Postpartum cerebral angiopathy presenting with non-aneurysmal subarachnoid hemorrhage

Parturition increases the risk of strokes of various types, including postpartum cerebral angiopathy (PCA), which is characterized by reversible multifocal vasoconstriction of the cerebral arteries. We describe an unusual presentation of PCA associated with postpartum non-aneurysmal subarachnoid hemorrhage (SAH). A 31-year-old multiparous woman complained of sudden headache 3 hours after an uncomplicated vaginal delivery. She had no history of pregnancy-induced hypertension. SAH was found over the bilateral frontoparietal convexities with multifocal vasculopathy. Her symptoms resolved completely within 1 week. The findings of a follow-up neurological examination, cerebral angiography, and brain MRI were normal after 2 months. PCA syndrome may be associated with postpartum non-aneurysmal SAH.     

Short- and long-term outcomes in non-aneurysmal non-perimesencephalic subarachnoid hemorrhage

Objective: Our aim was to assess the short- and long-term prognosis in patients suffering from non-aneurysmal non-perimesencephalic SAH (Na-NPM-SAH).

Methods: Based on admission CT-scan, SAH was categorized as perimesencephalic (PM) or non-perimesencephalic (NPM). Based on digital subtraction angiography (DSA) results, patients were classified as normal DSA (Na-SAH) or aneurysmal SAH (aSAH). Between 1997 and 2010, 67 of 571 patients with non-traumatic SAH (11.7%) suffered from non-aneurysmal non-perimesencephalic SAH. Retrospective analyses of the 67 patients were undertaken, and compared with the aneurysmal SAH group. Long-term follow-up was assessed.

Results: The cohort consisted of 67 Na-NPM-SAH patients, mean age 54.8 years (range: 21–84), 56.7% male. Acute phase: 10.4% mortality and 3% rebleeding (two patients) during the acute phase. Long-term: extensive follow-up was possible in all except one of the survivors at discharge. Mortality was 6.6% during the 510 patient-years follow-up period (median follow-up time per patient, 8.95 years); rebleeding rate was 0–1.6%. An aneurysmal source was found in 13% of patients who underwent a second angiography. Aneurysmal SAH: 312 patients, with confirmed aneurysm by angiography. The mortality rate for Na-NPM-SAH during the acute phase was 10.4%, vs. 20% for aneurysmal SAH in the general database, p = 0.049.

Discussion: Na-NPM-SAH patients without an identifiable bleeding source on initial angiography might have a more benign short- and long-term prognosis than aneurysmal SAH patients. Our study confirms an important diagnostic advantage of a second arteriography. Still, despite the major concern of an undetected aneurysm, the long-term rebleeding rate was low in this subgroup of patients.     

Clinical outcome of spontaneous non-aneurysmal subarachnoid hemorrhage in 108 patients

Background: The cause of spontaneous subarachnoid hemorrhage (SAH) is unknown in 15% of cases; idiopathic SAH has a better prognosis than aneurysmal SAH. When bleeding is confined to the perimesencephalic cisterns, SAH has an especially benign course. Methods: We retrospectively studied 108 patients admitted for spontaneous non‐aneurysmal SAH between 1991 and 2004. We divided patients into two groups according to the bleeding pattern at cranial CT: perimesencephalic pattern (n = 60) and aneurysmal pattern (n = 48). We included only patients in whom no source of bleeding was detected at angiography; patients with aneurysmal pattern underwent at least two angiographic examinations. Mean follow‐up was 5.5 years; follow‐up consisted of telephone interview in 84.7% of patients. Results: All but one patient with perimesencephalic pattern were classified as grade I or II on the Hunt and Hess scale; the exception was the only patient in this group with a complication (hydrocephalus), who was classified as grade IV. Three‐quarters of the patients with aneurysmal pattern were classified as grade I or II on the Hunt and Hess scale; 5 patients presented with hydrocephalus that required drainage and 2 with vasospasms without repercussions. No rebleeding or long‐term complications were observed in either group. Conclusions: Non‐aneurysmal SAH with a perimesencephalic pattern of bleeding has a benign course and excellent short‐term and long‐term prognosis. Patients with non‐aneurysmal SAH with an aneurysmal pattern of bleeding have more complications, and the initial clinical situation has a significant impact on their prognosis.     

