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Case 288


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A 65-year-old female patient was referred by the Emergency Care Unit due to sudden headache in fron-tal and occipital areas initiated in the last 24 hours, associated with vomiting and loss of consciousness. Presented hypertensive spikes during hospitalization as well as photophobia, nuchal rigidity and pain on cervical mobilization. She is a former smoker (60 pack-years, interrupted use for 9 years), with a social drinking habit and hypertension (losartan suspended for 3 years by medical guidance). Computed tomo-graphy (CT) of the brain was performed during the first care - attached.

Given the clinical case and the images provided, what is the diagnosis and the preferred exam for the im-mediate decision in the clinical conduction of this patient?

a) Chronic subdural hematoma - Computed tomography (CT)


b) Hypertensive intracerebral haemorrhages - Magnetic resonance imaging (MRI)


c) Acute subarachnoid hemorrhage - Cerebral CT angiography


d) Reversible cerebral vasoconstriction syndrome - Conventional angiograpy


Image analysis

Image 1 - a and b:Computed tomography (CT) of the brain, without intravenous injection of contrast medium evidencing acute

subarachnoid hemorrhage, characterized by spontaneously hyperdense  cortical grooves and lateral fissures, especially in the left insular and opercular regions (white arrows) associated with left hemoventricle (red arrow) . Absence of intraparenchymal hemorrhage.


Image 2 - a and b:Computed tomography (CT) of the brain, without intravenous injection of contrast medium evidencing acute subarachnoid hemorrhage, characterized by spontaneously hyperdense basal cisterns (white arrows), with presence of blood also in the IV ventricle (red arrow). 


Image 3: Angio-CT of the patient's brain (three-dimensional reconstructions): saccular aneurysm dilatation in the supraclinoid portion of the left internal carotid artery, in posterolateral position (arrows), measuring about 5.0 x 4.5 mm; aneurysm neck with approximately 2.5 mm in diameter.


- The main cause of acute subarachnoid hemorrhage (ASH) is aneurysm rupture, except in traumatic brain injury;

- Symptoms of HSA: sudden severe headache, associated or not with loss of consciousness, seizures, nausea and meningism;

- CT scan (without intravenous contrast) diagnoses more than 90% of the cases in the 24 hours;

- CT angiography is a non-invasive method, useful for screening and pre-surgical planning especially of those patients with rapid neurological decline;

- Complications of HSA: rebleeding, vasospasm, delayed cerebral ischemia, hydrocephalus, increased intracranial pressure and seizures;

- The treatment of HSA consists of: clinical support, treatment of neurological complications and ruptured aneurysm.


- Rocha, Antônio. Encéfalo. 1ª Edição. Rio de Janeiro: Editora Elsevier, 2012. (Colégio Brasileiro de Radiologia e Diagnóstico por Imagem).

- Martins, Herlon Saraiva. Medicina de emergência: abordagem prática. 12 ed. Manole, 2017.

- Robert J Singer, MD, Christopher S Ogilvy, MD, Guy Rordorf, MD. Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage - Up To Date  Acess in July 2017. Available at:

- Todd J Schwedt, MD, MSCIDavid W Dodick, MD. Approach to the patient with thunderclap headache - Up To Date Access in July 2017. Available at: 


Laio Bastos de Paiva Raspante, 6th year medical student of the Federal University of Minas Gerais.

E-mail: laioopaiva[at]

Fábio Satake, Médico - Doctor graduated from the Faculty of Medicine of the Federal University of Minas Gerais.

E-mail: fabiosatake[at]


José Nelson Mendes Vieira, Professor of the Anatomy and Medical Imaging Department of the Medical School of Federal Unversity of Minas Gerais. 

E-mail: zenelson.vieira[at]


Lucas Bruno Rezende, Wellerson Mayrink, André Naback, Bruno Campos e Profa. Viviane Parisotto

Translated by

Lucas Raso

Test question

(HSJJ - São José de Joinville Hospital / 2011) MRC, a female student, is attended at the emergency room of the hospital with a report of sudden severe headache, followed by ptosis, mydriasis, non-photorreative and divergent strabismus on the right. The cranial CT scan revealed subarachnoid hemorrhage in cisterns at the base of the skull. The most likely diagnosis and the conduct to be taken by the attending physician should be:

a) cerebral infarction: watchful waiting


b) cerebral contusion: indication of craniotomy


c) cerebral aneurysm: arteriography of cerebral vessels


d) intracerebral hematoma: indication of craniotomy


e) subdural hematoma: drainage using a trephine craniotomy



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