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Yang W, Feghali J, Sattari SA, Hung AL, Chen Y, Huang J. The Natural History of Hemorrhage in Brain Arteriovenous Malformations-Poisson Regression Analysis of 1066 Patients in a Single Institution. Neurosurgery 2024; 94:389-398. [PMID: 37681967 DOI: 10.1227/neu.0000000000002674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 07/17/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Natural history of hemorrhage in brain arteriovenous malformations (bAVM) is reported at 2%-4% per year. Published studies using survival analysis fail to account for recurrent hemorrhagic events. In this study, we present a large, single institution series to elucidate the natural history of bAVM using multivariable Poisson regression. METHODS This is a retrospective cohort study. All patients with bAVM seen at our institution from 1990 to 2021 were included. Hemorrhages after detection of bAVM during the untreated interval were recorded. Natural history of hemorrhage was calculated by dividing number of hemorrhages by untreated interval. The frequency of hemorrhages followed a Poisson distribution. Multivariable Poisson regression with an offset variable of untreated interval in patient-years was constructed. Model selection was through a stepwise Akaike information criterion method. Stratified hemorrhagic rate was presented using different combinations of significant factors. RESULTS A total of 1066 patients with nonhereditary hemorrhagic telangiectasia harboring a single bAVM were included. Ninety (8.44%) patients had 101 hemorrhages during an untreated interval of 3596.3344 patient-years, translating to an overall hemorrhagic rate of 2.81% per year. Significant factors increasing hemorrhage risk included ruptured presentation ( P < .001), increasing age ( P < .001), female sex ( P = .043), and deep location ( P = .040). Adult male patients with ruptured presentation and deep bAVMs sustained the highest annual risk at 10.81%, whereas no hemorrhages occurred in unruptured pediatric male patients or ruptured pediatric (younger than 18 years) male patients with superficial bAVMs. CONCLUSION Hemorrhage after bAVM detection occurs in 8.41% of all patients, and the rate averages 2.81% per year. However, this risk varies from 0.00% to 10.81% per year depending on various risk factor combinations. Efforts should be made to stratify bAVM hemorrhage rate by risk factors for more precise estimation of bleeding risk if left untreated.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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2
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Cui X, Wang L, Zhao Y, Wang B, Wu Z, Zhao Z, Zhang H, Chen L, Yang X. Risk Factors and Location of Intracranial Aneurysm Rupture in a Consecutive Chinese Han Population. World Neurosurg 2024; 181:e214-e221. [PMID: 37813333 DOI: 10.1016/j.wneu.2023.10.010] [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: 06/09/2023] [Accepted: 10/03/2023] [Indexed: 10/11/2023]
Abstract
OBJECTIVE The aim of the present study was to retrospectively analyze and investigate the clinical data of 704 cases of ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The risk factors predicting aneurysm rupture were explored from the perspective of the clinical characteristics of intracranial aneurysm (IA). METHODS The clinical data of 704 patients with RIAs (494 patients) and UIAs (210 patients) admitted to the Department of Neurosurgery of Tianjin Medical University General Hospital and Tianjin Fifth Central Hospital between January 2016 and May 2022 were analyzed. A detailed analysis of sex, age, history, personal history, drug intake, and site of aneurysm occurrence was performed. Age was analyzed in segments and strata, and parameters with significant differences in the preliminary analysis results were analyzed by logistic regression to predict factors associated with the risk of aneurysm rupture. RESULTS Among 494 patients with RIA (70.2%) and 210 patients with UIA (29.8%), the logistic regression showed that IA location appeared to be the most significant factor associated with RIA (OR, 95% CI: internal carotid artery (ICA), reference; anterior communicating artery,27.864,12.548-61.878; posterior communicating artery,12.408,6.658-23.124; anterior cerebral artery,5.804,2.333-14.440; middle cerebral artery,9.284,4.599-18.744; posterior circulation arteries, 4.224,2.011-8.871). Age was not a significant factor associated with RIA in the model and Hyperlipidemia (OR: 0.365; 95% CI: 0.171-0.779), Atherosclerosis (OR: 0.277; 95% CI: 0.172-0.446) and Multiple aneurysms (OR: 0.275; 95% CI: 0.177-0.425) patients were less likely to have RIA.IA location and age were the best predictors of RIA using the model. CONCLUSIONS The present findings indicated that hyperlipidemia and atherosclerosis have a protective effect on aneurysm rupture, and different anatomical sites of IA may be risk factors for the occurrence of IA rupture. Among the anatomical sites of IA, the anterior communicating artery and posterior communicating artery have a higher fracture risk.
