Intracranial Subarachnoid Hemorrhage Research Articles

Abstract WMP112: A 3-s=step Process Improves the Performance of Dysphagia Screens and Reduces Aspiration Pneumonia Rates Among Stroke Inpatients

Background: Dysphagia occurs in up to 78% of stroke patients and is associated with poor patient outcomes. We have previously reported low concordance rates between dysphagia screens performed by neuroscience bedside nurses compared with Speech Language Pathologists (SLPs) using the 3oz water test. Hypothesis: A multidisciplinary intervention can improve concordance rates of dysphagia screening between bedside nurses and SLPs and reduce aspiration pneumonia rates among stroke patients. Methods: An interdisciplinary team including stroke quality nurses, clinical nurse specialists, SLPs, and nursing informatics developed a 3-step intervention including 1) modifications of the electronic dysphagia screen forms to simplify documentation and provide step-by-step instructions for nursing staff, 2) hospital-wide re-education to nurses on performing dysphagia screens and 3) adjustment of all stroke ordersets to include prechecked NPO orders to prevent diet orders prior to a dysphagia screen. Interventions were completed by August 31, 2016. All stroke patients admitted to a Comprehensive Stroke Center from March 1, 2016 to May 31, 2017 were included in this analysis to determine aspiration pneumonia rates pre- and post-intervention (N=988). To determine concordance rates in dysphagia screening, neuroscience nurses and SLPs performed the same screen on consecutive stroke patients within <24 hours of each other; concordance rates were compared before and after study intervention. Results: Overall aspiration pneumonia rates significantly declined after the intervention from 11.8% to 7.3% (p=0.03). Significant declines in aspiration pneumonia rates after intervention were seen in ischemic stroke (10.4% vs 4.3%, p=0.02) patients but not seen in intracranial hemorrhage (14.8% vs 10.1%, p=0.41) or subarachnoid hemorrhage patients (11.5% vs 10.1%, p=0.85). Concordance rates between nurses and SLPs significantly increased from 52% pre-intervention up to 73% post-intervention (p=0.04). Conclusion: Our 3-step multidisciplinary dysphagia screening intervention significantly reduced aspiration pneumonia rates among ischemic stroke patients and improved concordance rates in screening results among neuroscience nurses and SLPs.

Elderly population have a decreased aneurysmal subarachnoid hemorrhage incidence rate than Middle aged population: a descriptive analysis of 8,144 cases in mainland China

Purpose: Rupture of an intracranial aneurysm is a life-threatening acute cerebrovascular event. The purpose of this study was to investigate whether aneurysmal subarachnoid haemorrhage (SAH) incidence rate is higher or lower in elderly population than in middle aged population.Materials and methods: Aneurysmal SAH cases were collected retrospectively from the archives of 21 hospitals in Mainland China. All the cases were collected from September 2016 and backward consecutively for a period of time up to 8 years. SAH was initially diagnosed by brain computed tomography (CT). CT angiography (CTA) or digital subtraction angiography (DSA) was followed and SAH was confirmed to be due to cerebral aneurysm rupture. For cases when multiple bleeding occurred, the age of the first SAH was used in this study. The total incidence from all hospitals at each age group were summed together for females and males respectively; then adjusted by the total population number at each age group for females and males which was from the 2010 population census of the People’s Republic of China.Results: In total there were 8,144 cases of intracranial aneurysmal SAH, with 4,861 females and 3,283 males. For females the relative aneurysmal SAH incidence rate started to decrease after around 65 years old, while for males the relative aneurysmal SAH incidence rate started to decrease after around 53 years old.Conclusion: Our data tentatively suggest elderly patients may be at a reduced risk of rupture compared with patients who are younger while have similar other risk factors.

