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 susceptibility (SWI)
Prior Study
CT head: pre1. 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.
MR T1-w pre contrast
1. The right temporal hematoma is virtually isointense to brain indicating it is in a hyperacute to acute timeframe (2 hrs to 2 days). The existing vasogenic perilesional edema is hypointense on T1 and surrounds the parenchymal hematoma.
2. There is a right posterior saccular aneurysm. It is not as well seen on MRA than on the CTA. There is no residual left MCA aneurysm, and the basilar tip pre-aneurysm is not evident.
3. The large right temporal mass reduces venocapillary filling, But this could be just delay in filling and not necessarily infarction.
MR T1-w post contrast/MRA
1. There is no residual aneurysm in the left MCA treatment area.
2. The active P-com aneurysm is present but is detail concerning the aneurysm is clearer on the CTA.
T2-w spin echo
1. The right temporal hematoma age is in the hyperacute to early acute timeframe.
MR flair
1. MR flair demonstrates that the degree of actual transependymal fluid migration is minimal. Most of the periventricular hyper intense signal is likely age-related leukomalacia.
2. The age of the hematoma also matches the hyperacute phase on MR flair.