Computed Tomographic Evaluation of Hemorrhage Secondary to

Intracranial Aneurysm

KENNETH A. DAVIS,1 P. F. J. NEW,1 ROBERT G. OJEMANN,2 ROBERT M. CROWELL,2

RICHARD B. MORAWETZ,2 AND GLENN H. ROBERSON1

Angiography in patients with subarachnoid hemorrhage TABLE 1

secondary to aneurysm gives precise information on the
Age and Sex of Patients
location and size of the aneurysm and the presence of
spasm but gives incomplete information on ventricular size,
size and location of hematoma, and extent of infarction. Sex

CT demonstrates precisely brain or intraventricular hema-

Age (Yr) Females Males
toma and, at times, subarachnoid hemorrhage; indicates
the extent of infarction ; and rapidly documents the degree 20-39 0 4
of hydrocephalus. Infarction secondary to spasm, hema- 40-49 0 3
toma, and hydrocephalus are readily differentiated. 50-59 5 5
The CT examination may be repeated as often as neces- 60-69 3 1
sary without patient discomfort or morbidity. Serial scans 70-79 2 0
allow rapid assessment of change in ventricular size, de- 80-89 1 0
velopment and persistence of infarction, and change in size
of hematoma. Total 11 13
American Journal of Roentgenology 1976.127:143-153.

Note.-58% had hypertension

Computed tomography may be of considerable assistance
in the management of subarachnoid hemorrhage due to
aneurysm. A graphic representation of intracranial anatomy TABLE 2
and pathology may easily and frequently be obtained with-
Studies Performed
out recourse to repeated angiography when clinical cm-
cumstances dictate.
Study No
Subjects and Methods
Anatomic clarity was improved after installation of the 1 60 x 60 CT,angiogram 10
matrix, enabling visualization of some abnormalities which had CT, angiogram, surgery 7
not been fully appreciated on the 80 x 80 matrix [1 ] . Consequently CT, angiogram, autopsy 3
only those patients with subarachnoid hemorrhage due to aneu- CT, autopsy 3
rysm who were studied using the 1 6Ox 1 60 matrix are included in CTonIy 1
this report ; 45 cases studied with the 80 x 80 matrix were eliminated.
A total of 3,000 CT examinations using the 1 60 x 60 matrix were
reviewed ; 24 patients with subarachnoid hemorrhage secondary to Neurologic Deficit
aneurysm were found (table 1 ). All patients had the diagnosis The neurologic deficit at the time of the scan was related
established by history, examination, and appropriate studies. Six of to the CT findings (table 4). The neurologic deficit was
the 24 cases came to autopsy ; angiograms had not been performed
classified according to the following grades as modified
in three (table 2). One other patient died before an angiogram was
from Botterell et al. [2] : grade 1-alert, mild headache, no
obtained. Of the 24 patients, 1 2 had a single CT scan and the re-
neunologic deficit ; grade 2-neunologically intact on nerve
mainder had serial studies, for a total of 46 CT scans.
palsy only with moderate to severe symptoms and signs of
Findings blood in the subarachnoid space ; grade 3-drowsy on
obtunded without major focal deficit ; grade 4-major
Origin of Hemorrhage
neurological deficit ; grade 5-decerebrate or decorticate
The location of subarachnoid, intraventnicular, on intra- posturing ; and grade 6-moribund, no spontaneous
cerebral hemorrhage may suggest the approximate site respirations, essentially dead.
of the aneurysm which bled (fig. 1 ). This occurred in nine In the drowsy on obtunded patients (grade 3), six of
of the 1 2 patients in this series who showed some evidence eight had hydnocephalus and three had infarction. In the
of hemorrhage (table 3). Multiple aneurysms were present grade 4 cases, eight of 1 4 had hydrocephalus, three had
in one case, and the area of infarction suggested the loca- intracerebral hemorrhage, and five had infarction, four with
tion of the bleeding aneurysm. a mass effect.

Received February 6. 1 976 ; revised April 5, 1 976.