Abstract P118: Inhibition of Endoplasmic Reticulum Stress Prevents Intracranial Aneurysmal Rupture in a Mouse Model

Background: Aneurysmal subarachnoid hemorrhage (SAH) can cause significant mortality and morbidity. To develop a therapy for prevention of intracranial aneurysmal rupture and subsequent SAH, it is important to clarify the mechanism of intracranial aneurysmal rupture. Stimulation of the renin-angiotensin system (RAS) causes hypertension and cardiovascular remodeling. Recent evidence shows that angiotensin II enhances endoplasmic reticulum (ER) stress and inhibition of ER stress prevents angiotensin II-induced vascular remodeling but not hypertension in mice. RAS has also been implicated in intracranial aneurysms. We have previously shown that angiotensin II receptor blocker (losartan) prevented intracranial aneurysmal rupture in a mouse model without affecting systemic hypertension. To clarify the mechanism of intracranial aneurysmal rupture via RAS, we have tested our hypothesis that inhibition of ER stress prevents intracranial aneurysmal rupture in a mouse model. Method: We used a mouse model of intracranial aneurysms in which spontaneous aneurysmal rupture causes neurologic symptoms. Intracranial aneurysms were induced in wild type mice by a single stereotactic injection of elastase (35mU) into the cerebrospinal fluid at right basal cistern and deoxycorticosterone (DOCA)-salt hypertension. Vehicle or 4-phenylbutyric acid (PBA, ER stress inhibitor , 100mg/kg/day) was subcutaneously injected into all mice once a day. To detect aneurysmal rupture, we performed daily neurological examinations. Symptomatic mice were euthanized immediately when they developed neurological symptoms, and all asymptomatic mice were euthanized 21 days after aneurysm induction. The incidence of aneurysms and rupture rate were compared between vehicle group and PBA group. Results: The incidence of aneurysms was not significantly different between two groups (100% in vehicle, 20 of 20 vs. 87% in PBA, 20 of 23, p=0.09). However, rupture rate was significantly lower in the PBA group (60%, 12 of 20) than the vehicle group (95%, 19 of 20). (p=0.008). Conclusion: Inhibition of ER stress reduced aneurysmal rupture in a mouse model of intracranial aneurysm induced by combination of elastase injection and DOCA-salt hypertension.

Brown-Séquard syndrome following intracranial subarachnoid hemorrhage-induced spinal arachnoid cyst

Abstract Objective Arachnoid cyst associated with spinal arachnoiditis following subarachnoid hemorrhage (SAH) is a rare complication. Correctly diagnosing this condition and providing an effective treatment are extremely important. Case report: A 60-year-old women had a history of SAH due to an intradural vertebral artery dissecting aneurysm post-coil embolization, without neurologic deficits on discharge from our institution. She experienced left hemiparesis with muscle power graded at 4/5 eight months later due to a right middle cerebral artery territory infarct. Nine months after stroke rehabilitation, there was a progression of left-side weakness and right-side numbness down below the nipple level. On neurological examination, there were right sensory deficits below T6, and left hemiparesis with muscle power of the left upper extremity graded at 4/5 and that of the left lower extremity graded at 3/5. Deep tendon reflex was symmetrically increased at the bilateral lower extremities. Spinal magnetic resonance imaging (MRI) revealed a cervicothoracic multiseptated arachnoid cyst with a major compression effect at T6. Eight months after T5–6 hemilaminectomy and fenestration of the cyst wall, the neurologic deficits had not improved. The patient then underwent a cysto-peritoneal shunt. A follow-up MRI documented a complete resolution of the arachnoid cyst. The patient's Brown-Sequard syndrome showed clinical improvement. Conclusion: Prompt investigation revealed a spinal arachnoid cyst in a patient with a history of intracranial SAH presenting with unexplained progressive Brown-Sequard syndrome. For cases of multiseptated and long arachnoid cyst, as in our patient, a shunting procedure is a better choice than fenestration alone.

