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Parkin K, Taylor E, Rane N, Dawe G, Hall C. Pearls & Oy-sters: What Came First, the Bleed or the Fall?: An Aneurysmal Subdural Hemorrhage. Neurology 2024; 102:e209491. [PMID: 38771999 DOI: 10.1212/wnl.0000000000209491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2024] Open
Abstract
Acute subdural hemorrhages are a common emergency presentation often associated with trauma. However, in the absence of significant trauma, it is important to consider alternative causes. In this case, a 58-year-old woman with trivial trauma after a sudden collapse had bilateral subdural hemorrhages on CT. CT-angiogram revealed anterior communicating artery aneurysm, which had ruptured. This case explores intracerebral aneurysms as a rare cause of subdural hemorrhage that is important to consider in the absence of significant trauma.
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MESH Headings
- Humans
- Female
- Middle Aged
- Intracranial Aneurysm/diagnostic imaging
- Intracranial Aneurysm/complications
- Aneurysm, Ruptured/diagnostic imaging
- Aneurysm, Ruptured/complications
- Hematoma, Subdural, Acute/diagnostic imaging
- Hematoma, Subdural, Acute/etiology
- Hematoma, Subdural/diagnostic imaging
- Hematoma, Subdural/etiology
- Hematoma, Subdural/complications
- Tomography, X-Ray Computed
- Computed Tomography Angiography
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Affiliation(s)
- Katherine Parkin
- From the Department of Radiology (K.P.), St Bartholomew's and the Royal London Hospital; Department of Imaging (E.T., G.D.) and Interventional Neuroradiology (N.R., C.H.), Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Eleanor Taylor
- From the Department of Radiology (K.P.), St Bartholomew's and the Royal London Hospital; Department of Imaging (E.T., G.D.) and Interventional Neuroradiology (N.R., C.H.), Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Neil Rane
- From the Department of Radiology (K.P.), St Bartholomew's and the Royal London Hospital; Department of Imaging (E.T., G.D.) and Interventional Neuroradiology (N.R., C.H.), Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Gemma Dawe
- From the Department of Radiology (K.P.), St Bartholomew's and the Royal London Hospital; Department of Imaging (E.T., G.D.) and Interventional Neuroradiology (N.R., C.H.), Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Charles Hall
- From the Department of Radiology (K.P.), St Bartholomew's and the Royal London Hospital; Department of Imaging (E.T., G.D.) and Interventional Neuroradiology (N.R., C.H.), Imperial College Healthcare NHS Trust, London, United Kingdom
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Aladawi M, Elfil M, Najdawi ZR, Ghaith H, Sayles H, Thorell W, Hawkes MA. Aneurysmal Subdural Hematoma: A Systematic Review. Neurocrit Care 2024:10.1007/s12028-024-01938-y. [PMID: 38332336 DOI: 10.1007/s12028-024-01938-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 01/03/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Aneurysmal subdural hematoma (aSDH) is a rare complication of aneurysm rupture, affecting between 0.5 and 7.9% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The clinical presentation, course, and outcomes of these patients are largely unknown. OBJECTIVE This study aims to systematically review the literature to evaluate the demographics, clinical presentation, aneurysm location, treatment options, and outcomes of patients with aSDH with and without aSAH. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review of three databases (PubMed, EMBASE, and Google Scholar). From identified reports, we extracted data on patients' demographics, clinical presentation, imaging findings, surgical interventions, and clinical outcomes. We compared clinical outcomes, need for surgical treatment, and aneurysm location between patients with aSDH with and without concurrent aSAH using χ2 and Fisher's exact tests. We used simple and multivariable logistic regression models to further examine the association between the presence of aSAH and surgical treatment with clinical outcomes. RESULTS We identified 112 articles with a total of 270 patients (70% women, mean age 52.8 [± 15.5] years). The most common aneurysm locations were the middle cerebral artery, followed by the posterior communicating artery, and the internal carotid artery. Patients with isolated aSDH fully recovered more frequently than those with concomitant aSAH (38% vs. 6%). The presence of aSAH increased the odds of unfavorable outcome (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.34-5.37). Surgical treatment was inversely associated with unfavorable outcome in the univariable (OR 0.48, 95% CI 0.28-0.84) but not in the multivariable analysis (OR 0.76, 95% CI 0.35-1.66). CONCLUSION aSDH occurs infrequently. Simultaneous presence of both aSDH and aSAH from an aneurysmal source is associated with poor outcomes. Surgical treatment is associated with lower rates of unfavorable outcomes including death and severe disability.
