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Case report
Republished: Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm
  1. Christopher Alan Hilditch,
  2. Hemant Sonwalkar,
  3. Siddhartha Wuppalapati
  1. Department of Neuroradiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, Lancashire, UK
  1. Correspondence to Dr C A Hilditch, Department of Neuroradiology, Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston Hospital, Sharoe Green Lane North, Fulwood, Preston, Lancashire PR2 9HT, UK; hilditchca{at}


Subpial hematoma is a rare type of intracranial hemorrhage with a poor prognosis. A new mechanism to explain subpial Sylvian hematoma formation in acute post-aneurysmal subarachnoid hemorrhage (SAH) was observed during coiling of a posterior communicating artery aneurysm. Multiple small bleeding points from pial branches of the left middle cerebral artery, which were remote from the ruptured aneurysm, were observed on conventional angiography. This bleeding led to the formation of a large expanding subpial Sylvian hematoma. Similar observations have been recently demonstrated on 4D CT angiography (4D CTA). We present a case that adds evidence to the literature in support of a new mechanism of subpial hematoma formation in the setting of acute SAH. This may advocate the early use of 4D CTA and conveys a poor prognosis, which might influence treatment decisions.

  • Subarachnoid
  • Aneurysm
  • Coil
  • Hemorrhage

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  • Republished with permission from BMJ Case Reports Published 17 November 2016; doi:10.1136/bcr-2016-012715

  • Contributors CAH wrote the case report and reviewed the relevant literature. HS helped to write the case report. SW and CAH performed the coiling procedure.

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.