Noninvasive assessment of the intracranial pressure in non-traumatic intracranial hemorrhage

The article describes the modified technique of measuring the diameters of the optic nerve sheath (ONSD) for assessment of the intracranial pressure (ICP) in patients with intracerebral or subarachnoid hemorrhage (SAH). The CT scans of 443 patients were analyzed retrospectively. The ONSDs were measured at 3mm behind the globe and at the point where the ophthalmic artery crosses the optic nerve. The ONSD/eyeball transverse diameter (ETD) ratio was calculated. The correlation analysis was performed with the Glasgow Coma Scale score, Hemispheric Stroke Scale score, Glasgow Outcome Score, and invasive ICP readings. ONSD was enlarged in 95% of patients with intracerebral hemorrhage or SAH. Pathological ONSDs were 6.6±0.8mm (cut-off value >5.5mm; p<0.05). ONSD/ETD ratio was 0.29±0.05 against normative 0.19±0.02 (p<0.01) with no correlation with initial Glasgow Coma Scale score or Hemispheric Stroke Scale score. There was an inverse correlation between ONSD/ETD ratio and Glasgow Outcome Score (r=−0.7) and direct correlation with invasive ICP readings. This study provides further evidence that in patients with intracranial hemorrhage and SAH, the presence of ONSD greater than a threshold of 5.5mm is significantly predictive of invasively measured elevated ICP. The prediction of raised ICP can be further refined by measuring ONSD at the point where the optic nerve and the ophthalmic artery cross, and by determining the ratio between the ONSD and ETD.

Takotsubo cardiomyopathy after intracranial aneurysmal subarachnoid hemorrhage

Objective To investigate the clinical characteristics of Takotsubo cardiomyopathy (TTC) following intracranial aneurysmal subarachnoid hemorrhage (SAH). Methods Review all patients with intracranial aneurysmal SAH from January 2013 to January 2015 in our hospital, and finally a total of 14 patients who complicated TTC were selected. Their clinical data, creatine kinase (CK), creatine kinase isoenzyme MB (CK-MB), N-terminal pro-B-type natriuretic peptide (NT-proBNP), ECG and echocardiographic findings were analyzed. Results For 14 patients of TTC following aneurysmal SAH, the value of CK was (591.93 ± 248.78) IU/L in the first 24 h on admission, and significantly decreased to (137.79 ± 29.93) IU/L 2 weeks later ( t = 7.090, P = 0.000); the value of CK-MB was (27.07 ± 7.66) IU/L in the first 24 h (3 cases were at normal levels), and significantly decreased to (14.36 ± 5.58) IU/L 2 weeks later ( t = 4.897, P = 0.000); the value of NT-proBNP was (8685.36 ± 3963.44) IU/L in the first 24 h, and significantly decreased to (577.14 ± 203.37) IU/L 2 weeks later ( t = 7.778, P = 0.000). ECG on admission mainly showed ST segment alternation, T wave inversion and QT interval prolongation. Echocardiograghic findings showed segmental left ventricular wall motion abnormalities. The average left ventricular ejection fraction (LVEF) was (36.07 ± 6.15)%, and increased to (56.43 ± 3.18)% 2 weeks later ( t = 13.381, P = 0.000). The results of ECG and echocardiographic findings were normal after one month. Conclusions Intracranial aneurysmal SAH can lead to Takotsubo cardiomyopathy, the incidence of which is 4.58% approximately, and the prognosis is good. Echocardiographic findings are significantly important for early screening of Takotsubo cardiomyopathy, and coronary angiography (CAG) can be used to make a clear diagnosis in acute phase. DOI: 10.3969/j.issn.1672-6731.2016.06.010

Controversies in epidemiology of intracranial aneurysms and SAH.

Rupture of an intracranial aneurysm is the most common cause of subarachnoid haemorrhage (SAH), which is a life-threatening acute cerebrovascular event that typically affects working-age people. The exact prevalence of unruptured intracranial aneurysms (UIAs) is unknown, but at least one in 20 to 30 adults is likely to carry an asymptomatic UIA. Approximately one quarter of these UIAs rupture in a lifetime. Complex methodological challenges in conducting studies of epidemiology and risk factors for UIAs and SAH might have led to conclusions being drawn on the basis of epidemiological data of variable quality. We believe that, as a result, misconceptions about UIAs and SAH may have arisen. In this Perspectives article, we discuss three possible misconceptions about the epidemiology of UIAs and SAH, and suggest how the quality of future research could be improved.

