Aneurysmal subarachnoid haemorrhage: guidance in making the correct diagnosis

Evaluation of subacute subarachnoid haemorrhage detection using a magnetic resonance imaging sequence: Double inversion recovery

BACKGROUND AND OBJECTIVES

The diagnosis of subarachnoid hemorrhage (SAH) especially at the subacute stage is still a challenging issue using the conventional imaging modalities. Here we evaluated the role of double inversion recovery (DIR) sequence of MRI compared with the conventional gradient-recalled echo (GRE)-T2*-W and susceptibility-weighted imaging (SWI) sequences in the diagnosis of subacute SAH.

MATERIALS AND METHODS

This prospective study was conducted on 21 patients with SAH, which were diagnosed using CT scan at the initial step. In the third week after the injury (14-20 days), all patients underwent a brain MRI exam that included T2*-W, SWI, and DIR imaging sequences. All images were independently read by two radiologists, who were blinded to the clinical history of the patients. The presence or absence of SAH was reviewed and assessed in 6 anatomical regions.

RESULTS

On the DIR images, 20 patients were found to have at least one subarachnoid signal abnormality, while the SWI and T2*-W images identified SAH areas on 17 and 15 patients, respectively. The highest rate of inter-observer consensus by the DIR sequence was found in the interhemispheric fissure and perimesencephalic area (k = 1). Also, a highest rate of inter-observer consensus using SWI was found in the interhemispheric fissure and posterior fossa cistern area (k = 1). A weak agreement was found in frontal-parietal convexity using SWI (k = 0.447), and in posterior fossa cistern by the T2* sequence (k = 0.447).

CONCLUSION

In conclusion, the DIR sequence was more reliable at identifying signal abnormalities in subacute SAH patients than the T2*-W and SWI sequence, and is suggested as a promising imaging technique for detecting hemorrhagic areas without considering the anatomical distribution of SAH.

Spontaneous subarachnoid haemorrhage incidence among hospitalised patients in Edirne, Turkey

BACKGROUND

To the best of our knowledge, no data has been published about the spontaneous subarachnoid haemorrhage (sSAH) incidence in Turkey. We aimed to report the estimation of sSAH incidence in Edirne Province, in Turkey for the first time, using the data acquired from a single medical centre which has the biggest and the most comprehensive emergency department in Edirne and to where a great majority of patients are referred.

METHODS

We investigated all the accessible sSAH patients' data obtained from computer-based automation systems and all the written documents in the neurosurgery and the emergency departments. Patients included in the study were diagnosed with sSAH between the dates of January 2007 and December 2011 and were resident in Edirne. We used this data to calculate the crude and age-adjusted incidence rates of sSAH for every decade.

RESULTS

One hundred fifty-four patients have been diagnosed with sSAH during a 5-year period. Among them, 72 were men (47.8%) and 82 (53.2%) were women. The mean age of the patients was 60.8 years and age range was 23-85 years. The overall annual adjusted incidence rate for sSAH was 10.3 per 100,000 person-years (95% confidence interval = 10.2-10.3). Annual adjusted incidence rate was 10 per 100,000 person-years (95% confidence interval = 10-10.1) for men. For women, it was 10.4 per 100,000 person-years (95% confidence interval = 10.4-10.5). For both sexes, after the 6th decade, the annual incidence rate of sSAH was higher than 10 per 100,000, reaching over 20 per 100,000 person-years after the 7th decade. The overall crude incidence rate for sSAH was 10.3 per 100,000 person-years. For men, the crude incidence rate was 9.4 per 100,000 person-years and for women, it was 11.2 per 100,000 person-years.

CONCLUSIONS

This study showing the first sSAH incidence estimation in Edirne might also be accepted as an estimation of overall epidemiological sSAH aspect in Turkey. Future investigations should be realised in different parts of Turkey to enlighten the epidemiological state of affairs and the course of sSAH in Turkey.

