Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis

The value of modified hijdra score in patients with aneurysmal subarachnoid hemorrhage

Background

The complexity of calculating the Hijdra score has limited its clinical utility in aiding the diagnosis of intracranial ruptured aneurysms.

Objective

This study aimed to investigate the diagnostic and prognostic value of the modified Hijdra score in patients with aneurysmal subarachnoid hemorrhage (aSAH).

Methods

Data from 773 patients with subarachnoid hemorrhage (SAH) at the First People's Hospital of Lianyungang from January 2018 to June 2023 were collected. The modified Hijdra scoring method simplifies the assessment of 10 basal cisterns/cisterns fissures compared to the traditional scoring method, with scores ranging from 0 to 2 for each item, and assigns specific scores to hematomas larger than 1 cm in diameter. The data were divided into an evaluation group (n = 641) and a validation group (n = 132). In the evaluation group, the performance of the modified Hijdra score in diagnosis and prognostic prediction was assessed, while the diagnostic and prognostic prediction efficacy of the modified Hijdra method was evaluated using the validation set.

Results

Among the 641 patients in the evaluation group,550 (85. 8%) were diagnosed with intracranial aneurysms. The modified Hijdra score demonstrated an AUC of 0. 894 for aneurysm diagnosis, with a sensitivity of 98. 0% and a specificity of 64. 8% at a CutOff value of 7. 5. The diagnostic efficacy of the modified Hijdra score was 93. 24%, with a negative predictive value of 84. 29%, while the Hijdra score 's diagnostic efficacy was 85. 34% with a negative predictive value of 48. 89%. The AUC of the modified Hijdra score for predicting prognosis in patients with aneurysms was 0. 824, with a sensitivity of 84. 3% and a specificity of 70. 0% at a CutOff value of 16. 5. In CTA-negative patients, the modified Hijdra score was significantly higher (P < 0. 0001) in patients with aneurysmal SAH (15. 48 ± 3. 93) compared to those with non-aneurysmal SAH (6. 31 ± 4. 52).

Conclusions

The modified Hijdra score is a valuable tool for assisting in the diagnosis and prognosis prediction of aneurysmal subarachnoid hemorrhage.

Comment on Roman-Filip et al. Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review. Diagnostics 2023, 13, 1195

We would like to congratulate Roman-Filip et al. on their recent review on perimesencephalic hemorrhages [...].

Endovascular Embolization with n-Butyl Cyanoacrylate for Ruptured Distal Posterior Inferior Cerebellar Artery Dissecting Aneurysm

Parent artery occlusion is a definitive treatment method for preventing rebleeding of dissecting aneurysms. We herein report a case of a ruptured distal posterior inferior cerebellar artery (PICA) dissecting aneurysm treated with internal trapping using n-butyl-2-cyanoacrylate (NBCA). A 65-year-old man visited our hospital with a complaint of headache and neck pain that began 1 week before his arrival. He had a history of spontaneous subarachnoid hemorrhage of unknown cause. Computed tomography of the brain revealed a small amount of subarachnoid hemorrhage, and distal subtraction angiogram showed a distal PICA dissecting aneurysm. We placed a guiding catheter in the left vertebral artery and an intermediate catheter in the PICA. A microcatheter was guided toward the proximal side of the aneurysm and was wedged into the parent artery. The dissecting aneurysm was treated with parent artery occlusion using 50% NBCA. The postoperative course was uneventful, and the patient was discharged 3 weeks after treatment without any neurological deficit. Parent artery occlusion with internal trapping using NBCA could be a safe and definitive treatment method for distal PICA dissecting aneurysms. Angiographical evaluation of the collateral network in the distal branch of PICA before embolization and wedged microcatheter technique in the parent artery are important for successful embolization using NBCA.

The Diagnostic Dilemma in Delayed Subarachnoid Hemorrhage: A Case Report

INTRODUCTION

Radiologically negative subarachnoid hemorrhage (SAH) has a low incidence and is associated with good clinical outcomes.

CASE REPORT

We present the case of a 44-year-old male with new-onset headaches, which began one week prior while bike riding. At an outside hospital, he had normal computed tomography head and angiogram. He declined a lumbar puncture. Over the following week, the headache was persistent. He lacked meningeal signs. Repeat studies were normal. Lumbar puncture was positive for xanthochromia.

