Aneurysmal rupture without subarachnoid hemorrhage: Case series and literature review

OBJECTIVE: Although an aneurysmal rupture typically presents on computed tomographic (CT) imaging as only subarachnoid hemorrhage (SAH), it may be associated with intraparenchymal hemorrhage (IPH), intraventricular hemorrhage (IVH), or sub-dural hemorrhage. On rare occasions, however, an aneurysmal rupture may present with IPH or IVH without SAH. METHODS: The Division of Cerebrovascular Neurosurgery at The Johns Hopkins Medical Institutions maintains a prospective database of all patients treated for intracranial aneurysms at this institution since 1991. Using this database, we identified patients with ruptured aneurysms who presented with IPH or IVH in the absence of SAH on CT imaging. RESULTS: Eight hundred twenty-two patients with radiographically documented ruptured aneurysms were admitted from January 1991 through June 2004. Of these, nine patients presented with IPH only, three with IPH and IVH, and one with IVH only, for a total of 13 cases. There were seven posterior communicating artery, four middle cerebral artery, one basilar apex, and one posterior cerebral artery aneurysms. The incidence of aneurysmal rupture with IPH and/or IVH without SAH is 1.6% CONCLUSION: Initial presentation of a ruptured aneurysm without SAH is rare and may have a multifactorial cause attributable to the timing of CT imaging, physiological parameters, or location of the aneurysm. Patients presenting with a head CT scan revealing IPH in the temporal lobe or with IVH should be considered for an urgent workup of a ruptured aneurysm, even in the absence of diffuse SAH.