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See AP, Smith ER. Management of Pediatric Intracranial Arteriovenous Malformations. J Korean Neurosurg Soc 2024; 67:289-298. [PMID: 38433517 PMCID: PMC11079567 DOI: 10.3340/jkns.2024.0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/05/2024] Open
Abstract
Pediatric intracranial arteriovenous malformations (AVMs) are challenging lesions managed by pediatric neurosurgeons. The high risk of hemorrhage and neurologic injury is compounded by the unique anatomy of each malformation that requires individualizing treatment options. This article reviews the current status of pediatric AVM epidemiology, pathophysiology and clinical care, with a specific focus on the rationale and methodology of surgical resection.
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Affiliation(s)
- Alfred Pokmeng See
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R. Smith
- Department of Neurosurgery, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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2
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Lu G, Wang C, Zhao L, Shi H, Liu S. Clinical Outcomes of Diffuse Angiogram-Negative Subarachnoid Hemorrhage Versus Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched Analysis. J Am Heart Assoc 2024; 13:e031066. [PMID: 38156544 PMCID: PMC10863825 DOI: 10.1161/jaha.123.031066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 11/28/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND The outcome of diffuse angiogram-negative subarachnoid hemorrhage (dan-SAH) compared with aneurysmal SAH (aSAH) remains unclear. This study aimed to compare outcomes using propensity score matching. METHODS AND RESULTS Sixty-five patients with dan-SAH and 857 patients with aSAH admitted between January 2018 and December 2022 were retrospectively reviewed. Propensity score matching resulted in matching 65 patients with dan-SAH to 260 patients with aSAH, and clinical outcomes were compared between the groups. Compared with patients with dan-SAH, patients with aSAH were more likely to experience rehemorrhage (8.8% versus 0%, P=0.027), death (11.2% versus 1.5%; odds ratios [OR] 8.04 [95% CI, 1.07-60.12]; P=0.042), or delayed cerebral ischemia (12.3% versus 3.1%; OR, 4.42 [95% CI, 1.03-18.95]; P=0.045). Multivariate analysis revealed that Hunt-Hess grade 4 to 5 (OR, 3.13 [95% CI, 2.11-4.64]; P<0.001), presence of intraventricular hemorrhage (OR, 3.58 [95% CI, 1.72-7.46]; P=0.001), and smoking (OR, 2.44 [95% CI, 1.12-5.28]; P=0.024) were independently associated with the incidence of unfavorable outcomes (modified Rankin scale score >2 at 3 months), whereas dan-SAH was not (OR, 0.66 [95% CI, 0.25-1.73]; P=0.40). CONCLUSIONS Compared with patients with dan-SAH, patients with aSAH had higher rehemorrhage rates and in-hospital mortality, as well as a higher incidence of delayed cerebral ischemia. Unfavorable outcomes were associated with admission Hunt-Hess grade, the presence of intravenetricular hemorrhage, and smoking history, but there was no relation with the pathogenesis of the hemorrhage (dan-SAH versus aSAH).
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Affiliation(s)
- Guang‐Dong Lu
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Cheng Wang
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Lin‐Bo Zhao
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Hai‐Bin Shi
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
| | - Sheng Liu
- Department of Interventional RadiologyThe First Affiliated Hospital of Nanjing Medical UniversityNanjingJiangsuChina
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3
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Mandel D, Moody S, Pan K, Subramaniam T, Thompson BB, Wendell LC, Reznik ME, Furie KL, Mahta A. A quantitative model to differentiate nonaneurysmal perimesencephalic subarachnoid hemorrhage from aneurysmal etiology. J Neurosurg 2023; 138:165-172. [PMID: 35523263 DOI: 10.3171/2022.3.jns22157] [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: 01/20/2022] [Accepted: 03/21/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes. METHODS The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model. RESULTS Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98-1.00; OR per point increase 10; 95% CI 2.18-46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92-1.00) of this model. CONCLUSIONS A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.
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Affiliation(s)
- Daniel Mandel
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Scott Moody
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 2Department of Physician Assistant Studies, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts
| | - Kelly Pan
- 3Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Thanujaa Subramaniam
- 4Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Bradford B Thompson
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Linda C Wendell
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- 6Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael E Reznik
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
| | - Karen L Furie
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Ali Mahta
- 1Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- 5Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
- 6Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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4
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Baumgartner K, Meyer A, Mandel D, Moody S, Wendell L, Thompson BB, Subramaniam T, Reznik ME, Furie KL, Mahta A. Radiographic predictors of aneurysmal etiology in patients with aneurysmal pattern subarachnoid hemorrhage. J Neurosurg 2022:1-7. [PMID: 36727566 DOI: 10.3171/2022.11.jns222192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Spontaneous angiogram-negative nonperimesencephalic subarachnoid hemorrhage (an-NPSAH) can represent a diagnostic and management dilemma. The authors sought to determine radiographic predictors of aneurysmal etiology based on admission noncontrast head CT scans. METHODS The authors performed a retrospective cohort study of prospectively collected data from consecutive patients who were admitted for spontaneous subarachnoid hemorrhage (SAH) with suspected aneurysmal etiology to an academic center from 2016 to 2021. They compared blood thickness in the basal cisterns and sylvian fissures and modified Graeb scores on admission head CT scans between the two groups and subsequently developed a predictive model to identify aneurysmal etiology. RESULTS Of 259 included patients (mean age 56 years [SD 12.7 years]; 55% female), 209 had aneurysmal SAH (aSAH) and 50 had an-NPSAH. The median modified Graeb scores were similar for aSAH and an-NPSAH (6 [IQR 2-10] vs 3.5 [IQR 0-8.5], p = 0.33). The mean blood thickness was greater in the sylvian fissure (p = 0.010) and interhemispheric cisterns (p = 0.002), and there was a greater median degree of extension of blood in the sylvian fissures (p = 0.001) in aSAH than in an-NPSAH patients, but the mean blood thickness was less in the prepontine cistern (p = 0.014). The authors' scoring model was constructed based on differences in radiographic features. Receiver operating characteristic curve analysis showed acceptable accuracy in predicting aneurysmal etiology (area under the curve 0.71, 95% CI 0.62-0.79). CONCLUSIONS There are differences in radiographic features on admission head CT between an-NPSAH and aSAH patients. The authors' proposed risk stratification model may be considered for further development and use in clinical practice in the future. ABBREVIATIONS an-NPSAH = angiogram-negative nonperimesencephalic SAH; aSAH = aneurysmal SAH; DSA = digital subtraction angiography; LOS = length of stay; NCHCT = noncontrast head CT; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage.
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Affiliation(s)
| | | | | | | | - Linda Wendell
- Division of Neurology, Mount Auburn Hospital, Cambridge, Massachusetts; and
| | - Bradford B. Thompson
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Thanujaa Subramaniam
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Michael E. Reznik
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Ali Mahta
- Departments of Neurology and
- Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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5
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Bacigaluppi S, Bragazzi NL, Ivaldi F, Benvenuto F, Uccelli A, Zona G. Systemic Inflammatory Response in Spontaneous Subarachnoid Hemorrhage from Aneurysmal Rupture versus Subarachnoid Hemorrhage of Unknown Origin. J Inflamm Res 2022; 15:6329-6342. [PMID: 36415221 PMCID: PMC9676007 DOI: 10.2147/jir.s380101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/26/2022] [Indexed: 09/09/2023] Open
Abstract
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.
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Affiliation(s)
- Susanna Bacigaluppi
- DINOGMI, University of Genoa, Genoa, Italy
- Department of Neurosurgery and Neurotraumatology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosurgery, E.O. Ospedali Galliera, Genoa, Italy
| | | | | | | | - Antonio Uccelli
- DINOGMI, University of Genoa, Genoa, Italy
- Department of Neurology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Gianluigi Zona
- DINOGMI, University of Genoa, Genoa, Italy
- Department of Neurosurgery and Neurotraumatology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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6
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Long-term outcomes of ruptured saccular intracranial aneurysm clipping versus coiling: systematic review and meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:4909-4915. [DOI: 10.1007/s10072-022-06039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
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7
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Akbik F, Pimentel-Farias C, Press DA, Foster NE, Luu K, Williams MG, Andea SG, Kyei RK, Wetsel GM, Grossberg JA, Howard BM, Tong F, Cawley CM, Samuels OB, Sadan O. Diffuse Angiogram-Negative Subarachnoid Hemorrhage is Associated with an Intermediate Clinical Course. Neurocrit Care 2021; 36:1002-1010. [PMID: 34932193 DOI: 10.1007/s12028-021-01413-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype. METHODS We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared. RESULTS Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6 months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016). CONCLUSIONS We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise.
