We present the case of a 23-year-old man who suddenly collapsed during a physical altercation with his friends while in a drunken state. The post-mortem computed tomography (CT) with angiography revealed acute basal subarachnoid hemorrhage with rupture of the left middle cerebral artery. On autopsy, the head, face, mandible and neck showed multifocal hemorrhages with fracture of the hyoid bone, and the pathologic findings of the brain was consistent with CT findings. However, the vascular rupture site was not observed macroscopically. On histologic examination, a microscopic focal rupture was identified at the proximal portion of the middle cerebral artery, and possibility of arteriopathy was considered. This case illustrates that other parts of intracerebral arteries (other than the vertebral arteries) can be the culprit of rupture in the case of traumatic basal subarachnoid hemorrhage, and the post-mortem angiographic findings can be helpful in targeting the site of vascular injury. Furthermore, meticulous sampling of intracranial vessels could help find the vascular rupture site and identify any histologic findings suspicious of arteriopathy. Therefore, we suggest that post-mortem angiography can be an effective and adjunctive tool for a tailored approach in finding the vascular injury, and that histologic examination of both the intracranial and extracranial arteries be important to medicolegally ensure the death of traumatic basal subarachnoid hemorrhage and to examine presence of arteriopathy as a predisposing factor.
Angiography ; Arteries ; Autopsy ; Brain ; Causality ; Forensic Pathology ; Friends ; Head ; Hemorrhage ; Humans ; Hyoid Bone ; Mandible ; Middle Cerebral Artery ; Neck ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic ; Vascular System Injuries ; Young Adult

An intracranial saccular aneurysm is uncommonly diagnosed in a patient with closed head trauma. We herein present a patient with delayed rebleeding of a cerebral aneurysm misdiagnosed as traumatic subarachnoid hemorrhage (SAH). A 26-year-old female visited our emergency department because of headache after a motorcycle accident. Brain computed tomography (CT) showed a right-side dominant SAH in Sylvian fissure. Although traumatic SAH was strongly suggested because of the history of head trauma, we performed a CT angiogram to exclude any vascular abnormalities. The CT angiogram showed no vascular abnormality. She was discharged after conservative treatment. One day after discharge, she returned to the emergency department because of mental deterioration. Brain CT showed diffuse SAH, which was dominant in the right Sylvian fissure. The CT angiogram revealed a right middle cerebral artery bifurcation aneurysm. During operation, a non-traumatic true saccular aneurysm was found. The patient recovered fully after successful clipping of the aneurysm and was discharged without neurologic deficit. Normal findings on a CT angiogram do not always exclude aneurysmal SAH. Follow-up vascular study should be considered in trauma patients who are highly suspicious of aneurysmal rupture.
Adult ; Aneurysm ; Brain ; Craniocerebral Trauma ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Head Injuries, Closed ; Headache ; Humans ; Intracranial Aneurysm* ; Middle Cerebral Artery ; Motorcycles ; Neurologic Manifestations ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic*

Terson syndrome is a vitreous hemorrhage associated with subarachnoid hemorrhage. This can be caused by spontaneous, aneurysmal rupture or traumatic subarachnoid hemorrhage, but never has been reported as a consequence of hemorrhage due to thrombolysis and thrombectomy treatments of acute ischemic stroke patient. A 48-year-old man presented with left sided weakness was diagnosed as cerebral infarction on right middle cerebral artery territory due to complete occlusion of right distal internal carotid, middle cerebral, and anterior cerebral artery. He underwent thrombolysis and mechanical thrombectomy, and subarachnoid hemorrhage developed. Later, visual disturbance on right eye occurred so he was consulted to ophthalmology. Vitreous hemorrhage was found and surgery was recommended after two weeks of observation. After pars planar vitrectomy, visual acuity improved, along with functional ability. Therefore, possibilities of Terson syndrome in patients with subarachnoid hemorrhage have to be kept in mind to improve not only visual acuity but also rehabilitation outcome.
Aneurysm ; Anterior Cerebral Artery ; Cerebral Infarction ; Hemorrhage ; Humans ; Middle Aged ; Middle Cerebral Artery ; Ophthalmology ; Rupture ; Stroke* ; Subarachnoid Hemorrhage* ; Subarachnoid Hemorrhage, Traumatic ; Thrombectomy* ; Treatment Outcome ; Visual Acuity ; Vitrectomy ; Vitreous Hemorrhage

