LAUSR

A 44-year-old female presented at our hospital after collapse with headache and decrease of consciousness. The patient was directly transferred for head CT, which demonstrated a large subarachnoid hemorrhage located in the insular cistern on the right side (Fig. 1). At this moment, there was no intraventricular hemorrhage (IVH). During acquisition of a subsequent dynamic CT angiography, also referred to as 4D-CTA, the patient suffered an aneurysmal rebleed with leakage of contrast out of a middle cerebral artery (MCA) aneurysm on the right side with spread in the insular cistern. Furthermore, intraventricular breakthrough was seen with spread of contrast agent into the right lateral ventricle, the third and fourth ventricles with outflow into the subarachnoid space at the level of the greater foramen (Figs. 2 and 3, videos 1, 2, and 3). The patient underwent surgical clipping of the aneurysm with evacuation of the insular cistern hematoma. A week after admission, the patient underwent surgical decompression craniectomy because of progressive brain tissue edema with subfalcine herniation. During admission, the clinical condition of the patient improved with recovery of consciousness. The patient was transferred to a rehabilitation institute, and at 3-month follow-up, the remaining neurological deficits included left side motor weakness and left side hemianopsia.