Vasculopathy and Increased Vascular Congestion in Fatal COVID-19 and Acute Respiratory Distress Syndrome.

Rationale: The leading cause of death in coronavirus disease 2019 (COVID-19) is severe pneumonia, with many patients developing acute respiratory distress syndrome (ARDS) and diffuse alveolar damage (DAD). Whether DAD in fatal COVID-19 is distinct from other causes of DAD remains unknown. Objective: To compare lung parenchymal and vascular alterations between patients with fatal COVID-19 pneumonia and other DAD-causing etiologies using a multidimensional approach. Methods: This autopsy cohort consisted of consecutive patients with COVID-19 pneumonia (n = 20) and with respiratory failure and histologic DAD (n = 21; non-COVID-19 viral and nonviral etiologies). Premortem chest computed tomography (CT) scans were evaluated for vascular changes. Postmortem lung tissues were compared using histopathological and computational analyses. Machine-learning-derived morphometric analysis of the microvasculature was performed, with a random forest classifier quantifying vascular congestion (CVasc) in different microscopic compartments. Respiratory mechanics and gas-exchange parameters were evaluated longitudinally in patients with ARDS. Measurements and Main Results: In premortem CT, patients with COVID-19 showed more dilated vasculature when all lung segments were evaluated (P = 0.001) compared with controls with DAD. Histopathology revealed vasculopathic changes, including hemangiomatosis-like changes (P = 0.043), thromboemboli (P = 0.0038), pulmonary infarcts (P = 0.047), and perivascular inflammation (P < 0.001). Generalized estimating equations revealed significant regional differences in the lung microarchitecture among all DAD-causing entities. COVID-19 showed a larger overall CVasc range (P = 0.002). Alveolar-septal congestion was associated with a significantly shorter time to death from symptom onset (P = 0.03), length of hospital stay (P = 0.02), and increased ventilatory ratio [an estimate for pulmonary dead space fraction (Vd); p = 0.043] in all cases of ARDS. Conclusions: Severe COVID-19 pneumonia is characterized by significant vasculopathy and aberrant alveolar-septal congestion. Our findings also highlight the role that vascular alterations may play in Vd and clinical outcomes in ARDS in general.

Student views on recognition and payment options for gamete donation in New Zealand.

BACKGROUND: Demand for donor gametes in New Zealand significantly outweighs the number of willing donors. Payment for donation has been suggested as a viable solution to increase the supply and attract more donors in acknowledging the time, effort and inconvenience associated with donation. AIMS: Internationally, university students are a commonly targeted group for paid gamete donation. This study aims to explore the views of university students in New Zealand to gauge their support and concerns relating to a range of options to recognise donors, including payment. METHODS: Two hundred and three tertiary students completed a questionnaire exploring their views on various forms of recognition for donation and concerns relating to payment. RESULTS: Participants indicated the greatest support for reimbursement for expenses directly related to the donation process. Payment constituting explicit financial advantage was regarded least favourably. Participants held concerns that payment would attract people donating for the 'wrong' reasons and lead to donors concealing relevant histories. Further concerns included payment increasing costs for recipients and causing disparities in access to gametes. CONCLUSIONS: The findings of this study suggest that within a New Zealand context a culture of gift-giving and altruism are strongly held principles towards reproductive donation, including among the student population. This highlights the need to consider alternative strategies to commercial models to overcome donor shortages which are in line with the cultural and legislative context of New Zealand.

Lymphocyte-activation gene 3 in non-small-cell lung carcinomas: correlations with clinicopathologic features and prognostic significance.