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Affiliation(s)
- Feras Akbik
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA. .,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.
| | - Cederic Pimentel-Farias
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Di'Jonai A Press
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Niara E Foster
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Kevin Luu
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Merin G Williams
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Sena G Andea
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Regina K Kyei
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Grace M Wetsel
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Brian M Howard
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Frank Tong
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - C Michael Cawley
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Owen B Samuels
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Ofer Sadan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
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8
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Ahmed SH, Haris M, Baseer N, Saleema A, Haris S, Deeba F, Khan MJ. Surgical Anatomy and Prevalence of Intracranial Aneurysms in Patients With Spontaneous Subarachnoid Hemorrhage. Cureus 2021; 13:e20463. [PMID: 35070527 PMCID: PMC8760894 DOI: 10.7759/cureus.20463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2021] [Indexed: 11/05/2022] Open
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9
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Vincent A, Pearson S, Pickering JW, Weaver J, Toney L, Hamill L, Hurrell M, Than M. Sensitivity of modern multislice CT for subarachnoid haemorrhage at incremental timepoints after headache onset: a 10-year analysis. Emerg Med J 2021; 39:810-817. [PMID: 34819306 DOI: 10.1136/emermed-2020-211068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 11/02/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND CT performed within 6 hours of headache onset is highly sensitive for the detection of subarachnoid haemorrhage (SAH). Beyond this time frame, if the CT is negative for blood, a lumbar puncture is often performed. Technology improvements in image noise reduction, resolution and motion artefact have enhanced the performance of multislice CT (MSCT) and may have further improved sensitivity. We aimed to describe how the sensitivity to SAH of modern MSCT changes with time from headache onset. METHODS This was a retrospective analysis of electronic data collected as part of routine care among all patients presenting to Christchurch Hospital diagnosed with a SAH between 1 January 2008 and 31 December 2017. Patients were imaged with MSCT. The primary outcome was the proportion of patients with spontaneous aneurysmal SAH (identified via coding and confirmed by clinical and radiological records) that had a positive MSCT. The secondary outcome was the proportion of patients with any type of spontaneous SAH that had a positive MSCT. RESULTS There were 347 patients with an SAH of whom 260 were aneurysmal SAH. MSCT identified 253 (97.3%) of all aneurysmal SAH and 332 (95.7%) of all SAH. The sensitivity of MSCT was 99.6% (95% CI 97.6 to 100) for aneurysmal SAH and 99.0% (95% CI 97.1 to 99.8) for all SAH at 48 hours after headache onset. At 24 hours after headache onset, the sensitivity for aneurysmal SAH was 100% (95% CI 98.3 to 100). CONCLUSION These data suggest that it may be possible to extend the timeframe from headache onset within which modern MSCT can be used to rule out aneurysmal SAH.
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Affiliation(s)
- Annabel Vincent
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Scott Pearson
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - John W Pickering
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand.,Department of Medicine, University of Otago Christchurch, Christchurch, New Zealand
| | - James Weaver
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Leanne Toney
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Laura Hamill
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Michael Hurrell
- Christchurch Hospital Radiology Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
| | - Martin Than
- Christchurch Hospital Emergency Department, Canterbury District Health Board, Christchurch, Canterbury, New Zealand
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10
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Baseline characteristics and outcome for aneurysmal versus non-aneurysmal subarachnoid hemorrhage: a prospective cohort study. Neurosurg Rev 2021; 45:1413-1420. [PMID: 34604940 PMCID: PMC8976787 DOI: 10.1007/s10143-021-01650-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 07/24/2021] [Accepted: 09/20/2021] [Indexed: 12/25/2022]
Abstract
This study aims to investigate the characteristics of patients with mild aneurysmal and non-aneurysmal perimesencephalic and non-perimesencephalic subarachnoid hemorrhage (aSAH, pmSAH, npmSAH) with emphasis on admission biomarkers, clinical course, and outcome. A prospective cohort of 115 patients with aSAH (Hunt and Hess 1–3) and of 35 patients without aneurysms (16 pmSAH and 19 npmSAH) admitted between January 2014 and January 2020 was included. Demographic data, blood samples on admission, complications (hydrocephalus, shunt dependency, delayed cerebral ischemia DCI, DCI-related infarction, and mortality), and outcome after 6 months were analyzed. Demographic data was comparable between all groups except for age (aSAH 55 [48–65] vs. npmSAH 60 [56–68] vs. pmSAH 52 [42–60], p = 0.032) and loss of consciousness (33% vs. 0% vs. 0%, p = 0.0004). Admission biomarkers showed poorer renal function and highest glucose levels for npmSAH patients. Complication rate in npmSAH was high and comparable to that of aSAH patients (hydrocephalus, shunt dependency, DCI, DCI-related infarction, mortality), but nearly absent in patients with pmSAH. Favorable outcome after 6 months was seen in 92.9% of pmSAH, 83.3% of npmSAH, and 62.7% of aSAH (p = 0.0264). In this prospective cohort of SAH patients, npmSAH was associated with a complicated clinical course, comparable to that of patients with aSAH. In contrast, such complications were nearly absent in pmSAH patients, suggesting fundamental differences in the pathophysiology of patients with different types of non-aneurysmal hemorrhage. Our findings underline the importance for a precise terminology according the hemorrhage etiology as a basis for more vigilant management of npmSAH patients. NCT02142166, 05/20/2014, retrospectively registered.
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11
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Jung HN, Suh SI, Ryoo I, Kim I. Usefulness of 3D High-resolution Vessel Wall MRI in Diffuse Nonaneurysmal SAH Patients. Clin Neuroradiol 2021; 31:1071-1081. [PMID: 33974086 DOI: 10.1007/s00062-021-01018-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 04/11/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE In 15-20% of patients with nontraumatic diffuse subarachnoid hemorrhage (SAH), the initial conventional angiography does not reveal a causative vascular abnormality, such as intracranial aneurysm. In this study, we evaluated clinical utility of 3D high-resolution vessel wall magnetic resonance imaging (HR-VWI) in patients with diffuse nonaneurysmal SAH. METHODS A total of 17 patients with diffuse nonaneurysmal SAH were included in this retrospective study. We characterized demographics and HR-VWI findings and reviewed the clinical management and outcomes. RESULTS Of the patients 14 (14/17; 82.4%,) showed abnormal findings on HR-VWI, including 5 with intracranial dissections (29.4%), 3 with blood blister-like aneurysm (17.6%), 1 with ruptured fusiform aneurysm (5.9%), and 5 with focal nodular wall enhancement without unclassified pathology (29.4%). Of these patients were treated with endovascular management. Most patients (16/17) had a favorable modified Rankin scale scores of 0-2 on discharge. CONCLUSION The 3D HR-VWI revealed various hidden pathologies, such as intracranial arterial dissection, blood blister-like aneurysm, and fusiform aneurysm in patients with diffuse nonaneurysmal SAH. In addition, 3D HR-VWI had an impact on the management of SAH. The 3D HR-VWI can be a complementary diagnostic method for patients with diffuse nonaneurysmal SAH in a research or clinical setting.
