{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T23:18:14Z","timestamp":1769728694923,"version":"3.49.0"},"reference-count":36,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"9","license":[{"start":{"date-parts":[[2025,9,1]],"date-time":"2025-09-01T00:00:00Z","timestamp":1756684800000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J Neurosurg Case Lessons"],"published-print":{"date-parts":[[2025,9,1]]},"abstract":"\n BACKGROUND<\/jats:title>\n Spontaneous rupture of an undiagnosed aneurysm during a neurosurgical procedure not aimed at treating it is exceedingly rare, although multiple intraoperative factors can contribute to this situation.<\/jats:p>\n <\/jats:sec>\n \n OBSERVATIONS<\/jats:title>\n \n A patient in his 20s with a history of a 60-cm\n 3<\/jats:sup>\n left intraparenchymal hematoma treated via decompressive craniectomy in November 2024 presented in March 2025 with a first-time seizure. Keppra was initiated, and the patient was admitted for cranioplasty. During the procedure, the previously sunken brain suddenly developed severe edema, herniating through the craniectomy defect. Intraoperative ultrasound was negative for hematoma but showed a thick subarachnoid hemorrhage (SAH) in the sylvian fissure. Postoperative CT revealed diffuse SAH and hydrocephalus; an external ventricular drain was urgently placed. Angiography identified and aided in coiling of an ophthalmic aneurysm.\n <\/jats:p>\n <\/jats:sec>\n \n LESSONS<\/jats:title>\n Several factors can precipitate intraoperative aneurysm rupture. Osmotic agents like mannitol can cause rapid intravascular fluid shifts, increasing hemodynamic stress across the aneurysm dome. Atmospheric pressure changes due to intraoperative manipulation can also alter extravascular forces on the aneurysm. Based on this experience, especially in young patients with prior unexplained hemorrhage, the authors advise careful use of mannitol and surgical technique. Surgeons should consider these risks in patients with known or suspected aneurysms to prevent catastrophic rupture.<\/jats:p>\n \n https:\/\/thejns.org\/doi\/10.3171\/CASE25431<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.3171\/case25431","type":"journal-article","created":{"date-parts":[[2025,9,1]],"date-time":"2025-09-01T23:49:15Z","timestamp":1756770555000},"source":"Crossref","is-referenced-by-count":1,"title":["A landmine during cranioplasty: unusual rupture of a previously undiagnosed aneurysm. Illustrative case"],"prefix":"10.3171","volume":"10","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2693-4640","authenticated-orcid":true,"given":"Aaron","family":"Miller","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Julio","family":"Isidor","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Liz","family":"Iglesias","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Isaiah","family":"Miller","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Aimee","family":"Weber","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ricardo","family":"Domingo","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Alejandro","family":"Spiotta","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"8","key":"bib1","series-title":"Stroke","first-page":"2368","article-title":"Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association\/American Stroke Association","volume":"46","author":"Thompson","year":"2015","unstructured":"Thompson BGBrown RDAmin-Hanjani SGuidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association\/American Stroke Association. Stroke. 2015;46(8):2368-2400."},{"issue":"2","key":"bib2","series-title":"Stroke","first-page":"365","article-title":"Risk analysis of unruptured intracranial aneurysms: prospective 10-year cohort study","volume":"47","author":"Murayama","year":"2016","unstructured":"Murayama YTakao HIshibashi TRisk analysis of unruptured intracranial aneurysms: prospective 10-year cohort study. Stroke. 2016;47(2):365-371."},{"issue":"1","key":"bib3","series-title":"AJNR Am J Neuroradiol","first-page":"75","article-title":"Hemodynamic characteristics in ruptured and unruptured intracranial aneurysms: a prospective cohort study utilizing the AneurysmFlow tool","volume":"46","author":"Vu","year":"2025","unstructured":"Vu DLNguyen VHNguyen HAHemodynamic characteristics in ruptured and unruptured intracranial aneurysms: a prospective cohort study utilizing the AneurysmFlow tool. AJNR Am J Neuroradiol. 2025;46(1):75-83."},{"issue":"2","key":"bib4","series-title":"Stroke","first-page":"641","article-title":"Rupture risk of small unruptured intracranial aneurysms in Japanese adults","volume":"51","author":"Suzuki","year":"2020","unstructured":"Suzuki TTakao HRapaka SRupture risk of small unruptured intracranial aneurysms in Japanese adults. Stroke. 2020;51(2):641-643."