Factors affecting dural penetration and prognosis in patients admitted to emergency department with cranial gunshot wound.

To explore the effect of admission physical examination findings, anamnesis, and computed tomography on dural penetration and prognosis in patients with cranial gunshot wound (CGW). In this study, the medical data of 56 subjects who were admitted to the Emergency Department of Dicle University Hospital with CGWs between January 2011 and December 2013 were retrospectively reviewed. The effects of type of incident (suicidal vs non-suicidal), pupil diameter and light reflex, hemodynamic status, type (bullet or pellet), velocity, trajectory of foreign material, trauma scores, and imaging findings on dural penetration and mortality were explored. The mean age of the study population was 24.8±13.50years. Thirty (53.6%) patients had penetrating injuries and 26 (46.4%) had non-penetrating injuries; 9 (16.1%) patients died and 47 (83.9%) survived. Suicidal injury, pupil diameter and light reflex, bullet as foreign material, and high velocity and lateral trajectory of foreign material significantly affected dural penetration and mortality (p<0.05). In addition, dural penetration, bilobar, multilobar, or bihemispheric involvement of brain parenchyma, presence of intracranial hemorrhage, subarachnoid hemorrhage, ventricular hemorrhage, fracture, shift, edema, and trauma scores significantly affected mortality (p<0.05). In CGWs, dural penetration and prognosis can be predicted by physical examination findings and patient characteristics on initial admission.

Spinal Epidural Hematoma and Intracranial Subarachnoid Hemorrhage Aggravated with Lumbar Puncture in a Patient with Polycythemia Vera

Spinal Epidural Hematoma and Intracranial Subarachnoid Hemorrhage Aggravated with Lumbar Puncture in a Patient with Polycythemia Vera

An Analysis of 88 Patients with Diffuse and “Benign” Perimesencephalic Subarachnoid Hemorrhage

Perimesencephalic subarachnoid hemorrhage (PMSAH) was previously defined as a variant of subarachnoid hemorrhage (SAH) associated with a relatively benign clinical presentation and better outcomes than aneurysmal SAH. However, several prior studies have shown complications associated with PMSAH including vasospasm and hydrocephalus, and the need for follow-up imaging. We therefore reviewed our experience to further characterize the clinical consequences of PMSAH. Eighty-eight consecutive patients who sustained spontaneous intracranial SAH and whose cerebral angiograms did not show any obvious source for SAH were retrospectively studied to characterize their prognosis and outcome based on SAH pattern. Glasgow Coma Scale and Hunt-Hess scores on admission, the incidence of vasospasm or hydrocephalus, the need for an external ventricular drain, and shunt dependence, along with Glasgow outcome score (GOS) at discharge and follow-up, were used to draw comparisons between perimesencephalic and diffuse SAH patient populations. Patients with perimesencephalic SAH differed statistically (p < 0.05) from patients with diffuse SAH in regard to age, Hunt-Hess score on presentation, hospital length of stay, GOS at discharge, and incidence of hydrocephalus, angiographic vasospasm, and clinical vasospasm. Our data demonstrate that although the patients with perimesencephalic SAH fared better than those with diffuse SAH, their outcomes were worse than those of similar patients with PMSAH who have been previously reported in the literature.

