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Mandel D, Moody S, Pan K, Subramaniam T, Thompson BB, Wendell LC, Reznik ME, Furie KL, Mahta A. A quantitative model to differentiate nonaneurysmal perimesencephalic subarachnoid hemorrhage from aneurysmal etiology. J Neurosurg 2023; 138:165-172. [PMID: 35523263 DOI: 10.3171/2022.3.jns22157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 03/21/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes. METHODS The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model. RESULTS Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98-1.00; OR per point increase 10; 95% CI 2.18-46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92-1.00) of this model. CONCLUSIONS A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.
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Affiliation(s)
- Daniel Mandel
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Scott Moody
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 2Department of Physician Assistant Studies, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts
| | - Kelly Pan
- 3Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Thanujaa Subramaniam
- 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Bradford B Thompson
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Linda C Wendell
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- 6Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael E Reznik
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Karen L Furie
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ali Mahta
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- 6Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Hou K, Yu J. Current status of perimesencephalic non-aneurysmal subarachnoid hemorrhage. Front Neurol 2022; 13:960702. [PMID: 36119687 PMCID: PMC9475169 DOI: 10.3389/fneur.2022.960702] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/08/2022] [Indexed: 01/21/2023] Open
Abstract
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.
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Sattenberg RJ, Atchaneeyasakul K, Meckler J, Saver JL, Gobin YP, Liebeskind DS. Cerebral Angiography. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00049-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Alimohammadi E, Ahadi P, Karbasforoushan A, Rahmani S, Bagheri SR, Abdi A. Nontraumatic Nonaneurysmal Subarachnoid Hemorrhage: Risk Factors, Complications, and Clinical Outcomes. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1714302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Background The present study aimed to investigate the risk factors, complications, and clinical outcomes of patients with nontraumatic, nonaneurysmal subarachnoid hemorrhage (NNSAH).
Methods We retrospectively evaluated 78 consecutive patients with NNSAH admitted to our center between April 2009 and April 2019. Patients were divided into two groups based on the distribution of blood in the CT scan, perimesencephalic subarachnoid hemorrhage ( PM-SAH) and nonperimesencephalic subarachnoid hemorrhage (nPM-SAH) groups. The outcome was assessed according to the Glasgow outcome scale (GOS). The demographic data and clinical records including age, sex, smoking history, hypertension, diabetes, history of anticoagulant medication, Glasgow coma score (GCS), Hunt–Hess (HH) grades, and in-hospital complications and clinical outcomes were retrospectively reviewed and compared between the two groups.
Results There were 45 patients (57.69%) in the PM-SAH group and 33 cases (42.30%) in the nPM-SAH group with the mean age of 53.98 ± 7.7 years. There were no significant differences between the two groups based on age, sex, smoking history, diabetes, hypertension, anticoagulation medication history, and HH grade at admission. The nPM-SAH group was significantly associated with a higher incidence of radiological and clinical vasospasm (p < 0.05). Moreover, the need for external ventricular drainage (EVD) placement because of the development of hydrocephalus was significantly higher in the nPM group (p < 0.05). Patients with PM-SAH had better clinical outcomes than those with nPM-SAH (p = 0.037).
Conclusions Our results showed that patients with nonaneurysmal subarachnoid hemorrhage (NSAH) had favorable clinical outcomes. The PM group had better clinical outcomes and lower complication rates in comparison with the nPM group. Repeated digital subtraction angiography (DSA) examinations are strongly recommended for patients with nPM-SAH.
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Affiliation(s)
- Ehsan Alimohammadi
- Department of Neurosurgery, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
| | - Paniz Ahadi
- Clinical Research Development Center of Taleghani and Imam Ali Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Karbasforoushan
- Department of Anesthesiology, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
| | - Shamsoddin Rahmani
- Department of Neurosurgery, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
| | - Seyed Reza Bagheri
- Department of Neurosurgery, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
| | - Alireza Abdi
- Nursing and Midwifery School, Kermanshah University of Medical Sciences, Imam Reza Hospital, Kermanshah, Iran
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The role of imaging in the management of non-traumatic subarachnoid hemorrhage: a practical review. Emerg Radiol 2021; 28:797-808. [PMID: 33580850 DOI: 10.1007/s10140-021-01900-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/12/2021] [Indexed: 01/01/2023]
Abstract
The purpose of this review is to understand the role of imaging in the diagnosis and management of non-traumatic subarachnoid hemorrhage (SAH). SAH is a life-threatening emergency and a relatively common entity, the most common etiology being ruptured aneurysms. Multiple conundrums exist in literature at various steps of its imaging workup: diagnosis, management, and follow-up. We target our review to highlight the most effective practice and suggest efficient workup plans based on literature search, and describe in detail the clinical diagnostic and prognostic scales, role of CT scan, lumbar puncture, and MR, including angiography in the diagnosis and workup of SAH and its complications, and try to simplify the conundrums. Practical knowledge of imaging workup of SAH can help guide correct management of these patients, so as to reduce morbidity and mortality without resource overutilization.
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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Yeole U, Nagesh M, Shukla D, R. AH, R. PA. The Yield of Repeat Angiography in Angiography-Negative Spontaneous Subarachnoid Hemorrhage. J Neurosci Rural Pract 2020; 11:565-572. [PMID: 33144792 PMCID: PMC7595787 DOI: 10.1055/s-0040-1714313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective
Despite the technological advancement in imaging, digital subtraction angiography (DSA) remains gold standard imaging modality for spontaneous subarachnoid hemorrhage (SAH). But even after DSA, around 15% of SAH remains elusive for the cause of the bleed. This is an institutional review to solve the mystery, “when is second DSA really indicated?”
Methods
In a retrospective review from January 2015 to December 2017, we evaluated cases of spontaneous SAH with initial negative DSA with repeat DSA after 6 weeks to rule out vascular abnormality. The spontaneous SAH was confirmed on noncontrast computed tomography (NCCT) and divided into two groups of perimesencephalic SAH (PM-SAH) or nonperimesencephalic SAH (nPM-SAH). The outcome was assessed by a modified Rankin’s score (mRS) at 6 months postictus.
Results
During the study period, we had 119 cases of initial negative DSA and 98 cases (82.3%) underwent repeat DSA after 6 weeks interval. A total of 53 cases (54.1%) had PM-SAH and 45 cases (45.9%) had nPM-SAH. Repeat DSA after 6 weeks showed no vascular abnormality in 53 cases of PM-SAH and in 2 (4.4%) out of 45 cases of nPM-SAH. At 6 months postictus, all cases of PM-SAH and 93% of nPM-SAH had mRS of 0.
Conclusion
We recommend, a repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH. Although the overall outcome for nonaneurysmal spontaneous SAH is better than aneurysmal SAH, nPM-SAH has poorer eventual outcome compared to PM-SAH.
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Affiliation(s)
- Ujwal Yeole
- Department of Surgical oncology, Neurosurgery Services, Tata Memorial Centre and Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Madhusudhan Nagesh
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Aravind H. R.
- Department of Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
| | - Prabhuraj A. R.
