Acute lacunar stroke in association with angiogram-negative subarachnoid hemorrhage. Mechanistic implications of two cases

Remote acute subarachnoid hemorrhage after drainage of chronic subdural hematoma: A case report and review of the literature

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Chronic subdural hematoma (CSDH) can be treated by a relatively simple burr hole surgery. Acute subarachnoid hemorrhage (SAH) occurring after surgery for CSDH has been reported as a rare but severe complication. So, we reported this case.

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Acute SAH occurring after surgery for CSDH is a rare but severe complication associated with the postoperative drainage speed. Rapid variation of cerebral blood flow and perioperative parenchymal shift occur due to the speed of the drainage system. Thus, the height of the tube should not be too low, thereby avoiding“too rapid or too excessive postoperative drainage.”

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Slow decompression with closed-system drainage is recommended to avoid rapid dynamic intracranial changes during drainage of a subdural hematoma, including brain shift or restoration of normal perfusion, to prevent devastating complications.

Introduction

Chronic subdural hematoma(CSDH) can be treated by a relatively simple burr hole surgery. Acute subarachnoid hemorrhage (SAH) occurring after surgery for CSDH has been reported as a rare but severe complication.

Case report

An 88-year-old female complained of progressive headache and dizziness for one month. A right fronto-temporo-parietal CSDH with a shift in the midline structures and lateral ventricle compression was shown by computed tomography (CT) scans. Closed-system drainage of the hematoma was performed via one burr hole under general anesthesia. Two hours after we began draining the hematoma at the patient’s bedside, the patient complained of headache and exhibited impaired consciousness that progressively degenerated. The drainage bag collected 200 ml of bloody liquid overa short time. A subsequent CT scan revealed SAH and an acute subdural hematoma. A CT angiogram excluded the presence of intracranial aneurysms. The patient died of hypostatic pneumonia after 15 days despite conservative medical management.

Discussion

Relevant literature was reviewed, and we believe that the occurrence of a hematoma in the opposite hemisphere and the hyperperfusion resulted from the rapid drainage of the hematoma, which caused the rupture of weak bridging veins during drainage.

Conclusion

Slow decompression with closed-system drainage is recommended to avoid rapid dynamic intracranial changes during drainage of a subdural hematoma, including brain shift or restoration of normal perfusion,to prevent devastating complications.

Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous Drainage Anomalies: A Systematic Literature Review and Meta-Analysis

BACKGROUND AND PURPOSE

Mechanisms underlying bleeding in nonaneurysmal perimesencephalic SAH remain unclear. Previous investigators have suggested a relationship between nonaneurysmal perimesencephalic SAH and primitive venous drainage of the basal vein of Rosenthal. We performed a meta-analysis to evaluate the relation between primitive basal vein of Rosenthal drainage and nonaneurysmal perimesencephalic SAH.

MATERIALS AND METHODS

We performed a comprehensive literature search of all studies examining the prevalence of primitive basal vein of Rosenthal drainage in patients with aneurysmal SAH and nonaneurysmal perimesencephalic SAH. Data collected were primitive basal vein of Rosenthal drainage (direct connection of perimesencephalic veins into the dural sinuses instead of the Galenic system) in at least 1 cerebral hemisphere, normal bilateral basal vein of Rosenthal drainage systems, and the number of overall primitive venous systems in the nonaneurysmal perimesencephalic SAH and aneurysmal SAH groups. Statistical analysis was performed by using a random-effects meta-analysis.

RESULTS

Eight studies with 888 patients (334 with nonaneurysmal perimesencephalic SAH and 554 with aneurysmal SAH) and 1657 individual venous systems were included. Patients with nonaneurysmal perimesencephalic SAH were more likely to have a primitive basal vein of Rosenthal drainage in at least 1 hemisphere (47.7% versus 22.1%; OR, 3.31; 95% CI, 2.15-5.08; P < .01) and were less likely to have bilateral normal basal vein of Rosenthal drainage systems than patients with aneurysmal SAH (18.3% versus 37.4%; OR, 0.27; 95% CI, 0.14-0.52; P < .01). When we considered individual venous systems, there were higher rates of primitive venous systems in patients with nonaneurysmal perimesencephalic SAH than in patients with aneurysmal SAH (34.9% versus 15.3%; OR, 3.90; 95% CI, 2.37-6.43; P < .01).

