High-Resolution Vessel Wall Imaging for Treatment Sequencing of Multiple Aneurysms in Subarachnoid Hemorrhage.

Objectives: Approximately 30% of patients with subarachnoid hemorrhage (SAH) present with multiple aneurysms. Identifying the ruptured aneurysm is often difficult, and not all lesions may be accessible through a single craniotomy. Magnetic resonance high-resolution vessel wall imaging (HR-VWI) is an innovative imaging modality that identifies aneurysm wall instability. Design: Technical note and literature review with an illustrative case report and operative videos. Setting: Outpatient, inpatient, and operating room of a quaternary neurosurgical referral center. Participants: SAH was diagnosed in a woman in her early 40s presenting with headache and left arm paresthesias. Main Outcome Measures: HR-VWI for treatment sequencing of multiple aneurysms in SAH. Results: Two saccular aneuryms were identified, arising from the right posterior inferior cerebellar artery (PICA) and basilar artery (BA) bifurcation. HR-VWI suggested the PICA aneurysm as the probable SAH source. Treatment recommendations were far lateral craniotomy for PICA aneurysm clipping, followed by staged orbitozygomatic craniotomy for BA aneurysm clipping at 3 months. Both procedures resulted in successful clip reconstruction of the aneurysm and an excellent neurological outcome. Conclusion: Effective management of SAH patients with multiple aneurysms demands specialized diagnostic and surgical strategies. Rapid, precise identification of the SAH source is imperative, as is comprehensive treatment of all aneurysms. Key educational findings include management pearls for patients with multiple aneurysms, SAH localization with HR-VWI, the importance of inspecting the circle of Willis in patients at high risk, and technical insights for PICA and BA aneurysm clipping.