Non-traumatic subarachnoid hemorrhage with normal angiogram. Long-term follow-up and CT predictors of complications.

We investigated 91 patients with non-traumatic subarachnoid hemorrhage (SAH) in whom no aneurysm was found on initial angiography. In 31 of these patients CT did not show subarachnoid blood. A typical feature was a localized blood clot in the prepontine or interpeduncular cistern. Follow-up was obtained 6 months to 11.8 years after SAH by personal re-examination (n = 49) or questionnaire sent to patients or their doctors. 79 patients were free of neurological signs, 3 had a mild and one a severe neurological deficit. Five patients had died from SAH. Those patients who died or had complications often had blood in the frontal basal interhemispheric fissure. None of the 3 therapeutic regimens applied proved to be superior. We conclude that prognosis is good, but an unidentified aneurysm must be considered and repeat angiogram is warranted if blood is found in the anterior part of the basal cisterns. When the hemorrhage is in the prepontine cistern, repeat angiogram is not necessary.     

Pseudo-subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) appears on CT as hyperdensity in the subarachnoid space. In rare circumstances a similar appearance may occur in the absence of subarachnoid blood, a finding that has been termed “pseudo-subarachnoid hemorrhage.” We describe three patients who presented with abrupt alterations in mental status in whom CT falsely suggested SAH, and we review the literature regarding this imaging finding. In contrast to prior reports, all three of our patients had a favorable outcome.     

The Effectiveness of Lumbar Cerebrospinal Fluid Drainage to Reduce the Cerebral Vasospasm after Surgical Clipping for Aneurysmal Subarachnoid Hemorrhage

ObjectiveRemoval of blood from subarachnoid space with a lumbar drainage (LD) may decrease development of cerebral vasospasm. We evaluated the effectiveness of a LD for a clinical vasospasm and outcomes after clipping of aneurysmal subarachnoid hemorrhage (SAH).MethodsBetween July 2008 and July 2013, 234 patients were included in this study. The LD group consisted of 126 patients, 108 patients in the non LD group. We investigated outcomes as follow : 1) clinical vasospasm, 2) angioplasty, 3) cerebral infarction, 4) Glasgow outcome scale (GOS) score at discharge, 5) GOS score at 6-month follow-up, and 6) mortality.ResultsClinical vasospasm occurred in 19% of the LD group and 42% of the non LD group (p<0.001). Angioplasty was performed in 17% of the LD group and 38% of the non LD group (p=0.001). Cerebral infarctions were detected in 29% and 54% of each group respectively (p<0.001). The proportion of GOS score 5 at 6 month follow-up in the LD group was 69%, and it was 58% in the non LD group (p=0.001). Mortality rate showed 5% and 10% in each group respectively. But, there was no difference in shunt between the two groups.ConclusionLD after aneurysmal SAH shows marked reduction of clinical vasospasm and need for angioplasty. With this technique we have shown favorable GOS score at 6 month follow-up.     

Familial subarachnoid hemorrhage. Outcome study

BACKGROUND AND PURPOSE: The aim of our study was to compare outcome and its determinants in familial subarachnoid hemorrhage and in sporadic subarachnoid hemorrhage in a large and well-documented patient population. METHODS: Patients with aneurysmal subarachnoid hemorrhage (SAH) treated at the Department of Neurosurgery, Kuopio University Hospital, from 1977 to 1995 were included. Patients with polycystic kidney disease were excluded. The Glasgow Outcome Scale (GOS) score at 12 months was studied. RESULTS: There were 120 patients (97 first-, 15 second-, and 8 third-degree family connections) in 96 different families with familial SAH and 1237 patients with sporadic SAH. Age, gender, and admission grade on the Hunt and Hess scale did not differ between these 2 groups. In both groups >80% of patients were in relatively good condition at admission. The outcome was good (GOS score of 1 to 2) in 87 patients (73%) with familial SAH and in 874 patients (71%) with sporadic SAH. Analysis of 20 variables, including presence of coexisting diseases, aneurysm site and size, amount of blood shown on CT scan, intraventricular bleeding, preoperative intracerebral hematoma and hydrocephalus, as well as postoperative bleeding and vasospasm, revealed no significant differences between study groups. The degree of family connection (first-, second-, and third-degree) did not have any statistically important effect on outcome in the familial group in the Finnish study population. In multivariate analysis the knowledge of familial SAH was not an independent prognostic factor. CONCLUSIONS: Admission status, postoperative course, and outcome were similar in the familial and sporadic SAH groups in this Finnish population, in contrast to previous results. Familial SAH may not be a significant risk factor for poor outcome.     