This work was supported in part by U.S. Public Health Service grant NS10828-02 from the National Institutes of Health.
1 Department of Radiology. Massachusetts General Hospital and Harvard Medical School, Boston. Massachusetts 021 1 4. Address reprint requests to
K. R. Davis.
2 Department of Neurosurgery. Massachusetts General Hospital and Harvard Medical School. Boston. Massachusetts 02114.

Am J Roentgenol 127:143-153, 1976 143

 144 DAVIS Et AL.
American Journal of Roentgenology 1976.127:143-153.

TABLE 3
Determination of Origin of Hemorrhage with CT

Site of Aneurysm Suggested

cT Finding No Patients ACA PA MCA PICA None

Subarachnoid hemorrhage 2 1 . . . - . . . . . 1
Subarachnoid and intraventricular hemorrhage 4 1 1 . . . . . - 2
Subarachnoid, intraventricular, and intracerebral hemorrhage 2 2 . . . - - . . . . , . .

Subarachnoid and intracerebral hemorrhage 2 . . . . - - 2 . . . . . -

Intraventricular hemorrhage 2 1 . . . . - . 1 . .

Note. -AcA = anterior communicating aneurysm . PtA = posterior communicating aneurysm ; MCA = middle cerebral artery aneurysm ; PICA posterior inferior cerebellar artery
aneurysm.
 CT IN BLEEDING ANEURYSMS 145

TABLE 4

Comparison of Neurologic Deficit and CT Findings

Neurologic Deficit (Grade)

CT Finding 1 2 3 4 5 Total

Hydrocephalus . - . 1 6 8 4 19
Subarachnoid hemorrhage -.. ... 1 2 1 4
Subarachnoid and intraventricular hemorrhage. . ... -.. .-. 5 1 6
Intraventnicular hemorrhage -.. .-. 1 2 1 4
Intracerebral hemorrhage ... --. 1 3 1 5
Infarct:
With mass ... 1 1 4 ... 6
Without mass ... 2 1 2 6
Aneurysm ... ... ... 2
Negative CT 2 1 ... ... 4

Total 4(4) 4(4) 13 (8) 25 (14) 10 (6) 56

Note-Grade is at time CT was obtained. Patient may be tabulated more than once if grade changed when repeat CT scan was done Multiple CT scans
on same patient with same deficit and CT findings were listed only once. More than one or none of the above pathologic findings may be present on a scan at
the time of a given neurologic deficit. Numbers in parentheses indicate scans in each grade having a specific CT abnormality.
American Journal of Roentgenology 1976.127:143-153.

TABLE 5
Infarction Relation of Ventricular Size to Time from Hemorrhage

In some cases, serial scans showed the infarct develop-

ing. One patient had CT scans on days 6, 34, and 78 and ventricular Size

was classified as grades 3, 2, and 1, respectively. The sub- Minimal Moderate

arachnoid hemorrhage was due to an aneurysm arising Days from Onset Normal Enlargement Enlargement

from the left posterior communicating artery. The scans

0-2 5 . . . 7
showed an evolving infarction in the distribution of the
3-8 5 3 ...

superior division of the left middle cerebral artery. Spasm of 9-14 1 2 .

this vessel was seen at angiography. In another case, an in- 15-21 1 2 .

farct was suspected but the scan was negative and the pa- 22-30 1 1 . .

tient remained well. In a third patient, reduction in mass ef- 30-60 4 5 1

fect was associated with good neurologic recovery. 60-90 1 2 ...

