• History & Physical: The patient is an 85 year old right-handed woman who presents to the emergency room complaining of a severe occipital headache. She states that she has been having “spells” for the last two weeks. Today she had a “spell” while loading the refrigerator and fell backwards, hitting her head on the floor. She is amnestic to the event. She has no complaints other than the headache. She is neurologically intact and has no other injuries.

    Fig 1 A, B, C (Below): Head CT reveals diffuse subarachnoid hemorrhage, greatest in the left sylvian fissure and a small right frontal subdural hematoma.

    Figure 1A.

    Figure 1B.

    Figure 1C.

    Figure 2. A CT angiogram was obtained revealing a 5 mm aneurysm in the right carotid cave.

    1. Do you think her SAH is related to her aneurysm?

    2. Does she need any further imaging?

    3. if she does need further imaging what?

    4. Would you offer her treatment for her aneurysm?

    5. How would you treat this aneurysm?

    6. Please add any suggestions or comments regarding this case:

    I think she needs an Angio to determine if there are any other aneurysms that may have caused the L sylvian fissure SAH. At the same time if it is determined that the aneurysm of the carotid cave has bled I would perform a baloon test occlusion. If it is possible to take the carotid on that side, I would do it via endascular Tx. I would not operate in this lady. All of this, of course assumes that the pt is a candidate for endovascular with no severe PMHx.

    Its a SAH, but I think the site of the hemorrage does not correspond with the aneurysm found in the CT, thus I looking further with an agiogram to find out probably another anomalies at the site of the hemorrage, like another aneurism.

    this is an intracavernous ICA aneurysm, this is not s surgical emergency, and case could be discussed more after angiogram

    Such combine pathological focus (diffuse subarachnoidal hemorrhage with subdural hematomas)ussually caused by rupture of arterial aneurism.

    leave the patient no interferance no more complication and left her to enjoy life untill complication occurs

    A localise convexity SAH is likely to be traumatic but other causes include AVM, Cavernoma and tumor. An MRA is non invasive procedure and may be useful in this. The aneurysm should be left alone.

    Her 5mm anerurysm is unlikely to have ruptured and the distribution of blood (R frontal SDH and Left SAH) is more likely to be secondary to trauma. Her spells are probably to be due to TIAs from artherosclerosis. In any event even if her aneurysm had ruptured, the risks of treatment are as great or greater than the natural history.

    An angiogram was performed confirming the presence of only a right carotid cave aneurysm. The SAH was felt to be traumatic. Given the low likelihood of SAH from carotid cave aneurysms and the patient’s age no intervention was offered. The patient was discharged after a repeat head CT showing no progression of her sub-dural hematoma / SAH.

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