DOI: https://doi.org/10.36347/sjmcr.2025.v13i11.044

Pages: 2846-2849

Background: Moyamoya disease (MMD) carries substantial hemorrhagic risk in adults, with intraventricular hemorrhage (IVH) occurring frequently. Intracranial complications after neuraxial procedures have been reported, but distinguishing procedure-related events from spontaneous progression of underlying cerebrovascular disease remains challenging, particularly when acute hemorrhagic changes are obscured by chronic baseline pathology and delayed radiological reporting complicates clinical decision-making. Case: A 67-year-old woman with MMD under regular neurosurgical follow-up underwent routine brain computed tomography (CT) angiography on June 23, 2025, which demonstrated acute IVH and subarachnoid hemorrhage while she remained completely asymptomatic. Formal radiological interpretation was delayed, and a scheduled caudal epidural injection for chronic low back pain was performed approximately 17 hours later on June 24. Following the procedure, the patient developed headache and dizziness and presented to the emergency department. Serial CT imaging on post-procedure days 1, 2, and 7 demonstrated no interval progression of hemorrhage compared with pre-procedural imaging, providing objective evidence that the bleeding predated rather than resulted from the intervention. Conclusions: This case demonstrates that acute intracranial hemorrhage in MMD may remain clinically silent for 24 hours or longer, and delayed symptom onset after neuraxial procedures does not establish procedural causation when pre-procedural imaging documents the hemorrhage and serial imaging demonstrate stability. The critical lesson is the importance of timely formal radiological interpretation and systematic verification of imaging results before elective procedures in high-risk cerebrovascular patients. Multidisciplinary communication protocols and pre-procedural imaging checklists represent practical strategies to prevent similar scenarios.