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Benomar A, Diestro JDB, Darabid H, Saydy K, Tzaneva L, Li J, Zarour E, Tanguay W, El Sayed N, Padilha IG, Létourneau-Guillon L, Bard C, Nelson K, Weill A, Roy D, Eneling J, Boisseau W, Nguyen TN, Abdalkader M, Najjar AA, Nehme A, Lemoine É, Jacquin G, Bergeron D, Brunette-Clément T, Chaalala C, Bojanowski MW, Labidi M, Jabre R, Ignacio KHD, Omar AT, Volders D, Dmytriw AA, Hak JF, Forestier G, Holay Q, Olatunji R, Alhabli I, Nico L, Shankar JJS, Guenego A, Pascual JLR, Marotta TR, Errázuriz JI, Lin AW, Alves AC, Fahed R, Hawkes C, Lee H, Magro E, Sheikhi L, Darsaut TE, Raymond J. Nonaneurysmal perimesencephalic subarachnoid hemorrhage on noncontrast head CT: An accuracy, inter-rater, and intra-rater reliability study. J Neuroradiol 2024; 51:101184. [PMID: 38387650 DOI: 10.1016/j.neurad.2024.02.002] [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: 12/06/2023] [Revised: 02/13/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE To evaluate the reliability and accuracy of nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) on Noncontrast Head CT (NCCT) between numerous raters. MATERIALS AND METHODS 45 NCCT of adult patients with SAH who also had a catheter angiography (CA) were independently evaluated by 48 diverse raters; 45 raters performed a second assessment one month later. For each case, raters were asked: 1) whether they judged the bleeding pattern to be perimesencephalic; 2) whether there was blood anterior to brainstem; 3) complete filling of the anterior interhemispheric fissure (AIF); 4) extension to the lateral part of the sylvian fissure (LSF); 5) frank intraventricular hemorrhage; 6) whether in the hypothetical presence of a negative CT angiogram they would still recommend CA. An automatic NAPSAH diagnosis was also generated by combining responses to questions 2-5. Reliability was estimated using Gwet's AC1 (κG), and the relationship between the NCCT diagnosis of NAPSAH and the recommendation to perform CA using Cramer's V test. Multi-rater accuracy of NCCT in predicting negative CA was explored. RESULTS Inter-rater reliability for the presence of NAPSAH was moderate (κG = 0.58; 95%CI: 0.47, 0.69), but improved to substantial when automatically generated (κG = 0.70; 95%CI: 0.59, 0.81). The most reliable criteria were the absence of AIF filling (κG = 0.79) and extension to LSF (κG = 0.79). Mean intra-rater reliability was substantial (κG = 0.65). NAPSAH weakly correlated with CA decision (V = 0.50). Mean sensitivity and specificity were 58% (95%CI: 44%, 71%) and 83 % (95%CI: 72 %, 94%), respectively. CONCLUSION NAPSAH remains a diagnosis of exclusion. The NCCT diagnosis was moderately reliable and its impact on clinical decisions modest.
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Affiliation(s)
- Anass Benomar
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada. https://twitter.com/AnassBenomarMD
| | - Jose Danilo B Diestro
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, ON, Canada. https://twitter.com/DanniDiestro
| | - Houssam Darabid
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Karim Saydy
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Lora Tzaneva
- Department of Experimental Surgery, McGill University, Montreal, QC, Canada
| | - Jimmy Li
- Division of Neurology, Centre Hospitalier Universitaire de Sherbrooke (CHUS), Sherbrooke, QC, Canada. https://twitter.com/neuroloJimmy
| | - Eleyine Zarour
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada. https://twitter.com/eleyine
| | - William Tanguay
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Nohad El Sayed
- Department of Radiology, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Igor Gomes Padilha
- Division of Neuroradiology, Diagnósticos da América SA - DASA, São Paulo, SP, Brazil; Division of Neuroradiology, Santa Casa de São Paulo School of Medical Sciences, São Paulo, SP, Brazil; Division of Neuroradiology, United Health Group, São Paulo, SP, Brazil
| | - Laurent Létourneau-Guillon
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada. https://twitter.com/LaurentLetG
| | - Céline Bard
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Kristoff Nelson
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Alain Weill
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Daniel Roy
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Johanna Eneling
- Department of Neurosurgery, Linköping University Hospital, Linköping, Sweden
| | - William Boisseau
- Department of Interventional Neuroradiology, Fondation Adolphe de Rothschild, Paris, France
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery, and Radiology, Boston Medical Center, Boston, MA, USA. https://twitter.com/NguyenThanhMD
| | - Mohamad Abdalkader
- Department of Neurology, Neurosurgery, and Radiology, Boston Medical Center, Boston, MA, USA. https://twitter.com/AbdalkaderMD
| | - Ahmed A Najjar
- Division of Neurosurgery, Department of Surgery, College of Medicine, Taibah University, Medina, Saudi Arabia. https://twitter.com/AhmedANajjar
| | - Ahmad Nehme
- Université Caen-Normandie, Neurology, CHU Caen-Normandie, Caen, France. https://twitter.com/ANehme
| | - Émile Lemoine
- Division of Neurology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada. https://twitter.com/lemoineemile
| | - Gregory Jacquin
- Division of Neurology, Department of Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - David Bergeron
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada. https://twitter.com/David__Bergeron
| | - Tristan Brunette-Clément
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada. https://twitter.com/BrunetteClement