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Affiliation(s)
- Xiaopeng Cui
- Department of Neurosurgery, Tianjin Fifth Central Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Liang Wang
- Department of Neurosurgery, Tianjin Fifth Central Hospital, Tianjin, China
| | - Yan Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Bangyue Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhuolin Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Zilin Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Hengrui Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
| | - Lei Chen
- Department of Neurosurgery, Tianjin Fifth Central Hospital, Tianjin, China
| | - Xinyu Yang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
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Sadeh M, McGuire LS, Ostrov PB, Alaraj A, Charbel FT. Acute Subdural Hematoma Associated with Aneurysmal Rupture: A Case Series and Review of Literature. World Neurosurg 2023; 171:e486-e492. [PMID: 36526225 DOI: 10.1016/j.wneu.2022.12.041] [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: 08/26/2022] [Revised: 12/08/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Ruptured cerebral aneurysms represent a neurosurgical emergency with characteristic clinical presentation and imaging findings. However, atypical presentations may occur in association with acute subdural hematomas (SDHs). METHODS A retrospective review was conducted at our institution between 2013 and 2021 to identify patients with aneurysmal rupture presenting with SDH. Cases were reviewed for clinical presentation, imaging findings, management, and outcome. RESULTS A total of 8 patients were included in this review with an average age of 48.5 years. Six patients were women. The average Glasgow coma scale upon arrival was 6.3, and the Hunt-Hess average grade was 4.6. Aneurysm locations included posterior communicating artery (n = 3), anterior communicating artery (n = 2), middle cerebral artery (n = 2), and internal carotid artery terminus (n = 1). The size of aneurysm varied between 3 and 11 mm. Seven patients required surgical intervention, either craniotomy or craniectomy for hematoma evacuation, and aneurysms were treated by coiling (n = 2) or clipping (n = 6). CONCLUSIONS Ruptured aneurysms may present with SDH with or without significant subarachnoid hemorrhage. This illustrative case series highlights this challenging presentation and the importance of early recognition and appropriate management.
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Affiliation(s)
- Morteza Sadeh
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Laura Stone McGuire
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Philip B Ostrov
- College of Medicine, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Fady T Charbel
- Department of Neurological Surgery, University of Illinois at Chicago, Chicago, Illinois, USA.
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4
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Saway BF, Fielder T, Alshareef MA, Rafka HE, Sattur M, Lena J. Infratentorial retroclival and tentorial subdural hematoma from posterior communicating artery aneurysm rupture: A case report and systematic review of literature. Surg Neurol Int 2022; 13:499. [DOI: 10.25259/sni_758_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 10/10/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
The objective of this systematic review is to evaluate the pathogenesis, clinical course, and prognosis of patients who suffer from aneurysm rupture, leading to subdural hematoma (SDH) of the infratentorial space without associated subarachnoid hemorrhage (SAH).
Methods:
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature review was conducted in PubMed and Scopus electronic databases for relevant published cases of aneurysmal SDH (AnSDH) of the infratentorial compartment without associated SAH. The presentation, treatment, clinical course, and outcome of identified cases are compiled. In addition, a patient suffering from an infratentorial SDH following aneurysm rupture is presented with an illustrative case.
Results:
Three articles were identified and met inclusion criteria. All cases occurred from ruptured posterior communicating artery aneurysms. All patients arrived with a Hunt and Hess classification of 2 or less. Only one case was managed with operative aneurysm clipping and hematoma evacuation while the other three cases were managed endovascularly. There were no reported postoperative complications, vasospasm, or seizures reported. All patients had a final Modified Rankin score of 3 or less at last reported follow-up.
Conclusion:
Infratentorial AnSDH without associated SAH is an etiology rarely reported in the literature. Here, we present a case report and systematic review demonstrating a relatively benign clinical course and outcome compared to report aneurysm rupture associated with SAH or mixed SAH and SDH. Moreover, there appear to be lower rates of vasospasm and improved outcomes in patients with isolated AnSDH compared to the literature aneurysmal SAH rates.