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Affiliation(s)
- Hye Na Jung
- Department of Radiology, Guro Hospital, Korea University College of Medicine, 148 Guro-dong, 08308, Guro-gu, Seoul, Korea (Republic of)
| | - Sang-Il Suh
- Department of Radiology, Guro Hospital, Korea University College of Medicine, 148 Guro-dong, 08308, Guro-gu, Seoul, Korea (Republic of).
| | - Inseon Ryoo
- Department of Radiology, Guro Hospital, Korea University College of Medicine, 148 Guro-dong, 08308, Guro-gu, Seoul, Korea (Republic of)
| | - InSeong Kim
- Siemens Healthineers Ltd., Seoul, Korea (Republic of)
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Goda R, Ganeshkumar A, Gurjar H, Agrawal D, Katiyar V, Sharma R. Predictive factors and timelines of rebleeding in aneurysmal SAH: what have we gleaned? Acta Neurochir (Wien) 2021; 163:1479-1480. [PMID: 33740135 DOI: 10.1007/s00701-021-04772-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 02/16/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Revanth Goda
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Akshay Ganeshkumar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Hitesh Gurjar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India.
| | - Deepak Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Varidh Katiyar
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
| | - Ravi Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Perfil clínico y evolución de pacientes con hemorragia subaracnoidea durante 11 años. Neurocirugia (Astur) 2021; 32:10-20. [DOI: 10.1016/j.neucir.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 12/06/2019] [Accepted: 03/23/2020] [Indexed: 11/20/2022]
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14
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Kole MJ, Shea P, Albrecht JS, Cannarsa GJ, Wessell AP, Miller TR, Jindal G, Gandhi D, Aldrich EF, Simard JM. Utility of the Hijdra Sum Score in Predicting Risk of Aneurysm in Patients With Subarachnoid Hemorrhage: A Single-Center Experience With 550 Patients. Neurosurgery 2020; 86:783-791. [PMID: 31501896 DOI: 10.1093/neuros/nyz346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 06/13/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is most commonly caused by a ruptured vascular lesion. A significant number of patients presenting with SAH have no identifiable cause despite extensive cerebrovascular imaging at presentation. Significant neurological morbidity or mortality can result from misdiagnosis of aneurysm. OBJECTIVE To generate a model to assist in predicting the risk of aneurysm in this patient population. METHODS We conducted a retrospective study of all patients aged ≥18 yr admitted to a single center from March 2008 to March 2018 with nontraumatic SAH (n = 550). Patient information was compared between those with and without aneurysm to identify potential predictors. Odds ratios obtained from a logistic regression model were converted into scores which were summed and tested for predictive ability. RESULTS Female sex, higher modified Fisher or Hijdra score, nonperimesencephalic location, presence of intracerebral hemorrhage, World Federation of Neurosurgical Societies (WFNS) score ≥3, need for cerebrospinal fluid diversion on admission, and history of tobacco use were all entered into multivariable analysis. Greater modified Fisher, greater Hijdra score, WFNS ≥3, and hydrocephalus present on admission were significantly associated with the presence of an aneurysm. A model based on the Hijdra score and SAH location was generated and validated. CONCLUSION We show for the first time that the Hijdra score, in addition to other factors, may assist in identifying patients at risk for aneurysm on cerebrovascular imaging. A simple scoring tool based on patient sex, SAH location, and SAH burden can assist in predicting the presence of an aneurysm in patients with nontraumatic SAH.
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Affiliation(s)
- Matthew J Kole
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Phelan Shea
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Jennifer S Albrecht
- Department of Epidemiology and Public Health, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Gregory J Cannarsa
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Aaron P Wessell
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Timothy R Miller
- Department of Diagnostic Radiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Gaurav Jindal
- Department of Diagnostic Radiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Dheeraj Gandhi
- Department of Diagnostic Radiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - E Francois Aldrich
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland
| | - J Marc Simard
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, Maryland
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Menon G. Angionegative Subarachnoid Hemorrhage: Need for Consensus Guidelines. J Neurosci Rural Pract 2020; 11:517-518. [PMID: 33144784 PMCID: PMC7595779 DOI: 10.1055/s-0040-1715082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Girish Menon
- Department of Neurosurgery, Kasturba Medical College, Manipal, India
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McIntyre MK, Gandhi C, Dragonette J, Schmidt M, Cole C, Santarelli J, Lehrer R, Al-Mufti F, Bowers CA. A comparison of frailty indices in predicting length of inpatient stay and discharge destination following angiogram-negative subarachnoid hemorrhage. Br J Neurosurg 2020; 35:402-407. [PMID: 32586162 DOI: 10.1080/02688697.2020.1781056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE While patients with angiogram-negative subarachnoid hemorrhages (ANSAH) have better prognoses than those with aneurysmal SAH, frailty's impact on outcomes in ANSAH is unclear. We previously showed that the modified frailty index (mFI-11) is associated with poor outcomes following ANSAH. Here, we compared the mFI-5, mFI-11, Charlson Comorbidity Index (CCI), and temporalis thickness (TMT) to determine which index was the best predictor of ANSAH outcomes and mortality rates. METHODS In this retrospective cohort analysis between 2014 and 2018, patients with non-traumatic, angiogram negative SAH (ANSAH) were identified. The admission mFI-5, mFI-11, CCI, and TMT were calculated for each patient. Primary outcomes were mortality rate, discharge location, and prolonged length of stay (PLOS; LOS >85th percentile). Multivariate logistic regression and receiver operating characteristic (ROC) curves were used to evaluate frailty as predictors of primary endpoints. RESULTS We included 75 patients with a mean age of 55.4 ± 1.5 years. There were 4 patient deaths (5.3%), 53 patients (70.7%) discharged home, and 11 patients (14.7%) with PLOS. On ROC analysis, the mFI-5 had the highest discriminatory value for mortality (AUC = 0.97) while the mFI-11 was most discriminatory for discharge home (AUC = 0.85) and PLOS (AUC = 0.78). On multivariate analysis, the only independent predictor of mortality was the mFI-11 (OR = 0.46; 95%CI: 1.45-14.23; p = 0.009) while the mFI-5 was the best predictor of discharge home (OR = 0.21; 95% CI: 0.08-0.61; p = 0.004). On multivariate analysis, the only independent predictor of PLOS was the Hunt and Hess score (OR = 2.63; 95%CI: 1.38-5.00; p = 0.003). The CCI and TMT were inferior to either mFI for predicting primary endpoints. CONCLUSIONS Increasing frailty is associated with poorer outcomes and higher mortality following ANSAH. The mFI-5 and mFI-11 were found to be superior predictors of discharge home and mortality rate. While larger prospective study is needed, frailty, as measured by mFI-11 and -5, should be considered when evaluating ANSAH prognosis.
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Affiliation(s)
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | | | - Meic Schmidt
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.,Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Rachel Lehrer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.,Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
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Neuroimaging of Pediatric Intracerebral Hemorrhage. J Clin Med 2020; 9:jcm9051518. [PMID: 32443470 PMCID: PMC7290500 DOI: 10.3390/jcm9051518] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/08/2020] [Accepted: 05/12/2020] [Indexed: 01/20/2023] Open
Abstract
Hemorrhagic strokes account for half of all strokes seen in children, and the etiologies of these hemorrhagic strokes differ greatly from those seen in adult patients. This review gives an overview about incidence and etiologies as well as presentation of children with intracerebral hemorrhage and with differential diagnoses in the emergency department. Most importantly it describes how neuroimaging of children with intracerebral hemorrhage should be tailored to specific situations and clinical contexts and recommends specific imaging protocols for acute and repeat imaging. In this context it is important to keep in mind the high prevalence of underlying vascular lesions and adapt the imaging protocol accordingly, meaning that vascular imaging plays a key role regardless of modality. Magnetic resonance imaging (MRI), including advanced sequences, should be favored whenever possible at the acute phase.
