Nontraumatic Subarachnoid Hemorrhage Research Articles

Acute convexity subarachnoid haemorrhage and cortical superficial siderosis in probable cerebral amyloid angiopathy without lobar haemorrhage

IntroductionAcute non-traumatic convexity subarachnoid haemorrhage (cSAH) is increasingly recognised in cerebral amyloid angiopathy (CAA). We investigated: (a) the overlap between acute cSAH and cortical superficial siderosis—a new CAA haemorrhagic imaging...

Nontraumatic convexity subarachnoid hemorrhage with ischemic stroke: report of four cases and literature review

Objective Nontraumatic convexity subarachnoid hemorrhage (cSAH) complicating acute ischemic stroke is rare.Here we report four cases and review the relevant literature. Methods All cSAH cases at Peking University Third Hospital between January 2010 and December 2014 were collected and those associated with acute cerebral infarction were identified.Clinical medical records, neuroimaging data, treatment and prognosis were retrospectively reviewed. Results We found four cSAH patients with co-existing acute cerebral infarction.Two had ipsilateral middle cerebral artery (MCA) stenosis, one had ipsilateral internal carotid artery (ICA) stenosis, and the fourth case did not present significant cerebrovascular stenosis on magnetic resonance angiogram but had atrial fibrillation.All patients underwent brain magnetic resonance imaging (MRI) and none showed signs of cerebral amyloid angiopathy.One patient took oral Plaix because of the progression of ischemic stroke and the other three did not receive oral antiplatelet medications Three patients who were followed up for one to three years remained in stable condition. Conclusions Patients with cSAH complicated by ischemic stroke usually have a good prognosis.Most patients show significant atherosclerotic stenosis of ipsilateral vessels.MRI and assessment of extracranial and intracranial cerebral vessels for cSAH patients are recommended. Key words: Subarachnoid hemorrhage; Cerebral stenosis; Brain infarction

273 Emergency Providers Did Not Adequately Manage Patients With Spontaneous Intracranial Hemorrhage and Suspected Intracranial Hypertension

Spontaneous intracranial hemorrhage (sICH) often presents with markedly elevated blood pressure. Systolic blood pressure (SBP) above 140 to 150 mmHg has been found to be associated with higher morbidity and mortality. The 2010 American Heart Association and American Stroke Association (AHA/ASA) guideline recommends reduction of SBP among these patients to less than 160 mmHg if presenting SBP≥160mm Hg. However, a retrospective study in 2013 of 78 patients with non-traumatic subarachnoid hemorrhage showed that emergency providers treated only 71% of patients with SBP ≥160mmHg. Therefore, we hypothesized that more than 50% of patients with hypertensive sICH will not have SBP<160 mmHg at ED departure. Our study objective was to assess the effectiveness of emergency providers’ blood pressure management among critically ill patients with sICH and suspected high intracranial pressure (ICP). We performed a retrospective study of adult patients with diagnosis of sICH transferred from referring EDs to a quaternary academic center between 01/01/2011 and 09/30/2015 and received external ventricular drains (EVD) during hospitalization. Patients were identified by International Classification of Disease, version 9 (ICD-9 codes of 430.XX, 431.XX) and procedure code 02.21. Patients were excluded if a) not transferred directly from an ED; b) ED triage SBP ≤160 mmHg; c) no ED records available. Primary outcome was percentage of patients with SBP≤160 mm Hg at ED departure; secondary outcome was ICP at time of EVD placement. Data was expressed in median and interquartile range [IQR]. Mann-Whitney U test was used to compare median values between groups. A total of 434 patients were electronically identified. One-hundred eighty-seven (187) patients, transferred from 40 unique referring EDs with triage SBP≥161 mm Hg and received EVD during hospitalization, were included in analysis. Median Glasgow Coma Scale (GCS) at ED presentation was 13 [7-15]. Median SBPs at ED triage and departure were 199 [IQR 175-221] and 163 [IQR 138-176], p<0.001, respectively. One-hundred one (54%) patients had transfer SBP (tSBP) ≥161 mmHg, while 86 (46%) patients had tSBP ≤160mmHg. Median time from triage to SBP <160 was 142 [70-236] minutes while median time from triage to EVD placement at academic referral hospital was 426 [320-678] minutes. Intracranial pressure for patients with tSBP≥161mmHg, comparing to patients with tSBP≤160 mm Hg respectively, was 20[15-25] vs 24 [15-30] mm Hg, p=0.437. Emergency providers’ management of hypertensive patients with sICH and suspected intracranial hypertension was inadequate with only 46% of patients’ SBP at time of transfer meeting recommended treatment guidelines. Further education opportunities exist to encourage emergency providers to treat critically ill patients with spontaneous intracranial hemorrhage more effectively.

