Multifocal Atraumatic Convexity Subarachnoid Hemorrhage.

Katarina B Dakay,Shawna M Cutting,Ali Mahta,Idrees Azher,Shadi Yaghi,Karen Furie

doi:10.7759/cureus.16091

Abstract

BackgroundMultifocal convexity subarachnoid hemorrhage (cSAH) has generally been described in the setting of traumatic brain injury, however, it has also been reported in the absence of trauma in conditions such as with reversible cerebral vasoconstriction syndrome. We describe the clinical and radiographic characteristics of multifocal cSAH in an academic center.MethodsWe analyzed our single-center retrospective database of nontraumatic convexity subarachnoid hemorrhage from January 2015-January 2018. Convexity subarachnoid hemorrhage was defined as blood in one or more cortical sulci in the absence of trauma; patients with blood in the cisterns or Sylvian fissure were excluded. Multifocal location was defined as at least two distinct foci of hemorrhage occurring in two or more lobes. Clinical and neuroimaging data were collected.ResultsOut of 70 total patients with convexity subarachnoid hemorrhage, 13 cases were of multifocal convexity subarachnoid hemorrhage, occurring in 18.6% of all cases. The mean age was 58 years (SD = 14.7). Eleven patients were female. Seven patients had reversible cerebral vasoconstriction syndrome (RCVS)/posterior reversible encephalopathy syndrome (PRES), two had cerebral amyloid angiopathy (CAA), three had intrinsic coagulopathy, and one patient had endocarditis as the etiology of multifocal cSAH. Headache was the most common complaint, in eight (61.5%) patients.ConclusionMultifocal cSAH occurs in approximately 18.6% of all cSAH and can occur in the absence of trauma. In our larger cohort of all cSAH, CAA was the most common cause; however, multifocal cSAH is more commonly caused by RCVS/PRES spectrum. Clinicians should be aware that multifocal cSAH can occur in the absence of trauma, and may be a harbinger of RCVS/PRES, particularly in young patients with thunderclap headaches.

Highlights

Convexity subarachnoid hemorrhage is commonly seen in the context of trauma; atraumatic convexity subarachnoid hemorrhage (cSAH) and accounts for approximately 5-7% of spontaneous subarachnoid hemorrhage (SAH). cSAH is defined as hemorrhage in one or more cortical sulci, without extension into the Sylvian fissure or basal cisterns
Multifocal convexity subarachnoid hemorrhage has generally been described in the setting of traumatic brain injury, it has been reported in the absence of trauma in conditions such as with reversible cerebral vasoconstriction syndrome
Out of 70 total patients with convexity subarachnoid hemorrhage, 13 cases were of multifocal convexity subarachnoid hemorrhage, occurring in 18.6% of all cases

Summary

Introduction

Convexity subarachnoid hemorrhage (cSAH) is commonly seen in the context of trauma; atraumatic cSAH and accounts for approximately 5-7% of spontaneous subarachnoid hemorrhage (SAH). cSAH is defined as hemorrhage in one or more cortical sulci, without extension into the Sylvian fissure or basal cisterns. Convexity subarachnoid hemorrhage (cSAH) is commonly seen in the context of trauma; atraumatic cSAH and accounts for approximately 5-7% of spontaneous subarachnoid hemorrhage (SAH). Unlike diffuse patterns of SAH involving the basal cisterns or Sylvian fissure and are often attributed to aneurysmal rupture, cSAH is most often related or caused by other conditions such as reversible cerebral vasoconstriction (RCVS)/posterior reversible encephalopathy syndrome (PRES), cerebral amyloid angiopathy (CAA), or venous sinus thrombosis. Multifocal cSAH is a commonly seen pattern in the context of trauma, occurring in 26.5% of cases [1]; multifocal cSAH can be seen in a minority of atraumatic cSAH. We hypothesized based on prior experience that multifocal cSAH may be suggestive of a diffuse process such as RCVS or coagulopathy, and less likely seen in structural causes of cSAH such as venous sinus thrombosis or tumor. We describe the clinical and radiographic characteristics of multifocal cSAH in an academic center

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