Non-aneurysmal subarachnoid hemorrhage: When is a second angiography indicated?

The diagnostic yield of repeat computed tomography angiography in cases of spontaneous subarachnoid haemorrhage after negative initial digital subtraction angiography

Purpose

It is currently unclear how useful repeat computed tomography angiography (CTA) is in spontaneous subarachnoid haemorrhage (SAH) patients after negative initial digital subtraction angiography (DSA). The purpose of this study is to assess the yield of repeat CTA for the detection of causative vascular lesions in patients with SAH in whom there has been a negative initial DSA.

Material and methods

This observational retrospective study was carried out from January 2013 to July 2022 at a single institution. Analysis of the SAH pattern on unenhanced CT showed that patients were divided into perimesencephalic SAH and diffuse SAH groups. A repeat CTA was performed on all spontaneous SAH patients who had a nega-tive initial CTA and DSA within a 2-week period. An interventional neuroradiologist and a diagnostic radiologist examined all images to search for causative vascular abnormalities.

Results

Forty-seven patients were included in our study, with a median age of 55 years and a range of 28-81 years. Thirty-seven had diffuse SAH (66%), and 16 had perimesencephalic SAH (34%). The repeat CTA revealed 2 causa-tive vascular lesions (a right PICA aneurysm and a mycotic aneurysm) in 2 separate patients (yield of 4.3%), both of whom had diffuse SAH (yield of 6.5%). In retrospect, none of these vascular lesions were evident in the initial CTA and DSA. No evidence of re-bleeding was observed in the follow-up period.

Conclusions

It is beneficial to repeat CTA when evaluating patients with diffuse SAH who initially present with nega-tive initial DSA. For occult aneurysms, the diagnostic yield of the follow-up CTA is 6.5%.

Comment on Roman-Filip et al. Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review. Diagnostics 2023, 13, 1195

We would like to congratulate Roman-Filip et al. on their recent review on perimesencephalic hemorrhages [...].

Management of perimesencephalic nonaneurysmal subarachnoid hemorrhage: a national survey

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (NASAH) is a rare type of subarachnoid hemorrhage (SAH), usually associated with minor complications compared to aneurysmal SAH. Up to date, data is scarce and consensus on therapeutic management and follow-up diagnostics of NASAH is often missing. This survey aims to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding.

Clinical outcome and prognostic factors of patients with non-traumatic angiography-negative subarachnoid hemorrhage

Purpose

The cause of spontaneous subarachnoid hemorrhage (SAH) is unknown in 10% of cases. The aim of this study was to demonstrate the characteristics of patients with angiography-negative subarachnoid hemorrhage (anSAH) and to analyze factors influencing the clinical outcome in patients suffering from anSAH.

Methods

A retrospective cohort of 75 patients with anSAH [26 perimesencephalic (pmSAH) and 49 non-perimesencephalic SAH (npmSAH)] admitted between January 2016 and June 2022 was included. We analyzed demographic, clinical data and 6-month functional outcomes. Enter regression analysis was performed to identify factors associated with outcomes.

Results

Unfavorable outcome was achieved in 10 of 75 patients (13.3%). Unfavorable outcome was associated with senior adults (p = 0.008), Hijdra cistern score (HCS) elevation (p = 0.015), long-time lumbar cistern continuous drainage (LCFD; p = 0.029) and hydrocephalus (p = 0.046). The only significant risk factor for unfavorable outcome after npmSAH was the HCS (OR 1.213 (95%CI 1.007-1.462), p = 0.042).

Conclusion

Our study provides valuable information on both SAH patterns and functional outcome in patients suffering from anSAH and should be taken into consideration during management of these patients.

Subarachnoid Hemorrhage with Negative Initial Digital Subtraction Angiography: Subsequent Detection of Aneurysms and Complication Rates of Repeated Angiography

BACKGROUND

 The data on handling of spontaneous, nontraumatic subarachnoid hemorrhage (SAH) with negative initial digital subtraction angiography (DSA) are still inconclusive. The intention of this study was to evaluate the requirement of repeat DSA in patients with negative initial DSA and to compare the clinical outcomes of these cases.

METHODS

 In a retrospective study, we reviewed patients with SAH and negative initial DSA treated in our department from January 2006 until December 2017. The patients were divided according to an established radiographic classification into perimesencephalic (pm) and nonperimesencephalic (npm) SAH. An interventional neuroradiologist and a neurosurgeon reviewed all DSA scans.

