• Ken Porche, Christopher Robinson, and Adam Polifka.
• McKnight Brain Institute, Department of Neurosurgery, University of Florida, Gainesville, Florida, USA. Electronic address: ken.porche@neurosurgery.ufl.edu.
• World Neurosurg. 2020 Dec 1; 144: 209-212.

BackgroundPerimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH) is characterized by a typical pattern of localized pretruncal hemorrhage on head computed tomography. PNSH is usually associated with a benign clinical course and a lower incidence of complications. The etiology is unknown, but many explanations have been proposed, including venous injury or rupture followed by thrombosis of a ruptured microaneurysm.Case DescriptionA 48-year-old man on apixaban for multiple venous thromboembolisms presented with the worst headache of his life associated with blurry vision, nausea, and neck stiffness. Computed tomography demonstrated a perimesencephalic pattern of blood (Hunt and Hess grade 2, Fisher grade 3). Computed tomography angiography and 6-vessel digital subtraction angiography demonstrated no precipitating cause. Systemic tissue plasminogen activator (tPA) was administered on postbleed day 8 owing to obstructive shock from saddle pulmonary embolism and pulseless electrical activity. He was safely discharged to rehabilitation with moderate neurological deficits attributed to ischemic effects of his cardiac arrest.ConclusionsSymptomatic saddle pulmonary embolism in the setting of intracranial hemorrhage creates conflicting risks of medical intervention. There are no case reports or evidence of the use of systemic thrombolysis in the setting of SAH. Owing to the benign natural history of PNSH, tPA may be a safe intervention. Neurointensivists and neurosurgeons should be aware that intravenous tPA was used safely for life-threatening pulmonary embolism in the setting of PNSH. Additionally, the use of tPA without resultant rebleeding in this case opposes the theory of the presence of a thrombosed ruptured microaneurysm.Copyright © 2020 Elsevier Inc. All rights reserved.

25 keywords...

hide…