Carotid Intima-Media Thickness – A Potential Predictor for Rupture Risk of Intracranial Aneurysms

Individual assessment of rupture risk of cerebral aneurysms is challenging, and increased knowledge of predictors for aneurysm rupture is needed. Smoking and hypertension are shared risk factors for atherosclerotic disease and cerebral aneurysms, and patients with atherosclerosis have an increased prevalence of intracranial aneurysms. Carotid ultrasound with evaluation of intima-media thickness (IMT) is a non-invasive, safe, rapid, well-validated and reproducible technique for quantification of subclinical atherosclerosis and assessment of cardio- and cerebrovascular risk. Increased IMT is associated with elevated risk for ischemic stroke and myocardial infarction, but sparse data exist on carotid ultrasound findings in patients with intracranial aneurysms. The purpose of this study was to investigate carotid IMT in patients with unruptured intracranial aneurysms (UIA) and aneurysmal subarachnoid hemorrhage (aSAH), and to assess if IMT might be associated with aneurysm rupture risk. Patients treated for saccular aneurysms (UIA and aSAH) from February 2011 to August 2012 were included. Standardized high resolution B-mode ultrasound assessment of carotid arteries was done after aneurysm treatment, and traditional vascular risk factors were recorded. Healthy partners of young patients with ischemic stroke were used as controls. 69 patients treated for UIA (n=28) and aSAH (n=41) were compared with 80 controls. Mean IMT was higher in patients with aSAH (0·79 mm) than patients with UIA (0·65 mm) and controls (0·63 mm). Multiple multinomial regression analysis comparing aSAH, UIA and control groups demonstrated that IMT was the only variable predicative of aSAH compared to UIA. According to the multiple regression model, the probability of having aSAH compared to non-rupture increased by 62% for each 0·10 mm increment of mean IMT (RRR=1·62, P=0·017). Taking into account only patients harboring intracranial aneurysms, simple binary logistic regression was then applied to the UIA and aSAH groups. According to this model the risk of belonging to the aSAH group increased with higher mean IMT values (OR=1·40 per 0·10 mm increase of mean IMT, P=0·024). There is an association between IMT and intracranial aneurysm rupture status at the time of aneurysm treatment. Carotid IMT can be a potential predictor of aneurysm rupture. IMT may thus be a possible adjunct in the risk assessment of aneurysm rupture, and a helpful tool in patient risk stratification and counseling.

Prolonged QTc interval is a powerful predictor of non-cardiac mortality in patients with aneurysmal subarachnoid hemorrhage independently of traditional risk factors

Prolonged QTc interval is a powerful predictor of non-cardiac mortality in patients with aneurysmal subarachnoid hemorrhage independently of traditional risk factors

Multimodal endovascular treatment of a vertebrovertebral fistula presenting with subarachnoid hemorrhage and hydrocephalus

Vertebrovertebral fistulae are rare vascular malformations that uncommonly can rupture to present clinically as intracranial subarachnoid hemorrhage. We report a 69-year-old man presenting following spontaneous apoplectic collapse. Initial workup revealed diffuse, intracranial subarachnoid hemorrhage, intraventricular hemorrhage and hydrocephalus. However, the etiology was not apparent on CT angiography of the head. Catheter-based angiography was performed, demonstrating a single-hole, high-flow vertebrovertebral fistula, arising from the V2 segment and decompressing into both cervical and skull base venous structures. Definitive treatment consisted of endovascular fistula obliteration with a combination of coil and liquid embolic material. The patient made a full neurological recovery. High cervical and skull base fistulae are rare causes of intracranial hemorrhage; endovascular treatment is effective at disconnection of the arteriovenous shunt.

Subarachnoid haemorrhage as the presenting feature of lumbar spinal arteriovenous malformation

A 41-year-old man presented with a sudden onset severe occipital headache, vomiting, neck stiffness and photophobia. He had been previously well, aside from chronic mid and lower back pain. There...

Spinal Subarachnoid Hematoma as a Complication of an Intramuscular Stimulation : Case Report and a Review of Literatures

Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.

Bevacizumab use and central nervous system (CNS) hemorrhage.

