Lower limb weakness with gyrus rectus hematoma: an unusual presentation of paraclinoid aneurysm; a case report with review of literature

Abstract

Lower limb weakness is usually a feature of ruptured anterior communicating (ACom) aneurysms due to spasm of the anterior cerebral arteries. Paraclinoid aneurysms, in addition to other cardinal features of subarachnoid haemorrhage (SAH), usually present with headache and visual field defects due to compression of the optic pathway. We report a case of left paraclinoid aneurysm presenting with right lower limb weakness and gyrus rectus hematoma without SAH. The aneurysm was long, passing beneath the optic nerve to emerge in the inter-optic cistern, leading to such atypical presentation. The aneurysm was clipped successfully after drilling the clinoid. As per our knowledge, such a clinical presentation of paraclinoid aneurysm has not been reported in the literature till date.

Rectus gyrus hematoma: An overview

“…In patients with ruptured Acom aneurysms, the symptoms are usually related to SAH, such as headache, vomiting, and other symptoms of SAH. [4,8,12] Disinhibition as one of the possible presentations has been reported. Winckler et al reported a case of a patient who had an athymhormic syndrome where there is a loss of interest for anterior preoccupations, loss of subjective feeling, mainly when dealing with a pleasant or unpleasant situation (anhedonia), and loss of spontaneity.…”

“…[14] Furthermore, other ruptured aneurysms linked to RGH include a left paraclinoid internal carotid artery aneurysm leading to the left GR hematoma without SAH, and anterior ethmoidal artery aneurysm rupture has been described to be in association with RGH. [4,12] Non-aneurysmal pathologies e literature did not name the RGH as a finding of any non-aneurysmal lesions. However, one can argue that hemorrhage in the inferomedial aspect of the frontal lobe from any cause can be included in the spectrum of RGH.…”

“…[14] e right lower limb weakness was documented when Patankar and Vaja reported an unusual presentation of RGH. [12] In addition, recurrent headaches with seizure episodes were reported as a potential presentation by Kareem et al [8] PROGNOSIS e isolated clinical prognosis of RGH cannot be specified based on the current available evidence. However, the general overview based the available reports, there is a noticeable good prognosis trend from all the described etiologies underlying RGH.…”

“…[ 14 ] Furthermore, other ruptured aneurysms linked to RGH include a left paraclinoid internal carotid artery aneurysm leading to the left GR hematoma without SAH, and anterior ethmoidal artery aneurysm rupture has been described to be in association with RGH. [ 4 , 12 ]…”

“…In patients with ruptured Acom aneurysms, the symptoms are usually related to SAH, such as headache, vomiting, and other symptoms of SAH. [ 4 , 8 , 12 ] Disinhibition as one of the possible presentations has been reported. Winckler et al .…”