Subarachnoid Hemorrhage as the Initial Imaging Finding of Atrial-Esophageal Fistula: A Case Report Highlighting Diagnostic Challenges

Siwei Chen¹Wei Sun¹Yongan Sun¹Lanqiu Yao²Qing Peng^1*

• ¹Department of Neurology, First Hospital, Peking University, Beijing, Beijing Municipality, China
• ²Department of Population Health, School of Medicine, New York University, New York, New York, United States

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.