Skip to main content
SpringerLink
Log in

The pseudo-SAH sign: an imaging pitfall in postmortem computed tomography

  • Original Article
  • Published:
International Journal of Legal Medicine Aims and scope Submit manuscript

Abstract

Postmortem computed tomography (PMCT) of the brain has an important role in detection of subarachnoid hemorrhage (SAH), which has a high mortality rate. However, a phenomenon known as “pseudo-SAH,” or high-attenuation areas along the cisterns mimicking SAH, may be seen on CT. The aim of this study was to evaluate the diagnostic accuracy of brain PMCT for SAH and to identify the characteristics of pseudo-SAH. Findings on PMCT (sulcal effacement, asymmetry, maximum thickness of SAH signs, presence of acute/subacute intraventricular/intraparenchymal hemorrhage) and clinical history (left ventricular assist device [LVAD] implantation, anticoagulation therapy/coagulation disorder, global ischemia) were compared between subjects with true SAH and those with pseudo-SAH. Twenty eight of 128 enrolled subjects had positive signs of SAH on PMCT, 20 (71.4%) had SAH on autopsy, and 8 (28.6%) did not. The sensitivity, specificity, positive predictive value, and negative predictive value of SAH signs seen on PMCT were 95.2, 94.6, 71.4, and 99.3%, respectively. Asymmetry of SAH signs and acute/subacute intraventricular and intraparenchymal hemorrhage were significantly more common in true SAH cases than in pseudo-SAH cases. The maximum thickness of SAH signs was significantly greater in true SAH cases. A history of LVAD implantation, anticoagulation therapy, and/or a coagulation disorder were more common in true SAH cases but not significantly so. A history of global ischemia was significantly more common in pseudo-SAH cases. If signs of SAH are observed on PMCT, it is important to look for other signs on PMCT and carefully review the clinical history to avoid a diagnostic error.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Bolliger SA, Thali MJ, Ross S, Buck U, Naether S, Vock P (2008) Virtual autopsy using imaging: bridging radiologic and forensic sciences. A review of the Virtopsy and similar projects. Eur Radiol 18:273–282

    Article  PubMed  Google Scholar 

  2. Thali MJ, Yen K, Schweitzer W et al (2003) Virtopsy, a new imaging horizon in forensic pathology: virtual autopsy by postmortem multislice computed tomography (MSCT) and magnetic resonance imaging (MRI)—a feasibility study. J Forensic Sci 48:386–403

    PubMed  Google Scholar 

  3. O'Donnell C, Woodford N (2008) Post-mortem radiology—a new sub-speciality? Clin Radiol 63:1189–1194. doi:10.1016/j.crad.2008.05.008

    Article  PubMed  Google Scholar 

  4. Roberts IS, Benamore RE, Benbow EW et al (2012) Post-mortem imaging as an alternative to autopsy in the diagnosis of adult deaths: a validation study. Lancet 379:136–142. doi:10.1016/s0140-6736(11)61483-9

    Article  PubMed  PubMed Central  Google Scholar 

  5. Cha JG, Kim DH, Paik SH et al (2010) Utility of postmortem autopsy via whole-body imaging: initial observations comparing MDCT and 3.0 T MRI findings with autopsy findings. Korean J Radiol 11:395–406. doi:10.3348/kjr.2010.11.4.395

    Article  PubMed  PubMed Central  Google Scholar 

  6. Flach PM, Thali MJ, Germerott T (2014) Times have changed! Forensic radiology—a new challenge for radiology and forensic pathology. AJR Am J Roentgenol 202:W325–W334. doi:10.2214/ajr.12.10283

    Article  PubMed  Google Scholar 

  7. Filograna L, Thali MJ, Marchetti D (2014) Forensic relevance of post-mortem CT imaging of the haemopericardium in determining the cause of death. Leg Med (Tokyo) 16:247–251. doi:10.1016/j.legalmed.2014.05.005

    Article  Google Scholar 

  8. Filograna L, Laberke P, Ampanozi G, Schweitzer W, Thali MJ, Bonomo L (2015) Role of post-mortem computed tomography (PMCT) in the assessment of the challenging diagnosis of pericardial tamponade as cause of death in cases with hemopericardium. Radiol Med 120:723–730. doi:10.1007/s11547-015-0517-1

    Article  PubMed  Google Scholar 

  9. Makino Y, Yamamoto S, Shiotani S et al (2015) Can ruptured abdominal aortic aneurysm be accurately diagnosed as the cause of death without postmortem computed tomography when autopsies cannot be performed? Forensic Sci Int 249:107–111. doi:10.1016/j.forsciint.2015.01.022

    Article  PubMed  Google Scholar 

  10. Araki A, Ishikawa N, Takami S et al (2016) Interpretation of postmortem head computed tomography for non-traumatic in-hospital deaths by non-radiologists: a preliminary study. Spring 5:978. doi:10.1186/s40064-016-2653-z

    Article  Google Scholar 

  11. Yokota H, Yokoyama K, Nakase H (2016) Spontaneous intracranial hypotension with pseudo-subarachnoid hemorrhage. Acta Neurol Belg. doi:10.1007/s13760-016-0623-4

