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Li J, Fang X, Yu FC, Du B. Recurrent perimesencephalic nonaneurysmal subarachnoid hemorrhage within a short period of time: A case report. World J Clin Cases 2021; 9:3356-3364. [PMID: 34002145 PMCID: PMC8107889 DOI: 10.12998/wjcc.v9.i14.3356] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 02/01/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Spontaneous subarachnoid hemorrhage (SAH) is primarily caused by a ruptured intracranial aneurysm. Perimesencephalic nonaneurysmal SAH (PNSAH) accounts for approximately 5% of all spontaneous SAH. PNSAH displays favorable prognosis. The risk of hemorrhage recurrence is low. We report a case of PNSAH recurrence, occurring within a short time after the initial episode in a patient not receiving antithrombotic or antiplatelet drugs.
CASE SUMMARY A 66-year-old male, without any history of recent trauma or antithrombotic/ antiplatelet medication, suffered two similar episodes of sudden onset of severe headache, nausea, and vomiting. A plain head computed tomography (CT) scan showed subarachnoid blood confined to the anterior part of the brainstem. Platelet count and coagulation function were normal. PNSAH was diagnosed by repeated head CT, magnetic resonance imaging, and cerebral angiography, none of which revealed the source of SAH. The patient was discharged without focal neurological deficits. At 6-mo follow-up, the patient had experienced no sudden onset of severe headache and presented favorable clinical outcome. Studies have reported a few patients with recurrent PNSAH, originating frequently from venous hemorrhage and conventionally associated with venous abnormalities. PNSAH recurs within a short time following the initial onset of symptoms, although the possibility of re-hemorrhage is extremely rare.
CONCLUSION PNSAH recurrence should arouse vigilance; however, the definite source of idiopathic SAH in this case report deserves further attention.
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Affiliation(s)
- Juan Li
- Operating Room Nurse, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
- Operating Room Nurse, Jinan Central Hospital Affiliated to Shandong University, Jinan 250000, Shandong Province, China
| | - Xiang Fang
- Department of Neurosurgery, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
- Department of Neurosurgery, Jinan Central Hospital Affiliated to Shandong University, Jinan 250000, Shandong Province, China
| | - Fu-Chao Yu
- Department of Neurosurgery, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
- Department of Neurosurgery, Jinan Central Hospital Affiliated to Shandong University, Jinan 250000, Shandong Province, China
| | - Bin Du
- Department of Neurosurgery, Jinan Central Hospital Affiliated to Shandong First Medical University, Jinan 250000, Shandong Province, China
- Department of Neurosurgery, Jinan Central Hospital Affiliated to Shandong University, Jinan 250000, Shandong Province, China
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Are modified Fisher Scale and bleeding pattern helpful predictors of neurological complications in non-aneurysmal subarachnoid hemorrhage? Neuroradiology 2020; 63:253-257. [PMID: 32812071 DOI: 10.1007/s00234-020-02524-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/13/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Non-aneurysmal subarachnoid hemorrhage (NA-SAH) is a clinical-radiological entity with a different prognosis than aneurysmal SAH (A-SAH). The purpose of this study is to assess the predictive value of the modified Fisher Scale (mFS) for neurological complications in patients with this diagnosis. METHODS We recruited patients admitted at our hospital services between 2009 and 2017 who were diagnosed with spontaneous SAH, with either perimesencephalic (PM-SAH) or diffuse pattern (D-SAH), an initial negative angio-CT, and at least one digital subtraction angiography of brain vessels discarding underlying brain aneurysms or other vascular malformations. RESULTS The retrospective observational study included 116 patients. The mean age was 54.4, and the sample included predominantly male subjects (62.9%). Hunt and Hess (HH) scores on admission ranged from 3 to 5 in 18.1% of patients. The prevalence of hydrocephalus requiring ventricular drainage was 18.1%. The prevalence of symptomatic vasospasm was 4.3%. A modified Rankin Scale (mRS) 0-2 at discharge was found in 95.6%. In a multivariate logistic regression for the presence of neurological complications including age, sex, admission HH 3-5 compared with < 3, mFS 4 compared with mFS < 4, D-SAH compared with PM-SAH, and mRS score at discharge of 0-2 compared with > 2, the only significant predictors were mFS 4 compared with mFS < 4 (OR 4.47 (95% CI 1.21, 16.66) p value = 0.03) and D-SAH compared with PM-SAH (OR 7.10 (95% CI 1.24, 40.8) p value = 0.03). CONCLUSION In patients with NA-SAH, a mFS score of 4 and/or a D-SAH bleeding pattern in non-contrast cranial CT on admission predicted the development of relevant neurological complications.