CONCLUSION

Radiologically negative SAH should be included in the differential diagnosis of patients presenting with unremitting headache in the setting of recent exercise, despite negative imaging, and meningeal signs.

Cost-effectiveness of repeat delayed imaging for spontaneous subarachnoid hemorrhage

BACKGROUND

In patients with intracranial aneurysm presenting with spontaneous subarachnoid hemorrhage (SAH), 15% of them could be missed by the initial diagnostic imaging. Repeat delayed imaging can help to identify previously undetected aneurysms, however, the cost-effectiveness of this strategy remains uncertain.

OBJECTIVE

The aim of this study is to assess the cost-effectiveness of repeat delayed imaging in patients with SAH who had a negative result during their initial imaging.

METHODS

A Markov model was developed to estimate the lifetime costs and quality-adjusted life-year (QALY) for patients who received or not received repeat delayed imaging. The analyses were conducted from a healthcare perspective, with costs reported in UK pounds and expressed in 2020 values. Extensive sensitivity analyses were performed to assess the robustness of the results.

RESULTS

The base case incremental cost-effectiveness ratio (ICER) of repeat delayed imaging is £9,314 per QALY compared to no-repeat delayed imaging. This ICER is below the National Institute for Health and Care Excellence (NICE) £20,000 per QALY willingness-to-pay threshold. At the NICE willingness-to-pay threshold of £20,000 per QALY, the probability that repeat delayed imaging is most cost-effective is 0.81. The results are sensitive to age, the utility of survived patients with a favorable outcome, the sensitivity of repeat delayed imaging, and the prevalence of aneurysm.

CONCLUSIONS

This study showed that, in the UK, it is cost-effective to provide repeat delayed imaging using computed tomographic angiography (CTA) for patients with SAH who had a negative result in their initial imaging.

Lumbar puncture-verified subarachnoid hemorrhage: bleeding sources, need of radiological examination, and functional recovery

BACKGROUND

The primary aim was to determine the diagnostic yield of vascular work-up, the clinical course during neurointensive care (NIC), and rate of functional recovery for patients with computed tomography (CT)-negative, lumbar puncture (LP)-verified SAH.

METHODS

In this retrospective study, 1280 patients with spontaneous SAH, treated at our NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiological examinations (CT angiography (CTA) and digital subtraction angiography (DSA)), treatments, and functional outcome (GOS-E) at 12 months were evaluated.

RESULTS

Eighty (6%) out of 1280 SAH patients were computed tomography (CT)-negative, LP-verified cases. Time between ictus and diagnosis was longer for the LP-verified SAH cohort in comparison to the CT-positive patients (median 3 vs 0 days, p < 0.001). One fifth of the LP-verified SAH patients exhibited an underlying vascular pathology (aneurysm/AVM), which was significantly less common than for the CT-verified SAH cohort (19% vs. 76%, p < 0.001). The CTA- and DSA-findings were consistent in all of the LP-verified cases. The LP-verified SAH patients exhibited a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to the CT-verified cohort. At 1-year post-ictus, 89% of the LP-verified SAH patients had recovered favorably, but 45% of the cases did not reach good recovery. Having an underlying vascular pathology and an external ventricular drainage were associated with worse functional recovery (p = 0.02) in this cohort.

CONCLUSIONS

LP-verified SAH constituted a small proportion of the entire SAH population. Having an underlying vascular pathology was less frequent in this cohort, but still occurred in one out of five patients. Despite the small initial bleeding in the LP-verified cohort, many of these patients did not reach good recovery at 1 year, this calls for more attentive follow-up and rehabilitation in this cohort.

Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review

Spontaneous non-aneurysmal subarachnoid haemorrhage (NAPMSAH) (addressing point 1) is a relatively rare occurrence in clinical settings as it is rarely misdiagnosed and usually involves a significantly better prognosis than the classical aneurysmal pattern. We hereby focused on a comprehensive analysis of this distinct pathological entity with the purpose of analysing possible pathophysiological entities, outcomes and treatment options involving this diagnosis with a focus on demographical, epidemiological and clinical data. The clinical setting includes focal neurological signs related to the anatomical structures, while computer tomography followed by tomographic angiography are the most common diagnosis tools, with a typical hyperdense lesion involving the midbrain, fourth ventricle and subthalamic areas without an angiographic correspondent, such as an aneurysmal pathology. Further investigations can also be used to highlight this diagnosis, such as interventional angiography or magnetic resonance imaging. Given the rarity of this condition and its relatively better prognosis, treatment options usually remain conservative. In the present review, the main characteristics of NAPMSAH are discussed.

