A very good morning to all the delegates and faculty members. My name is Kati Sharma and I'm a third year resident in Jawaharlal Nehru Medical College, Peldaw. Today I would be presenting a rare demonstration of active bleed by re-rupture in a case of ruptured intracranial aneurysm. Starting with the introduction, CT angiography plays the main role in diagnosis, prognosticating and treating planning of a ruptured intracranial aneurysm. Although active bleeding during intracranial angiography is well documented, only a few case reports have been able to demonstrate it in CT angiography in the past. Only a handful number of reports are available which have shown varied appearance of active bleed. Higher mortality and poor prognosis has been associated with the rupture of aneurysm. Hence further studies on its appearance is necessary to improve its diagnostic rate of this lethal complication. This report describes the case of young female patient with active bleed or re-ruptured or CT angiography from an already ruptured tri-lobed aneurysm from an M1 segment of the right MCR2. This had prompted immediate therapeutic intervention in this patient. The patient underwent CT brain angiography using a 128 slice CT machine. This 22-year-old female had presented to the emergency department of Kaili Dr. Prabhakar Kori Hospital in Belgaon with complaints of sudden onset headache and loss of consciousness. Patient was hypertensive on admission. There was no history of trauma. There was no relevant past history and no relevant family history. On getting CT brain plane done, we could see intrapirinocameral hemorrhage in the right temporal region which was resulting in mass effect and midline shift to the left side. There was a STH subdural hematoma in the right frontal parietal region. Also there were few streaks of subarachnoid hemorrhage in the right frontal temporal region. Given that there was no history of trauma, the patient was advised CT angiography to rule out any aneurysm. So on post-contrast study, we can see an outpouching from the M1 segment of right MCR2 which was suggestive of aneurysm. But in these images, we can see apart from the vessels, there is another tubular structure which is shown in yellow arrows, which was seen post-treated to the hematoma. This, if we go back to our plane scan, we see it was not present in the plane brain. We checked the attenuation of the structure which showed attenuation values between 200 to 250 and then that of the adjacent arteries like MCR2 was around 350 to 400. Hence, it was suggested that this is extraversation of contrast that we are seeing as attenuation values are less than that of the adjacent contrast filled blood vessels. And further delayed images taken three minutes after, we can still see pooling of the contrast in the subarachnoid space in the right temporal region, which was confirming our suspicion of the contrast extraversation or pre rupture. These are 3D post-processed images in which we can see the aneurysm in the right MCR2 with contrast extraversation. Coming to the discussion, previous literature tells the incidence of aneurysm of G-breeding during intra-artificial angiography varies from 0.01 person to 0.35 person. It could be suggested that prevalence of re rupture on CT angiography is quite rare as the contrast injection is made in the peripheral vein and this technique is unlikely to result in acute aneurysm re rupture. Only handful number of studies have reported transient hypertension in response to contrast administration. This could be because of re rupture. However, there are no studies available to suggest correlation between the hemodynamics changes in patient undergoing CT angiography and re rupture. In case report previously done by Kathuria et al, two cases were discussed which shows active extraversation on CT angiography as a tubular structure with undulating contue mimicking a vascular structure. The attenuation was similar to the contrast pacified adjacent arteries. He had also suggested that active extraversation could be easily detected in relayed images taken after three minutes and confirm diagnosis of re-breed by demonstrating pooling of contrast in subarachnoid spaces. Hence the proof that additional relayed images post-contrast could improve diagnostic rate of active breed. It was not mentioned in any previous such reports. High mortality and poor prognosis have been associated with re rupture of aneurysm since CT angiography is used in almost all the cases being evaluated for rupture analysis. It is essential to recognize this condition as earliest as from diagnosis may help in improving the prognosis in sleeper complication. Studying the characteristics appearances are necessary. Only a few cases of active breeding during CT angiography have been reported in the past. Moreover, the cases reported so far had varied appearances. Further, reporting these cases might help in understanding different imaging appearances and increase the diagnostic rate. Volodomy et al. had reported a nebulous area of increased attenuation outside and adjacent to the right internal scattered artery, indicating extraversated contrast. They had also told about decreased density of the area of increased density as one moved further from the analysis due to attenuation. Nekotsula et al. had similarly reported the coaxial sign and cap sign on the appearance of extraversated contrast to suggest active breeding. Extraversated contrast can also be seen in ventricle system in anterior communicating artery arousal. The undulating ribbon-like twisting structure mimicking the vessel was told by Komiyama et al. in the report, which was similar to what we saw in our case. So in conclusion, higher mortality of poor prognosis has been associated with re-rupture of aneurysm. Hence, it's essential to recognize this condition at the earliest, as prom diagnosis may help in improving the prognosis in this little complication. Studying the characteristic appearances of re-rupture on CT angiography is necessary to diagnose this condition at the earliest. These were the references which I had used. Thank you so much.