Intracerebral Hematoma without Subarachnoid Hemorrhage Presentation of Ruptured Left Middle Cerebral Artery Bifurcating Giant Aneurysm, Case Report

Background: The subarachnoid hemorrhage is most common presentation of ruptured brain aneurysm .The intracerebral hematoma (ICH) is blood collection within the brain parenchyma mainly caused by brain arterio-venous malformations (AVM), arterio-venous fistula, hypertension or secondary to head trauma. One of rare presentation that ruptured middle cerebral artery aneurysm become with ICH only without subarachnoid hemorrhage. One such case was reported in this paper. Case presentation: We had reported a case of 36 year old male, presented with sudden aphasia with complete right sided weakness, associated with nausea vomiting and severe headache. Computed tomography (CT) and magnetic resonance imaging (MRI) was done immediately to the patient, showed left front parietal intracerebral hematoma without subarachnoid hemorrhage. Then digital subtraction angiography (DSA) was done to the patient showed giant left middle cerebral artery aneurysm at its bifurcation with large pseudoanerysm arise from its dome which appears to be the cause of the intracerebral hematoma (ICH). Conclusion:This rare pattern of bleeding in such a case ,because of pseudo- part of this aneurysm communicated indirectly with the intracerebral hematoma by faint linear density seen in the initial brain computed tomography (CT).That mean this aneurysm at high chance of recurrent bleeding ,with higher mortality rate to the patient, so the endovascular coiling was take place immediately.