Usefulness of computed tomography in predicting outcome after aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study

We evaluated the ability of CT performed soon after subarachnoid hemorrhage (SAH) to predict outcome. Generally, the results of CT paralleled level of consciousness in predicting mortality or good recovery. However, CT did detect some groups of patients who were at greater or lesser risk of mortality. If an alert patient had normal CT, 6-month mortality was 2.8%; if blood was detected, mortality rose to 12.3%. Intracerebral hemorrhage or local, thick, or diffuse subarachnoid deposits of blood seen on CT among alert patients were particularly related to increased mortality. CT abnormalities could be used to detect higher mortality rates among drowsy or comatose patients. CT is useful as an adjunct to the clinical examination in predicting outcome after SAH.     

Predictors for cognitive impairment one year after surgery for aneurysmal subarachnoid hemorrhage

OBJECTIVE: To assess predictors for cognitive impairment one year after spontaneous subarachnoid hemorrhage (SAH). Evaluated predictors were the total amount of cisternal blood seen on computed tomography (CT) in the acute phase as measured by the Fisher grade, neurological grade at admission classified according to the Hunt and Hess scale, aneurysm site and patient's age, gender and education level. METHOD: 44 patients were operated by surgical clipping within 72 hours after CT verified aneurysmal SAH. After twelve months the remaining 42 patients were assessed by neuropsychological test, Beck Depression Inventory (BDI), the Glasgow Outcome Scale (GOS) and CT. Multiple regression analysis was conducted where predictor variables were independent factors and a global impairment index calculated for each patient was the dependent factor. RESULTS: The Fisher grade was the only independent predictor for neuropsychological impairment. Most patients had good neurological outcome as measured by the GOS and at the same time suffered from some degree of cognitive impairment at follow-up. Individual analysis of cognitive test scores showed mild to moderate dysfunction across multiple cognitive domains. Most frequent impairments were found in domains of memory, executive function and speed of information processing. Age below 50 years was associated with relatively better outcome. CONCLUSION: The severity of cognitive impairment one year post SAH is predicted by the volume of blood in the subarachnoid space as measured by the Fisher score.     

Factors associated with hydrocephalus after subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study

Hydrocephalus is an important complication of subarachnoid hemorrhage (SAH). We analyzed several factors possibly related to hydrocephalus following SAH in 3521 patients from the International Study on the Timing of Aneurysm Surgery. Hydrocephalus was diagnosed on admission computed tomographic (CT) scans in 15% of patients and was thought to be clinically symptomatic in 13.2% of patients. There was a 5.9% overlap between these groups. Using contingency table analysis, we found the following were significantly related to clinical hydrocephalus: increasing age; preexisting hypertension; admission blood pressure measurements; postoperative hypertension; admission CT findings of intraventricular hemorrhage, a diffuse collection of subarachnoid blood, and a thick focal collection of subarachnoid blood; posterior circulation site of aneurysm; focal ischemic deficits; use of antifibrinolytic drugs preoperatively; hyponatremia; admission level of consciousness; and a low score on the Glasgow outcome scale. Using discriminate factor analysis to predict clinical hydrocephalus, the most important variables in order were the following: CT hydrocephalus, intraventricular hemorrhage, admission level of consciousness, presubarachnoid hypertension, increasing age, subarachnoid blood noted on CT scan, posterior circulation aneurysm site, and hypertension postoperatively (canonical correlation = .399). We conclude that the development of hydrocephalus after SAH is multifactorial. Factors that compromise cerebrospinal fluid circulation acutely (eg, intraventricular hemorrhage, hemorrhage from a posterior circulation site of aneurysm, and diffuse spread of subarachnoid blood) contribute to the development of acute hydrocephalus. These same factors, plus the use of antifibrinolytic drugs preoperatively, are also important in the pathogenesis of clinical hydrocephalus, perhaps by promoting subarachnoid fibrosis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Bilateral chronic subdural hematoma in a young adult mimicking subarachnoid hemorrhage]

