The cause of intracerebral, subarachnoid and subdural haemorrhage is different, and
the simultaneous appearance in the same case is extremely rare. We describe the case
of a patient with a ruptured aneurysm on the distal segment of the middle cerebral
artery, with a concomitant subdural and intracerebral haemorrhage, and a subsequent
secondary brainstem (buret) haemorrhage. The 59-year-old woman had hypertension and
diabetes in her medical history. She experienced anomic aphasia and left-sided headache
starting one day before admission. She had no trauma. A few minutes after admission
she suddenly became comatose, her breathing became superficial. Non-contrast CT revealed
left sided fronto-parietal subdural and subarachnoid and intracerebral haemorrhage,
and bleeding was also observed in the right Pontine region. The patient had leucocytosis
and hyperglycemia but normal hemostasis. After the subdural haemorrhage had been evacuated,
the patient was transferred to intensive care unit. Sepsis developed. Echocardiography
did not detect endocarditis. Neurological status, vigilance gradually improved. The
rehabilitation process was interrupted by epileptic status. Control CT and CT angiography
proved an aneurysm in the peripheral part of the left middle cerebral artery, which
was later clipped. Histological examination excluded mycotic etiology of the aneurysm
and "normal aneurysm wall" was described. The brain stem haemorrhage - Duret bleeding
- was presumably caused by a sudden increase in intracranial pressure due to the supratentorial
space occupying process and consequential trans-tentorial herniation. This case is
a rarity, as the patient not only survived, but lives an active life with some residual
symptoms.