},{"issue":"7","key":"bib5","series-title":"Stroke","first-page":"e314","article-title":"2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association\/American Stroke Association","volume":"54","author":"Hoh","year":"2023","unstructured":"Hoh BLKo NUAmin-Hanjani S2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association\/American Stroke Association. Stroke. 2023;54(7):e314-e370."},{"issue":"21","key":"bib6","series-title":"Circulation","first-page":"e661","article-title":"Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association","volume":"137","author":"Eskey","year":"2018","unstructured":"Eskey CJMeyers PMNguyen TNIndications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association. Circulation. 2018;137(21):e661-e689."},{"key":"bib7","series-title":"Front Neurosci","first-page":"233","article-title":"The morphological and hemodynamic characteristics of the intraoperative ruptured aneurysm","volume":"13","author":"Liu","year":"2019","unstructured":"Liu QJiang PWu JGao BWang S.The morphological and hemodynamic characteristics of the intraoperative ruptured aneurysm. Front Neurosci. 2019;13:233."},{"issue":"3","key":"bib8","series-title":"Case Rep Neurol","first-page":"261","article-title":"Intraoperative rupture of unruptured cerebral aneurysm during craniotomy: a case report","volume":"9","author":"Yoshiki","year":"2017","unstructured":"Yoshiki KMisaki KNambu IIntraoperative rupture of unruptured cerebral aneurysm during craniotomy: a case report. Case Rep Neurol. 2017;9(3):261-266."},{"issue":"1","key":"bib9","series-title":"BMC Neurol","first-page":"135","article-title":"Intraoperative rupture of intracerebral aneurysm immediately after meningioma resection: a case report","volume":"22","author":"Tanaka","year":"2022","unstructured":"Tanaka SKobayashi MIchinose TIntraoperative rupture of intracerebral aneurysm immediately after meningioma resection: a case report. BMC Neurol. 2022;22(1):135."},{"issue":"4","key":"bib10","series-title":"Neurosurg Clin N Am","first-page":"861","article-title":"Intraoperative aneurysm rupture and complication avoidance","volume":"9","author":"Chandler","year":"1998","unstructured":"Chandler JPGetch CCBatjer HH.Intraoperative aneurysm rupture and complication avoidance. Neurosurg Clin N Am. 1998;9(4):861-868."},{"issue":"12","key":"bib11","series-title":"Acta Neurochir (Wien)","first-page":"1255","article-title":"Intra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management","volume":"141","author":"Houkin","year":"1999","unstructured":"Houkin KKuroda STakahashi AIntra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management. Acta Neurochir (Wien). 1999;141(12):1255-1263."},{"issue":"1","key":"bib12","series-title":"J Cerebrovasc Sci","first-page":"26","article-title":"Anesthetic management of intraoperative rupture of intracranial aneurysms","volume":"10","author":"Kaur","year":"2022","unstructured":"Kaur HKaur H.Anesthetic management of intraoperative rupture of intracranial aneurysms. J Cerebrovasc Sci. 2022;10(1):26-34."},{"issue":"1","key":"bib13","series-title":"Anesthesiol Res Pract","first-page":"595837","article-title":"Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm","volume":"2014","author":"Chowdhury","year":"2014","unstructured":"Chowdhury TPetropolis AWilkinson MSchaller BSandu NCappellani RB.Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. 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Stroke. 2016;47(2):365-371."},{"issue":"1","key":"bib3","series-title":"AJNR Am J Neuroradiol","first-page":"75","article-title":"Hemodynamic characteristics in ruptured and unruptured intracranial aneurysms: a prospective cohort study utilizing the AneurysmFlow tool","volume":"46","author":"Vu","year":"2025","unstructured":"Vu DLNguyen VHNguyen HAHemodynamic characteristics in ruptured and unruptured intracranial aneurysms: a prospective cohort study utilizing the AneurysmFlow tool. AJNR Am J Neuroradiol. 2025;46(1):75-83."},{"issue":"2","key":"bib4","series-title":"Stroke","first-page":"641","article-title":"Rupture risk of small unruptured intracranial aneurysms in Japanese adults","volume":"51","author":"Suzuki","year":"2020","unstructured":"Suzuki TTakao HRapaka SRupture risk of small unruptured intracranial aneurysms in Japanese adults. Stroke. 2020;51(2):641-643."},{"issue":"7","key":"bib5","series-title":"Stroke","first-page":"e314","article-title":"2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association\/American Stroke Association","volume":"54","author":"Hoh","year":"2023","unstructured":"Hoh BLKo NUAmin-Hanjani S2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association\/American Stroke Association. Stroke. 2023;54(7):e314-e370."},{"issue":"21","key":"bib6","series-title":"Circulation","first-page":"e661","article-title":"Indications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association","volume":"137","author":"Eskey","year":"2018","unstructured":"Eskey CJMeyers PMNguyen TNIndications for the performance of intracranial endovascular neurointerventional procedures: a scientific statement from the American Heart Association. Circulation. 