Presentation
Severe sudden onset headache 1 week ago. Did not attend hospital. Now has developed right facial weakness
Patient Data
Deep intracerebral hematoma involving the left external capsule and inferior left frontal white matter, extending inferiorly to abut the left middle cerebral artery. There is perihaematomal edema. A small amount of subarachnoid hemorrhage is visible in the left sylvian fissure. No intraventricular hemorrhage.
Partial effacement of the left lateral ventricle and minor rightward midline shift. No hydrocephalus.
Chronic right cerebellar cortical infarct.
The left middle cerebral artery is diffusely narrowed, in keeping with vasospasm. There is a small focus of enhancement arising superiorly from the left middle cerebral artery into the parenchymal hematoma (best seen on the coronal reformat), suspicious for an aneurysm.
5 mm right middle cerebral artery trifurcation aneurysm.
Very small left middle cerebral artery bifurcation aneurysm. This measures approximately 1.7 mm, with quite a narrow neck. It is oriented superiorly.
After coiling, there is no residual filling. There is no protrusion of any of the coil into the parent artery.
Case Discussion
- Macrovascular lesions, such as arterial aneurysms, underlie 10-15% of spontaneous intracerebral hemorrhage.
- Early identification of such abnormalities is important to allow appropriate treatment.
- Subarachnoid hemorrhage in the basal cisterns, ICH location adjacent to the circle of Willis and younger age (<60 years) are risk factors for an underlying macrovascular lesion.