Tag: Perimesencephalic subarachnoid hemorrhage

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Spontaneous angiogram-negative subarachnoid hemorrhage

Acta Neurochirurgica (2022) 164:129–140

Spontaneous angiogram-negative subarachnoid hemorrhage (SAH) is considered a benign illness with little of the aneurysmal SAH-related complications. We describe the clinical course, SAH-related complications, and outcome of patients with angiogram-negative SAH.

Methods We retrospectively reviewed all adult patients admitted to a neurosurgical intensive care unit during 2004–2018 due to spontaneous angiogram-negative SAH. Our primary outcome was a dichotomized Glasgow Outcome Scale (GOS) at 3 months. We assessed factors that associated with outcome using multivariable logistic regression analysis.

Results Of the 108 patients included, 84% had a favorable outcome (GOS 4–5), and mortality was 5% within 1 year. The median age was 58 years, 51% were female, and 93% had a low-grade SAH (World Federation of Neurosurgical Societies grading I–III). The median number of angiograms performed per patient was two. Thirty percent of patients showed radiological signs of acute hydrocephalus, 28% were acutely treated with an external ventricular drain, 13% received active vasospasm treatment and 17% received a permanent shunt. In the multivariable logistic regression model, only acute hydrocephalus associated with unfavorable outcome (odds ratio = 4.05, 95% confidence interval = 1.05–15.73). Two patients had a new bleeding episode.

Conclusion SAH-related complications such as hydrocephalus and vasospasm are common after angiogram-negative SAH. Still, most patients had a favorable outcome. Only acute hydrocephalus was associated with unfavorable outcome. The high rate of SAH-related complications highlights the need for neurosurgical care in these patients.

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Pre-mesencephalic subarachnoid hemorrhage: rupture of tiny aneurysms of the basilar artery perforator

Acta Neurochir (2009) 151:1639–1646. DOI 10.1007/s00701-009-0416-0

Subarachnoid hemorrhage (SAH) around the midbrain without evidence of aneurysm, a so-called perimesencephalic SAH, has been considered a typical nonaneurysmal SAH. Recently, we have encountered several patients with SAHs that could have been classified as having perimesencephalic SAH, but a common cause of the bleeding was demonstrated. In this article, we describe clinical and radiologic characteristics of these patients.

Methods: Clinical and radiologic data from patients with spontaneous SAH (total number 339) who were treated at Seoul National University Bundang Hospital between May 2003 and December 2007 were reviewed.

Results: Of the 13 patients that could be classified as having perimesencephalic SAH, three had common radiologic features that were distinct from others. On computed tomography, the main hemorrhage (hematoma) was found localized in front of the midbrain (interpeduncular and/or peduncular cistern). Angiographically, the cause of the bleeding was not seen on conventional views and rotational angiograms. In three-dimensional reconstructed angiographic images, very small-sized (tiny) aneurysmal lesions were visible at the origin of mesencephalic perforators from the basilar artery. All the aneurysms were positioned at the exact site corresponding to the pre-mesencephalic clots. Follow-up angiography was performed on the three patients and all showed complete disappearance of the lesions at 1 month, 15 months, and 16 months follow-up, respectively.

Conclusions: Based on our experience, we suggest a subtype of spontaneous SAH that has unique hemorrhage localization (pre-mesencephalic cistern), specific cause (tiny aneurysms at the origin of the mesencephalic perforator), and a common benign clinical course.

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