MANAGEMENT OF HEADACHE IN PATIENTS WITH NON-TRAUMATIC SUBARACHNOID HEMORRHAGE

This review of the literature is devoted to the current state of the problem of management of headache in patients with non-traumatic subarachnoid hemorrhage (NSAH). This pathology is associated with severe and prolonged headache. Despite the huge amount of references on subarachnoid hemorrhage, a little attention is paid to headache in this pathology, so it remains largely unexplored. The article presents data on the epidemiology of the syndrome, possible mechanisms of occurrence, diagnostic methods. Details of the advantages and disadvantages of drugs for anesthesia, available in the arsenal of the clinician at the moment. The results of many previously published studies are diametrically opposed, which does not facilitate the choice of tactics for effective treatment and prevention of complications. The article also identifies the problems, the solution of which, possibly, will lead to an improvement in the results of treatment of SAH and further the quality of life of the patients. The lack of evidance data on the subject suggests that the research is relevant.

Evidence for the Use of Tranexamic Acid in Subarachnoid and Subdural Hemorrhage: A Systematic Review.

AbstractDespite neurosurgical treatment, a subarachnoid hemorrhage (SAH) can cause a debilitating stroke. The case fatality rate ranges from 27 to 44%, and many survivors are left permanently disabled; therefore, the need for improved treatment is obvious. Furthermore, subdural hemorrhages (SDHs) have a cumulative recurrence rate of 14% in the first year and are potentially fatal. The aim of this systematic review is to assess and discuss the evidence for the role of tranexamic acid (TXA) in treatment of SAH and SDH. Systematic literature searches were performed in MEDLINE, Embase, Scopus, and Web of Science (1946–2016). The inclusion criteria were TXA-treated group and control group; SAH or SDH verified by imaging, intraoperatively or at autopsy; human subjects; English; and an objective outcome. The search terms matched 443 records. Eight studies including nontraumatic SAH patients and one study including traumatic intracranial bleeding met the inclusion criteria. Comparing TXA-treated nontraumatic patients with controls, we found an overall odds ratio (OR) for rebleeding of 0.41 (95% confidence interval [CI]: 0.26–0.64), six studies reported the mortality rate with an overall OR of 0.88 (95% CI: 0.68–1.12), four studies reported no statistically significant difference on the Glasgow Outcome Scale, and one study showed a statistically significant increased risk of cerebral ischemia, whereas seven studies found no statistically significant difference. No studies including SDH patients met the inclusion criteria. TXA reduced the overall risk of rebleeding following nontraumatic SAH. A nonsignificant reduction in mortality was demonstrated in nontraumatic SAH without substantial indication of increased risk of ischemic lesions.