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Affiliation(s)
- Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Zaid R Najdawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Hazem Ghaith
- Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Harlan Sayles
- Department of Biostatistics, University of Nebraska Medical Center, Omaha, NE, USA
| | - William Thorell
- Department of Neurosurgery, University of Nebraska Medical Center, Omaha, NE, USA
| | - Maximiliano A Hawkes
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA.
- Department of Neurology, Mayo Clinic, 200 1st ST SW, Rochester, MN, 55905, USA.
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Sadeh M, McGuire LS, Ostrov PB, Alaraj A, Charbel FT. Acute Subdural Hematoma Associated with Aneurysmal Rupture: A Case Series and Review of Literature. World Neurosurg 2023; 171:e486-e492. [PMID: 36526225 DOI: 10.1016/j.wneu.2022.12.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ruptured cerebral aneurysms represent a neurosurgical emergency with characteristic clinical presentation and imaging findings. However, atypical presentations may occur in association with acute subdural hematomas (SDHs). METHODS A retrospective review was conducted at our institution between 2013 and 2021 to identify patients with aneurysmal rupture presenting with SDH. Cases were reviewed for clinical presentation, imaging findings, management, and outcome. RESULTS A total of 8 patients were included in this review with an average age of 48.5 years. Six patients were women. The average Glasgow coma scale upon arrival was 6.3, and the Hunt-Hess average grade was 4.6. Aneurysm locations included posterior communicating artery (n = 3), anterior communicating artery (n = 2), middle cerebral artery (n = 2), and internal carotid artery terminus (n = 1). The size of aneurysm varied between 3 and 11 mm. Seven patients required surgical intervention, either craniotomy or craniectomy for hematoma evacuation, and aneurysms were treated by coiling (n = 2) or clipping (n = 6). CONCLUSIONS Ruptured aneurysms may present with SDH with or without significant subarachnoid hemorrhage. This illustrative case series highlights this challenging presentation and the importance of early recognition and appropriate management.
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Affiliation(s)
- Morteza Sadeh
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laura Stone McGuire
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Philip B Ostrov
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA.
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Detection and Morphological Analysis of Micro-Ruptured Cortical Arteries in Subdural Hematoma: Three-Dimensional Visualization Using the Tissue-Clearing Clear, Unobstructed, Brain/Body Imaging Cocktails and Computational Analysis Method. Diagnostics (Basel) 2022; 12:diagnostics12112875. [PMID: 36428935 PMCID: PMC9689514 DOI: 10.3390/diagnostics12112875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/15/2022] [Accepted: 11/18/2022] [Indexed: 11/22/2022] Open
Abstract
One of the causes of bleeding in subdural hematoma is cortical artery rupture, which is difficult to detect at autopsy. Therefore, reports of autopsy cases with this condition are limited and hence, the pathogenesis of subdural hematoma remains unclear. Herein, for the detection and morphological analysis of cortical artery ruptures as the bleeding sources of subdural hematoma, we used the tissue-clearing CUBIC (clear, unobstructed, brain/body imaging cocktails and computational analysis) method with light-sheet fluorescence microscopy and reconstructed the two-dimensional and three-dimensional images. Using the CUBIC method, we could clearly visualize and detect cortical artery ruptures that were missed by conventional methods. Indeed, the CUBIC method enables three-dimensional morphological analysis of cortical arteries including the ruptured area, and the creation of cross-sectional two-dimensional images in any direction, which are similar to histopathological images. This highlights the effectiveness of the CUBIC method for subdural hematoma analysis.
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Yanagawa T, Yamashita K, Harada Y, Hatayama T, Kono T. Location of hemorrhage with nontraumatic acute subdural hematoma due to ruptured microaneurysm. Surg Neurol Int 2021; 12:401. [PMID: 34513167 PMCID: PMC8422455 DOI: 10.25259/sni_210_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/26/2021] [Indexed: 11/04/2022] Open
Abstract
Background Nontraumatic acute subdural hematoma (ASDH) may be caused by rupture of a microaneurysm of a cortical artery. In some cases, microaneurysms may have been caused by earlier trauma. Although it is difficult to detect microaneurysms on contrast-enhanced computed tomography (CT) angiography or digital subtraction angiography, it may be suspected based on the plain CT scan results and the clinical course. Case Description We experienced three cases presumed to be ASDH due to rupture of a microaneurysm. Plain CT scan showed that the midline shift was smaller than the hematoma thickness, and we judged from the clinical course that there was no trauma immediately before the onset. All three patients had decreased consciousness after arrival and underwent craniotomy for hematoma removal. The source of hemorrhage was in the distal part of the cortical artery, and a microaneurysm was found. In one case, histopathological examination was performed, and traumatic pseudoaneurysm was diagnosed. The postoperative course was good in all three cases. Conclusion If nontraumatic ASDH is suspected, the source of hemorrhage may be located more distally to the middle cerebral artery than in traumatic ASDH; hence, extensive craniotomy is required to search for the location of hemorrhage.
