====== Q12221 ======

**Medical History**: [[Dyslipidemia]] (DLP)  

**Current Medications**:
- [[Simvastatin]] 40 mg 
-   - Paracetamol 1000 mg 

**Reason for Consultation**:  
A 68-year-old patient brought to the emergency department by the Emergency Medical Service (SAMU) due to a severe [[headache]] and decreased level of [[consciousness]], followed by recovery. She reported vomiting, and upon arrival at the emergency department, presented further deterioration in her level of consciousness.

**Initial Physical Exam**:  
- [[Glasgow Coma Scale]]: 3 points  
- Blood Pressure: 211/110 mmHg  
- Oxygen Saturation: 99% with nasal cannula at 4 L/min  
- Pupils: Miotic, centered  
- Lung auscultation: Clear breath sounds, no added sounds  
- Movement: Flexion and rotation of the left upper limb (LUL) lasting a few seconds  

**Diagnostic Imaging**

1. **Non-contrast Cranial CT**

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   - Central [[subarachnoid hemorrhage]] in [[perimesencephalic cistern]]s, predominantly in the anterior aspect of the interhemispheric fissure.
   - Bilateral hemoventricle with blood in the lateral, third, and fourth ventricles.
   - Midline centered, with sulcal depth consistent with the patient’s age.

2. **CT Angiography of Supra-aortic Trunks and Circle of Willis** 
   - Saccular aneurysm of the anterior communicating artery, approximately 7 x 5 mm.
   - Fetal origin of both posterior cerebral arteries.
   - No filling defects or stenosis in the rest of the Circle of Willis or posterior circulation.

**Conclusion**: Subarachnoid hemorrhage with intraventricular extension secondary to rupture of an anterior communicating artery aneurysm.

**Endovascular Procedure**

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**Access**: Right femoral artery  
**Selective Angiography Findings**:  
- Aneurysm in the left A1-A2 segment, 6.4 mm width and 4.6 mm height, with a neck of 2.3 mm, irregular morphology, and cranial orientation.

**Embolization Technique**:  
- Primary coiling via microcatheter, using Target 360 and helical microcoils of varying sizes.
- Complete occlusion of the aneurysmal sac, with a neck remnant of less than 1 mm.
- Classification: Modified Raymond-Roy Class 2.

**Procedure Outcome**: Procedure completed without complications; hemostasis achieved using Angio-Seal closure.