Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature

Hafez, Ahmad; Numminen, Jussi; Raj, Rahul; Järveläinen, Juha; Niemelä, Mika

doi:10.1007/s00701-016-2801-9

Cited by 8 publications

(5 citation statements)

References 29 publications

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“…It is thought to originate from a venous origin, given its amount of hemorrhage and benign clinical course [ 23 ]. A report by Hafez et al found a venous saccular aneurysm in the lateral pontine vein, in a patient with PMH [ 7 ]. Another theory suggests a leakage from the ventriculostriate and thalamoperforating vessels [ 1 ].…”

Section: Discussionmentioning

confidence: 99%

“…Abbreviations: CSF cerebrospinal fluid; DCI delayed cerebral ischemia; GCS Glasgow Coma Scale; ICH intracerebral hemorrhage; ICU intensive care unit; IQR interquartile range; IVH intraventricular hemorrhage; PMH perimesencephalic subarachnoid hemorrhage; WFNS World Federation of Neurosurgical Societies †missing for 3 patient [7]. Another theory suggests a leakage from the ventriculostriate and thalamoperforating vessels [1].…”

Section: Comparison With Previous Studiesmentioning

confidence: 99%

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Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study

et al. 2021

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Background 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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Section: Discussionmentioning

confidence: 99%

Section: Comparison With Previous Studiesmentioning

confidence: 99%

Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study

et al. 2021

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“…Table 1 showed the results: 11 patients with underlying venous pathology associated with PNSAH. Venous abnormalities, including venous aneurysm, [ 35 ] venulitis associated with Behcet disease, [ 17 ] stenosis or occlusion of vein of Galen, straight sinus, jugular vein and brachiocephalic vein, and cerebral venous thrombosis of cavernous sinus, [ 34 ] widespread sinuses, [ 17 ] straight sinus, and the vein of Galen, [ 17 ] have been implicated in various case reports as potential sources of the bleeding. So, underlying venous pathology may be identified as an important predisposing factor in the pathogenesis of PNSAH.…”

Section: Discussionmentioning

confidence: 99%

“…Most of the cases with PNSAH caused by underlying venous pathology had an excellent outcome without any complication. [ 8 , 9 , 15 , 17 , 35 ] However, patients with cerebral venous thrombosis were likely to have poorer neurological symptoms, higher scores of WFNS scale, longer duration of hospital stay together with higher frequencies of initial neurologic deficits, poor outcome relevant complication including rebleeding and hemorrhagic infarction. [ 17 , 34 ] The prognosis of patients with PNSAH caused by CVST is not as good as those of patients with PNSAH caused by other etiology.…”

Section: Discussionmentioning

confidence: 99%

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis

Fu¹,

Rao

Zheng³

et al. 2017

Medicine

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Rationale:Perimesencephalic nonaneurysmal subarachnoid hemorrhage (PNSAH) is characterized by a pattern of extravasated blood restricted to the perimesencephalic cisterns, normal angiographic findings, and an excellent prognosis with an uneventful course and low risks of complication. The precise etiology of bleeding in patients with PNSAH has not yet been established. The most common hypothesis is that PNSAH is venous in origin. Intracranial venous hypertension has been considered as the pivotal factor in the pathogenesis of PNSAH. The underlying venous pathology such as straight sinus stenosis, jugular vein occlusion may contribute to PNSAH. We describe a patient in whom transverse sinus thrombosis preceded intracranial venous hypertension and PNSAH. These findings supported that the source of the subarachnoid hemorrhage is venous in origin.Patient concerns and diagnoses:A 45-year-old right-handed man was admitted to the hospital with a sudden onset of severe headache associated with nausea, vomiting, and mild photophobia for 6 hours. The patient was fully conscious and totally alert. An emergency brain computed tomography (CT) revealed an acute subarachnoid hemorrhage restricted to the perimesencephalic cisterns. CT angiography revealed no evidence of an intracranial aneurysm or underlying vascular malformation. Digital subtraction angiography of arterial and capillary phases confirmed the CT angiographic findings. Assessment of the venous phase demonstrated right transverse sinus thrombosis. Magnetic resonance imaging confirmed the diagnosis of cerebral venous sinus thrombosis (CVST). Lumbar puncture revealed an opening pressure of 360 mmH2O, suggestive of intracranial venous hypertension. Grave disease was diagnosed by endocrinological investigation.Interventions:Low-molecular-weight heparin, followed by oral warfarin, was initiated immediately as the treatment for cerebral venous sinus thrombosis and PNSAH.Outcomes:The patient discharged without any neurologic defect after 3 weeks of hospital stay. MR venography revealed recanalization of right transverse sinus at the 6-month follow-up. No clinical or neuroimaging evidence of relapse was detected at 12 months follow-up.Lessons:Hyperthyroidism may contribute to the development of CVST. The presence of acute transverse sinus thrombosis, as a cause of PNSAH, provides further support for the hypothesis that the source of PNSAH is venous in origin and intracranial venous hypertension plays a critical role in the pathogenesis of PNSAH.

