Diagnostic value of magnetic resonance imaging in perimesencephalic and nonperimesencephalic subarachnoid hemorrhage of unknown origin

Clinical article

View More View Less
  • Department of Neurosurgery, University Hospitals Schleswig-Holstein, Campus Kiel, Germany
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object

The aim of this study was to evaluate the diagnostic value of MR imaging in perimesencephalic (PM) and nonperimesencephalic (non-PM) subarachnoid hemorrhage (SAH) of unknown origin.

Methods

The authors conducted a retrospective review of all patients with SAH (1226 patients) in their department between January 1991 and December 2008. Included in the study were cases of spontaneous SAH diagnosed using CT scans obtained within 24 hours of the initial symptoms and initially negative digital subtraction (DS) angiograms. Patients with traumatic SAH and an unknown history were excluded from the study. Patients with initially negative DS angiograms were divided into 2 groups: Group 1, a typically PM bleeding pattern (PM SAH); and Group 2, a non-PM bleeding pattern (non-PM SAH) such as hemorrhage in the sylvian or interhemispheric fissure. Cranial MR imaging including the craniocervical region was performed within 72 hours after SAH was diagnosed in all patients in Groups 1 and 2.

Results

One thousand sixty-eight patients underwent DS angiography, and among them were 179 (16.7%) with negative angiograms—47 patients (26.3%) from Group 1 and 132 patients (73.7%) from Group 2. Magnetic resonance imaging demonstrated no bleeding sources in any case (100% negative). Thirty-four patients in Group 1 and 120 patients in Group 2 underwent a second DS angiography study. Digital subtraction angiography revealed an aneurysm as the bleeding source in 1 case in Group 1 and in 13 cases in Group 2.

Conclusions

Magnetic resonance imaging of the brain and craniocervical region did not produce additional benefit for the detection of a bleeding source and the therapy administered for PM SAH and non-PM SAH (100% negative). The costs of this examination exceeded the clinical value. Despite the results of this study, MR imaging should be discussed on a case-by-case basis because rare bleeding sources are periodically diagnosed in cases of non-PM SAH. A second-look DS angiogram is necessary because aneurysmal hemorrhage occasionally produces PM SAH as well as non-PM SAH. Further prospective studies are needed to verify the authors' results in the future.

Abbreviations used in this paper: ACoA = anterior communicating artery; DS = digital subtraction; MCA = middle cerebral artery; PM = perimesencephalic; SAH = subarachnoid hemorrhage.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address correspondence to: Homajoun Maslehaty, M.D., Klinik für Neurochirurgie, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3, 24105 Kiel, Germany. email: h.maslehaty@gmx.de.

Please include this information when citing this paper: published online July 30, 2010; DOI: 10.3171/2010.6.JNS10310.

  • 1

    af Björkesten G, & Halonen V: Incidence of intracranial vascular lesions in patients with subarachnoid hemorrhage investigated by four-vessel angiography. J Neurosurg 23:2932, 1965

    • Search Google Scholar
    • Export Citation
  • 2

    Andaluz N, & Zuccarello M: Yield of further diagnostic work-up of cryptogenic subarachnoid hemorrhage based on bleeding patterns on computed tomographic scans. Neurosurgery 62:10401047, 2008

    • Search Google Scholar
    • Export Citation
  • 3

    Barth H, , Nabavi A, , Stein H, , Behnke A, & Mehdorn HM: [Perimesencephalic subarachnoid hemorrhage—an independent clinical picture of non-aneurysmatic subarachnoid hemorrhage with a benign course.]. Zentralbl Neurochir 57:108112, 1996. (Ger)

    • Search Google Scholar
    • Export Citation
  • 4

    Berdoz D, , Uske A, & de Tribolet N: Subarachnoid haemorrhage of unknown cause: Clinical, neuroradiological and evolutive aspects. J Clin Neurosci 5:274282, 1998

    • Search Google Scholar
    • Export Citation
  • 5

    Beseoglu K, , Pannes S, , Steiger HJ, & Hänggi D: Long-term outcome and quality of life after nonaneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 152:409416, 2010

    • Search Google Scholar
    • Export Citation
  • 6

    Bunai Y, , Nagai A, , Nakamura I, & Ohya I: Traumatic rupture of the basilar artery: report of two cases and review of the literature. Am J Forensic Med Pathol 21:343348, 2000

