Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by jugular venous occlusion: case report

A New Insight in Nonaneurysmal Subarachnoid Hemorrhage: the Potential Role of the Internal Jugular Veins

BACKGROUND

 Causes of the nonaneurysmal subarachnoid hemorrhage (na-SAH) are still debated. Many studies confirmed the possible involvement of the intracranial venous system, in particular variants of the basal vein of Rosenthal.

STUDY OBJECT

 The aim of this study is to investigate the role of extracranial venous system, in particular the jugular drainage, in the na-SAH pathophysiology.

MATERIALS AND METHODS

 This is a multicenter retrospective study including patients suffering from na-SAH who were radiologically screened to exclude vascular malformations. The course of the internal jugular veins was evaluated to reveal any stenosis (caliber reduction >80%). Particular attention was paid at the passage between the styloid process and the arch of C1 to detect possible compression. As a control group, we enrolled patients who underwent CT angiograms and/or cerebral DSAs in the past 2 years.

RESULTS

 We included 194 patients. The na-SAH group consisted of 94 patients, whereas the control group consisted of 100 patients. Fifty patients of the control group underwent a CT angiography for an ischemic cerebrovascular disease or trauma and 50 patients for an SAH due to a ruptured aneurysm. A significant jugular stenosis was found in 49 (52.1%) patients in the na-SAH group and in 18 (18%) patients in the control group. At univariate and multivariate analysis, the difference was statistically significant (p < 0.0001).

CONCLUSIONS

 This is the first study investigating the correlation between jugular stenosis and the occurrence of na-SAH. The impaired venous outflow due to reduced venous caliber could result in an engorgement of the upstream intracranial veins with transient hypertensive phases facilitating ruptures. Further larger prospective studies are necessary to confirm these data.

Dural Venous Sinus Variations in Idiopathic Subarachnoid Hemorrhage: A New Indicator of the Venous Origin with Diagnostic Usefulness?

OBJECTIVE

Venous hypertension associated with a primitive basal vein of Rosenthal (BVR) has been noted as the most likely cause of idiopathic subarachnoid hemorrhage (iSAH). Other types of venous drainage variations have been scarcely studied but may further explain the cases not associated with a BVR anomaly. Our aim was to investigate if dural venous sinus (DVS) anomalies are related with iSAH.

METHODS

A total of 76 patients diagnosed with iSAH were identified from a prospectively maintained database and their angiographic findings compared with 76 patients diagnosed with aneurysmal subarachnoid hemorrhage.

RESULTS

On top of the BVR variations, our data showed a higher prevalence of transverse sinus hypoplasia (47.4% vs. 28.9%; P = 0.019), superior petrosal sinus hypoplasia (32.9% vs. 13.2%; P = 0.003), and clival plexus hyperplasia (65.8% vs. 43.4%; P = 0.005) in patients with iSAH. Analyzing by total number of angiograms, the iSAH group showed also a higher prevalence of inferior petrosal sinus hyperplasia (36.2% vs. 25%; P = 0.003). Of the patients with iSAH without a primitive BVR, 84% harbored ≥1 perimesencephalic DVS variation and the overall number of venous drainage variations was significantly higher in patients with iSAH.

CONCLUSIONS

In addition to the well-documented BVR anomalies, there seems to be a significant relationship of other DVS variations in patients with iSAH. Transverse sinus hypoplasia, superior petrosal sinus hypoplasia, inferior petrosal sinus hyperplasia, and clival plexus hyperplasia were significantly more frequent in patients with iSAH. The presence of ≥3 of those variations would increase the suspicion of a nonaneurysmatic subarachnoid hemorrhage and could help avoid a second angiogram.

Recurrent perimesencephalic nonaneurysmal subarachnoid hemorrhage within a short period of time: A case report

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.

