Clinical Neuroscience

Simultaneous subdural, subarachnoideal and intracerebral haemorrhage after rupture of a peripheral middle cerebral artery aneurysm

BÉRES-MOLNÁR Anna Katalin1, FOLYOVICH András1, SZLOBODA Péter2, SZENDREY-KISS Zsolt2, BERECZKI Dániel3, BAKOS Mária4, VÁRALLYAY György5, SZABÓ Huba6, NYÁRI István2

MAY 30, 2020

Clinical Neuroscience - 2020;73(05-06)

DOI: https://doi.org/10.18071/isz.73.0213

The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and the simultaneous appearance in the same case is extremely rare. We describe the case of a patient with a ruptured aneurysm on the distal segment of the middle cerebral artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent secondary brainstem (Duret) haemorrhage. The 59-year-old woman had hypertension and diabetes in her medical history. She experienced anomic aphasia and left-sided headache starting one day before admission. She had no trauma. A few minutes after admission she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage, and bleeding was also observed in the right pontine region. The patient had leucocytosis and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated, the patient was transferred to intensive care unit. Sepsis developed. Echocardiography did not detect endocarditis. Neurological status, vigilance gradually improved. The rehabilitation process was interrupted by epileptic status. Control CT and CT angiography proved an aneurysm in the peripheral part of the left middle cerebral artery, which was later clipped. Histolo­gical examination excluded mycotic etiology of the aneu­rysm and “normal aneurysm wall” was described. The brain stem haemorrhage – Duret bleeding – was presumably caused by a sudden increase in intracranial pressure due to the supratentorial space occupying process and consequential trans-tentorial herniation. This case is a rarity, as the patient not only survived, but lives an active life with some residual symptoms.

AFFILIATIONS

  1. Department of Neurology and Stroke, Szent János Hospital, Budapest
  2. Department of Neurosurgery, Szent János Hospital, Budapest
  3. Department of Neurology, Semmelweis University, Budapest
  4. Department of Radiology, Szent János Hospital, Budapest
  5. MR Research Center, Semmelweis University, Budapest
  6. Department of Pathology, Szent János Hospital, Budapest

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