Near Complete Giant Intracranial Aneurysm Mimicking Anaplastic Glioma: A Rare Case Report and Surgical Management

   

Bikash Bhandari^1*, Sai Charan Sharma¹, Sushmita Pandey¹, Sandesh Dhakal¹ and Diwas Bhandari^s

 

¹MBBS, College of Medical Sciences

 ²MBBS, Lumbini Medical College

Abstract

Introduction

A large spherical intracranial mass can sometimes be misdiagnosed due to the lack of typical radiographic features. Though rare, Giant intracranial aneurysm with thrombosis (GIAs) must be considered in differential diagnoses to ensure the optimal surgical approach and resection of the lesion.

Materials and Method

We present a case of a 34-year-old female patient who complained of gradual onset and progressive weakness of the right side of her body for 5 days, along with multiple episodes of vomiting, dizziness, slurring of speech, and being unable to speak. An MRI of the brain was conducted, and a time-resolved angiography with interleaved stochastic trajectories (TWIST-MRI) was utilized to assess the vascular origin of the lesion.

Results and Discussion

The MRI revealed a near-completely thrombosed left internal carotid aneurysm with surrounding edema and a mass effect with midline shift. Initially, the lesion was considered a glioma due to its atypical radiographic features. However, TWIST-MRI indicated the vascular origin of the lesion.. If typical radiographic features are absent, completely thrombosed GIAs with parent vessel thrombosis, being rare lesions, might be misdiagnosed. Thus, in the case of an intracranial spherical mass with signs of intralesional hemorrhage and mural calcifications, the presence of a completely thrombosed GIA should be considered as a possible differential diagnosis.

Keywords

Giant intracranial aneurysm; Intraluminal thrombosis; Clipping; Parent vessel; Anaplastic glioma

Introduction

Giant intracranial aneurysms (GIAs) are rare and heterogeneous lesions with complex vascular anatomy [1] and represent almost 5% of intracranial aneurysms (IAs) [2]. These aneurysms typically present symptoms between the 4th and 7th decades of life, with a female to male ratio of 1:1 to 3:1 [2], and intraluminal thrombosis occur in 10 to 30 % of cases [3]. However, a complete aneurysmal thrombosis is extremely rare [4]. The majority of these aneurysms are located in the internal carotid artery (ICA) and in the middle cerebral artery (MCA), with the anterior cerebral artery (ACA) being an exceptional location [1].

In this report, we present an unusual case of a completely thrombosed GIA of the left ACA that was initially misdiagnosed as glioma because of the lack of typical radiographic features.

Case Presentation

A 34-year-old female with no comorbidities and no drug history presented with intermittent weakness of the right side of the body for 15 days with multiple vomiting episodes during the last 3 days, along with a progressive Holocephali headache and slurring of speech with a tingling sensation in the right hand. Ptosis and loss of the nasolabial fold of the right side were also present. Hyperreflexia of the knee and ankle jerk along with hypoesthesia on the right side of the body, predominantly on the lower limb, with intact reflexes and sensation on the left side, along with intact bowel and bladder control. The left pupil was dilated symmetrically and showed no reaction to light or near objects. The right pupil was intact with a normal response to light and near objects. MRI and MRA findings of a near-completely thrombosed left ICA giant aneurysm (likely cavernous part) with surrounding edema and mass effect with midline shift. There was no fever, no weight loss, and no loss of consciousness. The rest of the physical examination showed an ataxic gait. During the hospital stay, the patient developed a focal seizure, starting as a tingling sensation in the right hand, which generalized to a tonic clinic seizure, and was treated with sodium valproate.

Radiological Finding

Figure 1