Systemic Inflammatory Response in Spontaneous Subarachnoid Hemorrhage from Aneurysmal Rupture versus Subarachnoid Hemorrhage of Unknown Origin

OBJECTIVE

It is well known that spontaneous non-aneurysmal subarachnoid hemorrhage (SAH), also known as sine materia SAH (smSAH), has usually a better course and prognosis than its aneurysmal counterpart (aSAH). This might depend on different inflammatory mechanisms initiated by bleeding events of different origins. The aim of the present study was to explore the systemic inflammatory response in spontaneous SAH, comparing aSAH and smSAH.

METHODS

We performed a prospective observational study over a consecutive series of patients with SAH. For these patients, we collected all clinical data and, furthermore, performed venous blood sampling over six time points to analyze blood cells. We further performed the analysis of lymphocytes and monocytes by means of flow cytometry to quantify common subtypes. Statistical analysis included a t-student test, Chi-square test, multivariate logistic regression, and ROC analysis.

RESULTS

48 patients were included: six (12.5%) with a diagnosis of spontaneous smSAH, and forty-two patients (87.5%) with aSAH. Significant differences on Day 0 were found for neutrophils and a systemic neuro-inflammatory index, namely, systemic inflammatory response index (SIRI). At the ROC analysis, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and SIRI exhibited satisfactory predictive power on day 0. At the multivariable logistic regression analysis, the combined index (NLR, LMR, SIRI at day 0) yielded an OR of 0.59 (95% CI 0.29-1.21]). LMR at day 0 yielded an OR of 1.25 ([95% CI 0.94-1.68]), NLR at day 0 exhibited an OR of 0.68 ([95% CI 0.42-1.09]), and SIRI at day 0 displayed an OR of 0.31 ([95% CI 0.06-1.49]).

CONCLUSION

This preliminary study indicated a possible role of some inflammatory indices that point out the importance of innate and adaptive immunity in the etiopathogenetic mechanisms. Drugs modulating these responses could eventually counteract or, at least, reduce secondary damage associated with SAH.

Spontaneous subarachnoid haemorrhage

Subarachnoid haemorrhage (SAH) is the third most common subtype of stroke. Incidence has decreased over past decades, possibly in part related to lifestyle changes such as smoking cessation and management of hypertension. Approximately a quarter of patients with SAH die before hospital admission; overall outcomes are improved in those admitted to hospital, but with elevated risk of long-term neuropsychiatric sequelae such as depression. The disease continues to have a major public health impact as the mean age of onset is in the mid-fifties, leading to many years of reduced quality of life. The clinical presentation varies, but severe, sudden onset of headache is the most common symptom, variably associated with meningismus, transient or prolonged unconsciousness, and focal neurological deficits including cranial nerve palsies and paresis. Diagnosis is made by CT scan of the head possibly followed by lumbar puncture. Aneurysms are commonly the underlying vascular cause of spontaneous SAH and are diagnosed by angiography. Emergent therapeutic interventions are focused on decreasing the risk of rebleeding (ie, preventing hypertension and correcting coagulopathies) and, most crucially, early aneurysm treatment using coil embolisation or clipping. Management of the disease is best delivered in specialised intensive care units and high-volume centres by a multidisciplinary team. Increasingly, early brain injury presenting as global cerebral oedema is recognised as a potential treatment target but, currently, disease management is largely focused on addressing secondary complications such as hydrocephalus, delayed cerebral ischaemia related to microvascular dysfunction and large vessel vasospasm, and medical complications such as stunned myocardium and hospital acquired infections.