90-120 1 1 1
Intraventricular Hemorrhage
Note -One scan in the same ti me period and one following shunt not included
One of the most important observations relates to intra-
ventricular hemorrhage. Six patients (five grade 4 and one
grade 5) had massive subarachnoid (basal cisterns) and
intraventnicular hemorrhage, and all died. However, four rebled and had respiratory arrest on day 6. The second CT
other patients (one grade 3, two grade 4, and one grade 5) scan just before this time showed no blood in the fourth
with only intraventnicular hemorrhage survived. Of the pa- ventricle and no sign of hydnocephalus. The neurologic
tients with major subanachnoid hemorrhage (blood in basal deficit was then grade 4. The last scan (day 1 3) showed no
cisterns visible on CT), 50% died. change in ventricular size but minimal blood in the fourth
ventricle ; the neurologic status remained unchanged.
lntracerebral Hematoma
CT delineated the exact location and configuration of the Hydrocephalus
hematoma. In one patient with a grade 4 neurologic status
The CT scan is of great value in assessing the degree and
after subarachnoid hemorrhage from an anterior com-
cause of hydnocephalus (table 5, figs. 2 and 3). One patient
municating aneurysm, CT scans were obtained 4 and 38
with subarachnoid hemorrhage from a right posterior com-
days after onset. Hematoma anterior to the lamina terminalis
municating aneurysm had three CT scans : day of onset
region and anterior interhemisphenic fissure was present on
(grade 5), day 6 (grade 4), and day 34 (grade 4). The first
the first scan and had been nesorbed except for a small
scan showed only hydrocephalus, and a ventniculostomy
amount in the lamina terminalis cistern on the second study.
was performed which was removed on the next day. The
The neurologic status did not improve during this time.
ventricles were progressively smaller on the next two scans
Another patient had three CT scans after subanachnoid
(normal size on the last scan). One of the most striking ob-
hemorrhage from a posterior inferior cerebellan artery
servations from table 5 is that more than half of the patients
aneurysm. The neurologic deficit was grade 3 at the time of
scanned within 48 hr of onset of hemorrhage had ventricular
the CT scan on the first day. This scan showed blood in the
enlargement.
fourth ventricle and hydnocephalus (fig. 2). The patient
 146 DAVIS ET AL.

TABLE 6
Additional Information Provided by CT

Information Provided No. Cases

Improved visualization of:

Intracerebral hematoma 3
Intraventricular hemorrhage 1
Infarction 2
Subarachnoid hemorrhage 4
Partial thrombosis of aneurysm 1
Exclusion of hematoma 2

Note-Data from 1 1 cases in which angiography and CT performed within 24 hr of

each other. CT provided additional information in nine. One patient had both CT and
angiography on two separate days. A case may be listed in more than one category

Most aneurysms are not large enough to permit assess-

ment of size, but one striking case was seen (fig. 4). An-
other case of a multilobulated aneurysm from the ambient
cistennal segment of the left posterior cerebral artery did not
American Journal of Roentgenology 1976.127:143-153.

show a change in apparent size on CT scans before and after

contrast infusion. The CSF was negative, but at the time of
operative clipping, the sac wall showed changes consistent
with a recent bleed.
CT rather than angiognaphy was used for evaluation of
the presence of hydrocephalus, intracerebral hematoma, on
infarction in many patients with severe on increasing neuno-
logic deficit or increased intracranial pressure (figs. 5-8).
The CT scan often obviated the need for repeated angio-
graphic studies.
In the following section, CT findings are compared with
findings at autopsy (six cases) and surgery (seven cases).

Case Reports

Autopsied Cases
Case 1. A 45-year-old hypertensive male was found comatose.
Examination revealed bilateral subhyaloid hemorrhages and no signs
of neurological function except respiration. CT scan showed blood
in the subarachnoid spaces and swelling of both cerebral hemi-
spheres, compressing the ventricles (fig. 6). He died 8 hours later.
At autopsy, marked subarachnoid hemorrhage was found,
Fig. 2.-Evaluation of ventricular size. Upper, Scan on day 1 showing
hydrocephalus and blood in fourth ventricle (arrow). Middle. Scan on day 4
especially at the base of the swollen brain as seen on CT. Buried in
showing no hydrocephalus and no blood in fourth ventricle. Lower. Scan the blood clot was a 5 mm aneurysm of the anterior communicating
on day 1 3 after rebleed on day 6. Minimal blood in fourth ventricle (arrow); artery, not seen on CT. Some blood was present in the fourth yen-
no hydrocephalus. tnicle near the foramina. A CT projection at that level was not done.
Case 2. A 50-year-old-male had sudden right frontal headache
and then became somnolent. CT scan on admission showed a
right frontal hematoma (a portion of which was the blood pool of
Correlation of CT and Angiography the aneurysmal sac), blood in the right sylvian and interhemisphenic
fissures with compression of the body of the right ventricle, and
Angiognaphic and CT findings were compared in 11
right-to-left shift of the septum pellucidum. Angiography demon-
cases in which the studies were performed within 24 hr of
strated a giant aneurysm of the right middle cerebral artery and a
each other (table 6). In nine cases, CT provided additional
deep right avascular frontal mass. Three days after onset left
information. In general, CT provided better visualization of hemiparesis developed. CT scan on that day showed enlargement
intracerebral and intraventniculan hemorrhage, infarction, of the hematoma and greater mass effect. The aneurysm was
subarachnoid hemorrhage, and partial thrombosis of an- excised. On day 9 the patient became obtunded and the right pupil
eurysm (fig. 4). CT studies could also definitely exclude the dilated. The third CT scan on day 1 1 showed massive right hemi-
presence of hematoma. spheric swelling. A frontotemporal decompression lobectomy was
 CT IN BLEEDING ANEURYSMS 147
American Journal of Roentgenology 1976.127:143-153.