CONCLUSIONS

Patients with nonaneurysmal perimesencephalic SAH have a higher prevalence of primitive basal vein of Rosenthal drainage in at least 1 hemisphere than patients with aneurysmal SAH. This finding suggests a venous origin of some nonaneurysmal perimesencephalic SAHs. A primitive basal vein of Rosenthal pattern is an imaging finding that has the potential to facilitate the diagnosis of nonaneurysmal perimesencephalic SAH.

Contrast Extravasation on Computed Tomography Angiography Imitating a Basilar Artery Trunk Aneurysm in Subsequent Conventional Angiogram-Negative Subarachnoid Hemorrhage: Report of Two Cases with Different Clinical Courses

Contrast extravasation on computed tomography angiography (CTA) is rare but becoming more common, with increasing use of CTA for various cerebral vascular diseases. We report on two cases of spontaneous subarachnoid hemorrhage (SAH) in which the CTA showed an upper basilar trunk saccular lesion suggesting ruptured aneurysm. However, immediate subsequent digital subtraction angiography (DSA) failed to show a vascular lesion. In one case, repeated follow up DSA was also negative. The patient was treated conservatively and discharged without any neurologic deficit. In the other case, the patient showed sudden mental deterioration on the third hospital day and her brain CT showed rebleeding. The immediate follow up DSA showed contrast stagnation in the vicinity of the upper basilar artery, suggestive of pseudoaneurysm. Double stents deployment at the disease segment was performed. Due to the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.

Embolic Stroke: A Rare but Probably Real Cause of Aneurysmal-Like Subarachnoid Hemorrhage

BACKGROUND

Ischemic stroke is being increasingly recognized as a possible cause of spontaneous isolated convexity subarachnoid hemorrhage (SAH). However, it is a much less established cause of cisternal, aneurysmal-like SAH. Only 3 case reports of concomitant cisternal SAH and perforator infarcts exist in the literature, raising the possibility of perforating artery rupture as a potential mechanism. In contrast, embolic stroke is not recognized as a cause of aneurysmal-like SAH.

CASE DESCRIPTION

In 2 patients with embolic cerebral infarctions mimicking intracranial aneurysm rupture, diagnosis was confirmed by magnetic resonance imaging with diffusion-weighted imaging after cerebral angiography failed to reveal an underlying vascular lesion. Extracranial atherosclerosis was identified as the source of emboli in each case. One patient was started on antiplatelet therapy, and the other underwent surgical revascularization. Both patients had a favorable hospital course, with no recurrent hemorrhage or ischemia.

CONCLUSIONS

Based on these observations, embolic stroke should be included in the differential diagnosis of angiogram-negative SAH. Therefore, brain magnetic resonance imaging and vascular imaging of the neck should be part of the routine work-up of this relatively common entity.

Contrast extravasation on computed tomography angiography imitating a basilar artery trunk aneurysm in subsequent conventional angiogram-negative subarachnoid hemorrhage: report of two cases with different clinical courses

Contrast extravasation on computed tomography angiography (CTA) is rare but becoming more common, with increasing use of CTA for various cerebral vascular diseases. We report on two cases of spontaneous subarachnoid hemorrhage (SAH) in which the CTA showed a saccular lesion of the upper basilar trunk suggesting a ruptured aneurysm. However, no vascular lesion was observed on immediate subsequent digital subtraction angiography (DSA).

In one case, repeated follow up DSA was also negative. The patient was treated conservatively and discharged with no neurologic deficit. In the other case, the patient showed sudden mental deterioration on the third hospital day and her brain CT showed rebleeding. The immediate follow up DSA showed contrast stagnation in the vicinity of the upper basilar artery, suggestive of pseudoaneurysm. Double stent deployment at the disease segment was performed.

Due to the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.

Contrast extravasation on computed tomographic angiography mimicking a basilar artery aneurysm in angiogram-negative subarachnoid hemorrhage: report of 2 cases

BACKGROUND AND IMPORTANCE

Contrast extravasation on computed tomography angiography (CTA) is becoming more common, with increasing use of CTA for myriad intracranial vascular pathologies. This article describes the first 2 documented cases of contrast extravasation from a nonaneurysmal basilar artery source seen on CTA and discusses possible pathophysiologic mechanisms.

CLINICAL PRESENTATION

We present 2 cases of diffuse atraumatic subarachnoid hemorrhage in which the CTA showed an abnormality in association with the basilar artery highly suggestive of a ruptured aneurysm. Follow-up digital subtraction angiography, however, was completely negative. Subsequent repeat digital subtraction angiography failed to reveal a vascular lesion. Both patients were treated for complications associated with SAH, but given the negative digital subtraction angiography, no intervention was performed.

CONCLUSION

Because of the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.

