Teaching NeuroImages: Middle cerebral artery aneurysm rupture presenting as pure acute subdural hematoma

Abstract

A previously well 33-year-old man with no history of trauma or substance abuse presented with poor right eye visual acuity, somnolence, and vomiting several hours after sudden onset of severe, persistent head-ache. Examination revealed only a right relative affer-ent papillary defect and subretinal blood on funduscopy (Terson syndrome, figure 1A). Hunt and Hess grade was 3. CT showed right subdural and subhyaloid hemorrhages (figure 1, B and C). Angiography re-vealed a right middle cerebral artery aneurysm (figure 2). Aneurysm rupture rarely presents as pure acute sub-dural hematoma. Proposed mechanisms involve direct aneurysm rupture into subdural space, from orienta-tion, adherence to dura, or rupture through subarach-noid space by a superficial or high-pressure bleed.1 Terson syndrome refers to intraocular hemor-rhage with aneurysm rupture. Proposed pathophysi-ology includes retinal venous bleeding from stasis secondary to increased intracranial pressure, or from blood forced into the subarachnoid space and then along the optic nerve sheath into the preretinal space under pressure.

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