Article Text

Unusual presentation of more common disease/injury
Intraventricular haemorrhage without subarachnoid haemorrhage due to a ruptured aneurysm
  1. K S Manjunath Prasad1,
  2. Shuaibu Sule Dambatta1,2,
  3. James E Dervin3
  1. 1
    James Cook University Hospital, Neurosurgery, Marton Road, Middlesbrough TS4 3BW, UK
  2. 2
    Skendleby Drive, Newcastle NE3 3GJ, UK
  3. 3
    James Cook University Hospital, Neuroradiology, Marton Road, Middlesbrough TS4 3BW, UK
  1. K S Manjunath Prasad, manjunath.prasad{at}doctors.org.uk

Summary

The incidence of aneurysmal subarachnoid haemorrhage (SAH) in the UK is about 10 per 100 000 of the population per year and it is a potentially fatal condition. Prompt recognition and referral to a neurosurgical unit is crucial for a better outcome. A typical history of sudden severe headache, CT scan and sometimes a lumbar puncture would help clinch the diagnosis. Though intracerebral haemorrhage (ICH) and intraventricular haemorrhage (IVH) are not uncommon after an aneurysmal rupture, ICH and/or IVH without SAH are rare (<2%). In such cases, a high index of suspicion is needed to deliver the correct management. This report describes a case of posterior communicating artery aneurysm presenting with pure IVH on CT. The aneurysm was diagnosed by performing a CT angiogram and the patient underwent a successful coil embolisation.

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BACKGROUND

This case is an illustration of the uncommon occurrence of an intracranial aneurysmal rupture without subarachnoid haemorrhage (SAH). It supports our opinion that even in the absence of subarachnoid blood, intraventricular bleed on CT deserves prompt investigation of an aneurysmal rupture.

CASE PRESENTATION

A 29-year-old woman presented with a history of sudden severe thunderclap headache, followed by vomiting. On examination, she had mild photophobia but nothing else of note.

INVESTIGATIONS

A CT scan of the head, done about 5 h after the ictus, revealed a small bleed in the anterior third ventricle and early hydrocephalus, but no SAH (fig 1). A CT angiogram revealed a posterior communicating artery aneurysm on the left side. This was seen again on the cerebral digital subtraction angiogram (fig 2).

Figure 1

CT scan showing blood in the anterior third ventricle.

Figure 2

Digital subtraction angiogram showing a left posterior communicating artery aneurysm.

DIFFERENTIAL DIAGNOSIS

An intracranial arteriovenous malformation was considered in the differential diagnosis.

TREATMENT

The patient underwent successful occlusion of the aneurysm by coil embolisation (fig 3).

Figure 3

Digital subtraction angiogram showing the successful occlusion of the aneurysm by coil embolisation.

OUTCOME AND FOLLOW-UP

At discharge from hospital, the patient was well and had no neurological deficit.

DISCUSSION

Rupture of an intracranial aneurysm causes the typical “thunderclap” headache. A CT scan is positive for subarachnoid haemorrhage in more than 90% of the cases on the day of haemorrhage1 and the sensitivity drops thereafter. Though intracerebral haemorrhage (ICH) and intraventricular haemorrhage (IVH) are not uncommonly associated with aneurysmal subarachnoid bleed, it is rare to find intracerebral haematoma and/or intraventricular haematoma without SAH.2 Though there have been a few case reports of subdural haematoma3 and ICH without SAH seen on CT in patients with ruptured aneurysms, only one case of pure IVH without SAH is known to have been cited, and this was in a case series of ruptured aneurysms without SAH on CT.2 In this series, the bleed was from a basilar artery aneurysm. Our case is probably the second case with only IVH and no SAH due to a ruptured aneurysm, and probably the first case of a ruptured posterior communicating artery aneurysm with only IVH. There are a few case reports of posterior communicating artery aneurysms presenting with temporal lobe bleeds, but presenting with only IVH makes this case unique.

In our case, the typical history of a sudden severe headache was given due consideration, and though the CT scan showed only IVH without SAH, the possibility of a ruptured aneurysm was entertained throughout the process of referral and investigation prior to successful treatment.

LEARNING POINTS

  • Though intraventricular haemorrhage (IVH) is not uncommon with aneurysmal subarachnoid haemorrhage (SAH), IVH without SAH is very rare.

  • This is thought to be the first case reported of a ruptured posterior communicating artery aneurysm presenting with pure IVH.

  • Even in the absence of subarachnoid blood, intraventricular bleed on CT deserves prompt investigation of an aneurysmal rupture.

REFERENCES

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Footnotes

  • Competing interests: none.

  • Patient consent: Patient/guardian consent was obtained for publication.

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