2073 Background: Bevacizumab is widely used and may cause life-threatening bleeding, usually at sites of disease involvement such as the CNS. We attempted to identify clinical characteristics associated with CNS hemorrhage in a broad population. Methods: We did a retrospective review of the FDA Medwatch database of adverse events reported with bevacizumab from 11/1997 to 5/2009. Results: We searched the database for keywords bleeding, hemorrhage, cerebral, intracranial, subarachnoid, cerebellar, hemorrhagic stroke, and brain. 17,466 reports were included in the database: 154 described CNS hemorrhage in 99 patients, and 1041 reports described non-CNS bleeds. For CNS bleeds, cerebral hemorrhage was the most frequent event reported (n=39), followed by intracranial hemorrhage (n=20) and subarachnoid hemorrhage (n=18). Median age was 62 years; 54% of patients were female. Primary cancer was colorectal (42%), glioma (13%), and breast cancer (10%). Patients received a median of three (1-36) doses of bevacizumab prior to the bleed. 54% of patients received myelosuppressive chemotherapy, and 30% had documented history of hypertension. Sixteen patients with CNS hemorrhage were reported to have CNS metastases. For 70 patients, information on CNS involvement was not reported. Death was reported as a complication of hemorrhage in 48% of patients. Nine patients with brain metastases died and CNS hemorrhage was the cause of death in seven. Six patients with glioma died, and CNS hemorrhage was the cause in three. One patient with brain metastases, and one patient with glioma also experienced a non-CNS bleed. Five patients in each group had received heparin, warfarin or NSAIDs. Low platelet counts were reported in 3 patients with CNS metastases and 2 patients with glioma. The most common factor associated with CNS hemorrhage was medication predisposing to bleeding, followed by thrombocytopenia. Hypertension, a risk factor for CNS hemorrhage, was reported in 4 patients with brain metastases, and 2 patients with glioma. Conclusions: In this database, 154 of 1195 reports of bleeding associated with bevacizumab described a CNS bleed. Although CNS bleeds were not common, they were the reported cause of death in more than half of the cases.

Abstract 2779: The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms: A Retrospective, Hospital-Based Study

Background and Purpose: Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue plasminogen activator (IV tPA) for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is significant. We sought to determine the safety of IV tPA administration in a cohort of patients with pre-existing aneurysms. Methods: We reviewed the medical records of patients treated for acute ischemic stroke with IV tPA during an 11-year period at two academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on pre-thrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage (ICH), symptomatic ICH, and subarachnoid hemorrhage (SAH). Fisher’s exact test was used to compare the rates of hemorrhage among patients with and without aneurysms. Results: We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of ICH among patients with aneurysms (14%, 95% CI 3-35%) did not significantly differ from the rate among patients without aneurysms (19%, 95% CI 14-25%). None of the patients with aneurysms developed symptomatic ICH (0%, 95% CI 0-15%), compared with 10 of 214 patients without aneurysms (5%, 95% CI 2-8%). Similar proportions of patients developed SAH (5%, 95% CI 0-23% versus 6%, 95% CI 3-10%). Conclusion: Our findings suggest that IV tPA for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms as the risk of aneurysm rupture and symptomatic ICH is low.

Effect of Intra-Arterial Nimodipine Infusion for the Treatment of Symptomatic Cerebral Vasospasm Following an Aneurysmal Subarachnoid Hemorrhage

Copyrights © 2012 The Korean Society of Radiology Purpose: Symptomatic cerebral vasospasm following an aneurysmal subarachnoid hemorrhage (SAH) is one of the major factors which cause morbidity and mortality of patients. The purpose of this study was to evaluate the effectiveness of intra-arterial nimodipine (IAN) infusion therapy in patients with symptomatic cerebral vasospasm. Materials and Methods: Between February 2005 and April 2011, fifty patients with symptomatic cerebral vasospasm following an aneurysmal SAH were treated with IAN infusion. After selective arterial catheterization, nimodipine was infused at a rate of 0.1 mg/min and a total of 2-3 mg per vessel was infused. We retrospectively reviewed the immediate angiographic results and clinical outcome at discharge. A grade of 5 and 4 in the Glasgow Outcome Scale (GOS) were considered favorable outcomes. Results: In 50 patients, 117 procedures of IAN infusion (1-7; mean, 2.3) were done. After the treatment, immediate angiographic improvement was achieved in 113 (96.6%) of 117 procedures. No major complications occurred. At discharge, 38 (76%) patients showed a favorable clinical outcome in the GOS. Conclusion: IAN infusion therapy is safe and effective for the treatment of cerebral vasospasm following an aneurysmal SAH. However, the limitation is that repeated treatment is needed. Index terms Vasospasm, Intracranial Subarachnoid Hemorrhage Nimodipine Intra-arterial Infusion Effect of Intra-Arterial Nimodipine Infusion for the Treatment of Symptomatic Cerebral Vasospasm Following an Aneurysmal Subarachnoid Hemorrhage 동맥류성 지주막하출혈 후 발생한 뇌혈관연축의 동맥 내 니모디핀 주입술의 효과

