The gyrus rectus hematoma should always prompt consideration of an ACOM aneurysm rupture - the major differential diagnosis for spontaneous hemorrhage in this region being ethmoidal anterior cranial fossa DAVF. When aneurysmal rupture is associated with SDH, it is more common in a second delayed bleed, but can occur with the first bleed as in this case.

The presence of mass effect, herniation and poor clinical grade and pupil dilatation indicate a surgical approach as an emergency - if the clinical grade is good and surgical evacuation of the SDH or IPH is not considered an emergency, coil embolization could be considered and surgery could follow as clinically indicated.