Clinical problem-solving: Aneurysm or spinal arteriovenous fistula-bait and switch

Objective: The authors use an instructive case to review the challenges of diagnosis in subarachnoid hemorrhage (SAH) and to reinforce the nuances of clinical management. Importance: The presented case highlights critical issues in patient selection and challenges in the diagnosis of SAH and the management of both aneurysmal and arteriovenous fistula-related SAH. The critical points in decision making and diagnosis are discussed, and the case is accompanied by a brief review of the literature on the issues being faced. Clinical Presentation: The present case is a patient presenting with SAH who was found to have an anterior communicating artery aneurysm. However, clues in the presentation and workup point to another etiology. Conclusion: A strong history of sudden neck pain before headache and abundance of SAH along the brainstem mandates a need to thoroughly evaluate the source of hemorrhage from cervical vessels through an angiogram.