Subarachnoid hemorrhage in Kashmir: Causes, risk factors, and outcome

Context:Kashmir, a snow bound and mountain locked valley, is populated by about 7 million ethnic and non-migratory Kashmiris who have specific dietary and social habits than rest of the world. The neurological disorders are common in Kashmiri population.Aims:To study the prevalence and outcome of spontaneous intracranial subarachnoid hemorrhage (SAH) in Kashmir compared withother parts of the world.Settings and Design:A retrospective and hospital based study from 1982 to 2010 in the single and only Neurosurgical Centre of the State of Jammu and Kashmir.Materials and Methods:A hospital based study, in which, information concerning all Kashmiri patients was collected from the case sheets, patient files, discharge certificates, death certificates, and telephonic conversations with the help of Medical Records Department and Central Admission Register of Sher–i-Kashmir Institute of Medical Sciences, Kashmir India.Statistical Analysis:Analysis of variance and students T-test were used at occasions.Results:Incidence of SAH in Kashmiris is about 13/100,000 persons per year. SAH comprises 31.02% of total strokes and aneurysmal ruptures are cause of 54.35% SAHs. The female suffers 1.78 times more than the male. Total mortality of 36.60% was recorded against a good recovery of 14.99%. The familial SAHs and multiple aneurysms were also common. Intra-operative finding of larger aneurysmal size than recorded on pre-operative computed tomography (CT) angiogram of same patients was noteworthy. In 493 patients of SAH, the angiography revealed 705 aneurysms.Conclusion:Spontaneous intracranial subarachnoid hemorrhage, due to aneurysmal rupture, is common in Kashmir, with worst outcome. Food habits like “salt-tea twice a day”, group-smoking of wet tobacco like “Jejeer”, winter season, female gender, hypertension, and inhalation of “Kangri” smoke are special risk factorsof SAH, in Kashmiris. The plain CT brain and CT angiography are best diagnostic tools. The preventive measures for aneurysmal formation and rupture seems most promising management of future. The detachable endovascular aneurysmal occupying video assisted micro-camera capsules or plugs may be future treatment.

Lumbar Subdural Hematoma From Intracranial Subarachnoid Hemorrhage Presenting With Bilateral Foot Drop: Case Report

We report a patient with lumbar subdural hematoma secondary to intracranial subarachnoid hemorrhage (SAH) presenting with bilateral foot drop and describe our management. A 37-year-old woman presented with grade 4 SAH and hydrocephalus requiring emergent external ventricular drainage. Angiography demonstrated a left vertebral artery dissection and pseudoaneurysm that was treated with embolization of the vertebral artery. Six days after admission, her neurologic examination significantly improved. She was awake, alert, following commands, and moving all her extremities normally except for bilateral foot drop. An MRI scan revealed a lumbar subdural hematoma with severe thecal sac compression at L4-S1. The patient was initially treated with expectant management followed by surgery after she demonstrated only modest improvement. Evacuation of the hematoma was undertaken by an L5-S1 laminectomy and drainage of the liquefied clot in the subdural, extra-arachnoid space. Postoperatively, the patient demonstrated improved strength in all muscle groups except for left lower extremity eversion. We present a case of subdural hematoma that caused bilateral foot drop. Neurologic improvement occurred after evacuation of the hematoma.