Observational study of treated non-traumatic subarachnoid hemorrhage in nonagenarians

Abstract Objective With an aging society worldwide, we can expect an increased frequency of clinical therapeutic judgements for patients 90 years or older, nonagenarians, with subarachnoid hemorrhage. However, little evidence exists as to whether surgical treatment is safe for them and leads to increased survival rates. We thus report the possible therapeutic strategies and clinical features thorough this observational study. Patients and methods 15 consecutive cases at two centers were collected retrospectively. Treatment methods were divided into conservative therapy or aggressive surgery including clipping or coiling surgery. Data were calculated statistically using SPSS® version 21 (Japan IBM, Tokyo, Japan). Results The mean age of patients was 91.5 ± 1.7 years. The World Federation of Neurological Surgeons (WFNS) grade on arrival was 3.5 ± 1.4, and the average Fisher scale was 3.8 ± 0.4. Mortality of all patients was 66.7%. Symptomatic vasospasm was observed in one case. Five patients underwent surgical treatment, including clipping or coiling surgery. Mortality was 20.0% in those who represented WFNS grade 2/3 and received surgical treatment while 90.0% in those who represented WFNS grade 3 to 5 and received conservative treatment. Therefore, our results indicate that surgical intervention is associated with increased life expectancy in good WFNS grade. Furthermore, the modified Rankin Scale score in all patients deteriorated with the disease, while relatively more deaths have occurred in the non-treated patient population. Conclusion Considering clipping surgery or intervention in nonagenarians might be of benefit in favorable circumstances, i.e. WFNS grade 1, 2 or 3.

Life situation 5years after subarachnoid haemorrhage.

Subarachnoid haemorrhage (SAH) has high mortality and morbidity among survivors. SAH mainly affects young people and may result in long-term disabilities such as decreased Health-related Quality of Life (HRQoL), mental health and cognitive function. The aim of this study was to investigate the life situation 5years after a SAH including physical/emotional status, participation and HRQoL. In this cross-sectional descriptive study, a mail survey was sent to all persons treated at a neurosurgery unit in Gothenburg, Sweden, for non-traumatic SAH in 2009-2010, approximately 5years post-SAH. The survey included questions regarding HRQoL; EuroQol 5-Dimensions (EQ-5D), the impact of the SAH; Stroke Impact Scale (SIS), Occupational Gaps Questionnaire and participation in society; Impact of Participation and Autonomy (IPA). Forty-two 5year survivors were sent the survey, of whom 26 (62%) responded (59years old, range 33-85). The participants had generally low HRQoL and scored low in the domain of anxiety and depression. Many reported problems with emotions, fatigue, memory and executive function, but few problems with physical condition. However, nearly all participants reported to have an acceptable level of participation and 64% were independent in their daily life. In this 5-year follow-up after SAH, the participants reported to have a greater number of hidden disabilities compared to physical problems, whereas most had acceptable participation in society. A yearly follow-up after a SAH could be suggested aiming to improving the cognitive and mental health.

Midterm Follow-Up of 20 Consecutive Patients with Nonaneurysmal Subarachnoid Hemorrhage of Unknown Origin in a Single-Center: Two Cases of De Novo Development of Dural Arteriovenous Fistula

The mechanisms and prognosis of underlying subarachnoid hemorrhage of unknown origin remain unclear. Previous investigators have suggested a relationship between nonaneurysmal perimesencephalic subarachnoid hemorrhage and venous abnormalities like a primitive venous drainage of the basal vein of Rosenthal. We report the outcome of a midterm follow-up of 20 consecutive patients with nonaneurysmal subarachnoid hemorrhage of unknown origin, and 2 patients in whom the development of new dural arteriovenous fistulas after subarachnoid hemorrhage of unknown origin were detected during follow-up. All patients who were admitted to our hospital for nontraumatic subarachnoid hemorrhage between April 2008 and March 2016 were retrospectively analyzed. Of 705 patients included in the study, 20 (2.8%) were diagnosed with nontraumatic subarachnoid hemorrhage of unknown origin. During the follow-up periods, there was no rebleeding. Although 18 patients did not show any vascular abnormalities, the other 2 patients were diagnosed with dural arteriovenous fistula. Both fistulas were successfully treated with endovascular embolization. Subarachnoid hemorrhage of unknown origin had a low incidence rate, and its clinical course was excellent without rebleeding. Although no vascular abnormalities were observed during the patients' initial admission, venous lesions might have been involved in both subarachnoid hemorrhages and delayed dural arteriovenous fistulas. Here, the possible pathogenesis is discussed with a review of the literature.