PURPOSE: Rupture of pre-existing cerebral aneurysms has occasionally been reported as a cause of traumatic subarachnoid hemorrhage (TSAH) and intraparenchymal hemorrhage (IPH). SAH due to rupture of pre-existing cerebral aneurysm is an important differential diagnosis in TSAH. The aim of our study was to determine whether a rupture in a pre-existing cerebral aneurysm could be predicted based on the pattern of hemorrhage on the initial computed tomography (CT) scan in patients with traumatic brain injury (TBI). METHODS: A total of 336 patients who had undergone computed tomography angiography (CTA) for detection of rupture of pre-existing cerebral aneurysm in TBI between the years 2004 and 2013 were retrospectively studied. In order to investigate CT findings of ruptured cerebral aneurysm, patients who had a lesion of SAH, IPH, or IVH were compared with the control group (who had intracranial lesions of contusion, epidural hematoma, subdural hematoma, or hemorrhagic contusion). RESULTS: Fifty eight (17.3%) patients with TSAH harbored cerebral aneurysms, and 45 (13.4%) patients had ruptured cerebral aneurysms. The ruptured aneurysms showed significant association with CT findings of a diffuse hemorrhage in the basal cisterns (29.2%, p=0.003, OR=23.130), unilateral sylvian fissure (13.8%, p=0.039, OR=8.842), anterior interhemispheric fissure (20.0%, p=0.028, OR=14.000), and associated IPH (22.6%, p=0.011, OR=16.333). However, the ruptured aneurysms did not show association with CT findings of hemorrhage on convexities, perimesencephalic cisterns, bilateral sylvian fissure, and IVH (p>0.1). CONCLUSION: Patterns of distribution of SAH and associated IPH on initial CT can be predicted of rupture pre-existing cerebral aneurysm in patients with TBI.
Aneurysm, Ruptured ; Angiography ; Brain Injuries* ; Contusions ; Diagnosis, Differential ; Hematoma ; Hematoma, Subdural ; Hemorrhage ; Humans ; Intracranial Aneurysm* ; Retrospective Studies ; Rupture* ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic

Isolated traumatic pseudoaneurysms of the basilar artery are extremely rare but often fatal resulting in a mortality rate as high as 50%. A 51-year-old man presented with craniofacial injury after blunt trauma. A brain computed tomography (CT) scan showed thick basal subarachnoid hemorrhage associated with multiple craniofacial fractures, while CT angiography revealed contrast extravasation at the distal basilar artery with pseudoaneurysm formation. After this primary survey, the condition of the patient suddenly deteriorated. Conventional angiography confirmed the contrast extravasation resulted from pseudoaneurysm formation, which was successfully treated with endovascular coil embolization. Decompressive craniectomy and coma therapy with propofol were also performed. However, the patient died on the 7th hospital day because of the poor initial clinical condition. The current case is the first report of acute pseudoaneurysm rupture arising from the basilar artery within the first day after trauma. Our findings suggest the possibility that pseudoaneurysm rupture should be considered if brain CT shows thick traumatic subarachnoid hemorrhage on the basal cistern with a basal skull fracture.
Aneurysm, False* ; Angiography ; Basilar Artery* ; Brain ; Brain Injuries ; Coma ; Decompressive Craniectomy ; Embolization, Therapeutic ; Humans ; Middle Aged ; Mortality ; Propofol ; Rupture ; Skull Fractures ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic*

We present a case of angiographically confirmed transection of the cisternal segment of the anterior choroidal artery (AChA) associated with a severe head trauma in a 15-year old boy. The initial brain computed tomography scan revealed a diffuse subarachnoid hemorrhage (SAH) and pneumocephalus with multiple skull fractures. Subsequent cerebral angiography clearly demonstrated a complete transection of the AChA at its origin with a massive extravasation of contrast medium as a jet trajectory creating a plume. We speculate that severe blunt traumatic force stretched and tore the left AChA between the internal carotid artery and the optic tract. In a simulation of the patient's brain using a fresh-frozen male cadaver, the AChA is shown to be vulnerable to stretching injury as the ipsilateral optic tract is retracted. We conclude that the arterial injury like an AChA rupture should be considered in the differential diagnosis of severe traumatic SAH.
Angiography ; Arteries* ; Brain ; Cadaver ; Carotid Artery, Internal ; Cerebral Angiography ; Choroid* ; Craniocerebral Trauma ; Diagnosis, Differential ; Humans ; Male ; Pneumocephalus ; Rupture ; Skull Fractures ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic* ; Visual Pathways

Subarachnoid hemorrhage (SAH) can be classified as traumatic SAH or spontaneous SAH based on etiology. The traumatic SAH is the common manifestation of head injury and difficult to make a diagnosis in forensic investigation. Based on practical experiences of forensic investigation and relevant references, the main points (SAH identification, examination, death mechanism) were summarized in this article. For the understanding, we try to classify the traumatic SAH into three subtypes: brain injury associated SAH, traumatic rupture of basal cerebral vessels SAH and traumatic focal SAH.
Aneurysm, Ruptured/complications* ; Cause of Death ; Craniocerebral Trauma/complications* ; Diagnosis, Differential ; Forensic Pathology ; Hematoma, Epidural, Cranial/complications* ; Humans ; Intracranial Aneurysm/complications* ; Intracranial Arteriovenous Malformations/complications* ; Rupture/complications* ; Subarachnoid Hemorrhage/pathology* ; Subarachnoid Hemorrhage, Traumatic/pathology*