| | - Chiraz Chaalala
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Michel W Bojanowski
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Moujahed Labidi
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Roland Jabre
- Division of Neurosurgery, Department of Surgery, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada
| | - Katrina H D Ignacio
- Calgary Stroke Program, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada. https://twitter.com/Katha_MD
| | - Abdelsimar T Omar
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; Division of Neurosurgery, McMaster University, Hamilton, ON, Canada. https://twitter.com/atomar_md
| | - David Volders
- Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS, Canada
| | - Adam A Dmytriw
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, ON, Canada; Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA. https://twitter.com/AdamDmytriw
| | - Jean-François Hak
- Department of Medical Imaging, University Hospital Timone APHM, Marseille, France. https://twitter.com/JFHak
| | - Géraud Forestier
- Department of neuroradiology, University Hospital of Limoges, Limoges, France. https://twitter.com/GeraudForestier
| | - Quentin Holay
- Department of Radiology, Sainte-Anne Military Hospital, Toulon, France
| | - Richard Olatunji
- Department of Radiology, College of Medicine, University of Ibadan, Ibadan, Nigeria. https://twitter.com/RICHARDOlat
| | - Ibrahim Alhabli
- Calgary Stroke Program, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada. https://twitter.com/ialhabli
| | - Lorena Nico
- Department of Neuroradiology, University Hospital Of Padova, Padova, Italy
| | - Jai J S Shankar
- Department of Radiology, Health Sciences Centre, Winnipeg, MB, Canada. https://twitter.com/shivajai1
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium. https://twitter.com/GuenegoAdrien
| | - Jose L R Pascual
- Department of Anatomy, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines. https://twitter.com/drbrainhacker
| | - Thomas R Marotta
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, ON, Canada. https://twitter.com/trmarot
| | - Juan I Errázuriz
- Department of Radiology, McGill University Health Centre (MUHC), Montreal, QC, Canada
| | - Amy W Lin
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, ON, Canada
| | - Aderaldo Costa Alves
- Division of Neurosurgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. https://twitter.com/jr_aderaldo
| | - Robert Fahed
- Division of Neurology, The Ottawa Hospital, Ottawa, ON, Canada
| | - Christine Hawkes
- Division of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada. https://twitter.com/CMHawkes
| | - Hubert Lee
- Division of Neurosurgery, Trillium Health Partners, Toronto, ON, Canada
| | - Elsa Magro
- Department of Neurosurgery, Hôpital de la Cavale Blanche, CHRU de Brest, Brest, France
| | - Lila Sheikhi
- Department of Neurology, University of Kentucky, Lexington, KY, USA. https://twitter.com/lila_sheikhi
| | - Tim E Darsaut
- Department of Surgery, Division of Neurosurgery, Walter C. Mackenzie Health Sciences Centre, University of Alberta Hospital, Edmonton, AB, Canada. https://twitter.com/tdarsaut
| | - Jean Raymond
- Department of Radiology, Radiation Oncology and Nuclear Medicine, Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
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Nützel R, Brandt S, Rampp S, Leisz S, Simmermacher S, Prell J, Strauss C, Scheller C. Subarachnoid Hemorrhage with Negative Initial Digital Subtraction Angiography: Subsequent Detection of Aneurysms and Complication Rates of Repeated Angiography. J Neurol Surg A Cent Eur Neurosurg 2023; 84:167-173. [PMID: 36302519 DOI: 10.1055/s-0042-1748771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The data on handling of spontaneous, nontraumatic subarachnoid hemorrhage (SAH) with negative initial digital subtraction angiography (DSA) are still inconclusive. The intention of this study was to evaluate the requirement of repeat DSA in patients with negative initial DSA and to compare the clinical outcomes of these cases. METHODS In a retrospective study, we reviewed patients with SAH and negative initial DSA treated in our department from January 2006 until December 2017. The patients were divided according to an established radiographic classification into perimesencephalic (pm) and nonperimesencephalic (npm) SAH. An interventional neuroradiologist and a neurosurgeon reviewed all DSA scans. RESULTS In all, 52 patients with negative initial DSA, comprising 36 (69.2%) patients with pm and 16 (30.8%) patients with npm bleeding pattern, were included. All patients underwent a second and 23 of these patients underwent a third DSA. In these 23 patients, subarachnoid blood distribution in the initial computed tomography (CT) scan was suspicious for the presence of aneurysm. In total, two aneurysms were detected during the second DSA (diagnostic yield: 3.85%). Both were in the pm group (diagnostic yield: 5.6%). The second repeat DSA did not show any causative vascular lesion. Complications after the DSA occurred in only 2 of 127 patients (1.6%). The rate of complications concerning vasospasm (pm 52.8%, npm 56.3%), hydrocephalus (pm 47.2%, npm 50%), and the need for temporary or permanent shunt (pm 44.4%, npm 50%) was similar in both groups and there was no statistically significant difference. CONCLUSION Repeat DSA after negative initial DSA in pm SAH had a diagnostic yield of 5.6%. However, a second repeat DSA cannot be recommended in case of SAH with initial negative DSA. The pm SAH should not be underrated concerning the occurrence of complications and cared with a high level of surveillance.