A 33-year-old man was admitted to our hospital with a sudden severe headache five days after the onset CT scan showed a slight high-density area in the basal cistern, mimicking subarachnoid hemorrhage (SAH), and diffuse brain swelling. However, conventional cerebral angiography and CT angiography failed to demonstrate aneurysms and vascular malformations. MRI showed bilateral subdural hematoma, but no SAH. Irrigation of liquefied subdural hematoma, causing high intracranial pressure, was carried out. Postoperative course was uneventful and his headache resolved within a day. The author presented a case of bilateral chronic subdural hematoma who presented with a sudden severe headache mimicking a SAH. Hyper attenuation in the basal cistern and subarachnoid space in CT, don't always indicate SAH. MRI, including fluid-attenuated inversion recovery (FLAIR) sequences, is useful in differentiating the "pseudo" SAH from "true" SAH, and lead to the right diagnosis.     

The Utility and Benefits of External Lumbar CSF Drainage after Endovascular Coiling on Aneurysmal Subarachnoid Hemorrhage

Objective

Cerebral vasospasm still remains a major cause of the morbidity and mortality, despite the developments in treatment of aneurysmal subarachnoid hemorrhage. The authors measured the utility and benefits of external lumbar cerebrospinal fluid (CSF) drainage to prevent the clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage in this randomized study.

Methods

Between January 2004 and March 2006, 280 patients with aneurysmal subarachnoid hemorrhage were treated at our institution. Among them, 107 patients met our study criteria. The treatment group consisted of 47 patients who underwent lumbar CSF drainage during vasospasm risk period (about for 14 days after SAH), whereas the control group consisted of 60 patients who received the management according to conventional protocol without lumbar CSF drainage. We created our new modified Fisher grade on the basis of initial brain computed tomography (CT) scan at admission. The authors established five outcome criteria as follows : 1) clinical vasospasm; 2) GOS score at 1-month to 6-month follow-up; 3) shunt procedures for hydrocephalus; 4) the duration of stay in the ICU and total hospital stay; 5) mortality rate.

Results

The incidence of clinical vasospasm in the lumbar drain group showed 23.4% compared with 63.3% of individuals in the control group. Moreover, the risk of death in the lumbar drain group showed 2.1% compared with 15% of individuals in the control group. Within individual modified Fisher grade, there were similar favorable results. Also, lumbar drain group had twice more patients than the control group in good GOS score of 5. However, there were no statistical significances in mean hospital stay and shunt procedures between the two groups. IVH was an important factor for delayed hydrocephalus regardless of lumbar drain.

Conclusion

Lumbar CSF drainage remains to play a prominent role to prevent clinical vasospasm and its sequelae after endovascular coiling on aneurysmal subarachnoid hemorrhage. Also, this technique shows favorable effects on numerous neurological outcomes and prognosis. The results of this study warrant clinical trials after endovascular treatment in patients with aneurysmal SAH.     