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McIntyre MK, Gandhi C, Dragonette J, Schmidt M, Cole C, Santarelli J, Lehrer R, Al-Mufti F, Bowers CA. A comparison of frailty indices in predicting length of inpatient stay and discharge destination following angiogram-negative subarachnoid hemorrhage. Br J Neurosurg 2020; 35:402-407. [PMID: 32586162 DOI: 10.1080/02688697.2020.1781056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE While patients with angiogram-negative subarachnoid hemorrhages (ANSAH) have better prognoses than those with aneurysmal SAH, frailty's impact on outcomes in ANSAH is unclear. We previously showed that the modified frailty index (mFI-11) is associated with poor outcomes following ANSAH. Here, we compared the mFI-5, mFI-11, Charlson Comorbidity Index (CCI), and temporalis thickness (TMT) to determine which index was the best predictor of ANSAH outcomes and mortality rates. METHODS In this retrospective cohort analysis between 2014 and 2018, patients with non-traumatic, angiogram negative SAH (ANSAH) were identified. The admission mFI-5, mFI-11, CCI, and TMT were calculated for each patient. Primary outcomes were mortality rate, discharge location, and prolonged length of stay (PLOS; LOS >85th percentile). Multivariate logistic regression and receiver operating characteristic (ROC) curves were used to evaluate frailty as predictors of primary endpoints. RESULTS We included 75 patients with a mean age of 55.4 ± 1.5 years. There were 4 patient deaths (5.3%), 53 patients (70.7%) discharged home, and 11 patients (14.7%) with PLOS. On ROC analysis, the mFI-5 had the highest discriminatory value for mortality (AUC = 0.97) while the mFI-11 was most discriminatory for discharge home (AUC = 0.85) and PLOS (AUC = 0.78). On multivariate analysis, the only independent predictor of mortality was the mFI-11 (OR = 0.46; 95%CI: 1.45-14.23; p = 0.009) while the mFI-5 was the best predictor of discharge home (OR = 0.21; 95% CI: 0.08-0.61; p = 0.004). On multivariate analysis, the only independent predictor of PLOS was the Hunt and Hess score (OR = 2.63; 95%CI: 1.38-5.00; p = 0.003). The CCI and TMT were inferior to either mFI for predicting primary endpoints. CONCLUSIONS Increasing frailty is associated with poorer outcomes and higher mortality following ANSAH. The mFI-5 and mFI-11 were found to be superior predictors of discharge home and mortality rate. While larger prospective study is needed, frailty, as measured by mFI-11 and -5, should be considered when evaluating ANSAH prognosis.
