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CT evaluation of subarachnoid hemorrhage: a practical review for the radiologist interpreting emergency room studies

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Abstract

Radiologists working in an emergency radiology setting frequently interpret computed tomography (CT) studies of patients with suspected subarachnoid hemorrhage (SAH). This article reviews the sensitivity of CT for detection of SAH, some major patterns of SAH related to a ruptured aneurysm, and the differential diagnosis of SAH not due to aneurysmal rupture.

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References

  1. Schwedt TJ (2007) Clinical spectrum of thunderclap headache. Expert Rev Neurother 7:1135–1144

    Article  PubMed  Google Scholar 

  2. Morgenstern LB, Luna-Gonzales H, Huber JC Jr et al (1998) Worst headache and subarachnoid hemorrhage: prospective, modern computed tomography and spinal fluid analysis. Ann Emerg Med 32:297–304

    PubMed  CAS  Google Scholar 

  3. Mayberg MR, Batjer HH, Dacey R et al (1994) Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 25:2315–2328

    PubMed  CAS  Google Scholar 

  4. Dupont SA, Wijdicks EF, Manno EM, Rabinstein AA (2008) Thunderclap headache and normal computed tomographic results: value of cerebrospinal fluid analysis. Mayo Clin Proc 83:1326–1331

    Article  PubMed  Google Scholar 

  5. Perry JJ, Stiell IG, Wells GA et al (2005) Attitudes and judgment of emergency physicians in the management of patients with acute headache. Acad Emerg Med 12:33–37

    Article  PubMed  Google Scholar 

  6. Vermeulen MJ, Schull MJ (2007) Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke 38:1216–1221

    Article  PubMed  Google Scholar 

  7. Mayer PL, Awad IA, Todor R et al (1996) Misdiagnosis of symptomatic cerebral aneurysm: prevalence and correlation with outcome at four institutions. Stroke 27:1558–1563

    PubMed  CAS  Google Scholar 

  8. van der Wee N, Rinkel GJE, Hasan D, van Gijn J (1995) Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan? J Neurol Neurosurg Psychiatry 58:357–359

    Article  PubMed  Google Scholar 

  9. Sames TA, Storrow AB, Finkelstein JA, Magoon MR (1996) Sensitivity of new-generation computed tomography in subarachnoid hemorrhage. Acad Emerg Med 3:16–20

    Article  PubMed  CAS  Google Scholar 

  10. Sidman R, Connolly E, Lemke T (1996) Subarachnoid hemorrhage diagnosis: lumbar puncture is still needed when the computed tomography scan is normal. Acad Emerg Med 3:827–831

    Article  PubMed  CAS  Google Scholar 

  11. Perry JJ, Stiell IG, Wells GA et al (2004) The sensitivity of CT for the diagnosis of subarachnoid hemorrhage in ED patients with acute headache. Acad Emerg Med 11:435–436

    Article  Google Scholar 

  12. Boesiger BM, Shiber JR (2005) Subarachnoid hemorrhage diagnosis by computed tomography and lumbar puncture: are fifth generation CT scanners better at identifying subarachnoid hemorrhage? J Emerg Med 29:23–27

    Article  PubMed  Google Scholar 

  13. Lourenco AP, Mayo-Smith WW, Tubbs RJ, Sidman R (2009) Does 16-detector computed tomography improve detection of non-traumatic subarachnoid hemorrhage in the emergency department? J Emerg Med 36:171–175

    Article  PubMed  Google Scholar 

  14. van Gijn J, van Dongen KJ (1982) The time course of aneurysmal haemorrhage on computed tomograms. Neuroradiology 23:153–156

    PubMed  Google Scholar 

  15. Kowalski RG, Claassen J, Kreiter KT et al (2004) Initial misdiagnosis and outcome after subarachnoid hemorrhage. JAMA 291:866–869

    Article  PubMed  CAS  Google Scholar 

  16. Kassell NF, Torner JC, Haley EC Jr et al (1990) The International Cooperative Study on the timing of aneurysm surgery. Part 1: overall management results. J Neurosurg 73:18–36

    Article  PubMed  CAS  Google Scholar 

  17. Edlow JA, Wyer PC (2000) How good is a negative cranial computed tomographic scan result in excluding subarachnoid hemorrhage? Ann Emerg Med 36:507–516

    PubMed  CAS  Google Scholar 

  18. Schriger DL, Kalafut M, Starkman S et al (1998) Cranial computed tomography interpretation in acute stroke: physician accuracy in determining eligibility for thrombolytic therapy. JAMA 279:1293–1297