Concurrent presentation of perimesencephalic subarachnoid hemorrhage and ischemic stroke

Perimesencephalic subarachnoid hemorrhage (SAH) is a relatively benign form of SAH. The etiology of this condition is unknown but venous leakage has been believed to be the most likely cause. This report describes a patient with perimesencephalic SAH who presented with a concurrent acute pontine infarct demonstrated on diffusion-weighted magnetic resonance imaging. These findings suggest that in some instances perimesencephalic SAH is caused by rupture of a perforating artery.

Midbrain stroke with angiogram-negative subarachnoid hemorrhage mimicking a perimesencephalic bleed

Angiogram-negative atraumatic subarachnoid hemorrhage (SAH) in a perimesencephalic pattern on computed tomography (CT) is associated with an almost invariably favorable prognosis with few rebleeds. We report a patient who exhibited a perimesencephalic hemorrhage pattern on CT and negative serial angiograms and who presented with severe neurologic disability from a concurrent midbrain stroke. We contend that both the acute infarction and hemorrhage arose from obliteration of a penetrating end artery. Possible etiologies of angiogram-negative SAH, including perimesencephalic hemorrhage, are discussed.

Subarachnoid hemorrhage without evident cause on initial angiography studies: diagnostic yield of subsequent angiography and other neuroimaging tests

OBJECT

The aim of this study was to assess the diagnostic yield of imaging tests performed in patients in whom the cause of subarachnoid hemorrhage (SAH) had not been demonstrated on initial angiography.

METHODS

By reviewing medical records of 806 patients with SAH who had been admitted during a 6.5-year period, the authors identified 86 in whom initial transfemoral catheter angiography failed to reveal the cause of SAH. Clinical and radiological data were analyzed to determine the diagnostic yield of subsequent catheter angiography, computerized tomography (CT) angiography, magnetic resonance (MR) angiography, and MR imaging of the brain and spine for various subtypes of SAH (bleeding not visualized on CT studies [CT-negative SAH], perimesencephalic SAH, and nonperimesencephalic SAH). Of 41 patients with nonperimesencephalic SAH, 36, 32, and 21 underwent repeated catheter angiography, CT angiography, and MR angiography, respectively; brain MR imaging was performed in 23 patients (18 with Gd and 15 with susceptibility contrast sequences), and spine MR imaging in 17. Of 36 patients with perimesencephalic SAH, 31, 23, and 17 underwent repeated catheter angiography, CT angiography, and MR angiography, respectively; brain MR imaging was performed in 18 patients (17 with Gd and 11 with susceptibility contrast sequences), and spine MR imaging in 14. Of nine patients with SAH not visualized on CT scanning, three, one, and six underwent repeated catheter angiography, CT angiography, and MR angiography, respectively; brain MR imaging was performed in eight patients (five with Gd and three with susceptibility contrast sequences), and spine MR imaging in seven. The cause of SAH could be determined in only four patients, all with nonperimesencephalic SAH. The only test that yielded a diagnosis was catheter angiography (three aneurysms on the second and one on the third angiography, all surgically secured). Diffusion-weighted MR imaging demonstrated small, deep infarcts in five patients.

CONCLUSIONS

Repeated catheter angiography remains the most sensitive test to determine the cause of SAH that is not demonstrated on initial angiography, particularly in the subtype of nonperimesencephalic SAH. Newer, noninvasive imaging techniques provide little diagnostic yield.

Origin of pretruncal nonaneurysmal subarachnoid hemorrhage: ruptured vein, perforating artery, or intramural hematoma?

Pretruncal (perimesencephalic) nonaneurysmal subarachnoid hemorrhage (SAH) is a benign variant of SAH. Although angiography fails to show a source of the hemorrhage, mild basilar artery narrowing may be observed. The cause of pretruncal nonaneurysmal SAH has not been established. Recent imaging studies have demonstrated that the center of this type of SAH is not around the mesencephalon but is in the prepontine or interpeduncular cistern with the hemorrhage closely associated with the basilar artery. We review the possible sources of hemorrhage in these cisterns and hypothesize that pretruncal nonaneurysmal SAH is caused by a primary intramural hematoma of the basilar artery. Such an intramural hematoma would explain bleeding under low pressure, the location of the hemorrhage anterior to the brainstem, and the typical findings of hemorrhage adjacent to the basilar artery lumen on magnetic resonance imaging and mild basilar artery narrowing on angiography. Although an intramural hematoma of the basilar artery would be easily identified at surgical exploration, such surgeries have never included the extensive base-of-the-skull approaches that are necessary to visualize the artery in the prepontine cistern.