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A difficult case
Intracranial bleeding from collaterals following carotid artery occlusion
  1. Brendan McKenna1,
  2. Peter Flynn2,
  3. Peter J Kirkpatrick3,
  4. Ferghal McVerry1,
  5. Mark O McCarron1
  1. 1Department of Neurology, Altnagelvin Hospital, Derry, UK
  2. 2Department of Neuroradiology, Royal Victoria Hospital, Belfast, Northern Ireland, UK
  3. 3University Department of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
  1. Correspondence to Dr Mark O McCarron, Department of Neurology, Altnagelvin Hospital, Derry, BT47 6SB, UK; markmccarron{at}doctors.org.uk

https://doi.org/10.1136/practneurol-2015-001287

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    Case history

    A 53-year-old right-handed woman developed left pulsatile tinnitus. One year later she presented with a severe occipital headache with neck stiffness while defecating. On admission to hospital she was normotensive (blood pressure 120/70 mm Hg), with a Glasgow coma scale score of 15/15. Examination showed meningism but no focal features.

    Investigations

    CT scan of head showed a linear periventricular haemorrhage, centred upon the posterior aspect of the corpus callosum (figure 1A) with intraventricular haemorrhage. An MR scan of the brain 1 year before (when she had presented with left pulsatile tinnitus) had shown left internal carotid artery occlusion (figure 1B) and left hemisphere signal change, consistent with a watershed infarction (figure 1C). The same MR scan also showed extensive collateralisation from the left internal carotid artery occlusion, including prominent vessels in the corpus callosum (figure 1D).

    Figure 1

    (A) Unenhanced axial CT scan of head showing transverse linear haemorrhage in the splenium of corpus callosum. Axial T2 MRI of brain 1 year earlier showing (B) left internal cavernous carotid artery flow void is absent (arrow) implying occlusion, (C) numerous small T2 hyperintense internal watershed zone infarcts and (D) excess flow voids due to collateral vessels (arrow) in region of corpus callosum.

    A CT …

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    Footnotes

    • Contributors BM wrote the first draft and performed a literature search. PF conceived the idea, provided the neuroimaging figures and revised previous drafts. PJK provided neuroimaging and revised drafts of the paper. FM helped write the paper and revise previous drafts. MOM had the idea of writing the paper, performed a literature search, helped write the first draft and subsequent reviews.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed. This paper was reviewed by Martin Punter, Salford, UK.

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