Significant aortic coarctation presenting as subarachnoid hemorrhage in the adult

A young woman presented with subarachnoid hemorrhage due to a ruptured intracranial aneurysm. Femoral vascular access for endovascular coiling was challenging. There was difficulty advancing the catheter past a narrow aortic coarctation, but eventually the intracranial aneurysm was coiled (A [3-dimensional reconstruction arteriogram of the right internal carotid in right anterior oblique view, demonstrating a 1.5-mm diameter aneurysm of the posterior communicating artery (arrow)]). Echocardiography demonstrated a peak velocity of 5.2 m/s across the coarctation, with a gradient of 109 mm Hg (B [suprasternal B-mode transthoracic echocardiogram with color Doppler flow aliasing in the thoracic descending aorta] and C [continuous Doppler spectrum obtained in line with the color flow in B; a prominent forward diastolic tail is seen], Online Video 1). Magnetic resonance imaging confirmed a 4-mm coarctation (arrow) and prominent collateralization (arrowheads) (D). The patient made a good neurological recovery and was referred for surgical repair. Intracranial aneurysms are reported in 10% of patients with coarctation. A presentation with intracranial hemorrhage is uncommon but is potentially fatal or severely disabling. As one-half of patients with coarctation remain hypertensive after intervention, we raise the question of whether they should undergo magnetic resonance angiography screening of the cerebral arteries to prospectively detect the presence of aneurysms and establish an optimal management strategy.