# Subarachnoid hemorrhage as the initial imaging finding of atrial-esophageal Fistula: a case report highlighting diagnostic challenges

## TL;DR

A rare case shows how subarachnoid hemorrhage can be the first sign of a dangerous heart condition after a cardiac procedure.

## Contribution

This case report highlights the diagnostic challenges of atrial-esophageal fistula presenting with atypical neurological symptoms.

## Key findings

- Subarachnoid hemorrhage was the initial imaging finding in a patient with atrial-esophageal fistula.
- Repeated imaging revealed worsening hemorrhage and air emboli, suggesting fistula progression.
- The case emphasizes the need to consider AEF in patients with neurological deficits after cardiac ablation.

## Abstract

Atrial-esophageal fistula (AEF) is a rare but life-threatening complication after catheter ablation. Neurological deficits represent the second most common clinical manifestation associated with AEF; however, diagnosis is often delayed because initial symptoms can be atypical and easily overlooked. Here we reported a case involving a 51-year-old male who presented with fever and headache three weeks after catheter ablation for atrial fibrillation. Initial cranial computed tomography (CT) showed right frontal subarachnoid hemorrhage (SAH) without aneurysm. As the patient's condition deteriorates, repeated imaging demonstrates worsening SAH, cerebral air emboli, and air signals in the left atrium. This case highlights the importance of considering AEF in patients with neurological deficits and recent cardiac ablation, even when initial imaging findings are atypical.