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Table of Contents    
LETTER TO EDITOR
Year : 2012  |  Volume : 60  |  Issue : 6  |  Page : 681-682

Tentorial subdural hemorrhage as a presentation of intracranial aneurysm rupture: A rare event


1 Hyman Newman Institute for Neurology and Neurosurgery, Center for Endovascular Surgery, Roosevelt Hospital, New York, USA
2 St. Luke's Roosevelt Hospital Center, New York, USA

Date of Submission26-Oct-2012
Date of Decision27-Oct-2012
Date of Acceptance27-Oct-2012
Date of Web Publication29-Dec-2012

Correspondence Address:
Srinivasan Paramasivam
Hyman Newman Institute for Neurology and Neurosurgery, Center for Endovascular Surgery, Roosevelt Hospital, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.105226

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How to cite this article:
Paramasivam S, Fifi JT, Chong JY. Tentorial subdural hemorrhage as a presentation of intracranial aneurysm rupture: A rare event . Neurol India 2012;60:681-2

How to cite this URL:
Paramasivam S, Fifi JT, Chong JY. Tentorial subdural hemorrhage as a presentation of intracranial aneurysm rupture: A rare event . Neurol India [serial online] 2012 [cited 2019 Aug 17];60:681-2. Available from: http://www.neurologyindia.com/text.asp?2012/60/6/681/105226


Sir,

A 43-year-old woman presented with a sudden-onset severe headache. She was stable with no neurologic deficits and signs of meningismus. Non-contrast computed tomography (CT) scan was interpreted as normal. Cerebrospinal fluid analysis was normal and no xanthochromia was observed. She was sent home. On review of CT scan, tentorial subdural hemorrhage (SDH) was identified [Figure 1]a. The patient was recalled on the same day and magnetic resonance imaging (MRI) confirmed the SDH. MR-angiography showed a left posterior communicating artery (Pcom) aneurysm [Figure 1]b. Digital subtraction angiography (DSA) confirmed a bilobed Pcom aneurysm with a narrow neck projecting posterolaterally [Figure 1]c. Coil embolization was performed and she had complete recovery of symptoms. Follow-up DSA at 6 months showed no evidence of recurrence or recanalization of the aneurysm [Figure 1]d.
Figure 1: (a) Computed tomography scan showing left sided tentorial subdural hemorrhage along the petroclinoidal ligament and tentorial surface. (Arrow). (b) The magnetic resonance imaging brain contrast coronal image showing the left posterior communicating artery aneurysm. (Arrowhead). (c) Digital subtraction angiography oblique projection revealing a bilobed posterior communicating artery aneurysm and (d) follow up angiogram post coil embolization at 6 months

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Intracranial aneurysm rupture usually presents with subarachnoid hemorrhage (SAH). Uncommonly, SAH can be associated with intracerebral hemorrhage (ICH) and SDH. [1],[2],[3],[4] There have been a few case reports of aneurysmal rupture presenting with pure SDH without SAH or ICH. [1],[2],[5],[6] The possible mechanisms for such presentation include breach of the arachnoid membrane due to rapid accumulation of blood under pressure, successive sentinel bleeds resulting in adhesion of arachnoid to the dome of aneurysm and rupture occurring directly into the subdural space, ICH rupturing through the pia-arachnoid membrane, and an aneurysm in the segment of carotid artery within the subdural space can rupture and cause SDH. [7] In our patient we hypothesize that, as the Pcom aneurysm expanded beyond a certain size, further growth might have been hindered by the petroclinoidal band of the tentorium (pica petroclinoidea). [8],[9] The arachnoid membrane might have subsequently compressed and stretched against the tentorium and later might have breached allowing the aneurysm to lie in the subdural location and it might have subsequently ruptured into the subdural space. Bilobed nature of the aneurysm projecting posterolaterally in MRA and DSA may go with this hypothesis.

SDH without SAH is extremely rare presentation of intracranial aneurysm rupture. In patients with spontaneous, sudden onset severe headache, clinician should exercise high index of suspicion and look for aneurysmal rupture given the high morbidity and mortality associated with ruptured aneurysms.

 
  References Top

1.Inamasu J, Saito R, Nakamura Y, Ichikizaki K, Suga S, Kawase T, et al. Acute subdural hematoma caused by ruptured cerebral aneurysms: Diagnostic and therapeutic pitfalls. Resuscitation 2002;52:71-6.  Back to cited text no. 1
    
2.Hashizume K, Nukui H, Horikoshi T, Kaneko M, Fukamachi A. Giant aneurysm of the azygos anterior cerebral artery associated with acute subdural hematoma: Case report. Neurol Med Chir (Tokyo) 1992;32:693-7.  Back to cited text no. 2
    
3.Triantafyllopoulou A, Beaumont A, Ulatowski J, Tamargo RJ, Varelas PN. Acute subdural hematoma caused by an unruptured, thrombosed giant intracavernous aneurysm. Neurocrit Care 2006;5:39-42.  Back to cited text no. 3
    
4.Hatayama T, Shima T, Okada Y, Nishida M, Yamane K, Okita S, et al. Ruptured distal anterior cerebral artery aneurysms presenting with acute subdural hematoma: Report of two cases. No Shinkei Geka 1994;22:577-82.  Back to cited text no. 4
    
5.Ishibashi A, Yokokura Y, Sakamoto M. Acute subdural hematoma without subarachnoid hemorrhage due to ruptured intracranial aneurysm: Case report. Neurol Med Chir (Tokyo) 1997;37:533-7.  Back to cited text no. 5
    
6.Freytag E. Fatal rupture of intracranial aneurysms. Survey of 250 medicolegal cases. Arch Pathol 1966;81:418-24.  Back to cited text no. 6
    
7.Barton E, Tudor J. Subdural haematoma in association with intracranial aneurysm. Neuroradiology 1982;23:157-60.  Back to cited text no. 7
    
8.Ono M, Ono M, Rhoton AL Jr, Barry M. Microsurgical anatomy of the region of the tentorial incisura. J Neurosurg 1984;60:365-99.  Back to cited text no. 8
    


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