PMC6302554_01
(a) Axial CT scan showing the Fisher Grade 3 aneurysmal subarachnoid hemorrhage. (b) Axial CT showing a left subdural hematoma with 3.94 mm of midline shift
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F1
A 72-year-old female presented with a Fisher Grade 3 and World Federation of Neurological Societies Grade V aneurysmal subarachnoid hemorrhage (SAH) and an acute left traumatic subdural hematoma (SDH) post fall [Figure 1a and b].
(a) Angiography (anteroposterior view) confirms the presence of a 5.5 x 3.4 x 3.7 mm superiorly projecting aneurysm arising from the supraclinoid internal carotid artery (ICA) with a 2.5 mm neck. (b) Angiography showing good occlusion of the fundus but some residual neck filling of the right ICA
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F2
Cerebral angiography showed a superiorly projecting 5.5x3.4x3.7 mm3 aneurysm arising from the supraclinoid internal carotid artery (ICA) [Figure 2a]. She underwent balloon assisted coiling of the right paraophthalmic aneurysm using microvention coils one day after the SAH [Figure 2b].
(a and b) Angiography showing severe vasospasm of the right (3a), left A1s and its distal branches
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F3
Angiography one week post coiling showed severe vasospasm of the bilateral A1s and its distal branches [Figure 3a and b].
(a) T1-weighted (T1W) axial MRI with gad shows multiple ring-enhancing abscesses in the right frontal, parietal, and occipital lobes with surrounding edema. (b) Corresponding T2-weighted (T2W) axial image showed multiple hyperintense centers and hypointense irregular rims. (c) The abscesses appear isointense with areas of hypointensity on apparent diffusion coefficient (ADC) map suggestive of restricted diffusion. One month after the commencement of antimicrobial therapy, MRI demonstrated resolution in many of the enhancing foci with significant decrease in the size of the surrounding vasogenic edema (e-f)
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F4
Magnetic resonance imaging (MRI) showed significant enhancement around the coil mass and multiple ring-enhancing lesions in the right frontal, parietal, and occipital lobes with surrounding edema [Figure 4a-c]. One month after the commencement of antimicrobial therapy, MRI brain demonstrated resolution of many of the enhancing foci with significant decrease in the size of the surrounding vasogenic edema [Figure 4d-f] despite corticosteroids being ceased two weeks prior.