Side Effects of Long-Term Continuous Intra-arterial Nimodipine Infusion in Patients with Severe Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage.

Long-term continuous intra-arterial nimodipine infusion (CIAN) is a rescue therapy option in cases of severe refractory cerebral vasospasm (CV) following acute non-traumatic subarachnoid hemorrhage (SAH). However, CIAN therapy can be associated with relevant side effects. Available studies focus on intracerebral complications, whereas extracerebral side effects are rarely examined. Aim of the present study was to generate descriptive data on the clinical course during CIAN therapy and expectable extracerebral side effects. All patients treated with CIAN therapy for at least 5days between May 2011 and December 2015 were included. We retrospectively extracted data from the patient data management system regarding the period between 2days before the beginning and 5days after the termination of CIAN therapy to analyze the course of ventilation parameters and pulmonary gas exchange, hemodynamic support, renal and liver function, integrity of the gastrointestinal tract, and the occurrence of infectious complications. In addition, we recorded the mean daily values of intracranial pressure (ICP) and intracerebral problems associated with CIAN therapy. Data from 28 patients meeting inclusion criteria were analyzed. The mean duration of long-term CIAN therapy was 10.5±4.5days. Seventeen patients (60.7%) reached a good outcome level (Glasgow Outcome Scale [GOS] 4-5) 6months after SAH. An impairment of the pulmonary gas exchange occurred only at the very beginning of CIAN therapy. The required vasopressor support with norepinephrine was significantly higher on all days during and the first day after CIAN therapy compared to the situation before starting CIAN therapy. Two patients required short-time resuscitation due to cardiac arrest during CIAN therapy. Acute kidney injury was observed in four patients, and one of them required renal replacement therapy with sustained low-efficiency daily dialysis. During CIAN therapy, 23 patients (82.1%) needed the escalation of a previous antiinfective therapy or the onset of antibiotics which was in line with a significant increase of C-reactive protein and white blood cell count. Obstipation was observed in 22 patients (78.6%). Ten patients (35.7%) even showed insufficient defecation on at least seven consecutive days. Compared to the situation before, ICP was significantly higher during the whole period of CIAN therapy. Long-term CIAN therapy is associated with diverse side effects. The leading problems are an impairment of the hemodynamic situation and cardiac problems, an increase in infectious complications, a worsening of the motility of the gastrointestinal tract, and rising ICP values. Teams on neurointensive care units must be aware of these side effects to avoid that the beneficial effects of CIAN therapy on CV reported elsewhere are foiled by the problems this technique can be associated with.

Impact of Weekend Presentation on Short-Term Outcomes and Choice of Clipping vs Coiling in Subarachnoid Hemorrhage.

Presentation on a weekend is commonly associated with higher mortality and a decreased likelihood of receiving invasive procedures. To determine whether weekend presentation influences mortality, discharge destination, or type of treatment received (clip vs coil) in subarachnoid hemorrhage (SAH). We performed a serial cross-sectional retrospective study using the Nationwide Inpatient Sample. All adult discharges with a primary diagnosis of SAH (ICD-9-CM 435) from 2005 to 2010 were included, and records with trauma or arteriovenous malformation were excluded. Unadjusted and adjusted associations between weekend presentation and 3 outcomes (in-hospital mortality, discharge destination, and treatment with clip vs coil) were estimated using chi-square tests and multilevel logistic regression. A total of 46 093 admissions for nontraumatic SAH were included in the sample; 24.6% presented on a weekend, 68.9% on a weekday, and 6.5% had unknown day of presentation. Weekend admission was not a significant predictor of inpatient mortality (25.4% weekend vs 24.9% weekday; P = .44), or a combined poor outcome measure of mortality or discharge to long-term acute care or hospice (30.3% weekend vs 29.4% weekday; P = .23). Among those treated for aneurysm obliteration, the proportion of clipped vs coiled did not change with weekend vs weekday presentation (21.5% clipped with weekend presentation vs 21.6% weekday, P = .95; 21.5% coiled with weekend presentation vs 22.4% weekday, P = .19). Presentation with nontraumatic SAH on a weekend did not influence mortality, discharge destination, or type of treatment received (clip vs coil) compared with weekday presentation.

