2992 A vexing haemorrhage

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Background/ Objectives In convexity subarachnoid haemorrhage (cSAH), when computed tomography (CT) and magnetic resonance imaging (MRI) do not demonstrate an apparent cause, consideration of invasive investigations may be required. This situation may present a challenge in instances of atypical presentations.Methods In this case report, a patient is described who presented with bilateral cSAH and atypical symptoms.Results A 76-year-old male presented to the emergency department initially with hypertension (approximately 200mmHg systolic), after having been told to do so by an after-hours helpline. He was asymptomatic, aside from 1 week of preceding lower back pain. A CT was performed of the abdomen to exclude a retroperitoneal hematoma, which was unrevealing. During this CT he described developing an abnormal sensation in his legs. He was discharged to home ambulant. After sleeping at home, he awoke to discover he was unable to move his right leg, and re-presented. A CT brain and angiogram demonstrated only cSAH overlying both frontal and parietal lobes. MRI of the brain confirmed cSAH and small volume intraventricular haemorrhage, and MRI spine demonstrated extensive spinal subarachnoid haemorrhage from T3-S2. Subsequently, the patient had a recurrence of back pain (without headache), likely epilepsia partialis continua manifesting as left foot myoclonus. A spinal digital subtraction angiography (DSA) was unrevealing. A subsequent cerebral DSA demonstrated a cerebral dural arteriovenous fistula (AVF), which was subsequently embolised.Conclusion This case demonstrates that cSAH can manifest with back pain without headache, and focal myoclonus. The value of pursuing invasive imaging in cSAH is highlighted.

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