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Affiliation(s)
- Brian Fabian Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, United States
| | - Tristan Fielder
- Department of Neurosurgery, University of Texas at San Antonio, San Antonio, Texas, United States
| | | | - Habib Emil Rafka
- College of Medicine, Medical University of South Carolina, Charleston, United States
| | - Mithun Sattur
- Department of Neurosurgery, Medical University of South Carolina, Charleston, United States
| | - Jonathan Lena
- Department of Neurosurgery, Medical University of South Carolina, Charleston, United States
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5
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Malik L, Butt W, Dhillon PS, Lenthall R. Isolated clival subdural haemorrhage from a dolicoectactic vertebrobasilar aneurysm: Case report and overview of endovascular treatment strategies. J Cerebrovasc Endovasc Neurosurg 2021; 23:365-371. [PMID: 34963259 PMCID: PMC8743819 DOI: 10.7461/jcen.2021.e2020.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Accepted: 07/17/2021] [Indexed: 11/23/2022] Open
Abstract
Posterior fossa aneurysms presenting with isolated subdural haemorrhage (SDH) have scarcely been described with no cases attributed to a vertebrobasilar (VB) location. Non-saccular VB aneurysms are a distinct sub-group and in this report we also discuss the pathophysiology and treatment options for these difficult-to-manage lesions. We present a case of a 49 year-old man who presented with a 7-day history of severe headaches who was found to have an isolated acute clival SDH. Vascular imaging revealed a VB dolicoectatic segment with superimposed fusiform dilatations that contacted the dura adjacent to the SDH. A staged treatment was performed with initial parental vessel occlusion of the ruptured vertebral artery segment and subsequent insertion of a braided stent (LEO) with flow diverting properties into the progressively dilating basilar artery. A third procedure was performed to occlude a recurrent pouch at the lower basilar dilatation. Complete angiographic occlusion was achieved and the patient is under continued surveillance. To our knowledge, this is the first case of a ruptured non-saccular VB aneurysm presenting with radiologically isolated clival SDH. Clinical history will often inform the need for vascular imaging in such atypical presentations. Managing these lesions remains an endovascular challenge and requires a specialist multi-disciplinary approach.
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Affiliation(s)
- Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Waleed Butt
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Permesh Singh Dhillon
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
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6
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Endovascular treatment of distal anterior cerebral artery aneurysm presenting with acute subdural hematoma. INTERDISCIPLINARY NEUROSURGERY 2021. [DOI: 10.1016/j.inat.2021.101332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Ya X, Zhang C, Liu J, Zhang S, Zhang Q, Wang S, Cao Y, Zhao J. Risk Factors for Higher Volume of Hemorrhage in Ruptured Anterior Circulation Intracranial Aneurysms. Front Surg 2020; 7:587790. [PMID: 33282906 PMCID: PMC7688892 DOI: 10.3389/fsurg.2020.587790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 10/06/2020] [Indexed: 11/13/2022] Open
Abstract
Purpose: To explore the influencing factors of volume hemorrhage in ruptured anterior circulation aneurysms, so as to identify the characteristics of anterior circulation aneurysms with high volume of hemorrhage, and to provide advice for clinical diagnosis and treatment for those aneurysms. Methods: We retrospectively reviewed 437 cases of ruptured anterior intracranial aneurysms in our center between the years 2012 and 2017. According to the inclusion criteria, a total of 100 qualified patients were screened out. We collected demographic characteristics, environmental exposure, and admission status of enrolled patients. In addition, morphological parameters and location of aneurysms were also included. The semiautomatic threshold method was used to measure the volume of hemorrhage. According to the results, the patients were divided into the group with high blood volume and low blood volume. Univariate and multivariate logistic regression analyses were used to discover the related factors affecting the bleeding volume. Results: In univariable analysis, pulse pressure (P = 0.014) showed a significant difference at the P < 0.05 test level. In terms of aneurysm morphology, the irregular shape (P < 0.001), calcification (P = 0.001), and flow angle (P = 0.006) showed significant statistical differences between the two groups at the P < 0.01 level (P < 0.01). Multivariate logistic regression analysis showed that irregular shape (OR = 5.370 P = 0.002 < 0.05), large flow angle (OR = 1.033 P = 0.016 < 0.05), and calcification (OR = 5.460 P = 0.003 < 0.05) were risk factors for volume of hemorrhage in ruptured anterior circulation aneurysms. The influence of hypertension history was at critical state (OR = 2.877 P = 0.051 > 005). Conclusions: According to our analysis results, intracranial anterior circulation aneurysms with irregular shapes, calcifications, and large flow angle are more dangerous. Aneurysms with these characteristics often have a large amount of hemorrhage, requiring timely treatment in clinical practice.