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Affiliation(s)
- Regina Nützel
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Silvio Brandt
- Department of Radiology, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany.,Department of Radiology and Neuroradiology, Chemnitz Hospital, Chemnitz, Germany
| | - Stefan Rampp
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Sandra Leisz
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Sebastian Simmermacher
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Julian Prell
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Christian Strauss
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Christian Scheller
- Department of Neurosurgery, Medical Faculty, Martin Luther University Halle-Wittenberg, Halle, Germany
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Angermann M, Jablawi F, Angermann M, Conzen-Dilger C, Schubert GA, Höllig A, Veldeman M, Reich A, Hasan D, Ridwan H, Clusmann H, Wiesmann M, Nikoubashman O. Clinical Outcome and Prognostic Factors of Patients with Perimesencephalic and Nonperimesencephalic Subarachnoid Hemorrhage. World Neurosurg 2022; 165:e512-e519. [PMID: 35753679 DOI: 10.1016/j.wneu.2022.06.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/16/2022] [Accepted: 06/17/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To demonstrate the clinical outcome of patients with nonperimesencephalic subarachnoid hemorrhage (npSAH) compared with patients with aneurysmal SAH (aSAH) and perimesencephalic SAH (pSAH) and to evaluate predictive value of various clinical and radiological findings in patients with npSAH. METHODS We retrospectively identified patients with SAH who presented at our institution between 2009 and 2018. We analyzed demographic and clinical data and outcomes. Multivariable analysis was performed for outcome parameters. RESULTS Of 608 patients with confirmed SAH, 78% had aSAH, and 22% had nonaneurysmal SAH. Nonaneurysmal SAH was perimesencephalic in 30% of cases and nonperimesencephalic in 70%. Initial clinical status (Hunt and Hess score) was significantly worse in patients with aSAH compared with patients with nonaneurysmal SAH. Complications such as delayed cerebral ischemia occurred significantly more often in patients with aSAH. Patients with pSAH had a more favorable clinical course than patients with aSAH or npSAH. There was no significant difference in 30-day mortality between aSAH (29%) and npSAH (28%) patients (P = 0.835). Hunt and Hess score emerged as a strong predictor of unfavorable outcome in both aSAH and npSAH in multivariable regression. CONCLUSIONS Patients with npSAH had a similar clinical outcome as patients with aSAH, although there were significantly fewer clinical complications in patients with npSAH. Patients with pSAH demonstrated an overall good clinical course. Our multivariable analysis showed that initial Hunt and Hess score was an important predictor for clinical outcome in aSAH as well as npSAH.
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Affiliation(s)
- Manuel Angermann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Fidaa Jablawi
- Department of Neurosurgery, Justus Liebig University Giessen, Giessen, Germany
| | - Maike Angermann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Gerrit A Schubert
- Department of Neurosurgery, Kantontsspital Aarau, Aarau, Switzerland
| | - Anke Höllig
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Dimah Hasan
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Hani Ridwan
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany.
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Larson AS, Brinjikji W. Subarachnoid Hemorrhage of Unknown Cause: Distribution and Role of Imaging. Neuroimaging Clin N Am 2021; 31:167-175. [PMID: 33902872 DOI: 10.1016/j.nic.2021.01.001] [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] [Indexed: 02/03/2023]
Abstract
Subarachnoid hemorrhage of unknown cause represents approximately 10% to 15% of nontraumatic subarachnoid hemorrhages. The key factors in determining the management strategy for a presumed nonaneurysmal subarachnoid hemorrhage are the distribution, location, and amount of subarachnoid blood. Hemorrhage distribution on computed tomography can be categorized as follows: perimesencephalic, diffuse, sulcal, and primary intraventricular. The extent of the workup required in determining the cause of hemorrhage depends on the distribution of blood. The authors review the potential causes, differential diagnoses, and acute and long-term follow-up strategies in patients with subarachnoid hemorrhage of unknown cause.
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Affiliation(s)
- Anthony S Larson
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA; Department of Neurosurgery, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
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Gardijan D, Herega T, Premužić V, Jovanović I, Ozretić D, Poljaković Z, Radoš M. Comparison between stenting and conservative management of posterior circulation perforator aneurysms: Systematic review and case series. Neuroradiology 2021; 63:639-651. [PMID: 33404790 DOI: 10.1007/s00234-020-02618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/01/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Posterior circulation perforator aneurysms (PCPAs) are a rare type of intracranial aneurysms whose natural history and optimal clinical management are still largely unexplored. This study aims to report our experience with treating ruptured PCPAs and to provide a systematic review of the literature to compare the two most established treatment options, endovascular stenting, and conservative management including administration of antifibrinolytic drugs and watchful waiting. METHODS We performed a systematic review of the literature following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Major databases were searched for case reports and case report series written in the English language between 1995 and 2020. Additionally, we retrospectively reviewed our stroke center database for cases of ruptured PCPAs between January 2014 and July 2020. Endovascular stenting and conservative treatment were compared using endpoints, including favorable outcome rate (mRS 0-2), occlusion rate, mortality rate, periinterventional complication rate, and re-hemorrhage rate. RESULTS We identified 31 patients treated endovascularly using stents and 33 patients treated conservatively, with the administration of antifibrinolytic drugs in 3 of them. Our analysis showed no statistically significant difference between the groups, except for the occlusion rate. CONCLUSIONS The optimal management strategy of PCPAs is still unknown, but stenting can be considered as an effective occlusion method with an acceptable complication rate. Preventive ventricular drainage may be necessary due to the high hydrocephalus rate encountered in ruptured PCPAs.
