Cerebral venous sinus thrombosis presenting with subarachnoid hemorrhage: a series of 11 cases

BACKGROUND AND PURPOSE

Cerebral venous sinus thrombosis (CVST) is a rare cerebrovascular disease with a wide spectrum of clinical manifestations. The aim of this study is to assess the presence of subarachnoid hemorrhage (SAH) in the context of CVST and to present its epidemiological, clinical and radiological/laboratory aspects.

METHODS

Between October 2012 and October 2019, 43 patients with CVST were reviewed. Eleven (25.58%) cases presented SAH.

RESULTS

A quarter of the patients evaluated with CVST had SAH. There were 9 women (81.82%) and 2 men, with a mean age at presentation of 37.7 years (range 28-49). The most common risk factor was the use of oral contraceptives and the most prevalent symptom was headache. Both sinuses, the superior sagittal sinus and the transverse sinus, were the most affected. There was no isolated involvement of the cortical vein. The SAH was limited to some sulci of cerebral convexity in 8 cases (72.73%). In one case, the location of SAH was in the cerebellum and in two cases in the Sylvian fissure. In two cases, there was an evolution to venous infarction; and in three cases, intraparenchymal hemorrhage was present. Seven patients (63.64%) improved considerably with anticoagulation after 6 months of treatment.

CONCLUSIONS

This series found that 25.58% of patients with CVST had SAH. It is the highest incidence described in the literature so far. Findings of SAH located in the cerebral convexities, without affecting the base cisterns, should always lead to the suspicion of CVST.

Perfusion-weighted MRI in cerebral amyloid angiopathy-related transient focal neurological episodes

INTRODUCTION

Sporadic cerebral amyloid angiopathy (CAA) is a common age-related cerebral small vessel disease characterized by progressive ß-amyloid deposition in the walls of small cortical arteries, arterioles, and capillaries in the cerebral cortex and overlying leptomeninges. CAA-related transient focal neurological episodes (CAA-TFNEs) represent a challenging clinical feature interesting from a pathophysiological point of view.

CASE REPORT

Here we present two cases of CAA-TFNEs in which we performed functional imaging with perfusion-weighted imaging MR and brain 18 F-FDG PET. In both cases, we found a topographic relationship between the involved cortical areas and the clinical expression of CAA-TFNEs. Cortical superficial siderosis in the first case and a convexity subarachnoid hemorrhage in the second case were found in the contralateral rolandic area corresponding to the clinical symptoms. The same areas showed a reduction of rCBV and rCBF on perfusion-weighted MR and were also associated in one case with hypometabolism on 18 F-FDG PET.

DISCUSSION

These new findings strengthen the hypothesis that CAA involves the superficial leptomeningeal arteries but also the short penetrating arterioles reaching different depths in the cortex generating hypoperfusion and altered vascular reactivity and consequently reduced neuronal activity.

CONCLUSION

Understanding CAA-TFNEs is pivotal because they carry a very high risk of subsequent lobar intracerebral hemorrhage but are frequently misdiagnosed as TIAs and treated with antithrombotics enhancing the bleeding risk associated with CAA.

Reversible cerebral vasoconstriction syndrome and dissection in the setting of COVID-19 infection

The current COVID-19 pandemic has recently brought to attention the myriad of neuro- logic sequelae associated with Coronavirus infection including the predilection for stroke, particularly in young patients. Reversible cerebral vasoconstriction syndrome (RCVS) is a well-described clinical syndrome leading to vasoconstriction in the intracra- nial vessels, and has been associated with convexity subarachnoid hemorrhage and oc- casionally cervical artery dissection. It is usually reported in the context of a trigger such as medications, recreational drugs, or the postpartum state; however, it has not been described in COVID-19 infection. We report a case of both cervical vertebral ar- tery dissection as well as convexity subarachnoid hemorrhage due to RCVS, in a pa- tient with COVID-19 infection and no other triggers.