    Article  PubMed  CAS  Google Scholar 

  19. Hunt WE, Hess RM (1968) Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20

    Article  PubMed  CAS  Google Scholar 

  20. Fisher CM, Kistler JP, Davis JM (1980) Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9

    Article  PubMed  CAS  Google Scholar 

  21. Bederson JB, Connolly ES Jr, Batjer HH et al (2009) American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 40:994–1025

    Article  PubMed  Google Scholar 

  22. Kallmes DF, Layton K, Marx WF, Tong F (2007) Death by nondiagnosis: why emergent CT angiography should not be done for patients with subarachnoid hemorrhage. AJNR Am J Neuroradiol 28:1837–1838

    Article  PubMed  Google Scholar 

  23. Fifi JT, Meyers PM, Lavine SD et al (2009) Complications of modern diagnostic cerebral angiography in an academic medical center. J Vasc Interv Radiol 20:442–447

    Article  PubMed  Google Scholar 

  24. Fox AJ, Symons SP, Aviv RI (2008) CT angiography is state-of-the-art first vascular imaging for subarachnoid hemorrhage. AJNR Am J Neuroradiol 29:e41–e42

    Article  PubMed  CAS  Google Scholar 

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

    PubMed  Google Scholar 

  26. Ammerman JM (2008) Pseudosubarachnoid hemorrhage: a zebra worth looking for. South Med J 101:1200

    PubMed  Google Scholar 

  27. Schievink WI, Maya MM, Tourje J, Moser FG (2005) Pseudo-subarachnoid hemorrhage: a CT-finding in spontaneous intracranial hypotension. Neurology 65:135–137

    Article  PubMed  Google Scholar 

  28. Rabinstein AA, Pittock SJ, Miller GM, Schindler JJ, Wijdicks EF (2003) Pseudosubarachnoid haemorrhage in subdural haematoma. J Neurol Neurosurg Psychiatry 74:1131–1132

    Article  PubMed  CAS  Google Scholar 

  29. Huang D, Abe T, Ochiai S et al (1999) False positive appearance of subarachnoid hemorrhage on CT with bilateral subdural hematomas. Radiat Med 17:439–442

    PubMed  CAS  Google Scholar 

  30. Sharp S, Stone J, Beach R (1999) Contrast agent neurotoxicity presenting as subarachnoid hemorrhage. Neurology 52:1503–1505

    PubMed  CAS  Google Scholar 

  31. Velden J, Milz P, Winkler F, Seelos K, Hamann GF (2003) Nonionic contrast neurotoxicity after coronary angiography mimicking subarachnoid hemorrhage. Eur Neurol 49:249–251

    Article  PubMed  Google Scholar 

  32. Karttunen AI, Jartti PH, Ukkola VA, Sajanti J, Haapea M (2003) Value of the quantity and distribution of subarachnoid haemorrhage on CT in the localization of a ruptured cerebral aneurysm. Acta Neurochir 145:655–661

    Article  CAS  Google Scholar 

  33. Tryfonidis M, Evans AL, Coley SC et al (2007) The value of radio-anatomical features on non-contrast CT scans in localizing the source in aneurysmal subarachnoid haemorrhage. Clin Anat 20:618–623

    Article  PubMed  CAS  Google Scholar 

  34. Kallmes DF, Lanzino G, Dix JE et al (1997) Patterns of hemorrhage with ruptured posterior inferior cerebellar artery aneurysms: CT findings in 44 cases. AJR Am J Roentgenol 169:1169–1171

    PubMed  CAS  Google Scholar 

  35. van der Jagt M, Hasan D, Bijvoet HWC et al (1999) Validity of prediction of the site of ruptured intracranial aneurysms with CT. Neurology 52:34–39

    PubMed  Google Scholar 

  36. Rinkel GJE, Wijdicks EFM, Vermeulen M et al (1991) Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture. AJNR Am J Neuroradiol 12:829–834

    PubMed  CAS  Google Scholar 

  37. van der Schaaf IC, Velthuis BK, Gouw A, Rinkel GJ (2004) Venous drainage in perimesencephalic hemorrhage. Stroke 35:1614–1618

    Article  PubMed  Google Scholar 

  38. Topcuoglu MA, Ogilvy CS, Carter BS, Buonanno FS, Koroshetz WJ, Singhal AB (2003) Subarachnoid hemorrhage without evident cause on initial angiography studies: diagnostic yield of subsequent angiography and other neuroimaging tests. J Neurosurg 98:1235–1240

    Article  PubMed  Google Scholar 

  39. van Gijn J, van Dongen KJ, Vermeulen M et al (1985) Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology 35:493–497

    PubMed  Google Scholar 

  40. Alen JF, Lagares A, Lobato RD, Gomez PA, Rivas JJ, Ramos A (2003) Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms. J Neurosurg 98:529–535