..,. ji

17r:fI

Fig. 3. -Case 4: evaluation of ventricular size. A. Upper to lower. CT scans on days 1. 6. 14. and 22. Only transient decrease in hydrocephalus: sylvian
fissures not visualized. B and C. Aneurysm (arrow) and clot in cisterns (arrows) found at autopsy on day 25.
 American Journal of Roentgenology 1976.127:143-153.

148
DAVIS

..!
ET AL
 CT IN BLEEDING ANEURYSMS 149
American Journal of Roentgenology 1976.127:143-153.

performed, but he did not improve. CT scan on day 44 showed a At autopsy a clot was present in the cisterns anterior to the brain-
large cavity in the right frontal region. He died on day 53. stem, cisterna magna, and interpeduncular and chiasmatic cisterns.
At autopsy a large amount of subarachnoid blood was found, There was an aneurysm at the point of basilar bifurcation and
especially in the chiasmatic, interpeduncular, pontine, and medul- ventricular enlargement.
lary cisterns. Clot was found in the lateral and fourth ventricles. Case 5. A 59-year-old male became hypertensive during an extra-
Case 3. A 57-year-old female had sudden onset of headache and cranial surgical procedure and remained unresponsive in the re-
nuchal rigidity. There was a bilateral sixth nerve palsy, limitation of covery room. CT scan on the following day showed hemorrhage in
upward gaze, and a positive left Babinski. The cerebrospinal fluid the lateral (left greater than right), third, and fourth ventricles, sub-
was bloody. Twelve hours after onset, she was unresponsive and arachnoid blood
in the basal cisterns, ambient cisterns, interhemi-
had bilateral papilledema. CT scan showed subarachnoid blood in spheric fissure,hematomaand in the rostrum of the corpus callosum.
the basal cisterns and interhemisphenic fissure, blood in the third He died on that day.
ventricle and both occipital horns, and hydrocephalus. Fifteen At autopsy a small anterior communicating aneurysm was
hours after onset, the pupils dilated and became nonreactive. She found to have ruptured, resulting in blood within and around the
died the next day. anterior corpus callosum, within the anterior interhemispheric
At autopsy a large amount of subarachnoid blood was present, fissure, ambient cisterns, circle of Willis and pontine cistern, and
especially in the chiasmatic interpeduncular, pontine, and medul- over the convexities. The brain was swollen. Massive intra-
lary cisterns. An aneurysm 6 mm in diameter was found, originating ventricular heniorrhage was seen in all four ventricles.
2 mm beyond the takeoff of the left posterior inferior cerebellar Case 6. A 34-year-old male became dizzy and then comatose.
artery. Clot was found in the lateral and fourth ventricles. An angiogram obtained 5 days after onset of symptoms showed an
Case 4. A 38-year-old hypertensive male had sudden headache, aneurysm of the left anterior communicating artery. The left anterior
light-headedness, and bizarre behavior. A seizure occurred, and cerebral artery was clipped 9 days after onset. He was akinetic and
then he became comatose. The spinal fluid was bloody. The next mute postoperatively. Five weeks later, still comatose, he was trans-
day he was awake and responsive. CT scan on that day showed ferred to the Massachusetts General Hospital. CT scan at that time
hydrocephalus (fig. 3). Angiography demonstrated a bibbed basilar showed communicating hydrocephalus and left anterior cerebral
bifurcation aneurysm without spasm. Paralysis on upward gaze and right middle cerebral infarctions. A radionuclide cerebrospinal
and disorientation developed on the sixth day. CT scan on that day fluid study showed ventricular stasis, and a ventriculoatrial shunt
showed slightly less hydrocephalus. CT scans on days 1 4 and 22 was done. CT scan 8 days after the shunt showed smaller ventricles,
showed mild progressive hydrocephalus. He died of recurrent but there was no change in his neurological status. Fifteen days
hemorrhage on day 24. after the shunt, he developed dilatation of the left pupil and was
 150 DAVIS ET AL.
American Journal of Roentgenology 1976.127:143-153.

