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Clinical outcome and prognostic factors of patients with angiogram-negative and non-perimesencephalic subarachnoid hemorrhage: benign prognosis like perimesencephalic SAH or same risk as aneurysmal SAH?

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Abstract

Subarachnoid hemorrhage (SAH) is usually caused by a ruptured intracranial aneurysm. However, in some patients, no source of hemorrhage might be detected despite repeated digital subtraction angiography (DSA). Our objective was to analyze factors influencing the clinical outcome in patients suffering from non-aneurysmal and non-perimesencephalic (NPM) SAH. Between 1999 and 2011, 68 of 1,188 patients with SAH (5.7 %) suffered from non-aneurysmal and NPM-SAH. Outcome was assessed according to the modified Rankin Scale (mRS) at 6 months (mRS 0–2 favorable vs. 3–6 unfavorable). In patients with angiogram-negative and NPM-SAH, favorable outcome was achieved in 56 patients (82.4 %). In the multivariate analysis, age <65 years and non-Fisher 3 bleeding pattern were significantly associated with favorable outcome. Angiogram-negative and NPM-SAH had good prognoses. Patients with non-Fisher-type 3 bleeding had excellent outcomes similar to patients with perimesencephalic SAH, but patients with Fisher-type 3 bleeding were at risk for poor outcome like aneurysmal SAH patients due to cerebral vasospasm and delayed cerebral ischemia. Age and bleeding type were detected as prognostic factors in the multivariate analysis.

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Authors and Affiliations

  1. Department of Neurosurgery, Goethe University Hospital, Frankfurt am Main, 60528, Germany

    Juergen Konczalla, Patrick Schuss, Johannes Platz, Hartmut Vatter, Volker Seifert & Erdem Güresir

Authors
  1. Juergen Konczalla
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  2. Patrick Schuss
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  3. Johannes Platz
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  4. Hartmut Vatter
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  5. Volker Seifert
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  6. Erdem Güresir
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Correspondence to Juergen Konczalla.

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Comments

Siamak Asgari, Ingolstadt, Germany

In a retrospective study, Konczalla et al. reported about 68 patients with non-perimesencephalic subarachnoid hemorrhage who did not show any kind of bleeding source. All of them underwent two cerebral angiographies and one MRI of the cerebrum/cervical spine. Eighty-two percent of the patients experienced favorable outcomes. Twenty-seven percent of the patients developed cerebral vasospasm and 19 % of the patients suffered from delayed cerebral ischemia. Ten percent of the patients needed insertion of a CSF shunt. The authors presented a multivariate analysis pointing out Fisher grade 3 and patient age over 65 years as negative prognostic factors. This paper is of significant value for the neurovascular-interested readers and well-prepared. The authors had a database of over 1,188 patients with spontaneous subarachnoid hemorrhage available. Personally, I estimate an increasing number of patients with spontaneous non-perimesencephalic hemorrhage without visualizing a bleeding source in the recent years. Some of these bleedings occurred under systemic anticoagulation or dual platelet inhibition. The authors re-evaluate their data showing both an increasing number of non-aneurysmal SAH and patients treated with systemic anticoagulation or platelet inhibition. However, the rehemorrhage rate in these patients was very low (1.5 %).

Nicholas C. Bambakidis, Cleveland, USA

The authors analyzed factors influencing the clinical outcome in 68 patients suffering from non-aneurysmal and non-perimesencephalic (NPM) subarachnoid hemorrhage (SAH). The authors demonstrated that angiogram-negative and NPM-SAH had good prognoses. Patients with Fisher-type 3 bleeding were at risk for poor outcome like aneurismal SAH patients due to cerebral vasospasm and delayed cerebral ischemia. This is a large case series of angiogram-negative and NPM-SAH. We routinely repeat cerebral angiography on these patients and do not rely on CTA or MRA. Additionally, it is important to image the cervical spine with MRI to rule out spinal vascular malformation or other hemorrhagic lesions. As the authors point out, patients with large amounts of SAH are at risk of developing all of the usual complications of aneurysmal SAH and must be monitored and treated closely.

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Konczalla, J., Schuss, P., Platz, J. et al. Clinical outcome and prognostic factors of patients with angiogram-negative and non-perimesencephalic subarachnoid hemorrhage: benign prognosis like perimesencephalic SAH or same risk as aneurysmal SAH?. Neurosurg Rev 38, 121–127 (2015). https://doi.org/10.1007/s10143-014-0568-0

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