蛛网膜下腔出血后迟发性脑血管痉挛的临床研究

为了探讨蛛网膜下腔出血（ＳＡＨ）后迟发性脑血管痉挛（ＤＣＶＳ）的临床规律，本文对６１例ＳＡＨ住院病人的脑动脉造影（ＣＡＧ）、ＣＴ及临床资料进行了回顾研究，结果如下：１、ＳＡＨ并ＤＣＶＳ的主要病因为颅内动脉瘤破裂，ＤＣＶＳ发生与颅内动脉瘤所在的部位及大小无明显关系．ＤＣＶＳ时轻度痉挛略多于重度痉挛．２、ＣＴ见基底池存在明显的高密度影时，能预示ＤＣＶＳ的发生。３、ＤＣＶＳ常与脑内血肿、脑室出血、脑积水或脑梗塞同时存在。４、ＳＡＨ再发出血，尤其是近期再发出血，可能产生或加重ＤＣＶＳ．５、ＤＣＶＳ的发生及程度与临床病情严重程度有关，ＤＣＶＳ的程度越重，临床病情也越重。６、ＤＣＶＳ的主要体征为意识障碍，近半数的病人有神经示位体征。     

实验性兔症状性蛛网膜下腔出血后脑血管痉挛模型的建立

目的 建立可靠的兔症状性蛛网膜下腔出血（ＳＡＨ）后脑血管痉挛（ＣＶＳ）的模型。方法 采用双侧颈动脉结扎后枕大池２次注血制成兔ＳＡＨ模型,观察ＳＡＨ前后动物进食量和神经功能改变,以氢清除法检测局部脑血流量。结果 ＳＡＨ后动物进食量下降、神经功能障碍和ｒＣＢＦ下降,且ｒＣＢＦ随出血时间延长和出血量增加而下降更为明显。结论 兔双侧劲动脉结扎后枕大池２次     

Does non-perimesencephalic type non-aneurysmal subarachnoid hemorrhage have a benign prognosis?

We reviewed and compared the clinical course and long-term prognosis of patients with non-aneurysmal subarachnoid hemorrhage (SAH) with and without a perimesencephalic pattern of hemorrhage on CT scan. In 876 patients with spontaneous SAH, 52 (5.9%) were diagnosed with non-aneurysmal SAH. Based on their CT scans, the SAH was classified as perimesencephalic non-aneurysmal SAH (PNSH) in 23 patients and non-perimesencephalic (non-PNSH) in 29 patients. The patients in the non-PNSH group were further divided into diffuse type (19 patients) and localized type (10 patients). We performed follow-up three-dimensional-CT angiography (3D-CTA) in all possible patients at least 1 year after the attack. The PNSH group had a lower rate of acute hydrocephalus (8.7%) and angiographic vasospasm (0%) complications than the non-PNSH group (37.9% and 27.6%, respectively). Only one case of rebleeding occurred in the non-PNSH group. No demonstrable source of bleeding was found on follow-up 3D-CTA, which was performed 1 year after the attack. All patients with non-aneurysmal SAH had similarly favorable long-term functional outcomes. Based on our study, patients with non-PNSH have a more complicated clinical course than those with PNSH. However, the long-term prognosis was similarly favorable for both the PNSH and non-PNSH in limited circumstances when they showed normal findings on a series of two-dimensional and 3D angiographic work-ups.     

中脑周围非动脉瘤性蛛网膜下腔出血的诊治

目的本探讨中脑周围非动脉瘤性蛛网膜下腔出血(PNSAH)的临床发病特点、影像学特点以及诊治。方法回顾性分析我科连续收治的92例脑血管造影(CAG)阴性SAH，发现PNSAH21例。所有患均进行CT、全脑血管造影、MR检查，16例行CT血管造影(CTA)检查。结果所有患无意识障碍，Hunt Hess分级1～2级，CT上SAH位于中脑周围的脑池内，Fisher分级梗阻2～3级。CAG、CTA和MR均无阳性发现。采用对症治疗，无再出血、症状性脑血管痉挛和脑积水等并发症，GOS均为优。结论PNSAH是一种预后佳且并发症低的良性SAH。首次CAG和CTA检查均正常的典型患，1月后可只行CTA省肯略CAG复查。     

A new experimental model in rats for study of the pathophysiology of subarachnoid hemorrhage

A new experimental model of subarachnoid hemorrhage (SAH) in rats is described. A needle was stereotaxically placed in the prechiasmatic cistern and 300, 250 or 200 microl of blood was injected manually, keeping the intracranial pressure (ICP) at the mean arterial blood pressure (MABP) level. An acceptable mortality was observed only after injection of 200 microl of blood. In this group, MABP and ICP increased immediately after SAH, but soon approached baseline levels. The subarachnoid blood was mainly distributed in the basal cisternal system and its estimated volume was about 95% of the amount injected. This new model resembles clinical SAH, is very reproducible, easy to use and seems to be a suitable model for studies of the pathophysiology of SAH.     

