Case Notes
History
64 yo female with acute onset headache, blurred vision, slurred speech, and hearing impairmentExam
Prior Study
CT head1. Focal intra and extraaxial hemorrhage in the left frontal parenchyma and adjacent interhemipheric fissure. The combination suggest an underlying A-com aneurysm with likely prior sentinel bleed.
2. Left fronto-temporal subdural hematoma, likely secondary to a fall after SAH
3. Left frontal region mass effect has caused a 5 mm left to right shift and produced early right lateral ventricular hydrocephalus.
Dicom
Findings
CTA/MRA/DSA Findings | Correct Answer | Your Answer |
---|---|---|
There is evidence of intracranial/extradural aneurysm: petrous canal cavernous sinus, sub clinoidal space, lower ICA ophthalmic segment, or superior hypophyseal segment. This can be any type, saccular aneurysm, arteriosclerotic giant aneurysm, or blister aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular or giant arteriosclerotic aneurysm(s): upper ophthalmic ICA segment for true ophthalmic, dorsal ophthalmic variant, or ICA apex aneurysms. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: communicating ICA segment for P-com aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: choroidal ICA segment for anterior choroidal aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: caudal P-com/P1 PCA junction aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: ICA vertex, or lenticulostriate (off M1 or A1), or anterior temporopolar aneurysm (off M1/2). |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: A1-2 segment for anterior communicating aneurysm. |
Yes | NA |
There is evidence of intracranial/intradural saccular aneurysm: distal ACA for pericallosal aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: M1-2 segment for lateral frontotemporal, or MCA trifurcation aneurysm. |
Yes | NA |
There is evidence of intracranial/intradural saccular aneurysm: basilar apex aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: PCA-SCA junction aneurysm. |
No | NA |
There is evidence of intracranial/intradural saccular aneurysm: PICA origin aneurysm. |
No | NA |
There is evidence of saccular aneurysm complexities including daughter aneurysms and wide neck (vs fundal width), aneurysm neck involvement of parent artery, local dissection of parent artery. |
No | NA |
There is evidence of major vessel vasospasm (minimal, moderate, or advanced). |
No | NA |
There is evidence of a bleb/blister type aneurysm (usually off ICA ophthalmic segment or dorsal side of A-com or basilar apex). |
No | NA |
There is evidence of a major artery spontaneous distal fusiform aneurysm. |
No | NA |
There is evidence of intracranial/intradural dissecting aneurysm: vertebral or carotid dural penetration site. |
No | NA |
There is evidence of intracranial/intradural dissecting aneurysm of distal artery branches: consistent with saccular appearing dissection or mycotic source. |
No | NA |
There is evidence of a distal pial artery inflammatory tubular aneurysms, especially M2-4, P2-4 arteries. |
No | NA |
There is evidence of aneurysms associated with vascular anomalies: arterial fenestrations, trigeminal anomaly, or any other arterial anomaly. |
No | NA |
There is evidence of major vessel atherosclerotic sacculo-fusiform aneurysm. |
No | NA |
There is evidence of significant arteriosclerotic dolichoectasia. |
No | NA |
There is CT perfusion evidence of dysautoregulation (mixed vasospasm and downstream vasodilatation from collaterals). |
No | NA |
Other abnormalities |
No | NA |
Impression
Expert Answer
When the fundal height exceeds the width by 2x or more, it increases the risk of SAH, as in the A-com aneurysm in this case. When the fundal height is less than 2x the width, it reduces the risk of SAH, as in the left MCA aneurysm in this case. This width to height proportion can help decide which is the likely aneurysm to have bled, when more than one aneurysm are present.