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Age: 77

Sex: Female

Indication: Severe headache

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Case #1


Findings

  • Large volume acute intraventricular hemorrhage with global ventricular enlargement, particularly of the fourth ventricle. Blood products extend through the foramina of Luschka into the basal cisterns as well as to a lesser extent into the sylvian fissures, anterior interhemispheric fissure, and several bilateral cerebral convexity sulci. Blood products also extend into the upper cervical spine subarachnoid space
  • Mild diffuse sulcal effacement without evidence of large vascular territory ischemia or herniation
  • Partially imaged endotracheal and orogastric tubes


Diagnosis

  • Ruptured left PICA aneurysm

Sample Report

Large volume of acute intraventricular hemorrhage with global ventricular enlargement, particularly of the fourth ventricle. Blood products extend through the foramina of Luschka into the basal cisterns as well as to a lesser extent into the sylvian fissures, anterior interhemispheric fissure, and several bilateral cerebral convexity sulci. Blood products also extend into the upper cervical spine subarachnoid space.  Findings raise concern for a ruptured aneurysm, possibly in the region of the fourth ventricle. Recommend CTA for further evaluation.

Mild diffuse sulcal effacement without evidence of large vascular territory ischemia or herniation.


Discussion

  • Posterior inferior cerebellar artery (PICA)
    • One of the three vessels that provide arterial supply to the cerebellum.
    • Its origin is highly variable:
      • ~20% arise from the vertebral artery just before the basilar and inferior to the foramen magnum
      • 10% arise from the basilar rather than vertebral artery
    • Occasionally a small vertebral artery will terminate in a common PICA/AICA trunk
  • Ruptured PICA aneurysms result in intraventricular hemorrhage and hydrocephalus much more commonly than they result in isolated subarachnoid hemorrhage
  • Complications of SAH
    • Hydrocephalus
    • Vasospasm (typically occurs 4-15 days after … look for this on follow up studies and compare to priors)
    • Cerebral edema
    • Herniation


Images

Blue arrow: ruptured left PICA aneurysm on the subsequent angiogram. Blue arrow: left PICA aneurysm. PICA aneurysm.

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