title: Ultra-early aneurysmal rebleeding and brainstem destruction.
abstract: BACKGROUND
  Early secondary neurologic deterioration after aneurysmal subarachnoid hemorrhage (SAH) may have many causes including rebleeding, hydrocephalus, parenchymal hematoma, or seizures.
  
  
  METHODS
  Case report.
  
  
  RESULTS
  A 69-year-old woman presented with thunderclap headache and nausea. A head computed tomography (CT) showed SAH. On initial evaluation she was awake, alert, and confused without focal neurologic deficits. Two episodes of marked clinical deterioration occurred, manifesting as acute unresponsiveness and fixed anisocoria. Serial head CTs showed massive extension of hemorrhage into the brainstem parenchyma and ventricles.
  
  
  CONCLUSIONS
  Sudden clinical deterioration after SAH with coma and a fixed "blown" pupil may result from hemorrhage extension into the brainstem parenchyma rather than oculomotor nerve injury from compression or stretch.
authors: Division of Critical Care Neurology, Mayo Clinic, Rochester, MN 55905, USA. fugate.jennifer@mayo.edu
authors: Jennifer E
authors: JE
authors: Fugate
authors: Grant W
authors: GW
authors: Mallory
authors: Eelco F M
authors: EF
authors: Wijdicks
mesh_terms: D000368:Aged; D015875:Anisocoria / Q000000981:diagnostic imaging; D001933:Brain Stem / Q000098:blood supply* / Q000000981:diagnostic imaging*; D003128:Coma / Q000000981:diagnostic imaging*; D018450:Disease Progression; D005260:Female; D006801:Humans; D012008:Recurrence; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging* / Q000601:surgery; D014057:Tomography, X-Ray Computed; D014696:Ventriculostomy