Case Notes
History
83 yo Fe with previous one (year earlier) subarachnoid hemorrhage related to a left MCA aneurysm: this was treated with endovascular device. Patient now presents with acute headache and change in mental status consistent with suspected recurrent SAH.Exam
MR T1-w pre contrast
Prior Study
CT head: pre contrast1. There is evidence of concurrent subarachnoid hemorrhage with subarachnoid clot concentrated in the proximal segment of the sylvian fissure and right lateral suprasellar space plus a large intraparenchymal hematoma in the adjacent mesial right temporal lobe. This complex of SAH & adjacent intraaxial is consistent with a sentinel hemorrhage condition where pial adhesions from prior hemorrhage (which this patient had from the left MCA aneurysm bleed) cause the hemorrhage direction to bleed into brain and subarachnoid space at the same time.
2. There is minimal to moderate external hydrocephalus and papiiledema.
3. There is early downward uncal herniation compressing the right cerebral peduncle.
CT head: CTA
1. There is no residual aneurysm in the left MCA treatment area.
2. There is a right P-com saccular aneurysm with a relatively wide neck for fundal size. There is no vasospasm nor incorporation of the parent artery in the aneurysm neck. It has a small apical daughter aneurysm.
3. There is a small basilar apex pre-aneurysm.