1/
A 59 year old woman presents with acute onset 10/10 headache (⛈️) and radiating occipital pain.
Non-con head CT is performed and reveals this👇
#problem
But the CTA shows no aneurysm.
So... now what?
A #ContinuumCase.
A 59 year old woman presents with acute onset 10/10 headache (⛈️) and radiating occipital pain.
Non-con head CT is performed and reveals this👇
#problem
But the CTA shows no aneurysm.
So... now what?
A #ContinuumCase.
2/
The most feared cause of subarachnoid hemorrhage is aneurysm rupture, but it’s super important to remember that not all SAH is aneurysmal.
Before jumping to any conclusion. It’s critical to assess the pattern of SAH:
The most feared cause of subarachnoid hemorrhage is aneurysm rupture, but it’s super important to remember that not all SAH is aneurysmal.
Before jumping to any conclusion. It’s critical to assess the pattern of SAH:
3/
Cortical SAH is rarely related to aneurysm unless it’s a mycotic aneurysm. Cortical SAH is much more likely to fall into one of these diagnoses:
Cortical SAH is rarely related to aneurysm unless it’s a mycotic aneurysm. Cortical SAH is much more likely to fall into one of these diagnoses:
PS slides from @drdangayach and my #HR2022 talk, you can find the @emcrit episode here (free): emcrit.org/emcrit/neuroem…
@ThinkingCC - can't wait for H&R23!
@ThinkingCC - can't wait for H&R23!
4/
That pattern, though, is not what we see in this case.
In this case there is perimesencephalic blood, but it’s a very thick amount, and my guess is that if we could scroll up and down, we’d see blood in the cisterns.
this is concerning for aneurysm...
That pattern, though, is not what we see in this case.
In this case there is perimesencephalic blood, but it’s a very thick amount, and my guess is that if we could scroll up and down, we’d see blood in the cisterns.
this is concerning for aneurysm...
5/
But if an aneurysm isn't seen on CTA...what could it be?
But if an aneurysm isn't seen on CTA...what could it be?
6/
Any of these can result in SAH. But,
- AVMs more commonly present as IPH.
- VST can cause SAH but normally the SAH is near the occluded sinus.
- Even DSA-occult aneurysms can be discovered in subsequent angios- so this is important to consider!
pubmed.ncbi.nlm.nih.gov/23277373/
Any of these can result in SAH. But,
- AVMs more commonly present as IPH.
- VST can cause SAH but normally the SAH is near the occluded sinus.
- Even DSA-occult aneurysms can be discovered in subsequent angios- so this is important to consider!
pubmed.ncbi.nlm.nih.gov/23277373/
7/
But in this case the culprit was a dAVF, which was initially detected as an abnormal vessel adjacent to the hemorrhage.
But in this case the culprit was a dAVF, which was initially detected as an abnormal vessel adjacent to the hemorrhage.
8/
I think dural AVFs are some of the most pathophysiologically confusing vascular lesions in neurology.
But no one can explain the pathophys better than the one and only @teachplaygrub in collaboration with @SVINJournal
I think dural AVFs are some of the most pathophysiologically confusing vascular lesions in neurology.
But no one can explain the pathophys better than the one and only @teachplaygrub in collaboration with @SVINJournal
https://twitter.com/teachplaygrub/status/1574745658073878529
9/
So.
Take Aways?
When you see a SAH, 1st evaluate the location!
✨cSAH is rarely due to aneurysm ✨
2nd, consider and eval for other vascular lesions!
So.
Take Aways?
When you see a SAH, 1st evaluate the location!
✨cSAH is rarely due to aneurysm ✨
2nd, consider and eval for other vascular lesions!
10/
For more about the Neuroimaging of CNS lesions, check out this article by Dr. Ryan Hakimi, in this issue of @ContinuumAAN!!
journals.lww.com/continuum/Full…
For more about the Neuroimaging of CNS lesions, check out this article by Dr. Ryan Hakimi, in this issue of @ContinuumAAN!!
journals.lww.com/continuum/Full…
lesions= hemorrhage 😉
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