Flow cytometry for the microscopy of body fluids in patients with suspected infection

Automating the microscopy of body fluids is challenging, due to the wider range and lower concentrations of cells in these fluids, as opposed to blood, while the viscous nature of some of these fluids can also be problematic. This review shows that there have been major improvements and that newer flow cytometers can have remarkably low limits of quantitation for WBCs. Accurate counting of RBCs is still problematic with many flow cytometers, but this is of no clinical significance. Many flow cytometers can give reasonably accurate WBC differential counts, but detection of eosinophils and neoplastic or other nucleated cells which are not blood cells can still be problematic, hence fail-safe measures are recommended. Cerebrospinal fluid is the most challenging body fluid as it requires the ability to count and differentiate WBCs down to a 'normal range', which is much lower than the diagnostic cut-off values used for serous fluids; precision at or around the cerebrospinal fluid WBC normal range is reduced even with the best flow cytometers, but manual microscopy is even less precise.

Relationship between plasma high mobility group box-1 protein levels and clinical outcomes of aneurysmal subarachnoid hemorrhage

Background

High-mobility group box 1 (HMGB1), originally described as a nuclear protein that binds to and modifies DNA, is now regarded as a central mediator of inflammation by acting as a cytokine. However, the association of HMGB1 in the peripheral blood with disease outcome and cerebrovasospasm has not been examined in patients with aneurysmal subarachnoid hemorrhage.

Methods

In this study, 303 consecutive patients were included. Upon admission, plasma HMGB1 levels were measured by ELISA. The end points were mortality after 1 year, in-hospital mortality, cerebrovasospasm and poor functional outcome (Glasgow Outcome Scale score of 1 to 3) after 1 year.

Results

Upon admission, the plasma HMGB1 level in patients was statistically significantly higher than that in healthy controls. A multivariate analysis showed that the plasma HMGB1 level was an independent predictor of poor functional outcome and mortality after 1 year, in-hospital mortality and cerebrovasospasm. A receiver operating characteristic curve showed that plasma HMGB1 level on admission statistically significantly predicted poor functional outcome and mortality after 1 year, in-hospital mortality and cerebrovasospasm of patients. The area under the curve of the HMGB1 concentration was similar to those of World Federation of Neurological Surgeons (WFNS) score and modified Fisher score for the prediction of poor functional outcome and mortality after 1 year, and in-hospital mortality, but not for the prediction of cerebrovasospasm. In a combined logistic-regression model, HMGB1 improved the area under the curve of WFNS score and modified Fisher score for the prediction of poor functional outcome after 1 year, but not for the prediction of mortality after 1 year, in-hospital mortality, or cerebrovasospasm.

Conclusions

HMGB1 level is a useful, complementary tool to predict functional outcome and mortality after aneurysmal subarachnoid hemorrhage. However, HMGB1 determination does not add to the accuracy of prediction of the clinical outcomes.

Elucidating novel mechanisms of brain injury following subarachnoid hemorrhage: an emerging role for neuroproteomics

Subarachnoid hemorrhage (SAH) is a devastating neurological injury associated with significant patient morbidity and death. Since the first demonstration of cerebral vasospasm nearly 60 years ago, the preponderance of research has focused on strategies to limit arterial narrowing and delayed cerebral ischemia following SAH. However, recent clinical and preclinical data indicate a functional dissociation between cerebral vasospasm and neurological outcome, signaling the need for a paradigm shift in the study of brain injury following SAH. Early brain injury may contribute to poor outcome and early death following SAH. However, elucidation of the complex cellular mechanisms underlying early brain injury remains a major challenge. The advent of modern neuroproteomics has rapidly advanced scientific discovery by allowing proteome-wide screening in an objective, nonbiased manner, providing novel mechanisms of brain physiology and injury. In the context of neurosurgery, proteomic analysis of patient-derived CSF will permit the identification of biomarkers and/or novel drug targets that may not be intuitively linked with any particular disease. In the present report, the authors discuss the utility of neuroproteomics with a focus on the roles for this technology in understanding SAH. The authors also provide data from our laboratory that identifies high-mobility group box protein-1 as a potential biomarker of neurological outcome following SAH in humans.

