Moscovici Samuel, Fraifeld Shifra, Ramirez-de-Noriega Fernando, Rosenthal Guy, Leker Ronen R, Itshayek Eyal, Cohen José E
Depatment of Neurosurgery, Hadassah–Hebrew University Medical Center, Jerusalem, Israel.
Neurol Res. 2013 Mar;35(2):117-22. doi: 10.1179/1743132812Y.0000000147.
We aimed to compare the presentation, management, and clinical course in patients with perimesencephalic and nonperimesencephalic (aneurysmal) bleeding patterns on noncontrast CT, but negative initial 4-vessel digital subtraction angiography (DSA).
We retrospectively reviewed clinical and imaging data for 280 patients presenting with spontaneous SAH admitted between 2005 and 2011. We identified 56 patients (20%) with SAH diagnosed on high resolution head CT performed within 48 hours of admission, and negative initial DSA, and divided them into perimesencephalic and non-perimesencephalic groups based on hemorrhage patterns. Patients with traumatic subarachnoid bleeding and those with initial positive DSA were excluded from this analysis.
Perimesencephalic SAH was seen in 25 patients (45%); non-perimesencephalic bleeding patterns were seen in 31 (55%). All patients with perimesencephalic SAH presented with Hunt and Hess (HH) I, versus 45% HH I and 55% HH II-IV in those with non-perimecenphalic SAH. All patients with perimesencephalic SAH achieved modified Rankin score (mRS) 0 at discharge and 6-month follow-up, compared with 45% mRS 0 at discharge and 68% at 6-month follow-up in non-perimesencephalic SAH. Patients with perimesencephalic SAH presented a uniformly uncomplicated clinical course. Among non-perimesencephalic SAH patients there were 19 neurological/neurosurgical and 10 medical complications, two small aneurysms diagnosed at follow-up DSA, and one death.
In this series, perimesencephalic SAH was associated with good clinical grades, consistently negative initial and follow-up angiograms, and an excellent prognosis. In contrast, non-perimesencephalic SAH was associated with a worse clinical presentation, higher complication rates, higher rates of true aneurysm detection on follow-up angiogram, and a poorer outcome.
我们旨在比较非增强CT上表现为中脑周围型和非中脑周围型（动脉瘤性）出血模式，但初次4血管数字减影血管造影（DSA）结果为阴性的患者的临床表现、治疗及临床病程。
我们回顾性分析了2005年至2011年间收治的280例自发性蛛网膜下腔出血患者的临床和影像学资料。我们确定了56例（20%）在入院48小时内进行的高分辨率头部CT诊断为蛛网膜下腔出血且初次DSA结果为阴性的患者，并根据出血模式将他们分为中脑周围型和非中脑周围型组。创伤性蛛网膜下腔出血患者和初次DSA结果为阳性的患者被排除在本分析之外。
25例（45%）患者表现为中脑周围型蛛网膜下腔出血；31例（55%）表现为非中脑周围型出血模式。所有中脑周围型蛛网膜下腔出血患者均表现为Hunt和Hess（HH）分级I级，而非中脑周围型蛛网膜下腔出血患者中45%为HH分级I级，55%为HH分级II-IV级。所有中脑周围型蛛网膜下腔出血患者出院时及6个月随访时改良Rankin量表（mRS）评分为0，而非中脑周围型蛛网膜下腔出血患者出院时mRS评分为0的比例为45%，6个月随访时为68%。中脑周围型蛛网膜下腔出血患者的临床病程均无并发症。在非中脑周围型蛛网膜下腔出血患者中，有19例发生神经科/神经外科并发症和10例内科并发症，2例在随访DSA时诊断为小动脉瘤，1例死亡。
在本系列研究中，中脑周围型蛛网膜下腔出血与良好的临床分级、初次及随访血管造影始终为阴性以及良好的预后相关。相比之下，非中脑周围型蛛网膜下腔出血与较差的临床表现、较高的并发症发生率、随访血管造影时真性动脉瘤的检出率较高以及较差的预后相关。
