62-year-old female.
* Sudden collapse
* Headache
* Paresis of mouth left-sided
* Pupil difference L>R
What is the most likely diagnosis? What should be the next diagnostic step?
Diagnosis: PCOM aneurysm subarachnoid bleed (with subdural hematoma, intraventricular bleed, midline shift, hydrocephalus)
Next step:CTA (you already see aneurysm on NECT)
NECT, reveals:
1- Smearing of cortical sulci bilaterally (more on right side) and CSF cisterns, consisting with subarachnoid hemorrhage.
2- Right Extra axial Cresenteric shaped subdural hematoma overlying right frontal and parietal lobes of maximal thickness of about…. It exerts mass effect added to SAH in form of compression of ipsilateral ventricle and mediastinal shift to the left.
3- ?? Intra-ventricular hemorrhage at right temporal horn and body of lateral ventricle.
The findings and sudden onset raising the possibility of ruptured cerebral aneurysm (ACOA). CTA is mandatory.
Signs of SAH
Mostly by aneurysm near the right cavernous sinus
CT angiography is next step