Republished: Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm

Abstract

Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed during coiling of a posterior communicating artery aneurysm. Multiple small bleeding points from pial branches of the left middle cerebral artery, which were remote from the ruptured aneurysm, were observed on conventional angiography. This bleeding led to the formation of a large expanding subpial Sylvian hematoma. Similar observations have been recently demonstrated on 4D CT angiography (4D CTA). We present a case that adds evidence to the literature in support of a new mechanism of subpial hematoma formation in the setting of acute SAH. This may advocate the early use of 4D CTA and conveys a poor prognosis, which might influence treatment decisions.

Factors associated with rebleeding after coil embolization in patients with aneurysmal subarachnoid hemorrhage

“…In addition, van Donkelaar et al [ 25 ] reported that the amount of blood acted as a surrogate marker of the defect size and stability of the ruptured aneurysm wall, showing a high correlation with the occurrence of rebleeding within 24 hours when the modified Fisher grade was 3 to 4 (aHR 4.7, 95% CI [2.1-0.6]). In addition, Hilditch et al [ 10 ] reported a case of rupture of small pial branches of sylvian middle cerebral artery by expansion of sylvian fissure hematoma after acute post-aSAH, causing remote multifocal bleeding, resulting in the formation of hematoma in the sylvian subpial space. As a result, it was argued that there is a relationship between hematoma amount and remote hemorrhage, as the greater the amount of SAH caused by ruptured aneurysm, the greater the expanding effect of sylvian fissure and the likelihood of the occurrence of remote subpial bleeding will increase.…”