Abstract-Text (inkl. Referenzen und Bildunterschriften)

A 54-year-old otherwise healthy female patient presented at another hospital due to persisting head and neck pain. She reported a thunderclap headache 7 days before admission. Neurological examination was unremarkable. Cerebral computed tomography (CT) revealed a left-sided subacute subdural hematoma (SDH) with a thickness greater than 10 mm causing significant midline shift to the right (Fig. 1A,B). The patient was transferred urgently to our tertiary care university hospital for further diagnostic work-up and neurosurgery. CT angiography demonstrated a small (5 mm) left middle cerebral artery (MCA) bifurcation aneurysm (Fig.1C). Because the patient convincingly denied recent head trauma, rupture of the cerebral aneurysm was suspected as probable etiology of the SDH. The patient underwent left-sided craniotomy with evacuation of the SDH and exploration of the left Sylvian fissure. Intraoperatively, subarachnoidal as well as blood on the surface of the MCA aneurysm supported the diagnosis of a recent aneurysm burst. Microsurgical clipping of the aneurysm was performed. On the next day, following extubation, neurological examination of the patient revealed expressive aphasia. Postoperative CT scan showed mild swelling of the left fronto-temporal operculum without evidence of ischemic stroke or re-bleeding. Non-convulsive status epilepticus was excluded by means of an electroencephalogram. Postoperative cerebral angiography demonstrated sufficient clipping of the aneurysm without vasospasm. A repeat CT scan was performed due to further neuroworsening demonstrating recurrence of the SDH. A second look craniotomy with SDH evacuation was performed. Complete clip occlusion of the left MCA aneurysm was confirmed. In the following, the patient"s neurological condition stabilized and the aphasia improved under intensive speech therapy.

Spontaneous SDH secondary to rupture of a cerebral aneurysm is rare. Our case highlights the importance of a thorough clinical work-up, especially considering the "red flags" for potentially life-threatening secondary headache disorders.