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Yokosuka J, Fukaya S, Yamomoto S, Ueki K, Kim P. Intracranial subarachnoid hemorrhage caused by an aneurysm at the thoracic spinal region: case report and literature review. Br J Neurosurg 2019; 34:672-676. [PMID: 31747814 DOI: 10.1080/02688697.2019.1690130] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The most common cause of intracranial subarachnoid hemorrhage (SAH) is an intracranial aneurysm or other vascular lesion; however, spinal lesions have also been implicated. Furthermore, vascular lesions rarely occur in the thoracolumbar region. We herein presented a case of intracranial SAH caused by an isolated aneurysm in the thoracic spinal artery.Case presentation: A 79-year-old woman developed the sudden onset of headaches in the parietal and occipital regions followed by vomiting. Head computed tomography (CT) scans showed SAH in the basal cistern and around the parietal lobe cortex. Cerebral angiography detected no aneurysm or vascular malformation. Spinal CT on day 1 showed extensive SAH at the posterior surface of the spinal cord, which was the most prominent at the level of T9/10, and spinal angiography subsequently revealed an aneurysm fed by the T10 radicular artery. The aneurysm was resected by T8-10 laminectomy, and the patient recovered with no long-term neurological deficit.Conclusions: A literature review revealed 17 cases of intracranial SAH from thoracolumbar vascular lesions. Most cases resulted in poor functional outcomes, which occurred in the later phase of the disease and may have been avoided with earlier diagnoses and interventions. We suggest whole spine CT as a useful tool for rapid screening of this rare lesion, and is recommended when an initial survey for intracranial lesions does not detect any likely lesions. Furthermore, ventricular reflux on head CT may lead to an accurate diagnosis in the absence of spinal symptoms.
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Affiliation(s)
- Junichi Yokosuka
- Department of Neurosurgery, Dokkyo Medical University, Mibu, Japan
| | - Shunsuke Fukaya
- Department of Neurosurgery, Dokkyo Medical University, Mibu, Japan
| | - Shinji Yamomoto
- Department of Neurosurgery, Dokkyo Medical University, Mibu, Japan
| | - Keisuke Ueki
- Department of Neurosurgery, Dokkyo Medical University, Mibu, Japan
| | - Phyo Kim
- Department of Neurosurgery, Dokkyo Medical University, Mibu, Japan
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Sadigh G, Menon RK, Bhojak M, Aladi A, Mossa-Basha M, Wu L, Lehman VT, Brinjikji W, Dehkharghani S, Derakhshani A, Mossa-Basha F, Allen JW. Radiological Management of Angiographically Negative, Spontaneous Intracranial Subarachnoid Hemorrhage: A Multicenter Study of Utilization and Diagnostic Yield. Neurosurgery 2019; 85:126-133. [DOI: 10.1093/neuros/nyy225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/30/2018] [Indexed: 01/04/2023] Open
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20
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Waweru P, Gatimu SM. Mortality and functional outcomes after a spontaneous subarachnoid haemorrhage: A retrospective multicentre cross-sectional study in Kenya. PLoS One 2019; 14:e0217832. [PMID: 31188844 PMCID: PMC6561561 DOI: 10.1371/journal.pone.0217832] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/20/2019] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Despite a reduction in poor outcomes in recent decades, spontaneous subarachnoid haemorrhage (SAH) remains associated with severe disability and high mortality rates. The exact extent of these outcomes is however unknown in Africa. This study aimed to determine the mortality and functional outcomes of patients with SAH in Kenya. METHODS We conducted a retrospective multicentre cross-sectional study involving patients admitted with SAH to three referral hospitals in Nairobi. All patients with a confirmed (primary) discharge diagnosis of first-time SAH between January 2009 and November 2017 were included (n = 158). Patients who had prior head trauma or cerebrovascular disease (n = 53) were excluded. Telephone interviews were conducted with surviving patients or their next of kin to assess out-of-hospital outcomes (including functional outcomes) based on modified Rankin Scale (mRS) scores. Chi-square and Fisher's exact tests were used to assess associations between mortality and functional outcomes and sample characteristics. RESULTS Of the 158 patients sampled, 38 (24.1%) died in hospital and 42 (26.6%) died within 1 month. In total, 87 patients were discharged home and followed-up in this study, of which 72 reported favourable functional outcomes (mRS ≤2). This represented 45.6% of all patients who presented alive, pointing to high numbers of unfavourable outcomes post SAH in Kenya. CONCLUSIONS Mortality following SAH remains high in Kenya. Patients who survive the initial ictus tend to do well after treatment, despite resource constraints. LIMITATIONS The study findings should be interpreted with caution because of unavoidable limitations in the primary data. These include its retrospective nature, the high number of patients lost to follow up, missing records and diagnoses, and/or possible miscoding of cases.
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Affiliation(s)
- Peter Waweru
- Neurosurgery Department, M.P Shah Hospital, Nairobi, Kenya
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21
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Nesvick CL, Oushy S, Rinaldo L, Wijdicks EF, Lanzino G, Rabinstein AA. Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage. Neurology 2019; 92:e2385-e2394. [PMID: 30996058 DOI: 10.1212/wnl.0000000000007501] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/19/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To define the in-hospital course, complications, short- and long-term functional outcomes of patients with angiographically negative subarachnoid hemorrhage (anSAH), particularly those with aneurysmal-pattern anSAH (aanSAH). METHODS Retrospective cohort study of patients with aneurysmal subarachnoid hemorrhage (aSAH), aanSAH, and perimesencephalic-pattern anSAH (panSAH) treated at a single tertiary referral center between January 2006 and April 2018. Ninety-nine patients with anSAH (33 aanSAH and 66 panSAH) and 464 patients with aSAH were included in this study. Outcomes included symptomatic hydrocephalus requiring CSF drainage, need for ventriculoperitoneal shunt, radiographic vasospasm, delayed cerebral ischemia (DCI), radiographic infarction, disability level within 1 year of ictus, and at last clinical follow-up as defined by the modified Rankin Scale. RESULTS Patients with aanSAH and panSAH had similar rates of DCI and radiologic infarction, and patients with aanSAH had significantly lower rates compared to aSAH (p ≤ 0.018). Patients with aanSAH were more likely than those with panSAH to require temporary CSF diversion and ventriculoperitoneal shunt (p ≤ 0.03), with similar rates to those seen in aSAH. Only one patient with anSAH died in the hospital. Compared to those with aSAH, patients with aanSAH were significantly less likely to have a poor functional outcome within 1 year of ictus (odds ratio 0.26, 95% confidence interval 0.090-0.75) and at last follow-up (hazard ratio 0.30, 95% confidence interval 0.19-0.49, p = 0.002). CONCLUSIONS DCI is very uncommon in anSAH, but patients with aanSAH have a similar need for short- and long-term CSF diversion to patients with aSAH. Nevertheless, patients with aanSAH have significantly better short- and long-term outcomes.
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Affiliation(s)
- Cody L Nesvick
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Soliman Oushy
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Lorenzo Rinaldo
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Eelco F Wijdicks
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Giuseppe Lanzino
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN
| | - Alejandro A Rabinstein
- From the Departments of Neurological Surgery (C.L.N., S.O., L.R., G.L.) and Neurology (E.F.W., A.A.R.), Mayo Clinic, Rochester, MN.
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Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke 2019; 50:e51-e96. [DOI: 10.1161/str.0000000000000183] [Citation(s) in RCA: 240] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Elevated C-reactive protein and white blood cell count at admission predict functional outcome after non-aneurysmal subarachnoid hemorrhage. J Neurol 2018; 265:2944-2948. [PMID: 30317466 DOI: 10.1007/s00415-018-9091-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 10/08/2018] [Accepted: 10/10/2018] [Indexed: 12/30/2022]
Abstract
INTRODUCTION Patients with non-aneurysmal subarachnoid hemorrhage (SAH) are considered to have an overall benign course of disease compared to patients suffering from aneurysmal SAH. Nevertheless, a small but significant number of such patients might only achieve unfavorable outcome. Therefore, the purpose of the present study was to determine if routine laboratory markers of acute phase response are associated with unfavorable outcome in patients with non-aneurysmal SAH. METHODS From 2006 to 2017, 154 patients suffering from non-aneurysmal SAH were admitted to our institution. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). C-reactive protein (CRP) and white blood cells (WBC) assessments were performed within 24 h of admission as part of routine laboratory workup. Outcome was assessed according to the modified Rankin Scale (mRS) after 6 months and stratified into favorable (mRS 0-2) vs. unfavorable (mRS 3-6). RESULTS The multivariate regression analysis revealed "CRP > 5 mg/l" (p = 0.004, OR 143.7), "WBC count > 12.1 G/l" (p = 0.006, OR 47.8), "presence of IVH" (p = 0.02, OR 13.5), "poor-grade SAH" (p = 0.01, OR 45.2) and "presence of CVS" (p = 0.003, OR 149.9) as independently associated with unfavorable outcome in patients with non-aneurysmal SAH. CONCLUSION Elevated C-reactive protein and WBC count at admission were associated with unfavorable outcome after non-aneurysmal SAH.