  12. Avrahami E, Katz R, Rabin A, Friedman V (1998) CT diagnosis of non-traumatic subarachnoid haemorrhage in patients with brain edema. Eur J Radiol 28:222–225

    Article  CAS  PubMed  Google Scholar 

  13. al-Yamany M, Deck J, Bernstein M (1999) Pseudo-subarachnoid hemorrhage: a rare neuroimaging pitfall. Can J Neurol Sci 26:57–59

    CAS  PubMed  Google Scholar 

  14. Chute DJ, Smialek JE (2002) Pseudo-subarachnoid hemorrhage of the head diagnosed by computerized axial tomography: a postmortem study of ten medical examiner cases. J Forensic Sci 47:360–365

    Article  PubMed  Google Scholar 

  15. Given CA 2nd, Burdette JH, Elster AD, Williams DW 3rd (2003) Pseudo-subarachnoid hemorrhage: a potential imaging pitfall associated with diffuse cerebral edema. AJNR Am J Neuroradiol 24:254–256

    PubMed  Google Scholar 

  16. Spiegel SM, Fox AJ, Vinuela F, Pelz DM (1986) Increased density of tentorium and falx: a false positive CT sign of subarachnoid hemorrhage. Can Assoc Radiol J 37:243–247

    CAS  PubMed  Google Scholar 

  17. Agha A, Al-Hakami M (2011) A case report of pseudo-subarachnoid hemorrhage. Maedica (Buchar) 6:210–212

    Google Scholar 

  18. Opeskin K, Silberstein M (1998) False positive diagnosis of subarachnoid haemorrhage on computed tomography scan. J Clin Neurosci 5:382–386

    Article  CAS  PubMed  Google Scholar 

  19. Patzig M, Laub C, Janssen H, Ertl L, Fesl G (2014) Pseudo-subarachnoid haemorrhage due to chronic hypoxaemia: case report and review of the literature. BMC Neurol 14:219. doi:10.1186/s12883-014-0219-7

    Article  PubMed  PubMed Central  Google Scholar 

  20. You JS, Park S, Park YS, Chung SP (2008) Pseudo-subarachnoid hemorrhage. Am J Emerg Med 26:521.e521–521.e522. doi:10.1016/j.ajem.2007.08.031

    Article  Google Scholar 

  21. Yuzawa H, Higano S, Mugikura S et al (2008) Pseudo-subarachnoid hemorrhage found in patients with postresuscitation encephalopathy: characteristics of CT findings and clinical importance. AJNR Am J Neuroradiol 29:1544–1549. doi:10.3174/ajnr.A1167

    Article  CAS  PubMed  Google Scholar 

  22. Zhang J, Li Q, Zhang Z, Sun X (2015) Pseudo-subarachnoid hemorrhage in a patient with hypoxic encephalopathy. Neurochirurgie 61:35–37. doi:10.1016/j.neuchi.2014.08.003

    Article  CAS  PubMed  Google Scholar 

  23. Barton BR, Prabhakaran S, Lopes DK, Lee VH (2007) Pseudo-subarachnoid hemorrhage in cerebellar infarction. Neurocrit Care 7:172–174. doi:10.1007/s12028-007-0049-1

    Article  PubMed  Google Scholar 

  24. Misra V, Hoque R, Gonzalez-Toledo E, Kelley RE, Minagar A (2008) Pseudo-subarachnoid hemorrhage in a patient with acute cerebellar infarction. Neurol Res 30:813–815. doi:10.1179/174313208x341021

    Article  PubMed  Google Scholar 

  25. Hsieh SW, Khor GT, Chen CN, Huang P (2012) Pseudo subarachnoid hemorrhage in meningeal leukemia. J Emerg Med 42:e109–e111. doi:10.1016/j.jemermed.2010.04.006

    Article  PubMed  Google Scholar 

  26. Lang JL, Leach PL, Emelifeonwu JA, Bukhari S (2013) Meningitis presenting as spontaneous subarachnoid haemorrhage (pseudo-subarachnoid haemorrhage). Eur J Emerg Med 20:140–141. doi:10.1097/MEJ.0b013e3283562c72

    Article  PubMed  Google Scholar 

  27. Lin CY, Lai PH, Fu JH, Wang PC, Pan HB (2014) Pseudo-subarachnoid hemorrhage: a potential imaging pitfall. Can Assoc Radiol J 65:225–231. doi:10.1016/j.carj.2013.07.003

    Article  PubMed  Google Scholar 

  28. Schievink WI, Maya MM, Tourje J, Moser FG (2005) Pseudo-subarachnoid hemorrhage: a CT-finding in spontaneous intracranial hypotension. Neurology 65:135–137. doi:10.1212/01.wnl.0000167192.86419.15

    Article  PubMed  Google Scholar 

  29. Koh E, Huang SH, Lai YJ, Hong CT (2011) Spontaneous intracranial hypotension presenting as pseudo-subarachnoid hemorrhage on CT scan. J Clin Neurosci 18:1264–1265. doi:10.1016/j.jocn.2011.01.015

