Non-traumatic Spontaneous Subarachnoid Hemorrhage Research Articles

METEOROLOGICAL VARIABLES ASSOCIATED WITH SUBARACHNOID HEMORRHAGE: A SINGLE CENTER STUDY.

Spontaneous subarachnoid hemorrhage (SAH) can occur unexpectedly and independently of the classic risk factors. Several different factors could affect intracranial aneurysm (IA) rupture, such as morphological and hemodynamic factors. The aim of this study was to establish the potential association of meteorological data such as temperature, atmospheric pressure, and humidity, and the onset of clinical symptoms preceding hospital admission of patients with acute SAH due to IA rupture. This retrospective study included 130 consecutive patients admitted for non-traumatic SAH with a determinable onset of SAH symptoms. The effects of meteorological parameters of atmospheric pressure, ambient temperature, and relative air humidity on the day of acute SAH onset and 24 hours prior to the onset of symptoms were recorded and analyzed in each patient. Spearman rank correlation analysis was used to assess the risks of incident SAH on the basis of daily meteorological data. Seasonal incidence of acute SAH showed the peak incidence in winter and a trough in summer, with monthly incidence peak in January and December. The circadian rhythm analysis showed the peak incidence of SAH in the forenoon, followed by the evening. Acute SAH incidence showed moderate positive association with daily atmospheric pressure (p<0.05), while no association was found with ambient temperature and relative air humidity. Our results suggested no significant association of changes in ambient temperature and relative humidity with the risk of SAH. Increases in atmospheric pressure were weakly associated with a higher SAH risk. Additional studies are needed to establish in detail both meteorological and morphological factors important to predict IA rupture and SAH.

Epidemiological Features of Nontraumatic Spontaneous Subarachnoid Hemorrhage in China: A Nationwide Hospital-based Multicenter Study.

Background:Nontraumatic spontaneous subarachnoid hemorrhage (SAH) is associated with a high mortality. This study was conducted to investigate the epidemiological features of nontraumatic spontaneous SAH in China.Methods:From January 2006 to December 2008, the clinical data of patients with nontraumatic SAH from 32 major neurosurgical centers of China were evaluated. Emergent digital subtraction angiography (DSA) was performed for the diagnosis of SAH sources in the acute stage of SAH (≤3 days). The results and complications of emergent DSA were analyzed. Repeated DSA or computed tomography angiography (CTA) was suggested 2 weeks later if initial angiographic result was negative.Results:A total of 2562 patients were enrolled, including 81.4% of aneurysmal SAH and 18.6% of nonaneurysmal SAH. The total complication rate of emergent DSA was 3.9% without any mortality. Among the patients with aneurysmal SAH, 321 cases (15.4%) had multiple aneurysms, and a total of 2435 aneurysms were detected. The aneurysms mostly originated from the anterior communicating artery (30.1%), posterior communicating artery (28.7%), and middle cerebral artery (15.9%). Among the nonaneurysmal SAH cases, 76.5% (n = 365) had negative initial DSA, including 62 cases with peri-mesencephalic nonaneurysmal SAH (PNSAH). Repeated DSA or CTA was performed in 252 patients with negative initial DSA, including 45 PNSAH cases. Among them, the repeated angiographic results remained negative in 45 PNSAH cases, but 28 (13.5%) intracranial aneurysms were detected in the remaining 207 cases. In addition, brain arteriovenous malformation (AVM, 7.5%), Moyamoya disease (7.3%), stenosis or sclerosis of the cerebral artery (2.7%), and dural arteriovenous fistula or carotid cavernous fistula (2.3%) were the major causes of nonaneurysmal SAH.Conclusions:DSA can be performed safely for pathological diagnosis in the acute stage of SAH. Ruptured intracranial aneurysms, AVM, and Moyamoya disease are the major causes of SAH detected by emergent DSA in China.

