Sylvian fissure subpial hematoma: a rare imaging presentation of a ruptured middle cerebral artery aneurysm

Hematoma subpial na fissura silviana: uma rara apresentação de imagem de um aneurisma roto da artéria cerebral media

A 68-year-old female patient with a previously unruptured aneurysm in the left middle cerebral artery (Figure 1) presented with aphasia and severe headache. A computed tomography angiography (CTA) showed growth and new lobulation (Figure 1) associated with hemorrhages, including a large sylvian hematoma, probably in the subpial compartment (Figure 2). The findings suggested aneurysm rupture.

Figure 1
Previous head computed tomography angiography (CTA) (A–C) and head magnetic resonance angiography (MRA) (D); head CTA (E-F) follow-up on acute presentation. Increased size and new lobulation of the saccular left middle cerebral artery (MCA) aneurysm bifurcation (orange and red arrows).

Figure 2
Head CT without IV contrast immediately after patient's severe headache. Interval large acute hematoma along the left sylvian fissure, probably in the subpial compartment (red arrowheads). There was local mass effect with adjacent opercular cortex compression (green arrows). Small component of subdural (yellow asterisks) and subarachnoid (orange arrows) hemorrhages were also visualized.

Subpial hemorrhages happen within the potential space between the pia mater and cortex and are extremely rare in adults.¹ It is hypothesized that the presence of blood below the pia may damage thin arteries, with secondary bleeding and hemorrhage expansion.² They may cause injury to the cortex and severe edema and vasospasm, resulting in a poor prognosis (Figure 3).¹–³

Figure 3
Immediate post operative CT head showing left decompressive craniectomy, right frontal ventriculostomy, aneurysm clipping (black arrow), and partial left sylvian fissure subpial hematoma evacuation (red arrowhead). Note is made for significant edematous changes along the left temporal and insular lobes (white asterisks).

References

• ¹
  Minami N, Kimura T, Ichikawa Y, Morita A. Emerging sylvian subpial hematoma after the repair of the ruptured anterior cerebral artery aneurysm with interhemispheric approach: case report. Neurol Med Chir (Tokyo) 2014;54(03):227–230. Doi: 10.2176/nmc.cr2013-0025
  » https://doi.org/10.2176/nmc.cr2013-0025
• ²
  Hilditch CA, Sonwalkar H, Wuppalapati S. Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm. J Neurointerv Surg 2017;9(07):e25
• ³
  Suzuki K, Matsuoka G, Abe K, Okada Y, Sakai S. Subpial Hematoma and Extravasation in the Interhemispheric Fissure with Subarachnoid Hemorrhage. Neuroradiol J 2015;28(03):337–340. Doi: 10.1177/1971400915576664
  » https://doi.org/10.1177/1971400915576664

Edited by

Editor-in-Chief

Hélio A. G. Teive.

Associate Editor

Leandro Tavares Lucato.

Publication Dates

• Publication in this collection
  16 Sept 2024
• Date of issue
  2024

History

• Received
  05 Apr 2024
• Reviewed
  21 Apr 2024
• Accepted
  01 May 2024