Clinical Reasoning: A rare cause of subarachnoid hemorrhage

A 48-year-old woman presented with severe headache radiating to her neck and chest, followed by a brief period of loss of consciousness in the emergency department. After she regained consciousness, the patient described a 2-year history of right-sided pulsatile tinnitus and hearing loss. She also had a history of poorly controlled hypertension and of noncompliance with her medication. On examination her blood pressure was 239/90 mm Hg. Results of a neurologic examination were unremarkable. Brain CT showed a subarachnoid hemorrhage (figure 1, A and B). Figure 1 Initial head CT scan revealing subarachnoid hemorrhage (A) Noncontrast brain CT scan demonstrates a posterior fossa mass and subarachnoid hemorrhage. (B) Intraventricular hemorrhage is also demonstrated. ### Questions for consideration: 1. What are the possible etiologies of her subarachnoid hemorrhage? 2. What additional diagnostic testing would you consider at this point? CT angiography of the head and neck did not reveal any intracranial aneurysm or vascular malformation (figure 2, A and B). However, a large mass was present in the right jugular foramen with erosion of temporal bone and encroachment of the right internal acoustic canal. MRI confirmed a hypervascular mass that contained numerous flow voids. The mass was located lateral to the medulla and extended superiorly into the cerebellopontine angle cistern. It extended inferiorly to the superior aspect of the right parapharyngeal space and displaced the right internal carotid artery (figure 2C). Figure 2 Radiologic imaging study revealing a jugular foramen mass (A) CT angiogram showing an enhancing jugular foramen mass extending into the posterior fossa. (B) Enhancing tumor mass at the skull base. (C) MRI T2-weighted image showed salt-and-pepper appearance. (D) Selective right ascending pharyngeal angiogram lateral view shows a hypervascularized tumor blush, fed by 2 major branches from the enlarged right ascending pharyngeal artery. Catheter-based cerebral angiography demonstrated an intense hypervascular tumor blush extending from the superior aspect of the right carotid sheath …