Lymphocyte-activation gene 3 (LAG-3) modulates the tumor microenvironment through immunosuppressive effects. Its associations with clinicopathologic parameters and prognostic significance in non-small-cell lung carcinomas remain unclear. We examined LAG-3 expression in 368 resected non-small-cell lung carcinomas (including 218 adenocarcinomas and 150 squamous-cell carcinomas) using tissue microarrays, with normalization to CD8+ T-cell count (LAG-3/CD8 index), and correlated LAG-3, CD8, and LAG-3/CD8 index with clinicopathologic features, molecular status, and survival. LAG-3 expression in the immune cells (ranged 0.35-540.1 cells/mm²) was identified in 92% of non-small-cell lung carcinomas. In adenocarcinomas and squamous-cell carcinomas, LAG-3 expression correlated with CD8+ T-cell count and PD-L1 expression. In adenocarcinomas, high LAG-3 expression (defined as >median) was additionally associated with smoking history, high T stage, aggressive pathologic features (solid-predominant histologic pattern, lymphovascular invasion, and nodal metastasis), and lack of EGFR mutation. In the entire resected tumor cohort and in adenocarcinomas, high LAG-3 and LAG-3/CD8 index were each associated with worse overall survival. In squamous-cell carcinomas, high CD8 was associated with better overall survival. In an exploratory analysis of pretreatment samples from advanced non-small-cell lung carcinoma patients treated with pembrolizumab, high CD8 was predictive of improved overall and progression-free survival, while high LAG-3, but not high LAG-3/CD8 index, was associated with improved progression-free survival. In conclusion, the clinicopathologic correlations and prognostic impact of LAG-3 in non-small-cell lung carcinoma are histotype-dependent, highlighting differences in the immune microenvironment between adenocarcinomas and squamous-cell carcinomas. The predictive impact of LAG-3 warrants further investigation.

Mosaicism for Receptor Tyrosine Kinase Activation in a Glioblastoma Involving Both PDGFRA Amplification and NTRK2 Fusion.

Rearrangements involving the neurotrophic receptor tyrosine kinase (NTRK) gene family have been reported in diverse tumor types, and NTRK-targeted therapies have recently been approved. In this article, we report a case of a 26-year-old man with an NTRK2-rearranged isocitrate dehydrogenase-wild-type glioblastoma who showed a robust but temporary response to the NTRK inhibitor larotrectinib. Rebiopsy after disease progression showed elimination of the NTRK2-rearranged tumor cell clones, with secondary emergence of a PDGFRA-amplified subclone. Retrospective examination of the initial biopsy material confirmed rare cells harboring PDGFRA amplification. Although mosaic amplification of multiple receptor tyrosine kinase genes in glioblastoma has been previously described, mosaicism involving a fusion gene driver event has not. This case highlights the potential efficacy of NTRK-targeted treatment in glioblastoma and the implications of molecular heterogeneity in the setting of targeted therapy. KEY POINTS: This case highlights the efficacy of the NTRK inhibitor larotrectinib in treating NTRK-rearranged glioblastoma. This is the first case to demonstrate mosaicism in glioblastoma involving both a fusion gene and amplification for receptor tyrosine kinases. Intratumoral heterogeneity in glioblastoma has significant implications for tumor resistance to targeted therapies.

Factors associated with myocardial SARS-CoV-2 infection, myocarditis, and cardiac inflammation in patients with COVID-19.

COVID-19 has been associated with cardiac injury and dysfunction. While both myocardial inflammatory cell infiltration and myocarditis with myocyte injury have been reported in patients with fatal COVID-19, clinical-pathologic correlations remain limited. The objective was to determine the relationships between cardiac pathological changes in patients dying from COVID-19 and cardiac infection by SARS-CoV-2, laboratory measurements, clinical features, and treatments. In a retrospective study, 41 consecutive autopsies of patients with fatal COVID-19 were analyzed for the associations between cardiac inflammation, myocarditis, cardiac infection by SARS-CoV-2, clinical features, laboratory measurements, and treatments. Cardiac infection was assessed by in situ hybridization and NanoString transcriptomic profiling. Cardiac infection by SARS-CoV-2 was present in 30/41 cases: virus+ with myocarditis (n = 4), virus+ without myocarditis (n = 26), and virus- without myocarditis (n = 11). In the cases with cardiac infection, SARS-CoV-2+ cells in the myocardium were rare, with a median density of 1 cell/cm2. Virus+ cases showed higher densities of myocardial CD68+ macrophages and CD3+ lymphocytes, as well as more electrocardiographic changes (23/27 vs 4/10; P = 0.01). Myocarditis was more prevalent with IL-6 blockade than with nonbiologic immunosuppression, primarily glucocorticoids (2/3 vs 0/14; P = 0.02). Overall, SARS-CoV-2 cardiac infection was less prevalent in patients treated with nonbiologic immunosuppression (7/14 vs 21/24; P = 0.02). Myocardial macrophage and lymphocyte densities overall were positively correlated with the duration of symptoms but not with underlying comorbidities. In summary, cardiac infection with SARS-CoV-2 is common among patients dying from COVID-19 but often with only rare infected cells. Cardiac infection by SARS-CoV-2 is associated with more cardiac inflammation and electrocardiographic changes. Nonbiologic immunosuppression is associated with lower incidences of myocarditis and cardiac infection by SARS-CoV-2.