Traumatic subarachnoid hemorrhage (tSAH) can be almost immediately fatal. However, sudden death due to tSAH caused by delayed aneurysmal rupture is very rare sequela of mild head trauma. We experienced a death case of a 47-year-old woman who had subarachnoid hemorrhage and intraventricular hemorrhage 3 days after head trauma. Delayed death after any kinds of trauma is important to forensic and legal aspects. Herein we report a case of fatal subarachnoid hemorrhage caused by delayed rupture of traumatic aneurysm.
Aneurysm ; Craniocerebral Trauma ; Death, Sudden ; Female ; Head ; Hemorrhage ; Humans ; Jurisprudence ; Middle Aged ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic

PURPOSE: Rupture of pre-existing cerebral aneurysms has been reported as a cause of traumatic subarachnoid hemorrhage (TSAH). SAH due to rupture of pre-existing cerebral aneurysm is an important differential diagnosis in TSAH. Our study was aimed to assess whether a rupture in a pre-existing cerebral aneurysm could be predicted on the basis of the quantity and distribution pattern of hemorrhage on the initial computed tomography (CT). METHODS: 197 patients with TSAH were retrospectively studied between the years 2003 and 2008. We examined the age and sex of patients, mechanisms of injury, consciousness level at admission, and CT parameters including the distribution and quantity of SAH, localized blood clot, intraventricular hemorrhage, or hemorrhagic contusion and extra-axial hematoma. We compared the patients with nonaneurysmal TSAH to the patients with aneurysmal TSAH. RESULTS: 22(11.2%) patients with TSAH harbored pre-existing cerebral saccular aneurysms. The aneurysms were found in the patients with diffuse or anteriorly located blood in the basal cisterns(40.6%), unilateral sylvian fissure (16.7%), and anterior interhemispheric fissure(18.2%). But the aneurysm was not found in all patients with perimesencephalic hemorrhage, bilateral sylvian fissures, and convexities. TSAH with localized clot in the anterior interhemispheric or sylvian fissure (OR=5.924, p=0.005), or SAH completely filling any cistern or fissure (OR=3.148, p=0.034) was significantly associated with rupture of pre-existing cerebral aneurysm in logistic regression analysis. CONCLUSION: SAH in the basal cisterns extended into bilateral sylvian fissures and anterior interhemispheric fissure, and SAH in the unilteral sylvian fissure on initial CT could be predicted rupture of pre-existing cerebral aneurysm.
Aneurysm ; Consciousness ; Contusions ; Craniocerebral Trauma ; Diagnosis, Differential ; Head ; Hematoma ; Hemorrhage ; Humans ; Intracranial Aneurysm ; Logistic Models ; Retrospective Studies ; Rupture ; Subarachnoid Hemorrhage ; Subarachnoid Hemorrhage, Traumatic ; Tomography, X-Ray Computed

Traumatic subarachnoid hemorrhage (T-SAH) is said to be typically occurred in a young, healthy, but intoxicated man who receives a minor blow, immediately collapses, and dies within minutes. Sixteen forensic cases of T-SAH were analysed in the point of time of collapse, blood alcohol level, injured site, vascular rupture sites, and sentenced servitude. Majority of the cases (12 cases) were autopsied in the department of Kyungpook National University. Two cases of National Institute of Scientific Investigation, South District Office and 1 case of Jeju National University were added. Autopsy was not done in one case. There were 14 male and 2 female victims. The peak age were their forties (7 cases) and under twenties (7 cases). The time of incident was most often at night. The survival time from the time of trauma until death indicates that 62.5% (10 victims) died immediately from the assault, 12.5% (2 victims) died within 30 minutes. Blood alcohol was detected in 11 cases (68.8%), and mean blood alcohol level was 0.16% (0.08-0.22%). The damage was generated to the facial region, especially around the jaw and below the ears (7 cases), and temporal areas (4 cases). Bleeding foci were detected in 7 cases; basilar artery (2 cases), left vertebral artery (2 cases), and right vertebral artery (3 cases). Meticulous autopsy techniques for identifying the vascular rupture sites are required. The author conclude that tremendous emphasis must be placed on the fact that fatal T-SAH can occur due to minor facial trauma and social campaign for alerting people to the danger of T-SAH is needed.
Autopsy ; Basilar Artery ; Death, Sudden ; Ear ; Female ; Gyeongsangbuk-do ; Hemorrhage ; Humans ; Jaw ; Male ; Rupture ; Subarachnoid Hemorrhage, Traumatic* ; Vertebral Artery