Korean J Leg Med.  2018 Feb;42(1):22-25. 10.7580/kjlm.2018.42.1.22.

Subarachnoid Hemorrhage with Subdural Hematoma due to Ruptured De Novo Aneurysm after Aneurysmal Clipping via Pterional Approach: An Autopsy Case

• Choi J
• Kim JY
• Jang H
• Ko K
• Park SH

• KMID: 2406018
• DOI: http://doi.org/10.7580/kjlm.2018.42.1.22

Abstract

Subdural hematoma (SDH) due to spontaneous rupture of intracranial aneurysm rarely occurs. The prevalence of subarachnoid hemorrhage (SAH) with SDH is approximately 0.5%-10.3% of all aneurysmal SAH. We report a case of aneurysmal rupture with SDH and SAH due to arachnoid defect after aneurysm clipping. The decedent was a 51-year-old woman who underwent brain surgery for SAH a few years ago. Two days before she died, she had nausea and sentinel headache. She was alive in the morning and was found dead at 6 PM. Injuries in the external surface were not found. A fresh SDH, measured approximately 90 mL, was found in the right hemisphere. SAH was diffusely distributed at the base of the brain and the right sylvian fissure. Two aneurysmal clippings were found in the anterior communicating artery and right internal carotid artery. A ruptured de novo aneurysm was also found in the right proximal middle cerebral artery. An uncal herniation was also observed. The cause of death was SAH with SDH due to de novo intracranial aneurysm. The tearing caused by the adhesion between the aneurysm and arachnoid, high blood pressure, and massive bleeding has been thought to be the causative mechanism of aneurysmal SAH with SDH. However, in this case, the arachnoid defect was caused by aneurysmal clipping through pterional approach. This defect served as the passage between the subarachnoid and subdural spaces. The autopsy for recurrent intracranial aneurysm will increase according to the extending life expectancy of patients after aneurysmal clipping.

Keyword

Subarachnoid hemorrhage; Subdural hematoma; Intracranial aneurysm; Autopsy

MeSH Terms

Aneurysm*
Arachnoid
Arteries
Autopsy*
Brain
Carotid Artery, Internal
Cause of Death
Female
Headache
Hematoma, Subdural*
Hemorrhage
Humans
Hypertension
Intracranial Aneurysm
Life Expectancy
Middle Aged
Middle Cerebral Artery
Nausea
Prevalence
Rupture
Rupture, Spontaneous
Subarachnoid Hemorrhage*
Subdural Space
Tears

Figure

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  Fig. 1. The scar of craniotomy via pterional approach in the right frontotemporal bone.

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  Fig. 2. The diffuse subdural hemorrhage in the right hemisphere measured approximately 100 mL.

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  Fig. 3. The subarachnoid hemorrhage centered in the right sylvian fissure after removing the subdural hematoma.

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  Fig. 4. Two aneurysmal clips. (A) The diffuse subarachnoid hemorrhage on the right side at the base of the brain and an aneurysmal clip (arrow) in the anterior communicating artery. (B) Another aneurysmal clip (arrow) in the right carotid artery.

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  Fig. 5. De novo aneurysm. (A) The de novo aneurysm (arrow) at the right proximal middle cerebral artery and an aneurysmal clip (arrowhead) in the anterior communicating artery. (B) The de novo aneurysm measured approximately 1 cm (the ruler units: inches).

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  Fig. 6. An uncal herniation with intracerebral hemorrhage at the right side.

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