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Rupture of anterior communicating artery aneurysm

Case contributed by Hoe Han Guan
Diagnosis probable

Presentation

Sudden syncope with persistent headache.

Patient Data

Age: 60 years
Gender: Female

Large acute extra-axial/subarachnoid hematoma with epicenter at the anterior interhemispheric fissure. A few areas of low attenuation within this hematoma are in keeping with the "swirl sign". Minimal perihaematoma edema.
Acute subarachnoid hemorrhage at the suprasellar cistern, parasagittal regions and bilateral Sylvian fissures.
Intraventricular hemorrhagic extension with non-communicating hydrocephalus. No periventricular lucency to suggest transependymal CSF seepage.
Well defined spherical shaped hypodense lesion at the area of the anterior communicating artery.
Generalized cerebral edema as demonstrated by effacement of cerebral sulci, gyri and basal cisterns.
The foramen magnum is tight with left cerebellar tonsil herniation.
No subfalcine herniation.

Case Discussion

The location of hematoma and the low density spherical shaped lesion from the anterior communicating artery raise high suspicion of rupture ACOM artery aneurysm.
The presence of a "swirl sign" indicates acute hematoma expansion.

The volume of hematoma, the degree of cerebral edema, hydrocephalus, midline shift, basal cistern effacement and brainstem herniation are important prognostic factors which are important to be included in the CT report for the neurosurgeon to make definite decisions and management.

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