Cisternal Hemorrhage Research Articles

Mystery Case: Acute clot within P1 segment mimicking cisternal hemorrhage in Percheron infarction

A 72-year-old man was admitted after sudden onset of coma (Glasgow Coma Scale score 6/15). At clinical examination he had tetraparesis, bilateral Babinski signs, bilateral unresponsive miosis, and vertical gaze palsy. Head CT scan demonstrated a linear hyperdensity outlining the interpeduncular cistern (figure, A). Additional MRI examination was performed promptly to rule out blood extravasation since thrombolysis was considered. Bilateral Percheron artery type II infarction was demonstrated on diffusion-weighted imaging (figure, B). Magnetic resonance (MR) angiogram demonstrated complete occlusion of right P1 segment (figure, C), the abnormal hyperintensity seen on CT image corresponding to the occluding fresh clot. Comparison of CT and MRI data appeared mandatory to reach an appropriate therapeutic option in this peculiar condition. Follow-up MR angiogram demonstrated complete recanalization (figure, D).

Roles of cistern and cisternal hemorrhage in the occurrence of acute hydrocephalus after aneurysmal subarachnoid hemorrhage

Objective To investigate the roles of cistern and cisternal hemorrhage in the occurrence of acute hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). Methods The clinical data of 306 patients with aSAH diagnosed and treated surgically at the Department of Neurosurgery, Nanfang Hospital, Southern Medical University from May 2011 to January 2014 were analyzed retrospectively. Their clinical variables were analyzed with the univariate analysis and multivariate logistic regression analysis, and the blood volume of each cistern was analyzed quantitatively. Results Among of the 306 patients, 112 had acute hydrocephalus, and the incidence was 36.6%. Univariate analysis suggested that there were significant differences in six factors, including Fisher grade, intraventricular hemorrhage, location of aneurysm, sides of aneurysm, rebleeding, and treatment (P<0.05); multivariate logistic regression analysis showed that the location of aneurysm and intraventricular hemorrhage were its independent occurrence factors. In patients without intraventricular hemorrhage, the incidence of acute hydrocephalus was 22.4%, of which the blood volumes of interpeduncular cistern and right sylvian cistern were the maximum in the hydrocephalus group. Compared with the non-hydrocephalus group, there were significant differences (P=0.000; P=0.005). Conclusions Acute hydrocephalus after aSAH is the result of multiple factors working together. The location of aneurysm and intraventricular hemorrhage are its independent risk factors. The acute hydrocephalus after aSAH is an obstructive hydrocephalus. The location of cistern and the distribution of cisternal hemorrhage have important influences in the occurrence of acute hydrocephalus after aSAH. In aSAH patients without intraventricular hemorrhage, the larger the hematocele volume of the interpeduncular cistern and right sylvian cistern, the more prone to acute hydrocephalus Key words: Intracranial aneurysm; Subarachnoid hemorrhage; Hydrocephalus; Risk factors; Subarachnoid cistern; Hemorrhage

Abstract 2456: Quantitative Analysis Of Hemorrhage Volume For Predicting Cerebral Vasospasm After Subarachnoid Hemorrhage Between Surgical Clipping And Coil Embolization

Objective: Subarachnoid clots are important in development of delayed vasospasm after subarachnoid hemorrhage (SAH). The purpose of this study was to define the association between the subarachnoid clot volume and the incidence of symptomatic vasospasm (SV) after surgical clipping and embolization with Guglielmi detachable coils (GDCs) for aneurysmal SAH. Methods: The subjects were 155 patients with aneurysmal SAHs that were detected with a CT scan at admission and were treated by surgical clipping (Clip group, n=112) or GDC embolization (Coil group, n=43) within 72 hours of ictus between January 22, 2002 and November 22, 2009. Software-based volumetric quantification of the subarachnoid clot was performed using the voxel count method (AZE Virtual Place Fujin Raijin, AZE Ltd.). Subarachnoid clot was defined as cisternal high density areas with a Hounsfield number from 43 to 90 in the CT scan. Results: SV occurred in 24.1% and 16.3% of the patients in the Clip group (age, 63.5±12.8; male, 33.9%) and the Coil group (age, 63.0±12.6; male, 18.6%), respectively. The area under the ROC curve for subarachnoid clots for SV patients was 0.588 (95% confidence interval: 0.472-0.704; Clip group) and 0.849 (95% confidence interval: 0.714-0.985; Coil group). Using subarachnoid clot volumes of 19.6 ml (Clip group) and 32.1 ml (Coil group) as the cut-off values, the sensitivity and specificity were 89 and 39% (Clip group) and 100 and 61% (Coil group), respectively. A χ 2 test also identified that subarachnoid clots (&gt;19.0 ml) were associated with the development of SV compared to lower blood volumes in the Clip group (≤19.0 ml, p=0.017) and that subarachnoid clots (&gt;32.0 ml) were associated with development of SV compared to lower blood volumes in the Coil group (≤32.0 ml, p=0.03). The hemorrhage volumes of the patients with SV in the Clip group were lower than those in the Coil group at admission (37.7±21.5 vs. 58.5±23.1 ml, p=0.034), on the day after the operation (16.5±14.6 vs. 38.3±17.4 ml, p=0.002), and on Day 3-10 after SAH (5.5±4.1 vs. 11.4±9.3 ml, p=0.017). The hemorrhage volume at admission did not differ significantly between the groups (Clip group: 32.5±22.9 ml, Coil group: 32.8±22.4 ml). Conclusions: A threshold of cisternal hemorrhage volume (&gt;19.0 ml in the Clip group and &gt;32.0 ml in the Coil group) may exist above which patients are very likely to develop SV. Aneurysm surgery itself may be harmful to the brain (brain retraction, use of a temporary clip, and mechanical manipulation of cerebral arteries) and can lead to the onset of cerebral vasospasm.