Sensitivity to Noise Following a Mild Traumatic Brain Injury: A Longitudinal Study.

OBJECTIVE: To describe changes in the prevalence and clinical correlates of noise sensitivity (NS) in mild traumatic brain injury (mTBI) across a 12-month period and to determine whether NS at an early stage of recovery has predictive value for later postconcussive symptoms. SETTING: A mixed urban and rural region of New Zealand. PARTICIPANTS: Data for 341 adults (201 males, 140 females; age range from 16 to 91 years) were extracted from a 1-year TBI incidence, and outcomes study was conducted in New Zealand. DESIGN: Secondary analysis of data from a community-based, longitudinal population study of an mTBI incidence cohort collected within 1 week of injury (baseline) and at 1, 6, and 12 months postinjury. MAIN MEASURES: Measures at baseline (within 2 weeks of the injury) and 1, 6, and 12 months included the Rivermead Post-concussion Symptoms Questionnaire and its NS item, the Hospital Depression and Anxiety Scale, and the computerized CNS-Vital Signs neurocognitive test. RESULTS: NS progressively declined postinjury, from 45% at baseline to 28% at 12 months. In turn, NS showed itself as a significant predictor of future postconcussive symptoms. CONCLUSION: Taken together with previous research, the findings of the current study indicate that NS may have clinical utility in flagging vulnerability to persistent postconcussive symptoms.

Support for recognition and payment options for egg and sperm donation in New Zealand and Australia.

STUDY QUESTION: To what extent do infertility clinic patients, fertility industry professionals and members of the public support different forms of payment and recognition for egg and sperm donation? SUMMARY ANSWER: While participants expressed support for reimbursement of expenses for both egg and sperm donation, payment constituting explicit financial advantage was regarded less favourably although potentially necessary to address donor gamete shortages. WHAT IS KNOWN ALREADY: In both New Zealand and Australia, commercial inducement for the supply of gametes is prohibited. This prohibition has been argued to contribute to limited availability of donor gametes with the effect of increasing waiting lists and/or the pursuit of potentially unregulated cross-border reproductive care by domestic patients requiring donor gametes. STUDY DESIGN, SIZE, DURATION: The study was a mixed methods study drawing on data from a questionnaire completed by 434 participants from across New Zealand and Australia between November 2018 and March 2019. PARTICIPANTS/MATERIALS, SETTING, METHODS: Stakeholders involved in donor-assisted conception (past and present infertility patients, gamete recipients and donors), fertility industry professionals and members of the public were recruited following online advertisement of the study. All participants spoke English and primarily identified as Caucasian. Participants anonymously completed an online questionnaire gauging their support for a range of recognition and payment options. Dependent samples t-tests were used to probe for differences in support of recognition and payment options in relation to egg and sperm donation. Linear regression models were used to determine factors predicting support for the different options for both egg and sperm donation. Thematic analysis was used to identify main themes in free text question responses. MAIN RESULTS AND THE ROLE OF CHANCE: Broadly, there was agreement that donors be reimbursed for medical expenses, travel time, unpaid time away from work relating to treatments and out-of-pocket expenses directly related to the gamete donation process, with greater support suggested for egg versus sperm donors. Items gauging support for non-material recognition and tokens of thanks for donations were not significantly different between egg and sperm donation programmes (P > 0.05) nor rated as highly as reimbursement alternatives. Lowest ratings of support were indicated for the outright payment or reward of donors for the supply of their gametes, options that would leave donors in better financial positions. Qualitatively, themes valuing gamete donation as ideally relating to gifting were identified, although counterbalanced in opinion by concepts of fairness in reimbursing gamete donors for their costs. Where payment over and above the reimbursement of costs was supported, this was related to pragmatic considerations of limited supply of donor gametes. LIMITATIONS, REASONS FOR CAUTION: This study used a cross-sectional design and consequently causal inferences cannot be made. Additionally, participants particularly professional fertility staff, were required to self-report on politically sensitive and legal issues with the potential for social desirability response bias. Snowball sampling may have led to participation of like-minded individuals, thus limiting generalizations of findings. WIDER IMPLICATIONS OF THE FINDINGS: In a climate of global commercialization of reproductive medicine, limited donor gamete availability and rising incidences of cross-border reproductive care, the findings of this study can be used as a basis for further discussion between regulators and professional industry stakeholders with respect to shaping ethical policy and practice relating to donor conception. STUDY FUNDING/COMPETING INTEREST(S): No external funds were sought for this work. None of the authors have any competing interests to declare. TRIAL REGISTRATION NUMBER: N/A.