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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Alhoobi M, Abu-Qadous F, Khan M, Shaaban A, Shaikh N, Hammadi F, Abu-Jarir R, Albanna W, Alrumaihi G, Belkhair S, Babu AR, Ayyad A. Ten Years' Experiences in the Treatment of Nonaneurysmal Subarachnoid Hemorrhage: A Retrospective Analysis of Outcome Parameters in a Single-Center Study. Asian J Neurosurg 2020; 15:315-321. [PMID: 32656125 PMCID: PMC7335133 DOI: 10.4103/ajns.ajns_315_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/16/2020] [Indexed: 12/18/2022] Open
Abstract
Objectives: Subarachnoid hemorrhage (SAH) with negative angiographic findings has a heterogeneous nature with variations in clinical course and outcome as compared to the aneurysmal SAH. It makes up to 15% of the spontaneous SAH and is characterized by milder clinical presentation. The purpose of this study was the analyses of risk factors, clinical observations, radiologic characteristics, and outcome in patients with nonaneurysmal SAH (NA-SAH). Patients and Methods: In a retrospective design, 77 consecutive patients with NA-SAH were recruited from May 2008, to October 2018. All patients underwent conventional cerebral angiography. We stratified patients into two groups based on the distribution of blood on their CT scan into perimesencephalic (PM) and non-PM (NPM) SAH. We performed the Outcome using Glasgow Coma Scale (GCS) and modified Rankin scale (favorable mRS 0–2 vs. unfavorable mRS 3–6). Data were analyzed using IBM® SPSS® Statistics V22.0. Results: The mean age at presentation was 48.5 ± 8.4 years with male predominance (71.4%). About 76.7% of the patients had headache and vomiting, most of the patients (75.3%) presented with GCS 15 at initial clinical presentation (61.03%) had NPM versus (38.96%) with PM characters in computed tomography scans. Fourteen (17.9%) patients developed hydrocephalus and 12 (15.3%) needed external ventricular drain placement, while none of the patients needed permanent shunt placement. However, all patients had a favorable clinical and functional outcome at discharge and at late follow-up (up to 3 months). Conclusions: NA-SAH does not affect the short- and long-term prognosis. In our results, the pattern of bleeding affects the initial presentation, clinical course, and complications. The clinical and functional outcomes in the majority of our patients were comparable in both groups with good prognosis. Hypertension, smoking, and elevated venous pressure, such as a history of deep venous thrombosis and asthma might be considered as a risk factor.
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Affiliation(s)
- Mohammed Alhoobi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Fatma Abu-Qadous
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Mohsin Khan
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Ahmed Shaaban
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Nissar Shaikh
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Firas Hammadi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Raed Abu-Jarir
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Walid Albanna
- Department of Neurosurgery, RWTH, Aachen University, Aachen, Germany
| | - Ghaya Alrumaihi
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | | | - Arun R Babu
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
| | - Ali Ayyad
- Department of Neurosurgery, Hamad Medical Corporation, Doha, Qatar
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Michelozzi C, Cognard C. [The role of interventional neuroradiology in treatment of hemorrhagic stroke]. Presse Med 2019; 48:684-695. [PMID: 31153680 DOI: 10.1016/j.lpm.2019.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Accepted: 05/02/2019] [Indexed: 11/15/2022] Open
Abstract
Treatment of hemorrhagic strokes necessitates hospitalization in an accommodated hospital offering the possibility of a multidisciplinary approach. In this setting, over recent years interventional radiology has become increasingly important from the diagnostic as well as the therapeutic standpoint. In the context of subarachnoid hemorrhage by intracranial aneurysm rupture, the NICE (National Institute for Health and Clinical Excellence) and ASA (American Stroke Academy) recommendations suggest that endovascular coiling should be considered as an alternative to surgical clipping (class I, level of evidence B). As stenting is associated with increased morbidity and mortality in the ruptured aneurysms, it should be avoided (class III, level of evidence C). The patient's clinical status on presentation should be taken into account when deciding on therapeutic management and determining prognosis. Long-term clinical outcome depends on several factors: clinical status on arrival, comorbidities, age, occurrence of operative complications and complications of subarachnoid hemorrhage such as hydrocephaly, vasospasm and delayed cerebral ischemia, as well as complications stemming from prolonged bed rest. In the event of vasospasm refractory to maximal medical therapy, endovascular treatment by intra-arterial injection of Nimodipine and angioplasty can be envisioned. In the event of intracerebral hemorrhage (ICH) by rupture cerebral dural arteriovenous fistula, once the diagnosis has been confirmed, and given the exceedingly high risk of rebleeding, first-line treatment will consist in emergency endovascular embolization. In the event of intracerebral hemorrhage (ICH) by arteriovenous rupture, treatment is decided on during a multidisciplinary meeting and either carried out immediately or delayed according to several factors: clinical conditions, age of the patient, angioarchitecture and ICH location.
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Affiliation(s)
- Caterina Michelozzi
- CHU Toulouse, hôpital Pierre Paul Riquet, service de neuroradiologie, 1, place du Dr Baylac, 31059 Toulouse cedex 9, France.
| | - Christophe Cognard
- CHU Toulouse, hôpital Pierre Paul Riquet, service de neuroradiologie, 1, place du Dr Baylac, 31059 Toulouse cedex 9, France
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Bashir A, Mikkelsen R, Sørensen L, Sunde N. Non-aneurysmal subarachnoid hemorrhage: When is a second angiography indicated? Neuroradiol J 2017; 31:244-252. [PMID: 29154725 DOI: 10.1177/1971400917743100] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Purpose Repeat imaging in patients with non-aneurysmal subarachnoid hemorrhage (NASAH) remains controversial. We aim to report our experience with NASAH with different hemorrhage patterns, and to investigate the need for further diagnostic workup to determine the underlying cause of hemorrhage. Method We conducted a retrospective analysis of all spontaneous SAH with an initial negative computed tomography (CT) with angiography (CTA) and/or digital subtraction angiography (DSA) from October 2011 through May 2017. According to the bleeding pattern on the admission CT scan, NASAH was divided into two subgroups: (1) perimesencephalic SAH (PMSAH) and (2) non-perimesencephalic SAH (nPMSAH). Radiological data included the admission CT, CTA, DSA, and magnetic resonance imaging (MRI) with angiography (MRA). Results Seventy-four patients met the inclusion criteria. Thirty-nine (52.7%) patients had PMSAH on the initial CT scan, and 35 (47.3%) had nPMSAH. All underwent CTA and/or DSA revealing no vascular abnormalities. Forty-seven (63.5%) patients underwent subsequent diagnostic workup. DSA was performed in all patients at least once. No abnormalities were found on the repeat DSA or other radiological follow-up studies except in one (1.4%) patient with nPMSAH, in whom a follow-up DSA revealed a small saccular anterior choroidal artery aneurysm, considered to be the source of hemorrhage. Conclusion A repeat DSA may not be needed in case of PMSAH, if the initial negative DSA is technically adequate with absence of hematoma and vasospasm. In contrast, a follow-up DSA should be mandatory for confirming or excluding vascular pathology in case of nPMSAH in order to prevent rebleeding.