Endovascular Treatment of Severe Vasospasm in Nonaneurysmal Perimesencephalic Subarachnoid Hemorrhage

Nonaneurysmal perimesencephalic subarachnoid hemorrhage (SAH) has usually a benign prognosis and uneventful course; however, recent reports suggest that these patients may develop severe symptomatic vasospasm. Description of the clinical course of one patient with nonaneurysmal perimesencephalic SAH who required intraarterial infusion of calcium antagonists and transluminal balloon angioplasty for treatment of symptomatic vasospasm. The perimesencephalic clot burden was quantified to determine if there is a relationship with the development of symptomatic vasospasm. Despite maximized clinical management, the patient described in this report developed vasospasm and delayed cerebral ischemia (DCI), requiring multiple endovascular interventions. The volumetric quantification of subarachnoid blood was 15.4ml, and was mostly localized in the cisternal space. Nonaneurysmal perimesencephalic SAH may have a "malignant" course requiring close neurocritical care monitoring and multiple clinical and endovascular interventions. Moreover, large cisternal hemorrhage was correlated with the development of DCI in this patient with non-aneurysmal SAH.

Thrombosis and subsequent recanalization of a ruptured intracranial aneurysm in 2 children, demonstrating the value of repeating catheter angiography after an initial negative study

The cases of 2 children with true aneurysmal subarachnoid hemorrhages (SAHs) and initial false-negative angiograms are reported. In both cases, the initial angiogram was of adequate technical quality and included the projections on which aneurysms were later documented. There was no significant vasospasm at the time of initial angiography; therefore, transient aneurysm sac thrombosis was the most likely explanation for the initial false-negative studies. It is particularly interesting to note that 1 of the 2 patients had a pattern of hemorrhage compatible with the most limited definition of a perimesencephalic SAH, that is, a small prepontine cistern hemorrhage. If a second angiogram had been deemed unnecessary based on that criterion alone, a ruptured basilar tip aneurysm would have escaped detection and treatment.

CT Demonstration of Dorsal Midbrain Hemorrhage in Traumatic Fourth Cranial Nerve Palsy

A 21-year-old man who suffered a traumatic brain injury from a motor vehicle accident recovered brain function except for an isolated left fourth cranial nerve palsy. Brain CT showed a focal hemorrhage in the right dorsal midbrain, directly in the brainstem path of what would become the left fourth cranial nerve. Although there has been previous imaging documentation of midbrain and cisternal hemorrhage in patients with isolated post-traumatic fourth cranial nerve palsy, this is the first report to show a large midbrain hemorrhage on CT. The mechanism is likely to be concussive impact of the dorsal midbrain on the tentorium cerebelli.

Post-Traumatic Interpeduncular Cistern Hemorrhage as a Marker for Brainstem Lesions

We retrospectively reviewed a prospectively collected database of our diffuse axonal injury (DAI) patients to evaluate the accuracy of the evidence of interpeduncular cistern (IPC) blood on computed tomography (CT) scan when diagnosing brainstem lesions (BSL) early after trauma. From December 1989 to December 2008 we prospectively maintained a clinical and radiological database of head injured patients admitted to our neurosurgical intensive care unit (ICU) that met the following criteria: coma (Glasgow Coma Scale [GCS] score < 9) following the traumatic event; neurological derangement not ascribable to hypoxia, hypotension, or long-acting drugs able to alter state of consciousness; absence of lesions accounting for the severity of coma either on the admission CT scan or on subsequent CT scans; and no contraindications to magnetic resonance imaging (MRI; e.g., indwelling metallic implants). Patients with MRI evidence of BSL exhibited a significantly higher incidence of IPC blood on CT scan than patients without such evidence (77.92% versus 20.00%; p < 0.0001). However, these same patients showed a similar incidence of lesions not associated with IPC blood (68.83% versus 56%; p = 0.2459). The evidence of IPC blood on CT scan as an indicator of BSL had a sensitivity of 0.78 (95% CI: 0.70, 0.86), and a specificity of 0.80 (95% CI: 0.72, 0.88), with a 3.90 likelihood ratio for a positive CT scan, and a 0.28 likelihood ratio for a negative CT scan. Our data suggest that the finding of IPC blood on CT scan early after trauma in patients with otherwise unexplained coma is a good marker for possible brainstem lesions.

