Presentation
Acute severe headache + neck stiffness. Hypertensive.
Patient Data
Extensive subarachnoid hemorrhage occupying the basal cisterns, right sylvian fissure, interhemispheric fissure, and the midline occipital and parietal lobe sulci. Grey-white matter differentiation is preserved, no evidence of definitive intraparenchymal hemorrhage. Small amount of blood in the posterior horn of the lateral ventricles and in the fourth ventricle. The temporal horns are slightly prominent in keeping with hydrocephalus. No midline shift or signs of brain herniation. The extracranial vessels, circle of Willis and vertebrobasilar system opacify normally with no aneurysm, vascular malformation, dissection or significant stenosis detected. Conventional aortic arch anatomy. The left vertebral artery is dominant.
The patient was then approached with a surgical insertion of a VP shunt due the hydrocephalus. Angiography was done hours later the shunt insertion.
Bilateral common carotid, internal carotid, external carotid and vertebral angiography was performed. No abnormalities have been detected. In particular there is no aneurysm, AVM or dAVF and there is no evidence of dissection. Conclusion: No cause for subarachnoid hemorrhage identified .
Case Discussion
Extensive subarachnoid hemorrhage (grade 3 of Fisher scale) associated with hydrocephalus. No evidence of dissection, aneurysm or vascular malformation on both the CTA and angiography studies.
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