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Bruder M, Kashefiolasl S, Keil F, Brawanski N, Won SY, Seifert V, Konczalla J. Pain medication at ictus of subarachnoid hemorrhage—the influence of one-time acetylsalicylic acid usage on bleeding pattern, treatment course, and outcome: a matched pair analysis. Neurosurg Rev 2018; 42:531-537. [DOI: 10.1007/s10143-018-1000-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/12/2018] [Accepted: 06/18/2018] [Indexed: 10/28/2022]
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Chen CJ, Turnage C, Sokolowski JD, Kumar JS, Kalani MY, Park MS. Dangers of outpatient nimodipine use after spontaneous subarachnoid hemorrhage in accordance with the Comprehensive Stroke Center guidelines. J Clin Neurosci 2018; 52:151-152. [DOI: 10.1016/j.jocn.2018.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/12/2018] [Accepted: 04/02/2018] [Indexed: 11/30/2022]
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Lee SU, Hong EP, Kim BJ, Kim SE, Jeon JP. Delayed Cerebral Ischemia and Vasospasm After Spontaneous Angiogram-Negative Subarachnoid Hemorrhage: An Updated Meta-Analysis. World Neurosurg 2018; 115:e558-e569. [PMID: 29689403 DOI: 10.1016/j.wneu.2018.04.096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 04/12/2018] [Accepted: 04/13/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To report clinical outcomes of delayed cerebral ischemia (DCI) and vasospasm in angiogram-negative subarachnoid hemorrhage (SAH) according to hemorrhage patterns, perimesencephalic hemorrhage (PMH) and non-PMH. METHODS Online databases from January 1990 to December 2017 were systematically reviewed. A fixed-effects model was used to control heterogeneity. To resolve publication bias, the trim and fill method was used to estimate number of missing studies and adjusted odds ratio (OR). Subgroup analysis of data from studies that defined angiogram-negative subarachnoid hemorrhage by angiography repeated at least twice or computed tomography angiography was performed. RESULTS Among 24 studies including 2083 patients, 23/985 patients (2.3%) with PMH and 144/1098 patients (13.1%) with non-PMH had DCI, indicating that patients with PMH experienced significantly lower DCI than patients with non-PMH (OR = 0.219; 95% confidence interval [CI], 0.144-0.334). Regarding vasospasm, 99/773 patients (12.8%) with PMH and 231/922 patients (25.1%) with non-PMH exhibited vasospasm, indicating that patients with PMH experienced significantly lower vasospasm than patients with non-PMH (OR = 0.445; 95% CI, 0.337-0.589). Funnel plots show asymmetry indicating possible publication bias. After trimming 10 studies for DCI and 7 for vasospasm, the adjusted ORs remained significant between PMH and lower risks of DCI and vasospasm. Subgroup analysis of 789 patients in 8 studies showed a lower risk of DCI (OR = 0.268; 95% CI, 0.151-0.473) and vasospasm (OR = 0.346; 95% CI, 0.221-0.538) in patients with PMH. CONCLUSIONS PMH showed a significantly lower risk of DCI and vasospasm than non-PMH. Clinical outcomes of angiogram-negative subarachnoid hemorrhage, based on meta-analysis of individual patient data, need to be investigated.
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Affiliation(s)
- Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul, Korea
| | - Eun Pyo Hong
- Department of Medical Genetics, Hallym University College of Medicine, Chuncheon, Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea
| | - Sung-Eun Kim
- Department of Emergency Medicine, Seoul Emergency Operations Center, Seoul, Korea
| | - Jin Pyeong Jeon
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, Korea; Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Korea.
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Schuss P, Hadjiathanasiou A, Brandecker S, Wispel C, Borger V, Güresir Á, Vatter H, Güresir E. Risk factors for shunt dependency in patients suffering from spontaneous, non-aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2018; 42:139-145. [PMID: 29594703 DOI: 10.1007/s10143-018-0970-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 03/14/2018] [Accepted: 03/20/2018] [Indexed: 10/17/2022]
Abstract
Patients presenting with spontaneous, non-aneurysmal subarachnoid hemorrhage (SAH) achieve better outcomes compared to patients with aneurysmal SAH. Nevertheless, some patients develop shunt-dependent hydrocephalus during treatment course. We therefore analyzed our neurovascular database to identify factors determining shunt dependency after non-aneurysmal SAH. From 2006 to 2016, 131 patients suffering from spontaneous, non-aneurysmal SAH were admitted to our department. Patients were stratified according to the distribution of cisternal blood into patients with perimesencephalic SAH (pSAH) versus non-perimesencephalic SAH (npSAH). Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months and stratified into favorable (mRS 0-2) versus unfavorable (mRS 3-6). A multivariate analysis was performed to identify predictors of shunt dependency in patients suffering from non-aneurysmal SAH. Overall, 18 of 131 patients suffering from non-aneurysmal SAH developed shunt dependency (14%). In detail, patients with npSAH developed significantly more often shunt dependency during treatment course, when compared to patients with pSAH (p = 0.02). Furthermore, patients with acute hydrocephalus, presence of intraventricular hemorrhage, presence of clinical vasospasm, and anticoagulation medication prior SAH developed significantly more often shunt dependency, when compared to patients without (p < 0.0001). However, "acute hydrocephalus" was the only significant and independent predictor for shunt dependency in all patients with non-aneurysmal SAH in the multivariate analysis (p < 0.0001). The present study identified acute hydrocephalus with the necessity of CSF diversion as significant and independent risk factor for the development of shunt dependency during treatment course in patients suffering from non-aneurysmal SAH.
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Affiliation(s)
- Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.
| | - Alexis Hadjiathanasiou
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Christian Wispel
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Valeri Borger
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Ági Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
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Chong MY, Martin SC, Phang I, St George E, Suttner N, Teo MK. The Prevalence of Cerebrovascular Abnormalities Detected in Various Diagnostic Subgroups of Spontaneous Subarachnoid Hemorrhage in the Modern Era. World Neurosurg 2018; 111:e355-e361. [DOI: 10.1016/j.wneu.2017.12.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 12/10/2017] [Accepted: 12/11/2017] [Indexed: 11/24/2022]
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Han MH, Kim J, Choi KS, Kim CH, Kim JM, Cheong JH, Yi HJ, Lee SH. Monthly variations in aneurysmal subarachnoid hemorrhage incidence and mortality: Correlation with weather and pollution. PLoS One 2017; 12:e0186973. [PMID: 29073210 PMCID: PMC5658131 DOI: 10.1371/journal.pone.0186973] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 10/11/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE Although the effect of weather and air pollution on the occurrence of subarachnoid hemorrhage (SAH) has been investigated, results have remained inconsistent. The present study aimed to determine the seasonality of aneurysmal subarachnoid hemorrhage occurrence and mortality. METHODS We used the National Inpatient Sample database to evaluate the effect of meteorological factors and air pollutants on patients with subarachnoid hemorrhage in Korea between 2011 and 2014. Monthly variations in SAH occurrence and mortality were analyzed using locally weighted scatter plot smoothing curves. Multivariate Poisson generalized linear regression models were used to evaluate potential independent meteorological and pollutant variables associated with SAH occurrence and mortality. RESULTS In total, 21,407 patients who underwent clip or coil treatment owing to aneurysmal SAH in Korea from January 1, 2011, to December 31, 2014, were included. The crude incidence rate of SAH in Korea was 10.5 per 100,000 people per year. An approximately 0.5% lower risk of SAH was observed per 1°C increase in mean monthly temperature (relative risk, 0.995; 95% confidence interval [CI], 0.992-0.997; p < 0.001), while an approximately 2.3% higher risk of SAH was observed per 1°C increase in mean monthly diurnal temperature. CONCLUSIONS We showed distinct patterns of seasonal and monthly variation in the occurrence and mortality of SAH. Our findings suggest that meteorological factors may play an important role in monthly variations in the occurrence of aneurysmal SAH.
