Presentation
Sudden collapse.
Patient Data
There is an intraparenchymal hemorrhage seen at the left frontoparietal area with an adjacent focal subarachnoid hemorrhage seen at the left temporal lobe, associated with minimal surrounding vasogenic edema causing midline shifting of about 0.5 cm, with an interventricular extension seen at both lateral ventricles, third and fourth ventricles.
The left uncus almost touches the ipsilateral midbrain which may indicate early/pending uncal herniation.
No cerebellar tonsillar herniation.
Case Discussion
This patient with no history of trauma presents with massive lobar hemorrhage and no identifiable mass lesion on CT scan, regardless of the predisposing factor which can be a ruptured AVM or clotting factor deficiency, the importance at this point in time is to evaluate detrimental complications, mainly the different forms of brain herniation.
In early uncal herniation, the uncus is pushed medially obliterating the ipsilateral ambient cistern as seen in this patient, although subtle and can easily be overlooked, it indicates pending uncal herniation which is associated with high mortality.
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