RESULTS

 In all, 52 patients with negative initial DSA, comprising 36 (69.2%) patients with pm and 16 (30.8%) patients with npm bleeding pattern, were included. All patients underwent a second and 23 of these patients underwent a third DSA. In these 23 patients, subarachnoid blood distribution in the initial computed tomography (CT) scan was suspicious for the presence of aneurysm. In total, two aneurysms were detected during the second DSA (diagnostic yield: 3.85%). Both were in the pm group (diagnostic yield: 5.6%). The second repeat DSA did not show any causative vascular lesion. Complications after the DSA occurred in only 2 of 127 patients (1.6%). The rate of complications concerning vasospasm (pm 52.8%, npm 56.3%), hydrocephalus (pm 47.2%, npm 50%), and the need for temporary or permanent shunt (pm 44.4%, npm 50%) was similar in both groups and there was no statistically significant difference.

CONCLUSION

 Repeat DSA after negative initial DSA in pm SAH had a diagnostic yield of 5.6%. However, a second repeat DSA cannot be recommended in case of SAH with initial negative DSA. The pm SAH should not be underrated concerning the occurrence of complications and cared with a high level of surveillance.

Delayed appearance of basilar trunk small atypical aneurysms in nontraumatic, initially angiogram-negative subarachnoid hemorrhage: A report of three patients

BACKGROUND

Repeat angiography will identify vascular pathology in approximately 10% of cases following angiogram-negative subarachnoid hemorrhage (anSAH), but small atypical aneurysms of the basilar artery are very uncommon.

OBJECTIVE

To report a case series of delayed appearance of nontraumatic basilar artery small atypical aneurysms.

METHODS

IRB approval was obtained for this retrospective case series and patient consent was waived.

RESULTS

Herein we report three cases of spontaneous anSAH, all of whom had a negative digital subtraction angiogram (DSA) on admission and all of whom had appearance of a small atypical aneurysms of the upper basilar trunk/apex on follow-up imaging (two during the initial admission and one in a delayed fashion). All three patients were ultimately treated with flow diversion (although one patient underwent attempted coiling that was abandoned due to inability to catheterize the aneurysm).

CONCLUSION

This report highlights the importance of a repeat DSA in cases of anSAH as well as the importance of scrutinizing the basilar trunk for these very small atypical aneurysms that may go unnoticed.

Systemic Inflammatory Response in Spontaneous Subarachnoid Hemorrhage from Aneurysmal Rupture versus Subarachnoid Hemorrhage of Unknown Origin

OBJECTIVE

It is well known that spontaneous non-aneurysmal subarachnoid hemorrhage (SAH), also known as sine materia SAH (smSAH), has usually a better course and prognosis than its aneurysmal counterpart (aSAH). This might depend on different inflammatory mechanisms initiated by bleeding events of different origins. The aim of the present study was to explore the systemic inflammatory response in spontaneous SAH, comparing aSAH and smSAH.

METHODS

We performed a prospective observational study over a consecutive series of patients with SAH. For these patients, we collected all clinical data and, furthermore, performed venous blood sampling over six time points to analyze blood cells. We further performed the analysis of lymphocytes and monocytes by means of flow cytometry to quantify common subtypes. Statistical analysis included a t-student test, Chi-square test, multivariate logistic regression, and ROC analysis.

RESULTS

48 patients were included: six (12.5%) with a diagnosis of spontaneous smSAH, and forty-two patients (87.5%) with aSAH. Significant differences on Day 0 were found for neutrophils and a systemic neuro-inflammatory index, namely, systemic inflammatory response index (SIRI). At the ROC analysis, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and SIRI exhibited satisfactory predictive power on day 0. At the multivariable logistic regression analysis, the combined index (NLR, LMR, SIRI at day 0) yielded an OR of 0.59 (95% CI 0.29-1.21]). LMR at day 0 yielded an OR of 1.25 ([95% CI 0.94-1.68]), NLR at day 0 exhibited an OR of 0.68 ([95% CI 0.42-1.09]), and SIRI at day 0 displayed an OR of 0.31 ([95% CI 0.06-1.49]).

CONCLUSION

This preliminary study indicated a possible role of some inflammatory indices that point out the importance of innate and adaptive immunity in the etiopathogenetic mechanisms. Drugs modulating these responses could eventually counteract or, at least, reduce secondary damage associated with SAH.

Current status of perimesencephalic non-aneurysmal subarachnoid hemorrhage

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.