Current status of perimesencephalic non-aneurysmal subarachnoid hemorrhage

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a distinctive disease, representing SAH centered in perimesencephalic cisterns, with negative angiography findings. In recent years, the number of patients with PNSAH has increased significantly; however, the knowledge of PNSAH is insufficient. Therefore, we performed a review of the literature from a PubMed search and recounted our understanding of PNSAH. In this review, we summarized that current high-resolution computed tomography angiography is an acceptable replacement for digital subtraction angiography to rule out aneurysms in PNSAH with strict criteria. The current hypothesis about the etiology of PNSAH is that there is deep vein rupture from aberrant venous anatomy and increased intracranial venous pressure. PNSAH is associated with mild symptoms and lower rates of hydrocephalus and symptomatic vasospasm. For PNSAH, conservative treatment has been the mainstream treatment. PNSAH has a benign clinical course and an excellent prognosis; in long-term follow-up, re-bleeding and death were uncommon.

Surgical and Endovascular Treatment of Saccular Posterior Inferior Cerebellar Artery Aneurysms: Systematic Review and Meta-Analysis

OBJECTIVE

The optimal treatment modality for saccular aneurysms of the posterior inferior cerebellar artery (PICA) remains unclear. A previous meta-analysis on the topic included a heterogenous study population, limiting the conclusions that can be drawn from its results. The aim of this study was to perform a systematic review and meta-analysis to compare outcomes of microsurgical and endovascular treatment (EVT) of these aneurysms.

METHODS

A search of 4 online databases was performed for studies describing the management of saccular PICA aneurysms. The primary outcome was complete aneurysm occlusion. Data were also collected on neurologic outcomes, cranial nerve palsies, and requirement for re-treatment. A random effects model was used for calculation of pooled proportions. Our protocol was registered with PROSPERO (CRD42021232784).

RESULTS

A total of 17 studies were included in the final analysis, reporting the treatment outcomes of 455 aneurysms, with a mean follow-up of 20 months. The pooled occlusion rates were 94.8% (95% confidence interval [CI] 90.6%-97.8%) for surgical treatment and 69.1% (95% CI 55.0%-81.7%) for EVT. Pooled rates of good neurologic outcome (modified Rankin scale score ≤2, Glasgow Outcome Scale score ≥4) at last follow-up were 78.1% (95% CI 67.4%-87.1%) for surgery and 77.6% (95% CI 67.9%-86.0%) for EVT.

CONCLUSIONS

This meta-analysis demonstrates that in the treatment of saccular PICA aneurysms, microsurgical clipping results in superior angiographic outcomes, similar functional outcomes, but higher rates of lower cranial nerve palsy compared with EVT. Further studies are required to assess the duration and severity of cranial nerve palsies following surgical treatment, and long-term aneurysm occlusion and the requirement for re-intervention following EVT.

Angiographically Occult Subarachnoid Hemorrhage: Yield of Repeat Angiography, Influence of Initial CT Bleed Pattern, and Sources of Diagnostic Error in 242 Consecutive Patients

BACKGROUND AND PURPOSE

Nearly 20% of patients with spontaneous SAH have no definitive source on initial DSA. The purpose of this study was to investigate the timing and yield of repeat DSA, to clarify the influence of initial CT bleed pattern, and to characterize sources of diagnostic error in this scenario.

MATERIALS AND METHODS

We evaluated the yield of repeat DSA and clinical outcomes stratified by hemorrhage pattern on CT in consecutive patients with nontraumatic SAH with negative initial DSA findings at a referral center. Cases in which the culprit lesion was subsequently diagnosed were classified as physiologically occult (ie, undetectable) on the initial DSA, despite adequate technique and interpretation or misdiagnosed due to operator-dependent error.

RESULTS

Two hundred forty-two of 1163 (20.8%) patients with spontaneous SAH had negative initial DSA findings between 2009 and 2018. The SAH CT pattern was nonperimesencephalic (41%), perimesencephalic (36%), sulcal (18%), and CT-negative (5%). Repeat DSA in 135/242 patients (55.8%) revealed a source in 10 patients (7.4%): 4 saccular aneurysms, 4 atypical aneurysms, and 2 arteriovenous shunts. The overall yield of repeat DSA was 11.3% with nonperimesencephalic and 2.2% for perimesencephalic patterns. The yield of the second and third DSAs with a nonperimesencephalic pattern was 7.7% and 12%, respectively. Physiologically occult lesions accounted for 6/242 (2.5%) and operator-dependent errors accounted for 7/242 (2.9%) of all angiographically occult lesions on the first DSA.