ECG abnormalities predict neurogenic pulmonary edema in patients with subarachnoid hemorrhage

ObjectiveThe study aims to assess if electrocardiographic (ECG) abnormalities could predict the development of neurogenic pulmonary edema (NPE) within 24 hours in cases of spontaneous subarachnoid hemorrhage (SAH). MethodsWe studied prospectively a cohort of 269 adult patients with nontraumatic SAH in an emergency department of a university-affiliated medical center. A 12-lead ECG was taken for these patients. The patients were stratified into NPE and non-NPE based on serially clinical and radiologic findings. The ECG abnormalities were compared between these 2 groups of patients. ResultsCompared with the non-NPE (n = 229), the NPE (n = 40) had significantly higher World Federation of Neurological Surgeons class (P < .001), higher Hunt-Hess scale (P < .001), and higher prevalence of diabetes mellitus (P = .033). In addition, the percentage of ECG morphological abnormality was significantly higher in NPE, in which nonspecific ST- or T-wave changes (NSSTTCs) are significantly higher. Multiple logistic regression model identified World Federation of Neurological Surgeons class (95% confidence interval [CI], 2.6-13.3; P < .001), abnormal Q or QS wave (95% CI, 1.1-9.1; P = .038), and NSSTTCs (95% CI, 1.2-7.5; P = .016) as the significant variables associated with NPE. ConclusionsElectrocardiographic abnormalities, especially abnormal Q or QS wave and NSSTTCs, may predict the development of NPE within 24 hours in adult patients with spontaneous SAH.

Sixty-four multi-slice cerebral CT angiographic findings in early non-traumatic subarachnoid hemorrhage

Background: spontaneous subarachnoid hemorrhage (SAH) is subtype of hemorrhagic stroke with extremely poor prognosis. It’s a medical emergency and can lead to death or severe disability even when recognized and treated at an early stage. Computed tomographic angiography (CTA) is frequently become the initial step in detecting intracranial aneurysms and planning therapeutic interventions.&#x0D; Objectives: to analyze the findings of non traumatic SAH in cerebral CTA and characterization of the underlying causes, emphasizing the importance of CTA as a new advent investigation in Iraq.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; J Fac Med Baghdad&#x0D; 2014; Vol.56, No .2&#x0D; Received Mar .2014&#x0D; Accepted May. 2014&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Patients and methods: This cross sectional study performed on 62 patients with non-traumatic SAH who underwent CTA in Baghdad Teaching Hospital at medical city-Baghdad from August 2012–August 2013 of patients with highly clinical suspicion of SAH or those who were diagnosed by native computed tomography (CT) or magnetic resonance imaging (MRI), the sample of the study was consist of 37 males and 25 females, age of patients ranged from 1-70 years; all patients examined by CTA using 64 multi-slice CT.&#x0D; Results: From 62 patients in our study, 10 patients have negative finding, 38 have aneurysm, 7 have AVM, 5 have cavernoma and 2 patients have venous angioma. 81.6 % of the aneurysms were saccular and 18.4% were fusiform in shape and mostly (89.5%) supratentorial in location and 10.5% infratentorially, which is single in 84.2% and more than one in 15.8% of patients. The most frequent types of arteriovenous malformation (AVM) were parenchymal (71.4%), from which the size 3-6 cm was most frequent (60%), while the Dural AVM identified in 28.6% of patients; from which, the size 3 cm most frequent size (66.6%) and no cases reported with mixed types.&#x0D; Conclusion: CTA can provide rapid, minimally-invasive evaluation of broad spectrum of cerebrovascular disorders and CTA adequate for detecting aneurysms in symptomatic SAH patients especially when conjoined with native CT, also CTA is helpful in intervention planning.