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Affiliation(s)
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | | | - Meic Schmidt
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.,Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Rachel Lehrer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.,Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
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Jeon JP, Kim SE, Chai CL, Hong EP, Yang JS, Kang SH, Choi HJ, Cho YJ. Seizure incidence of angiogram-negative subarachnoid hemorrhage: An updated meta-analysis. J Chin Med Assoc 2020; 83:466-470. [PMID: 32217992 DOI: 10.1097/jcma.0000000000000293] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND To provide updated information on seizure events and patterns in patients with angiogram-negative subarachnoid hemorrhage based on the initial hemorrhage patterns: perimesencephalic subarachnoid hemorrhage (PMH) vs non-PMH. METHODS A review of online database literature from January 1990 to November 2017 was systematically performed. In case of heterogeneity <50%, a fixed effect model was used. Publication bias was determined using Begg funnel plot and the trim-and-fill method. RESULTS A total of 9 studies with 645 patients were included for final analysis after excluding one study without any seizure within either cohort. PMH patients had lower seizure rates (odds ratio, 0.393; 95% CI, 0.158-0.978) compared with non-PMH patients. The funnel plot showed a relatively asymmetric pattern, suggesting possible publication bias. After correction of the forest plot, the adjusted odds ratio was 0.362 (95% CI, 0.148-0.886), indicating significant relationships between PMH and lower incidence of seizure. CONCLUSION PMH is associated with lower seizure risk than non-PMH. However, possible publication bias could be a concern to the interpretation. Additional meta-analyses based on individual patient data from prospective large-scale studies are necessary.
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Affiliation(s)
- Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon, Korea
- Genetic and Research, Chuncheon, Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Chung Liang Chai
- Department of Neurosurgery, Yee Zen General Hospital, Taoyuan, Taiwan, ROC
| | - Eun Pyo Hong
- Molecular Neurogenetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Jin Seo Yang
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Suk Hyung Kang
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Hyuk Jai Choi
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
| | - Yong Jun Cho
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea
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McIntyre M, Gandhi C, Dragonette J, Schmidt M, Cole C, Santarelli J, Lehrer R, Al-Mufti F, Bowers CA. Increasing Frailty Predicts Worse Outcomes and Increased Complications After Angiogram-Negative Subarachnoid Hemorrhages. World Neurosurg 2019; 134:e181-e188. [PMID: 31605860 DOI: 10.1016/j.wneu.2019.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/30/2019] [Accepted: 10/01/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The effect of frailty on outcomes after angiogram-negative subarachnoid hemorrhages (ANSAH) is currently unknown. We investigated frailty's effects on ANSAH outcomes, including mortality and in-hospital complications. METHODS Patients from 2014 to 2018 with non-traumatic subarachnoid hemorrhage and cerebral angiograms with an unidentifiable hemorrhage source were retrospectively reviewed. The cohort was divided into non-frail (modified frailty index [mFI] = 0) and frail (mFI ≥1) groups based on pre-hemorrhage characteristics. Primary outcomes were mortality rate and discharge location. Multivariate logistic regression analyses determined predictors of ANSAH severity and primary endpoints. Receiver operating characteristic curves were used to discriminate risks for primary endpoints comparing mFI, Hunt and Hess and Fisher scores, and age. RESULTS We included 75 patients with a mean age of 55.4 ± 1.5 years, comprising 42 (56%) women, and 41 (54.7%) with perimesencephalic bleeds. A total of 32 of 75 (42.7%) patients were classified as frail. Frail individuals were 6.2 times less likely to be discharged home (odds ratio [OR] = 0.16; 95% confidence interval [CI]: 0.05-0.5; P = 0.001) and all mortalities occurred in frail patients (12.5% [n = 4 of 32]; P = 0.030). The only independent predictor of mortality was higher mFI (OR = 5.4; 95% CI: 1.5-19.1; P = 0.009), and lower mFI best predicted discharge home (OR = 0.39; 95% CI: 0.17-0.88; P = 0.023). Receiver operating characteristic analysis showed that mFI best predicted both mortality (area under the curve = 0.9718; P = 0.002) and discharge home (area under the curve = 0.7998; P < 0.001). CONCLUSIONS Frail ANSAH patients have poorer outcomes and increased mortality compared with non-frail patients. Although prospective study is needed, this information significantly impacts our understanding of ANSAH outcomes and frailty should be used for prognostication as it was a better predictor than Hunt and Hess or Fisher scores.
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Affiliation(s)
- Matthew McIntyre
- School of Medicine, New York Medical College, Valhalla, New York
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - James Dragonette
- School of Medicine, New York Medical College, Valhalla, New York
| | - Meic Schmidt
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Rachel Lehrer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Christian A Bowers
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York.