CONCLUSIONS

Atypical aneurysms and small arteriovenous shunts are important causes of SAH negative on angiography. Improving DSAs technique can modestly reduce the need for repeat DSA; however, a small fraction of SAH sources remain occult despite adequate technique. These findings support the practice of repeating DSA in patients with a nonperimesencephalic SAH pattern.

The Value of the Correlation Coefficient Between the ICP Wave Amplitude and the Mean ICP Level (RAP) Combined With the Resistance to CSF Outflow (Rout) for Early Prediction of the Outcome Before Shunting in Posttraumatic Hydrocephalus

Objective

To evaluate the value of the correlation coefficient between the ICP wave amplitude and the mean ICP level (RAP) and the resistance to CSF outflow (Rout) in predicting the outcome of patients with post-traumatic hydrocephalus (PTH) selected for shunting.

Materials and Methods

As a training set, a total of 191 patients with PTH treated with VP shunting were retrospectively analyzed to evaluate the potential predictive value of Rout, collected from pre-therapeutic CSF infusion test, for a desirable recovery level (dRL), standing for the modified rankin scale (mRS) of 0–2. Eventually, there were 70 patients with PTH prospectively included as a validation set to evaluate the value of Rout-combined RAP as a predictor of dRL. We calculated Rout from a CSF infusion test and collected RAP during continuous external lumbar drainage (ELD). Maximum RAP (RAPmax) and its changes relative to the baseline (ΔRAPmax%) served as specific parameters of evaluation.

Results

In the training set, Rout was proved to be a significant predictor of dRL to shunting, with the area under the curve (AUC) of 0.686 (p &lt; 0.001) in receiver-operating characteristic (ROC) analysis. In the validation set, Rout alone did not present a significant value in the prediction of desirable recovery level (dRL). ΔRAPmax% after 1st or 2nd day of ELD both showed significance in predicting of dRL to shunting with the AUC of 0.773 (p &lt; 0.001) and 0.786 (p &lt; 0.001), respectively. Significantly, Rout increased the value of ΔRAPmax% in the prediction of dRL with the AUC of 0.879 (p &lt; 0.001), combining with ΔRAPmax% after the 1st and 2nd days of ELD. RAPmax after the 1st and 2nd days of ELD showed a remarkable predictive value for non-dRL (Levels 3-6 in Modified Rankin Scale) with the AUC of 0.891 (p &lt; 0.001) and 0.746 (p &lt; 0.001).

Conclusion

Both RAP and Rout can predict desirable recovery level (dRL) to shunting in patients with PTH in the early phases of treatment. A RAP-combined Rout is a better dRL predictor for a good outcome to shunting. These findings help the neurosurgeon predict the probability of dRL and facilitate the optimization of the individual treatment plan in the event of ineffective or unessential shunting.

Cost-Effective Analysis of Different Diagnostic Strategies in Screening for Aneurysms After Spontaneous Subarachnoid Hemorrhage

PURPOSE

With an increasing number of patients being treated by coiling for aneurysms, using computed tomographic angiography (CTA) or magnetic resonance angiography (MRA) as an initial screening test becomes less important because digital subtraction angiography (DSA) is the first step of endovascular treatment procedure. The objective of this study is to investigate whether CTA or MRA remained to be the optimal screening strategy in patients with spontaneous subarachnoid hemorrhage (SAH).

METHODS

CTA, MRA, and DSA strategy were evaluated in a decision tree model created with TreeAge Pro Suite 2011. Input parameters were derived from published literature and our institutional database. Base case and sensitivity analyses were conducted to assess the cost-effectiveness of each strategy. A Monte Carlo simulation was performed with all parameters ranged among their distributions to evaluate the validation of results.

RESULTS

The base case scenario showed that MRA was the most cost-effective strategy. Using a willingness-to-pay threshold of ¥70,892/quality adjusted life year, MRA remained to be most cost-effective when its sensitivity is >0.907. DSA was not cost-effective compared to CTA or MRA unless over 91.56% of patients were treated by coiling. The Monte Carlo simulation reported DSA not to be a cost-effective strategy at willingness-to-pay of ¥70,892 in 99.99% of the iterations.

