Symptomatic Giant Basilar Pseudoaneurysm in a Young Male
Brain aneurysms can go undetected for years and are usually asymptomatic. Approximately 3% of the population have them and live a full life with no associated comorbidities. Once hereditary and familial factors are excluded, the main risk factors associated with aneurysms and subarachnoid hemorrhage are hypertension, cigarette smoking, and alcohol. If diagnosed prior to a bleed, the prognosis and treatment of brain aneurysms depends most importantly on size and location. Cutting edge endovascular coiling or flow divertors have proven to improve clinical outcomes in some; otherwise medical management is the mainstay of therapy. This is the case of a 36-year-old man who presented to the emergency department with mild dysarthria, dysphagia, and worsening headaches associated with cough, only to be diagnosed with a 3.5x3.0cm mid basilar giant pseudoaneursym compressing his brainstem. He had a long-standing history of smoking 5-10 marijuana cigarettes per day alongside heavy tobacco and methamphetamine drug use. His physical exam only revealed mild dysarthria and hypertension. Because of dysphagia, a CT scan with contrast of the soft tissue of neck was performed. This revealed a vascular lesion adjacent to his midbrain and brainstem; subsequently, an MRI/MRA and cerebral arteriogram were performed to better characterize a giant basilar pseudoaneurysm. Neuroendovascular surgery consult was obtained which prompted discussions as to the significant morbidity, mortality, and prognosis of open surgical or endovascular repair. Typically, endovascular techniques are associated with improved clinical outcomes for ruptured and unruptured brain aneurysms. Because of our patient’s aneurysm size and location, decision was made to treat via medical therapy with blood pressure goals of less than 120/80 and anticoagulation. Our patient was discharged with close follow up and instructions to avoid all smoking, illicit drugs, stimulants, and excessive straining in anyway. This is the case of a common complaint with an uncommon cause. The advances in medical science were only of value to diagnose the reasons for this young man’s complaints – not to cure them. The ethical dilemma to intervene with a high complication risk or to allow for the natural progression of the disease is complicated by his young age and lack of supporting data. He has a 10% survival rate for the next 5 years. Knowing about a diagnosis where there are no ‘good’ options for treatment is still valuable. He was given a chance to put his life in order and actively focus on the important things in his life.