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Affiliation(s)
- Danilo Gardijan
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Tomislav Herega
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia.
| | - Vedran Premužić
- Department of Nephrology, Hypertension, Dialysis and Transplantation, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Ivan Jovanović
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - David Ozretić
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Zdravka Poljaković
- Department of Neurology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
| | - Marko Radoš
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Centre Zagreb, Kišpatićeva 12, 10000, Zagreb, Croatia
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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Atchie B, McGraw C, McCarthy K, van Vliet R, Frei D, Bennett A, Bartt R, Orlando A, Wagner J, Bar-Or D. Comparing Outcomes of Patients With Idiopathic Subarachnoid Hemorrhage by Stratifying Perimesencephalic Bleeding Patterns. J Stroke Cerebrovasc Dis 2019; 28:2407-2413. [PMID: 31303438 DOI: 10.1016/j.jstrokecerebrovasdis.2019.06.032] [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] [Received: 06/05/2019] [Revised: 06/14/2019] [Accepted: 06/24/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND To determine the clinical outcomes of perimesencephalic subarachnoid hemorrhages based on the computed tomography (CT) bleeding patterns. METHODS This retrospective cohort study included: (1) patients (≥18 years) admitted to a comprehensive stroke center (January 2015-May 2018), (2) with angiography-negative, nontraumatic subarachnoid hemorrhage in a perimesencephalic or diffuse bleeding pattern, and (3) had CT imaging performed in ≤ 72 hours of symptom onset. Patients were stratified by location of bleeding on CT: Peri-1: focal prepontine hemorrhage; Peri-2: prepontine with suprasellar cistern +/- intraventricular extension; and diffuse. RESULTS Of the 39 patients included, 13 were Peri-1, 11 were Peri-2, and 15 were diffuse. The majority were male (n = 26), with a mean (standard deviation) age of 55.3 (11.3) years, who often presented with headache (n = 37) and nausea (n = 28). Overall, patients in Peri-1 were significantly less likely to have hydrocephalus compared to Peri-2 and dSAH (P= .003), and 4 patients required an external ventricular drain. Five patients developed symptomatic vasospasm. Patients in Peri-1, compared to Peri-2 and diffuse, had a significantly shorter median neuro critical care unit length of stay (LOS) and hospital LOS. Most patients (n = 35) had a discharge modified Rankin Score between 0 and 2 with no significant differences found between groups. CONCLUSION These data suggest that patients with the best clinical course were those in Peri-1, followed by Peri-2, and then diffuse. Because these patients often present with similar clinical signs, stratifying by hemorrhage pattern may help clinicians predict which patients with perimesencephalic subarachnoid hemorrhage develop complications.
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Affiliation(s)
- Benjamin Atchie
- Department of Neurology, Swedish Medical Center, Englewood, CO; Radiology Imaging Associates, Englewood, CO
| | - Constance McGraw
- Department of Trauma Research, Swedish Medical Center, Englewood, CO
| | - Kathryn McCarthy
- Department of Neurology, Swedish Medical Center, Englewood, CO; Blue Sky Neurology, Englewood, CO
| | - Rebecca van Vliet
- Department of Neurology, Swedish Medical Center, Englewood, CO; Blue Sky Neurology, Englewood, CO
| | - Donald Frei
- Department of Neurology, Swedish Medical Center, Englewood, CO; Radiology Imaging Associates, Englewood, CO
| | - Alicia Bennett
- Department of Neurology, Swedish Medical Center, Englewood, CO; Blue Sky Neurology, Englewood, CO
| | - Russell Bartt
- Department of Neurology, Swedish Medical Center, Englewood, CO; Blue Sky Neurology, Englewood, CO
| | | | - Jeffrey Wagner
- Department of Neurology, Swedish Medical Center, Englewood, CO; Blue Sky Neurology, Englewood, CO
| | - David Bar-Or
- Department of Trauma Research, Swedish Medical Center, Englewood, CO.
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8
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An explainable deep-learning algorithm for the detection of acute intracranial haemorrhage from small datasets. Nat Biomed Eng 2018; 3:173-182. [DOI: 10.1038/s41551-018-0324-9] [Citation(s) in RCA: 201] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 11/12/2018] [Indexed: 01/25/2023]
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Mensing LA, Vergouwen MD, Laban KG, Ruigrok YM, Velthuis BK, Algra A, Rinkel GJ. Perimesencephalic Hemorrhage. Stroke 2018; 49:1363-1370. [DOI: 10.1161/strokeaha.117.019843] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/07/2018] [Accepted: 03/14/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Liselore A. Mensing
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (L.A.M., M.D.I.V., K.G.L., Y.M.R., A.A., G.J.E.R.)
| | - Mervyn D.I. Vergouwen
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (L.A.M., M.D.I.V., K.G.L., Y.M.R., A.A., G.J.E.R.)
| | - Kamil G. Laban
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (L.A.M., M.D.I.V., K.G.L., Y.M.R., A.A., G.J.E.R.)
| | - Ynte M. Ruigrok
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (L.A.M., M.D.I.V., K.G.L., Y.M.R., A.A., G.J.E.R.)
| | | | - Ale Algra
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (L.A.M., M.D.I.V., K.G.L., Y.M.R., A.A., G.J.E.R.)
- Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Gabriel J.E. Rinkel
- From the Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery (L.A.M., M.D.I.V., K.G.L., Y.M.R., A.A., G.J.E.R.)
