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Dakay K, Mahta A, Rao S, Reznik ME, Wendell LC, Thompson BB, Potter NS, Saad A, Gandhi CD, Santarelli J, Al-Mufti F, MacGrory B, Burton T, Jayaraman MV, McTaggart RA, Furie K, Yaghi S, Cutting S. Yield of diagnostic imaging in atraumatic convexity subarachnoid hemorrhage. J Neurointerv Surg 2019; 11:1222-1226. [PMID: 31076550 DOI: 10.1136/neurintsurg-2019-014781] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2019] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Atraumatic convexity subarachnoid hemorrhage is a subtype of spontaneous subarachnoid hemorrhage that often presents a diagnostic challenge. Common etiologies include cerebral amyloid angiopathy, vasculopathies, and coagulopathy; however, aneurysm is rare. Given the broad differential of causes of convexity subarachnoid hemorrhage, we assessed the diagnostic yield of common tests and propose a testing strategy. METHODS We performed a single-center retrospective study on consecutive patients with atraumatic convexity subarachnoid hemorrhage over a 2-year period. We obtained and reviewed each patient's imaging and characterized the frequency with which each test ultimately diagnosed the cause. Additionally, we discuss clinical features of patients with convexity subarachnoid hemorrhage with respect to the mechanism of hemorrhage. RESULTS We identified 70 patients over the study period (mean (SD) age 64.70 (16.9) years, 35.7% men), of whom 58 patients (82%) had a brain MRI, 57 (81%) had non-invasive vessel imaging, and 27 (38.5%) underwent catheter-based angiography. Diagnoses were made using only non-invasive imaging modalities in 40 patients (57%), while catheter-based angiography confirmed the diagnosis in nine patients (13%). Further clinical history and laboratory testing yielded a diagnosis in an additional 17 patients (24%), while the cause remained unknown in four patients (6%). CONCLUSION The etiology of convexity subarachnoid hemorrhage may be diagnosed in most cases via non-invasive imaging and a thorough clinical history. However, catheter angiography should be strongly considered when non-invasive imaging fails to reveal the diagnosis or to better characterize a vascular malformation. Larger prospective studies are needed to validate this algorithm.
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Affiliation(s)
- Katarina Dakay
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Ali Mahta
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Shyam Rao
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Michael E Reznik
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Linda C Wendell
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Bradford B Thompson
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - N Stevenson Potter
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Ali Saad
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Brian MacGrory
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Tina Burton
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Mahesh V Jayaraman
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Diagnostic Imaging, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Ryan A McTaggart
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Diagnostic Imaging, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Karen Furie
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.,Department of Neurology, NYU Langone Health, New York, New York, USA
| | - Shawna Cutting
- Department of Neurology, Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
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Jacoby N, Kaunzner U, Dinkin M, Safdieh J. Diagnosing RCVS Without the CV: The Evolution of Reversible Cerebral Vasoconstriction Syndrome. Neurohospitalist 2015; 6:NP1-4. [PMID: 27366300 DOI: 10.1177/1941874415599576] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This is a case of a 52-year-old man with a past medical history of 2 episodes of coital thunderclap headaches as well as recent cocaine, marijuana, and pseudoephedrine use, who presented with sudden, sharp, posterior headache associated with photophobia and phonophobia. His initial magnetic resonance imaging (MRI) of the brain, magnetic resonance angiography (MRA) of the head, and magnetic resonance venography (MRV) of the head were all normal as well as a normal lumbar puncture. Given the multiple risk factors for reversible cerebral vasoconstriction syndrome (RCVS), the patient was treated for suspected RCVS, despite the normal imaging. Repeat MRI brain 3 days after hospital admission demonstrated confluent white matter T2 hyperintensities most prominent in the occipital lobes, typical of posterior reversible encephalopathy syndrome (PRES). Repeat MRA of the head 1 day after discharge and 4 days after the abnormal MRI brain showed multisegment narrowing of multiple arteries. This case demonstrates that RCVS may present with PRES on MRI brain and also exemplifies the need to treat suspected RCVS even if imaging is normal, as abnormalities in both the MRI and the MRA may be delayed.
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Affiliation(s)
- Nuri Jacoby
- New York Presbyterian Weill Cornell, New York, NY, USA
| | | | - Marc Dinkin
- New York Presbyterian Weill Cornell, New York, NY, USA
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Choi KS, Yi HJ. Progressive manifestations of reversible cerebral vasoconstriction syndrome presenting with subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction. J Korean Neurosurg Soc 2014; 56:419-22. [PMID: 25535520 PMCID: PMC4273001 DOI: 10.3340/jkns.2014.56.5.419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Revised: 01/13/2014] [Accepted: 01/15/2014] [Indexed: 11/30/2022] Open
Abstract
Reversible cerebral vasoconstriction syndrome (RCVS) is characterized by sudden-onset headache with focal neurologic deficit and prolonged but reversible multifocal narrowing of the distal cerebral arteries. Stroke, either hemorrhagic or ischemic, is a relatively frequent presentation in RCVS, but progressive manifestations of subarachnoid hemorrhage, intracerebral hemorrhage, cerebral infarction in a patient is seldom described. We report a rare case of a 56-year-old woman with reversible cerebral vasoconstriction syndrome consecutively presenting as cortical subarachnoid hemorrhage, intracerebral hemorrhage, and cerebral infarction. When she complained of severe headache with subtle cortical subarachnoid hemorrhage, her angiography was non-specific. But, computed tomographic angiography showed typical angiographic features of this syndrome after four days. Day 12, she suffered mental deterioration and hemiplegia due to contralateral intracerebral hematoma, and she was surgically treated. For recurrent attacks of headache, medical management with calcium channel blockers has been instituted. Normalized angiographic features were documented after 8 weeks. Reversible cerebral vasoconstriction syndrome should be considered as differential diagnosis of non-aneurysmal subarachnoid hemorrhage, and repeated angiography is recommended for the diagnosis of this under-recognized syndrome.
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Affiliation(s)
- Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
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