The Epidemiology of Noise Sensitivity in New Zealand.

BACKGROUND: Sensitivity to noise, or nuisance sounds that interrupt relaxation and task-related activities, has been shown to vary significantly across individuals. The current study sought to uncover predictors of noise sensitivity, focussing on possible social and cultural determinants, including social position, education, ethnicity, gender, and the presence of an illness. METHOD: Data were collected from 746 New Zealand adults residing in 6 areas differentiated by social position. Participants responded to questions probing personal characteristics, noise sensitivity, illness, neighbourhood problems, and noise annoyance. It was hypothesized that those in high-deprivation areas and/or experiencing illness report higher levels of noise sensitivity. RESULTS: Approximately 50 and 10% of the participants reported being moderately or very noise sensitive, respectively. Significant predictors of noise sensitivity included age, length of residence, level of social deprivation, and self-reported illness. CONCLUSION: There is evidence of social determinants of noise sensitivity, including social position and residential factors.

The association between health-related quality of life and noise or light sensitivity in survivors of a mild traumatic brain injury.

PURPOSE: Sensory impairment is a common aftereffect of mild traumatic brain injury (TBI); however, their influence upon treatment outcomes and quality of life has yet to be investigated. This study sought to determine the effects of noise and light sensitivity upon the quality of life of individuals diagnosed with a TBI. METHODS: A cross-sectional adult sample obtained from a longitudinal study (n = 293) provided measures of light and noise sensitivity and quality of life 12 months post injury. Sensitivities were taken from the Rivermead Post-concussion Symptoms Questionnaire, while quality of life was estimated using the Short-Form 36 health survey (SF-36). RESULTS: Approximately 42% of participants reported ongoing difficulties with noise and light sensitivity. Additionally, those reporting sensory difficulties also reported lower SF-36 domain and composite scores compared to those reporting no such symptoms. After controlling for known co-factors, hierarchical multiple regression analyses indicated that the combination of light and noise sensitivity explained between 8 and 35% of the variance in SF-36 scores. CONCLUSIONS: Light and noise sensitivity appear to degrade the quality of life of those with a mild TBI. Our findings challenge contemporary rehabilitation practices that tend to sideline sensory complaints and instead focus on the remediation of acute TBI symptoms.

Clinical correlates of noise sensitivity in patients with acute TBI.

Primary objective: The impact of noise sensitivity (NS) on the daily functioning of people who have experienced a traumatic brain injury (mTBI) is an understudied area, particularly following mTBI. The primary objective of this cross-sectional study was to investigate clinical markers of NS in a sample of New Zealand adults following mTBI. Research design: Cross-sectional study. Methods and procedures: A community-based sample of 151 adults who had experienced a brain injury in the last two weeks completed assessments estimating cognitive functioning, postconcussion symptoms (including NS), and affective state. Results: Over half the sample (59%) reported some degree of NS. Exploratory statistical analyses indicated that NS was associated with being female, living in a rural area, number of previous brain injuries, cognitive flexibility scores, reaction time, perceptions of recovery, anxiety, and depression. Regression analyses revealed that anxiety was the dominant correlate of NS (B = .120, p < .001, 95% CI [0.069, 1.71]). Conclusions: As the first study to explore the correlates of NS following mild TBI, the findings have important clinical and research implications. The present findings suggest that treatment approaches targeting anxiety may be effective in reducing NS in people who have experienced a brain injury. Moreover, evidence is presented suggesting that NS is unlikely to reflect malingering, and should be treated as a genuine somatic symptom of brain injury.

Resection of an extensive thoracic arachnoid cyst via less-invasive targeted laminoplasties.