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Added value of double reading in diagnostic radiology,a systematic review. Insights Imaging 2018; 9:287-301. [PMID: 29594850 PMCID: PMC5990995 DOI: 10.1007/s13244-018-0599-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 01/10/2018] [Accepted: 01/15/2018] [Indexed: 01/10/2023] Open
Abstract
Objectives Double reading in diagnostic radiology can find discrepancies in the original report, but a systematic program of double reading is resource consuming. There are conflicting opinions on the value of double reading. The purpose of the current study was to perform a systematic review on the value of double reading. Methods A systematic review was performed to find studies calculating the rate of misses and overcalls with the aim of establishing the added value of double reading by human observers. Results The literature search resulted in 1610 hits. After abstract and full-text reading, 46 articles were selected for analysis. The rate of discrepancy varied from 0.4 to 22% depending on study setting. Double reading by a sub-specialist, in general, led to high rates of changed reports. Conclusions The systematic review found rather low discrepancy rates. The benefit of double reading must be balanced by the considerable number of working hours a systematic double-reading scheme requires. A more profitable scheme might be to use systematic double reading for selected, high-risk examination types. A second conclusion is that there seems to be a value of sub-specialisation for increased report quality. A consequent implementation of this would have far-reaching organisational effects. Key Points • In double reading, two or more radiologists read the same images. • A systematic literature review was performed. • The discrepancy rates varied from 0.4 to 22% in various studies. • Double reading by sub-specialists found high discrepancy rates. Electronic supplementary material The online version of this article (10.1007/s13244-018-0599-0) contains supplementary material, which is available to authorised users.
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11
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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12
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Cho KC, Kim JJ, Hong CK, Joo JY, Kim YB. Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage After Clipping of an Unruptured Aneurysm. World Neurosurg 2017; 102:694.e15-694.e19. [PMID: 28391019 DOI: 10.1016/j.wneu.2017.03.134] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 03/25/2017] [Accepted: 03/27/2017] [Indexed: 01/22/2023]
Abstract
BACKGROUND Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is a benign form of subarachnoid hemorrhage with an excellent clinical outcome. The cause of PNSAH remains unknown. We report a case of PNSAH in a patient with a history of clipping of an unruptured aneurysm. PNSAH after clipping of an unruptured aneurysm is extremely rare. CASE DESCRIPTION A 56-year-old man with a history of clipping surgery for an unruptured aneurysm 10 months previously presented with severe headache. No precipitating causes were shown; however, the patient had been engaged in an exertional activity before the event. After conservative treatment, he was discharged home without any complication from the hemorrhage. CONCLUSIONS On the basis of this case report, clinicians should consider the possibility of PNSAH in a patient who had an unruptured aneurysm previously treated with clipping. Nevertheless, diagnostic workup can be more important than keeping in mind that a subarachnoid hemorrhage might be a PNSAH.
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Affiliation(s)
- Kwang-Chun Cho
- Department of Neurosurgery, College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea
| | - Jung-Jae Kim
- Department of Neurosurgery, College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea
| | - Chang-Ki Hong
- Department of Neurosurgery, College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea
| | - Jin-Yang Joo
- Department of Neurosurgery, College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea
| | - Yong Bae Kim
- Department of Neurosurgery, College of Medicine, Yonsei University, Gangnam Severance Hospital, Seoul, Korea.
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13
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Bianchi C, Clerc D, Yersin B. Revue de littérature et dérivation d’un algorithme clinique diagnostique pour une suspicion d’hémorragie sous-arachnoïdienne. ANNALES FRANCAISES DE MEDECINE D URGENCE 2017. [DOI: 10.1007/s13341-017-0727-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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14
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Rouchaud A, Lehman VT, Murad MH, Burrows A, Cloft HJ, Lindell EP, Kallmes DF, Brinjikji W. Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous Drainage Anomalies: A Systematic Literature Review and Meta-Analysis. AJNR Am J Neuroradiol 2016; 37:1657-63. [PMID: 27173362 DOI: 10.3174/ajnr.a4806] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Accepted: 02/09/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Mechanisms underlying bleeding in nonaneurysmal perimesencephalic SAH remain unclear. Previous investigators have suggested a relationship between nonaneurysmal perimesencephalic SAH and primitive venous drainage of the basal vein of Rosenthal. We performed a meta-analysis to evaluate the relation between primitive basal vein of Rosenthal drainage and nonaneurysmal perimesencephalic SAH. MATERIALS AND METHODS We performed a comprehensive literature search of all studies examining the prevalence of primitive basal vein of Rosenthal drainage in patients with aneurysmal SAH and nonaneurysmal perimesencephalic SAH. Data collected were primitive basal vein of Rosenthal drainage (direct connection of perimesencephalic veins into the dural sinuses instead of the Galenic system) in at least 1 cerebral hemisphere, normal bilateral basal vein of Rosenthal drainage systems, and the number of overall primitive venous systems in the nonaneurysmal perimesencephalic SAH and aneurysmal SAH groups. Statistical analysis was performed by using a random-effects meta-analysis. RESULTS Eight studies with 888 patients (334 with nonaneurysmal perimesencephalic SAH and 554 with aneurysmal SAH) and 1657 individual venous systems were included. Patients with nonaneurysmal perimesencephalic SAH were more likely to have a primitive basal vein of Rosenthal drainage in at least 1 hemisphere (47.7% versus 22.1%; OR, 3.31; 95% CI, 2.15-5.08; P < .01) and were less likely to have bilateral normal basal vein of Rosenthal drainage systems than patients with aneurysmal SAH (18.3% versus 37.4%; OR, 0.27; 95% CI, 0.14-0.52; P < .01). When we considered individual venous systems, there were higher rates of primitive venous systems in patients with nonaneurysmal perimesencephalic SAH than in patients with aneurysmal SAH (34.9% versus 15.3%; OR, 3.90; 95% CI, 2.37-6.43; P < .01). CONCLUSIONS Patients with nonaneurysmal perimesencephalic SAH have a higher prevalence of primitive basal vein of Rosenthal drainage in at least 1 hemisphere than patients with aneurysmal SAH. This finding suggests a venous origin of some nonaneurysmal perimesencephalic SAHs. A primitive basal vein of Rosenthal pattern is an imaging finding that has the potential to facilitate the diagnosis of nonaneurysmal perimesencephalic SAH.
