Acute subdural hematoma is a rare presentation of ruptured aneurysms. The rarity of the disease makes it difficult to establish reliable clinical guidelines. Many patients present comatose and differential diagnosis is complicated due to aneurysm rupture results in or mimics traumatic brain injury. Fast decision-making is required to treat this life-threatening condition. Determining initial diagnostic studies, as well as making treatment decisions, can be complicated by rapid deterioration of the patient, and the mixture of symptoms due to the subarachnoid hemorrhage or mass effect of the hematoma. This paper reviews initial clinical and radiological findings, diagnostic approaches, treatment modalities, and outcome of patients presenting with aneurysmal subarachnoid hemorrhage complicated by acute subdural hematoma. Clinical strategies used by several authors over the past 20 years are discussed and summarized in a proposed treatment flowchart. 1. Introduction Rupture of a cerebral aneurysm normally results in subarachnoid hemorrhage (SAH) and is often complicated by intracerebral hematoma (ICH), but only on rare occasions does it cause acute subdural hematoma (aSDH) [1]. Diagnosis of aneurysmal SAH can be difficult in comatose patients in whom loss of conscious due to aneurysm rupture results in or mimics a traumatic brain injury [2]. Determining a differential diagnosis and treatment modalities can further be complicated by the rapid clinical course and the mixture of symptoms due to the ruptured aneurysm and the mass effect of the hematoma. Rapid decision making is required to treat this life-threatening condition. The majority of patients with aneurysmal SAH and coincidental acute subdural bleeding present in a severe clinical condition, and immediate surgical management is required [2–4]. Decisions to be made include whether preoperative diagnostic studies should precede surgery and whether obliteration of the aneurysm should be performed during hematoma evacuation or in a separate delayed intervention after resuscitation procedures. The incidence of combined SAH and aSDH varies from 0.5% [5, 6] to 10% [7] in clinical series. The rarity of aneurysmal aSDH makes it difficult to design reliable clinical treatment guidelines. Large systematic series do not exist, and thus treatment decisions are mainly based on personal experience. The aim of this review is to propose a management flow chart and protocol based on published experience with such cases over the past two decades. 2. Materials and Methods 2.1. Search Strategy The literature was screened
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