Atypical Presentation of a Ruptured Anterior Communicating Artery Aneurysm With Subdural, Intraparenchymal, and Subarachnoid Hemorrhage

Anterior communicating artery (ACom) aneurysm, one of the most frequent types of intracranial aneurysm rupture, usually results in a subarachnoid hemorrhage (SAH) with intraventricular hemorrhage. We describe a case of an ACom aneurysm rupture with subarachnoid, intraparenchymal, and subdural hemorrhages (SDH) with midline shift in a 55-year-old woman. Decompressive craniectomy was performed to evacuate the SDH with subsequent microsurgical clipping of the aneurysm. Postoperative angiogram showed occlusion of the ACom aneurysm without residual flow. Mechanisms to explain multimodal bleeding with SAH, intraparenchymal hemorrhage, and SDH include adhesion of aneurysm to arachnoid membrane, high pressure hemorrhage, and spontaneous laceration of the arachnoid membrane. Management of multifocal hemorrhage pattern including SDH after ACom aneurysm rupture is dependent on anatomical and radiographic features as well as the clinical condition of the patient on admission. Decompressive craniectomy is a suitable treatment option for patients with concurrent spontaneous SAH, intraparenchymal hemorrhage, and SDH.