CONCLUSION

DSA is not cost-effective compared to CTA or MRA and should not be used as the initial diagnostic tool for spontaneous SAH.

A giant basilar artery perforator aneurysm

Basilar artery perforator aneurysms (BAPA's) are a rare entity. Their natural history and treatment are unclear. We describe the largest BAPA reported thus far in literature in a 64-year-old Caucasian woman. This patient did not present with subarachnoid hemorrhage, but with left hemiparesis due to pontine ischemia. The aneurysm was initially misdiagnosed as a tumoral mass in a referring center. Angiography confirmed the presence of a BAPA and a flow diverter was successfully placed. This case shows us that a BAPA can mimic a tumoral mass and can cause ischemia due to mass effect without having ruptured. Both conservative and flow diverter placement seems viable treatment options. Individual patient characteristics and preferences should be considered in decision-making for treatment.

Radiological investigations in non-aneurysmal subarachnoid haemorrhage: A 5-year review

•

All patients with a Fisher grade 2 bleed and a negative CT angiogram had catheter angiography negative for any abnormality.

•

Neuroradiologists identified vascular abnormalities not reported by district general hospitals.

•

Follow-up MRI may be a useful adjunct in subarachnoid haemorrhage.

Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study

Background

Spontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH.

Methods

We retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis.

Results

Of the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode.

Conclusion

SAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-021-05069-7.

Factors determining outcome of post-angiogram-negative subarachnoid hemorrhage

Aim:

To determine the risk factors affecting outcome at the end of 90 days of post-angiogram-negative subarachnoid hemorrhage (SAH).

Methods:

Non-traumatic SAH cases were reviewed from the case records of patients who had reported to the Department of Neurology of a tertiary care hospital and 50 angio-negative SAH cases were included after excluding all the cases with known cause of hemorrhage after doing computed tomography angiography (CTA)/digital subtraction angiography (DSA). The presence of hypertension, diabetes mellitus, coronary artery disease (CAD), history of alcohol and smoking, and various scales like Hunt and Hess Scale (HHS), World Federation of Neurological Surgeons (WFNS), and Fisher scale had been recorded at admission. The outcome was assessed at 90 days post-SAH using the Modified Rankin Scale (mRS).

Statistical analyses:

The association between the outcome and the factors was assessed using the Pearson Chi-Square test and the risk factors/predictors of outcome were assessed using logistic regression.

Results:

The following variables were important risk factors for predicting poor outcome of angio-negative SAH (mRS 3 to 6): hypertension (P = 0.011), diabetes mellitus (P = 0.032), being an alcoholic (P = 0.019), HHS grade 4 to 5 (P < 0.01), and WFNS grade 4 to 5 (P < 0.01). On multivariate regression analysis, hypertension (P = 0.032) was an independent predictor of unfavorable outcome.

Conclusions:

At time of admission, presence of hypertension, diabetes mellitus, history of alcohol consumption, and poor grades of HHS and WFNS scale are predictors of poor outcome of angio-negative SAH.

Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report

Background:

The causes of angiogram-negative subarachnoid hemorrhage (SAH) on initial angiography, which accounts for 10–30% of spontaneous SAH, are heterogeneous and still unclear. We report a case of nonaneurysmal SAH, in which initial computed tomographic angiography (CTA) showed no source of bleeding, but the subsequent digital subtraction angiography (DSA) revealed contrast extravasation from the basilar artery without aneurysms.

Case Description:

A 67-year-old woman with a medical history of hypertension presented as SAH of World Federation of Neurological Surgeons Grade II. CTA on admission did not show any cause of bleeding and DSA was subsequently performed to show contrast extravasation from a perforator of the middle third of the basilar artery without aneurysms during the subsequent DSA, resulting in profound deterioration SAH and neurological status. The patient was conservatively treated. Follow-up DSAs on days 2 and 16 showed no source of bleeding as well.

Conclusion:

Although the precise cause of bleeding in this case is uncertain, SAH might be caused by local dissection of the basilar artery perforator, and the bleeding site might heal spontaneously without forming of a pseudoaneurysm.