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Affiliation(s)
- Myung-Hoon Han
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyeongchun-ro, Guri, Gyonggi-do, Korea
| | - Jinhee Kim
- Department of Nursing, College of Medicine, Chosun University, Gwangju, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Wangsimni-ro, Seongdong-gu, Seoul, Korea
| | - Choong Hyun Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyeongchun-ro, Guri, Gyonggi-do, Korea
| | - Jae Min Kim
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyeongchun-ro, Guri, Gyonggi-do, Korea
| | - Jin Hwan Cheong
- Department of Neurosurgery, Hanyang University Guri Hospital, Gyeongchun-ro, Guri, Gyonggi-do, Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, Hanyang University Medical Center, Wangsimni-ro, Seongdong-gu, Seoul, Korea
| | - Seon Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Hambangmoe-ro, Yeonsu-gu, Incheon, Korea
- * E-mail:
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Affiliation(s)
- Michael T Lawton
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ (M.T.L.); and the Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY (G.E.V.)
| | - G Edward Vates
- From the Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ (M.T.L.); and the Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY (G.E.V.)
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Konczalla J, Kashefiolasl S, Brawanski N, Bruder M, Gessler F, Senft C, Berkefeld J, Seifert V, Tritt S. Cerebral Vasospasm-Dependent and Cerebral Vasospasm-Independent Cerebral Infarctions Predict Outcome After Nonaneurysmal Subarachnoid Hemorrhage: A Single-Center Series with 250 Patients. World Neurosurg 2017; 106:861-869.e4. [PMID: 28711533 DOI: 10.1016/j.wneu.2017.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The number of patients with nonaneurysmal subarachnoid hemorrhage (naSAH) has increased during the last decade. Data regarding infarctions in naSAH are still limited. The aim of this study was to identify the rate of cerebral vasospasm (CVS)-dependent and CVS-independent infarctions and their influence on clinical outcomes. METHODS Between 1999 and 2015, 250 patients suffering from naSAH were analyzed retrospectively. A delayed infarction was analyzed whether it was associated with CVS (CVS-dependent infarction) or not (CVS-independent). RESULTS A total of 36 patients (14%) had cerebral infarctions. CVS was detected in 54 patients (22%), and 15 (6%) of them developed infarctions (CVS-dependent). Infarctions without signs of CVS (CVS-independent) occurred in 21 patients (8%). Overall, 86% of the patients had favorable outcome. Patients without cerebral infarctions had the best outcome (91% favorable outcome, 5% mortality rate). Patients with CVS-independent infarctions (57%) as well as patients with CVS-dependent infarctions (53%) had a favorable outcome less often. The mortality rate was also significantly greater in patients with CVS-independent (19%) and CVS-dependent infarctions (33%). A further independent predictor was anticoagulative therapy, which increased during study period and was associated with nonperimesencephalic blood distribution. CONCLUSIONS CVS-dependent and independent infarctions occur in naSAH and contribute to unfavorable outcomes. Whereas CVS-independent infarctions occur in any subgroup, CVS-dependent infarctions seem to be associated with blood pattern (Fisher 3). Anticoagulative therapy seems to be not only a predictor for worse outcome but also for nonperimesencephalic SAH. Accordingly, the proportion of perimesencephalic and nonperimesencephalic SAH changed during the study period (from 2.2:1 to 1:1.7).
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany.
| | - Sepide Kashefiolasl
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Stephanie Tritt
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
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Spetzler RF, Zabramski JM, McDougall CG, Albuquerque FC, Hills NK, Wallace RC, Nakaji P. Analysis of saccular aneurysms in the Barrow Ruptured Aneurysm Trial. J Neurosurg 2017; 128:120-125. [PMID: 28298031 DOI: 10.3171/2016.9.jns161301] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Barrow Ruptured Aneurysm Trial (BRAT) is a prospective, randomized trial in which treatment with clipping was compared to treatment with coil embolization. Patients were randomized to treatment on presentation with any nontraumatic subarachnoid hemorrhage (SAH). Because all other randomized trials comparing these 2 types of treatments have been limited to saccular aneurysms, the authors analyzed the current BRAT data for this subgroup of lesions. METHODS The primary BRAT analysis included all sources of SAH: nonaneurysmal lesions; saccular, blister, fusiform, and dissecting aneurysms; and SAHs from an aneurysm associated with either an arteriovenous malformation or a fistula. In this post hoc review, the outcomes for the subgroup of patients with saccular aneurysms were further analyzed by type of treatment. The extent of aneurysm obliteration was adjudicated by an independent neuroradiologist not involved in treatment. RESULTS Of the 471 patients enrolled in the BRAT, 362 (77%) had an SAH from a saccular aneurysm. Patients with saccular aneurysms were assigned equally to the clipping and the coiling cohorts (181 each). In each cohort, 3 patients died before treatment and 178 were treated. Of the 178 clip-assigned patients with saccular aneurysms, 1 (1%) was crossed over to coiling, and 64 (36%) of the 178 coil-assigned patients were crossed over to clipping. There was no statistically significant difference in poor outcome (modified Rankin Scale score > 2) between these 2 treatment arms at any recorded time point during 6 years of follow-up. After the initial hospitalization, 1 of 241 (0.4%) clipped saccular aneurysms and 21 of 115 (18%) coiled saccular aneurysms required retreatment (p < 0.001). At the 6-year follow-up, 95% (95/100) of the clipped aneurysms were completely obliterated, compared with 40% (16/40) of the coiled aneurysms (p < 0.001). There was no difference in morbidity between the 2 treatment groups (p = 0.10). CONCLUSIONS In the subgroup of patients with saccular aneurysms enrolled in the BRAT, there was no significant difference between modified Rankin Scale outcomes at any follow-up time in patients with saccular aneurysms assigned to clipping compared with those assigned to coiling (intent-to-treat analysis). At the 6-year follow-up evaluation, rates of retreatment and complete aneurysm obliteration significantly favored patients who underwent clipping compared with those who underwent coiling. Clinical trial registration no.: NCT01593267 (clinicaltrials.gov).