Systemic interleukin-6 concentrations in patients with perimesencephalic non-aneurysmal subarachnoid hemorrhage

Patients with spontaneous non-aneurysmal subarachnoid hemorrhage (non-aSAH) are considered to have a benign illness in contrast to patients with aSAH. The occurrence of the systemic inflammatory response syndrome has been linked to worse outcomes in patients with aSAH. We analyzed systemic interleukin (IL)-6, a proinflammatory cytokine, to determine whether its concentration differs between patients with non-aSAH and those with aSAH, reflecting the more benign illness. Daily systemic IL-6 levels were measured in the acute phase in 11 patients with non-aneurysmal perimesencephalic SAH (pmSAH), with bleeding strictly located around the midbrain, and in nine patients with non-aneurysmal non-perimesencephalic (non-pmSAH), with hemorrhage extending into adjacent cisterns (group 1). IL-6 levels were compared with those from patients suffering from aSAH with cerebral vasospasm (CVS) (group 2) and without CVS (group 3). The mean IL-6 level (±standard error of the mean) was significantly lower in group 1 compared to group 2 (9.9±1.9 vs. 29.1±6.7 pg/mL, p=0.018). The difference in mean IL-6 level between group 1 and 3 fell short of significance (9.9±1.9 vs. 14.9±1.1 pg/mL, p=0.073). Patients in group 1 had a significantly better outcome (Glasgow Outcome Scale score 4-5) compared to group 2 (p<0.001) and a trend towards better outcome compared to group 3 (p=0.102). A subgroup analysis revealed a higher mean IL-6 concentration in patients with non-pmSAH compared to patients with pm-SAH (p=0.001). We concluded that systemic IL-6 concentration reflects the severity of the inflammatory stress response and course of the illness. The more benign illness and good prognosis of patients with pmSAH or non-pmSAH in contrast to patients with aSAH is reflected by the lower concentrations of IL-6.     

Quadrigeminal non-aneurysmal subarachnoid hemorrhage--a true variant of perimesencephalic subarachnoid hemorrhage. Case report

Spontaneous non-aneurysmal subarachnoid hemorrhage (SAH) centered in the quadrigeminal cistern has been proposed as a variant of perimesencephalic non-aneurysmal SAH (PNSH). Some authors contest the existence of this entity, claiming it results either from head trauma or an undiscovered P2-P3 aneurysm, and conclude that all PNSH arise in front of the brainstem in a 'pretruncal' location. We report a patient with a quadrigeminal pattern of subarachnoid blood who was investigated with two digital catheter angiograms, including 3-D angiography, plus a high-resolution computed tomography angiogram. No abnormal findings were present and the patient had an excellent outcome. We propose that the more common pretruncal PNSH and less common quadrigeminal PNSH are two types of perimesencephalic SAH with separate, distinct etiologies, both of which have a more benign clinical course than aneurysmal SAH.     

Spinal syringomyelia following subarachnoid hemorrhage

Subarachnoid blood has been reported as a cause of chronic spinal arachnoiditis. Although syringomyelia has been thought to be caused by spinal arachnoiditis, reports of syringomyelia following aneurysmal subarachnoid hemorrhage (SAH) are very rare. We describe two patients with syringomyelia associated with chronic spinal arachnoiditis following SAH. From January 2001 to December 2010, 198 patients with aneurysmal SAH were treated at Kinki University School of Medicine. Two of the 198 patients had syringomyelia following aneurysmal SAH; thus the rate of syringomyelia associated with aneurysmal SAH was 1.0%. Patient 1 was a 54-year-old woman who presented with back pain, back numbness and gait disturbance 20 months after SAH. Her MRI revealed syringomyelia of the spinal cord from C2 to T10. She underwent shunting of the syrinx to the subarachnoid space. Patient 2 was a 49-year-old man, who was admitted to the hospital with headache, diplopia, hoarseness, dysphagia and ataxia five months after SAH. MRI revealed syringomyelia from the medulla oblongata to C6, and an enlargement of the lateral and fourth ventricles. After foramen magnum decompression and C1 laminectomy, a fourth ventricle-subarachnoid shunt was placed by insertion of a catheter. Spinal arachnoiditis and spinal syringomyelia are rare but important chronic complications after SAH.     

Demographic,circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage

Background

Although, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before.

Objective

For the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH.

Methods

We reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n = 338) or naSAH (n = 46) on clinical and radiological criteria. PMH (n = 32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared.

Results

Aneurysmal SAH occurred most often from 6 am to 12 pm (p < 0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p = 0.008) and smoking (p = 0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p = 0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p < 0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p = 0.0159).

Conclusion

Statistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.     