The Spectrum of Nontraumatic Convexity Subarachnoid Hemorrhage

BACKGROUND

Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a nonaneurysmal variant that is associated with diverse etiologies.

METHODS

With IRB approval, we retrospectively reviewed consecutive nontraumatic cSAH from July 1, 2006 to July 1, 2016. Data were abstracted on demographics, medical history, neuroimaging, etiology, and clinical presentation.

RESULTS

We identified 94 cases of cSAH. The cases were classified according to the following etiologies: reversible cerebral vasoconstriction syndrome (RCVS) 17 (18%), cerebral amyloid angiopathy (CAA) 15 (16%), posterior reversible encephalopathy syndrome 16 (17%), cerebral venous thrombosis 10 (11%), large artery occlusion 7 (7%), endocarditis 6 (6%), and cryptogenic 25 (27%). Early rebleeding occurred in 9 (10%) patients. Time from initial imaging to CT rebleeding was 40 hours (range, 5-74). CAA was associated with the highest mean age at 75.8 and RCVS the lowest at 47.6 years (P< .0001). Among patients with RCVS, initial vascular imaging was negative in 6 (35%), and repeat imaging documented vasoconstriction at a mean delay of 5 days (range, 3-16).

CONCLUSION

There were significant differences among the subgroups in cSAH, with CAA presenting as older men with transient neurological deficits, and RCVS presenting as younger women with thunderclap headache. Rebleeding was seen in 10% of cSAH patients. One-third of RCVS patients with cSAH required repeat vascular imaging to diagnose vasoconstriction.

Subarachnoid Hemorrhage with Progressive Cerebral Steno-Occlusive Disease: Report of 2 Cases

Nontraumatic nonaneurysmal subarachnoid hemorrhage (SAH) is a rare condition. Among them, SAH with cerebral steno-occlusive disease is quite rare. Moreover there has been no report of SAH patient who had been diagnosed with steno-occlusive disease since before. We here report 2 cases of nontraumatic nonaneurysmal convexity SAH who originally had progressive cerebral steno-occlusive disease. Case 1, a woman in her 40s who had diagnosed left internal carotid artery (ICA) stenosis 6 years before complained of headache. She was diagnosed SAH and progressive ICA stenosis, then performed revascularization. Case 2, a woman in her 40s who had diagnosed right ICA stenosis 7 months before complained of headache. She was diagnosed with SAH and ICA occlusion. These 2 cases suggested that progressive cerebral steno-occlusive disease lead to SAH due to collapse of their fragile pial anastomoses.

Patterns, Predictors, and Outcomes of Postprocedure Delayed Hemorrhage Following Flow Diversion for Intracranial Aneurysm Treatment

OBJECTIVE

To evaluate patterns, predictors, and outcomes of postprocedure delayed hemorrhage (PPDH) following flow diversion therapy for intracranial aneurysm treatment.

METHODS

From 2012 to 2016, 50 patients with 52 aneurysms were treated with the Pipeline embolization device. Device placement was performed as a standalone therapy or with adjunctive coil embolization. Patients underwent dual antiplatelet therapy for 6 months after treatment. Medical comorbidities; aneurysm traits; and treatment factors, including platelet function testing, were studied. Statistical analysis was performed using cross-tabulation.

RESULTS

Six PPDHs (12%) occurred 2-16 days (mean 6.8 days) after Pipeline placement, manifesting as 1 of 2 distinct patterns: convexity subarachnoid hemorrhage (cSAH) (n = 4) or lobar intraparenchymal hemorrhage (IPH) (n = 2). All PPDHs occurred ipsilateral to the device; 1 IPH occurred ipsilateral but in a different arterial territory. PPDH occurred in both treated anterior communicating artery aneurysms. Cases of PPDH demonstrated on average lower P2Y12 reaction unit values at the time of treatment. Platelet function testing at the time of hemorrhage was consistently hypertherapeutic. Patients with cSAH had only minimal worsening of modified Rankin Scale score at the time of discharge, whereas the 2 patients with IPH experienced significant deterioration.

