Abstract
This study aims to investigate the characteristics of patients with mild aneurysmal and non-aneurysmal perimesencephalic and non-perimesencephalic subarachnoid hemorrhage (aSAH, pmSAH, npmSAH) with emphasis on admission biomarkers, clinical course, and outcome. A prospective cohort of 115 patients with aSAH (Hunt and Hess 1–3) and of 35 patients without aneurysms (16 pmSAH and 19 npmSAH) admitted between January 2014 and January 2020 was included. Demographic data, blood samples on admission, complications (hydrocephalus, shunt dependency, delayed cerebral ischemia DCI, DCI-related infarction, and mortality), and outcome after 6 months were analyzed. Demographic data was comparable between all groups except for age (aSAH 55 [48–65] vs. npmSAH 60 [56–68] vs. pmSAH 52 [42–60], p = 0.032) and loss of consciousness (33% vs. 0% vs. 0%, p = 0.0004). Admission biomarkers showed poorer renal function and highest glucose levels for npmSAH patients. Complication rate in npmSAH was high and comparable to that of aSAH patients (hydrocephalus, shunt dependency, DCI, DCI-related infarction, mortality), but nearly absent in patients with pmSAH. Favorable outcome after 6 months was seen in 92.9% of pmSAH, 83.3% of npmSAH, and 62.7% of aSAH (p = 0.0264). In this prospective cohort of SAH patients, npmSAH was associated with a complicated clinical course, comparable to that of patients with aSAH. In contrast, such complications were nearly absent in pmSAH patients, suggesting fundamental differences in the pathophysiology of patients with different types of non-aneurysmal hemorrhage. Our findings underline the importance for a precise terminology according the hemorrhage etiology as a basis for more vigilant management of npmSAH patients. NCT02142166, 05/20/2014, retrospectively registered.
Highlights
In up to 15% of patients with spontaneous subarachnoid hemorrhage (SAH), no aneurysm as a source of hemorrhage can be identified [20, 24]
Data from all patients with spontaneous SAH admitted to our institution between January 2014 and January /2020 and meeting the following inclusion criteria were prospectively recorded: (1) patient age greater than 18 years, (2) SAH verified by Computed tomography (CT) scan or lumbar puncture when imaging was inconclusive, (3) Hunt and Hess 1–3 on admission, and (4) diagnosis or exclusion of a bleeding source was performed by digital subtraction angiography (DSA) including a 3D rotational run
Hemorrhages restricted to the interpeduncular cistern with or without extension to the ambient, chiasmatic, and horizontal part of the Sylvian cistern were classified as Perimesencephalic subarachnoid hemorrhage (pmSAH)
Summary
In up to 15% of patients with spontaneous subarachnoid hemorrhage (SAH), no aneurysm as a source of hemorrhage can be identified [20, 24]. According to the blood distribution on the initial CT scan, non-aneurysmal hemorrhages can be divided into perimesencephalic SAH (pmSAH, blood within the interpeduncular, ambient, and chiasmatic cistern) and non-perimesencephalic SAH (npmSAH, diffuse distribution of blood) [13, 20, 23]. The clinical course and outcomes of patients with pmSAH and npmSAH are commonly reported as rather. The assumption that patients suffering from SAH without evidence of an aneurysm do not require intensive neurological monitoring during the early stage of admission is increasingly challenged [1, 12, 19], but robust prospective data are scarce. Differences in the pathogenesis, clinical management, and outcomes across these three entities, i.e., aSAH, pmSAH, and npmSAH, have been seldom investigated in a balanced, prospective cohort.
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