This study aims to investigate the characteristics of patients with mild aneurysmal and non-aneurysmal perimesencephalic and non-perimesencephalic subarachnoid hemorrhage (aSAH, pmSAH, npmSAH) with emphasis on admission biomarkers, clinical course, and outcome. A prospective cohort of 115 patients with aSAH (Hunt and Hess 1–3) and of 35 patients without aneurysms (16 pmSAH and 19 npmSAH) admitted between January 2014 and January 2020 was included. Demographic data, blood samples on admission, complications (hydrocephalus, shunt dependency, delayed cerebral ischemia DCI, DCI-related infarction, and mortality), and outcome after 6 months were analyzed. Demographic data was comparable between all groups except for age (aSAH 55 [48–65] vs. npmSAH 60 [56–68] vs. pmSAH 52 [42–60], p = 0.032) and loss of consciousness (33% vs. 0% vs. 0%, p = 0.0004). Admission biomarkers showed poorer renal function and highest glucose levels for npmSAH patients. Complication rate in npmSAH was high and comparable to that of aSAH patients (hydrocephalus, shunt dependency, DCI, DCI-related infarction, mortality), but nearly absent in patients with pmSAH. Favorable outcome after 6 months was seen in 92.9% of pmSAH, 83.3% of npmSAH, and 62.7% of aSAH (p = 0.0264). In this prospective cohort of SAH patients, npmSAH was associated with a complicated clinical course, comparable to that of patients with aSAH. In contrast, such complications were nearly absent in pmSAH patients, suggesting fundamental differences in the pathophysiology of patients with different types of non-aneurysmal hemorrhage. Our findings underline the importance for a precise terminology according the hemorrhage etiology as a basis for more vigilant management of npmSAH patients. NCT02142166, 05/20/2014, retrospectively registered.

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Baseline characteristics and outcome for aneurysmal versus non-aneurysmal subarachnoid hemorrhage: a prospective cohort study

It is well known that spontaneous non-aneurysmal subarachnoid hemorrhage (SAH), also known as sine materia SAH (smSAH), has usually a better course and prognosis than its aneurysmal counterpart (aSAH). This might depend on different inflammatory mechanisms initiated by bleeding events of different origins. The aim of the present study was to explore the systemic inflammatory response in spontaneous SAH, comparing aSAH and smSAH.We performed a prospective observational study over a consecutive series of patients with SAH. For these patients, we collected all clinical data and, furthermore, performed venous blood sampling over six time points to analyze blood cells. We further performed the analysis of lymphocytes and monocytes by means of flow cytometry to quantify common subtypes. Statistical analysis included a t-student test, Chi-square test, multivariate logistic regression, and ROC analysis.48 patients were included: six (12.5%) with a diagnosis of spontaneous smSAH, and forty-two patients (87.5%) with aSAH. Significant differences on Day 0 were found for neutrophils and a systemic neuro-inflammatory index, namely, systemic inflammatory response index (SIRI). At the ROC analysis, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and SIRI exhibited satisfactory predictive power on day 0. At the multivariable logistic regression analysis, the combined index (NLR, LMR, SIRI at day 0) yielded an OR of 0.59 (95% CI 0.29-1.21]). LMR at day 0 yielded an OR of 1.25 ([95% CI 0.94-1.68]), NLR at day 0 exhibited an OR of 0.68 ([95% CI 0.42-1.09]), and SIRI at day 0 displayed an OR of 0.31 ([95% CI 0.06-1.49]).This preliminary study indicated a possible role of some inflammatory indices that point out the importance of innate and adaptive immunity in the etiopathogenetic mechanisms. Drugs modulating these responses could eventually counteract or, at least, reduce secondary damage associated with SAH. 

Systemic Inflammatory Response in Spontaneous Subarachnoid Hemorrhage from Aneurysmal Rupture versus Subarachnoid Hemorrhage of Unknown Origin

Aim: Angiogram-negative subarachnoid hemorrhage (AN-SAH) is defined as subarachnoid hemorrhage with no vascular defect detected in radiological imaging. In approximately 15% of patients with subarachnoid hemorrhage, no visible bleeding cause is found during the initial examination. Our main objective of the study was to analyze epidemiological data and clinical conditions of AN-SAH patients in comparison with patients suffering from subarachnoid hemorrhage caused by a ruptured aneurysm (A-SAH). Methods: This was a single-center retrospective cohort study carried out in Heliodor Święcicki Hospital in Poznań, Poland. All the patients underwent Computed Tomography (CT) scans and Digital Subtraction Angiography (DSA). If no vascular defect was presented, a follow-up after two weeks post-initial examination was suggested. Obtained data were analyzed in Statistica 13. Results: We included 564 patients admitted to the hospital between April 2016 to May 2021 with subarachnoid hemorrhage. 60 of all patients were diagnosed with angiogram-negative subarachnoid hemorrhage (AN-SAH). The average age of the AN-SAH patients group was similar to the A-SAH patients group (53 ± 11.38 vs. 56.8 ± 14.1). Contrary to the A-SAH patients where women were the dominant sex (66.27%), the AN-SAH group comprises mostly men (65%). The clinical condition measured by Hunt Hess (HH) score for both patient groups was more favorable for the AN-SAH group (the median HH score was I) than those of patients with a ruptured aneurysm (the median HH score was II). Conclusion: There is a significant difference between clinical outcome and gender distribution of AN-SAH patients in comparison to A-SAH patients.

