Intracerebral hematoma of the frontal lobe and subarachnoid hemorrhage due to arterial aneurysms and structural abnormalities of the anterior cerebral artery. A clinical case. The course of the operation

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Introduction. Intracerebral hematoma are the most rare type of hematoma, which is represented by a cavity filled with liquid blood, blood clots or cerebral detritus and located in the medulla [1]. The most common causes of the formation of this type of hematoma are traumatic, as a result of mechanical action. The rarest causes are non–traumatic, as a result of spontaneous rupture of an aneurysm, arterial hypertension or arteriovenous malformation [2]. Sometimes atypical causes of intracerebral hematoma are possible, for example, abnormalities of the main arteries of the brain [3].
The purpose of the work. Description of a clinical case and surgical intervention for an intracerebral hematoma of the right frontal lobe caused by an anomaly in the structure of the anterior cerebral artery and subarachnoid hemorrhage as a result of an arterial aneurysm in the rupture stage, which increases doctors' awareness of this disease and helps to diagnose it in a timely manner, as well as fully prescribe the necessary treatment or perform surgery.
Materials and methods of research. The main material of the study is the medical documentation of the neurosurgical department of the BUZ VOKB No. 1. A 59-year-old man in serious condition with complaints of acute headaches and nausea was admitted to the hospital of the Department of Neurosurgery on 11/13/2023. Upon examination of the patient, the following was observed: the level of consciousness on the Glasgow scale of 13 points, body temperature 36.6 ° C, heart rate 72 beats per minute, blood pressure 150/80 mmHg, the patient's consciousness is moderately stunned, the patient is adynamic, speech contact is preserved, but limited due to pronounced adynamia. Moderate photophobia is observed, the reaction of the pupils to light is preserved, the movement of the eyeballs is moderately painful, horizontal nystagmus. The rigidity of the muscles of the occiput is up to 5 cm. There are no bulbar symptoms. Tendon reflexes in the upper extremities and in the lower extremities are the same. There are no motor disorders. Muscle tone is not reduced. Sensitivity disorders are not observed. Instrumental and laboratory research methods were scheduled.
As laboratory methods of examination, studies were conducted, including general and biochemical blood tests, assessment of the coagulation system, and ion balance. The results of these laboratory studies are shown in table 1.
Table 1
The patient's laboratory test results taken on the day of admission

Indicators	Values	Reference values	Units of measurement
General blood test
The amount of hemoglobin (HGB)	163,0	122,0-172,0	г/л
Hematocrit (HCT)	50,0	30,0-49,5	%
White Blood Cell Count (WBC)	10,2	4,0-8,8	109/л
СОЭ (ESR)	4,0	2,0-15,0	Мм/ч
Platelet Count (PLT)	301,0	150-400	109/л
Assessment of the hemostasis system
APTT (Activated Partial Thromboplastin time)	32,0	25,1-36,5	сек
PV (Prothrombin time)	10,9	9,4-12,5	сек
МНО	0,950	0,9-1,2	-
Biochemical research
Glucose level	6,20	4,2-6,4	Ммоль/л
Amylase level	33,0	0,0-90,0	Ед./л
Urea level	5,2	1,7-8,3	Ммоль/л
The level of creatinine in the blood	95,0	62,0-132,0	Мкмоль/л
Total protein	75,0	66,0-87,0	г/л
Total bilirubin	16,0	2,0-21,0	Мкмоль/л
АСАТ	40,0	0,0-37,0	Ед./л
АЛАТ	36,0	0,0-42,0	Ед./л
Indicators of ion exchange
Potassium	3,60	3,5-5,1	Ммоль/л
Sodium	128,0	136,0-145,0	Ммоль/л
Calcium	1,05	1,1-1,3	Ммоль/л