Subarachnoid Hemorrhage of Unknown Cause: Distribution and Role of Imaging

Subarachnoid hemorrhage of unknown cause represents approximately 10% to 15% of nontraumatic subarachnoid hemorrhages. The key factors in determining the management strategy for a presumed nonaneurysmal subarachnoid hemorrhage are the distribution, location, and amount of subarachnoid blood. Hemorrhage distribution on computed tomography can be categorized as follows: perimesencephalic, diffuse, sulcal, and primary intraventricular. The extent of the workup required in determining the cause of hemorrhage depends on the distribution of blood. The authors review the potential causes, differential diagnoses, and acute and long-term follow-up strategies in patients with subarachnoid hemorrhage of unknown cause.

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.

The eagle jugular syndrome

BACKGROUND

The elongation of the styloid process is historically associated with two variants of the Eagle syndrome. The classic one, mainly characterized by pain and dysphagia, and the carotid variant characterized by pain and sometimes by cerebral ischemia. We observed a further variant characterized by a styloid elongation coursing adjacent to the transverse process of C1, causing significant compression of the internal jugular vein.

METHODS

We reviewed all the cases of Eagle syndrome, including the jugular variant, admitted in our Hospital in the last six years. We compared symptomatology, associated comorbidities and imaging. Data were statistically analyzed.

RESULTS

Overall 23 patients were admitted to the Hospital for symptomatic elongation of the styloid process, 11 male and 12 females. The jugular variant of the Eagle syndrome is clinically delineated by significant differences, as compared to the classic variant and carotid variants. Headache was the more prominent symptom (p < .009) as well as a documented peri-mesencephalic hemorrhage was the more significant comorbidity (p < .0003). The group classic-carotid variant was characterized by ipsilateral pain respect to the jugular variant (p < .0003). CT angiography with venous phase extended to the neck veins and imaging reconstruction is highly recommended as imaging technique, complemented by color-Doppler ultrasound.

CONCLUSIONS

The elongation of the styloid process may have different paths which creates compression on the surrounding anatomical structures. There may be a possible association of jugular impingement by an elongated styloid process with symptoms.

TRIAL REGISTRATION

Protocol n°45-2013.

Neural Vascular Mechanism for the Cerebral Blood Flow Autoregulation after Hemorrhagic Stroke

During the initial stages of hemorrhagic stroke, including intracerebral hemorrhage and subarachnoid hemorrhage, the reflex mechanisms are activated to protect cerebral perfusion, but secondary dysfunction of cerebral flow autoregulation will eventually reduce global cerebral blood flow and the delivery of metabolic substrates, leading to generalized cerebral ischemia, hypoxia, and ultimately, neuronal cell death. Cerebral blood flow is controlled by various regulatory mechanisms, including prevailing arterial pressure, intracranial pressure, arterial blood gases, neural activity, and metabolic demand. Evoked by the concept of vascular neural network, the unveiled neural vascular mechanism gains more and more attentions. Astrocyte, neuron, pericyte, endothelium, and so forth are formed as a communicate network to regulate with each other as well as the cerebral blood flow. However, the signaling molecules responsible for this communication between these new players and blood vessels are yet to be definitively confirmed. Recent evidence suggested the pivotal role of transcriptional mechanism, including but not limited to miRNA, lncRNA, exosome, and so forth, for the cerebral blood flow autoregulation. In the present review, we sought to summarize the hemodynamic changes and underline neural vascular mechanism for cerebral blood flow autoregulation in stroke-prone state and after hemorrhagic stroke and hopefully provide more systematic and innovative research interests for the pathophysiology and therapeutic strategies of hemorrhagic stroke.

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis: A case report and review of literature

RATIONALE

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is characterized by a pattern of extravasated blood restricted to the perimesencephalic cisterns, normal angiographic findings, and an excellent prognosis with an uneventful course and low risks of complication. The precise etiology of bleeding in patients with PNSAH has not yet been established. The most common hypothesis is that PNSAH is venous in origin. Intracranial venous hypertension has been considered as the pivotal factor in the pathogenesis of PNSAH. The underlying venous pathology such as straight sinus stenosis, jugular vein occlusion may contribute to PNSAH. We describe a patient in whom transverse sinus thrombosis preceded intracranial venous hypertension and PNSAH. These findings supported that the source of the subarachnoid hemorrhage is venous in origin.

