Presentation
Worst headache of his life for the past 1 day followed by seizure-like activity. Intubated at an outside hospital due to unresponsiveness.
Patient Data
There is intraventricular hemorrhage within the lateral ventricles, third and fourth ventricle, with diffuse subarachnoid hemorrhage throughout the cerebral sulci, basilar cisterns and sylvian fissure. There is a subacute infarct within the left inferior frontal gyrus, left inferior frontal lobe, left anterior temporal lobe and insula, with associated blood clot expanding the left sylvian fissure and lateral suprasellar cistern.
There are scattered areas of vascular narrowing, which may be due to vasospasm. There is a stent extending from the ophthalmic segment of the left ICA to the proximal left M1 segment. There is an aneurysm at the junction of the ophthalmic and communicating segment of the left ICA.
Diffuse subarachnoid hemorrhage in bilateral cerebral sulci, basal cisterns and sylvian fissures, left greater than the right. There is also subdural hemorrhage along the tentorial leaflets, left greater than right. There has been an interval increase in the mass effect and midline shift to the right. There is increased effacement of the left lateral ventricle.
There is no radiotracer activity within cerebral arteries.
There is increased uptake within the sinonasal region.
Case Discussion
This is a case of brain death. The patient was previously healthy but suddenly developed a "thunderclap headache", classically from a subarachnoid hemorrhage. CTA demonstrated a relatively large ICA aneurysm with diffuse subarachnoid hemorrhage. The hemorrhage progressively worsened. The nuclear medicine study showed characteristic findings of brain death, such as the empty light bulb sign and hot nose sign.
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