Fig. 6.-Case 1 : subarachnoid hemorrhage with edema. CT scan on day

of onset showing bilateral swelling with compression of ventricles (arrows). Fig. 7.-._.a 9 : infarction foliowing clipping of aneurysm of a. ..
Note subarachnoid hemorrhage (arrowhead). Aneurysm not identifiable. communicating artery. Upper. Scan 9 days postoperatively showing mass
effect (arrow). Lower, Scan almost 1 month later showing less mass effect.

flaccid with intermittent decerebrate posturing. He died 3 days The sac was not entered, but the neck of the aneurysm was clipped.
later. Case 8. A 38-year-old male had a seizure followed by a right
At autopsy a saccular aneurysm (7.5 mm diameter) of the anterior hemisensory deficit. Lumbar puncture was negative. CT scan
communicating artery and a 10x20 mm aneurysm of the right an- showed a high absorption abnormality in the lower blood range
tenor cerebral artery were found. There was massive hemorrhage (1 8-30 EMI units) adjacent to the lateral and inferior aspect of the
into both frontal lobes and the ventricular system. Subarachnoid left ambient cistern. Absorption values elevated to 24-44
EMI units
hemorrhage was also found, due to a rebleed after the last CT scan. after infusion of contrast medium. An angiogram showed a multi-
Recent massive left frontoparietal and moderate right parietal in- lobulated aneurysm of the ambient segment of a left posterior cere-
farctions were seen. Both frontal areas were swollen. bral artery, projecting infeniorly.
At surgery a 5-B mm multilobulated aneurysm of the posterior
cerebral artery was clipped. No thrombosis or adjacent hematoma
Surgica! Cases was present, and the appearance suggested a recent bleed.
Case 9. A 67-year-old female had sudden syncope followed by
Case 7. A 54-year-old male had a seizure. The cerebrospinal fluid left hemiparesis and aphasia. which cleared rapidly. Angiography
was clear and the neurological examination normal. CT scan (fig. 4) demonstrated an aneurysm of the anterior communicating artery.
showed a right supraclinoid inferior frontal abnormality with ab- The neurologic status was grade 1 at the time the aneurysm was
sorption values in the lower blood range (1 8-27 EMI units). Calci- clipped. Nine days after surgery she developed left hemiparesis and
fication was present posteriorly (31-66 EMI units) Following in- drowsiness. The CT scan (fig. 7) showed mass effect from a right
fusion of 300 ml of meglumine diatnizoate, the posterior portion and middle cerebral artery infarct and slight ventricular enlargement.
anterior rim of the abnormality showed enhancement (18-41 and There was progressive improvement, and a second scan was ob-
27-31 EMI units, respectively). A low absorption region in the cen- tamed 26 days later to check ventricular size. There was no hydro-
tral anterior aspect (18-27 EMI units) was consistent with a par- cephalus and less mass effect. One year after surgery she remained
tially thrombosed aneurysm. Angiography showed an aneurysm grade 1.
arising from the right internal carotid artery, just above the origin Case 10. A 51 -year-old hypertensive male had sudden left
of the ophthalmic artery. The size of the aneurysm was smaller than facial weakness, slurred speech, and nuchal rigidity. A multilobu-
the total volume of the high absorption abnormality on CT scan. lated aneurysm of the right middle cerebral artery was seen at
This was consistent with thrombus anteriorly. The low absorption angiography. The aneurysm was coated when the patient was
changes were interpreted as compressed edematous frontal lobe. grade 1 . The first CT study was obtained postoperatively 22 days
Surgical findings correlated well with CT findings, whereas the after onset. The patient was grade 1 , and the scan was negative.
angiognam had incompletely revealed the size of the aneurysm. A month later the patient developed a cough and left hemiparesis
 American Journal of Roentgenology 1976.127:143-153.