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Affiliation(s)
- Asma Bashir
- 1 Department of Neurosurgery, 11297 Aarhus University Hospital , Denmark
| | - Ronni Mikkelsen
- 2 Department of Neuroradiology, 11297 Aarhus University Hospital , Denmark
| | - Leif Sørensen
- 2 Department of Neuroradiology, 11297 Aarhus University Hospital , Denmark
| | - Niels Sunde
- 1 Department of Neurosurgery, 11297 Aarhus University Hospital , Denmark
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Recurrent Bleeding After Perimesencephalic Hemorrhage. World Neurosurg 2017; 108:990.e17-990.e21. [PMID: 28867322 DOI: 10.1016/j.wneu.2017.08.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 08/18/2017] [Accepted: 08/22/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Perimesencephalic hemorrhage (PMH) is a type of subarachnoid hemorrhage with excellent long-term outcomes. Only 1 well-documented case of in-hospital rebleeding after PMH is described in the literature, which occurred after initiating antithrombotic treatment because of myocardial ischemia. We describe a patient with PMH without antithrombotic treatment who had 2 episodes of recurrent bleeding on the day of ictus. To validate the radiologic findings, we conducted a case-control study. Six neuroradiologists and 2 neuroradiology fellows performed a blinded assessment of serial unenhanced head computed tomography (CT) scans of 8 patients with a perimesencephalic bleeding pattern (1 index patient, 6 patients with PMH, 1 patient with perimesencephalic bleeding pattern and basilar artery aneurysm) to investigate a potential increase in amount of subarachnoid blood. CASE DESCRIPTION A 56-year-old woman with a perimesencephalic bleeding pattern and negative CT angiography had 2 episodes after the onset headache with a sudden increase of the headache. Blinded assessment of serial head CT scans of 8 patients with a perimesencephalic bleeding pattern identified the patient who was clinically suspected to have 2 episodes of recurrent bleeding to have an increased amount of subarachnoid blood on 2 subsequent CT scans. CONCLUSIONS Recurrent bleeding after PMH may also occur in patients not treated with antithrombotics. Even after early rebleeding, the prognosis of PMH is excellent.
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Lin A, Rawal S, Agid R, Mandell DM. Cerebrovascular Imaging: Which Test is Best? Neurosurgery 2017; 83:5-18. [DOI: 10.1093/neuros/nyx325] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 05/12/2017] [Indexed: 11/12/2022] Open
Abstract
Abstract
Optimal diagnosis and characterization of cerebrovascular disease requires selection of the appropriate imaging exam for each clinical situation. In this review, we focus on intracranial arterial disease and discuss the techniques in current clinical use for imaging the blood vessel lumen and blood vessel wall, and for mapping cerebral hemodynamic impairment at the tissue level. We then discuss specific strategies for imaging intracranial aneurysms, arteriovenous malformations, dural arterial venous fistulas, and arterial steno-occlusive disease.
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Affiliation(s)
- Amy Lin
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Sapna Rawal
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Ronit Agid
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Daniel M Mandell
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
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Management of Spontaneous Subarachnoid Hemorrhage Patients with Negative Initial Digital Subtraction Angiogram Findings: Conservative or Aggressive? BIOMED RESEARCH INTERNATIONAL 2017; 2017:2486859. [PMID: 28540294 PMCID: PMC5433417 DOI: 10.1155/2017/2486859] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 03/21/2017] [Indexed: 12/30/2022]
Abstract
Background. The ideal management of SAH patients with negative initial DSA findings remains unresolved. Objective. (i) To present risk factors, clinical courses, and outcomes in different types of SAH patients with negative DSA findings; (ii) to explore the differences of basal vein between aSAH patients and NASAH patients; and (iii) to evaluate the value of repeated DSA for these patients. Methods. All SAH patients with negative initial DSA findings between 2013 and 2015 in our hospital were enrolled and were further categorized as perimesencephalic SAH (PMN-SAH) or nonperimesencephalic SAH (nPMN-SAH). Risk factors, clinical courses, outcomes, and the basal vein drainage patterns were compared. Results. A total of 137 patients were enrolled in the present study. The PMN-SAH group had better GOS and mRS values at 1-year follow-up. Moreover, the nPMN-SAH group had a higher rate of complications. The basal vein drainage pattern showed significant difference when comparing each of the NASAH subtypes with aSAH groups. There was a significant higher rate of a responsible aneurysm in nPMN-SAH group upon repeated DSA. Conclusions. SAH patients with negative initial DSA findings had benign clinical courses and outcomes. Repeated DSA studies are strongly advised for patients with the nPMN-SAH pattern.
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Song JP, Ni W, Gu YX, Zhu W, Chen L, Xu B, Leng B, Tian YL, Mao Y. Epidemiological Features of Nontraumatic Spontaneous Subarachnoid Hemorrhage in China: A Nationwide Hospital-based Multicenter Study. Chin Med J (Engl) 2017; 130:776-781. [PMID: 28345540 PMCID: PMC5381310 DOI: 10.4103/0366-6999.202729] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Nontraumatic spontaneous subarachnoid hemorrhage (SAH) is associated with a high mortality. This study was conducted to investigate the epidemiological features of nontraumatic spontaneous SAH in China. METHODS From January 2006 to December 2008, the clinical data of patients with nontraumatic SAH from 32 major neurosurgical centers of China were evaluated. Emergent digital subtraction angiography (DSA) was performed for the diagnosis of SAH sources in the acute stage of SAH (≤3 days). The results and complications of emergent DSA were analyzed. Repeated DSA or computed tomography angiography (CTA) was suggested 2 weeks later if initial angiographic result was negative. RESULTS A total of 2562 patients were enrolled, including 81.4% of aneurysmal SAH and 18.6% of nonaneurysmal SAH. The total complication rate of emergent DSA was 3.9% without any mortality. Among the patients with aneurysmal SAH, 321 cases (15.4%) had multiple aneurysms, and a total of 2435 aneurysms were detected. The aneurysms mostly originated from the anterior communicating artery (30.1%), posterior communicating artery (28.7%), and middle cerebral artery (15.9%). Among the nonaneurysmal SAH cases, 76.5% (n = 365) had negative initial DSA, including 62 cases with peri-mesencephalic nonaneurysmal SAH (PNSAH). Repeated DSA or CTA was performed in 252 patients with negative initial DSA, including 45 PNSAH cases. Among them, the repeated angiographic results remained negative in 45 PNSAH cases, but 28 (13.5%) intracranial aneurysms were detected in the remaining 207 cases. In addition, brain arteriovenous malformation (AVM, 7.5%), Moyamoya disease (7.3%), stenosis or sclerosis of the cerebral artery (2.7%), and dural arteriovenous fistula or carotid cavernous fistula (2.3%) were the major causes of nonaneurysmal SAH. CONCLUSIONS DSA can be performed safely for pathological diagnosis in the acute stage of SAH. Ruptured intracranial aneurysms, AVM, and Moyamoya disease are the major causes of SAH detected by emergent DSA in China.