Differences in Neuropeptide Y Secretion Between Intracerebral Hemorrhage and Aneurysmal Subarachnoid Hemorrhage

Neuropeptide Y (NPY) is one of the most potent endogenous vasoconstrictors, and its contribution to the multifactorial cascade of cerebral vasospasm due to nontraumatic subarachnoid hemorrhage (SAH) is not yet fully understood. This experimental study compared the hemorrhage-specific course of NPY secretion into cerebrospinal fluid (CSF) and into plasma between 2 groups: patients with SAH and patients with basal ganglia hemorrhage (BGH) or cerebellar hemorrhage (CH) over the first 10 days after hemorrhage. Seventy-nine patients were prospectively included: SAH patients (n=66) (historic population) and intracerebral hemorrhage patients (n=13). All patients received an external ventricular drain within 24 hours of the onset of bleeding. CSF and plasma were drawn daily from day 1 to day 10. The levels of NPY were determined by means of competitive enzyme immunoassay. The CSF samples of 29 patients (historic population) who had undergone spinal anesthesia due to orthopedic surgery served as the control group. NPY levels in CSF were significantly higher in the 2 hemorrhage groups than in the control group. However, the 2 hemorrhage groups showed significant differences in NPY levels in CSF (SAH mean, 0.842 ng/mL vs. BGH/CH mean, 0.250 ng/mL; P<0.001) as well as in the course of NPY secretion into CSF over the 10-day period. NPY levels in plasma did not differ significantly among SAH, BGH/CH, and controls. Our findings support the hypothesis that excessive release of NPY into CSF but not into plasma is specific to aneurysmal SAH in the acute period of 10 days after hemorrhage. In BGH/CH, CSF levels of NPY were also increased, but the range was much lower.

Early Prediction of Delayed Ischemia and Functional Outcome in Acute Subarachnoid Hemorrhage

Diffusion tensor imaging (DTI) parameters are markers of cerebral lesion in some diseases. In patients with acute subarachnoid hemorrhage (SAH), we investigated whether DTI parameters measured at <72 hours might be associated with delayed cerebral ischemia (DCI) and with poor functional outcome at 3 months (modified Rankin Scale score ≥3). DTI was performed in a prospective cohort of 60 patients with nontraumatic SAH at <72 hours. Association of fractional anisotropy and apparent diffusion coefficient values at <72 hours with the occurrence of DCI and outcome at 3 months was evaluated with logistic regression models, adjusting for known predictors of prognosis. At <72 hours after SAH, fractional anisotropy values at the cerebellum were associated with DCI occurrence (78% less odds of DCI for each 0.1 increase in fractional anisotropy; P=0.019). Early apparent diffusion coefficient values were not associated with DCI. After adjusting for confounding variables, an increase of 10 U in apparent diffusion coefficient at the frontal centrum semiovale corresponded to 15% increased odds of poor outcome (P=0.061). DTI parameters at <72 hours post-SAH are independently associated with the occurrence of DCI and functional outcome. These preliminary results suggest the role of DTI parameters as surrogate markers of prognosis in nontraumatic SAH.

Imaging Appearance of Advanced Chronic Adhesive Arachnoiditis: A Retrospective Review.