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Affiliation(s)
- A Rouchaud
- From the Departments of Radiology (A.R., V.TL., H.J.C., E.P.L., D.F.K., W.B.)
| | - V T Lehman
- From the Departments of Radiology (A.R., V.TL., H.J.C., E.P.L., D.F.K., W.B.)
| | - M H Murad
- Preventive Medicine and Center for the Science of Healthcare Delivery (M.H.M.)
| | - A Burrows
- Neurosurgery (A.B.)., Mayo Clinic, Rochester, Minnesota
| | - H J Cloft
- From the Departments of Radiology (A.R., V.TL., H.J.C., E.P.L., D.F.K., W.B.)
| | - E P Lindell
- From the Departments of Radiology (A.R., V.TL., H.J.C., E.P.L., D.F.K., W.B.)
| | - D F Kallmes
- From the Departments of Radiology (A.R., V.TL., H.J.C., E.P.L., D.F.K., W.B.)
| | - W Brinjikji
- From the Departments of Radiology (A.R., V.TL., H.J.C., E.P.L., D.F.K., W.B.)
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15
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Neuroimaging in encephalitis: analysis of imaging findings and interobserver agreement. Clin Radiol 2016; 71:1050-1058. [PMID: 27185323 PMCID: PMC5021199 DOI: 10.1016/j.crad.2016.03.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 03/08/2016] [Accepted: 03/23/2016] [Indexed: 01/17/2023]
Abstract
Aim To assess the role of imaging in the early management of encephalitis and the agreement on findings in a well-defined cohort of suspected encephalitis cases enrolled in the Prospective Aetiological Study of Encephalitis conducted by the Health Protection Agency (now incorporated into Public Health England). Materials and methods Eighty-five CT examinations from 68 patients and 101 MRI examinations from 80 patients with suspected encephalitis were independently rated by three neuroradiologists blinded to patient and clinical details. The level of agreement on the interpretation of images was measured using the kappa statistic. The sensitivity, specificity, and negative and positive predictive values of CT and MRI for herpes simplex virus (HSV) encephalitis and acute disseminated encephalomyelitis (ADEM) were estimated. Results The kappa value for interobserver agreement on rating the scans as normal or abnormal was good (0.65) for CT and moderate (0.59) for MRI. Agreement for HSV encephalitis was very good for CT (0.87) and MRI (0.82), but only fair for ADEM (0.32 CT; 0.31 MRI). Similarly, the overall sensitivity of imaging for HSV encephalitis was ∼80% for both CT and MRI, whereas for ADEM it was 0% for CT and 20% for MRI. MRI specificity for HSV encephalitis between 3–10 days after symptom onset was 100%. Conclusion There is a subjective component to scan interpretation that can have important implications for the clinical management of encephalitis cases. Neuroradiologists were good at diagnosing HSV encephalitis; however, agreement was worse for ADEM and other alternative aetiologies. Findings highlight the importance of a comprehensive and multidisciplinary approach to diagnosing the cause of encephalitis that takes into account individual clinical, microbiological, and radiological features of each patient. We assessed the role of imaging in encephalitis. We assessed the agreement between raters on scan interpretation. Diagnosis for herpes simplex encephalitis (HSE) was good. Agreement was worse for ADEM and other alternative aetiologies. HSE can be dismissed if MRI normal 72 hours after neurological symptom onset (with negative CSF tests).
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16
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Wallace AN, Vyhmeister R, Viets R, Whisenant JT, Chatterjee AR, Kansagra AP, Cross DT, Moran CJ, Derdeyn CP. Quadrigeminal perimesencephalic subarachnoid hemorrhage. Clin Neurol Neurosurg 2015; 137:67-71. [PMID: 26151343 DOI: 10.1016/j.clineuro.2015.06.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Revised: 06/23/2015] [Accepted: 06/24/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE A variant of perimesencephalic subarachnoid hemorrhage (PSAH) has been described characterized by blood centered in the quadrigeminal cistern and limited to the superior vermian and perimesencephalic cisterns. Herein, three cases of quadrigeminal PSAH are presented. MATERIALS AND METHODS Medical records of all patients who underwent digital subtraction angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Two blinded reviewers identified admission noncontrast CT scans with pretruncal and quadrigeminal patterns of PSAH. RESULTS The total cohort included 106 patients: 53% (56/106) with one or more negative digital subtraction angiograms and 47% (50/106) with posterior circulation or posterior communicating artery aneurysms. Three patients with quadrigeminal PSAH were identified, two with nonaneurysmal SAH and one with a posterior circulation aneurysm. Seventeen patients (16%; 17/106) with pretruncal PSAH were identified, none of whom were found to have an aneurysm. The quadrigeminal pattern comprised 11% (2/19) of cases of pretruncal or quadrigeminal nonaneurysmal PSAH. CONCLUSION A small subset of patients with nonaneurysmal PSAH present with blood centered in the quadrigeminal cistern, and the etiology of this pattern may be similar to that of the classic pretruncal variant. However, patients with quadrigeminal PSAH must still undergo thorough vascular imaging, including at least two digital subtraction angiograms, to exclude a ruptured aneurysm.