CONCLUSIONS

PPDH is a poorly understood complication following flow diversion therapy that can result in significant morbidity. In our experience, nonaneurysmal cSAH does not result in poor clinical outcomes, whereas IPH leads to long-term deficits or death. As previously suggested, there appears to be a correlation between low P2Y12 reaction unit values and PPDH.

A Case Report

An 83 year-old-man with left atrial appendage occluder (LAAO) developed Pseudomonas Aeruginosa (PA) infective endocarditis. MRI at day 3 of onset showed distal small infarcts in both middle cerebral arteries and left postero-inferior cerebellar artery territories. MRI at day 6 revealed two sites of convexity subarachnoid hemorrhage (cSAH). MRA and CTA failed to reveal a Mycotic aneurysm.

The radiologic findings favor the assumption of necrosis of distal branches of mca or of pial arteries wall.

This case present three unusual features: the presence of localized cSAH after initiation of antibiotherapy without mycotic aneurysm being individualized; the late occurrence of infective endocarditis after LAAO implantation; the very rare occurrence of PA in prosthetic infections.

Convexity subarachnoid hemorrhage in ischemic stroke

OBJECTIVE

To report three cases of convexity subarachnoid hemorrhage (cSAH) after acute ischemic stroke and review the relevant literature.

BACKGROUND

cSAH is an unusual presentation and the association with acute ischemic stroke has only infrequently been reported.

DESIGN AND METHODS

Case series with retrospective review of the clinical presentation and neuroimaging features of patients who presented with cSAH and acute ischemic stroke.

RESULTS

We describe three cases of cSAH who presented with ipsilateral acute ischemic stroke. Two patients had ipsilateral ICA stenosis, with one patient developing cSAH after ICA stenting. The third patient developed cSAH in setting of small distal cortical ischemic lesions with normal cranial vasculature. None of these patients had evidence for cerebral amyloid angiopathy on magnetic resonance imaging-gradient echo (MRI-GRE) sequence. All our patients remained clinically stable with limited neurological deficit at the time of discharge.

CONCLUSION

We report three more cases linking cSAH with ischemic strokes. All of our patients had good outcome with minimal neurological deficit. cSAH should remain in differential diagnosis and early complication of acute ischemic stroke.

Nontraumatic convexity subarachnoid hemorrhage: different etiologies and outcomes

BACKGROUND

Nontraumatic convexity subarachnoid hemorrhage (cSAH) is a rarely reported condition with multiple etiologies. We report the clinical presentation, imaging findings, etiologies, and long-term outcomes of a case series of cSAH.

METHODS

We retrospectively analyzed consecutive cases of cSAH, admitted at a Stroke Unit of a tertiary hospital (January 2006 to March 2012). Recorded variables were demographics, clinical presentation, complementary investigation, etiology, and outcome.

RESULTS

We included 15 patients (9 men, median age of 65 years), 7% of the 210 nontraumatic SAH patients in this period. The most common clinical manifestation was a focal neurologic deficit. Predominant location of the cSAH was frontal. In 5 cases, there was a clinical significant internal carotid artery (ICA) atheromatous stenosis, ipsilateral to cSAH. Two patients had a possible cerebral amyloid angiopathy (CAA) at presentation. There were 2 cases of reversible cerebral vasoconstriction syndrome, 1 cerebral venous thrombosis, 2 dural fistulae, and 3 undetermined. Short-term outcomes were good in most patients. At follow-up (24.3 months), 2 of the patients with undetermined etiology had a lobar hematoma conferring a severe disability, and the diagnosis of CAA was made. There were no other relevant events or added disability in the other patients.

CONCLUSIONS

Significant ICA atherosclerotic stenosis was the most frequent cause of cSAH in our series, reinforcing that cSAH should prompt vascular imagiological evaluation including cervical vessels. Outcomes in cSAH seem to be related to etiology. Patients with undetermined etiology should be followed up because cSAH may be the first manifestation of CAA.