PATIENT CONCERNS AND DIAGNOSES

A 45-year-old right-handed man was admitted to the hospital with a sudden onset of severe headache associated with nausea, vomiting, and mild photophobia for 6 hours. The patient was fully conscious and totally alert. An emergency brain computed tomography (CT) revealed an acute subarachnoid hemorrhage restricted to the perimesencephalic cisterns. CT angiography revealed no evidence of an intracranial aneurysm or underlying vascular malformation. Digital subtraction angiography of arterial and capillary phases confirmed the CT angiographic findings. Assessment of the venous phase demonstrated right transverse sinus thrombosis. Magnetic resonance imaging confirmed the diagnosis of cerebral venous sinus thrombosis (CVST). Lumbar puncture revealed an opening pressure of 360 mmH2O, suggestive of intracranial venous hypertension. Grave disease was diagnosed by endocrinological investigation.

INTERVENTIONS

Low-molecular-weight heparin, followed by oral warfarin, was initiated immediately as the treatment for cerebral venous sinus thrombosis and PNSAH.

OUTCOMES

The patient discharged without any neurologic defect after 3 weeks of hospital stay. MR venography revealed recanalization of right transverse sinus at the 6-month follow-up. No clinical or neuroimaging evidence of relapse was detected at 12 months follow-up.

LESSONS

Hyperthyroidism may contribute to the development of CVST. The presence of acute transverse sinus thrombosis, as a cause of PNSAH, provides further support for the hypothesis that the source of PNSAH is venous in origin and intracranial venous hypertension plays a critical role in the pathogenesis of PNSAH.

Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage After Clipping of an Unruptured Aneurysm

BACKGROUND

Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage with an excellent clinical outcome. The cause of PNSAH remains unknown. We report a case of PNSAH in a patient with a history of clipping of an unruptured aneurysm. PNSAH after clipping of an unruptured aneurysm is extremely rare.

CASE DESCRIPTION

A 56-year-old man with a history of clipping surgery for an unruptured aneurysm 10 months previously presented with severe headache. No precipitating causes were shown; however, the patient had been engaged in an exertional activity before the event. After conservative treatment, he was discharged home without any complication from the hemorrhage.

CONCLUSIONS

On the basis of this case report, clinicians should consider the possibility of PNSAH in a patient who had an unruptured aneurysm previously treated with clipping. Nevertheless, diagnostic workup can be more important than keeping in mind that a subarachnoid hemorrhage might be a PNSAH.

Quadrigeminal perimesencephalic subarachnoid hemorrhage

OBJECTIVE

A variant of perimesencephalic subarachnoid hemorrhage (PSAH) has been described characterized by blood centered in the quadrigeminal cistern and limited to the superior vermian and perimesencephalic cisterns. Herein, three cases of quadrigeminal PSAH are presented.

MATERIALS AND METHODS

Medical records of all patients who underwent digital subtraction angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Two blinded reviewers identified admission noncontrast CT scans with pretruncal and quadrigeminal patterns of PSAH.

RESULTS

The total cohort included 106 patients: 53% (56/106) with one or more negative digital subtraction angiograms and 47% (50/106) with posterior circulation or posterior communicating artery aneurysms. Three patients with quadrigeminal PSAH were identified, two with nonaneurysmal SAH and one with a posterior circulation aneurysm. Seventeen patients (16%; 17/106) with pretruncal PSAH were identified, none of whom were found to have an aneurysm. The quadrigeminal pattern comprised 11% (2/19) of cases of pretruncal or quadrigeminal nonaneurysmal PSAH.

CONCLUSION

A small subset of patients with nonaneurysmal PSAH present with blood centered in the quadrigeminal cistern, and the etiology of this pattern may be similar to that of the classic pretruncal variant. However, patients with quadrigeminal PSAH must still undergo thorough vascular imaging, including at least two digital subtraction angiograms, to exclude a ruptured aneurysm.