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Mohan M, Islim AI, Rasul FT, Rominiyi O, deSouza RM, Poon MTC, Jamjoom AAB, Kolias AG, Woodfield J, Patel K, Chari A, Kirollos R. Subarachnoid haemorrhage with negative initial neurovascular imaging: a systematic review and meta-analysis. Acta Neurochir (Wien) 2019; 161:2013-2026. [PMID: 31410556 PMCID: PMC6739283 DOI: 10.1007/s00701-019-04025-w] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/25/2019] [Indexed: 02/07/2023]
Abstract
Background In patients with spontaneous subarachnoid haemorrhage (SAH), a vascular cause for the bleed is not always found on initial investigations. This study aimed to systematically evaluate the delayed investigation strategies and clinical outcomes in these cases, often described as “non-aneurysmal” SAH (naSAH). Methods A systematic review was performed in concordance with the PRISMA checklist. Pooled proportions of primary outcome measures were estimated using a random-effects model. Results Fifty-eight studies were included (4473 patients). The cohort was split into perimesencephalic naSAH (PnaSAH) (49.9%), non-PnaSAH (44.7%) and radiologically negative SAH identified on lumbar puncture (5.4%). The commonest initial vascular imaging modality was digital subtraction angiography. A vascular abnormality was identified during delayed investigation in 3.9% [95% CI 1.9–6.6]. There was no uniform strategy for the timing or modality of delayed investigations. The pooled proportion of a favourable modified Rankin scale outcome (0–2) at 3–6 months following diagnosis was 92.0% [95% CI 86.0–96.5]. Complications included re-bleeding (3.1% [95% CI 1.5–5.2]), hydrocephalus (16.0% [95% CI 11.2–21.4]), vasospasm (9.6% [95% CI 6.5–13.3]) and seizure (3.5% [95% CI 1.7–5.8]). Stratified by bleeding pattern, we demonstrate a higher rate of delayed diagnoses (13.6% [95% CI 7.4–21.3]), lower proportion of favourable functional outcome (87.2% [95% CI 80.1–92.9]) and higher risk of complications for non-PnaSAH patients. Conclusion This study highlights the heterogeneity in delayed investigations and outcomes for patients with naSAH, which may be influenced by the initial pattern of bleeding. Further multi-centre prospective studies are required to clarify optimal tailored management strategies for this heterogeneous group of patients. Electronic supplementary material The online version of this article (10.1007/s00701-019-04025-w) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Midhun Mohan
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Abdurrahman I Islim
- Department of Neurosurgery, The Walton Centre NHS Foundation Trust and University of Liverpool, Liverpool, UK
| | - Fahid T Rasul
- Department of Neurosurgery, Queen's Hospital, Romford, UK
| | - Ola Rominiyi
- Department of Neurosurgery, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | | | - Aimun A B Jamjoom
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Angelos G Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Julie Woodfield
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Krunal Patel
- Division of Neurosurgery, Krembil Research Institute, Toronto Western Hospital, University Health Network and University of Toronto, Toronto, Canada
| | - Aswin Chari
- Institute of Child Health, University College London, London, UK.
- Department of Neurosurgery, Great Ormond Street Hospital, Great Ormond Street, WC1N 3JH, London, UK.