Radiological investigations in non-aneurysmal subarachnoid haemorrhage: A 5-year review

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All patients with a Fisher grade 2 bleed and a negative CT angiogram had catheter angiography negative for any abnormality.

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Neuroradiologists identified vascular abnormalities not reported by district general hospitals.

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Follow-up MRI may be a useful adjunct in subarachnoid haemorrhage.

Dry Mouth Caused by Facial Nerve Ischemia due to Subarachnoid Hemorrhage: An Experimental Study

OBJECTIVE

Parasympathetic network damage results in facial nerve damage, sublingual ganglion degeneration, sublingual gland dysfunction, and dry mouth. In this study, subarachnoid hemorrhage (SAH) was considered to be the cause of dry mouth.

METHODS

We assessed 23 hybrid rabbits, including 5 control (group 1, Control). One milliliter of serum saline was injected into the cisterna magna of 5 animals (group 2). SAH was induced by injecting 1 mL of autologous blood into the cisterna magna of 13 animals (group 3). The animals were killed after 3 weeks of induction. The animals' sublingual ganglion and sublingual gland were excised for histopathological examination. The number of degenerated cells in the sublingual ganglion, secretory vesicles, and secretory granules in the sublingual gland that contain salivary components were estimated using Sequential Window Acquisition of All Theoretical Mass Spectra data analysis. The values were compared by the Mann-Whitney U-test.

RESULTS

The numbers of secretory vesicles in the sublingual gland were 5.3 ± 1.1 × 10³ (group 1), 4.23 ± 0.45 × 10³ (group 2), and 1.56 ± 0.22 × 10³ (group 3); the numbers of secretory vesicles containing saliva in the sublingual gland were 324 ± 12.18 (group 1), 263 ± 36.23 (group 2), and 114 ± 23.14 (group 3); and the numbers of degenerated cells in the sublingual ganglion were 11 ± 3/mm³ (group 1), 98.43 ± 15.54/mm³ (group 2), and 346 ± 12.28/mm³ (group 3) (P < 0.05).

CONCLUSIONS

Clinical findings in infection and diseases such as Sjögren syndrome, aseptic meningitis, and SAH are similar. However, until now, SAH has not been demonstrated experimentally to cause dry mouth. Discovering that SAH might cause dry mouth might prevent unnecessary use of antibiotics and decrease morbidity due to the wrong or late diagnosis.

Repeat Catheter Angiography in Patients with Aneurysmal-Pattern Angiographically Negative Subarachnoid Hemorrhage

BACKGROUND

A significant proportion of patients with subarachnoid hemorrhage have a normal cerebral angiogram. Patients with angiographically negative subarachnoid hemorrhage (anSAH) with either perimesencephalic- (panSAH) or aneurysmal-pattern hemorrhage (aanSAH, also known as diffuse anSAH) have an excellent prognosis, but only if underlying vascular abnormalities are completely excluded. The rate of occult aneurysms in patients with aanSAH varies widely across studies. The purpose of this study was to quantify the value of repeat DSA in these patients.

METHODS

We reviewed the records of all patients initially diagnosed with aanSAH after a screening DSA at a single tertiary neurovascular referral center from January 2006-April 2018. Patients with panSAH and traumatic SAH were excluded. We also performed a systematic review and meta-analysis of positive second DSAs in previously published case series of patients with aanSAH who underwent two serial DSAs. For meta-analysis, PubMed Central, MEDLINE and Cochrane Library databases were searched for pertinent studies up to November 2019. The rate of aneurysm detection on repeat angiography was extracted from each study. Pooled rates for positive second angiogram were calculated as untransformed proportions in a binary random-effects model meta-analysis. Inter-study heterogeneity was calculated using an I² statistic.

RESULTS

Three of 27 patients (11.1%) with aanSAH and at least two DSAs were subsequently found to have a cerebral aneurysm in our institutional dataset. Twenty-six studies in our systematic review met inclusion criteria, and the pooled rate of positive second angiogram was 10.4% (95% CI 7.3%-13.5%, P < 0.001). Substantial inter-study heterogeneity was observed in the meta-analysis (I² = 61.7%, P < 0.001).

CONCLUSIONS

One in 10 patients with aanSAH has an occult ruptured aneurysm. A second-look DSA should be strongly considered in these cases.

AH, R. PA. The Yield of Repeat Angiography in Angiography-Negative Spontaneous Subarachnoid Hemorrhage

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.

