CASE PRESENTATION:
A 54-year-old female had a history of systemic arterial hypertension and migraine. She had previously been treated with atenolol 25 mg once daily and hydrochlorothiazide 25 mg once daily. She sought medical care at a secondary hospital due to chest pain, which began suddenly 2h before admission and had irradiated to the left upper limb and back. The initial electrocardiogram (EKG) was normal but showed a troponin curve (33,38 ng/l, 26,42 ng/l, 13,82 ng/l), which led to the hypothesis of non-ST elevation myocardial infarction, Killip I. Loading doses of acetylsalicylic acid (ASA) 300 mg, clopidogrel 300 mg, enoxaparin 60 mg, and nitroglycerin were administered intravenously due to persistent pain. The patient was later transferred to a tertiary hospital. Upon admission she was lucid, oriented in time and space, and pain-free, with the use of nitroglycerin 8 ml/h. Her blood pressure was 128/74 mmHg, mean blood pressure was 92 mmHg, and heart rate was 78 bpm. Serial EKG showed dynamic changes with ST-segment elevation in DIII, AvF, V5 and V6(Fig. 1) . Therefore, urgent cardiac catheterisation was performed, but it did not reveal any obstructive lesions. However, ventriculography revealed hypokinesia in the inferoapical wall(Fig. 2) , which supported the hypothesis of takotsubo syndrome. During hospitalisation, the patient experienced a severe refractory headache. Computed tomography (CT) of the head was performed under suspicion of SAH, and the examination results were normal. Subsequently, CT angiography (angio CT) of the head was performed to rule out a rupture of the aneurism. The angio CT identified ”mirror” saccular aneurysms in the ophthalmic segment of the ICAs. The largest aneurysm was on the right, and in superior orientation the lesion measured 5 mm x 4 mm with a neck of 3 mm (Fig. 3). The patient was subsequently transferred from the cardiology unit to the intensive care unit and underwent lumbar puncture. Clear and colourless cerebral spinal fluid was observed after centrifugation, which confirmed the absence of SAH. The patient was diagnosed with unerupted aneurysm and underwent embolization of a supraclinoid ICA aneurysm using two stents to contain the metal coil. This procedure had no complications. The patient progressed satisfactorily and was discharged with a recommendation for outpatient follow-up in the general cardiology department. She was treated with enalapril, atenolol, atorvastatin, and ASA/clopidogrel.