A quantitative model to differentiate nonaneurysmal perimesencephalic subarachnoid hemorrhage from aneurysmal etiology

Daniel MandelDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;

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Scott MoodyDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
Department of Physician Assistant Studies, Massachusetts General Hospital Institute of Health Professions, Boston, Massachusetts;

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Kelly PanWarren Alpert Medical School of Brown University, Providence, Rhode Island;

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Thanujaa SubramaniamDepartment of Neurology, Yale University School of Medicine, New Haven, Connecticut;

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Bradford B. ThompsonDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and

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Linda C. WendellDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island

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Michael E. ReznikDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and

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Karen L. FurieDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;

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Ali MahtaDepartment of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island;
Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island; and
Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island

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OBJECTIVE

Nonaneurysmal perimesencephalic subarachnoid hemorrhage (pmSAH) is considered to have a lower-risk pattern than other types of subarachnoid hemorrhage (SAH). However, a minority of patients with pmSAH may harbor a causative posterior circulation aneurysm. To exclude this possibility, many institutions pursue exhaustive imaging. In this study the authors aimed to develop a novel predictive model based on initial noncontrast head CT (NCHCT) features to differentiate pmSAH from aneurysmal causes.

METHODS

The authors retrospectively reviewed patients admitted to an academic center for treatment of a suspected aneurysmal SAH (aSAH) during the period from 2016 to 2021. Patients with a final diagnosis of pmSAH or posterior circulation aSAH were included. Using NCHCT, the thickness (continuous variable) and location of blood in basal cisterns and sylvian fissures (categorical variables) were compared between groups. A scoring system was created using features that were significantly different between groups. Receiver operating characteristic curve analysis was used to measure the accuracy of this model in predicting aneurysmal etiology. A separate patient cohort was used for external validation of this model.

RESULTS

Of 420 SAH cases, 48 patients with pmSAH and 37 with posterior circulation aSAH were identified. Blood thickness measurements in the crural and ambient cisterns and interhemispheric and sylvian fissures and degree of extension into the sylvian fissure were all significantly different between groups (all p < 0.001). The authors developed a 10-point scoring model to predict aneurysmal causes with high accuracy (area under the curve [AUC] 0.99; 95% CI 0.98–1.00; OR per point increase 10; 95% CI 2.18–46.4). External validation resulted in persistently high accuracy (AUC 0.97; 95% CI 0.92–1.00) of this model.

CONCLUSIONS

A risk stratification score using initial blood clot burden may accurately differentiate between aneurysmal and nonaneurysmal pmSAH. Larger prospective studies are encouraged to further validate this quantitative tool.

ABBREVIATIONS

aSAH = aneurysmal SAH; AUC = area under the curve; IVH = intraventricular hemorrhage; LOS = length of stay; mRS = modified Rankin Scale; NCHCT = noncontrast head CT; pmSAH = perimesencephalic SAH; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage.
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Figure from Ramos et al. (pp 95–103).

  • 1

    Mensing LA, Vergouwen MDI, Laban KG, et al. Perimesencephalic hemorrhage: a review of epidemiology, risk factors, presumed cause, clinical course, and outcome. Stroke. 2018;49(6):13631370.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Troupp H. The natural history of aneurysms of the basilar bifurcation. Acta Neurol Scand. 1971;47(3):350356.

  • 3

    Potter CA, Fink KR, Ginn AL, Haynor DR. Perimesencephalic hemorrhage: yield of single versus multiple DSA examinations—a single-center study and meta-analysis. Radiology. 2016;281(3):858864.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Germans MR, Coert BA, Majoie CB, et al. Yield of spinal imaging in nonaneurysmal, nonperimesencephalic subarachnoid hemorrhage. Neurology. 2015;84(13):13371340.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Howard BM, Hu R, Barrow JW, Barrow DL. Comprehensive review of imaging of intracranial aneurysms and angiographically negative subarachnoid hemorrhage. Neurosurg Focus. 2019;47(6):E20.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Sadigh G, Holder CA, Switchenko JM, Dehkharghani S, Allen JW. Is there added value in obtaining cervical spine MRI in the assessment of nontraumatic angiographically negative subarachnoid hemorrhage? A retrospective study and meta-analysis of the literature. J Neurosurg. 2018;129(3):670676.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Rinkel GJ, Wijdicks EF, Vermeulen M, et al. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture. AJNR Am J Neuroradiol. 1991;12(5):829834.

    • Search Google Scholar
    • Export Citation
  • 8

    Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208.

  • 9

    Ruigrok YM, Rinkel GJ, Buskens E, Velthuis BK, van Gijn J. Perimesencephalic hemorrhage and CT angiography: a decision analysis. Stroke. 2000;31(12):29762983.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Kalra VB, Wu X, Matouk CC, Malhotra A. Use of follow-up imaging in isolated perimesencephalic subarachnoid hemorrhage: a meta-analysis. Stroke. 2015;46(2):401406.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Delgado Almandoz JE, Jagadeesan BD, Refai D, et al. Diagnostic yield of repeat catheter angiography in patients with catheter and computed tomography angiography negative subarachnoid hemorrhage. Neurosurgery. 2012;70(5):11351142.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    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. 2006;13(10):10111017.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Andaluz N, Zuccarello M. Yield of further diagnostic work-up of cryptogenic subarachnoid hemorrhage based on bleeding patterns on computed tomographic scans. Neurosurgery. 2008;62(5):10401047.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Maslehaty H, Petridis AK, Barth H, Mehdorn HM. Diagnostic value of magnetic resonance imaging in perimesencephalic and nonperimesencephalic subarachnoid hemorrhage of unknown origin. J Neurosurg. 2011;114(4):10031007.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Little AS, Garrett M, Germain R, et al. Evaluation of patients with spontaneous subarachnoid hemorrhage and negative angiography. Neurosurgery. 2007;61(6):11391151.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Ringelstein A, Mueller O, Timochenko O, et al. Reangiography after perimesencephalic subarachnoid hemorrhage. Article in German. Nervenarzt. 2013;84(6):715719.

  • 17

    Bakker NA, Groen RJ, Foumani M, et al. Repeat digital subtraction angiography after a negative baseline assessment in nonperimesencephalic subarachnoid hemorrhage: a pooled data meta-analysis. J Neurosurg. 2014;120(1):99103.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Elhadi AM, Zabramski JM, Almefty KK, et al. Spontaneous subarachnoid hemorrhage of unknown origin: hospital course and long-term clinical and angiographic follow-up. J Neurosurg. 2015;122(3):663670.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kapadia A, Schweizer TA, Spears J, Cusimano M, Macdonald RL. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: diagnosis, pathophysiology, clinical characteristics, and long-term outcome. World Neurosurg. 2014;82(6):11311143.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Topcuoglu MA, Ogilvy CS, Carter BS, Buonanno FS, Koroshetz WJ, Singhal AB. Subarachnoid hemorrhage without evident cause on initial angiography studies: diagnostic yield of subsequent angiography and other neuroimaging tests. J Neurosurg. 2003;98(6):12351240.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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