Transient amnesia after perimesencephalic haemorrhage: the role of enlarged temporal horns

Perimesencephalic subarachnoid hemorrhage: Etiologies, risk factors, and necessity of the second angiogram

Aim:

In this paper, we aim to present our experience with a series of patients with PMSAH. In addition, the clinical course of perimesencephalic subarachnoid hemorrgade (PMSAH) is discussed with an evaluation of etiologies, risk factors, and the necessity for a second angiogram on follow-up.

Materials and Methods:

The data for this study were obtained retrospectively from patients who were treated at the Uludag University, School of Medicine, Department of Neurosurgery, Division of Neurovascular Surgery's clinic with a diagnosis of PMSAH between January 1980 and March 2002.

Results:

We identified a total of 24 patients, 12 male. The mean age at the time of hemorrhage was 53 ± 12 years. In all patients, the onset was typical with a sudden severe headache. Five of the patients were Hunt-Hess Grade I, 15 were Grade II, and 4 were Grade III. The initial 4-vessel angiography was normal in 23 cases. Twenty-two had a second 4-vessel angiography, and all were normal. We observed acute hydrocephalus in 5 patients (20.8%). We did not observe re-bleeding during the follow-up of our patients.

Conclusion:

Patients with PMSAH have a particularly excellent outcome, and there is no need to evaluate these patients with repeat angiography.

Z-score-based semi-quantitative analysis of the volume of the temporal horn of the lateral ventricle on brain CT images

The volume of the temporal horn of the lateral ventricle (THLV) on brain computed tomography (CT) images is important for neurologic diagnosis. Our purpose in this study was to develop a z-score-based semi-quantitative analysis for estimation of the THLV volume by using voxel-based morphometry. The THLV volume was estimated by use of a z-score mapping method that consisted of four main steps: anatomic standardization, construction of a normal reference database, calculation of the z score, and calculation of the mean z score in a volume of interest (VOI). A mean z score of the CT value obtained from a VOI around the THLV was used as an index for the THLV volume. CT scans from 50 subjects were evaluated. For evaluation of the accuracy of this method for estimating the THLV volume, the THLV volume was determined manually by neuroradiologists (serving as the reference volume). A mean z score was calculated from the VOI for each THLV of the 50 subjects by use of the proposed method. The accuracy of this method was evaluated by use of the relationship between the mean z score and the reference volume. The quadratic polynomial regression equation demonstrated a statistically significant correlation between the mean z score and the reference volume of the THLV (R (2) = 0.94; P < 0.0001). In 92 of 100 THLVs (92 %), the 95 % prediction interval of the regional mean z score captured the reference volume of the THLV. The z-score-based semi-quantitative analysis has the potential quantitatively to estimate the THLV volume on CT images.

Neuropsychological Assessment and Intervention Following Perimesencephalic Subarachnoid Hemorrhage

Mrs. H, aged 51, was referred for a neuropsychological assessment by her general practitioner. According to the referral, Mrs. H had been suffering from fatigue, headaches, and low mood following a subarachnoid hemorrhage in 2003. She reported continuing problems with concentration, memory, fatigue, and severe debilitating headaches. She attended for neuropsychological assessment in 2009, which identified specific impairments in attention and some aspects of executive function. Following assessment, Mrs. H engaged in a rehabilitation program designed to help her to manage her cognitive deficits, pace her activity levels, and manage her fatigue and headaches. She found this approach effective and reported an increase in quality of life at the end of the treatment.

The radiological investigation of subarachnoid haemorrhage

Subarachnoid haemorrhage is an important condition with a high mortality, so prompt diagnosis is essential. This article will review the investigation of subarachnoid haemorrhage with a radiological bias. Appropriate clinical correlation will be included and it will look at some of the more interesting areas in the investigation of this condition.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by physical exertion

