Presentation
Collapse with GCS 4, dilated pupil. No relevant past history.
Patient Data
Large right acute subdual hematoma, right gyrus rectus intraparenchymal hematoma, right to left subfalcine herniation. Note the gyrus rectus hematoma extends anteriorly from the region of the anterior communicating artery. CTA performed confirms the expected ACOM aneurysm. Due to clinical state, patient immediately transferred to the operating room for neurosurgical clipping of the aneurysm and drainage of the SDH, without preceding catheter angiography.
Case Discussion
The gyrus rectus hematoma should always prompt consideration of an ACOM aneurysm rupture - the major differential diagnosis for spontaneous hemorrhage in this region being ethmoidal anterior cranial fossa DAVF. When aneurysmal rupture is associated with SDH, it is more common in a second delayed bleed, but can occur with the first bleed as in this case.
The presence of mass effect, herniation and poor clinical grade and pupil dilatation indicate a surgical approach as an emergency - if the clinical grade is good and surgical evacuation of the SDH or IPH is not considered an emergency, coil embolization could be considered and surgery could follow as clinically indicated.