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Endgames Picture quiz

An unusual case of haemorrhagic stroke

BMJ 2009; 339 doi: (Published 26 August 2009) Cite this as: BMJ 2009;339:b3204
  1. Hani Marcus, speciality trainee in neurosurgery,
  2. Ibrahim Jalloh, speciality trainee in neurosurgery,
  3. Rhys Roberts, specialist registrar in neurology,
  4. Peter Martin, consultant in neurology
  1. 1Department of Clinical Neurosciences, Cambridge University Hospitals NHS Foundation Trust, Cambridge CB2 2QQ
  1. Correspondence to: H Marcus hani.marcus{at}

    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.

    Fig 1 The patient’s head computed tomogram

    Fig 2 The patient’s digital subtraction angiogram


    • 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?


    Short answers

    • 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.

    Long answers

    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 …

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