Evaluation of an anatomic definition of non-aneurysmal perimesencephalic subarachnhoid hemorrhage

Background and purpose

Perimesencephalic subarachnoid hemorrhage (PSAH) is not consistently defined in the existing literature. The purpose of this study was to test the inter-observer variability and specificity for non-aneurysmal subarachnoid hemorrhage (SAH) of an anatomic definition of PSAH.

Methods

Medical records of all patients who underwent catheter angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Three blinded reviewers assessed whether each admission CT scan met the following anatomic criteria for PSAH: (1) center of bleeding located immediately anterior and in contact with the brainstem in the prepontine, interpeduncular, or posterior suprasellar cistern; (2) blood limited to the prepontine, interpeduncular, suprasellar, crural, ambient, and/or quadrigeminal cisterns and/or cisterna magna; (3) no extension of blood into the Sylvian or interhemispheric fissures; (4) intraventricular blood limited to incomplete filling of the fourth ventricle and occipital horns of the lateral ventricles (ie, consistent with reflux); (5) no intraparenchymal blood.

Results

56 patients with non-aneurysmal SAH and 50 patients with posterior circulation or posterior communicating artery aneurysms were identified. Seventeen (16%) of the 106 admission CT scans met the anatomic criteria for PSAH. No aneurysm was identified in this subgroup. Inter-observer agreement was excellent with κ scores of 0.89–0.96 and disagreement in 2.8% (3/106) of cases.

Conclusions

Our anatomic definition of PSAH correlated with a low risk of brain aneurysm and was applied with excellent inter-observer agreement.

Underlying Venous Pathology Causing Perimesencephalic Subarachnoid Hemorrhage

Background:

Perimesencephalic subarachnoid hemorrhage (PSH) is a relatively benign clinical entity with a low risk of recurrent bleeding. The precise etiology of PSH has not yet been determined. We report here three cases of PSH with clinical and radiological features that support a venous system as a cause.

Case Presentation:

The first patient, a 72-year-old woman, had PSH and venous hemorrhagic infarct in the left thalamus on non-contrast CT. Subsequent cerebral angiography revealed widespread thrombosis in the cerebral venous system, a potential cause for reflux overflow hemorrhage. The second patient, a 55-year-old man with an established diagnosis of neuro-Behçet's disease, a well-known cause for cerebral venulitis, presented with PSH one year later. The third patient, a 39-year-old female, with incomplete Behçet's disease was admitted with PSH.

Discussion:

Current concepts on the anatomic origin and the possible pathophysiologic mechanism leading to PSH are discussed. The underlying pathological conditions in the venous system in our cases provide theoretical clues to the anatomic origin of PSH in general.

Nonaneurysmal perimesencephalic subarachnoid hemorrhage: diagnosis, pathophysiology, clinical characteristics, and long-term outcome

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.

Perimesencephalic subarachnoid hemorrhage triggered by hypoxic training during swimming

INTRODUCTION

Perimesencephalic subarachnoid hemorrhage is a rare neurologic condition of unclear etiology. Multiple mechanisms have been postulated as potential triggers, but none are universally accepted.

METHODS

Single observational case report and review of the literature.

RESULTS

We describe a patient who developed perimesencephalic subarachnoid hemorrhage in the setting of "hypoxic training" (breath-holding while swimming). We describe the plausible pathophysiologic events that caused the hemorrhage.

CONCLUSION

The occurrence of perimesencephalic subarachnoid hemorrhage during hypoxic training suggests that acute venous congestion may be a triggering factor. The increasing popularity of hypoxic training demands vigilance from health care providers.

Neurological sequelae from brachiocephalic vein stenosis

Stenosis of central veins (brachiocephalic vein [BCV] and superior vena cava) occurs in 30% of hemodialysis patients, rarely producing intracranial pathology. The authors present the first cases of BCV stenosis causing perimesencephalic subarachnoid hemorrhage and myoclonic epilepsy.

