title: Sphenoid and subdural hemorrhage as a presenting sign of ruptured clinoid aneurysm.
abstract: BACKGROUND
  Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage.
  
  
  METHODS
  Case report and review of the literature.
  
  
  RESULTS
  We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence.
  
  
  CONCLUSIONS
  Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.
authors.affiliation: Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.
authors.forename: Daniel
authors.initials: D
authors.lastname: Shepherd
authors.forename: Joseph
authors.initials: J
authors.lastname: Kapurch
authors.forename: Sudhir
authors.initials: S
authors.lastname: Datar
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lanzino
authors.forename: Eelco F M
authors.initials: EF
authors.lastname: Wijdicks
mesh_terms: D017542:Aneurysm, Ruptured / Q000000981:diagnostic imaging*; D005260:Female; D020199:Hematoma, Subdural, Acute / Q000000981:diagnostic imaging*; D006801:Humans; D008875:Middle Aged; D012658:Sella Turcica / Q000098:blood supply / Q000000981:diagnostic imaging*; D013101:Sphenoid Sinus / Q000098:blood supply / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed
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