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Affiliation(s)
- Jian-Ping Song
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yu-Xiang Gu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Wei Zhu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Liang Chen
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Bin Xu
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Bin Leng
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Yan-Long Tian
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040, China
| | - Ying Mao
- Department of Neurosurgery, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai 200040; State Key Laboratory of Medical Neurobiology, School of Basic Medical Sciences and Institutes of Brain Science, Fudan University, Shanghai 200032, China
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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16
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Malhotra A, Wu X, Borse R, Matouk CC, Bulsara K. Should Patients Be Counseled About Possible Recurrence of Perimesencephalic Subarachnoid Hemorrhage? World Neurosurg 2016; 94:580.e17-580.e22. [PMID: 27521726 DOI: 10.1016/j.wneu.2016.07.112] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 07/27/2016] [Accepted: 07/30/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND Isolated perimesencephalic subarachnoid hemorrhage (pSAH) is a distinct subtype of subarachnoid hemorrhage (SAH) seen in 5% of patients with SAH, with a relatively benign natural course and good outcome compared with diffuse, aneurysmal SAH. Traditionally, the prognosis of pSAH is believed to be excellent compared with aneurysmal SAH, with no risk of recurrent hemorrhage after long-term follow-up. We describe a case of pSAH in which the patient had a recurrent perimesencephalic bleed 8 years after the initial episode. There are 5 previous reports of recurrent pSAH in existing literature. CASE REPORT A patient in sixth decade of life with no history of trauma presented in 2006 with acute-onset, severe headache, and "off-balance" gait. The patient was diagnosed with pSAH on the basis of computed tomography angiography and digital subtraction angiography. The patient was discharged, and follow-up computed tomography angiography over the next 2 years revealed no underlying vascular anomaly. The patient presented in 2014 with sudden onset of headache, similar to the previous episode with no new neurologic signs. Patient had repeated imaging over the succeeding 2 years, which were all negative for new blood or source of subarachnoid bleed. REVIEW AND DISCUSSION There are only a couple of case reports of recurrent pSAH, some of which were defined questionably. We review the reported cases and discuss the imaging results and outcome. Considering the rarity, low risks of complications, as well as the good outcome even after recurrence, we do not recommend routinely counseling patients about possibility of recurrence of pSAH.
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Affiliation(s)
- Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Riddhi Borse
- Topiwala National Medical College, Mumbai, India
| | - Charles C Matouk
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA; Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ketan Bulsara
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut, USA
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Abstract
Imaging of acute neurologic disease in the emergency department can be challenging because of the wide range of possible causes and the overlapping imaging appearance of many of these entities on nonenhanced computed tomography (CT). The key to formulating a succinct, pertinent differential diagnosis includes characterizing the pattern of abnormalities on CT and identifying key features that suggest a particular diagnosis. This article divides neurologic emergencies into 5 scenarios based on the CT findings, including subarachnoid hemorrhage, intraparenchymal hemorrhage, vasogenic edema without and with underlying mass lesion, and acute hydrocephalus. Specific common or important diagnoses in each category are discussed.
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Affiliation(s)
- Kathleen R Fink
- Department of Radiology, University of Washington, Box 359728, 325 9th Avenue, Seattle, WA 98104, USA.
| | - Jayson L Benjert
- Department of Radiology, VA Puget Sound Health Care System, 1660 South Columbian Way, Seattle, WA 98108, USA
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Rahme R, Vyas NA. Recurrent Perimesencephalic Subarachnoid Hemorrhage After 12 Years: Missed Diagnosis, Vulnerable Anatomy, or Random Events? World Neurosurg 2015. [PMID: 26210714 DOI: 10.1016/j.wneu.2015.07.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Perimesencephalic subarachnoid hemorrhage (PMSAH) is a well-defined subtype of angiogram-negative SAH, characterized by a benign natural history and a virtually nonexistent risk of recurrence. Few case reports of recurrent PMSAH exist in the literature, all occurring after relatively short time intervals ranging from 5 days to 31 months, mostly in patients on antithrombotic therapy. We present a unique case of ultra-late PMSAH recurrence after 12 years, in a patient not receiving antithrombotic medications. CASE DESCRIPTION A woman presented with 2 similar episodes of sudden-onset severe headache and neck pain, without associated neurologic deficits: a first episode at the age of 48 years and a second at 60 years. In each instance, the pattern of hemorrhage was consistent with PMSAH, platelet count and coagulation tests were normal, and a full etiologic work-up, including CTA, catheter angiography, and magnetic resonance imaging, failed to reveal an underlying vascular or tumoral etiology. The patient had a favorable clinical course each time. CONCLUSIONS Although exceptional, recurrence of PMSAH is not impossible. If the 2 events are assumed to be random and independent of each other, binomial statistics yield approximately a 79 per billion chance of 2 or more episodes occurring over an 80-year lifetime. However, other possibilities should be kept in mind, including tiny and radiographically occult vascular lesions or particular venous anatomy predisposing patients to recurrent bouts of PMSAH. Patients should not be told that the risk of recurrence is zero, but that it is close to zero.
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Affiliation(s)
- Ralph Rahme
- Inova Neuroscience Institute, and Department of Neurosciences, Virginia Commonwealth University School of Medicine - Inova Campus, Falls Church, Falls Church, Virginia, USA
| | - Nilesh A Vyas
- Inova Neuroscience Institute, and Department of Neurosciences, Virginia Commonwealth University School of Medicine - Inova Campus, Falls Church, Falls Church, Virginia, USA.
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Mortimer AM, Appelman APA, Renowden SA. The negative predictive value of CT angiography in the setting of perimesencephalic subarachnoid hemorrhage. J Neurointerv Surg 2015; 8:728-31. [DOI: 10.1136/neurintsurg-2015-011814] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 05/18/2015] [Indexed: 11/03/2022]
Abstract
BackgroundPerimesencephalic subarachnoid hemorrhage (PMSAH) is only rarely associated with a ruptured cerebral aneurysm and CT angiography (CTA) has very good sensitivity and specificity for aneurysm detection. The necessity for invasive imaging with digital subtraction angiography (DSA) is therefore debatable. We chose to assess the negative predictive value (NPV) of CTA in a series of patients with PMSAH treated at our institution over a 9-year period.MethodsWe retrospectively assessed the diagnostic yield of DSA after initial negative CTA in patients with a PMSAH pattern defined as blood centered anterior to the midbrain and/or pons within the pre-pontine or interpeduncular cistern with possible quadrigeminal or ambient cistern extension; possible extension into the basal parts of the sylvian fissures but not the lateral sylvian fissures; possible extension to the cisterna magna but not centered on the cisterna magna; and possible extension into the fourth ventricle and occipital horns of the lateral ventricles.ResultsUsing this definition of PMSAH, of 72 patients, one patient showed a potentially significant finding on DSA that was not demonstrated on initial CTA (NPV 98.61% (95% CI 92.47% to 99.77%)). However, when cisterna magna extension was excluded from the definition of PMSAH, no false negative CTAs in 56 patients were encountered (NPV 100% (95% CI 93.56% to 100.00%)).ConclusionsThe NPV of normal CTA for an arterial abnormality in patients with PMSAH is high and our results therefore question the role of invasive imaging. The findings also suggest that a prospective study designed to clarify the necessity of performing DSA in this population would be feasible.
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20
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Kapadia A, Schweizer TA, Spears J, Cusimano M, Macdonald RL. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: diagnosis, pathophysiology, clinical characteristics, and long-term outcome. World Neurosurg 2014; 82:1131-43. [PMID: 25003696 DOI: 10.1016/j.wneu.2014.07.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 06/24/2014] [Accepted: 07/03/2014] [Indexed: 02/06/2023]
Abstract
Patients with nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) have no discernible source for the bleeding and generally are considered to have a benign condition. Correctly diagnosing these patients is essential because a missed aneurysm can have catastrophic consequences. Those presenting with NAPSAH have a low risk of complications and better outcome than patients presenting with aneurysmal subarachnoid hemorrhage; however, a limited body of literature suggests that not all of these patients are able to return to their premorbid functional status. Clinical screens of cognitive status, such as the mini-mental status examination, suggest good recovery of these patients, although these tests may lack sensitivity for identifying deficits in this patient population. More comprehensive neuropsychologic testing in some studies has identified deficits in a wide range of cognitive domains at long-term follow-up in patients with NAPSAH. Because these patients often do not lose consciousness (and thus do not have substantial transient global ischemia) and they do not undergo a procedure for aneurysm repair, the cognitive sequelae can be explained by the presence of blood in the subarachnoid space. NAPSAH presents an opportunity to understand the effects of subarachnoid blood in a clinical setting.