[General management in intensive care of patient with spontaneous subarachnoid hemorrhage]

Aneurysmal subarachnoid hemorrhage (SAH) is a neurologic emergency and often a neurologic catastrophe. Nontraumatic subarachnoid hemorrhage is characterized by the extravasation of blood into the spaces covering the central nervous system. The leading cause of SAH is rupture of an intracranial aneurysm, which accounts for about 80-85% of cases. Mortality and morbidity can be reduced if SAH is treated urgently. Sudden, explosive headache is a cardinal but nonspecific feature in the diagnosis of SAH; computered tomography (CT) scanning is mandatory in all the patients with symp toms that are suggestive of SAH. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. Diagnosing SAH can be challenging and treatment is complex, sophisticated and multidisciplinary. Reble eding is the most imminent danger, which must be prevented by endovascular occlusion with detachable coils (coiling) or by surgical clipping of the aneurysm; the risk of delayed cerebral ischemia is reduced with nimodipine and avoiding hypovolemia; hydrocephalus can be treated by ventricular drainage. Intensive care plays a more important role in the management of SAH than in any other neurological disorder. Excellence in neurologic diagnosis, in operative neurosurgery or neuroradiologic procedures must be accompanied by excellence in Intensive Care. This review emphasizes treatment in the Intensive Care Unit, surgical and endovascular therapeutic options and the current state of treatment of major complications such as rebleeding, cerebral vasospasm and acute hydrocephalus.

Headache caused by an intracranial aneurysm in a 32-year-old woman

OBJECTIVES

We describe the case of a woman with a headache later found to be a result of an intracranial aneurysm. Through this article, we aim to raise awareness regarding the red flags that should lead doctors of chiropractic to suspect the presence of this condition to facilitate appropriate patient management that increases the likelihood of patients' recovery.

CLINICAL PRESENTATION

A 32-year-old woman sought care for a constant headache of 4 days' duration. She described the headache as severe throughout her entire head, centralized at the base of the occiput, and unlike any headache she had experienced. She had concomitant neck pain. Her left eye deviated toward the midline and had excessive tearing 12 hours after the onset of the headache.

INTERVENTION AND OUTCOME

No chiropractic adjustment was administered; immediate transfer for emergency treatment was arranged instead. The diagnosis of a bleeding intracranial aneurysm was confirmed by magnetic resonance imaging. The patient was transferred to a local university hospital for surgical intervention. Unfortunately, she died of vasospastic complications.

CONCLUSIONS

The red flags to be considered in evaluating patients with such headache as that described for our case patient include a history of hypertension, cigarette smoking, oral contraceptive use, alcohol consumption, pregnancy, and cocaine use. Practitioners need to be aware of the signs and symptoms that indicate whether a headache may be a result of serious problems such as an aneurysm.

An overview of intracranial aneurysms

Intracranial aneurysms are relatively common, with a prevalence of approximately 4%. Unruptured aneurysms may cause symptoms mainly due to a mass effect, but the real danger is when an aneurysm ruptures, leading to a subarachnoid hemorrhage. Most aneurysms are asymptomatic and will not rupture, but they grow unpredictably and even small aneurysms carry a risk of rupture. Intracranial aneurysms are diagnosed and monitored with imaging including intra-arterial digital subtraction angiography, computed tomography angiography, magnetic resonance angiography, and recently transcranial Doppler ultrasonograpy has been proposed as a potential modality. Treatment options include observation, endovascular coiling, and surgical clipping. This paper will review the epidemiology, pathogenesis, clinical presentation, diagnosis, natural history, and management of unruptured saccular intracranial aneurysms.