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Affiliation(s)
| | | | | | | | - Nancy K Hills
- 3Department of Neurology, University of California, San Francisco, California
| | - Robert C Wallace
- 2Neuroradiology, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and
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Liu JH, Li XK, Chen ZB, Cai Q, Wang L, Ye YH, Chen QX. D-dimer may predict poor outcomes in patients with aneurysmal subarachnoid hemorrhage: a retrospective study. Neural Regen Res 2017; 12:2014-2020. [PMID: 29323040 PMCID: PMC5784349 DOI: 10.4103/1673-5374.221158] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Serum biomarkers may play a reliable role in predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage. This study retrospectively analyzed the relationship between serum biomarkers on admission and outcomes in patients with aneurysmal subarachnoid hemorrhage. We recruited 146 patients with aneurysmal subarachnoid hemorrhage who were treated in Renmin Hospital of Wuhan University of China between 1 May 2014 and 30 March 2016. There were 57 males and 89 females included and average age of included patients was 57.03 years old. Serum samples were taken immediately on admission (within 48 hours after initial hemorrhage) and the levels of serum biomarkers were detected. Baseline information, complications, and outcomes at 6 months were recorded. Univariate and multivariate logistic regression analyses were used to explore the relationship between biomarkers and clinical outcomes. Receiver operating characteristic curves were obtained to investigate the possibility of the biomarkers predicting prognosis. Of the 146 patients, 102 patients achieved good outcomes and 44 patients had poor outcomes. Univariate and multivariate analyses showed that high World Federation of Neurosurgical Societies grade, high serum D-dimer levels, and high neurological complications were significantly associated with poor outcomes. Receiver operating characteristic curves verified that D-dimer levels were associated with poor outcomes. D-dimer levels strongly correlated with neurological complications. In conclusion, we suggest that D-dimer levels are a good independent prognostic factor for poor outcomes in patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Jun-Hui Liu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Xiang-Kui Li
- Department of Neurosurgery, Affiliated Hospital of Shandong Medical College, Linyi, Shandong Province, China
| | - Zhi-Biao Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Qiang Cai
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Long Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Ying-Hu Ye
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
| | - Qian-Xue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, Hubei Province, China
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Tao C, Fan C, Hu X, Ma J, Ma L, Li H, Liu Y, Sun H, He M, You C. The effect of fenestration of the lamina terminalis on the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage (FISH): Study protocol for a randomized controlled trial. Medicine (Baltimore) 2016; 95:e5727. [PMID: 28033279 PMCID: PMC5207575 DOI: 10.1097/md.0000000000005727] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Shunt-dependent hydrocephalus (SDH) is a well-known sequela following aneurysmal hemorrhage, adversely affecting the outcome after securing ruptured aneurysm. Fenestration of lamina terminalis (FLT) creates an anterior ventriculostomy, facilitates cerebrospinal fluid circulation and clot clearance in the basal cistern. However, controversy exists over whether microsurgical FLT during aneurysm repair can decrease the incidence of SDH. AIMS The study is designed to determine the efficacy of lamina terminalis fenestration on the reduction of SDH after aneurysm clipping. METHODS/DESIGN A total of 288 patients who meet the inclusion criteria will be randomized into single aneurysm clipping or aneurysm clipping plus FLT in the Department of Neurosurgery, West China Hospital. Follow-up was performed 1, 3, 6, and 12 months after aneurysm clipping. The primary outcome is the incidence of SDH and the secondary outcomes include cerebral vasospasm, functional outcome evaluated by the modified Rankin Scale and Extended Glasgow Outcome Scale, and mortality. DISCUSSION The FISH trial is a large randomized, parallel controlled clinical trial to define the therapeutic value of FLT, the results of which will help to guide the surgical procedure and resolve the long-puzzled debate in the neurosurgical community. CONCLUSIONS This protocol will determine the efficacy of FLT in the setting of aneurysmal subarachnoid hemorrhage. TRIAL REGISTRATION IDENTIFIER CHINESE CLINICAL TRIAL REGISTRY:: ChiCTR-INR-16009249.
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Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, Sivilotti MLA. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med 2016; 23:963-1003. [PMID: 27306497 DOI: 10.1111/acem.12984] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/31/2016] [Accepted: 04/02/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic. OBJECTIVES The objective was to perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP). METHODS PubMed, Embase, Scopus, and research meeting abstracts were searched up to June 2015 for studies of emergency department patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios. To identify test and treatment thresholds, we employed the Pauker-Kassirer method with Bernstein test indication curves using the summary estimates of diagnostic accuracy. RESULTS A total of 5,022 publications were identified, of which 122 underwent full-text review; 22 studies were included (average SAH prevalence = 7.5%). Diagnostic studies differed in assessment of history and physical examination findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95% confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical examination (LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Noncontrast cranial CT within 6 hours of headache onset accurately ruled in (LR+ = 230; 95% CI = 6 to 8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond 6 hours had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 10(6) /L, the LR+ was 5.7 (95% CI = 1.4 to 23) and LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate that LP only benefits CT-negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%. CONCLUSIONS Less than one in 10 headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pretest probability range. With improvements in CT technology and an expanding body of evidence, test thresholds for LP may become more precise, obviating the need for a post-CT LP in more acute headache patients. Existing SAH clinical decision rules await external validation, but offer the potential to identify subsets most likely to benefit from post-CT LP, angiography, or no further testing.
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Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Adnan M. Hussain
- Department of Emergency Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
| | - Michael J. Ward
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Gregory J. Zipfel
- Department of Neurosurgery; Washington University in St. Louis; St. Louis MO
| | - Susan Fowler
- Becker Medical Library; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Jesse M. Pines
- Department of Emergency Medicine and Center for Practice Innovation; George Washington University; Washington DC
| | - Marco L. A. Sivilotti
- Department of Emergency Medicine and Department of Biomedical & Molecular Sciences; Queen's University; Kingston Ontario Canada
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Aboukais R, Zairi F, Estrade L, Quidet M, Leclerc X, Lejeune JP. A dissecting aneurysm of a basilar perforating artery. Neurochirurgie 2016; 62:263-265. [PMID: 27546881 DOI: 10.1016/j.neuchi.2016.03.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 02/26/2016] [Accepted: 03/11/2016] [Indexed: 10/21/2022]
Abstract
We report an additional case of a ruptured basilar trunk perforator aneurysm, for which an endovascular treatment was initially planned, but aborted due to the spontaneous regression of the aneurysm. Thus, a conservative management consisting on a close follow-up was decided that confirmed the favorable radiological outcome. Spontaneous regression of such aneurysm should be well-known by neurosurgeons and neuroradiologists in order to prevent the potential iatrogenic effects of the related treatment modalities.
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Affiliation(s)
- R Aboukais
- Department of Neurosurgery, Lille University Hospital, France.
| | - F Zairi
- Department of Neurosurgery, Lille University Hospital, France
| | - L Estrade
- Department of Neuroradiology, Lille University Hospital, France
| | - M Quidet
- Department of Neurosurgery, Lille University Hospital, France
| | - X Leclerc
- Department of Neuroradiology, Lille University Hospital, France
| | - J-P Lejeune
- Department of Neurosurgery, Lille University Hospital, France
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Lago A, López-Cuevas R, Tembl JI, Fortea G, Górriz D, Aparici F, Parkhutik V. Short- and long-term outcomes in non-aneurysmal non-perimesencephalic subarachnoid hemorrhage. Neurol Res 2016; 38:692-7. [PMID: 27338138 DOI: 10.1080/01616412.2016.1200306] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Our aim was to assess the short- and long-term prognosis in patients suffering from non-aneurysmal non-perimesencephalic SAH (Na-NPM-SAH). METHODS Based on admission CT-scan, SAH was categorized as perimesencephalic (PM) or non-perimesencephalic (NPM). Based on digital subtraction angiography (DSA) results, patients were classified as normal DSA (Na-SAH) or aneurysmal SAH (aSAH). Between 1997 and 2010, 67 of 571 patients with non-traumatic SAH (11.7%) suffered from non-aneurysmal non-perimesencephalic SAH. Retrospective analyses of the 67 patients were undertaken, and compared with the aneurysmal SAH group. Long-term follow-up was assessed. RESULTS The cohort consisted of 67 Na-NPM-SAH patients, mean age 54.8 years (range: 21-84), 56.7% male. Acute phase: 10.4% mortality and 3% rebleeding (two patients) during the acute phase. Long-term: extensive follow-up was possible in all except one of the survivors at discharge. Mortality was 6.6% during the 510 patient-years follow-up period (median follow-up time per patient, 8.95 years); rebleeding rate was 0-1.6%. An aneurysmal source was found in 13% of patients who underwent a second angiography. Aneurysmal SAH: 312 patients, with confirmed aneurysm by angiography. The mortality rate for Na-NPM-SAH during the acute phase was 10.4%, vs. 20% for aneurysmal SAH in the general database, p = 0.049. DISCUSSION Na-NPM-SAH patients without an identifiable bleeding source on initial angiography might have a more benign short- and long-term prognosis than aneurysmal SAH patients. Our study confirms an important diagnostic advantage of a second arteriography. Still, despite the major concern of an undetected aneurysm, the long-term rebleeding rate was low in this subgroup of patients.