Chronic adhesive arachnoiditis (CAA) is rare and has potentially devastating clinical consequences. The objective of this article is to review the clinical features of CAA and describe its appearance on imaging, to increase radiologists' awareness of this challenging diagnosis. Twenty-nine cases of advanced CAA seen at our institution over 18 years (1995-2013) were retrospectively reviewed. Chart review was performed, with attention given to data on clinical presentation, suspected cause, and interventions performed. All patients underwent MRI, and seven patients also underwent CT myelography. Clinical and imaging features were evaluated and categorized. The 29 patients ranged in age from 23 to 96 years and included 11 women and 18 men. Suspected underlying causative factors included trauma (n = 10), prior surgery (n = 9), nontraumatic subarachnoid hemorrhage (n = 7), infection (n = 3), myelography with iophendylate used as contrast medium (n = 1), Guillain-Barré syndrome (n = 1), ankylosing spondylitis (n = 1), and unknown causes (n = 1). Imaging characteristics include loculated CSF collections (n = 23), nerve root clumping, enhancement, and displacement (n = 15), cord swelling with increased T2 signal (n = 12), arachnoid septations (n = 11), cord atrophy (n = 6), syrinx (n = 5), and intrathecal calcifications (n = 3). Ten patients underwent surgical procedures, and most had only brief clinical improvement. CAA is a rare cause of devastating neurologic symptoms and chronic pain. The imaging features of CAA range from subtle to severe. Advanced arachnoiditis can present with spinal cord swelling and syrinx formation, which can mimic other disease processes. Inclusion of advanced CAA in the differential diagnosis can prevent unnecessary interventions.

The Effect of Morbid Obesity on Subarachnoid Hemorrhage Prognosis in the United States.

The association between obesity and nontraumatic subarachnoid hemorrhage (SAH) patient outcome is unclear. The aim of this study was to determine the impact of morbid obesity (body mass index ≥40 kg/m2) on nontraumatic SAH outcomes. Using the Nationwide Inpatient Sample, we identified hospitalized, nontraumatic SAH patients who received their diagnoses from 2008 to 2013 and tested the effect of obesity on their mortality and clinical outcomes. Odds ratios were estimated with a mixed effects linear logistic model with adjustment for hospital clustering. All statistical testing was 2-sided, with a significance level of 5%. Out of 224,561 discharged patients with a diagnosis of nontraumatic SAH, 4714 (2.10%) were defined as morbidly obese. Patients with morbid obesity were younger (54.3 ± 0.44 vs. 59.5 ± 0.08 years; P < 0.001) and had longer length of stay (LOS) (13 ± 0.46 vs. 11.5 ± 0.06 days; P= 0.002). Morbid obesity was associated with significantly higher hospital costs (P < 0.001) and charges (P < 0.001). The risk of acute respiratory failure was higher in morbidly obese patients (odds ratio [OR] 1.49, 95% confidence interval [CI]: 1.3-1.71, P < 0.001). In a multivariate analysis of hospital mortality, obesity had a negative impact on mortality (OR 0.83, 95% CI: 0.74-0.92, P < 0.001). Overall, in-hospital mortality was associated with age, morbid obesity, LOS, clipping and coiling, and acute respiratory failure but not the symptomatic vasospasm. Morbid obesity is associated with increased LOS, hospital costs and charges and with acute respiratory failure. However, it is also associated with a decrease in hospital mortality.

Subarachnoid Hemorrhage in Germany Between 2010 and 2013: Estimated Incidence Rates Based on a Nationwide Hospital Discharge Registry.

