JNS181814

21. Damani R, Mayer S, Dhar R, Martin RH, Nyquist

P, Olson DM, . . .Investigators SCP. Common Data

Element for Unruptured Intracranial Aneurysm and

Subarachnoid Hemorrhage: Recommendations from

Assessments and Clinical Examination Workgroup/

Subcommittee.

Neurocrit Care

2019;30(Suppl 1):28-

35 Doi:10.1007/s12028-019-00736-1

22. Goubergrits L, Hellmeier F, Bruening J, Spuler A, Hege

HC, Voss S, . . .Berg P. Multiple Aneurysms AnaTomy

CHallenge 2018 (MATCH): uncertainty quantification of

geometric rupture risk parameters.

Biomed Eng Online

2019; 18(1):35 Doi:10.1186/s12938-019-0657-y

23. Fung C, Mavrakis E, Filis A, Fischer I, Suresh M,

Tortora A, . . .Petridis AK. Anatomical evaluation of

intracranial aneurysm rupture risk in patients with

multiple aneurysms.

Neurosurg Rev

2019;42(2):539-

547 Doi:10.1007/s10143-018-0998-1

24. Zhong W, Su W, Li T, Tan X, Chen C, Wang Q, . .

.Wang Y. Aneurysm Wall Enhancement in Unruptured

Intracranial Aneurysms: A Histopathological

Evaluation.

J Am Heart Assoc

2021;10(2):e018633

Doi:10.1161/JAHA.120.018633

25. Jin D, Song C, Leng X and Han P. A systematic review

and meta-analysis of risk factors for unruptured

intracranial aneurysm growth.

Int J Surg

2019;69:68-

76 Doi:10.1016/j.ijsu.2019.07.023

26. Backes D, Rinkel GJ, Laban KG, Algra A and Vergouwen

MD. Patient- and Aneurysm-Specific Risk Factors for

Intracranial Aneurysm Growth: A Systematic Review

and Meta-Analysis.

Stroke

2016;47(4):951-957

Doi:10.1161/strokeaha.115.012162

27. Wermer MJ, van der Schaaf IC, Algra A and Rinkel GJ.

Risk of rupture of unruptured intracranial aneurysms

in relation to patient and aneurysm characteristics:

an updated meta-analysis.

Stroke

2007;38(4):1404-

1410 Doi:10.1161/01.STR.0000260955.51401.cd

28. Brinjikji W, Zhu YQ, Lanzino G, Cloft HJ, Murad

MH, Wang Z and Kallmes DF. Risk Factors for

Growth of Intracranial Aneurysms: A Systematic

Review and Meta-Analysis.

AJNR Am J Neuroradiol

2016;37(4):615-620 Doi:10.3174/ajnr.A4575

29. Liu X, Haraldsson H, Wang Y, Kao E, Ballweber

M, Martin AJ, ...Saloner D. A Volumetric

Metric for Monitoring Intracranial Aneurysms:

Repeatability and Growth Criteria in a Longitudinal

MR Imaging Study.

AJNR Am J Neuroradiol

2021;42(9):1591-1597 Doi:10.3174/ajnr.A7190

30. Weng JC, Wang J, Li H, Jiao YM, Fu WL, Huo R, ...Small

Unruptured Aneurysms Study G. Aspirin and Growth

of Small Unruptured Intracranial Aneurysm: Results of

a Prospective Cohort Study.

Stroke

2020;51(10):3045-

3054 Doi:10.1161/STROKEAHA.120.029967

31. Valença MM, Andrade-Valença LP, Martins C, de

Fátima Vasco Aragão M, Batista LL, Peres MF and

da Silva WF. Cluster headache and intracranial

aneurysm.

J Headache Pain

2007;8(5):277-282

Doi:10.1007/s10194-007-0412-9

32. Lawson MF, Neal DW, Mocco J and Hoh BL.

Rationale for treating unruptured intracranial

aneurysms: actuarial analysis of natural history risk

versus treatment risk for coiling or clipping based on

14,050 patients in the Nationwide Inpatient Sample

database.

World Neurosurg

2013;79(3-4):472-478

Doi:10.1016/j.wneu.2012.01.038