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Fatal aneurysmal subarachnoid haemorrhage (ICH predicts a poor outcome)

  
 
 
 

Case report:

 
 
Patient with massive aneurysmal subarachnoid haemorrhage due to a large middle cerebral artery aneurysm (associated with an intracerebral haematoma (ICH) and multiple aneurysms). This 65 year old lady was found collapsed at home following line dancing. She complained of the sudden onset of severe headache and drowsiness. Her family noted profound weakness of the left side of the face and the body. At the local hospital, she had a GCS of E2, M6,V3 with profound weakness on the left side. CT scan (below, left) revealed a massive ICH and SAH. Following routine medical care, she underwent angiography (below, middle). The angiogram demonstrated multiple aneurysms. The ruptured aneurysm is the right middle cerebral artery aneurysm due to the location of the ICH. Emergency craniotomy for evacuation of the ICH and clipping of the aneurysm was performed. The brain was tense and angry looking at operation. There was a massive ICH surrounding the wide necked aneurysm which was clipped successfuly . Postoperative recovery was complicated by ischemia in the right hemisphere and progressive decline. She died 5 days following her admission.
 
 
 
 

Discussion

  
 
Aneurysmal Subarachnoid Haemorrhage (SAH) is a serious clinical condition with a 30-50% chance of a fatal outcome. Death occurs suddenly in about a third of cases and these patients may never present to the hospital. In another third (those who present to hospital!) the mortality is due to complications of the bleed such as intracerebral haematoma (as in the case to be presented), hydrocephalus and vasospasm. In a retrospective study, patients who developed more than 25 ml of ICH had significantly worse outcomes (p < 0.05). Factors that could be used to predict a favourable outcome include temporal ICH, WFNS Grade I or II, absence of a surgical and postoperative complication, and a haematoma volume less than 25 ml.
  
 
 
 
Images:
 
 
CT brain scan of a patient with massive subarachnoid haemorrhage. There is a large intracerebral hematoma in the right sylvian fissure. Inset: upper slice of the same patient's scan Cerebral angiography of the right internal carotid artery demonstrating large aneurysms of the anterior communicating artery complex and the middle cerebral artery. Inset: the left internal carotid with a mirror MCA aneurysm Postoperative CT scan. Areas of low density are evident in the right hemisphere.
 
 
 
 

The presentation CT scan showing massive SAH with a large intracerebral haematoma in the right sylvian fissure. The angiography demonstrates large aneurysms of the right middle cerebral artery (and the left MCA -inset) and the anterior communicating artery. The vertebro-basilar trunk was normal. The 4th day post-operative scan is shown on the left. This shows no residual clot, but demonstrates low density in the right middle cerebral artery territory.

 
   
     
 
Created by B I Ogungbo in September 2002. Modified January 2008. ©