Long-Term Outcome of Endoscopic Third Ventriculostomy in Obstructive Hydrocephalus

This multicentric study reports on 140 patients who underwent endoscopic third ventriculostomy for obstructive hydrocephalus in four Italian neurosurgical centers between 1994 and 1999. Its aim is to define the long-term outcome of these patients many years (6-12) after the initial procedure. The study includes both children and adults; the etiology of the hydrocephalus was malformative aqueductal stenosis in 88 cases (62.8%), compression by tumors of the mesencephalic and pineal regions and posterior fossa in 45 (32.2%) and post-infection aqueductal stenosis in 7 (5%). The ETV was performed by using the standard technique. The overall rate of good results (shunt-independent patients with clinical remission or improvement) was 87.1%. Eighteen patients (12.9%) required a shunt because of ETV failure. The long-term outcome of ETV in this study was not influenced by the patient's age and the etiology of the hydrocephalus (although cases secondary to cisternal hemorrhage and infections are not included). Other series including cases with long follow-up are analyzed. In conclusion, ETV results in a high rate of good long-term outcome in patients with obstructive hydrocephalus. Because postoperative failures occur early, clinical and radiological control studies must be performed particularly in the first years after the neuroendoscopic procedure.

Volumetric quantification of Fisher Grade 3 aneurysmal subarachnoid hemorrhage: a novel method to predict symptomatic vasospasm on admission computerized tomography scans.

Predicting which patients with aneurysmal subarachnoid hemorrhage (SAH) will develop delayed ischemic neurological deficit (DIND) due to vasospasm remains subjective and unreliable. The authors analyzed the utility of a novel software-based technique to quantify hemorrhage volume in patients with Fisher Grade 3 aneurysmal SAH. Patients with aneurysmal SAH in whom a computerized tomography (CT) scan was performed within 72 hours of ictus and demonstrated Fisher Grade 3 SAH were analyzed. Severe DIND was defined as new onset complete focal deficit or coma. Moderate DIND was defined as new onset partial focal deficit or impaired consciousness without coma. Fifteen consecutive patients with severe DIND, 13 consecutive patients with moderate DIND, and 12 consecutive patients without DIND were analyzed. Software-based volumetric quantification was performed on digitized admission CT scans by a single examiner blinded to clinical information. There was no significant difference in age, sex, admission Hunt and Hess grade, or time to admission CT scan among the three groups (none, moderate, or severe DIND). Patients with severe DIND had a significantly higher cisternal volume of hemorrhage (median 30.5 cm3) than patients with moderate DIND (median 12.4 cm3) and patients without DIND (median 10.3 cm3; p < 0.001). Intraparenchymal hemorrhage and intraventricular hemorrhage were not associated with DIND. All 13 patients with cisternal volumes greater than 20 cm3 developed DIND, compared with 15 of 27 patients with volumes less than 20 cm3 (p = 0.004). The authors developed a simple and potentially widely applicable method to quantify SAH on CT scans. A greater volume of cisternal hemorrhage on an admission CT scan in patients with Fisher Grade 3 aneurysmal SAH is highly associated with DIND. A threshold of cisternal hemorrhage volume (> 20 cm3) may exist above which patients are very likely to develop DIND. Prospective application of software-based volumetric quantification of cisternal SAH may predict which patients will develop DIND.

Acute hydrocephalus after aneurysmal subarachnoid hemorrhage.

Hydrocephalus, defined as a bicaudate index above the 95th percentile for age, was found in 34 (20%) of 174 prospectively studied patients with subarachnoid hemorrhage (SAH) who survived the first 24 hours and who underwent computerized tomography (CT) scanning within 72 hours. The occurrence of acute hydrocephalus was related to the presence of intraventricular blood, and not to the extent of cisternal hemorrhage. The level of consciousness was depressed in 30 of the 34 patients. Characteristic clinical features were present in 19 patients, including a gradual obtundation after the initial hemorrhage in 16 patients and small nonreactive pupils in nine patients (all with a Glasgow Coma Scale score of 7 or less). In the remaining 15 patients (44%), the diagnosis could be made only by CT scanning. After 1 month, 20 of the 34 patients had died: six from rebleeding (four after shunting), 11 from cerebral infarction (eight after an initial improvement), and three from other or mixed causes. Only one of nine patients in whom a shunt was placed survived, despite rapid improvement in all immediately after shunting. The mortality rate among patients with acute hydrocephalus was significantly higher than in those without, with the higher incidence caused by cerebral infarction (11 of 34 versus 12 of 140 cases, respectively; p less than 0.001). Death from infarction could not be attributed to the extent of cisternal hemorrhage, the use of antifibrinolytic drugs, or failure to apply surgical drainage, but could often be explained by the development of hyponatremia, probably accompanied by hypovolemia.