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Affiliation(s)
- Anish Kapadia
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Tom A Schweizer
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada; Heart and Stroke Foundation of Ontario Centre for Stroke Recovery, Toronto, ON, Canada
| | - Julian Spears
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
| | - Michael Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada.
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21
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Konczalla J, Platz J, Schuss P, Vatter H, Seifert V, Güresir E. Non-aneurysmal non-traumatic subarachnoid hemorrhage: patient characteristics, clinical outcome and prognostic factors based on a single-center experience in 125 patients. BMC Neurol 2014; 14:140. [PMID: 24986457 PMCID: PMC4088361 DOI: 10.1186/1471-2377-14-140] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Accepted: 06/26/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is mainly caused by ruptured cerebral aneurysms but in up to 15% of patients with SAH no bleeding source could be identified. Our objective was to analyze patient characteristics, clinical outcome and prognostic factors in patients suffering from non-aneurysmal SAH. METHODS From 1999 to 2009, data of 125 patients with non-aneurysmal SAH were prospectively entered into a database. All patients underwent repetitive cerebral angiography. Outcome was assessed according to the modified Rankin Scale (mRS) (mRS 0-2 favorable vs. 3-6 unfavorable). Also, patients were divided in two groups according to the distribution of blood in the CT scan (perimesencephalic and non-perimesencephalic SAH). RESULTS 106 of the 125 patients were in good WFNS grade (I-III) at admission (85%). Overall, favorable outcome was achieved in 104 of 125 patients (83%). Favorable outcome was associated with younger age (P < 0.001), good admission status (P < 0.0001), and absence of hydrocephalus (P = 0.001).73 of the 125 patients suffered from perimesencephalic SAH, most patients (90%) were in good grade at admission, and 64 achieved favorable outcome.52 of the 125 patients suffered from non-perimesencephalic SAH and 40 were in good grade at admission. Also 40 patients achieved favorable outcome. CONCLUSIONS Patients suffering from non-aneurysmal SAH have better prognosis compared to aneurysm related SAH and poor admission status was the only independent predictor of unfavorable outcome in the multivariate analysis. Patients with a non-perimesencephalic SAH have an increased risk of a worse neurological outcome. These patients should be monitored attentively.
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Johann Wolfgang Goethe-University Frankfurt am Main, Schleusenweg 2-16, 60528 Frankfurt am Main, Germany.
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22
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Woodfield J, Rane N, Cudlip S, Byrne JV. Value of delayed MRI in angiogram-negative subarachnoid haemorrhage. Clin Radiol 2014; 69:350-6. [DOI: 10.1016/j.crad.2013.11.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/05/2013] [Indexed: 12/28/2022]
Affiliation(s)
- J Woodfield
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK.
| | - N Rane
- Department of Neuroradiology, John Radcliffe Hospital, Oxford, UK
| | - S Cudlip
- Department of Neurosurgery, John Radcliffe Hospital, Oxford, UK
| | - J V Byrne
- Department of Neuroradiology, John Radcliffe Hospital, Oxford, UK
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23
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Abstract
OBJECTIVE Spontaneous subarachnoid hemorrhage (SAH) typically prompts a search for an underlying ruptured saccular aneurysm, which is the most common nontraumatic cause. Depending on the clinical presentation and pattern of SAH, the differential diagnosis may include a diverse group of causes other than aneurysm rupture. CONCLUSION For the purposes of this review, we classify SAH into three main patterns, defined by the distribution of blood on unenhanced CT: diffuse, perimesencephalic, and convexal. The epicenter of the hemorrhage further refines the differential diagnosis and guides subsequent imaging. Additionally, we review multiple clinical conditions that can simulate the appearance of SAH on CT or MRI, an imaging artifact known as pseudo-SAH.
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Wenz H, Al Mahdi MM, Ehrlich G, Scharf J, Schmiedek P, Seiz M. De novo aneurysm of the anterior communicating artery presenting with subarachnoid hemorrhage 7 years after initial cryptogenic subarachnoid hemorrhage: a case report and review of the literature. Clin Neuroradiol 2014; 25:93-7. [PMID: 24384679 DOI: 10.1007/s00062-013-0278-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2013] [Accepted: 12/12/2013] [Indexed: 11/25/2022]
Abstract
Spontaneous subarachnoid hemorrhage (SAH) is usually caused by a ruptured cerebral aneurysm. Despite the use of initial four-vessel cerebral digital subtraction angiography (DSA), 15 % of all cases remain idiopathic. According to the initial computed tomographic scan, the spontaneous SAH can be divided into a perimesencephalic group associated with a benign nature and a nonperimesencephalic group with a similar clinical course as aneurysmal SAH. We present a case of a 49-year-old man with a de novo aneurysm formation of the anterior communicating artery with SAH 7 years after initial cryptogenic nonperimesencephalic SAH. This observation suggests that in some cases, long-term angiographic studies might be justified.
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Affiliation(s)
- H Wenz
- Department of Neuroradiology, University Medical Center Mannheim, University of Heidelberg, Mannheim, Germany,
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25
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Dalyai R, Chalouhi N, Theofanis T, Jabbour PM, Dumont AS, Gonzalez LF, Gordon DS, Thakkar V, Rosenwasser RH, Tjoumakaris SI. Subarachnoid hemorrhage with negative initial catheter angiography: a review of 254 cases evaluating patient clinical outcome and efficacy of short- and long-term repeat angiography. Neurosurgery 2013; 73:E913. [PMID: 23277373 DOI: 10.1227/neu.0b013e3182846de8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial. OBJECTIVE To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging. METHODS Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram. RESULTS Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of short-term and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients. CONCLUSION Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH.
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Affiliation(s)
- Richard Dalyai
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
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Jethwa PR, Punia V, Patel TD, Duffis EJ, Gandhi CD, Prestigiacomo CJ. Cost-Effectiveness of Digital Subtraction Angiography in the Setting of Computed Tomographic Angiography Negative Subarachnoid Hemorrhage. Neurosurgery 2013; 72:511-9; discussion 519. [DOI: 10.1227/neu.0b013e318282a578] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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MacKinnon A, Clifton A, Rich P. Acute subarachnoid haemorrhage: Is a negative CT angiogram enough? Clin Radiol 2013; 68:232-8. [DOI: 10.1016/j.crad.2012.07.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 06/26/2012] [Accepted: 07/05/2012] [Indexed: 11/16/2022]
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Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013; 35:93-112. [PMID: 23406828 DOI: 10.1159/000346087] [Citation(s) in RCA: 735] [Impact Index Per Article: 66.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 11/22/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50-60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm. METHODS We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines. RESULTS These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms. CONCLUSION Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.
