An unusual case of haemorrhagic strokeBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b3204 (Published 26 August 2009) Cite this as: BMJ 2009;339:b3204
- Hani Marcus, speciality trainee in neurosurgery,
- Ibrahim Jalloh, speciality trainee in neurosurgery,
- Rhys Roberts, specialist registrar in neurology,
- Peter Martin, consultant in neurology
- 1Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 2QQ
- Correspondence to: H Marcus
A 50 year old right handed woman presented to the emergency department with her first generalised tonic clonic seizure, followed by a severe unremitting headache and neck stiffness. The seizure was preceded by a three week history of pain around the left ear and nausea, which her general practitioner had diagnosed as otitis media and had treated with a course of amoxicillin. She had no history of trauma and her medical history was otherwise unremarkable.
On examination the patient had a low grade fever but her pulse rate, blood pressure, respiratory rate, and oxygen saturation on air were all normal. She had also developed a global dysphasia and a right sided homonymous hemianopia. The patient’s head computed tomogram⇓ and digital subtraction angiogram⇓ are shown in the two images.
1 What key signs are present on the head computed tomogram?
2 What are the most common causes of these signs in the absence of trauma?
3 What underlying cause is shown on the digital subtraction angiogram?
4 How should the underlying cause be treated?
1 The head computed tomogram shows a subarachnoid haemorrhage in the left sylvian fissure and overlying convexity.
2 The most common causes of non-traumatic subarachnoid haemorrhage are ruptured intracranial aneurysms and arteriovenous malformations.
3 A filling defect throughout the left transverse and sigmoid sinuses can be seen on the digital subtraction angiogram, which is suggestive of venous sinus thrombosis.
4 The treatment for venous sinus thrombosis is anticoagulation with heparin and subsequently warfarin.
1 Diagnosis of subarachnoid haemorrhage
Unenhanced computed tomography of the brain is the investigation of choice for the assessment of acute haemorrhage and bony injury. A good quality non-contrast high resolution computed tomogram can …