2018;137(21):e661-e689."},{"key":"bib7","series-title":"Front Neurosci","first-page":"233","article-title":"The morphological and hemodynamic characteristics of the intraoperative ruptured aneurysm","volume":"13","author":"Liu","year":"2019","unstructured":"Liu QJiang PWu JGao BWang S.The morphological and hemodynamic characteristics of the intraoperative ruptured aneurysm. Front Neurosci. 2019;13:233."},{"issue":"3","key":"bib8","series-title":"Case Rep Neurol","first-page":"261","article-title":"Intraoperative rupture of unruptured cerebral aneurysm during craniotomy: a case report","volume":"9","author":"Yoshiki","year":"2017","unstructured":"Yoshiki KMisaki KNambu IIntraoperative rupture of unruptured cerebral aneurysm during craniotomy: a case report. Case Rep Neurol. 2017;9(3):261-266."},{"issue":"1","key":"bib9","series-title":"BMC Neurol","first-page":"135","article-title":"Intraoperative rupture of intracerebral aneurysm immediately after meningioma resection: a case report","volume":"22","author":"Tanaka","year":"2022","unstructured":"Tanaka SKobayashi MIchinose TIntraoperative rupture of intracerebral aneurysm immediately after meningioma resection: a case report. BMC Neurol. 2022;22(1):135."},{"issue":"4","key":"bib10","series-title":"Neurosurg Clin N Am","first-page":"861","article-title":"Intraoperative aneurysm rupture and complication avoidance","volume":"9","author":"Chandler","year":"1998","unstructured":"Chandler JPGetch CCBatjer HH.Intraoperative aneurysm rupture and complication avoidance. Neurosurg Clin N Am. 1998;9(4):861-868."},{"issue":"12","key":"bib11","series-title":"Acta Neurochir (Wien)","first-page":"1255","article-title":"Intra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management","volume":"141","author":"Houkin","year":"1999","unstructured":"Houkin KKuroda STakahashi AIntra-operative premature rupture of the cerebral aneurysms. Analysis of the causes and management. Acta Neurochir (Wien). 1999;141(12):1255-1263."},{"issue":"1","key":"bib12","series-title":"J Cerebrovasc Sci","first-page":"26","article-title":"Anesthetic management of intraoperative rupture of intracranial aneurysms","volume":"10","author":"Kaur","year":"2022","unstructured":"Kaur HKaur H.Anesthetic management of intraoperative rupture of intracranial aneurysms. J Cerebrovasc Sci. 2022;10(1):26-34."},{"issue":"1","key":"bib13","series-title":"Anesthesiol Res Pract","first-page":"595837","article-title":"Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm","volume":"2014","author":"Chowdhury","year":"2014","unstructured":"Chowdhury TPetropolis AWilkinson MSchaller BSandu NCappellani RB.Controversies in the anesthetic management of intraoperative rupture of intracranial aneurysm. Anesthesiol Res Pract. 2014;2014(1):595837."},{"issue":"12","key":"bib14","series-title":"Appl Sci","article-title":"The cerebral arterial wall in the development and growth of intracranial aneurysms","volume":"12","author":"Abbate","year":"2022","unstructured":"Abbate PMHasan ATMHVenier AThe cerebral arterial wall in the development and growth of intracranial aneurysms. Appl Sci. 2022;12(12)."},{"key":"bib15","series-title":"World Neurosurg","first-page":"672.e5","article-title":"Life-threatening mannitol-induced hyperkalemia in neurosurgical patients","volume":"91","author":"Fanous","year":"2016","unstructured":"Fanous AATick RCGu EYFenstermaker RA.Life-threatening mannitol-induced hyperkalemia in neurosurgical patients. World Neurosurg. 2016;91:672.e5-672.e9."},{"issue":"4","key":"bib16","series-title":"J Anaesthesiol Clin Pharmacol","first-page":"546","article-title":"Mannitol-induced intraoperative hyperkalemia, a little-known clinical entity","volume":"28","author":"Sharma","year":"2012","unstructured":"Sharma JSalhotra R.Mannitol-induced intraoperative hyperkalemia, a little-known clinical entity. J Anaesthesiol Clin Pharmacol. 2012;28(4):546-547."},{"issue":"6","key":"bib17","series-title":"Neurosurgery","first-page":"1052","article-title":"A review of brain retraction and recommendations for minimizing intraoperative brain injury","volume":"33","author":"Andrews","year":"1993","unstructured":"Andrews RJBringas JR.A review of brain retraction and recommendations for minimizing intraoperative brain injury. Neurosurgery. 1993;33(6):1052-1064."},{"issue":"3","key":"bib18","series-title":"Br J Neurosurg","first-page":"191","article-title":"The effect of changes in barometric pressure on the risk of rupture of intracranial aneurysms","volume":"11","author":"Landers","year":"1997","unstructured":"Landers ATNarotam PKGovender STVan Dellen JR.The effect of changes in barometric pressure on the risk of rupture of intracranial aneurysms. 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