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Cruz JP, Sarma D, Noel de Tilly L. Perimesencephalic subarachnoid hemorrhage: when to stop imaging? Emerg Radiol 2011; 18:197-202. [DOI: 10.1007/s10140-011-0939-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2010] [Accepted: 01/17/2011] [Indexed: 11/28/2022]
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30
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Kelliny M, Maeder P, Binaghi S, Levivier M, Regli L, Meuli R. Cerebral aneurysm exclusion by CT angiography based on subarachnoid hemorrhage pattern: a retrospective study. BMC Neurol 2011; 11:8. [PMID: 21255395 PMCID: PMC3033809 DOI: 10.1186/1471-2377-11-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Accepted: 01/21/2011] [Indexed: 11/26/2022] Open
Abstract
Background To identify patients with spontaneous subarachnoid hemorrhage for whom CT angiography alone can exclude ruptured aneurysms. Methods An observational retrospective review was carried out of all consecutive patients with non-traumatic subarachnoid hemorrhage who underwent both CT angiography and catheter angiography to exclude an aneurysm. CT angiography negative cases (no aneurysm) were classified according to their CT hemorrhage pattern as "aneurismal", "perimesencephalic" or as "no-hemorrhage." Results Two hundred and forty-one patients were included. A CT angiography aneurysm detection sensitivity and specificity of 96.4% and 96.0% were observed. All 35 cases of perimesencephalic or no-hemorrhage out of 78 CT angiography negatives also had negative angiography findings. Conclusions CT angiography is self-reliant to exclude ruptured aneurysms when either a perimesencephalic hemorrhage or no-hemorrhage pattern is identified on the CT within a week of symptom onset.
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Affiliation(s)
- Marc Kelliny
- Department of Radiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, 1011 Lausanne, Switzerland
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31
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Perimesencephalic subarachnoid hemorrhage: risk factors, clinical presentations, and outcome. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 110:197-201. [PMID: 21116939 DOI: 10.1007/978-3-7091-0353-1_34] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH) appears to have an origin and natural history distinct from aneurysm rupture. However, the risk factors and complications of this pattern are still in debate. We performed a study with goals of comparing PNSH risk factors and clinical presentations with other sorts of spontaneous subarachnoid hemorrhages (SAH) and exhibit the PNSH outcome and prognosis. METHODS Retrospective review of patients who experienced SAH between May 2006 and July 2008 in the First Affiliated Hospital of Chongqing Medical University was undertaken. Patients were categorized as perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSH), nonperimesencephalic nonaneurysmal subarachnoid hemorrhage (NPNSH), aneurismal subarachnoid hemorrhage (ASH), and uncertain SAH of which the patterns were not clear. The possible risk factors and clinical presentations within the three groups were used to proceed for statistical analysis. RESULTS A total of 159 residents were identified. Among of them, 12 patients had the perimesencephalic pattern. Patients with PNSH showed less likelihood with the female (P=0.029), alcohol consumption (P=0.033), hypertensive (P=0.005), diabetes (P=0.013) or hyperlipidemia (P=0.034) when compared with aneurismal SAH. The clinical presentations of this pattern showed less conscious disturbance (P=0.004), vomiting (P=0.005), or poor Hunt & Hess Grade (P=0.003). There was one death among PNSH patients during 12 months mean follow-up. CONCLUSIONS Patients with PNSH present better clinical course than other forms of SAH, which could assist the diagnosis of this pattern. The moderate clinical course may suggest clinician apt to exclude aneurysm rupture. However, similar presents in remaining nonaneurysmal subarachnoid hemorrhage might suggest benign entities in other forms of nonaneurysmal subarachnoid hemorrhage.
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Wiseman JE, Agange N, Milliken JC. Coarctation of the Aorta Presenting as Spontaneous Subarachnoid Haemorrhage in the Absence of Cerebral Aneurysm: A Report of a Rare Clinical Entity. Heart Lung Circ 2010; 19:432-4. [DOI: 10.1016/j.hlc.2009.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 11/10/2009] [Accepted: 12/13/2009] [Indexed: 11/15/2022]
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Pretruncal Nonaneurysmal Subarachnoid Hemorrhage Causing Basilar Artery Vasospasm. Neurocrit Care 2010; 13:256-60. [DOI: 10.1007/s12028-010-9354-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Brinjikji W, Kallmes DF, White JB, Lanzino G, Morris JM, Cloft HJ. Inter- and intraobserver agreement in CT characterization of nonaneurysmal perimesencephalic subarachnoid hemorrhage. AJNR Am J Neuroradiol 2010; 31:1103-5. [PMID: 20075084 DOI: 10.3174/ajnr.a1988] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The perimesencephalic pattern of SAH as seen on unenhanced CT is associated with significantly better outcomes when compared to an aneurysmal pattern of SAH. The aim of this study was to determine the degree of inter- and intraoberver agreement for characterization of the NAPH as seen on unenhanced CT. MATERIALS AND METHODS We retrospectively reviewed the CT scans of 37 patients with spontaneous SAH, all of whom had undergone CT within 24 hours of onset of headache symptoms. All patients had undergone conventional cerebral angiography to confirm or exclude aneurysms or other vascular pathology. All 37 cases were angiographically confirmed nonaneurysmal SAHs. Four readers with neuroradiology subspecialty training independently evaluated CT images to characterize the hemorrhage pattern as compatible with the well-described NAPH. Each reader performed a second reading session blinded to the initial readings. The first and second sets of readings were performed approximately 4 months apart. Inter- and intraobserver agreement for characterization of the NAPH was determined by using the kappa statistic. RESULTS Of the 37 angiographically confirmed nonaneurysmal SAHs, there was unanimous agreement as to the hemorrhage pattern in 29 (78%) cases and disagreement in 8 (22%) cases. Overall, intraobserver agreement was good (kappa = 0.80). Interobserver agreement was also good (kappa = 0.79). CONCLUSIONS Overall, inter- and intraobserver agreement for the NAPH was good. There was, however, a level of disagreement among observers, thus suggesting that clinicians should be cautious when deciding whether to pursue follow-up imaging.
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Affiliation(s)
- W Brinjikji
- Mayo Medical School, Mayo Clinic, 200 SW First Street, Rochester, MN 55905, USA
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Agid R, Andersson T, Almqvist H, Willinsky RA, Lee SK, terBrugge KG, Farb RI, Söderman M. Negative CT angiography findings in patients with spontaneous subarachnoid hemorrhage: When is digital subtraction angiography still needed? AJNR Am J Neuroradiol 2009; 31:696-705. [PMID: 19942709 DOI: 10.3174/ajnr.a1884] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CTA is becoming the frontline modality to reveal aneurysms in patients with SAH. However, in about 20% of SAH patients no aneurysm is found. In these cases, intra-arterial DSA is still performed. Our aim was to evaluate whether negative findings on CTA can reliably exclude aneurysms in patients with acute SAH. MATERIALS AND METHODS We conducted a retrospective analysis of all negative findings on CTAs performed from 2005 to 2009 in patients with spontaneous SAH. Findings were compared with DSA. CTAs were performed with a 64-section multidetector row CT scanner. RESULTS One hundred ninety-three patients with SAH and negative findings on CTA who underwent subsequent DSA were identified. The distribution of blood on unenhanced CT was the following: PMH in 93 patients, diffuse aneurysmal pattern in 50, no blood on CT (xanthochromic LP) in 32, and peripheral sulcal distribution in 18. All patients with PMH had negative findings on DSA. One patient with no blood on CT had vasculitis on DSA. Six of 18 (33%) patients with peripheral blood had vasculitis on DSA. Three of these were also diagnosed by CTA. All except 1 patient with diffuse aneurysmal blood had negative findings on DSA. One patient was diagnosed with an aneurysm on DSA (1/50, 0.5%). Repeat delayed DSA performed in 28 of these patients revealed a small aneurysm in 4 (14%). Five patients had a complication of DSA (2.6%); 1 was a clinical stroke (0.5%). CONCLUSIONS In patients with SAH, negative CTA findings are reliable in ruling out aneurysms in the PMH pattern or no blood on CT. DSA is indicated in the diffuse aneurysmal pattern of SAH, and repeat delayed DSA is required if the initial DSA findings are negative. When the blood is peripheral, CTA should be scrutinized for vasculitis and DSA is recommended for confirmation.
