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Emergency Radiology

, Volume 26, Issue 5, pp 567–571 | Cite as

Non-traumatic subdural hemorrhage: beware of ruptured intracranial aneurysm

  • Michael Travis CatonJrEmail author
  • Walter F. Wiggins
  • Diego Nuñez
Pictorial Essay
  • 111 Downloads

Abstract

Acute subdural hemorrhage (SDH) is commonly encountered by emergency radiologists in the setting of trauma. When history or imaging evidence of trauma is absent, the differential diagnosis for SDH should be expanded. Intracranial aneurysm rupture is a rare and underrecognized cause of SDH which may present without concurrent subarachnoid hemorrhage. The mechanism of aneurysmal SDH is controversial, but understanding the anatomic microenvironment of the aneurysm provides insight and clarifies aneurysm features predisposing to subdural compartment rupture. Aneurysmal SDH is a neurosurgical emergency and its treatment strategies differ from traumatic SDH. Outcomes are poor if treatment is delayed; thus, radiologists play a central role in recognizing this uncommon but potentially devastating complication of aneurysm rupture. The goal of this article is to familiarize radiologists with clinical and imaging characteristics of aneurysmal SDH and review pertinent anatomy, risk factors, and potential etiologies. Aneurysmal rupture can easily be overlooked in the routine workup of atraumatic SDH, and radiologists must know when to recommend vascular imaging to avoid the catastrophic consequences of a missed diagnosis.

Keywords

Subdural hemorrhage Intracranial aneurysm Perianeurysmal environment Aneurysm rupture Neuroimaging 

