Spontaneous subarachnoid hemorrhage and negative initial vascular imaging—should further investigation depend upon the pattern of hemorrhage on the presenting CT?

Yap, L.; Dyde, Richard; Hodgson, Timothy J.; Patel, Umang; Coley, Stuart C.

doi:10.1007/s00701-015-2506-5

Cited by 11 publications

(5 citation statements)

References 33 publications

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“…Approximately 15% of intracranial SAH cases ultimately remain cryptogenic. 16 , 17 Scrutinizing the etiology of a nonperimesencephalic SAH with an initial negative angiography, Andaluz et al. 17 mentioned the role of spinal CT angiography as a next step, but advised regarding the lack of evidence.…”

Section: Discussionmentioning

confidence: 99%

“…12,13 Approximately 15% of intracranial SAH cases ultimately remain cryptogenic. 16,17 Scrutinizing the etiology of a nonperimesencephalic SAH with an initial negative angiography, Andaluz et al 17 mentioned the role of spinal CT angiography as a next step, but advised regarding the lack of evidence. Germans et al 18 specifically investigated the yield of spinal imaging for nonaneurysmal nonperimesencephalic SAH in a multicenter prospective study, concluding that the yield and clinical relevance of spinal MRI in this context are low and thus would not be recommended.…”

Section: Observationsmentioning

confidence: 99%

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Thoracic root–related intradural extramedullary cavernoma presenting with subarachnoid hemorrhage: illustrative case

Martins Coelho Junior,

Toop,

Kobalka

et al. 2024

Journal of Neurosurgery: Case Lessons

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BACKGROUND Just 5% of all cavernomas are located in the spine. Thoracic root–related subtypes are the rarest, with a total of 14 cases reported in the literature to date. Among them, only 4 presented with subarachnoid hemorrhage (SAH). OBSERVATIONS A 65-year-old female presented after an ictus of headache with no neurological deficits. Computed tomography (CT) demonstrated sulcal SAH, with the remainder of the workup nondiagnostic for etiology. Three weeks later, she re-presented with acute thoracic back pain and thoracic myelopathy. CT and magnetic resonance imaging suggested dubiously a T9–10 disc herniation with spinal cord compression. Surgical decompression and resection were then planned. Intraoperative ultrasound (IUS) demonstrated an intradural extramedullary lesion, confirmed to be cavernoma. Complete resection was achieved, and the patient was discharged a few days postoperatively to inpatient rehabilitation. LESSONS Although spine imaging is deemed to be low yield in the evaluation of cryptogenic SAH, algorithms can be revisited even in the absence of spine-related symptoms. Surgeons can be prepared to change the initial surgical plan, especially when preoperative imaging is unclear. IUS is a powerful tool to assess the thecal sac after its exposure and to help guide this decision, as in this rare entity.

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Section: Discussionmentioning

confidence: 99%

Section: Observationsmentioning

confidence: 99%

Thoracic root–related intradural extramedullary cavernoma presenting with subarachnoid hemorrhage: illustrative case

Martins Coelho Junior,

Toop,

Kobalka

et al. 2024

Journal of Neurosurgery: Case Lessons

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“…Other studies have recommended the use of c-MRI only in selected cases in which there are signs and symptoms raising the suspicion for spinal pathology, 16,25 or for patients with a second clinical episode. 27 However, all of these studies have been limited by small sample sizes.…”

Section: Discussionmentioning

confidence: 99%

Is there added value in obtaining cervical spine MRI in the assessment of nontraumatic angiographically negative subarachnoid hemorrhage? A retrospective study and meta-analysis of the literature

