Fig 2.

A 63-year-old patient with a long-standing history of cigarette smoking presented with a 3-week history of visual disturbance. A, NCCT demonstrates a subacute ICH in the left occipital lobe. The patient underwent further evaluation with contrast-enhanced brain MR imaging, CTA, and conventional angiography, none of which demonstrated an etiology for the ICH. B, 3D image of a right ICA angiogram demonstrates 3 incidental cerebral aneurysms, with a 2-mm right A2 segment anterior cerebral artery aneurysm (arrowhead). There were 2 additional incidental left-sided cerebral aneurysms, not in the vicinity of the ICH (not shown). Three months after presentation, a repeat contrast-enhanced brain MR image showed expected evolution of the left occipital ICH without new foci of hemorrhage or abnormal enhancement. The patient expressed a strong desire to undergo endovascular treatment of all the incidental cerebral aneurysms, despite the fact that amyloid angiopathy was the leading differential diagnosis for the ICH. After careful discussion with the patient and family regarding the risk of potentially-devastating rehemorrhage, DAT with aspirin and clopidogrel was instituted, and the right MCA bifurcation aneurysm was treated uneventfully with stent-assisted coil embolization. C, Sixteen days later, balloon-assisted coil embolization of the 2-mm right anterior cerebral artery aneurysm was complicated by aneurysm rupture. Hemostasis was achieved with immediate balloon inflation, and the aneurysm was ultimately treated with several coils and a 2.5 × 12 mm PED across its neck. D, Final lateral right ICA angiogram demonstrates patent cerebral vasculature. The patient recovered from the subarachnoid hemorrhage and was discharged to a rehabilitation facility on postoperative day 25. The patient demonstrated conversion to a clopidogrel hyper-response (PRU 34) 26 days after initiation of DAT and underwent 3 clopidogrel dose adjustments in an attempt to reach the target P2Y12 receptor inhibition range of 60–240 PRU. A dosing regimen of 75-mg clopidogrel every fourth day was instituted 65 days after initiation of DAT, but follow-up P2Y12 receptor inhibition testing had not been completed. E, On postoperative day 50, the patient was found unresponsive at home. NCCT demonstrates a recurrent left occipital ICH with extensive subdural extension causing a severe rightward midline shift. PRU at the time of the ICH was 58. The patient died that evening. Postmortem examination revealed amyloid angiopathy affecting the left occipital lobe.