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Affiliation(s)
- R Agid
- Department of Medical Imaging, Toronto Western Hospital, University of Toronto, Ontario, Canada.
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Abstract
OBJECTIVE Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many patients with SAH are seriously ill and require a prolonged intensive care unit stay. Cardiopulmonary complications are common. The management of patients with SAH focuses on the anticipation, prevention, and management of these secondary complications. DATA SOURCES Source data were obtained from a PubMed search of the medical literature. DATA SYNTHESIS AND CONCLUSION The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means. During the first 1-2 weeks after hemorrhage, patients are at risk of delayed ischemic deficits due to vasospasm, autoregulatory failure, and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty, and intra-arterial vasodilators. SAH is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
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Nonaneurysmal nonperimesencephalic subarachnoid hemorrhage: is it a benign entity? ACTA ACUST UNITED AC 2009; 71:566-71; discussion 571,571-2,572. [PMID: 18617230 DOI: 10.1016/j.surneu.2008.04.021] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Accepted: 04/11/2008] [Indexed: 11/18/2022]
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Hirsch KG, Froehler MT, Huang J, Ziai WC. Occurrence of perimesencephalic subarachnoid hemorrhage during pregnancy. Neurocrit Care 2009; 10:339-43. [PMID: 19184552 DOI: 10.1007/s12028-009-9189-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2008] [Accepted: 01/12/2009] [Indexed: 12/14/2022]
Abstract
BACKGROUND Perimesencephalic subarachnoid hemorrhage (P-SAH) is a benign subset of subarachnoid hemorrhage with a favorable prognosis and low rate of re-bleeding. Risk factors may include hypertension and tobacco use, but it has not previously been reported during pregnancy. METHODS We report two cases of P-SAH in pregnant women, a 40-year-old female, 8-weeks pregnant and a 37-year-old female at 35 weeks gestational age. RESULTS CT scan confirmed P-SAH in both cases. CT angiography in one case and cerebral angiogram in the other did not reveal aneurysm or other potential bleeding source. The patients underwent transcranial Doppler ultrasound monitoring without evidence of vasospasm. CONCLUSION P-SAH hemorrhage may occur during early or late pregnancy. We do not propose an increased risk of P-SAH during pregnancy. The clinical course appears favorable and CT angiography alone may be considered the preferred diagnostic test to assess for aneurysm in first trimester pregnancy.
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Affiliation(s)
- Karen G Hirsch
- Department of Neurology, Johns Hopkins University School of Medicine, Meyer 8-140, 600 N. Wolfe St., Baltimore, MD, USA
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Refai D, Botros JA, Strom RG, Derdeyn CP, Sharma A, Zipfel GJ. Spontaneous isolated convexity subarachnoid hemorrhage: presentation, radiological findings, differential diagnosis, and clinical course. J Neurosurg 2008; 109:1034-41. [DOI: 10.3171/jns.2008.109.12.1034] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Object
The clinical characteristics and overall outcome in patients with spontaneous isolated convexity subarachnoid hemorrhage (SAH) are not well described in the literature. The purpose of this study was to examine the mode of presentation, common origins, radiographic findings, and clinical course in a large case series of such patients.
Methods
A retrospective single-center chart review of all patients in whom nontraumatic primary convexity SAH was diagnosed between 2002 and 2007 was performed. Twenty patients were identified and analyzed for presenting symptoms, radiological and laboratory findings, hospital course, and outcome.
Results
There were 15 women and 5 men in our series, and the mean age was 52 years (range 18–86 years). The most common presenting symptom was headache, with 15 patients experiencing it as a chief complaint. Other frequent manifestations included altered mental status (8 patients), focal neurological deficits (7), and seizure (4 patients). An underlying cause of the hemorrhage was identified in 13 cases, whereas the remainder went unresolved. Of the known causes, 5 were due to posterior reversible encephalopathy syndrome, 3 were caused by thrombocytopenia or anticoagulation, and the remainder were isolated cases of lupus vasculitis, drug-induced vasculopathy, postpartum cerebral angiopathy, hypertensive microangiopathy, and Call–Fleming syndrome. All patients with unknown disease origins had favorable outcomes, whereas 8 of 13 patients with an identifiable underlying disorder experienced favorable outcomes.
Conclusions
Spontaneous isolated convexity SAH is rarely caused by aneurysm rupture, has a distinct mode of presentation, and generally carries a more favorable prognosis than that of aneurysmal SAH.
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Affiliation(s)
| | | | | | - Colin P. Derdeyn
- 1Department of Neurosurgery,
- 2Mallinckrodt Institute of Radiology, and
- 3Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri
| | | | - Gregory J. Zipfel
- 1Department of Neurosurgery,
- 3Department of Neurology, Washington University School of Medicine, Saint Louis, Missouri
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van der Worp HB, Fonville S, Ramos LMP, Rinkel GJE. Recurrent perimesencephalic subarachnoid hemorrhage during antithrombotic therapy. Neurocrit Care 2008; 10:209-12. [PMID: 18972074 DOI: 10.1007/s12028-008-9160-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2008] [Accepted: 10/06/2008] [Indexed: 01/08/2023]
Abstract
INTRODUCTION In patients with non-aneurysmal perimesencephalic hemorrhage, spontaneous rebleeding does not occur. The lack of reported recurrences may lead to less cautious administration of antithrombotic therapy. METHODS Case report. RESULTS A 57-year-old woman with a perimesencephalic pattern of hemorrhage and negative CT angiography was treated with carbasalate calcium and intravenous heparin because of an acute coronary syndrome. Three days after installment of this antithrombotic therapy she experienced a recurrent perimesencephalic hemorrhage leading to hydrocephalus and a decrease in consciousness. She died the same day as a result of ventricular fibrillation. CONCLUSION In the early phase after perimesencephalic hemorrhage, anticoagulant therapy may lead to rebleeding. The risks and benefits of antithrombotic therapy should be carefully weighed in patients with a perimesencephalic pattern of hemorrhage and negative CT angiography.
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Affiliation(s)
- H Bart van der Worp
- Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, Heidelberglaan 100, 3584 Utrecht, The Netherlands.
