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.