• Kayhan Kuzeyli, Ertuğrul Cakir, Hasan Dinç, and Ozgür C Sayin.
• Department of Neurosurgery, Karadeniz Technical University School of Medicine, Beyin ve Sinir Cerrahi Anabilim D, 61080 Trabzon, Turkey.
• Neurosurgery. 2003 Jun 1; 52 (6): 1460-3; discussion 1463-4.

Objective And ImportanceWe describe the presentation, screening, management, and clinical outcome of a 21-year-old man who sought care for a ruptured middle cerebral artery (MCA) aneurysm and midaortic syndrome (MAS). Only three cases of MAS and intracranial aneurysm rupture have previously been described in the literature.Clinical PresentationCranial computed tomographic (CT) scanning, cerebral and abdominal angiography, and multislice three-dimensional CT angiography were used to evaluate intracerebral hemorrhage and to assess medically intractable hypertension in the patient. Digital subtraction angiography revealed a right MCA aneurysm, and multislice three-dimensional CT angiography revealed narrowing of the abdominal aorta.InterventionThe patient's right MCA aneurysm was successfully clipped via a right pterional craniotomy. A narrowed abdominal aorta was confirmed by an abdominal aortic angiogram (performed at Day 5 after surgery) and then dilated by using percutaneous transcatheter angioplasty during the same session. The patient was normotensive even without antihypertensive medications. Neurological examination and postoperative cranial CT findings were within normal limits at the last follow-up examination, performed 4 months after the operation.ConclusionOur patient is the first reported case of ruptured MCA aneurysm with MAS in an adult. The most important problem in the management of MAS associated with ruptured intracranial aneurysm is medically intractable hypertension, which may markedly increase the incidence of rebleeding. It is hard to achieve normotension unless the narrowed aorta and its branches are dilated. For these reasons, MAS should be considered in patients with medically intractable hypertension associated with ruptured intracranial aneurysm.

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