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Affiliation(s)
- Xiaolong Ya
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Chaoqi Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jichao Liu
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qian Zhang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yong Cao
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jizong Zhao
- Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,National Clinical Research Center for Neurological Diseases, Beijing, China
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8
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Huhtakangas J, Lehecka M, Lehto H, Rezai Jahromi B, Niemelä M, Kivisaari R. Riskier-than-expected occlusive treatment of ruptured posterior communicating artery aneurysms: treatment and outcome of 620 consecutive patients. J Neurosurg 2019; 131:1269-1277. [PMID: 30485236 DOI: 10.3171/2018.4.jns18145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 04/05/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Occlusive treatment of posterior communicating artery (PCoA) aneurysms has been seen as a fairly uncomplicated procedure. The objective here was to determine the radiological and clinical outcome of patients after PCoA aneurysm rupture and treatment and to evaluate the risk factors for impaired outcome. METHODS In a retrospective clinical follow-up study, data were collected from 620 consecutive patients who had been treated for ruptured PCoA aneurysms at a single center between 1980 and 2014. The follow-up was a minimum of 1 year after treatment or until death. RESULTS Of the 620 patients, 83% were treated with microsurgical clipping, 8% with endovascular coiling, 2% with the two procedures combined, 1% with indirect surgical methods, and 6% with conservative methods. The most common procedural complications were treatment-related brain infarctions (15%). The occurrence of artery occlusions (10% microsurgical, 8% endovascular) was higher than expected. Most patients made a good recovery at 1 year after aneurysmal subarachnoid hemorrhage (modified Rankin Scale [mRS] score 0-2: 386 patients [62%]). A fairly small proportion of patients were left severely disabled (mRS score 4-5: 27 patients [4%]). Among all patients, 20% died during the 1st year. Independent risk factors for an unfavorable outcome, according to the multivariable analysis, were poor preoperative clinical condition, intracerebral or subdural hematoma due to aneurysm rupture, age over 65 years, artery occlusion on postoperative angiography, occlusive treatment-related ischemia, delayed cerebral vasospasm, and hydrocephalus requiring a shunt. CONCLUSIONS Even though most patients made a good recovery after PCoA aneurysm rupture and treatment during the 1st year, the occlusive treatment-related complications were higher than expected and caused morbidity even among initially good-grade patients. Occlusive treatment of ruptured PCoA aneurysms seems to be a high-risk procedure, even in a high-volume neurovascular center.
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Rothrock RJ, Li AY, Rumsey J, Fifi JT, Kellner CP, Roonprapunt C. Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature. World Neurosurg 2019; 128:240-247. [PMID: 31103768 DOI: 10.1016/j.wneu.2019.05.069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/08/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH. METHODS A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case. RESULTS Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH. CONCLUSION S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.
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Affiliation(s)
- Robert J Rothrock
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Adam Y Li
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Jamie Rumsey
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Chan Roonprapunt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Caton MT, Wiggins WF, Nuñez D. Non-traumatic subdural hemorrhage: beware of ruptured intracranial aneurysm. Emerg Radiol 2019; 26:567-571. [PMID: 31037589 DOI: 10.1007/s10140-019-01691-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/09/2019] [Indexed: 11/28/2022]
Abstract
Acute subdural hemorrhage (SDH) is commonly encountered by emergency radiologists in the setting of trauma. When history or imaging evidence of trauma is absent, the differential diagnosis for SDH should be expanded. Intracranial aneurysm rupture is a rare and underrecognized cause of SDH which may present without concurrent subarachnoid hemorrhage. The mechanism of aneurysmal SDH is controversial, but understanding the anatomic microenvironment of the aneurysm provides insight and clarifies aneurysm features predisposing to subdural compartment rupture. Aneurysmal SDH is a neurosurgical emergency and its treatment strategies differ from traumatic SDH. Outcomes are poor if treatment is delayed; thus, radiologists play a central role in recognizing this uncommon but potentially devastating complication of aneurysm rupture. The goal of this article is to familiarize radiologists with clinical and imaging characteristics of aneurysmal SDH and review pertinent anatomy, risk factors, and potential etiologies. Aneurysmal rupture can easily be overlooked in the routine workup of atraumatic SDH, and radiologists must know when to recommend vascular imaging to avoid the catastrophic consequences of a missed diagnosis.
