Clinical problem-solving: aneurysm or spinal arteriovenous fistula-bait and switch

The authors use an instructive case to review the challenges of diagnosis in subarachnoid hemorrhage (SAH) and to reinforce the nuances of clinical management.

The presented case highlights critical issues in patient selection and challenges in the diagnosis of SAH and the management of both aneurysmal and arteriovenous fistula-related SAH. The critical points in decision making and diagnosis are discussed, and the case is accompanied by a brief review of the literature on the issues being faced.

The present case is a patient presenting with SAH who was found to have an anterior communicating artery aneurysm. However, clues in the presentation and workup point to another etiology.

A strong history of sudden neck pain before headache and abundance of SAH along the brainstem mandates a need to thoroughly evaluate the source of hemorrhage from cervical vessels through an angiogram.