Treatment of acute thrombosis during stent-assisted coil embolization of ruptured proximal posterior inferior cerebellar artery aneurysm

Aneurysms located in the posterior inferior cerebellar artery (PICA) are not a majority of the intracranial aneurysms cases. Many challenges were addressed in the endovascular procedure to treat the disease. The authors have successfully diagnosed and treated a ruptured proximal PICA aneurysm. However, digital subtraction angiography showed acute thrombosis in the vertebral artery in the procedure, which probably could be an acute in-stent thrombosis. The tirofiban hydrochloride injection was subjected through a microcatheter, and then, the second Neuroform EZ stent was planted. In the 6-month follow-up, no recurrence of the aneurysm and complete patency of the right PICA at the site of aneurysm formation were found. We believe that the treatment of PICA aneurysms with Neuroform EZ stents could get a favorable result. Combination of tirofiban hydrochloride and Neuroform EZ stent could be an effective approach in treating acute thrombotic complications.

Digital subtraction cerebral angiography after negative computed tomography angiography findings in non-traumatic subarachnoid hemorrhage

Background

CT angiography (CTA) is widely used for the detection of vascular lesions in patients with non-traumatic subarachnoid hemorrhage (ntSAH); however, digital subtraction angiography (DSA) remains the gold standard for diagnosis. Our aim was to analyze the diagnostic yield of DSA after negative high-resolution CTA findings.

Methods

Records of patients with a CTA-negative ntSAH at a single institution from 2014 to 2018 were retrospectively analyzed. ntSAH patterns were categorized as cortical, perimesencephalic, or diffuse. Subsequent DSA findings were compared across the three cohorts.

Results

A total of 186 patients had CTA-negative ntSAH. The ntSAH pattern was identified as cortical (n=77, 41.4%), diffuse (n=60, 32.3%), or perimesencephalic (n=49, 26.3%). In eight patients (4%), DSA revealed a vascular lesion (one cervical arteriovenous fistula and seven atypical aneurysms) after negative CTA findings. All eight patients with positive DSA findings had diffuse SAH (13% of patients with a diffuse pattern). The seven aneurysms included four blister or dissecting (two basilar artery, one superior cerebellar artery, and one dorsal wall internal carotid artery), two fusiform (one posterior communicating artery and one anterior spinal artery), and one saccular aneurysm (middle cerebral artery).

Conclusion

DSA identified a causative lesion in 4% of patients with CTA-negative ntSAH, but only in patients with diffuse ntSAH. Most of the lesions detected were atypical aneurysms and were found on delayed angiograms. These results suggest that DSA can help to diagnose CTA-negative ntSAH caused by unusual aneurysms, and repeat DSA may be needed only for patients with diffuse ntSAH.

Increasing Frailty Predicts Worse Outcomes and Increased Complications After Angiogram-Negative Subarachnoid Hemorrhages

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.

CT angiogram negative perimesencephalic subarachnoid hemorrhage: is a subsequent DSA necessary? A systematic review

Background

Perimesencephalic subarachnoid hemorrhage (PMSAH) is a benign subtype with distinct clinical-radiologic features. Digital subtraction angiography (DSA) remains the gold standard investigation for exclusion of a macrovascular cause, although increasingly more clinicians rely solely on CT angiography (CTA). The primary aim of this systematic review was to evaluate the current literature regarding the negative predictive value of CTA.

Methods

A systematic search in concordance with the PRISMA checklist was performed for studies published between 2000 and 2018. Studies with ≥10 adult patients diagnosed on a non-contrast brain CT with a PMSAH, who underwent a negative CTA and were subsequently subject to a DSA, were included. Simple pooled analysis was performed to inform the negative predictive value (95% CI) of CTA and the risk of DSA- and CTA-related complications.

Results

Eighteen studies (669 patients) were included. All patients were subject to at least one DSA, the first one mostly performed within 24 hours of CTA (68.6%). 144 patients (21.5%) underwent a second DSA and a third repeat DSA was performed in one patient. The overall negative predictive value of CTA was 99.0% (95% CI 97.8% to 99.5%). The risk of complications following DSA and CTA were 1.35% (3/222) and 0% (0/41), respectively.

Conclusions

Undertaking a DSA after a negative CTA may not add any further diagnostic value in patients with PMSAH and may lead to net harm. This observation needs to be validated in a large-scale prospective multicenter study with complete case ascertainment and robust data on CTA and DSA complications.