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Affiliation(s)
- Adam N Wallace
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Saint Louis, MO 63110, United States.
| | - Ross Vyhmeister
- Washington University School of Medicine, Saint Louis, MO, United States
| | - Ryan Viets
- Sharp Grossmont Hospital, San Diego, CA, United States
| | | | - Arindam R Chatterjee
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Saint Louis, MO 63110, United States
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Saint Louis, MO 63110, United States
| | - DeWitte T Cross
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Saint Louis, MO 63110, United States
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Saint Louis, MO 63110, United States
| | - Colin P Derdeyn
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Boulevard, Saint Louis, MO 63110, United States
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17
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Wallace AN, Vyhmeister R, Dines JN, Chatterjee AR, Kansagra AP, Viets R, Whisenant JT, Moran CJ, Cross DT, Derdeyn CP. Evaluation of an anatomic definition of non-aneurysmal perimesencephalic subarachnhoid hemorrhage. J Neurointerv Surg 2015; 8:378-85. [DOI: 10.1136/neurintsurg-2015-011680] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 03/02/2015] [Indexed: 01/30/2023]
Abstract
Background and purposePerimesencephalic subarachnoid hemorrhage (PSAH) is not consistently defined in the existing literature. The purpose of this study was to test the inter-observer variability and specificity for non-aneurysmal subarachnoid hemorrhage (SAH) of an anatomic definition of PSAH.MethodsMedical records of all patients who underwent catheter angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Three blinded reviewers assessed whether each admission CT scan met the following anatomic criteria for PSAH: (1) center of bleeding located immediately anterior and in contact with the brainstem in the prepontine, interpeduncular, or posterior suprasellar cistern; (2) blood limited to the prepontine, interpeduncular, suprasellar, crural, ambient, and/or quadrigeminal cisterns and/or cisterna magna; (3) no extension of blood into the Sylvian or interhemispheric fissures; (4) intraventricular blood limited to incomplete filling of the fourth ventricle and occipital horns of the lateral ventricles (ie, consistent with reflux); (5) no intraparenchymal blood.Results56 patients with non-aneurysmal SAH and 50 patients with posterior circulation or posterior communicating artery aneurysms were identified. Seventeen (16%) of the 106 admission CT scans met the anatomic criteria for PSAH. No aneurysm was identified in this subgroup. Inter-observer agreement was excellent with κ scores of 0.89–0.96 and disagreement in 2.8% (3/106) of cases.ConclusionsOur anatomic definition of PSAH correlated with a low risk of brain aneurysm and was applied with excellent inter-observer agreement.
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Kalra VB, Wu X, Matouk CC, Malhotra A. Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage. Stroke 2015; 46:401-6. [DOI: 10.1161/strokeaha.114.007370] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background and Purpose—
Multiple studies have shown that negative computed tomographic angiograms (CTAs) are reliable in excluding aneurysms in patients with isolated perimesencephalic subarachnoid hemorrhage (pSAH). We evaluate the use of digital subtraction angiography versus CTA for initial diagnosis and of angiographic follow-ups in patients with pSAH by performing an institutional analysis and a meta-analysis of literature.
Methods—
Retrospective institutional analysis of patients with pSAH was performed from 2008 to 2014. The number and types of follow-up imaging studies were tabulated. Initial and follow-up studies were evaluated by an experienced neuroradiologist for intracranial aneurysm. Meta-analysis of literature was performed to assess the use of initial digital subtraction angiography and of follow-up imaging.
Results—
Our institutional review revealed no additional use of initial digital subtraction angiography or of any angiographic follow-up after initial negative CTA in patients with pSAH on noncontrast CT. Meta-analysis of 40 studies yielded a total of 1031 patients. Only 8 aneurysms were first diagnosed on follow-ups (0.78%). Careful review showed that some of these aneurysms reported on follow-up are of questionable validity. Initial digital subtraction angiography and follow-up imaging after a negative initial CTA showed no statistically significant benefits.
Conclusions—
In patients meeting the strict imaging criteria of pSAH, initial negative CTA is reliable in excluding aneurysms. A critical review of the literature through meta-analysis shows no foundation for multiple follow-up studies in patients with pSAH.
