Sylvian fissure subpial hematoma: a rare imaging presentation of a ruptured middle cerebral artery aneurysm

A 68-year-old female patient with a previously unruptured aneurysm in the left middle cerebral artery ([Figure 1]) presented with aphasia and severe headache. A computed tomography angiography (CTA) showed growth and new lobulation ([Figure 1]) associated with hemorrhages, including a large sylvian hematoma, probably in the subpial compartment ([Figure 2]). The findings suggested aneurysm rupture.

Figure 1 Previous head computed tomography angiography (CTA) (A–C) and head magnetic resonance angiography (MRA) (D); head CTA (E-F) follow-up on acute presentation. Increased size and new lobulation of the saccular left middle cerebral artery (MCA) aneurysm bifurcation (orange and red arrows).

Figure 2 Head CT without IV contrast immediately after patient's severe headache. Interval large acute hematoma along the left sylvian fissure, probably in the subpial compartment (red arrowheads). There was local mass effect with adjacent opercular cortex compression (green arrows). Small component of subdural (yellow asterisks) and subarachnoid (orange arrows) hemorrhages were also visualized.

Subpial hemorrhages happen within the potential space between the pia mater and cortex and are extremely rare in adults.[1] It is hypothesized that the presence of blood below the pia may damage thin arteries, with secondary bleeding and hemorrhage expansion.[2] They may cause injury to the cortex and severe edema and vasospasm, resulting in a poor prognosis ([Figure 3]).[1] [2] [3]

Figure 3 Immediate post operative CT head showing left decompressive craniectomy, right frontal ventriculostomy, aneurysm clipping (black arrow), and partial left sylvian fissure subpial hematoma evacuation (red arrowhead). Note is made for significant edematous changes along the left temporal and insular lobes (white asterisks).

Editor-in-Chief

Hélio A. G. Teive.

Associate Editor

Leandro Tavares Lucato.

Authors' Contributions

JAS: conceptualization or design of the work, data acquisition, and writing the manuscript; TPR: conceptualization or design of the work, and data acquisition; MDB: conceptualization or design of the work, data acquisition, and analysis or interpretation; JEM: conceptualization or design of the work, data acquisition, and analysis or interpretation; LFF: analysis or interpretation, and review of the manuscript. All authors approved the final version of the manuscript and agree to be responsible for all aspects of the work.

Publication History

Received: 05 April 2024

Accepted: 01 May 2024

Article published online:
31 August 2024

• References

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• 2 Hilditch CA, Sonwalkar H, Wuppalapati S. Remote multifocal bleeding points producing a Sylvian subpial hematoma during endovascular coiling of an acutely ruptured cerebral aneurysm. J Neurointerv Surg 2017; 9 (07) e25
• 3 Suzuki K, Matsuoka G, Abe K, Okada Y, Sakai S. Subpial Hematoma and Extravasation in the Interhemispheric Fissure with Subarachnoid Hemorrhage. Neuroradiol J 2015; 28 (03) 337-340