    • Search Google Scholar
    • Export Citation
  • 7

    Flaherty ML, , Haverbusch M, , Kissela B, , Kleindorfer D, , Schneider A, & Sekar P, : Perimesencephalic subarachnoid hemorrhage: incidence, risk factors, and outcome. J Stroke Cerebrovasc Dis 14:267271, 2005

    • Search Google Scholar
    • Export Citation
  • 8

    Fujii M, , Takasato Y, , Masaoka H, , Ohta Y, , Hayakawa T, & Honma M: [Analysis of unknown cause subarachnoid hemorrhage with repeated negative angiogram.]. No To Shinkei 58:489493, 2006. (Jpn)

    • Search Google Scholar
    • Export Citation
  • 9

    Germans MR, , Pennings FA, , Sprengers ME, & Vandertop WP: Spinal vascular malformations in non-perimesencephalic subarachnoid hemorrhage. J Neurol 255:19101915, 2008

    • Search Google Scholar
    • Export Citation
  • 10

    Huttner HB, , Hartmann M, , Köhrmann M, , Neher M, , Stippich C, & Hähnel S, : Repeated digital substraction angiography after perimesencephalic subarachnoid hemorrhage?. J Neuroradiol 33:8789, 2006

    • Search Google Scholar
    • Export Citation
  • 11

    Jung JY, , Kim YB, , Lee JW, , Huh SK, & Lee KC: Spontaneous subarachnoid haemorrhage with negative initial angiography: a review of 143 cases. J Clin Neurosci 13:10111017, 2006

    • Search Google Scholar
    • Export Citation
  • 12

    Lang EW, , Khodair A, , Barth H, , Hempelmann RG, , Dorsch NW, & Mehdorn HM: Subarachnoid hemorrhage of unknown origin and the basilar artery configuration. J Clin Neurosci 10:7478, 2003

    • Search Google Scholar
    • Export Citation
  • 13

    Mehdorn HM, , Dietrich U, , Kalff R, , Hoffmann B, , Rauhut F, & Grote W: Subarachnoid hemorrhage of unknown origin. Longterm prognosis. Neurosurg Rev 15:2731, 1992

    • Search Google Scholar
    • Export Citation
  • 14

    Meisenzahl EM, , Gottschalk S, , Lechner C, & Lehmann R: [Spontaneous perimesencephalic subarachnoid hemorrhage (PMH). A disease category with good prognosis?]. Fortschr Neurol Psychiatr 66:387390, 1998. (Ger)

    • Search Google Scholar
    • Export Citation
  • 15

    Rogg JM, , Smeaton S, , Doberstein C, , Goldstein JH, , Tung GA, & Haas RA: Assessment of the value of MR imaging for examining patients with angiographically negative subarachnoid hemorrhage. AJR Am J Roentgenol 172:201206, 1999

    • Search Google Scholar
    • Export Citation
  • 16

    Schievink WI, & Wijdicks EF: Pretruncal subarachnoid hemorrhage: an anatomically correct description of the perimesencephalic subarachnoid hemorrhage. Stroke 28:2572, 1997

    • Search Google Scholar
    • Export Citation
  • 17

    Schwartz TH, & Solomon RA: Perimesencephalic nonaneurysmal subarachnoid hemorrhage: review of the literature. Neurosurgery 39:433440, 1996

    • Search Google Scholar
    • Export Citation
  • 18

    Takahara T, , Terai C, , Okada Y, , Mimura K, & Mukaida M: Fatal traumatic subarachnoid hemorrhage due to rupture of the vertebral artery. Intensive Care Med 19:172173, 1993

    • Search Google Scholar
    • Export Citation
  • 19

    van Gijn J, , van Dongen KJ, , Vermeulen M, & Hijdra A: Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology 35:493497, 1985

    • Search Google Scholar
    • Export Citation
  • 20

    Wijdicks EF, , Schievink WI, & Miller GM: MR imaging in pretruncal nonaneurysmal subarachnoid hemorrhage: is it worthwhile?. Stroke 29:25142516, 1998

    • Search Google Scholar
    • Export Citation
  • 21

    Yamamoto M, , Fukushima T, , Ikeda K, , Nagasaka S, , Sakamoto S, & Oka K, : Intracranial cavernous angioma manifesting as subarachnoid hemorrhage—case report. Neurol Med Chir (Tokyo) 33:706709, 1993

    • Search Google Scholar
    • Export Citation

Metrics