• Swati Jain, Anil Gopinathan, Zhi Xu Ng, Yang Eugene Wei Ren EWR Division of Neurosurgery, Department of Surgery, Khoo Teach Puat Hospital, Singapore., Sein Lwin, Tseng Tsai Yeo, Ming Yang, Jiaxu Lim, Chee Hong Hew, Brian Chan, and Boon Chuan Pang.
• Division of Neurosurgery, University Surgical Cluster, National University Health System, Singapore. Electronic address: swati_jain@nuhs.edu.sg.
• World Neurosurg. 2020 Nov 1; 143: 1-6.

BackgroundSpontaneous intracerebral hemorrhage (ICH) is a devastating cerebrovascular disease with high morbidity and mortality. Branching pattern of the lenticulostriate arteries from the middle cerebral artery makes them susceptible to formation of microaneurysms, which have been implicated in hypertensive ICH. Recurrence of hematoma due to delayed development of pseudoaneurysm after initial surgical evacuation is uncommon.Case DescriptionOur patient is a 61-year-old gentleman who underwent primary evacuation of a spontaneous right-sided ICH. The initial vascular imaging was unremarkable for any underlying vascular malformation. After initial neurologic recovery, the patient developed another rebleeding in the hematoma cavity nearly 10 days after presentation. A formal angiogram showed the presence of a pseudoaneurysm that was treated via endovascular means.ConclusionsThe rates of rebleeding have ranged from 10%-40% in various studies and have been directly correlated with mortality. Since follow-up with angiograms are not a usual practice in spontaneous ICH management, such as pseudoaneurysmal rebleeds could go undiagnosed. This case report reinforces the need for a thorough angiographic evaluation in the event of a deviation from expected clinical course, rebleeding not in concordance with intraoperative findings and significantly delayed hematoma recurrence.Copyright © 2020 Elsevier Inc. All rights reserved.

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