Spontaneous Subarachnoid Haemorrhage in Spinal Hemangioblastoma: Illustrative Case and Discussion of a Pathophysiological Hypothesis

Spontaneous non-aneurysmal subarachnoid haemorrhage (naSAH) is an unusual finding that could be burdened by significant mortality and morbidity rates. Rare pathologies and delayed diagnosis could be advocated as responsible of unfavourable outcomes. Herein, we describe an exceedingly rare giant lumbar spinal hemangioblastoma (80 × 23 mm) presenting as an intracranial naSAH. Based on our radiological and clinical findings a pathophysiological hypothesis linking intracranial naSAH to venous hypertension was discussed for the first time even among lumbar spinal tumors. Although rare, unusual causes should be investigated in presence of radiological atypical finding as a prompt evaluation and treatment could be needed.

Usefulness of 3D High-resolution Vessel Wall MRI in Diffuse Nonaneurysmal SAH Patients

PURPOSE

In 15-20% of patients with nontraumatic diffuse subarachnoid hemorrhage (SAH), the initial conventional angiography does not reveal a causative vascular abnormality, such as intracranial aneurysm. In this study, we evaluated clinical utility of 3D high-resolution vessel wall magnetic resonance imaging (HR-VWI) in patients with diffuse nonaneurysmal SAH.

METHODS

A total of 17 patients with diffuse nonaneurysmal SAH were included in this retrospective study. We characterized demographics and HR-VWI findings and reviewed the clinical management and outcomes.

RESULTS

Of the patients 14 (14/17; 82.4%,) showed abnormal findings on HR-VWI, including 5 with intracranial dissections (29.4%), 3 with blood blister-like aneurysm (17.6%), 1 with ruptured fusiform aneurysm (5.9%), and 5 with focal nodular wall enhancement without unclassified pathology (29.4%). Of these patients were treated with endovascular management. Most patients (16/17) had a favorable modified Rankin scale scores of 0-2 on discharge.

CONCLUSION

The 3D HR-VWI revealed various hidden pathologies, such as intracranial arterial dissection, blood blister-like aneurysm, and fusiform aneurysm in patients with diffuse nonaneurysmal SAH. In addition, 3D HR-VWI had an impact on the management of SAH. The 3D HR-VWI can be a complementary diagnostic method for patients with diffuse nonaneurysmal SAH in a research or clinical setting.

Aneurysmal Subarachnoid Hemorrhage: the Last Decade

Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.

Are modified Fisher Scale and bleeding pattern helpful predictors of neurological complications in non-aneurysmal subarachnoid hemorrhage?

PURPOSE

Non-aneurysmal subarachnoid hemorrhage (NA-SAH) is a clinical-radiological entity with a different prognosis than aneurysmal SAH (A-SAH). The purpose of this study is to assess the predictive value of the modified Fisher Scale (mFS) for neurological complications in patients with this diagnosis.

METHODS

We recruited patients admitted at our hospital services between 2009 and 2017 who were diagnosed with spontaneous SAH, with either perimesencephalic (PM-SAH) or diffuse pattern (D-SAH), an initial negative angio-CT, and at least one digital subtraction angiography of brain vessels discarding underlying brain aneurysms or other vascular malformations.

RESULTS

The retrospective observational study included 116 patients. The mean age was 54.4, and the sample included predominantly male subjects (62.9%). Hunt and Hess (HH) scores on admission ranged from 3 to 5 in 18.1% of patients. The prevalence of hydrocephalus requiring ventricular drainage was 18.1%. The prevalence of symptomatic vasospasm was 4.3%. A modified Rankin Scale (mRS) 0-2 at discharge was found in 95.6%. In a multivariate logistic regression for the presence of neurological complications including age, sex, admission HH 3-5 compared with < 3, mFS 4 compared with mFS < 4, D-SAH compared with PM-SAH, and mRS score at discharge of 0-2 compared with > 2, the only significant predictors were mFS 4 compared with mFS < 4 (OR 4.47 (95% CI 1.21, 16.66) p value = 0.03) and D-SAH compared with PM-SAH (OR 7.10 (95% CI 1.24, 40.8) p value = 0.03).

CONCLUSION

In patients with NA-SAH, a mFS score of 4 and/or a D-SAH bleeding pattern in non-contrast cranial CT on admission predicted the development of relevant neurological complications.