OBJECTIVE: Spinal arachnoid cysts are a known cause of spinal cord compression. When symptomatic, treatment of choice entails laminectomies over the length of the cyst in order to achieve complete cyst removal and fenestration. METHODS: A 60-year-old woman presented with a one-year history of progressive pain between the shoulder blades, exacerbated by sitting up or standing, and relieved by lying supine. MRI imaging revealed a T3-T7 dorsal intradural arachnoid cyst. Due to extant spinal deformity and medical comorbidity, the decision was made to proceed with selective laminoplasties at the superior and inferior limits of the cyst. RESULTS: After the dura was opened to reveal the margins, the cyst was sharply fenestrated and drained. Irrigation was passed through the cyst to ensure open communication, and a lumbar drain catheter was passed from the inferior to superior margin. The catheter was removed before closure. Postoperatively, MRI of the thoracic spine revealed decompression of the spinal cord and the patient noticed improvement in her symptoms. At 7-month follow-up, the patient remained free of symptoms and MRI demonstrated near-complete resolution of the cyst. CONCLUSION: Although open exposure and complete resection are considered the treatment of choice for spinal arachnoid cysts, cyst fenestration through selective bony windows at the margins of the cyst represents a viable, less invasive alternative approach to effective cyst decompression, and can be considered in patients in whom a full exposure would be prohibitive.

Design, Application and Infield Validation of a Pre-Hospital Emergent Large Vessel Occlusion Screening Tool: Ventura Emergent Large Vessel Occlusion Score.

BACKGROUND: The outcome of endovascular treatment for emergent large vessel occlusion (ELVO) is dependent on timely recanalization. To identify ELVO in the field, we present a simplified score, which has been applied and validated in the field by emergency medical services (EMS). Methods and Analysis: Ventura ELVO Scale (VES) comprise of 4 components: Eye Deviation, Aphasia, Neglect, and Obtundation with score range 0-4. The score of greater than or equal to 1 will be considered as ELVO positive. A positive VES along with positive Cincinnati scale prompts ELVO activation. EMS then notify to neurointervention protocol at the receiving stroke center. The performance of VES was evaluated retrospectively. For statistical analysis, SAS version 9.4 was used and Fisher's modelling was used for the comparative analysis. RESULTS: Total 184 patients were included in the final analysis, 62 (33.7%) patients were called VES positive from the field. Out of 62, 36 (58%) patients had ELVO. The mean NIHSS on arrival was 16 in VES positive and 5 in VES negative patients. VES was 94.7% sensitive and 82.4% specific while the PPV and NPV of VES were 58.1% and 98.4%, respectively. It showed 84.9% accuracy. CONCLUSIONS: VES is an effective and simplified prehospital screening tool for detection of ELVO in the field. Its implementation can beat the target door to groin time to improve outcomes and in future it can be used for rerouting of ELVO patients to comprehensive stroke center.

The use of freeze-dried retronasal stimuli to assess olfactory function.

OBJECTIVES: To evaluate a test of olfactory perception that uses freeze-dried stimuli developed to rapidly release aromas capable of migrating to the olfactory mucosa retronasally. DESIGN: Validation study. SETTING: Psychology and Chemistry Departments. PARTICIPANTS: First, 15 participants provided data for psychometric functions. Second, 70 participants made perceptual judgments of retronasal stimuli. Inclusion criterion included informed consent and a satisfactory Nasal Obstruction Symptom Evaluation result. MAIN OUTCOME MEASURES: First, psychometric functions were generated for two types of freeze-dried stimuli (coffee and orange) using the Single-Interval Adjustment Matrix method. Second, participants provided ratings of pleasantness, intensity, and familiarity and performed a standardised identification test using seven retronasally presented aromas alongside the previously validated Sniffin' Sticks orthonasal olfactory test. RESULTS: Psychometric functions indicated a dose-response relationship between aroma concentration and probability of detection. Test-retest reliability of the retronasal stimuli was acceptable (r70  = 0.72, P < 0.001), and identification scores were not dependent on testing method (ie, retronasal vs Sniffin' Sticks). Stimuli delivered using the Sniffin' Sticks test were rated more pleasant than their retronasal counterparts. CONCLUSIONS: Freeze-dried retronasal stimuli offer an easy-to-use and rapid means to test olfaction function and are arguably well suited for clinical practice, but require further development and trialing prior to the adoption in the clinical context.