| | - Ramez Kirollos
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
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Kim SE, Kim BJ, Cho SS, Kim HC, Jeon JP. The Incidence of Hydrocephalus and Shunting in Patients with Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis. World Neurosurg 2018; 119:e216-e227. [PMID: 30048789 DOI: 10.1016/j.wneu.2018.07.119] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/12/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the incidence of hydrocephalus and implanted shunts in angiogram-negative subarachnoid hemorrhage (SAH) according to hemorrhage patterns: perimesencephalic SAH (PMH) versus non-PMH. METHODS The online database literature from January 1990 to November 2017 was systematically reviewed. A fixed-effect model was used when heterogeneity was <50%. A Begg funnel plot was used to assess publication bias. An additional trim and fill method was used to estimate the number of missing studies. A subgroup analysis with studies, which defined angiogram-negative SAH using repeated angiography or computed tomography angiography, was further performed. RESULTS A total of 28 articles including 2577 patients were enrolled. Patients with PMH showed a significantly decreased incidence of hydrocephalus (odds ratio [OR], 0.269; 95% confidence interval [CI], 0.208-0.348) and shunts (OR, 0.263; 95% CI, 0.169-0.411) than did patients without PMH. A subgroup analysis of 7 studies with 675 patients showed less hydrocephalus in patients with PMH than in patients without PMH (OR, 0.358; 95% CI, 0.161-0.793), with possible publication bias. Shunt procedures were marginally less common in patients with PMH compared with those patients without PMH (OR, 0.490; 95% CI, 0.236-1.018) with possible publication bias. After correction of the forest plot, the adjusted OR was 0.617 (95% CI, 0.251-1.513) for hydrocephalus and 0.618 (95% CI, 0.310-1.232) for shunts, suggesting no significant relationships between PMH and the risk of hydrocephalus or shunting. CONCLUSIONS Hydrocephalus and shunts were more evident in non-PMH than PMH. However, subgroup analyses did not show significant associations between PMH and lower risks of these events after correction for possible publication bias. Further meta-analyses based on individual patient data are necessary.
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Affiliation(s)
- Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Steve S Cho
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Heung Cheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon, Korea
| | - Jin Pyeong Jeon
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea; Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.
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Lee SU, Hong EP, Kim BJ, Kim SE, Jeon JP. Delayed Cerebral Ischemia and Vasospasm After Spontaneous Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis. World Neurosurg 2018; 115:e558-e569. [PMID: 29689403 DOI: 10.1016/j.wneu.2018.04.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report clinical outcomes of delayed cerebral ischemia (DCI) and vasospasm in angiogram-negative subarachnoid hemorrhage (SAH) according to hemorrhage patterns, perimesencephalic hemorrhage (PMH) and non-PMH. METHODS Online databases from January 1990 to December 2017 were systematically reviewed. A fixed-effects model was used to control heterogeneity. To resolve publication bias, the trim and fill method was used to estimate number of missing studies and adjusted odds ratio (OR). Subgroup analysis of data from studies that defined angiogram-negative subarachnoid hemorrhage by angiography repeated at least twice or computed tomography angiography was performed. RESULTS Among 24 studies including 2083 patients, 23/985 patients (2.3%) with PMH and 144/1098 patients (13.1%) with non-PMH had DCI, indicating that patients with PMH experienced significantly lower DCI than patients with non-PMH (OR = 0.219; 95% confidence interval [CI], 0.144-0.334). Regarding vasospasm, 99/773 patients (12.8%) with PMH and 231/922 patients (25.1%) with non-PMH exhibited vasospasm, indicating that patients with PMH experienced significantly lower vasospasm than patients with non-PMH (OR = 0.445; 95% CI, 0.337-0.589). Funnel plots show asymmetry indicating possible publication bias. After trimming 10 studies for DCI and 7 for vasospasm, the adjusted ORs remained significant between PMH and lower risks of DCI and vasospasm. Subgroup analysis of 789 patients in 8 studies showed a lower risk of DCI (OR = 0.268; 95% CI, 0.151-0.473) and vasospasm (OR = 0.346; 95% CI, 0.221-0.538) in patients with PMH. CONCLUSIONS PMH showed a significantly lower risk of DCI and vasospasm than non-PMH. Clinical outcomes of angiogram-negative subarachnoid hemorrhage, based on meta-analysis of individual patient data, need to be investigated.
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Affiliation(s)
- Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Eun Pyo Hong
- Department of Medical Genetics, Hallym University College of Medicine, Chuncheon, Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Jin Pyeong Jeon
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea; Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.
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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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