Objective To describe a rarely described case of severe internal carotid artery stenosis presented as convexal subarachnoid haemorrhage (SAH) in the setting of acute ischemic stroke.

Case report A 52 year old female, smoker, presented with right sided numbness, slurred speech and difficulty in walking. Neurological observation revealed mild expressive dysphasia and subtle right sided weakness. Brain imaging showed left cortical sulcal SAH with ischemia in the left corona radiata. Carotids ultrasound showed 90% stenosis of left internal carotid artery that was later confirmed by magnetic resonance angiogram. She was treated conservatively for acute ischemic stroke and later underwent left carotid endarterectomy.

Conclusions This case shows that ICA stenosis can cause convexal SAH and it should therefore be added to the differential diagnosis of atraumatic SAH. The association is under recognised and can be missed due to the unusual location of the blood and failure to image the extra cranial carotid arteries.