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Affiliation(s)
- Taro Yanagawa
- Department of Stroke Center, Sagamihara Kyodo Hospital, Sagamihara, Kanagawa
| | - Keiichi Yamashita
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
| | - Yoichi Harada
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
| | - Toru Hatayama
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
| | - Takuji Kono
- Department of Neurosurgery, Mito Brain Heart Center, Mito, Ibaraki, Japan
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The usefulness of postmortem computed tomography angiography for subdural hematoma caused by rupture of the cortical artery: A report of two autopsy cases and a literature review. Leg Med (Tokyo) 2021; 53:101941. [PMID: 34293697 DOI: 10.1016/j.legalmed.2021.101941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/02/2021] [Accepted: 07/08/2021] [Indexed: 11/23/2022]
Abstract
Acute subdural hematoma (SDH) occurs following severe head trauma with brain contusion or rupture of bridging veins. Conversely, SDH caused by rupture of a cortical artery without trauma or with minor trauma is also possible. Although over 150 cases of the latter SDH have been reported, they were predominantly diagnosed only during surgery, and therefore, no adequate histological evaluation has been performed. Therefore, essential etiology of this SDH type has remained unclear. In addition, the scarcity of autopsy cases may be attributed to arterial rupture being missed if the macroscopic findings are too minimal to detect during autopsy. Here, we describe two autopsy cases of SDH of cortical artery origin. Extravasation on postmortem computed tomography angiography and arterial leakage on macroscopic observation during autopsy facilitated detection of the ruptured artery and allowed detailed histological evaluation of the ruptured artery and adjacent dura mater. The etiology of arterial rupture is briefly described on the basis of histopathological findings in this study and the available literature.
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Goto Y, Ochi T, Sakaguchi Y, Yoshida T, Fujitani S, Maeda K. Usefulness of computed tomography angiography “spot sign” in the endoscopically assisted evacuation of acute subdural hematoma in the elderly. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Hoz SS, Aljuboori Z, Albanaa SA, Al-Sharshahi ZF, Alrawi MA, Neamah AM, Al-Khafaji AO. Ruptured giant aneurysm of a cortical middle cerebral artery: A case report. Surg Neurol Int 2021; 12:95. [PMID: 33767899 PMCID: PMC7982092 DOI: 10.25259/sni_952_2020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 02/14/2021] [Indexed: 11/04/2022] Open
Abstract
Background Aneurysms of the cortical branches of the middle cerebral artery (MCA) are rare. They usually are secondary to traumatic or infectious etiologies and are rarely idiopathic. The specific characteristics of idiopathic aneurysms in such location are not well defined in the literature. The authors report a rare case of a ruptured giant idiopathic cortical MCA aneurysm with review of the available literature on this clinical entity. Case Description A 24-year-old female presented with headache, disturbed level of consciousness, and right-sided weakness. Imaging studies showed a left frontoparietal intracerebral hematoma and a giant saccular aneurysm in the posterior parietal cortical branch of the MCA. The patient had no history of head trauma or active infection; therefore, the aneurysm was considered idiopathic. A microsurgical clipping of the aneurysm with evacuation of the hematoma was performed. There were no surgical complications, and the patient achieved a good outcome modified Rankin Scale of 1 with no neurological deficits. Conclusion Idiopathic aneurysms of the cortical branches of the MCA are rare, and usually present with intraparenchymal hemorrhage due to rupture. There is no clear consensus regarding the optimal management strategy. This case shows that timely management can lead to good outcomes.