Instrumental research methods were also carried out, where multispiral computed tomography of the brain was used, without contrast. As a result of CT, it was observed: displacement of the median structures of the brain to the left up to 3 mm, in the frontal lobe of the right hemisphere of the brain, against the background of a low density area, an intracerebral hematoma with dimensions up to 57 ×20 ×31 mm and a volume of up to 18 ml is determined, with a volumetric effect on the anterior horn and the body of the right lateral ventricle. The attending doctors also took into account the MRI of the brain, which the patient independently did in a private clinic. The results of an MRI scan of the brain are shown in Figure 1.
On the MRI of the brain performed on the eve of admission to the hospital of the neurosurgeon department on 11/19/2023, an acute intracerebral hematoma measuring 6.1×2.3×3.6 with pronounced perifocal edema, with deformation of the anterior horns of the lateral ventricles and dislocation of the median structures to the right by 6 mm is subcortically determined in the right frontal lobe. The subarachnoid convexity space is narrowed.
To complete the picture, before surgery, a computed tomography of the brain with bolus intravenous contrast or cerebral angiography was performed to visualize the arteries of the brain. A puncture of the common femoral artery on the right was performed under local anesthesia, and the artery was cannulated along the Seldinger with a catheter with a hemostatic valve 6F. Through it, Judkins Right diagnostic catheters were delivered to the aorta via a 0.035 J-conductor, the left and right carotid arteries and vertebral arteries on both sides were sequentially catheterized [4]. Multi-projection, selective carotid and cerebral angiography was performed. Next, catheters were removed and hemostasis was performed by pressing, a pressure bandage on the puncture site. There were no complications during the procedure. 50 ml of contrast agent was used. The results of the patient's cerebral angiography are summarized and presented in Table 2.
Table 2
Results of computed tomography of the brain with intravenous bolus contrast on the day of admission

Name of the artery	Description
Left middle cerebral artery	They leave in a typical place. Their contours are clear and even, the diameter is unchanged.
Right middle cerebral artery	They leave in a typical place. Their contours are clear and even, the diameter is unchanged.
Internal carotid arteries on the right and left	They have a normal stroke and diameter, and are arranged symmetrically. The siphons of the internal carotid arteries are not displaced. The contours of the internal carotid arteries are clear and even.
Posterior cerebral arteries	They leave in a typical place. Their contours are clear and even, the diameter is unchanged.
Vertebral arteries	They have a normal stroke and diameter, and are arranged symmetrically. The contours are clear and even, the diameter is unchanged.
Basilar artery	The course is unchanged. Its contours are clear and even.
Posterior connective arteries	They are being visualized. Not changed
Anterior cerebral arteries	An anomaly of the development of the left anterior cerebral artery is determined, it is formed by bifurcation of the right anterior cerebral artery in the area of the proper location of the anterior connective artery. An aneurysm measuring 5×5 mm is determined in the bifurcation area.