Subarachnoid hemorrhage in patients without a vascular defect - A retrospective observational study

Objective It is well known that spontaneous non-aneurysmal subarachnoid hemorrhage (SAH), also known as sine materia SAH (smSAH), has usually a better course and prognosis than its aneurysmal counterpart (aSAH). This might depend on different inflammatory mechanisms initiated by bleeding events of different origins. The aim of the present study was to explore the systemic inflammatory response in spontaneous SAH, comparing aSAH and smSAH. Methods We performed a prospective observational study over a consecutive series of patients with SAH. For these patients, we collected all clinical data and, furthermore, performed venous blood sampling over six time points to analyze blood cells. We further performed the analysis of lymphocytes and monocytes by means of flow cytometry to quantify common subtypes. Statistical analysis included a t-student test, Chi-square test, multivariate logistic regression, and ROC analysis. Results 48 patients were included: six (12.5%) with a diagnosis of spontaneous smSAH, and forty-two patients (87.5%) with aSAH. Significant differences on Day 0 were found for neutrophils and a systemic neuro-inflammatory index, namely, systemic inflammatory response index (SIRI). At the ROC analysis, neutrophil-to-lymphocyte ratio (NLR), lymphocyte-to-monocyte ratio (LMR), and SIRI exhibited satisfactory predictive power on day 0. At the multivariable logistic regression analysis, the combined index (NLR, LMR, SIRI at day 0) yielded an OR of 0.59 (95% CI 0.29–1.21]). LMR at day 0 yielded an OR of 1.25 ([95% CI 0.94–1.68]), NLR at day 0 exhibited an OR of 0.68 ([95% CI 0.42–1.09]), and SIRI at day 0 displayed an OR of 0.31 ([95% CI 0.06–1.49]). Conclusion This preliminary study indicated a possible role of some inflammatory indices that point out the importance of innate and adaptive immunity in the etiopathogenetic mechanisms. Drugs modulating these responses could eventually counteract or, at least, reduce secondary damage associated with SAH.

https://www.dovepress.com/getfile.php?fileID=85465

Objectives: Subarachnoid hemorrhage (SAH) with negative angiographic findings has a heterogeneous nature with variations in clinical course and outcome as compared to the aneurysmal SAH. It makes up to 15% of the spontaneous SAH and is characterized by milder clinical presentation. The purpose of this study was the analyses of risk factors, clinical observations, radiologic characteristics, and outcome in patients with nonaneurysmal SAH (NA-SAH). Patients and Methods: In a retrospective design, 77 consecutive patients with NA-SAH were recruited from May 2008, to October 2018. All patients underwent conventional cerebral angiography. We stratified patients into two groups based on the distribution of blood on their CT scan into perimesencephalic (PM) and non-PM (NPM) SAH. We performed the Outcome using Glasgow Coma Scale (GCS) and modified Rankin scale (favorable mRS 0–2 vs. unfavorable mRS 3–6). Data were analyzed using IBM® SPSS® Statistics V22.0. Results: The mean age at presentation was 48.5 ± 8.4 years with male predominance (71.4%). About 76.7% of the patients had headache and vomiting, most of the patients (75.3%) presented with GCS 15 at initial clinical presentation (61.03%) had NPM versus (38.96%) with PM characters in computed tomography scans. Fourteen (17.9%) patients developed hydrocephalus and 12 (15.3%) needed external ventricular drain placement, while none of the patients needed permanent shunt placement. However, all patients had a favorable clinical and functional outcome at discharge and at late follow-up (up to 3 months). Conclusions: NA-SAH does not affect the short- and long-term prognosis. In our results, the pattern of bleeding affects the initial presentation, clinical course, and complications. The clinical and functional outcomes in the majority of our patients were comparable in both groups with good prognosis. Hypertension, smoking, and elevated venous pressure, such as a history of deep venous thrombosis and asthma might be considered as a risk factor.

Ten years' experiences in the treatment of nonaneurysmal subarachnoid hemorrhage: A retrospective analysis of outcome parameters in a single-center study

Objectives: Approaches to the hypothalamus and anterior third ventricle are variable. We present a technical note on access of the hypothalamus using the trans-lamina terminalis approach by supraorbital craniotomy in a patient who had a hypothalamic cavernoma and presented to us with recurrent hemorrhage. Patients and methods: The trans-lamina terminalis approach, including anatomical landmarks and surgical steps through a supra-orbital craniotomy, is described and a comparison with other surgical corridors is discussed. Results: The supraorbital trans lamina terminalis approach allowed an effective access to the hypothalamic lesions. This approach provided a safe and minimally invasive corridor for gross total resection of the lesion since trespass of viable brain tissue is avoided. One clinical case illustrates the feasibility of the approach allowing complete removal of a cavernoma without surgery related neurological of endocrinological deficits. Conclusions: The supra-orbital craniotomy for trans-lamina terminalis approach is a valid surgical choice for hypothalamic lesions. The major strengths of this approach include minimal brain retraction and direct end-on view; however, the long and narrow surgical corridor requires some technical familiarization. The clinical outcomes are comparable to other surgical corridors.

Firas Hammadi

Papers

Ten years' experiences in the treatment of nonaneurysmal subarachnoid hemorrhage: A retrospective analysis of outcome parameters in a single-center study

Translamina terminalis approach to the hypothalamus using supraorbital craniotomy: Technical note and comparison with other surgical corridors

Rare pontine metastasis operated via endoscopic transsphenoidal transclival approach, a case report and brief review of literature