首次全脑血管造影阴性的自发性蛛网膜下腔出血的临床及影像学分析

目的探讨首次全脑血管造影阴性的自发性蛛网膜下腔出血患者的病因和诊疗策略。方法回顾性分析43例经头颅CT或腰穿脑脊液检查确诊为自发性蛛网膜下腔出血，但首次全脑血管造影检查为阴性患者的临床及影像学资料。结果43例患者临床表现出现头痛43例，恶心呕吐36例，一过性意识障碍3例，局灶性神经功能障碍（肢体瘫痪）3例，癫痫发作2例，脑膜刺激征阳性39例。头颅CT显示为典型蛛网膜下腔出血者35例，其余8例通过腰穿发现血性脑脊液确诊。35例患者中符合中脑周围非动脉瘤性蛛网膜下腔出血（PNSH）者21例。其余14例为非PNSH。所有患者于发病后2～7d内行首次全脑血管造影检查，结果均为阴性。发病14-21d后全部复查全脑血管造影或CTA，41例仍为阴性；1例发现颅内动脉瘤，1例发现脊髓血管畸形，且均为非PNSH患者。经病因及对症治疗后，患者均预后良好。结论首次全脑血管造影阴性的自发性蛛网膜下腔出血患者临床症状较轻，并发症少，预后较好。对于临床症状和影像学表现符合PNSH的患者，应避免重复造影。但对于高度怀疑颅内动脉瘤或血管畸形可能的非PNSH患者，应积极复查DSA或高质量的CTA或MRA以免漏诊和误诊。

Clinical and imaging characteristics of subarachnoid hemorrhage with initial normal DSA

Objective To analysis the etiology of patients suffering subarachnoid hemorrhage with initial normal DSA and discuss the treatment strategies. Methods Clinical and imaging data of 43 subarachnoid hem- orrhage cases with initial normal DSA were analyzed retrospectively. Results The clinical manifestations were headache（43 cases）, nausea and vomiting（36 cases）, transient unconsciousness（3 cases）, focal dysfunction（3 cases） ,seizure（2 cases） and neck-stiffness（39 cases）. 35 cases were diagnosed by typical CT imaging, while 8 cases by lamber puncture. CT imaging of 21 patients of the 35 cases showed typical perimesencephalic nonaneu- rysmal subarachnoid hemorrhage. All patients had undergone DSA in 2-7 days after onset and no abnormal findings were obtained. The. second DSA or CTA had been performed in 14-21 days after onset, showed in- tracranial aneurysm（1 case） and vascular malformation of spinal cord（1 case）. The respective treatment strate- gies have good clinical efficacy on most patients. Conclusions Subarachnoid hemorrhage with initial normal DSA is a distinct clinical entity, with few manifestations, low rate of severe complications and good prognosis. Repeated angiography should be avoided for PNSH patients. But for non PNSH patients of whom intracranial aneurysm or vascular malformation is highly suspected,DSA or quality CTA or MRA should be repeated to a- void misdiagnosis.