    Article  PubMed  Google Scholar 

  30. Ferrante E, Regna-Gladin C, Arpino I et al (2013) Pseudo-subarachnoid hemorrhage: a potential imaging pitfall associated with spontaneous intracranial hypotension. Clin Neurol Neurosurg 115:2324–2328. doi:10.1016/j.clineuro.2013.08.028

    Article  PubMed  Google Scholar 

  31. Kibayashi K, Shojo H, Sumida T (2005) Dural hemorrhage of the tentorium on postmortem cranial computed tomographic scans in children. Forensic Sci Int 154:206–209. doi:10.1016/j.forsciint.2004.10.019

    Article  PubMed  Google Scholar 

  32. Torbey MT, Selim M, Knorr J, Bigelow C, Recht L (2000) Quantitative analysis of the loss of distinction between gray and white matter in comatose patients after cardiac arrest. Stroke 31:2163–2167

    Article  CAS  PubMed  Google Scholar 

  33. Fujioka M, Okuchi K, Sakaki T, Hiramatsu K, Miyamoto S, Iwasaki S (1994) Specific changes in human brain following reperfusion after cardiac arrest. Stroke 25:2091–2095

    Article  CAS  PubMed  Google Scholar 

  34. Baumann Kreuziger LM, Kim B, Wieselthaler GM (2015) Antithrombotic therapy for left ventricular assist devices in adults: a systematic review. J Thromb Haemost 13:946–955. doi:10.1111/jth.12948

    Article  CAS  PubMed  Google Scholar 

  35. Sakaguchi M, Kitagawa K, Okazaki S et al (2015) Sulcus subarachnoid hemorrhage is a common stroke subtype in patients with implanted left ventricular assist devices. Eur J Neurol 22:1088–1093. doi:10.1111/ene.12712

    Article  CAS  PubMed  Google Scholar 

  36. Downer JJ, Pretorius PM (2009) Symmetry in computed tomography of the brain: the pitfalls. Clin Radiol 64:298–306. doi:10.1016/j.crad.2008.08.012

    Article  CAS  PubMed  Google Scholar 

  37. Hayman EG, Wessell A, Gerzanich V, Sheth KN, Simard JM (2016) Mechanisms of global cerebral edema formation in aneurysmal subarachnoid hemorrhage. Neurocrit Care 26:301–310. doi:10.1007/s12028-016-0354-7

    Article  Google Scholar 

  38. Shirota G, Gonoi W, Ishida M et al (2015) Brain swelling and loss of gray and white matter differentiation in human postmortem cases by computed tomography. PLoS One 10:e0143848. doi:10.1371/journal.pone.0143848 eCollection 0142015

    Article  PubMed  PubMed Central  Google Scholar 

  39. Shirota G, Ishida M, Shintani Y et al (2016) Can postmortem computed tomography detect antemortem hypoxic-ischemic encephalopathy? Forensic Sci Med Pathol 12:267–275. doi:10.1007/s12024-016-9787-8

    Article  PubMed  Google Scholar 

Download references

Acknowledgments

This work was supported by a grant from the Japanese Ministry of Health, Labor, and Welfare for research on “Usefulness of Postmortem Images as an Ancillary Method for Autopsy in Evaluation of Death Associated with Medical Practice (2008–2009)” and by a research grant from the Japan Radiological Society supported by Bayer (2017–2018). The authors wish to acknowledge Dr. Kuni Ohtomo, President, International University of Health and Welfare, for his intellectual support.

Author information

Authors and Affiliations

  1. Department of Radiology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan

    Go Shirota, Wataru Gonoi, Masanori Ishida, Tomohiko Higashida, Hidemi Okuma & Osamu Abe

  2. Department of Pathology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan

    Masako Ikemura, Yukako Shintani, Hiroyuki Abe & Masashi Fukayama

  3. Department of Radiology, Mutual Aid Association for Tokyo Metropolitan Teachers and Officials, Sanraku Hospital, 2-5 Kandasurugadai, Chiyoda-ku, Tokyo, 101-8326, Japan

    Masanori Ishida

Authors
  1. Go Shirota
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Wataru Gonoi
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Masako Ikemura
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Masanori Ishida
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Yukako Shintani
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Hiroyuki Abe
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Masashi Fukayama
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Tomohiko Higashida
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Hidemi Okuma
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Osamu Abe
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Wataru Gonoi.

Ethics declarations

Conflicts of interest

The authors declare that they have no conflicts of interest.

Research involving human participants and/or animals

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Written informed consent for use of the clinical and radiographic data presented in this report was obtained from the next of kin of each study subject.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Shirota, G., Gonoi, W., Ikemura, M. et al. The pseudo-SAH sign: an imaging pitfall in postmortem computed tomography. Int J Legal Med 131, 1647–1653 (2017). https://doi.org/10.1007/s00414-017-1651-1

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00414-017-1651-1

Keywords

Search

Navigation