Title : Fatal Intracranial Bleed: A case of ruptured cerebral aneurysm with subarachnoid hemorrhage presenting as sudden loss of consciousness postcoitus
Abstract:
Background: Individuals with unruptured intracranial aneurysms are usually asymptomatic. Aneurysmal rupture is frequently precipitated by sudden increase in intracranial pressure or systemic blood pressure particularly during active exertion. This case report highlights a catastrophic presentation of postcoital aneurysmal rupture, emphasizing the importance of recognizing precipitating factors and rapid neurologic decline.
Case Presentation: This is a case of a 55-year old hypertensive male, noncompliant to his maintenance medications, who was brought to the emergency room due to sudden loss of consciousness immediately after sexual intercourse, preceded by headache. On assessment, he was noted to have severely depressed sensorium at GCS 8 with anisocoria and nuchal rigidity hence was subsequently hooked to ventilatory support. CT of the brain revealed extensive intracranial hemorrhage involving the right frontotemporoparietal region with intraventricular extension, subarachnoid hemorrhage, diffuse cerebral edema, and evidence of herniation. CT angiography demonstrated aneurysmal defects involving the right middle cerebral artery bifurcation, left anterior cerebral artery and anterior communicating artery.
Outcome: Despite aggressive management with hemodynamic support, patient had progressive neurologic deterioration and refractory shock. Neurosurgical intervention was considered, including craniotomy with evacuation of hematoma with or without clipping but was deferred due to poor prognosis and the patient ultimately succumbed to death in less than 30 hours of admission.
Conclusions: Subarachnoid hemorrhage secondary to aneurysmal rupture remains an important cause of mortality despite steady advances in diagnosis and management. Sexual intercourse is a recognized but an underreported trigger, as it induces transient hemodynamic changes. This case underscores the critical association between postcoital activity as a precipitating factor for aneurysmal rupture, likely mediated by abrupt surges in blood pressure and intracranial pressure during sexual activity in the background of noncompliance to hypertensive treatment.