    Article  PubMed  Google Scholar 

  41. Kallmes DF, Clark HP, Dix JE et al (1996) Ruptured vertebrobasilar aneurysms: frequency of the nonaneurysmal perimesencephalic pattern of hemorrhage on CT scans. Radiology 201:657–660

    PubMed  CAS  Google Scholar 

  42. Provenzale JM (1995) Dissection of the internal carotid and vertebral arteries: imaging findings. AJR Am J Roentgenol 165:1099–1104

    PubMed  CAS  Google Scholar 

  43. Sasaki O, Ogawa H, Koike T, Koizumi T, Tanaka R (1991) A clinicopathological study of dissecting aneurysms of the intracranial vertebral artery. J Neurosurg 75:874–882

    Article  PubMed  CAS  Google Scholar 

  44. Kim BM, Suh SH, Park SI et al (2008) Management and clinical outcome of acute basilar artery dissection. AJNR Am J Neuroradiol 29:1937–1941

    Article  PubMed  CAS  Google Scholar 

  45. Flis CM, Jäger HR, Sidhu PS (2007) Carotid and vertebral artery dissections: clinical aspects, imaging features and endovascular treatment. Eur Radiol 17:820–834

    Article  PubMed  Google Scholar 

  46. de Bruijn SF, Stam J, Kappelle LJ (1996) Thunderclap headache as first symptom of cerebral venous sinus thrombosis. CVST Study Group. Lancet 348:1623–1625

    Article  PubMed  Google Scholar 

  47. Jaiser SR, Raman A, Maddison P (2008) Cerebral venous sinus thrombosis as a rare cause of thunderclap headache and nonaneurysmal subarachnoid haemorrhage. J Neurol 255(3):448–449

    Article  PubMed  Google Scholar 

  48. Chang R, Friedman DP (2004) Isolated cortical venous thrombosis presenting as subarachnoid hemorrhage: a report of three cases. AJNR Am J Neuroradiol 25:1676–1679

    PubMed  Google Scholar 

  49. McEvoy AW, Kitchen ND, Thomas DG (2000) Intracerebral haemorrhage and drug abuse in young adults. Br J Neurosurg 14:449–454

    Article  PubMed  CAS  Google Scholar 

  50. Kaneria MV, Pagar S, Samant H, Yeole S, Patil S (2008) Subarachnoid haemorrhage: possibly caused by the illegitimate use of sildenafil citrate. J Assoc Phys India 56:809–811

    Google Scholar 

  51. Jacobs IG, Roszler MH, Kelly JK, Klein MA, Kling GA (1989) Cocaine abuse: neurovascular complications. Radiology 170:223–227

    PubMed  CAS  Google Scholar 

  52. Broderick JP, Viscoli CM, Brott T et al (2003) Major risk factors for aneurysmal subarachnoid hemorrhage in the young are modifiable. Stroke 34:1375–1381

    Article  PubMed  Google Scholar 

  53. Peterson PL, Roszler M, Jacobs I, Wilner HI (1991) Neurovascular complications of cocaine abuse. J Neuropsychiatry Clin Neurosci 3:143–149

    PubMed  CAS  Google Scholar 

  54. Takahashi S, Sonobe M, Shirane R, Kubota Y, Kawakami H (1982) Computer tomography of ruptured intracranial arteriovenous malformations in the acute stage. Acta Neurochir (Wien) 66:87–94

    Article  CAS  Google Scholar 

  55. Yamamoto M, Fukushima T, Ikeda K et al (1993) Intracranial cavernous angioma manifesting as subarachnoid hemorrhage—case report. Neurol Med Chir (Tokyo) 33:706–709

    Article  CAS  Google Scholar 

  56. Hentschel S, Toyota B (2003) Intracranial malignant glioma presenting as subarachnoid hemorrhage. Can J Neurol Sci 30:63–66

    PubMed  Google Scholar 

  57. Berlis A, Schumacher M, Spreer J, Neumann HP, van Velthoven V (2003) Subarachnoid haemorrhage due to cervical spinal cord haemangioblastomas in a patient with von Hippel-Lindau disease. Acta Neurochir (Wien) 145:1009–1113

    Article  CAS  Google Scholar 

  58. Shephard RH (1992) Spinal arteriovenous malformations and subarachnoid haemorrhage. Br J Neurosurg 6:5–12

    Article  PubMed  CAS  Google Scholar 

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Correspondence to James M. Provenzale.

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Provenzale, J.M., Hacein-Bey, L. CT evaluation of subarachnoid hemorrhage: a practical review for the radiologist interpreting emergency room studies. Emerg Radiol 16, 441–451 (2009). https://doi.org/10.1007/s10140-009-0824-8

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  • DOI: https://doi.org/10.1007/s10140-009-0824-8

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