-
.-.
CT
IN

,.
BLEEDING
ANEURYSMS
151
 152 DAVIS ET AL.

and dysarthria. Angiography showed occluded right middle cerebral cerebral hematoma or subanachnoid or intraventricular
artery branches, thought to be secondary to a dislodged clot from
blood in the vicinity of one of the aneurysms, suggesting
the aneurysm. A CT scan 4 days later showed infarction with mass
that particular aneurysm as the cause of the bleed.
effect in the right frontotemporal region. He was grade 4 at this
time but subsequently improved.
Case 1 1. A 57-year-old hypertensive female had subarachnoid Patient Management
hemorrhage secondary to an aneurysm of the anterior communicat- Subarachnoid hemorrhage may be accompanied by
ing artery. The aneurysm was clipped. The patient was confused and
varying neurological symptoms. If the patient is alert on
drowsy postoperatively. CT scans were obtained 1 and 2 months
drowsy with little neunologic deficit, angiography is mdi-
postoperativelyto assess ventricularsize. The confusion and drowsi-
cated. If the patient has severe on increasing neurological
ness persisted even though both scans showed the ventricles to be
only minimally enlarged There was no evidence of infarction. deficit on increased intracranial pressure, the CT scan may
Case 12. A 55-year-old female was shown to have an aneurysm demonstrate the presence of hydrocephalus, intracenebral
of the right posterior communicating artery and severe spasm of on intraventniculan hemorrhage, on cerebral edema [5, 6]
the superior division of the night middle cerebral artery 4 and 8 (figs. 5-7), which could obviate the need for angiography
days, respectively. after subarachnoid hemorrhage. When the (table 4) and lead to prompt, appropriate treatment.
aneurysm was clipped 1 2 days after onset, the patient’s neurologic The patient with moderate to severe but stable neurologic
status was grade 1 . On the fourth postoperative day, angiography deficit who has subarachnoid hemorrhage will be medically
was performed, showing marked spasm in the right anterior and
treated for a period of time. The CT scan allows assessment
middle cerebral arteries and a mass effect. In an effort to exclude
for infarction and evaluation of hydnocephalus [5] as well
hematoma, a CT scan was obtained ; mass effect from infarct was
as resolution of associated edema.
seen. The patient was comatose. Three additional scans were ob-
American Journal of Roentgenology 1976.127:143-153.

tamed at monthly intervals for evaluation of ventricular size. A grade

Some patients who are alert develop deficit without evi-
3 neurologic deficit persisted, whereas the CT studies showed slight dence of recurrent hemorrhage. CT allows evaluation for
ventricular enlargement and evolution of the infarction. Use of developing hydrocephalus or infarction (fig. 8).
serial CT scans to assess ventricular size and define the infarction If some type of shunt is needed for hydrocephalus, CT
eliminated the need for angiography. permits evaluation of ventricular size (figs. 2 and 3). In
Case 13. After subarachnoid hemorrhage, a 51 -year-old female patients with a seizure disorder but no history of subarach-
was shown by angiognaphy to have an aneurysm of the posterior noid hemorrhage, CT with contrast medium may depict a
communicating artery. There was a question of a small mass effect, large aneurysm or arteniovenous malformation [5].
but two preoperative CT studies showed no abnormality. A grade 1 The CT scan may demonstrate a larger aneurysmal
neurologic deficit persisted before and after surgery. Two months
volume than the angiographic representation, due to
later there was a question of nebleed, but the scan was negative.
thrombosis in a portion of the sac (fig. 4). This information
The patient subsequently returned to grade 1 neurologic status.
may be very helpful if surgery is contemplated. Without use
of contrast medium, absorption values in the range of blood
Discussion may be seen. This can represent a thrombosed portion of
the aneurysm, a sufficiently large blood pool in the an-
The advent of CT has revolutionized the diagnostic and
eunysm, on an adjacent hematoma [5].
therapeutic approach to many intracranial problems [3, 4],
including subarachnoid hemorrhage due to aneurysm. Calcification in the wall of the aneurysm may be seen.
The blood pool of an aneurysm, if large enough to be de-
However, one difficulty is that the very sick patient is often
tected, will be noted as an area of enhancement following
not able to hold his head motionless for the required time.
administration of contrast medium. This region may be sub-
Use of short-acting sedatives has proved valuable in ob-
tracted from the remainder of the adjacent elevated absonp-
taming a satisfactory study. Hopefully, newer equipment
with shorter scanning times will obviate the need for seda- tion values seen on the baseline study. The difference be-