蛛网膜下腔出血的影像学检查

颅内动脉瘤破裂是造成蛛网膜下腔出血的最主要原因，因此，一旦明确诊断即应迅速对动脉瘤的数目、位置、大小、形态，以及与载瘤动脉和邻近颅内结构的关系等进行全面评价，     

Spinal vascular malformations in non-perimesencephalic subarachnoid hemorrhage

Objective   In patients with non-traumatic subarachnoid hemorrhage (SAH) and no evidence for a cerebral aneurysm on angiography, a frequent cause of the hemorrhage is perimesencephalic hemorrhage or other cerebral vascular pathology. In some patients no cause is found. The exact incidence of a spinal vascular malformation (SVM) as the origin for the SAH is not known. We assessed the occurrence of SVM in angiogram-negative, non-perimesencephalic subarachnoid hemorrhage (NPSAH). Methods   47 patients (from a consecutive cohort of 632) were identified with an angiogramnegative, non-perimesencephalic subarachnoid hemorrhage and 42 of these were analyzed by performing MR-imaging of the complete spinal neuraxis with additional spinal angiography on indication. Results   In four patients a spinal vascular malformation was identified as the cause of the SAH, indicating an incidence of 9 % of SVM in NPSAH, and an incidence of 1 % of SVM in all patients with SAH. Interpretation   Systematic analysis of angiogram-negative, non-perimesencephalic subarachnoid hemorrhage by MR imaging of the complete spinal neuraxis yields a higher incidence of SVM than previously documented. We recommend MR imaging of the complete spinal neuraxis in patients with a non-perimesencephalic subarachnoid hemorrhage in whom no cause for the hemorrhage has been found.     

Correction to: Hypothalamic injury in spontaneous subarachnoid hemorrhage: a diffusion tensor imaging study

Clinical Autonomic Research - Unfortunately, the electronic supplementary material (ESM) has been incorrectly published in the original publication.     

Spinal angiolipoma with acute subarachnoid hemorrhage.

Angiolipoma is a rare tumor of the spine commonly presenting with compressive myelopathy. We report a spinal angiolipoma in a 14-year-old patient with acute spinal subarachnoid hemorrhage (SAH). To our knowledge this is the first reported case of a spinal angiolipoma presenting with SAH, associated with post-subclavian coarctation with diffuse hypoplasia of the descending aorta. This association of coarctation of aorta, aortic hypoplasia and spinal angiolipoma has also not been reported previously.     

Warning signs in subarachnoid hemorrhage: a cooperative study

The present study is part of a survey of subarachnoid hemorrhage cases observed in 16 neurosurgical and 8 neurological departments in Italy between June 1985 and June 1986. Warning signs preceding major hemorrhage were analyzed in 364 patients with intracranial aneurysms confirmed by angiography and reliable clinical history. Seventy-four (20.3%) had warning signs. Clinical features of premonitory warning signs were compared with symptoms of 78 patients without a history of minor leak and clinical grade 1 (according to the criteria of Hunt & Hess) at admission. Symptoms of warning signs are generally clear enough to be considered a misdiagnosis of intracranial aneurysm. Thunderclap headache described as severe, unusual and sudden was the main symptom in every case though the higher frequency of focal of diffuse signs in groups with a correct diagnosis attracted more careful attention in referral and diagnostic-therapeutic management. Improving the identification of minor leak and defining diagnostic strategy are discussed.     

Predictive nomogram models for unfavorable prognosis after aneurysmal subarachnoid hemorrhage: Analysis from a prospective,observational cohort in China

Aim

The aim of the study was to identify predictors for 3-month poor functional outcome or death after aSAH and develop precise and easy-to-use nomogram models.

Methods

The study was performed at the department of neurology emergency in Beijing Tiantan Hospital. A total of 310 aSAH patients were enrolled between October 2020 and September 2021 as a derivation cohort, while a total of 208 patients were admitted from October 2021 to March 2022 as an external validation cohort. Clinical outcomes included poor functional outcome defined as modified Rankin Scale score (mRS) of 4–6 or all-cause death at 3 months. Least absolute shrinkage and selection operator (LASSO) analysis, as well as multivariable regression analysis, were applied to select independent variables associated with poor functional outcome or death and then to construct two nomogram models. Model performance were evaluated through discrimination, calibration, and clinical usefulness in both derivation cohort and external validation cohort.

