A 43 year-old man presents with a 4 day history of a constant headache. Initial CT Head demonstrates very small Hunt Hess Grade 1 supra-sellar Subarachnoid Hemorrhage (SAH), prompting cerebral angiography, which confirmed complex wide-neck anterior communicating artery aneurysm (Figure 1. A. NCT B. Lateral DSA C. 3-D DSA Recon). He underwent open microsurgical clipping of the aneurysm with preservation of the parent vessels and complete obliteration of the aneurysm (Figure 3. A. Lateral DSA B. 3-D DSA Recon). After monitoring and critical care management for SAH, he made a complete functional recovery, returning to all activities of daily living.
Figure 1: A) NCT Brain with faint hyperdense SAH in suprasellar cisterns B) DSA angiography of Acom Aneurysm with anterior “beak” C) 3-D DSA Recon demonstrates complex morphology and wide-neck
Figure 2: Post Microsurgical Clipping A) DSA lateral B) 3-D DSA Recon 
KEY LEARNING POINTS:
  1. Persistent constant headaches lasting beyond 24-48 hours should prompt immediate medical attention and Brain scanning to evaluate for potential high-risk pathologies, especially SAH and sentinel leaks from ruptured brain aneurysms.
  2. Multi-disciplinary evaluation by a team of cerebrovascular surgeons and interventionalists should be performed to determine the optimal treatment and management strategies for often complex aneurysm geometries.
  3. Microsurgical clipping represents a very effective option for definitive treatment and complete functional recovery in many patients.
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