Nordic countries are the primary source for nationwide data on the incidence of subarachnoid hemorrhage (SAH). Reliable estimates of national incidence rates of SAH in other countries are lacking, yet studies from Nordic countries with exceptional incidence rates are sometimes disregarded because of concerns regarding external validity. Autopsies are rarely performed for sudden deaths; therefore, estimates of the SAH incidence commonly reflect the hospital discharge rates. Our aim was to estimate the nationwide incidence of nontraumatic SAH in Germany using a national hospital discharge register. The German federal statistical office provided the number of patients discharged from all German hospitals between 2010 and 2013 with the primary diagnosis of nontraumatic SAH (ICD code I60.0-I60.9) and corresponding age distribution. Age-standardized attack rates of nontraumatic SAH were calculated using the 2011 German demographic distribution. Between 2010 and 2013, the overall age-standardized incidence rate of nontraumatic SAH was 11.3 per 100,000 person-years, and it reached a maximum of 22.1 per 100,000 person-years in the oldest age group. The absolute number of SAHs was highest in the 50-55-year age group. The distribution of intracranial aneurysms displayed a propensity toward the posterior circulation with advancing age (P < 0.001), although in absolute numbers SAH originated mostly from the anterior circulation. Our estimate of the German nationwide attack rate suggests that the incidence of nontraumatic SAH is more homogeneous than previously assumed. Rejecting the external validity of studies from countries believed to display an exceptional incidence rates may therefore not be justified.

Re-bleed in Nontraumatic Convexity Subarachnoid Hemorrhage (P2.282)

Re-bleed in Nontraumatic Convexity Subarachnoid Hemorrhage (P2.282)

Obstructive Sleep Apnea is Associated with Improved Non-Traumatic Subarachnoid Hemorrhage Outcomes (P4.311)

Obstructive Sleep Apnea is Associated with Improved Non-Traumatic Subarachnoid Hemorrhage Outcomes (P4.311)

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.

Acute Kidney Injury After Subarachnoid Hemorrhage.

Acute kidney injury (AKI) is common in critically ill patients and may contribute to poor outcome. Few data are available on the incidence and impact of AKI in patients suffering from nontraumatic subarachnoid hemorrhage (SAH). We reviewed all patients admitted to our Department of Intensive Care with SAH over a 3-year period. Exclusion criteria were time from SAH symptoms to intensive care unit (ICU) admission >96 hours and ICU stay <48 hours. AKI was defined as sustained oligoanuria (urine output <0.5 mL/kg/h for 24 h) or an increase in plasma creatinine (≥0.3 mg/dL or a 1.5-fold increase from baseline level within 48 h). Neurological status was assessed at day 28 using the Glasgow Outcome Scale (GOS) (from 1=death to 5=good recovery; favorable outcome=GOS 4 to 5). Of 243 patients admitted for SAH during the study period, 202 met the inclusion/exclusion criteria (median age 56 y, 78 male). Twenty-five patients (12%) developed AKI, a median of 8 (4 to 10) days after admission. Independent predictors of AKI were development of clinical vasospasm, and treatment with vancomycin. AKI was more frequent in ICU nonsurvivors than in survivors (11/50 vs. 14/152, P=0.03), and in patients with an unfavorable neurological outcome than in other patients (17/93 vs. 8/109, P=0.03). Nevertheless, in multivariable regression analysis, AKI was not an independent predictor of outcome. AKI occurred in >10% of patients after SAH. These patients had more severe neurological impairment and needed more aggressive ICU therapy; AKI did not significantly influence outcome.

Non-aneurysmal and non-traumatic subarachnoid hemorrhage after attempted suicide by incomplete hanging.

Hanging is a common method of suicide that is being reported more frequently in many countries. Several complications including injuries to the cervical spine, neck vessels, and brain can occur after attempted suicide by hanging. There are only a few reports of brain computed tomography and magnetic resonance imaging of hanging victims. The most common abnormality was diffuse cerebral edema. A subarachnoid hemorrhage is an atypical complication by suicidal hanging. We report a case of a female patient who presented to an emergency department with altered mental status after attempting suicide by incomplete hanging. The patient was diagnosed with a non-aneurysmal and non-traumatic subarachnoid hemorrhage. This case shows that spontaneous subarachnoid hemorrhage can develop due to a sudden elevation of intracranial pressure, as occurs with hanging.