After the initial examination, as well as the necessary laboratory and instrumental research methods, the diagnosis was made: subarachnoid hemorrhage from the anterior connective artery as a result of the presence of an aneurysm of the anterior right cerebral artery in the rupture stage, intracerebral hematoma in the projection of the left frontal lobe of non-traumatic origin and preparation for surgery for removal of an intracerebral hematoma and clipping of an arterial aneurysm anterior cerebral artery.
On 14.12.2023, a planned surgical intervention was performed for clipping of the aneurysm neck of the anterior cerebral artery and removal of an intracerebral hematoma of the left frontal lobe. The operating team consisted of: an operator, an assistant, a blood transfusion doctor, an anesthesiologist, an operating room nurse, an anesthesiologist nurse, and a health worker.
The anesthetic manual included: the introduction of 0.9% sodium chloride solution in the volume of 1000 ml for the entire operation, Rocuronium was used as relaxants based on kg of body weight, 5 ml was used, non-inhalation anesthetics included Propofol 1% - 10 ml, Fentanyl 0.005% solution 3 times per operation for 4 ml and 4 times for 2 ml, inhalation anesthetics: nitric oxide (N2O) 2 l/m and Sevoran 98% with oxygen.
Surgical intervention was performed as follows: under endotracheal anesthesia, in the position of the patient on his back with the head turned to the left, with the head fixed in the Mayfield brace, after three times treatment of the surgical field with an antiseptic solution, an arcuate incision of the skin and soft tissues in the right frontal-temporal region was made [5]. The bone is skeletonized. A bone defect measuring 6×8 cm was formed using an electric trepan. The dura mater is tense, not pulsating. At this stage, a microscope was installed, and further stages were carried out using microsurgical techniques. The dura mater is opened and turned horseshoe-shaped to the base. The brain is swollen, somewhat hyperemic, and does not pulsate. To reduce edema, a puncture of the anterior horn of the right lateral ventricle was performed. After the removal of the cerebrospinal fluid, the brain tension decreased noticeably, and pulsation appeared. When the frontal and temporal lobes are raised with spatulas, the optic-carotid complex is exposed. Next, the bifurcation of the common carotid artery is highlighted. When the A1 segment of the right anterior artery was isolated, an aneurysm directed by the dome anteriorly and to the left was found at the level of the anterior cerebral artery-anterior connective artery. A temporary clip is applied to the A1 segment. After visualization of A2 segments, aneurysm were isolated from blood clots and adhesions on both sides. A vascular clip curved along the plane is applied to the neck of the aneurysm. The standing time of the time clip is about 3 minutes. When the aneurysm wall was pierced, the body slept, there was no bleeding. Both anterior cerebral arteries are functioning. The next step was the removal of an intracerebral hematoma of the left frontal lobe. The volume of the removed hematoma is about 20 ml. After removal, thorough hemostasis was performed, which was reduced to suturing the ruptured abnormally located left anterior cerebral artery at the junction of the anterior connective cerebral artery. The dura mater is sutured tightly. Subsequently, the bone flap is put in place and fixed with ligatures. After that, a layered suture of the wound was performed with the application of an aseptic bandage.

No complications were observed during the operation, the volume of blood loss was 400 ml, 0.9% sodium chloride solution was injected with a volume of 1000 ml for the entire operating period.
After the rehabilitation period, the patient's condition improved. On 12/14/2023, the man was discharged and given the necessary recommendations: a visit to a neurologist at his place of residence, blood pressure monitoring, to exclude the effects of high temperatures on the body.
Results. Thus, with a combination of primary examination, laboratory and instrumental research methods, it was possible to diagnose the patient as follows: subarachnoid hemorrhage, intracerebral hematoma in the projection of the frontal lobe on the left (non-traumatic genesis), arterial aneurysm of the anterior cerebral artery-anterior connective artery in the acute period of rupture. From the data of cerebral angiography, it was found that the patient has an anomaly in the structure of the anterior cerebral arteries, which are part of the Willis circle. Most likely, the patient has a bipolar anterior cerebral artery, based on the data from the description of cerebral angiography. Surgical intervention was performed with a favorable course of the surgical and postoperative periods.
Conclusion. This clinical case shows a variety of pathologies in neurosurgical practice. Awareness of such types of diseases makes it possible to fully produce the necessary physical, laboratory and instrumental research methods. As well as timely prescribe the necessary medication and surgical treatment.

About the authors

Dmitry Valerievich Sviridov

Voronezh State Medical University named after N.N. Burdenko

Email: sviridovroll29@mail.ru
ORCID iD: 0009-0005-1284-2939

Student

Russian Federation, 394036 Russia, Voronezh, st. Studentskaya 10

Helena Viktorovna Mikulich

Voronezh State Medical University named after N.N. Burdenko

Author for correspondence.
Email: evmikulich@vsmaburdenko.ru

Candidate of Medical Sciences, Associate Professor of the Department of General and Outpatient Surgery at N.N. Burdenko State Medical University

Russian Federation, 394036 Russia, Voronezh, st. Studentskaya 10

References

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