Journal Of Cardiovascular, Neurovascular & Stroke

A CLUSTER HEADACHE MIMIC: CT-NEGATIVE SUBARACHNOID HEMORRHAGE FROM MCA ANEURYSM

Rifki Bachtiar — 2026-09-30

Abstract

Introduction: Primary cluster headache is a debilitating trigeminal autonomic cephalalgia. While diagnostic criteria are well-established, secondary structural lesions can closely mimic this phenotype, posing a significant diagnostic challenge in emergency settings.

Case Presentation: A 51-year-old woman presented with sudden-onset, severe, unilateral right temporal headache clinically mimicking a primary cluster headache. Initial emergency non-contrast computed tomography (NCCT) demonstrated no acute intracranial abnormalities. Due to persistent symptoms, a subsequent brain MRI was performed. Multi-sequence MRI revealed a small saccular aneurysm arising from the M1 segment of the right middle cerebral artery (MCA). Accompanying right temporal sulcal hyperintensities on FLAIR and subtle hyperintensity on T1-weighted imaging confirmed a localized, late subacute subarachnoid hemorrhage (SAH).

Discussion: This case illustrates a critical clinical pitfall driven by time-dependent radiologic attenuation, where transitional subacute blood becomes isodense on NCCT. The structural mimicry could be explained by mechanical irritation or a minor leak from the MCA aneurysm stimulating the closely adjacent ophthalmic branch (V1) of the trigeminal nerve, triggering the trigeminovascular pain pathway.

Conclusion: Multi-sequence MRI is indispensable for ruling out occult, life-threatening secondary vascular pathologies when strong clinical suspicion persists despite negative initial CT findings.

Malaysian Congress of Radiology's Abstracts 1

Malaysian Congress of Radiology — 2026-09-30

Malaysian Congress of Radiology's Abstracts 2

Malaysian Congress of Radiology — 2026-09-30

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Malaysian Congress of Radiology — 2026-09-30

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Malaysian Congress of Radiology — 2026-09-30

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Malaysian Congress of Radiology — 2026-09-30

Malaysian Congress of Radiology's Abstracts 10

Malaysian Congress of Radiology — 2026-09-30

Long-Term Efficacy, Safety, and Recurrence Rates of Coiling, Stent-Assisted Coiling, and Flow Diversion in Unruptured Intracranial Aneurysms: A Systematic Review

Vincentius Handy Suria — 2026-09-30

Background : Unruptured intracranial aneurysms (UIA) affect approximately 2%–3% of adults, and their management must balance rupture prevention against periprocedural risk. This systematic review compares the long-term efficacy, safety, and recurrence of coiling, stent-assisted coiling (SAC), and flow diversion (FD).

Methods : Following PRISMA guidelines, a comprehensive search yielded 18 eligible studies (RCTs, prospective/retrospective cohorts, and propensity-score matching) covering more than 5,000 procedures. Risk of bias, assessed with RoB 2, NOS, ROBINS-I, and MINORS, ranged from moderate to high.

Results : Coiling achieved 63.0%–76.8% complete occlusion with the lowest permanent morbidity (0.27%) but the highest recurrence (37.1%), reduced by 8.4% with hydrogel coils. SAC gave superior occlusion (90%–94.1%) in wide-neck aneurysms and stable long-term recanalization (8.0% at >24 months) but higher first-year ischemic complications (8.8% vs 2.2%). FD provided the best progressive durability (80.7%–81.81%) with near-zero recanalization and only 1.2% periprocedural neurological morbidity using new-generation coated devices.

Conclusion : Optimal UIA management is individualized by aneurysm size and morphology: coiling for small aneurysms (high safety, high recurrence), SAC for wide-neck aneurysms (improved efficacy, moderate first-year ischemic risk), and FD for complex or giant aneurysms (durable occlusion, near-zero recurrence, minimal morbidity).