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“…During a severe SAH, the leakage of blood causes a momentary increase in ICP and as the ICP rises, the cerebral perfusion pressure of the intracranial circulation may be not enough to guarantee the oxygen supply to the brain tissue resulting in a transient global ischemia. The lack of LOC in patients with PSAH (2/77) supports the idea that the source of PSAH is from other than arterial source, for example of venous origin around the midbrain [ 4 , 7 ], as the bleed from venous origin does not cause such a momentary increase in ICP. In aneurysmal SAH, LOC is known to be a marker for early brain injury, and it is associated with 2.8-fold increase in the risk of unfavorable outcome [ 18 ].…”

Section: Discussionmentioning

confidence: 63%

The clinical course and outcomes of non-aneurysmal subarachnoid hemorrhages in a single-center retrospective study

Tarkiainen,

Hovi,

Pyysalo

et al. 2023

Acta Neurochir

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Background Non-aneurysmal subarachnoid hemorrhages (SAHs) are thought to have a benign clinical course compared to aneurysmal SAHs. The aim of this study is to report the clinical course and outcomes of non-aneurysmal SAHs in a large single-center study. Methods The patients with non-aneurysmal SAHs were screened from Tampere University Hospital from 2005 to 2020. The clinical data were collected from the patient’s medical records and from the imaging studies. The primary interest was the neurological outcome assessed by dichotomized GOS at 2 months. Multivariable logistic regression was used to study the factors associated with unfavorable outcome. Results We found 216 non-aneurysmal SAHs in 214 patients (2 patients with > 1 bleed). Ninety-seven percent of patients with a typical perimesencephalic bleeding pattern SAH (PSAH) (75/77) had a favorable outcome, while 86% of patients with non-perimesencephalic SAH (NPSAH) had a favorable outcome (84/98). In a multivariable logistic regression analysis, loss of consciousness (LOC) (aOR 214.67, 95% CI 17.62–2615.89) and Fisher grade 4 bleeding pattern (aOR 23.32, 95% CI 1.40–387.98) were associated with increased risk for unfavorable outcome (GOS 1–3). Vasospasm was seen in 20% of non-aneurysmal SAH patients, hydrocephalus in 17%, and 13% needed ventriculostomy. Conclusions Non-aneurysmal SAH seems to have a good prognosis for majority of patients, especially for patients with a PSAH. Non-aneurysmal SAH patients are however affected by vasospasm and hydrocephalus and have similar risk factors for poor outcome as patients with aneurysmal SAH. This suggests that it is the severity of the bleed rather than the etiology that associates with poor outcome.

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Perimesencephalic subarachnoid hemorrhage with a positive angiographic finding: case report and review of the literature

Cited by 8 publications

References 29 publications

Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study

Spontaneous angiogram-negative subarachnoid hemorrhage: a retrospective single center cohort study

Perimesencephalic nonaneurysmal subarachnoid hemorrhage caused by transverse sinus thrombosis

The clinical course and outcomes of non-aneurysmal subarachnoid hemorrhages in a single-center retrospective study

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