A 20-year-old man presented with a severe headache and confusion and was found to have a subarachnoid hemorrhage from a ruptured basilar tip aneurysm. He was also found to have long-standing hypertension. Further cardiac imaging revealed an aortic coarctation, which had gone undiagnosed and likely caused his hypertension. Cardiac MRI and MRA clearly showed the coarctation and extensive collateral vessels that had formed. A cardiac catheterization further demonstrated a significant pressure gradient across the coarctation, confirming it as the cause of his hypertension. The patient subsequently underwent stent placement in the coarcted segment.

1. SUBARACHNOID
HEMORRHAGE UNMASKS
AORTIC COARCTATION IN
A YOUNG MAN
Tayeb Rahim, MS4, Clint Walters, MD,
Aamisha Gupta, MD, Jayanth
Keshavamurthy, MD, William B. Bates, MD,
and Gyanendra Sharma, MD

2. Disclosure of conflicts of interest
• We have no conflicts of interest to declare

3. Clinical Presentation
• 20 year old male with severe headache,
confusion
• Hx of hypertension
• VS:
• BP: 135/61
• T: 35.6°C (97.9°F)
• P: 78
• RR: 24

4. Physical Exam
• Grade III/VI diastolic murmur in third left
intercostal space
• Strong pulse
• No edema
• Warm skin
• Capillary refill < 3 seconds

5. Workup
• Head CT showed subarachnoid
hemorrhage
• Ruptured basilar tip aneurysm
• Patient underwent coil embolization
• Ventricular drain was placed

15. CMR Findings

16. • Numerous collateral
intercostal arteries
associated with ribs 4-9
• Large anastomotic
collateral between left
subclavian and T8
intercostal artery
• Prominent internal
thoracic arteries
• Moderate-sized spinal
artery originating
immediately distal to
coarctation
CE-MRA

17. • Numerous collateral
intercostal arteries
associated with ribs 4-
9
• Large anastomotic
collateral between left
subclavian and T8
intercostal artery
• Prominent internal
thoracic arteries
• Moderate-sized spinal
artery originating
immediately distal to
coarctation
CE-MRA

18. • True bicuspid valve
• Fusion of right and left
coronary aortic cusps w/
small rudimentary
raphae
• Normal RV and LV function
• Normal LV ejection fraction
• No delayed myocardial
enhancement to suggest
myocardial scar
• EF of 55% (borderline low)
• LV EDV: 85.4 mL/m2
(normal)
• LV ESV: 38.1 mL/m2 (high)
• LV end diastolic wall mass:
91.5 g/m2 (high)
Balanced steady-state free precession imaging

19. Velocity-encoded cine MR imaging
• Pressure gradient across coarctation can be
measured using the modified Bernoulli
equation:
ΔP = 4(v2
2-v1
2)
• Pressure gradient not accurately quantified in
this case
• Moderate aortic regurgitation of 44%

20. Case Follow-Up
• Cardiac catheterization
• Ascending aorta pressure: 85/40
• Descending aorta pressure: 65/50
• 20 mmHg peak gradient between these
segments
•Pressure gradient greater than 15-20
mmHg suggests need for intervention
• Stent placed in coarcted segment

21. Conclusion
• Maintain suspicion for coarctation in young patients with
HTN
• Advantages of CMR
• Non-invasive assessment of anatomic and functional integrity of the
heart and great vessels
• No radiation exposure
• Velocity-encoded cine MR imaging to measure peak flow velocities
and derive pressure gradient across coarctation
• Dependent on user proficiency and accurate placement of
measurement planes
• Fully refocused steady-state sequence to visualize the heart at
different phases of the cycle with very little motion artifact and to
evaluate cardiac function

22. Acknowledgements
• SCMR Associate Editor Dr. Sierra Galan for her help in
preparing this case

23. References
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