The safety and feasibility of continuous intravenous magnesium sulfate for prevention of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Introduction: Cerebral vasospasm in aneurysmal subarachnoid hemorrhage (SAH) is associated with poor outcome. The safety and feasibility of continuous high-dose intravenous magnesium sulfate (MgSO₄) for the prevention of cerebral vasospasm and ischemic cerebral injury has not been well studied. Methods: Patients presenting to our center within 72 hours of aneurysmal SAH (confirmed by computed tomography [CT] scanning and cerebral angiography) between June 2001 and October 2002 were enrolled in a prospective pilot study in which they received MgSO₄ as an adjunct to standard SAH management. Study patients received an intravenous infusion of 12 g of MgSO₄ in a 500-mL solution of 0.9% NaCl administered at a rate of 4.06 mM (or 0.5 g) every hour over a 24-hour period for 10 days to achieve a target predetermined serum Mg range of more than 1.5 to less than 4.0 mM/L. The effect of MgSO₄ on clinical examination, heart rate, and blood pressure was measured every 2 hours; serum glucose and phenytoin levels were monitored daily. Outcome measures included evidence of vasospasm on clinical examination, transcranial Doppler study ((TCD); velocity ≥100 cm/s), or repeat cerebral angiogram obtained within 10 days of SAH; and Glasgow Outcome Scale (GOS) score assessment and CT scan evidence of ischemic infarction at 30 days. Results: Nineteen patients (mean age: 55 years; range: 39–84 years; 11 males, 8 females) were enrolled in the study. Presenting Hunt & Hess grade was II or higher; mean Fisher grade was 3. Vasospasm was observed in nine patients (by clinical examination in two, TCD in five, and angiogram in nine). The mean serum Mg level was 2.7 mM/L (standard deviation: ±0.37) and was maintained during the infusion period. No clinical adverse effects, hemodynamic changes, or fluctuations in serum glucose or phenytoin levels were observed. None of the patients died; no CT evidence of ischemic infarction was present; and most had good outcomes (GOS 5 in 10 patients; GOS 4 in 8 patients). Conclusion: Our study confirmed the safety and feasibility of a continuous infusion of high-dose intravenous MgSO₄ in patients with aneurysmal SAH. Randomized controlled trials are required to confirm the promising results.     

三种方法制作大鼠蛛网膜下腔出血模型

目的探讨三种方法制作大鼠蛛网膜下腔出血(SAH)模型的应用价值。方法分别采用颈内动脉穿刺法(PIC)、枕大池2次注血法(ACM)和交叉前池注血法(APC)制作大鼠SAH模型。观察不同模型的病死率、蛛网膜下腔血液分布及含量、脑血管痉挛程度及持续时间、伴发脑水肿、血-脑屏障(BBB)通透性等方面的改变。结果三种方法均成功制作SAH模型。病死率:PIC为46.2%,ACM为25.0%,APC为11.1%。血管痉挛高峰时间:PIC与APC均为第2天,第3～5天恢复正常;ACM为第5天,持续7 d。蛛网膜下腔血液量:ACM为(240.50±25.38)lμ,APC为(172.15±25.45)μl;PIC模型变异大,为60～520 lμ,平均(267.12±45.86)μl。PIC模型脑水肿最重,ACM与APC模型脑水肿相对较轻。PIC模型造成严重的BBB通透性损害,另两组损害程度相近。结论三种方法制成的模型适用于研究SAH不同病理生理改变的需要。PIC脑水肿重,病死率高,适用于SAH后脑损害的机制研究;ACM脑血管痉挛的时间特征与人SAH后血管痉挛接近,适用于血管痉挛的机制研究;APC血液恒定分布于前循环,病死率低,...     

