Teaching NeuroImages: Multicompartmental intracranial hemorrhage in a pediatric patient.

A previously healthy 9-year-old girl presented with sudden-onset headache followed by confusion. In the emergency department, she was hypertensive, bradycardic, and no longer responsive to any stimuli. An emergent head CT scan demonstrated a left frontal intraparenchymal hematoma with intraventricular and subarachnoid extension as well as subfalcine herniation (figure). She underwent decompressive hemicraniectomy, and digital subtraction angiography confirmed a 7-mm left middle cerebral artery aneurysm (figure). Intracranial hemorrhage in a pediatric patient that traverses multiple compartments (intraparenchymal, subarachnoid, and intraventricular) has a short differential that should include trauma, coagulopathy, vascular abnormalities (middle cerebral artery aneurysm, arteriovenous malformation, dural arteriovenous fistulas, and reversible cerebral vasoconstriction), venous thrombosis, and cocaine abuse.