Korean J Neurotrauma.  2019 Apr;15(1):28-33. 10.13004/kjnt.2019.15.e11.

Pseudo-Subarachnoid Hemorrhage; Chronic Subdural Hematoma with an Unruptured Aneurysm Mistaken for Subarachnoid Hemorrhage

• Son D
• Kim Y
• Kim C
• Lee S

• KMID: 2444202
• DOI: http://doi.org/10.13004/kjnt.2019.15.e11

Abstract

Subarachnoid hemorrhage (SAH) usually occurs due to aneurysmal rupture of intracranial arteries and its typical computed tomography (CT) findings are increased attenuation of cisterns and subarachnoid spaces. However, several CT findings mimicking SAH are feasible in diverse conditions. They are so-called as pseudo-SAH, and this report is a case of pseudo-SAH which is misdiagnosed as aneurysm rupture accompanied by bilateral chronic subdural hematoma (cSDH). A 42-year-old male with severe headache visited our institute. Non-contrast brain CT images showed increased attenuation on basal cistern, and cSDH on both fronto-temporo-parietal convexity with midline shifting. Trans-femoral cerebral angiography was done and we confirmed small aneurysm at right M1 portion of middle cerebral artery. Under diagnosis of SAH, we planned an operation in order to clip aneurysmal neck and remove cSDH. cSDH was removed as planned, however, there was no SAH and we also couldn't find the rupture point of aneurysm. Serial follow-up CT showed mild cumulative cSDH recurrence, but the patient was tolerant and had no neurologic deficit during hospitalization. We have checked the patient via out-patient department for 6 months, there are no significant changes in volume and density of cSDH and the patient also have no neurologic complications.

Keyword

Pseudo-subarachnoid hemorrhage; Subarachnoid hemorrhage; Chronic subdural hematoma; Elevated intracranial pressure; Cerebral edema

MeSH Terms

Adult
Aneurysm*
Arteries
Brain
Brain Edema
Cerebral Angiography
Diagnosis
Follow-Up Studies
Headache
Hematoma, Subdural, Chronic*
Hemorrhage*
Hospitalization
Humans
Intracranial Hypertension
Male
Middle Cerebral Artery
Neck
Neurologic Manifestations
Outpatients
Recurrence
Rupture
Subarachnoid Hemorrhage*
Subarachnoid Space

Figure

• 

  FIGURE 1 Initial non-contrast brain computed tomography findings showed increased attenuation at basal cistern (arrow) and fluid collection along the right fronto-parietal convexity (triangles) with midline shifting.

• 

  FIGURE 2 Previous magnetic resonance angiography showed unruptured aneurysm at right M1 (arrow).

• 

  FIGURE 3 Trans-femoral cerebral angiography was performed, and then small aneurysm at right anterior temporal branch origin of middle cerebral artery M1 portion was confirmed (arrow).

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  FIGURE 4 (A) Vascularized inner membrane of cSDH looks like arachnoid adhesion. (B) Neovascularization of inner membrane of cSDH was also found. (C) After resection of inner membrane of cSDH, normal arachnoid membrane was observed. (D) No subarachnoid hemorrhage was observed during sylvian fissure dissection.cSDH: chronic subdural hematoma.

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