Abstract
A 47-year-old man with a history of smoking and hypertension had a severe, sudden headache. Head CT showed subarachnoid hemorrhage (SAH) (figure, A). Progressive ophthalmoplegia developed without alteration of consciousness. Catheter angiography was normal (figure, B). Brain MRI documented bilateral thalamic infarcts (figure, C). Repeat catheter angiography after 4 days showed a 2-mm dissecting pseudoaneurysm of a thalamoperforator (figure, D and E). Serial noninvasive vascular studies documented no growth. Six weeks later, a catheter angiogram demonstrated complete resolution of the pseudoaneurysm (figure, F).Bilateral third nerve palsy persisted at 1 year follow-up. Dissecting pseudoaneurysms of perforating posterior circulation vessels can present with a pattern suggestive of perimesencephalic SAH. Presence of associated neurologic deficits should increase the level of suspicion. Spontaneous resolution can occur without invasive treatment.1
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