Background: First onset of focal epileptic seizures can be caused by intracranial space occupying processes such as tumors or subdural hematomas, as well as by direct irritation of the cortex by a subarachnoid hemorrhage. The differentiation of cause and consequence of a patient’s fall as well as the rapid clinical deterioration of these patients can make diagnosis and therapeutic management a major challenge.
Case report: A 53 year-old-woman presented with an acute subdural hematoma and a history of a fall due to suspected hypotension. On the next day, the patient reported a gastric aura. Control CT revealed a paraclival
mass with contrast enhancement. The following angiography showed an aneurysm of the internal carotid artery. The hematoma was evacuated and the aneurysm clipped via pterional approach. In 6-month routine follow-up,
the patient did not show any epileptic activity.
Conclusion: First onset of seizures has to be investigated by all available neuroimaging techniques, as well as by an extensive anamnesis interview. In case of an atraumatic acute subdural hematoma we have to look for
a ruptured aneurysm. Therapeutic management (clipping or coiling) is determined by the often rapid clinical course of these patients.

Keywords: Seizures, Subdural hematoma, Aneurysm, Epilepsy