Notes

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Kulwin C, Bohnstedt BN, Payner TD, Leipzig TJ, Scott JA, DeNardo AJ, Cohen-Gadol AA (2014) Aneurysmal acute subdural hemorrhage: prognostic factors associated with treatment. J Clin Neurosci 21:1333–1336.  https://doi.org/10.1016/j.jocn.2013.12.010 CrossRefGoogle Scholar
  2. 2.
    Inamasu J, Saito R, Nakamura Y, Ichikizaki K, Suga S, Kawase T, Hori S, Aikawa N (2002) Acute subdural hematoma caused by ruptured cerebral aneurysms: diagnostic and therapeutic pitfalls. Resuscitation 52:71–76.  https://doi.org/10.1016/S0300-9572(01)00433-6 CrossRefGoogle Scholar
  3. 3.
    Handel S, Perpetuo F, Handel C (1978) Subdural hematomas due to ruptured cerebral aneurysms: angiographic diagnosis and potential pitfall for CT. Am J Roentgenol 130:507–509.  https://doi.org/10.2214/ajr.130.3.507 CrossRefGoogle Scholar
  4. 4.
    Gilad R, Fatterpekar GM, Johnson DM, Patel AB (2007) Migrating subdural hematoma without subarachnoid hemorrhage in the case of a patient with a ruptured aneurysm in the intrasellar anterior communicating artery. Am J Neuroradiol 28:2014–2016.  https://doi.org/10.3174/ajnr.A0726 CrossRefGoogle Scholar
  5. 5.
    Hackenberg KAM, Hänggi D, Etminan N (2018) Unruptured intracranial aneurysms. Stroke 49:2268–2275.  https://doi.org/10.1161/STROKEAHA.118.021030 CrossRefGoogle Scholar
  6. 6.
    Biesbroek JM, Rinkel GJE, Algra A, van der Sprenkel JWB (2012) Risk factors for acute subdural hematoma from intracranial aneurysm rupture. Neurosurgery 71:264–269.  https://doi.org/10.1227/NEU.0b013e318256c27d CrossRefGoogle Scholar
  7. 7.
    Schuss P, Konczalla J, Platz J, Vatter H, Seifert V, Güresir E (2013) Aneurysm-related subarachnoid hemorrhage and acute subdural hematoma: single-center series and systematic review. J Neurosurg 118:984–990.  https://doi.org/10.3171/2012.11.JNS121435 CrossRefGoogle Scholar
  8. 8.
    Vlak MH, Algra A, Brandenburg R, Rinkel GJ (2011) Prevalence of unruptured intracranial aneurysms, with emphasis on sex, age, comorbidity, country, and time period: a systematic review and meta-analysis. Lancet Neurol 10:626–636.  https://doi.org/10.1016/S1474-4422(11)70109-0 CrossRefGoogle Scholar
  9. 9.
    Park SM, Han YM, Park YS et al Acute aneurysmal subdural hematoma: clinical and radiological characteristics. J Korean Neurosurg Soc 37:329–335Google Scholar
  10. 10.
    Marbacher S, Tomasi O, Fandino J (2012) Management of patients presenting with acute subdural hematoma due to ruptured intracranial aneurysm. J Vasc Med. https://www.hindawi.com/journals/ijvm/2012/753596/abs/. Accessed 30 Nov 2018
  11. 11.
    Kondziolka D, Bernstein M, ter Brugge K, Schutz H (1988) Acute subdural hematoma from ruptured posterior communicating artery aneurysm. Neurosurgery 22:151–154.  https://doi.org/10.1227/00006123-198801000-00029 CrossRefGoogle Scholar
  12. 12.
    Kleinloog R, de Mul N, Verweij BH et al (2018) Risk factors for intracranial aneurysm rupture: a systematic review. Neurosurgery 82:431–440.  https://doi.org/10.1093/neuros/nyx238 Google Scholar
  13. 13.
    Cebral JR, Sheridan M, Putman CM (2010) Hemodynamics and bleb formation in intracranial aneurysms. Am J Neuroradiol 31:304–310.  https://doi.org/10.3174/ajnr.A1819 CrossRefGoogle Scholar
  14. 14.
    Thiarawat P, Jahromi BR, Kozyrev DA et al (2018) Are fetal-type posterior cerebral arteries associated with an increased risk of posterior communicating artery aneurysms? Neurosurgery.  https://doi.org/10.1093/neuros/nyy186
  15. 15.
    Otani N, Takasato Y, Masaoka H, Hayakawa T, Yoshino Y, Yatsushige H, Miyawaki H, Sumiyoshi K, Sugawara T, Chikashi A, Takeuchi S, Suzuki G (2011) Clinical characteristics and surgical outcomes of patients with aneurysmal subarachnoid hemorrhage and acute subdural hematoma undergoing decompressive craniectomy. World Neurosurg 75:73–77.  https://doi.org/10.1016/j.wneu.2010.10.021 CrossRefGoogle Scholar
  16. 16.
    Satoh T, Omi M, Ohsako C et al (2005) Influence of perianeurysmal environment on the deformation and bleb formation of the unruptured cerebral aneurysm: assessment with fusion imaging of 3D MR cisternography and 3D MR angiography. Am J Neuroradiol 26:2010–2018Google Scholar
  17. 17.
    Ruíz DSM, Yilmaz H, Dehdashti AR et al (2006) The perianeurysmal environment: influence on saccular aneurysm shape and rupture. Am J Neuroradiol 27:504–512Google Scholar
  18. 18.
    González-Darder JM, Quilis-Quesada V, Talamantes-Escribá F, Botella-Maciá L, Verdú-López F (2012) Microsurgical relations between internal carotid artery–posterior communicating artery (ICA-PComA) segment aneurysms and skull base: an anatomoclinical study. J Neurol Surg B 73:337–341.  https://doi.org/10.1055/s-0032-1322795 Google Scholar
  19. 19.
    Eid M, De Cecco CN, Nance JW et al (2017) Cinematic rendering in CT: a novel, lifelike 3D visualization technique. Am J Roentgenol 209:370–379.  https://doi.org/10.2214/AJR.17.17850 CrossRefGoogle Scholar
  20. 20.
    Feng Z, Tan Q, Li L, Chen Z (2016) Subdural hematoma caused by rupture of a posterior cerebral artery aneurysm. Neurosciences (Riyadh) 21:161–163.  https://doi.org/10.17712/nsj.2016.2.20150332 CrossRefGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2019

Authors and Affiliations

  1. 1.Department of RadiologyBrigham and Women’s HospitalBostonUSA

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