In the first case, a 73-year-old man on hemodialysis presented with headache and blurry vision, and was admitted with presumed idiopathic intracranial hypertension after negative CT studies and confirmatory lumbar puncture. The patient mildly improved until hospital Day 3, when he experienced a seizure; emergency CT scans showed perimesencephalic subarachnoid hemorrhage. Cerebral angiography failed to find any vascular abnormality, but demonstrated venous congestion. A fistulogram found left BCV occlusion with jugular reflux. The occlusion could not be reopened percutaneously and required open fistula ligation. Postoperatively, symptoms resolved and the patient remained intact at 7-month follow-up.

In the second case, a 67-year-old woman on hemodialysis presented with right arm weakness and myoclonic jerks. Admission MRI revealed subcortical edema and a possible dural arteriovenous fistula. Cerebral angiography showed venous engorgement, but no vascular malformation. A fistulogram found left BCV stenosis with jugular reflux, which was immediately reversed with angioplasty and stent placement. Postprocedure the patient was seizure free, and her strength improved. Seven months later the patient presented in myoclonic status epilepticus, and a fistulogram revealed stent occlusion. Angioplasty successfully reopened the stent and she returned to baseline; she was seizure free at 4-month follow-up.

Central venous stenosis is common with hemodialysis, but rarely presents with neurological findings. Prompt recognition and endovascular intervention can restore normal venous drainage and resolve symptoms.

Nonaneurysmal subarachnoid hemorrhage: an update

Nonaneurysmal subarachnoid hemorrhage (NA-SAH) constitutes a heterogeneous group of patients, both perimesencephalic (PMN-SAH) and non-perimesencephalic (nPMN-SAH). Despite many reports and case series, the etiology of NA-SAH remains uncertain. The differences in clinical course and outcome between PMN-SAH and nPMN-SAH are evident and have to be taken into consideration at the time of admission, as aggressive diagnostic evaluation and management are required for latter patient. In terms of diagnostic evaluation, the most important determination is to differentiate PMN-SAH from nPMN-SAH and aneurysmal SAH. PMN-SAH can be distinguished on CT in the majority of patients, but should be confirmed by a negative cerebral angiography. In addition, Convexal NA-SAH is another important subtype of NA-SAH associated with diverse etiologies and symptoms, although prognosis is generally favorable.

Classification of Non-Aneurysmal Subarachnoid Haemorrhage: CT Correlation to the Clinical Outcome

To propose a new computed tomography (CT)-based classification system for nonaneurysmal subarachnoid haemorrhage (SAH), which predicts patients' discharge clinical outcome and helps to prioritize appropriate patient management. A 5-year, retrospective, two-centre study was carried out involving 1486 patients presenting with SAH. One hundred and ninety patients with nonaneurysmal SAH were included in the study. Initial cranial CT findings at admission were correlated with the patients' discharge outcomes measured using the Modified Rankin Scale (MRS). A CT-based classification system (type 1 e 4) was devised based on the topography of the initial haemorrhage pattern. Seventy-five percent of the patients had type 1 haemorrhage and all these patients had a good clinical outcome with a discharge MRS of 1. Eight percent of the patients presented with type 2 haemorrhage, 62% of which were discharged with MRS of 1 and 12% of patients had MRS 3 or 4. Type 3 haemorrhage was found in 10%, of which 16% had good clinical outcome, but 53% had moderate to severe disability (MRS 3 and 4) and 5% were discharged with severe disability (MRS 5). Six percent of patients presented with type 4 haemorrhage of which 42% of the patients had moderate to severe disability (MRS 3 and 4), 42% had severe disability and one-sixth of the patients died. Highly significant differences were found between type 1 (1a and 1b) and type 2 (p 1/4 0.003); type 2 and type 3 (p 1/4 0.002); type 3 and type 4 (p 1/4 0.001). Haemorrhages of the type 1 category are usually benign and do not warrant an extensive battery of clinical and radiological investigations. Type 2 haemorrhages have a varying prognosis and need to be investigated and managed along similar lines as that of an aneurysmal haemorrhage with emphasis towards radiological investigation. Type 3 and type 4 haemorrhages need to be extensively investigated to find an underlying cause.