The clinical characteristics of perimesencephalic nonaneurysmal subarachnoid hemorrhage (SAH) caused by physical exertion were analyzed to investigate the causes and mechanisms of perimesencephalic nonaneurysmal SAH. Nine of 209 patients with spontaneous SAH were identified as having perimesencephalic nonaneurysmal SAH. Perimesencephalic nonaneurysmal SAH in four males and three females was precipitated by exertion. Age, sex predominance, type of exertion, symptoms, loss of consciousness during bleeding, clinical grade, angiographic spasm, hydrocephalus, delayed ischemic deficit, rebleeding, hypertension, and outcome were evaluated in these seven patients. Outcomes were assessed using the Glasgow Outcome Scale. Patients showed male predominance (57.1%), relatively young age (mean 50 years), low frequency of hypertension (28.6%), good clinical grade (World Federation of Neurological Surgeons grade I or II), and excellent outcomes including no rebleeding, no symptomatic hydrocephalus, and no delayed ischemic deficits. The type of exertion was swimming in two patients, golfing in two patients, heavy lifting in two patients, and bending forward during gymnastics in one patient. Physical exertion including components of the Valsalva maneuver is an important predisposing factor for perimesencephalic nonaneurysmal SAH. Such physical exertion produces increased intrathoracic pressure, which blocks the internal jugular venous return, resulting in elevated intracranial venous pressure or mechanical swelling of the intracranial veins, and leads to venous or capillary breakdown.

Painful third nerve palsy in a patient with perimesencephalic subarachnoid haemorrhage

A patient with perimesencephalic subarachnoid haemorrhage (PMSAH) developed a delayed third nerve palsy. Three formal cerebral angiograms, a computed tomography cerebral angiogram and a magnetic resonance angiogram all failed to reveal a vascular abnormality. Further investigations did not show any medical cause for the palsy. This appears to be the first case report of a patient with PMSAH presenting with a painful third nerve palsy.

Computed Tomography in the Diagnosis of Subarachnoid Haemorrhage

Early computed tomography (CT) is very useful in detecting subarachnoid haemorrhage (SAH). It offers a lot of information about the origin, the extent of the haemorrhage and the early complications (hydrocephalus, haematoma).

Moreover, CT scan can suggest the site of bleeding aneurysm and the risk of severe vasospasm.

In some cases, CT shows a perimesencephalic SAH in which often no aneurysm can be detected.

The sensitivity of CT in demonstrating SAH decreases as the time between onset of SAH and CT scanning increases.

Causes and management of thunderclap headache: a comprehensive review

BACKGROUND

Thunderclap headache (or sudden severe headache) is an uncommon type of headache. Recognition and accurate diagnosis of this headache are important, because there is often a serious underlying brain disorder.

SUMMARY

In this article, causes and management of thunderclap headache are discussed. In the primary care setting, there is a serious cause in one third of patients, but in the hospital setting, up to two thirds of patients have a serious underlying brain disorder. Clues in history and physical examination can point to a possible serious underlying cause of thunderclap headache, such as subarachnoid hemorrhage, intracranial hematoma, or cerebral venous thrombosis. The remaining patients with thunderclap headache, however, have a primary headache disorder, such as migraine or (less frequently) tension headache with an unusual sudden onset, exertional headache, coital headache, cough headache, or cluster headache. The concept of thunderclap headache as a distinct clinical entity is discussed, with implications for its evaluation. Present radiological techniques are reviewed with regard to their diagnostic utility in detecting a serious brain disorder.

CONCLUSIONS

Thunderclap headache is an uncommon type of headache, and a serious underlying cause should be excluded.

Subarachnoid haemorrhage: diagnosis, causes and management

The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

Quadrigeminal variant of perimesencephalic nonaneurysmal subarachnoid hemorrhage

OBJECTIVE

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH) is a benign entity with a low risk of rebleeding. The most widely accepted definition emphasizes the presence of blood ventral to the midbrain or pons on early computed tomography. We sought to determine the frequency of PNSH with blood centered in the quadrigeminal cistern.

METHODS

We reviewed a prospectively collected database of all patients admitted to our institution over a 2.5-year period with subarachnoid hemorrhage (SAH) and identified PNSH patients from early computed tomographic scans and negative four-vessel angiograms.

RESULTS

Of 220 SAH patients, we identified 9 with PNSH. Two (22%) of these patients had SAH centered in the quadrigeminal cistern without pretruncal blood, negative repeat angiograms, and an uncomplicated clinical course.

CONCLUSION

Quadrigeminal SAH is a variant of PNSH that is not well described in the literature. It may comprise up to one-fifth of PNSH cases and carries a similar benign prognosis.