tion.
tween the two areas will either represent thrombus in the
sac or adjacent hematoma. A rim of enhancement may be
seen, representing the wall of the aneurysm (fig. 4).
Origin of Hemorrhage
Angiography requires a shorten period of head immobil-
Usually the origin of hemorrhage is determined by ization for a filming sequence and is obviously superior to
angiography. However, the CT scan may suggest the origin the CT scan in demonstrating an aneurysm and blood
of the bleed. At times an aneurysm is not seen on the first vessels. But since angiography is an invasive study associ-
angiogram but may be visualized on a later study. Spasm ated with potential morbidity and discomfort, the CT scan is
on an avascular mass effect from probable intracerebral valuable for repetitive studies (e.g., for assessing ventricular
hematoma, if present, may suggest the location of the size during the course of management). The CT scan is
angiognaphically invisible aneurysm. The CT scan may superior to the angiogram in depicting the presence of in-
demonstrate subarachnoid, intraventniculan, or intracenebral tracerebral or intraventricular hemorrhage [5] . The two
hemorrhage [5] confined to one particular region and studies are complementary in showing the presence of in-
thereby suggest the site of origin of the bleed (fig. 1, fanction when the clinical status has deteriorated and
table 3). spasm has been demonstrated angiognaphically [6] (table
Occasionally, multiple aneurysms are found at angiogna- 6).
phy without angiographic or neunologic criteria to suggest An initial CT scan revealing a marked amount of sub-
which aneurysm has bled. The CT scan may show an intra- anachnoid blood from an aneurysm suggests that com-
 CT IN BLEEDING ANEURYSMS 153

municating hydnocephalus may develop at a later date setts General Hospital, in Cerebra! Vascular Diseases, edited by
(fig. 2). The finding of marked subarachnoid and intra- Whisnant JP. Sandok BA, New York, Grune & Stratton, 1975,
ventricular blood usually correlates with poor neurologic pp 203-219

status and a poor prognosis. Deterioration of neunologic 2. Botterall EH, Loughead WM, Scott JW, Vanderwater SL:
Hypothermia and interruption of carotid, or carotid and vertebral
status, marked spasm, hydnocephalus, or angiographic
circulation in the surgical management of intracranial aneurysms.
demonstration of extravasation of contrast medium into the
J Neurosurg 1 3 : 1-42, 1956
ventricle also suggest a poor prognosis; depiction of large
3. New PFJ, Scott WA, Schnur JA, Davis KR, Taveras JM : Com-
amounts of subanachnoid and intraventnicular blood by CT
puterized axial tomography with the EMI scanner. Radiology
are now used as additional criteria (fig. 9). An occasional 1 1 0 : 1 09-1 23, 1 974
patient may do well after ventniculostomy has been per- 4. Paxton A, Ambrose J : The EMI scanner : a brief review of the
formed based on findings of intraventnicular hemorrhage on first 650 patients. BrJ Radio! 47 : 530-565, 1974
CT scan. The patient may need a shunt for communicating 5. Scott WA, New PFJ, Davis KR, Schnur JA : Computerized axial
hydnocephalus and is best followed by CT scan for yen- tomography in intracerebral and intraventnicular hemorrhage.
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Cerebral infarction diagnosis by computerized tomography:
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