Prospective Comparison of Multi-Detector Computed Tomographic Angiography with Digital Subtraction Angiography for the Diagnosis of Intracranial Aneurysms in Patients with Acute Non-Traumatic Subarachnoid Hemorrhage

Background Rupture of intracranial aneurysms and malformations are the main causes of spontaneous subarachnoid hemorrhage (SAH). Multi-detector computed tomography angiography (CTA) and intra-arterial digital subtraction angiography (DSA) are used to evaluate cerebrovascular structures and to detect such abnormalities with an intention to treat them. Objective The aim of the present study was to compare CTA and DSA findings in the detection of a cerebral aneurysm in patients with acute non-traumatic SAH and to depict the diagnostic value of CTA. Methods During the last 3 years 52 patients with non-traumatic SAH were prospectively studied. Four patients underwent only 16-slice multi-detector CTA and 48 patients underwent both CTA and DSA in an acute setting. Aneurysm morphologic information on CTA was compared to DSA, which is considered the gold standard imaging technique. Results The sensitivity of CTA per aneurysm was 97.9% (95% confidence intervals-CI 0.83-1), the specificity 100% (CI 0.50-0.99), the positive diagnostic likelihood ratio 0 and the negative diagnostic likelihood ratio 0.02. DSA successfully depicted 47 aneurysms in 40 patients from our study group. One aneurysm was missed on CTA (2 mm) which retrospectively was identified. In 8 patients with SAH no aneurysm was detected by either CTA or DSA. Conclusion 16-slice multi-detector CTA can be successfully used as a first choice imaging tool in the diagnostic algorithm of non-traumatic SAH and efficiently guide the therapeutic strategy.

Demographic, circadian, and climatic factors in non-aneurysmal versus aneursymal subarachnoid hemorrhage

BackgroundAlthough, the relationship of spontaneous subarachnoid hemorrhage (SAH) to climatic or circadian factors has been widely studied, epidemiologic, circardian and climatic factors in non-aneurysmal SAH (naSAH), particularly perimesencephalic SAH (PMH), has not been reported before. ObjectiveFor the first time, demographic, climatic, and circadian variables are examined together as possible contributing factors comparing aSAH and naSAH. MethodsWe reviewed records for 384 patients admitted to University of Wisconsin Neurosurgery Service from January 2005 to December 2010 with spontaneous non-traumatic SAH. Patients were grouped as aSAH (n=338) or naSAH (n=46) on clinical and radiological criteria. PMH (n=32) was identified as a subgroup of naSAH based on radiological criteria. We logged demographic data, time of SAH, temperature at onset and atmospheric pressure at onset. The three subgroups were compared. ResultsAneurysmal SAH occurred most often from 6am to 12pm (p<0.001); this correlation was not found in naSAH or PMH subgroups. Demographic analysis demonstrated predominance of female gender (p=0.008) and smoking (p=0.002) in aSAH, with predominance of hypercholesterolemia in naSAH (p=0.033). Atmospheric pressure, correlated with aSAH in the main county referral area, where we had detailed weather data (p<0.05); however, there was no weather correlation in the entire referral region taken together. Multivariate analysis supported a statistical difference only in smoking status between aSAH and naSAH groups (p=0.0159). ConclusionStatistical differences in gender, smoking status, and history of hypercholesterolemia support a clinical distinction between aSAH and naSAH. Furthermore, circadian patterning of aSAH is not reproduced in naSAH, supporting pathophysiologic differences. Only smoking status provides a robust difference in aSAH and naSAH groups. Our data prompt further investigation into the relationship between aSAH and atmospheric pressure.

E-030 Initial hemorrhage pattern affects utility of repeat angiography following negative initial angiogram for non-traumatic subarachnoid hemorrhage

IntroductionAngiography is usually performed in the work-up of patients with spontaneous subarachnoid hemorrhage (SAH). If the angiogram is negative, the role of follow-up imaging is less clear, and this role...

Utility of Delayed Digital Subtraction Angiography (DSA) in CT Angiography or Immediate DSA Negative Spontaneous Subarachnoid Hemorrhage (P04.075)