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Affiliation(s)
- Michael Travis Caton
- Department of Radiology, Brigham and Women's Hospital, 15 Francis St, Boston, MA, 02115, USA.
| | - Walter F Wiggins
- Department of Radiology, Brigham and Women's Hospital, 15 Francis St, Boston, MA, 02115, USA
| | - Diego Nuñez
- Department of Radiology, Brigham and Women's Hospital, 15 Francis St, Boston, MA, 02115, USA
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Boukobza M, Duval X, Laissy JP. Mycotic intracranial aneurysms rupture presenting as pure acute subdural hematoma in infectious endocarditis. Report of 2 cases and review of the literature. J Clin Neurosci 2019; 62:222-225. [PMID: 30638783 DOI: 10.1016/j.jocn.2018.12.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/23/2018] [Indexed: 11/29/2022]
Abstract
Acute subdural hematoma (ASDH) revealing mycotic aneurysm (MA) is an exceptional occurrence. We report 2 cases of MA-related pure ASDH in the course of infective endocarditis (IE) without history of head trauma, hypertension or coagulopathy. Case 1: A 54-year-old man presented with a 10-day history of headache, fever. At admission neurologic examination and Brain-CT were normal. Blood cultures showed Streptococcus bovis. MRI 5 days later revealed ischemic spots and minime ASDH over the right convexity. Cerebral angiography, revealed a 3 mm saccular aneurysm at the bifurcation of a distal branch of the right posterior cerebral artery (PCA). Case 2: A 42-year-old man presented with a 8-day history of fever, and worsening headache. Mitral regurgitation was evidenced. A methicillin-sensitive staphylococcus aureus left-sided IE was diagnosed. Pre- and post-contrast Brain-CT were normal. He presented 15 days later a secondarily generalized status epilepticus. Brain CT showed an ASDH over the convexity with falco-tentorial extension, midline shift and temporal herniation. It was removed in emergency. Cerebral angiography revealed a MA of a peripheral branch of the left PCA. The 2 patients were successfully treated by endovascular glue embolization and recovered without complications. Even rare, ruptured MA should be considered as a cause of pure ASDH of unknown origin. As MA can be missed on CT- and MR-Angiography because of mass effect, cerebral angiography may be mandatory.
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Affiliation(s)
- Monique Boukobza
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat University Hospital, 46 rue Henri Huchard, 75018 Paris, France.
| | - Xavier Duval
- Department of Infectious Diseases, Assistance Publique-Hôpitaux de Paris, Bichat University Hospital, Paris, France; INSERM Clinical Investigation Center 007, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, France.
| | - Jean-Pierre Laissy
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat University Hospital, 46 rue Henri Huchard, 75018 Paris, France; INSERM U738, Paris, France; Université Paris Diderot, Sorbonne Paris Cité, France.
