Case ReportEmbolic Stroke: A Rare but Probably Real Cause of Aneurysmal-Like Subarachnoid Hemorrhage
Introduction
Nearly 15% of all cases of spontaneous subarachnoid hemorrhage (SAH) are nonaneurysmal, and in one third of those cases, another vascular, tumoral, or systemic cause is ultimately identified.1 More recently, ischemic stroke has been recognized as a possible cause of spontaneous isolated convexity SAH.2, 3, 4, 5, 6, 7 However, it remains a much less established cause of cisternal SAH and is seldom considered in the differential diagnosis of intracranial aneurysm rupture. Only 3 previous case reports of concomitant cisternal SAH and perforator infarcts exist in the literature, which have been postulated to result from rupture of small perforating arteries.8, 9 In contrast, embolic stroke is not a recognized cause of aneurysmal-like SAH. We report 2 unique cases of embolic cerebral infarction mimicking intracranial aneurysm rupture.
Section snippets
Patient 1
A 64-year-old woman, who was hypertensive and a heavy smoker, presented with sudden onset of the worst headache of her life but no other accompanying neurologic symptoms. The neurologic examination was unremarkable. Head computed tomography (CT) revealed diffuse and symmetric cisternal SAH (Figure 1A). She was classified as World Federation of Neurosurgical Societies grade 1 and Fisher grade 3. CT angiography of the head was unremarkable. CT angiography of the neck demonstrated high-grade
Discussion
In 85% of cases, spontaneous SAH results from rupture of an intracranial aneurysm. Another 5% are caused by less common entities, including cerebrovascular malformations, intracranial dissections, cerebral venous thrombosis, moyamoya disease, cerebral vasculitides, amyloid angiopathy, tumors, vascular lesions in the spinal cord, coagulopathy, and central nervous system stimulant (e.g., cocaine, amphetamines) abuse. Finally, despite a complete work-up, the cause of approximately 10% of SAH cases
Conclusions
Embolic stroke is a rare cause of cisternal SAH and should be included in the differential diagnosis of angiogram-negative SAH, particularly in older patients, patients with multiple cardiovascular risk factors, and patients with known atherosclerotic disease. In this setting, brain MRI and vascular imaging of the neck can provide invaluable information and should thus be incorporated in the routine work-up of patients with angiogram-negative SAH. Specifically, our findings suggest that the
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.