Sadigh

Holder

Switchenko

et al. 2018

Journal of Neurosurgery

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OBJECTIVE Diagnostic algorithms for nontraumatic angiographically negative subarachnoid hemorrhage (AN-SAH) vary, and the optimal method remains subject to debate. This study assessed the added value of cervical spine MRI in identifying a cause for nontraumatic AN-SAH. METHODS Consecutive patients 18 years of age or older who presented with nontraumatic SAH between February 1, 2009, and October 31, 2014, with negative cerebrovascular catheter angiography and subsequent cervical MRI were studied. Patients with intraparenchymal, subdural, or epidural hemorrhage; recent trauma; or known vascular malformations were excluded. All cervical MR images were reviewed by two blinded neuroradiologists. The diagnostic yield of cervical MRI was calculated. A literature review was conducted to identify studies reporting the diagnostic yield of cervical MRI in patients with AN-SAH. The weighted pooled estimate of diagnostic yield of cervical MRI was calculated. RESULTS For all 240 patients (mean age 53 years, 48% male), catheter angiography was performed within 4 days after admission (median 12 hours, interquartile range [IQR] 10 hours). Cervical MRI was performed within 19 days of admission (median 24 hours, IQR 10 hours). In a single patient, cervical MRI identified a source for SAH (cervical vascular malformation). Meta-analysis of 7 studies comprising 538 patients with AN-SAH produced a pooled estimate of 1.3% (95% confidence interval 0.5%–2.5%) for diagnostic yield of cervical MRI. No statistically significant between-study heterogeneity or publication bias was identified. CONCLUSIONS Cervical MRI following AN-SAH, in the absence of findings to suggest spinal etiology, has a very low diagnostic yield and is not routinely necessary.

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“…59 This recommendation was further corroborated by Ruigrok et al 60 in 2000, who determined that CTA without additional follow-up was the best diagnostic strategy compared with no angiographic work-up, DSA without follow-up, and CTA with DSA follow-up to exclude aneurysms in patients with pSAH using a mathematical model. [62][63][64][65] in 2014 (41 patients) and of our institutional data of 18 patients have been performed, and none showed positive findings at DSA or any follow-up imaging studies.…”

Section: Discussionmentioning

confidence: 99%

Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

Kalra

Matouk

et al. 2015

Stroke

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A retrospective keyword search was performed for reports containing the words perimesencephalic, prepontine, or pretruncal in the past 6 years at our single, large, multisite, academic institution after obtaining Institutional Review Board approval with waiver of consent. Inclusion criteria consisted of patients with perimesencephalic pattern of blood on initial noncontrast CT undergoing CTA and DSA within 24 hours of admission and additional follow-up angiographic imaging. Patients with history of trauma, diffuse SAH, thick blood above the perimesencephalic cistern, and intraventricular blood were excluded. Two-hundred fourteen CTA reports met keyword search Background and Purpose-Multiple studies have shown that negative computed tomographic angiograms (CTAs) are reliable in excluding aneurysms in patients with isolated perimesencephalic subarachnoid hemorrhage (pSAH). We evaluate the use of digital subtraction angiography versus CTA for initial diagnosis and of angiographic follow-ups in patients with pSAH by performing an institutional analysis and a meta-analysis of literature. Methods-Retrospective institutional analysis of patients with pSAH was performed from 2008 to 2014. The number and types of follow-up imaging studies were tabulated. Initial and follow-up studies were evaluated by an experienced neuroradiologist for intracranial aneurysm. Meta-analysis of literature was performed to assess the use of initial digital subtraction angiography and of follow-up imaging. Results-Our institutional review revealed no additional use of initial digital subtraction angiography or of any angiographic follow-up after initial negative CTA in patients with pSAH on noncontrast CT. Meta-analysis of 40 studies yielded a total of 1031 patients. Only 8 aneurysms were first diagnosed on follow-ups (0.78%). Careful review showed that some of these aneurysms reported on follow-up are of questionable validity. Initial digital subtraction angiography and follow-up imaging after a negative initial CTA showed no statistically significant benefits. Conclusions-In

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Spontaneous subarachnoid hemorrhage and negative initial vascular imaging—should further investigation depend upon the pattern of hemorrhage on the presenting CT?

Cited by 11 publications

References 33 publications

Thoracic root–related intradural extramedullary cavernoma presenting with subarachnoid hemorrhage: illustrative case

Thoracic root–related intradural extramedullary cavernoma presenting with subarachnoid hemorrhage: illustrative case

Is there added value in obtaining cervical spine MRI in the assessment of nontraumatic angiographically negative subarachnoid hemorrhage? A retrospective study and meta-analysis of the literature

Use of Follow-Up Imaging in Isolated Perimesencephalic Subarachnoid Hemorrhage

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