Results

The nomogram model to predict poor functional outcome included seven predictors: age, heart rate, Hunt-Hess grade on admission, lymphocyte, C-reactive protein (CRP), platelet, and direct bilirubin levels. It demonstrated high discrimination ability (AUC, 0.845; 95% CI: 0.787–0.903), satisfactory calibration curve, and good clinical usefulness. Similarly, the nomogram model combining age, neutrophil, lymphocyte, CRP, aspartate aminotransferase (AST) levels, and treatment methods to predict all-cause death also revealed excellent discrimination ability (AUC, 0.944; 95% CI: 0.910–0.979), satisfactory calibration curve, and clinical effectiveness. Internal validation showed the bias-corrected C-index for poor functional outcome and death was 0.827 and 0.927, respectively. When applied to the external validation dataset, both two nomogram models exhibited high discrimination capacity [poor functional outcome: AUC = 0.795 (0.716–0.873); death: AUC = 0.811 (0.707–0.915)], good calibration ability, and clinical usefulness.

Conclusions

Nomogram models constructed for predicting 3-month poor functional outcome or death after aSAH are precise and easily applicable, which can help physicians to identify patients at risk, guide decision-making, and provide new directions for future studies to explore the novel treatment targets.     

Spinal subarachnoid hemorrhage due to a filum terminale ependymoma.

We present a case of spinal subarachnoid hemorrhage due to an ependymoma of the filum terminale in a 23-year-old male. Clinical signs indicating a spinal origin of the subarachnoid hemorrhage are discussed. Subarachnoid hemorrhages are only rarely caused by an intraspinal tumor, most of which are located in the cauda equina. Our findings in this case proved the value of MRI examination in tumors of the cauda equina.     

Aneurysmal subarachnoid hemorrhage in patients with migraine and tension headache: A cohort comparison study

Migraine headache is a common condition with an estimated lifetime prevalence of greater than 20%. While it is a well-established risk factor for cardiovascular disease and ischemic stroke, its association with subarachnoid hemorrhage is largely unexplored. We sought to compare the incidence of aneurysmal subarachnoid hemorrhage in a cohort of migraine patients with a cohort of patients with tension headache. A cohort comparison study utilizing the MarketScan insurance claims database compared patients diagnosed with migraine who were undergoing treatment with abortive or prophylactic pharmacotherapy (treatment cohort) and patients diagnosed with tension headache who had never been diagnosed with a migraine and who were naïve to migraine pharmacotherapy (control cohort). Patients with major pre-existing risk factors for aSAH were excluded from the study, and minor risk factors such as smoking status and hypertension were accounted for using coarsened exact matching (CEM) and subsequent cox proportional-hazards (CPH) regression. More than 679,000 patients (~125,000 treatment and ~ 550,000 control) with an average follow-up of more than three years were analyzed for aneurysmal subarachnoid hemorrhage. CPH regression on matched data showed that treated migraine patients had a significantly lower hazard of aneurysmal subarachnoid hemorrhage compared with tension headache patients (HR = 0.40, 95% CI: 0.19 – 0.86, p = 0.02). This large cohort comparison study, analyzing more than 679,000 patients, demonstrated that migraine patients undergoing pharmacologic treatment had a lower hazard of aneurysmal subarachnoid hemorrhage than patients diagnosed with tension headaches. Future work specifically focusing on migraine medications may identify the mechanisms underlying this association.     

Safety of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage: A retrospective cohort study

ObjectiveTo investigate the safety and efficacy of early rehabilitation in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients.MethodsOne hundred eleven patients with aSAH admitted between April 2015 and March 2019, were retrospectively evaluated. The early rehabilitation program was introduced in April 2017 to actively promote mobilization and walking training for aSAH patients. Therefore, patients were divided into two groups (The conventional group (n = 55) and the early rehabilitation group (n == 56). Clinical characteristics, mobilization progression, and treatment variables were analyzed. Complications (rebleeding, symptomatic cerebral vasospasm, hydrocephalus, disuse complications,) and a modified Rankin Scale (mRS) at 90 days were compared in two groups. Factors associated with favorable outcomes (mRS≤2) at 90 days were also assessed.ResultsThe early rehabilitation group had a significantly shorter span to first walking (9 vs. 5 days; P = 0.007). The prevalence of complications was not significantly increased in the early rehabilitation group. Approximately 40% of patients in both groups had pneumonia and urinary tract infections but significantly reduced antibiotic-administration days (13 vs. 6 days; P < 0.001). mRS at 90 days also showed significant improvement in the early rehabilitation group (3 vs. 2; P=0.01). Multivariate logistic regression analysis of favorable outcomes associated that the administration of the early rehabilitation program has a significant independent factor (odds ratio, 3.03; 95% confidence interval, 1.1-8.37).ConclusionsEarly rehabilitation for patients with aSAH can be feasible without increasing complication occurrences. The early rehabilitation program with active mobilization and walking training reduced antibiotic use and was associated with improved independence.