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12
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“Sentinel Seizure” as a Warning Sign Preceding Fatal Rupture of a Giant Middle Cerebral Artery Aneurysm. World Neurosurg 2017; 100:709.e11-709.e13. [DOI: 10.1016/j.wneu.2017.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 11/22/2022]
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13
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Ruptured berry aneurysm with minimal subarachnoid hemorrhage. J Forensic Leg Med 2017; 47:35-38. [DOI: 10.1016/j.jflm.2017.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 02/21/2017] [Accepted: 02/26/2017] [Indexed: 11/23/2022]
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14
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Torné R, Rodríguez-Hernández A, Romero-Chala F, Arikan F, Vilalta J, Sahuquillo J. Prognosis of patients in coma after acute subdural hematoma due to ruptured intracranial aneurysm. J Clin Neurosci 2016; 26:126-9. [DOI: 10.1016/j.jocn.2015.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 05/21/2015] [Accepted: 06/14/2015] [Indexed: 11/29/2022]
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15
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Song TW, Kim SH, Jung SH, Kim TS, Joo SP. Rupture of distal anterior cerebral artery aneurysm presenting only subdural hemorrhage without subarachnoid hemorrhage: a case report. SPRINGERPLUS 2016; 5:73. [PMID: 26844020 PMCID: PMC4726640 DOI: 10.1186/s40064-016-1727-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Accepted: 01/15/2016] [Indexed: 11/21/2022]
Abstract
Intracranial aneurysm rupture usually manifests with subarachnoid hemorrhage, often combined with intracerebral hemorrhage with intraventricular hemorrhage extension. In rare cases, however, these aneurysms present only as subdural hematomas. Recently, we treated a 48-years-old female patient who presented only with subdural hematoma. Interestingly, she did not have a history of trauma. Computed tomography angiography and digital subtraction angiography revealed a 5 × 3 mm sized aneurysm at the A3–A4 junction of the left anterior cerebral artery. On admission, emergency operation (clipping and hematoma evacuation) was performed to protect against re-bleeding. Along with postoperative intensive care, the patient returned to normal daily life with only a mild headache. Given that patients may present with atraumatic acute subdural hematoma, the clinician must bear in mind the possibility of intracranial vascular pathology and obtain angiographic scans to evaluate for any underlying conditions to prevent patient deaths.
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Affiliation(s)
- Tae-Wook Song
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Donggu, Gwangju, 501-757 Republic of Korea
| | - Sung-Hyun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Donggu, Gwangju, 501-757 Republic of Korea
| | - Seung-Hoon Jung
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Donggu, Gwangju, 501-757 Republic of Korea
| | - Tae-Sun Kim
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Donggu, Gwangju, 501-757 Republic of Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital and Medical School, 42, Jebong-ro, Donggu, Gwangju, 501-757 Republic of Korea
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Shepherd D, Kapurch J, Datar S, Lanzino G, Wijdicks EFM. Sphenoid and subdural hemorrhage as a presenting sign of ruptured clinoid aneurysm. Neurocrit Care 2015; 20:489-93. [PMID: 23893075 DOI: 10.1007/s12028-013-9866-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Aneurysm rupture presenting as an isolated or pure subdural hematoma (SDH) without subarachnoid hemorrhage is an extremely rare radiographic presentation. We present a case of a ruptured internal carotid artery aneurysm with a pure SDH and concurrent sphenoid sinus hemorrhage. METHODS Case report and review of the literature. RESULTS We describe a case of a 48-year-old right-handed woman found comatose brought by emergency medical services to an outside hospital. A non-contrast head CT scan demonstrated bilateral acute SDHs without evidence of intraparenchymal or subarachnoid hemorrhage. A CT angiogram of the head showed a focal hyperdensity in the distal left internal carotid artery (ICA) and was confirmed by conventional cerebral angiography to be a 7-mm left supraclinoid ICA aneurysm. On repeat CT scan a new hemorrhage was seen in the sphenoid sinus indicating a re-bleeding. The aneurysm was treated with coil embolization and complete occlusion was confirmed with subsequent angiograms. The patient had an eventful hospital course complicated by a Takotsubo cardiomyopathy and pulmonary edema. She was medically treated with successful recovery of her cardiopulmonary function. She remained markedly disabled and was transferred to an inpatient rehabilitation center for continued convalescence. CONCLUSIONS Acute subdural hematoma may be due to a ruptured clinoid carotid aneurysm. Acute hemorrhage into the sphenoid sinus can be an important clue.
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Affiliation(s)
- Daniel Shepherd
- Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA
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17
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Abstract
Spontaneous “pure acute subdural hematoma (SDH)” is arguably a rare condition. We report on a pregnant female patient presenting as spontaneous acute SDH without subarachnoid hemorrhage (SAH) due to rupture of distal (M5 segment) middle cerebral artery aneurysm. We hereby discuss the diagnostic dilemma of this rare condition, along with the need for watchful evaluation of acute SDH without preceding head injury presenting in emergency outpatient departments, especially when it is first encountered by a trainee resident.