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Andaluz N, Zuccarello M. YIELD OF FURTHER DIAGNOSTIC WORK-UP OF CRYPTOGENIC SUBARACHNOID HEMORRHAGE BASED ON BLEEDING PATTERNS ON COMPUTED TOMOGRAPHIC SCANS. Neurosurgery 2008; 62:1040-1047. [DOI: 10.1227/01.neu.0000315895.74803.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
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Andaluz N, Zuccarello M. YIELD OF FURTHER DIAGNOSTIC WORK-UP OF CRYPTOGENIC SUBARACHNOID HEMORRHAGE BASED ON BLEEDING PATTERNS ON COMPUTED TOMOGRAPHIC SCANS. Neurosurgery 2008; 62:1040-6; discussion 1047. [DOI: 10.1227/01.neu.0000325865.22011.1f] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Shad A, Rourke TJ, Hamidian Jahromi A, Green AL. Straight sinus stenosis as a proposed cause of perimesencephalic non-aneurysmal haemorrhage. J Clin Neurosci 2008; 15:839-41. [PMID: 18406143 DOI: 10.1016/j.jocn.2007.03.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2006] [Accepted: 03/20/2007] [Indexed: 12/28/2022]
Abstract
Perimesencephalic nonaneurysmal haemorrhage (PMNH), a term first coined in 1985, is a diagnosis of exclusion. It is considered a benign form of subarachnoid haemorrhage with a good prognosis and a low risk of rebleeding. Its precise aetiology has not yet been determined. Haemorrhage of venous origin has been proposed as a cause, and has been demonstrated to be associated with venous abnormalities of the basal vein of Rosenthal. We present a patient with PMNH in whom an 80% stenosis at the union of the vein of Galen with the straight sinus is demonstrated. We thus propose hypertensive venous rupture secondary to venous sinus stenosis as an alternative cause for PMNH.
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Affiliation(s)
- Amjad Shad
- Department of Neurosurgery, Radcliffe Infirmary, Woodstock Road, Oxford, OX2 6HE, Oxford, UK
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Mashiah A, Wolach O, Sandbank J, Uziel O, Raanani P, Lahav M. Lymphoma and leukemia cells possess fractal dimensions that correlate with their biological features. Acta Haematol 2008; 119:142-50. [PMID: 18417956 DOI: 10.1159/000125551] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2007] [Accepted: 01/31/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND Living cells can be viewed as complex adaptive systems that exhibit non-linear dynamics and fractal features. We investigated the fractal qualities of normal and malignant hematological cells and their potential as a tool for characterizing cell phenotype and clinical behavior. METHODS A mathematical algorithm and an optic tool for fractal analysis of nuclei were developed. A total of 4,713 lymphoid cells derived from 66 patients of five distinct diagnostic groups (normal and reactive lymphocytes, low-grade lymphomas and an aggressive lymphoma) were assessed for their fractal dimension. In addition, in 19 patients fractal analysis of leukemia cells was compared to clinical endpoints. RESULTS After validating our method, hematological cells possessed fractal dimensions corresponding to their clinical entity. There was a highly significant overall difference in fractal dimensions between various types of hematological malignancies. A preliminary correlation was found between the fractal dimension and the clinical outcome of leukemia patients. CONCLUSIONS Hematological cells possess fractal dimensions that correlate with their biological properties. Measurement of fractal dimension seems to be a sensitive method to assess the hematological cell phenotype and to define a clinical group. This tool may be potentially useful for the evaluation of clinical behavior of hematological diseases.
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MESH Headings
- Algorithms
- Bone Marrow/pathology
- Cluster Analysis
- Cohort Studies
- Fractals
- Humans
- Image Processing, Computer-Assisted/methods
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Leukemia, Myeloid, Acute/mortality
- Leukemia, Myeloid, Acute/pathology
- Lymph Nodes/pathology
- Lymphocytes/ultrastructure
- Lymphoma, Follicular/pathology
- Lymphoma, Large B-Cell, Diffuse/pathology
- Photomicrography/instrumentation
- Photomicrography/methods
- Prognosis
- Pseudolymphoma/pathology
- Sensitivity and Specificity
- Treatment Outcome
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Affiliation(s)
- Adi Mashiah
- Department of Internal Medicine A, Rabin Medical Center-Beilinson Hospital, Petah Tikva, Israel
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Turner R, Obuchowski N, Gonugunta V, Kelly M, Woo HH, Fiorella D. Brain Computed Tomography Angiographic Scans as the Sole Diagnostic Examination for Excluding Aneurysms in Patients with Perimesencephalic Subarachnoid Hemorrhage. Neurosurgery 2007; 61:E1340. [DOI: 10.1227/01.neu.0000306130.36355.93] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Bruder N. [Non-aneurysmal subarachnoid haemorrhage]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2007; 26:954-958. [PMID: 17936566 DOI: 10.1016/j.annfar.2007.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
A subarachnoid haemorrhage (SAH) is frequent after a severe head injury. Traumatic-SAH is associated with a bad outcome and may induce cerebral vasospasm. There is no agreement on the treatment based on the amount of traumatic-SAH. Non-aneurysmal SAH accounts for 15% of all causes of non-traumatic SAH. There is a risk of cerebral vasospasm, although less frequent than after aneurysmal rupture. The improvement in imaging techniques has decreased the frequency of idiopathic SAH.
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Affiliation(s)
- N Bruder
- Département d'anesthésie-réanimation, CHU de la Timone-Adultes, 264, rue Saint-Pierre, 13385 Marseille cedex, France.
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Westerlaan HE, Gravendeel J, Fiore D, Metzemaekers JDM, Groen RJM, Mooij JJA, Oudkerk M. Multislice CT angiography in the selection of patients with ruptured intracranial aneurysms suitable for clipping or coiling. Neuroradiology 2007; 49:997-1007. [PMID: 17891387 PMCID: PMC2082066 DOI: 10.1007/s00234-007-0293-2] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2007] [Accepted: 07/12/2007] [Indexed: 11/28/2022]
Abstract
Introduction We sought to establish whether CT angiography (CTA) can be applied to the planning and performance of clipping or coiling in ruptured intracranial aneurysms without recourse to intraarterial digital subtraction angiography (IA-DSA). Methods Over the period April 2003 to January 2006 in all patients presenting with a subarachnoid haemorrhage CTA was performed primarily. If CTA demonstrated an aneurysm, coiling or clipping was undertaken. IA-DSA was limited to patients with negative or inconclusive CTA findings. We compared CTA images with findings at surgery or coiling in patients with positive CTA findings and in patients with negative and inconclusive findings in whom IA-DSA had been performed. Results In this study, 224 consecutive patients (mean age 52.7 years, 135 women) were included. In 133 patients (59%) CTA demonstrated an aneurysm, and CTA was followed directly by neurosurgical (n = 55) or endovascular treatment (n = 78). In 31 patients (14%) CTA findings were categorized as inconclusive, and in 60 (27%) CTA findings were negative. One patient received surgical treatment on the basis of false-positive CTA findings. In 17 patients in whom CTA findings were inconclusive, IA-DSA provided further diagnostic information required for correct patient selection for any therapy. Five ruptured aneurysms in patients with a nonperimesencephalic SAH were negative on CTA, and four of these were also false-negative on IA-DSA. On a patient basis the positive predictive value, negative predictive value, sensitivity, specificity and accuracy of CTA for symptomatic aneurysms were 99%, 90%, 96%, 98% and 96%, respectively. Conclusion CTA should be used as the first diagnostic modality in the selection of patients for surgical or endovascular treatment of ruptured intracranial aneurysms. If CTA renders inconclusive results, IA-DSA should be performed. With negative CTA results the complementary value of IA-DSA is marginal. IA-DSA is not needed in patients with negative CTA and classic perimesencephalic SAH. Repeat IA-DSA or CTA should still be performed in patients with a nonperimesencephalic SAH.
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Affiliation(s)
- H E Westerlaan
- Department of Radiology, University Medical Center Groningen, Post Box 30.001, Hanzeplein 1, 9700 RB Groningen, The Netherlands.
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Abstract
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.
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