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Affiliation(s)
- Vivek B. Kalra
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Xiao Wu
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Charles C. Matouk
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
| | - Ajay Malhotra
- From the Departments of Diagnostic Radiology (V.B.K., X.W., C.C.M., A.M.) and Neurosurgery (C.C.M.), Yale School of Medicine, New Haven, CT
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Jeong HW, Seo JH, Kim ST, Jung CK, Suh SI. Clinical practice guideline for the management of intracranial aneurysms. Neurointervention 2014; 9:63-71. [PMID: 25426300 PMCID: PMC4239410 DOI: 10.5469/neuroint.2014.9.2.63] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/05/2014] [Indexed: 11/29/2022] Open
Abstract
Purpose An intracranial aneurysm, with or without subarachnoid hemorrhage (SAH), is a relevant health problem. The rupture of an intracranial aneurysm is a critical concern for individual health; even an unruptured intracranial aneurysm is an anxious condition for the individual. The aim of this guideline is to present current and comprehensive recommendations for the management of intracranial aneurysms, with or without rupture. Materials and Methods We performed an extensive literature search, using Medline. We met in person to discuss recommendations. This document is reviewed by the Task Force Team of the Korean Society of Interventional Neuroradiology (KSIN). Results We divided the current guideline for ruptured intracranial aneurysms (RIAs) and unruptured intracranial aneurysms (UIAs). The guideline for RIAs focuses on diagnosis and treatment. And the guideline for UIAs focuses on the definition of a high-risk patient, screening, principle for treatment and selection of treatment method. Conclusion This guideline provides practical, evidence-based advice for the management of patients with an intracranial aneurysm, with or without rupture.
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Affiliation(s)
- Hae Woong Jeong
- Department of Radiology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Jung Hwa Seo
- Department of Neurology, Busan Paik Hospital, Inje University, Busan, Korea
| | - Sung Tae Kim
- Department of Neurosurgery, Busan Paik Hospital, Inje University, Busan, Korea
| | - Cheol Kyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sang-Il Suh
- Department of Radiology, Korea University Guro Hospital, Seoul, Korea
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Kapadia A, Schweizer TA, Spears J, Cusimano M, Macdonald RL. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: diagnosis, pathophysiology, clinical characteristics, and long-term outcome. World Neurosurg 2014; 82:1131-43. [PMID: 25003696 DOI: 10.1016/j.wneu.2014.07.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 06/24/2014] [Accepted: 07/03/2014] [Indexed: 02/06/2023]
Abstract
Patients with nonaneurysmal perimesencephalic subarachnoid hemorrhage (NAPSAH) have no discernible source for the bleeding and generally are considered to have a benign condition. Correctly diagnosing these patients is essential because a missed aneurysm can have catastrophic consequences. Those presenting with NAPSAH have a low risk of complications and better outcome than patients presenting with aneurysmal subarachnoid hemorrhage; however, a limited body of literature suggests that not all of these patients are able to return to their premorbid functional status. Clinical screens of cognitive status, such as the mini-mental status examination, suggest good recovery of these patients, although these tests may lack sensitivity for identifying deficits in this patient population. More comprehensive neuropsychologic testing in some studies has identified deficits in a wide range of cognitive domains at long-term follow-up in patients with NAPSAH. Because these patients often do not lose consciousness (and thus do not have substantial transient global ischemia) and they do not undergo a procedure for aneurysm repair, the cognitive sequelae can be explained by the presence of blood in the subarachnoid space. NAPSAH presents an opportunity to understand the effects of subarachnoid blood in a clinical setting.
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Affiliation(s)
- Anish Kapadia
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Tom A Schweizer
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada; Heart and Stroke Foundation of Ontario Centre for Stroke Recovery, Toronto, ON, Canada
| | - Julian Spears
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
| | - Michael Cusimano
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada
| | - R Loch Macdonald
- Division of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada; Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada; Keenan Research Centre of the Li Ka Shing Knowledge Institute at St. Michael's Hospital, Toronto, ON, Canada.
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Abstract
OBJECTIVE Spontaneous subarachnoid hemorrhage (SAH) typically prompts a search for an underlying ruptured saccular aneurysm, which is the most common nontraumatic cause. Depending on the clinical presentation and pattern of SAH, the differential diagnosis may include a diverse group of causes other than aneurysm rupture. CONCLUSION For the purposes of this review, we classify SAH into three main patterns, defined by the distribution of blood on unenhanced CT: diffuse, perimesencephalic, and convexal. The epicenter of the hemorrhage further refines the differential diagnosis and guides subsequent imaging. Additionally, we review multiple clinical conditions that can simulate the appearance of SAH on CT or MRI, an imaging artifact known as pseudo-SAH.
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Abstract
Nonaneurysmal subarachnoid hemorrhage (NA-SAH) constitutes a heterogeneous group of patients, both perimesencephalic (PMN-SAH) and non-perimesencephalic (nPMN-SAH). Despite many reports and case series, the etiology of NA-SAH remains uncertain. The differences in clinical course and outcome between PMN-SAH and nPMN-SAH are evident and have to be taken into consideration at the time of admission, as aggressive diagnostic evaluation and management are required for latter patient. In terms of diagnostic evaluation, the most important determination is to differentiate PMN-SAH from nPMN-SAH and aneurysmal SAH. PMN-SAH can be distinguished on CT in the majority of patients, but should be confirmed by a negative cerebral angiography. In addition, Convexal NA-SAH is another important subtype of NA-SAH associated with diverse etiologies and symptoms, although prognosis is generally favorable.
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Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012; 43:1711-37. [PMID: 22556195 DOI: 10.1161/str.0b013e3182587839] [Citation(s) in RCA: 2222] [Impact Index Per Article: 185.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). METHODS A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. RESULTS Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. CONCLUSIONS aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.
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