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Affiliation(s)
- Navneet Singla
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
| | - Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
| | - Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, Punjab and Haryana, India
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18
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Acute Aneurismal Bilateral Subdural Haematoma without Subarachnoid Haemorrhage: A Case Report and Review of the Literature. Case Rep Neurol Med 2014; 2014:260853. [PMID: 25045554 PMCID: PMC4086224 DOI: 10.1155/2014/260853] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2014] [Revised: 05/17/2014] [Accepted: 05/19/2014] [Indexed: 11/17/2022] Open
Abstract
Spontaneous pure acute bilateral subdural haematoma (ASDH) without intraparenchymal or subarachnoid haemorrhage caused by a ruptured cerebral aneurysm is extremely rare. It can follow rupture of different aneurysms specially located in anterior incisural space; the most frequently encountered location is the PcoA aneurysms as demonstrated in the present case. We present a case report of a PcoA aneurysm presenting as pure bilateral ASDH. A high level of suspicion for bleeding of arterial origin should be maintained in all cases of acute subdural haematoma without history of trauma. The neurological status on admission dictates the appropriate timing and methodology of the neuroradiological investigations.
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19
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Germans MR, Macdonald RL. Is a sylvian fissure hematoma caused by leaking vessels? World Neurosurg 2013; 82:e689-91. [PMID: 24076213 DOI: 10.1016/j.wneu.2013.09.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Accepted: 09/23/2013] [Indexed: 11/17/2022]
Affiliation(s)
- Menno R Germans
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Toronto, Ontario, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada.
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20
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Schuss P, Konczalla J, Platz J, Vatter H, Seifert V, Güresir E. Aneurysm-related subarachnoid hemorrhage and acute subdural hematoma: single-center series and systematic review. J Neurosurg 2013; 118:984-90. [DOI: 10.3171/2012.11.jns121435] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Subarachnoid hemorrhage (SAH) with simultaneous acute subdural hematoma (SDH) is a severe disease. The authors' objective was to analyze the incidence, prognosis, and clinical outcome of patients suffering from aneurysm-related SAH and space-occupying acute SDH.
Methods
Between June 1999 and June 2011, data from 989 patients with aneurysm-related SAH were prospectively entered into a database. Eighteen patients (1.8%) presented with aneurysm-related SAH and space-occupying acute SDH. The treatment decision (clip or coil) was based on an interdisciplinary approach. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and was dichotomized into favorable outcome (mRS Score 0–2) versus unfavorable outcome (mRS Score 3–6). PubMed was searched for published studies of aneurysm-related SAH and acute SDH to gain a larger population. A multivariate regression analysis was performed on the pooled data.
Results
Literature data, including the current series, revealed a total of 111 patients. Overall, 38 (34%) of 111 patients with aneurysm-related SAH and acute SDH achieved favorable outcome. Favorable outcome was achieved in 68% of patients with good-grade clinical presentation on admission (Hunt and Hess Grades I–III) versus 23% of the patients with poor-grade presentation (Hunt and Hess Grades IV and V, p < 0.0001). In the multivariate analysis, poor clinical condition at admission was the only predictor for unfavorable outcome (p = 0.02).
Conclusions
The present data confirm that patients with aneurysm-related SAH and acute SDH, even when presenting in poor clinical condition, might achieve favorable outcome. Therefore, treatment of patients with SAH and acute SDH should not be discontinued, but careful individual decision making is necessary for each patient.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany.
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21
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Abstract
Presentation of a cerebral aneurysm can be incidental, discovered at imaging obtained for unrelated causes, can occur in the occasion of imaging obtained for symptoms possibly or likely related to the presence of an unruptured aneurysm, or can occur with signs and symptoms at the time of aneurismal rupture. Most unruptured intracranial aneurysms are thought to be asymptomatic, or present with vague or non-specific symptoms like headache or dizziness. Isolated oculomotor nerve palsies, however, may typically indicate the presence of a posterior circulation aneurysm. Ruptured intracranial aneurysms are by far the most common cause of non-traumatic subarachnoid hemorrhage and represent a neurological emergency with potentially devastating consequences. Subarachnoid hemorrhage may be easily suspected in the presence of sudden and severe headache, vomiting, meningism signs, and/or altered mental status. However, failure to recognize milder and more ambiguous clinical pictures may result in a delayed or missed diagnosis. In this paper we will describe the clinical spectrum of unruptured and ruptured intracranial aneurysms by discussing both typical and uncommon clinical features emerging from the literature review. We will additionally provide the reader with descriptions of the underlying pathophysiologic mechanisms, and main diagnostic pitfalls.
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