Health-related quality of life is impacted by proximity to an airport in noise-sensitive people.

INTRODUCTION: The aim of the study was to determine whether those who are noise sensitive are more adversely affected by airport noise than those who are not noise sensitive. PARTICIPANTS AND METHODS: One area was very close to Wellington International Airport and the other was distant from the airport and any other major sources of noise such as motorways and railways. Noise sensitivity was self-rated on a three-point scale as follows: non-noise sensitive, moderately noise sensitive, or highly noise sensitive. Statistical analysis consisted of analyses of variance using the domains of the WHOQOL score with the year, area (airport or the control), and noise sensitivity as covariates. RESULTS: Noise-sensitive people were found to have a significantly poorer HRQOL than others when they lived near an airport, but not when they lived in the control area. The same effect was present at both of the time points investigated, suggesting that it is a general finding. DISCUSSION: This finding is consistent with similar studies using the WHOQOL-BREF for investigating noise from road traffic, suggesting consistency in effect across transport noise sources.

Listening to music can influence hedonic and sensory perceptions of gelati.

The dominant taste sensations of three different types of chocolate gelati (milk chocolate, dark chocolate, and bittersweet chocolate) were determined using forty five trained panellists exposed to a silent reference condition and three music samples differing in hedonic ratings. The temporal dominance of sensations (TDS) method was used to measure temporal taste perceptions. The emotional states of panellists were measured after each gelati-music pairing using a scale specifically developed for this study. The TDS difference curves showed significant differences between gelati samples and music conditions (p < 0.05). Sweetness was perceived more dominant when neutral and liked music were played, while bitterness was more dominant for disliked music. A joint Canonical Variate Analysis (CVA) further explained the variability in sensory and emotion data. The first and second dimensions explained 78% of the variance, with the first dimension separating liked and disliked music and the second dimension separating liked music and silence. Gelati samples consumed while listening to liked and neutral music had positive scores, and were separated from those consumed under the disliked music condition along the first dimension. Liked music and disliked music were further correlated with positive and negative emotions respectively. Findings indicate that listening to music influenced the hedonic and sensory impressions of the gelati.

A Cross-Sectional Comparison of Quality of Life Between Physically Active and Underactive Older Men With Prostate Cancer.

Men with prostate cancer experience many side effects and symptoms that may be improved by a physically active lifestyle. It was hypothesized that older men with prostate cancer who were physically active would report significantly higher levels of quality of life (QOL) as assessed by the WHOQOL-BREF and the WHOQOL-OLD. Of the 348 prostate cancer survivors who were invited to participate in the present postal survey, 137 men returned the questionnaires. Those who were physically active had significantly lower prostate specific antigen (PSA) scores and higher social participation than those insufficiently active. These findings offer some support for the benefits of physical activity (PA) within the prostate cancer population in managing the adverse side effects of their treatments on aspects of their QOL. Future research should more closely examine what types of PA best promote improvements in varying aspects of QOL and psychological well-being for prostate cancer survivors.

Elucidating the relationship between noise sensitivity and personality.

Sensitivity to unwanted sounds is common in general and clinical populations. Noise sensitivity refers to physiological and psychological internal states of an individual that increase the degree of reactivity to noise in general. The current study investigated the relationship between the Big Five personality dimensions and noise sensitivity using the 240-item NEO Personality Inventory (NEO-PI) and 35-item The Noise-Sensitivity-Questionnaire (NoiSeQ) scales, respectively. Overall, the Big Five accounted for 33% of the variance in noise sensitivity, with the Introversion-Extroversion dimension explaining the most variability. Furthermore, the Big Five personality dimensions (neuroticism, extroversion, openness, agreeableness, and conscientiousness) had an independent effect on noise sensitivity, which were linear. However, additional analyses indicated that the influence of gender and age must be considered when examining the relationship between personality and noise sensitivity. The findings caution against pooling data across genders, not controlling for age, and using personality dimensions in isolation.

Sphenoid and subdural hemorrhage as a presenting sign of ruptured clinoid aneurysm.

BACKGROUND: Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage. METHODS: Case report and review of the literature. RESULTS: We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence. CONCLUSIONS: Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.