Ruptured berry aneurysm with minimal subarachnoid hemorrhage

Abstract Cerebral artery aneurysm rupture is usually associated with significant subarachnoid hemorrhage; however, there are rare cases where there is a lack of hemorrhage into the subarachnoid space. While subdural hemorrhage can occur with ruptured aneurysms, isolated subdural hemorrhage is more often associated with trauma. In this case, a 51-year-old obese woman, who recently visited an Urgent Care Center for elevated blood pressure, was found dead roughly a month later. She had been complaining of headaches, and received medication for her blood pressure at the visit. A medicolegal autopsy revealed that the cause of death was determined to be a ruptured cerebral artery berry aneurysm of the right anterior cerebral artery, with a contributing underlying cause of hypertensive and atherosclerotic cardiovascular disease. There was significant subdural hemorrhage overlying the right cerebrum. Subarachnoid hemorrhage was present only minimally and in a patchy distribution, with virtual absence of basilar hemorrhage. An additional unruptured aneurysm was found in the left common carotid artery before the bifurcation. There was cardiomegaly (510 gm), and mild to moderate atherosclerosis in multiple vessels. The classic clinical presentation of a ruptured cerebral artery berry aneurysm involves the sudden onset of an excruciating headache.1 While angiography provides the most conclusive image-based antemortem evidence of an aneurysm, CT scans are used frequently in an emergency setting to identify basilar subarachnoid hemorrhage, a very common associated finding, thus allowing for a diagnosis of probable ruptured aneurysm.1 Depending on the circumstances of a given case, the presence of subdural hemorrhage with absence of subarachnoid hemorrhage on CT scan may suggest a different underlying process, such as trauma. The presented case serves to remind clinicians that ruptured berry aneurysms do not always produce significant subarachnoid hemorrhage.