Year: 2025 | Month: December | Volume: 12 | Issue: 12 | Pages: 543-548
DOI: https://doi.org/10.52403/ijrr.20251258
Perimesencephalic SAH Masquerading as Aneurysmal Bleed: Diagnostic and Critical Care Challenges
Badhra Ajit Nair1, Megha Satish2, Zidan Abdul Hameed Rahim3, Mohammed Shazin4
1Department of Medicine, Faculty of Medicine, Tbilisi State Medical University, Georgia.
2Department of Medicine, Faculty of Medicine, Tbilisi State Medical University, Georgia.
3Department of Medicine, Faculty of Medicine, Tbilisi State Medical University, Georgia.
4Department of Medicine, Faculty of Medicine, Tbilisi State Medical University, Georgia.
Corresponding Author: Badhra Ajit Nair
ABSTRACT
Subarachnoid hemorrhage (SAH) refers to bleeding within the subarachnoid space, often due to ruptured aneurysms. However, perimesencephalic subarachnoid hemorrhage (PMSAH) represents a rare, non-aneurysmal subtype, typically confined to the basal cisterns surrounding the midbrain. This case report describes a 52-year-old male with a background of hypertension, type 2 diabetes mellitus, hyperlipidemia, and chronic ischemic heart disease, who presented with sudden, intense headache and a single episode of vomiting. Initial non- contrast CT imaging revealed a classic perimesencephalic bleed. Due to suspicion of a basilar artery aneurysm, the patient was referred for digital subtraction angiography (DSA). On arrival, he had a GCS of 8/15 and was immediately intubated and admitted to the ICU for critical care. While DSA showed no aneurysms or vascular malformations, CT cerebral angiography confirmed SAH involving the suprasellar, interpeduncular, ambient, prepontine, perimesencephalic, and cerebellar cisterns. Complications during the ICU stay included hydrocephalus, cerebral edema, and hospital-acquired pneumonia due to Klebsiella pneumoniae. Cardiac evaluation revealed native coronary artery atherosclerosis, and a right-sided external ventricular drain (EVD) was placed to manage intracranial pressure.This case underscores the significance of timely neuroimaging, early intervention, and multidisciplinary care in managing spontaneous SAH, especially when complicated by comorbid systemic illness.
Keywords: Subarachnoid hemorrhage, basilar artery aneurysm, digital subtraction angiography, external ventricular drain, hypertension, hyperlipidemia, diabetes mellitus.
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