American Journal of Neuroradiology 25:1006-1007, June-July 2004
© 2004 American Society of Neuroradiology
Case Report
BRAIN
Bilateral Tentorial Subdural Hematoma without Subarachnoid Hemorrhage Secondary to Anterior Communicating Artery Aneurysm Rupture: A Case Report and Review of the Literature
Ajit A. Krishnaneya,
Peter A. Rasmussena and
Thomas Masaryka,b
a Section of Endovascular Neurosurgery, Department of Neurosurgery, Cleveland Clinic, Cleveland, OH
b Department of Neuroradiology, Cleveland Clinic, Cleveland, OH
Address correspondence to Ajit A. Krishnaney, MD, Department of Neurosurgery, Cleveland Clinic, S-80, 9500 Euclid Avenue, Cleveland, OH 44195
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Abstract
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Summary: A case of acute subdural hematoma over the tentorium
secondary to rupture of an anterior communicating artery aneurysm
is reported. A 42-year-old female patient presented with acute-onset,
severe bifrontal and retro-orbital headache. CT revealed only
symmetric thickening of the tentorium. MR imaging revealed the
presence of a 10-mm anterior communicating artery aneurysm,
which was confirmed by digital subtraction angiography. The
radiologic findings and possible mechanisms of this hemorrhage
are discussed.
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Introduction
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Approximately 3% of ruptures of intracranial aneurysms result
in subdural hematomas. Seventy percent of these aneurysms arise
from either the internal carotid artery or the middle cerebral
artery. Subdural hematoma from intracranial aneurysm rupture
without radiographic evidence of subarachnoid hemorrhage, however,
is rare.
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Case Report
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A 42-year-old, right-handed female patient with a history of
hypertension presented to the emergency department reporting
sudden-onset, severe headache approximately 4 hours before admission.
The headache was described as bilateral and retro-orbital in
location and was associated with photophobia, nausea, and lightheadedness.
The patient reported having had mild headache on each of the
4 days before admission as well as a similar episode of severe
headache 3 months before admission, all of which had been treated
with oral analgesic medications. Upon admission, the patient
was sleepy but easily arousable and was oriented to person,
place, and time. Her pupils were equal and reactive, and there
was no meningismus. Her reflexes were equal and symmetric with
plantar flexion of the toes. Noncontrast cranial CT revealed
diffuse thickening and increased attenuation of the tentorium
cerebelli bilaterally (
Fig 1). MR imaging revealed the presence
of a 3-mm extra-axial collection extending from the tentorium
symmetrically to envelop both cerebral hemispheres, as well
as a collection dorsal to the clivus extending inferiorly below
the foramen magnum. This collection was isointense relative
to brain on T1-weighted images and hyperintense on T2-weighted
MR images (
Fig 2). These findings were interpreted as consistent
with acute subdural hematoma (SDH). No evidence of subarachnoid
hemorrhage was noted on either CT or MR images. MR angiography
(MRA) and subsequent conventional angiography showed the presence
of a 10-mm anterior communicating artery aneurysm extending
inferiorly and posteriorly from its parent vessel (
Fig 3). No
vasospasm was present (
Fig 4). Lumbar puncture was performed
2 days after admission. CSF analysis revealed an rbc of 28,000/µL,
a wbc of 80/µL, protein of 651 mg/dL, and glucose of 78
mg/dL; however, no xanthochromia was seen. Surgery was performed
6 days after admission. Intraoperatively, an anterior communicating
artery aneurysm extending inferiorly with the dome embedded
anteriorly in the optic chiasm was identified and a clip placed
therein. The patient also had a large amount of subdural blood
overlying the convexity under the craniotomy that was irrigated
with lactated ringers and evacuated. No evidence of subarachnoid
blood was seen intraoperatively. She awoke from surgery with
no neurologic deficits and had an uneventful convalescence.
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FIG 1. Axial noncontrast CT scans show thickening of the tentorium bilaterally and no evidence of subarachnoid hemorrhage.
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FIG 2. Coronal FLAIR MR image reveals hyperintensities along the tentorium consistent with acute blood.
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FIG 3. Coronal T1-weighted MR image reveals enhancing suprasellar mass consistent with an anterior communicating artery aneurysm.
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FIG 4. Submentovertex view of a right internal carotid artery-injection cerebral angiogram reveals a 10-mm anterior communicating artery aneurysm.
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Discussion
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Although the incidence of acute SDH secondary to intradural
aneurysm rupture is well documented, occurring in 0.5–7.9%
of all cases, acute SDH without radiologic evidence of SAH is
rare (
1–
4). Only 150 cases of SDH without SAH have been
reported in the literature since 1855 (
5). Only three describe
hematomas of the tentorium, all of which resulted from ruptures
of internal carotid artery aneurysms (
6). This case appears
to be the first in the literature to describe a tentorial SDH
from an aneurysm arising from the anterior communicating artery.
Two possible mechanisms for the development of SDH associated
with aneurysm rupture have been proposed in the literature (
1,
3,
4,
6). One theory suggests the force of the rupture results
in a tearing of the arachnoid with subsequent spilling of blood
into the subdural space. The second proposes that one or more
"sentinel" hemorrhages result in the formation of adhesions
between the aneurysm and the arachnoid, creating a path for
blood to enter the subdural space with subsequent rupture. The
history of headaches 3 months before ictus in this case may
represent a prior rupture. Furthermore, the adhesions from the
aneurysm to the optic chiasm would support the theory of previous
hemorrhage. Although this appears to be the first report of
an aneurysm in this location causing a tentorial SDH, there
have undoubtedly been other cases that have gone undiagnosed.
In this case, the unusual pattern of the SDH, along with the
history, led to MRA, which yielded the diagnosis. With the continuing
advancement of MR imaging technology and more widespread use
of MRA and CT angiography, perhaps more cases of SDH without
SAH from aneurysm rupture will be diagnosed.
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References
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- Kondziolka D, Bernstein M, ter Brugge K, Schutz H. Acute subdural hematoma from rupture posterior communicating artery aneurysm.
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- Freidman MB, Brant-Zawadzki M. Interhemispheric subdural hematoma from ruptured aneurysm.
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Received August 6, 2003;
accepted after revision September 23, 2003.
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Abstract
Introduction