蛛网膜下腔出血脑脊液引流并置换的治疗时机与方式选择

目的探讨研究蛛网膜下腔出血(SAH)早期行脑脊液引流与置换术的时机和方式,观察其临床效果。方法共入选重度原发性SAH患者43例,根据入院先后随机分为治疗组(采用腰池置管密闭式循环引流与置换CSF技术治疗)21例和对照组(采用间断腰穿CSF置换术治疗)22例。另选择同期住院的轻-中度SAH患者23例作为空白组(单纯内科保守治疗)。观察指标为神经功能缺损评分(NIHSS)、日常生活活动能力评分(ADL)、意识障碍评分(GCS)、头痛缓解时间、蛛网膜下腔血液廓清时间、住院时间、病死率及并发症。结果治疗组NIHSS 5.85±5.35、ADL 95.42±16.35、GCS 13.95±1.03;对照组NIHSS 20.83±8.78、ADL 63.23±10.45、GCS 9.80±1.47。两组比较差异均有统计学意义(P<0.01);治疗组并发脑积水、脑血管痉挛发生率为23.81%(5/21),死亡2例(9.5%),低于对照组的54.54%(12/22),死亡4例(18.2%),差异有统计学意义(P<0.05);治疗组患者头痛缓解时间5±1.38d、蛛网膜下腔血液廓清时间3±1.6d、住院时间17±1.8d,低于对照组的16±2.57d、8±2.5d及33±1.5d,差异有统计学意义(P<0.01)。三组再出血的发生率分别为14.29%(3/21)、18.18%(4/22)及21.74%(5/23),差异无统计学意义(P>0.05)。结论根据SAH的轻重程度早期选择不同的CSF引流与置换技术能提高治愈率,降低病死率和致残率,减少症状性脑血管痉挛和慢性脑积水的发生率,缩短住院时间,无增加再出血的风险,提高患者的生活质量。     

CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study

Computed tomography was performed on 1,378 patients admitted within 3 days of subarachnoid hemorrhage (SAH) at 71 centers in a cooperative study. CT on the day of SAH (day 0) was abnormal in 95.8%. Intracranial blood was detected in 95.3% of patients on day 0, 90.5% on the first day after SAH (day 1), and 73.8% on day 3. CT was normal in only 1 of 284 patients in stupor or coma but was normal in 14.6% of 638 alert patients. In the first few days after SAH, CT is highly accurate, often obviating the need of CSF examinations. The interval from SAH until CT and the seriousness of the patient's condition are two factors that influence the results of CT.     

Timing of Computed Tomography and Prediction of Vasospasm after Aneurysmal Subarachnoid Hemorrhage

Background  The initial noncontrast computed tomography (CT) study of the head after an aneurysmal subarachnoid hemorrhage (SAH) is used to predict the risk of developing vasospasm. Changes in the extent of subarachnoid blood seen on CT images occur as a function of time after SAH, but there is no consensus on the time interval during which this study needs to be completed. Methods  Clinical and radiological information on adult SAH patients were reviewed. Patients were grouped based on the time elapsed from ictus to the initial head CT study. The amount of subarachnoid blood on CT was graded using the Hijdra sum score (HSS) and the modified Fisher scale (MFS). The relationship between the initial CT grading score and the risk of angiographic vasospasm was assessed for each group. Results  A total of 224 consecutive patients were identified (145 females, 65%). Initial CT was performed within 24 h of the event in 163 (Group 1, 73%) and after 24 h in 61 patients (Group 2, 27%). A total of 54 patients (24%) developed angiographic vasospasm. A statistically significant association between the extent of subarachnoid blood and subsequent development of vasospasm was observed only if the initial CT imaging study was performed within 24 h of aneurysmal rupture (P = 0.0001 and 0.02 for HSS and MFS, respectively). Conclusions  We propose that only CT scans obtained within 24 h of a subarachnoid bleeding event should be used to estimate the risk of vasospasm.