Objective: To determine the utility of delayed digital subtraction angiography (DSA) in CT angiography and immediate DSA negative spontaneous subarachnoid hemorrhage (SAH). Background 15% - 20% of patients presenting with spontaneous SAH are known to have no aneurysm or other underlying vascular abnormality detected on their initial vascular imaging. The standard protocol in many institutions is to perform delayed (1 week to 3 months) DSA in patients whose initial imaging (CTA and/or immediate DSA) is negative to find a previously occult aneurysm. Recently, the practice of performing an immediate DSA after negative CTA has been questioned. Our institutional data was reviewed to find if delayed DSA provided any advantage over previously acquired information. Design/Methods: Retrospective review of consecutive SAH cases presenting to a tertiary care hospital from 01/01/2001 to 08/31/2011 was performed. All cases with a known traumatic cause or CTA negative with no follow up DSA were excluded from analysis. The outcomes of delayed DSA were compared to immediate DSA. Results: Of total 547 patients records reviewed, 70 were found to be CTA negative non-traumatic SAH with an immediate DSA follow up study. Immediate DSA was performed on an average 1.32 days after initial CTA. Of these, 10 were found to have a source of bleed on immediate DSA. 20 patients of remaining 60 underwent delayed DSA on an average of 46.35 days after first DSA. Of them, only 1 was found to have an aneurysm giving a yield of 5%. Conclusions: Though the results are based on a small patient pool, the yield of delayed DSA in an initial non-aneurysmal spontaneous SAH is low enough that the wisdom of delayed DSA warrants further exploration. Disclosure: Dr. Jethwa has nothing to disclose. Dr. Punia has nothing to disclose. Dr. Gandhi has nothing to disclose. Dr. Prestigiacomo has nothing to disclose.

Prevalence of Herniation and Intracranial Shift on Cranial Tomography in Patients With Subarachnoid Hemorrhage and a Normal Neurologic Examination

Patients frequently present to the emergency department (ED) with headache. Those with sudden severe headache are often evaluated for spontaneous subarachnoid hemorrhage (SAH) with noncontrast cranial computed tomography (CT) followed by lumbar puncture (LP). The authors postulated that in patients without neurologic symptoms or signs, physicians could forgo noncontrast cranial CT and proceed directly to LP. The authors sought to define the safety of this option by having senior neuroradiologists rereview all cranial CTs in a group of such patients for evidence of brain herniation or midline shift. This was a retrospective study that included all patients with a normal neurologic examination and nontraumatic SAH diagnosed by CT presenting to a tertiary care medical center from August 1, 2001, to December 31, 2004. Two neuroradiologists, blinded to clinical information and outcomes, rereviewed the initial ED head CT for evidence of herniation or midline shift. Of the 172 patients who presented to the ED with spontaneous SAH diagnoses by cranial CT, 78 had normal neurologic examinations. Of these, 73 had initial ED CTs available for review. Four of the 73 (5%; 95% confidence interval [CI] = 2% to 13%) had evidence of brain herniation or midline shift, including three (4%; 95% CI = 1% to 12%) with herniation. In only one of these patients was herniation or shift noted on the initial radiology report. Awake and alert patients with a normal neurologic examination and SAH may have brain herniation and/or midline shift. Therefore, cranial CT should be obtained before LP in all patients with suspected SAH.

Hemorragia subaracnoidea como forma de debut de lupus eritematoso sistémico

The most frequent cause of spontaneous subarachnoid hemorrhage (SAH) is rupture of intracranial arterial aneurysms (> 70%). The remainder are due to many different aetiologies. Although SAH is a relatively common neuropathological finding in systemic lupus erythematosus (SLE), it is normally due to the extent of the intercerebral hemorrhage and not to its isolated presentation. We report the case of a 34 year old woman who presented with non-traumatic SAH at the onset of her lupus disorder. The patient was attended for SAH and at the same time a multisystemic disorder and severe thrombocytopenia were found, leading to a diagnosis of SLE. The neuroimaging techniques, selective cerebral arteriography, cerebral and spinal magnetic resonance, and magnetic resonance angiography did not show any vascular malformations. The patient was treated with immunosuppressive therapy, nimodipine, and following angiographic tests, with antiaggregants and anticoagulants. The greater frequency of SAH in patients with lupus, as compared to the general population, has been attributed to the presence of intracranial vasculitis. However, neuropathological studies have shown that true vasculitis is very infrequent in the central nervous system of SLE patients. In the case we describe, the first in which SAH appeared at the onset of the disease, we consider that the origin of the hemorrhage was her high arterial blood pressure and thrombopenia.