J Neurocrit Care.  2024 Dec;17(2):75-78. 10.18700/jnc.240026.

A ruptured aneurysmal subarachnoid hemorrhage and vasospasm initially manifesting as acute ischemic stroke: a case report

• Park J
• Jeon W
• Choi J
• Kim C

• KMID: 2563025
• DOI: http://doi.org/10.18700/jnc.240026

Abstract

Background
Most aneurysmal subarachnoid hemorrhages (SAHs) are accompanied by focal neurological deficits caused by a thunderclap headache. The neurological symptoms of aneurysmal SAH rarely present as vasospasm-induced cerebral ischemia.
Case Report
A 51-year-old male presented to the emergency department with weakness in the left upper and lower limbs combined with dysarthria, which developed on the day of admission. An initial brain computed tomography scan revealed no clear signs of hemorrhage. However, the patient’s age (51 years) and history of thunderclap headache prompted further evaluation. Finally, the patient was diagnosed with vasospasm-induced ischemic stroke, caused by a ruptured cerebral aneurysm.
Conclusion
For patients with abrupt focal neurological deficits and severe thunderclap headaches, further consideration of aneurysmal rupture and the resulting vasospasm-induced cerebral ischemia may prevent the worst complications of stroke due to misdiagnosis.

Keyword

Cerebral aneurysm; Intracranial vasospasm; Ischemic stroke

Figure

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  Fig. 1. Images taken during additional diagnostic work-up. Brain computed tomography (CT) angiography showing an aneurysm in the left anterior cerebral artery (long white arrows; A, B). Further, bilateral middle cerebral artery (B, C) and posterior cerebral artery narrowing (white arrows) were observed in CT angiography (A). Brain CT image taken 1 day after hospital admission showing a hypodense area corresponding to an infarct in the left Sylvian cortex (arrow, D). Cerebral angiography on day 11 confirmed significant improvement of the vasospasm (E).

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  Fig. 2. Initial diagnostic evaluation in the emergency department. Non-enhanced brain computed tomography image (A) showing an ambiguous sign of hemorrhage (white arrows), with no clear hemorrhage in the basal and interhemispheric cistern (B). Diffusion-weighted imaging showing multiple diffusion restrictive lesion in bilateral middle cerebral artery territories (white arrows) (C).

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