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Patients with imaging findings concerning for subarachnoid hemorrhage, however, with no evidence of hemorrhage following autopsy or cerebrospinal fluid testing are diagnosed with having pseudo-subarachnoid hemorrhage. A 73-year-old female presented to the emergency department with altered mental status one day after undergoing a lumbar epidural steroid injection at an outside hospital; a noncontrast computed tomography scan of the head revealed evidence of diffuse hyperdensity within the subarachnoid space concerning for subarachnoid hemorrhage. The patient underwent magnetic resonance imaging which demonstrated diffuse opacification of the cerebrospinal fluid spaces with gadolinium and the diagnoses of pseudo-subarachnoid hemorrhage and gadolinium encephalopathy were made. The combination of the neurologic symptoms related to gadolinium encephalopathy and the radiographic findings of pseudo-subarachnoid hemorrhage can create a clinical presentation nearly identical to ruptured aneurysmal subarachnoid hemorrhage. Patient history, magnetic resonance imaging findings, and temporal changes in computed tomography provide vital tools in establishing a diagnosis of pseudo-subarachnoid hemorrhage, especially after an iatrogenic intrathecal contrast administration.

We report the case of an extended pseudo-subarachnoid hemorrhage (PSAH) related to contrast intracerebral diffusion from blood-brain barrier breakdown on periprocedural percutaneous coronary intervention right corticofrontal ischemic stroke. PSAH is a rare and complex phenomenon, and it is important to differentiate PSAH from subarachnoid hemorrhage to avoid inappropriate treatment with potentially severe consequences. (Level of Difficulty: Beginner.), Graphical abstract, We report the case of an extended pseudo-subarachnoid hemorrhage (PSAH) related to contrast intracerebral diffusion from blood-brain barrier…