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Affiliation(s)
- Aida Lago
- a Department of Neurology , HU La Fe , Valencia , Spain
| | | | | | | | - David Górriz
- a Department of Neurology , HU La Fe , Valencia , Spain
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Hafez A, Numminen J, Rahul R, Järveläinen J, Niemelä M. Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature. Acta Neurochir (Wien) 2016; 158:1045-9. [PMID: 27106848 DOI: 10.1007/s00701-016-2801-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 04/04/2016] [Indexed: 11/29/2022]
Abstract
The vast majority of perimesencephalic subarachnoid hemorrhage cases are reported as negative-finding etiologies. Recently, high-resolution images allowed us to overcome the previous difficulty of finding the source of bleeding, which underlies the concept of a "negative finding". We discovered a venous etiology, hidden behind the tip of the basilar artery; namely, the lateral pontine vein. Here, we review the literature on perimesencephalic subarachnoid hemorrhage and on venous aneurysm. We highlight this type of aneurysm as a candidate source of perimesencephalic hemorrhage. This case may change our way of dealing with what we have termed a negative finding of subarachnoid hemorrhage.
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Affiliation(s)
- Ahmad Hafez
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland.
| | - Jussi Numminen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Raj Rahul
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Juha Järveläinen
- Department of Radiology, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
| | - Mika Niemelä
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Topeliuksenkatu 5, PB-266, 00029, Hus, Finland
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39
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Konczalla J, Kashefiolasl S, Brawanski N, Senft C, Seifert V, Platz J. Increasing numbers of nonaneurysmal subarachnoid hemorrhage in the last 15 years: antithrombotic medication as reason and prognostic factor? J Neurosurg 2016; 124:1731-7. [PMID: 26566212 DOI: 10.3171/2015.5.jns15161] [Citation(s) in RCA: 24] [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) is usually caused by a ruptured intracranial aneurysm, but in some patients no source of hemorrhage can be detected. More recent data showed increasing numbers of cases of spontaneous nonaneurysmal SAH (NASAH). The aim of this study was to analyze factors, especially the use of antithrombotic medications such as systemic anticoagulation or antiplatelet agents (aCPs), influencing the increasing numbers of cases of NASAH and the clinical outcome.
METHODS
Between 1999 and 2013, 214 patients who were admitted to the authors’ institution suffered from NASAH, 14% of all patients with SAH. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months. Risk factors were identified based on the outcome.
RESULTS
The number of patients with NASAH increased significantly in the last 15 years of the study period. There was a statistically significant increase in the rate of nonperimesencephalic (NPM)-SAH occurrence and aCP use, while the proportion of elderly patients remained stable. Favorable outcome (mRS 0–2) was achieved in 85% of cases, but patients treated with aCPs had a significantly higher risk for an unfavorable outcome. Further analysis showed that elderly patients, and especially the subgroup with a Fisher Grade 3 bleeding pattern, had a high risk for an unfavorable outcome, whereas the subgroup of NPM-SAH without a Fisher Grade 3 bleeding pattern had a favorable outcome, similar to perimesencephalic (PM)-SAH.
CONCLUSIONS
Over the years, a significant increase in the number of patients with NASAH has been observed. Also, the rate of aCP use has increased significantly. Risk factors for an unfavorable outcome were age > 65 years, Fisher Grade 3 bleeding pattern, and aCP use. Both “PM-SAH” and “NPM-SAH without a Fisher Grade 3 bleeding pattern” had excellent outcomes. Patients with NASAH and a Fisher Grade 3 bleeding pattern had a significantly higher risk for an unfavorable outcome and death. Therefore, for further investigations, NPM-SAH should be stratified into patients with or without a Fisher Grade 3 bleeding pattern. Also, cases of spontaneous SAH should be stratified into NASAH and aneurysmal SAH.
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Coutinho JM, Sacho RH, Schaafsma JD, Agid R, Krings T, Radovanovic I, Matouk CC, Mikulis DJ, Mandell DM. High-Resolution Vessel Wall Magnetic Resonance Imaging in Angiogram-Negative Non-Perimesencephalic Subarachnoid Hemorrhage. Clin Neuroradiol 2015; 27:175-183. [PMID: 26608742 DOI: 10.1007/s00062-015-0484-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 11/05/2015] [Indexed: 11/30/2022]
Abstract
PURPOSE Standard magnetic resonance imaging (MRI) rarely identifies the cause of hemorrhage in patients with an angiogram-negative, non-perimesencephalic subarachnoid hemorrhage (SAH). Yet up to 10 % of these patients have recurrent hemorrhage. The aim of the study was to explore the potential role of high-resolution contrast-enhanced 3-Tesla vessel wall-MRI in patients with angiogram-negative SAH. METHODS We performed intracranial vessel wall-MRI of the circle of Willis using a 3-Tesla scanner in consecutive patients presenting with a spontaneous, angiogram-negative, non-perimesencephalic SAH. Vessel wall-MRI included T1-, T2-, and gadolinium-enhanced T1-weighted two-dimensional black-blood sequences in multiple planes (voxel size 0.4 × 0.4 × 2.0 mm). Two neuroradiologists independently scored abnormalities of the arterial wall. RESULTS In all, 11 patients (mean age 59 years) underwent vessel wall-MRI. A total of seven patients had vessel wall abnormalities despite normal catheter angiography. Two patients had focal abnormalities contiguous with the outer margin of the basilar artery wall for which we considered a differential of ruptured blood blister aneurysm, thrombosed aneurysm, and loculated extramural blood from elsewhere. Two patients had arterial wall enhancement involving multiple arteries, possibly secondary to SAH. Three patients had arterial wall enhancement at sites of dural penetration, remote from the SAH, likely related to age and atherosclerotic risk factors. Vessel wall-MRI did not alter patient management in this cohort. CONCLUSION Vessel wall-MRI showed abnormalities in seven patients with angiogram-negative SAH. These findings did not alter patient management, but the findings may be useful for other physicians who choose to perform vessel wall-MRI in this patient population.
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Affiliation(s)
- J M Coutinho
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and the University of Toronto, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - R H Sacho
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and the University of Toronto, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - J D Schaafsma
- Division of Neurology, Department of Medicine, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - R Agid
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and the University of Toronto, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - T Krings
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and the University of Toronto, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - I Radovanovic
- Division of Neurosurgery, Department of Surgery, University Health Network and the University of Toronto, Toronto, ON, Canada
| | - C C Matouk
- Departments of Diagnostic Radiology and Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - D J Mikulis
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and the University of Toronto, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada
| | - D M Mandell
- Division of Neuroradiology, Department of Medical Imaging, Toronto Western Hospital, University Health Network and the University of Toronto, 399 Bathurst St, M5T 2S8, Toronto, ON, Canada.
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Schievink WI, Maya MM. Diffuse non-aneurysmal SAH in spontaneous intracranial hypotension: Sequela of ventral CSF leak? Cephalalgia 2015; 36:589-92. [DOI: 10.1177/0333102415604473] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 07/30/2015] [Indexed: 11/15/2022]
Abstract
Background Spontaneous intracranial hypotension due to a spinal cerebrospinal fluid (CSF) leak has become a well-recognized cause of headaches. Recently, various unusual neurological syndromes have been described in such patients with chronic ventral CSF leaks, including superficial siderosis and an amyotrophic lateral sclerosis-like syndrome. The authors now report two patients with spontaneous intracranial hypotension due to a chronic ventral CSF leak who suffered a diffuse non-aneurysmal subarachnoid hemorrhage (SAH). Description of cases A 62-year-old woman underwent uneventful microsurgical repair of a ventral thoracic CSF leak that had been present for 13 years. Seventeen months after surgery, she was found unresponsive and CT showed a diffuse intracranial SAH. Cerebral angiography and spine and brain MRI did not reveal a source of the SAH. A 73-year-old woman was found unresponsive and CT showed a diffuse intracranial SAH. Cerebral angiography and brain MRI did not reveal a source of the SAH, although superficial siderosis was detected. Spine MRI showed a ventral thoracic CSF leak that by history had been present for 41 years. She underwent uneventful microsurgical repair of the CSF leak. Discussion The authors suggest that patients with a ventral spinal CSF leak of long duration may be at risk of diffuse non-aneurysmal SAH.
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Affiliation(s)
| | - M Marcel Maya
- Department of Radiology, Cedars-Sinai Medical Center, USA
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