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Affiliation(s)
- Samer S Hoz
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | - Zaid Aljuboori
- Department of Neurosurgery, University of Washington, Seattle, Washington, United States
| | - Saja A Albanaa
- Department of Medical Students, College of Medicine, University of Baghdad, Baghdad, Iraq
| | | | - Mohammed A Alrawi
- Department of Neurosurgery, Neurosurgery Teaching Hospital, Baghdad, Iraq
| | - Ali M Neamah
- Department of Medical Students, College of Medicine, University of Baghdad, Baghdad, Iraq
| | - Aktham O Al-Khafaji
- Department of Medical Students, College of Medicine, University of Baghdad, Baghdad, Iraq
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Abecassis ZA, Nistal DA, Abecassis IJ, Sen RD, Levitt MR. Ghost Aneurysms in Acute Subdural Hematomas: A Report of Two Cases. World Neurosurg 2020; 139:e159-e165. [PMID: 32272269 PMCID: PMC10947780 DOI: 10.1016/j.wneu.2020.03.175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Acute subdural hematoma (aSDH) is a common pathology encountered in neurosurgery. Although most cases are associated with trauma and injuries to draining veins, traumatic aSDH from injury to arteries or spontaneous aSDH because of a ruptured intracranial aneurysm can occur. For some patients without a clear clinical history, it can be difficult to distinguish between these etiologies purely based on radiography. The objective of this research was to describe a case series in which imaging was suggestive of the presence of distal cortical intracranial aneurysm associated with aSDH, but operative management demonstrated no evidence of aneurysm. METHODS We retrospectively reviewed 2 patients known to have aSDH with suspicion for associated aneurysm between May 2019 and September 2019 at our institution. Data collected included demographic, clinical, and operative course, including age, gender, past medical history, presenting symptoms, and pre and postoperative imaging. RESULTS In 2 patients presenting with aSDH with preoperative radiographic imaging suggesting distal middle cerebral artery aneurysms, surgical exploration revealed no aneurysm. In both cases, noniatrogenic active arterial bleeding from an injured cortical middle cerebral artery branch was identified. CONCLUSIONS Although there are prior reports of arterial aSDH, to our knowledge, this is the first to describe the radiographic "ghost aneurysm" sign. It is important for clinicians to be aware of this potential misleading radiographic sign, which indicates active extravasation into a spherical cast of clot.
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Affiliation(s)
- Zachary A Abecassis
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Dominic A Nistal
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Rajeev D Sen
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Michael R Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke and Applied Neuroscience Center, University of Washington, Seattle, Washington, USA.
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Beucler N, Haikal C, Hibbert D, Sellier A, Joubert C, Desse N, Dagain A. Spontaneous Acute Subdural Hematoma: Beware of the Aneurysm. J Neurosci Rural Pract 2019; 10:537-541. [PMID: 31595130 PMCID: PMC6779585 DOI: 10.1055/s-0039-1697770] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Spontaneous acute subdural hematoma should raise clinical suspicion for underlying pathology, the most common etiology being a ruptured aneurysm. Through this case report, our team developed a clinical decision-making tool to help physicians decide when it is necessary to order an acute subdural hematoma to assess for ruptured aneurysm.
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Affiliation(s)
- Nathan Beucler
- Departments of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Christelle Haikal
- Departments of Radiology, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - David Hibbert
- Department of Internal Medicine, Hospitalist Service, UC San Diego Medical Center, San Diego, California, United States
| | - Aurore Sellier
- Departments of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Christophe Joubert
- Departments of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Nicolas Desse
- Departments of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France
| | - Arnaud Dagain
- Departments of Neurosurgery, Sainte-Anne Military Teaching Hospital, Toulon, France
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Thapa A, Kc B, Shakya B. Pure Acute-on-Chronic Subdural Hematoma Due to Ruptured Posterior Communicating Artery Aneurysm: Unsuspecting Entity. World Neurosurg 2018; 114:335-338. [PMID: 29631078 DOI: 10.1016/j.wneu.2018.03.211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 03/29/2018] [Accepted: 03/29/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Even though rarely reported as a cause of pure subdural hematoma (SDH), aneurysmal rupture should be suspected in patients with spontaneous SDH without coagulopathy. CASE DESCRIPTION We report a case of acute-on-chronic SDH in a 55-year-old lady with cerebral herniation due to a ruptured posterior communicating artery aneurysm. She was managed with single-stage SDH evacuation along with clipping of the aneurysm. CONCLUSIONS Computed tomography angiography of the head is advisable in patients with spontaneous SDH without coagulopathy. Pure SDH as compared with SDH associated with subacute hemorrhage, intraventricular hemorrhage, or intracerebral hemorrhage due to aneurysmal rupture has a good outcome.
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Affiliation(s)
- Amit Thapa
- Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal.
| | - Bidur Kc
- Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
| | - Bikram Shakya
- Kathmandu Medical College Teaching Hospital, Kathmandu, Nepal
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