Atraumatic nonaneurysmal sulcal subarachnoid hemorrhages: a diagnostic workup based on a case series.

P. Renou, T. Tourdias, O. Fleury, S. Debruxelles, F. Rouanet, I. Sibon
Cerebrovasc Dis. 2012-01-01; 34(2): 147-152
DOI: 10.1159/000339685

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1. Cerebrovasc Dis. 2012;34(2):147-52. doi: 10.1159/000339685. Epub 2012 Aug 8.

Atraumatic nonaneurysmal sulcal subarachnoid hemorrhages: a diagnostic workup
based on a case series.

Renou P(1), Tourdias T, Fleury O, Debruxelles S, Rouanet F, Sibon I.

Author information:
(1)Pôle des neurosciences cliniques, CHU de Bordeaux, Université Bordeaux
Segalen, Bordeaux, France.

INTRODUCTION: Atraumatic and nonaneurysmal sulcal subarachnoid hemorrhage (sSAH)
is a rare type of cerebrovascular disease with various etiologies previously
reported in small case reports. In this study, we propose to analyze clinical
presentations, imaging patterns and etiologies in a large case series of such
patients in order to propose a diagnostic workup.
METHODS: We retrospectively analyzed clinical and radiological data of
consecutive patients with a diagnosis of atraumatic and nonaneurysmal sSAH,
admitted to our institution between 2008 and 2011. All patients had both computed
tomography (CT) and magnetic resonance imaging (MRI) as a part of their initial
RESULTS: 30 patients (18 women and 12 men, mean age: 60 years) were identified.
The main clinical symptoms at presentation were focal and transient neurological
deficit (n = 22) and thunderclap headache (n = 10). Four patients had progressive
headache and 4 other had partial or generalized epileptic seizures. MRI
abnormalities associated with sSAH were prior hemorrhages, microbleeds, severe
leukoencephalopathy and hemosiderosis suggesting cerebral amyloid angiopathy
(CAA; n = 9), vasogenic edema in parieto-occipital areas compatible with a
posterior reversible encephalopathy syndrome (PRES; n = 3), cortical venous
thrombosis (n = 2) and concomitant acute cortical stroke (n = 3). Other
underlying causes of sSAH, not diagnosed on MRI, were reversible cerebral
vasoconstriction syndrome (RCVS) based on clinical criteria and conventional
angiography (n = 4), angiitis diagnosed by skin biopsy (n = 1), vascular
malformation diagnosed on CT and digital subtraction angiographies (n = 3), and
overanticoagulation (n = 1). Four cases remained unresolved.
CONCLUSION: This study confirmed that sSAH is a rare condition related to a wide
spectrum of etiologies. Combination of brain MRI and magnetic resonance
angiography and eventually digital subtraction angiography allowed the
identification of an underlying etiology for 87% of patients. CAA, RCVS and PRES
represented more than 50% of the etiological mechanisms. Among older patients,
sSAH was mainly related to CAA while in younger patients, RCVS represented the
most frequent etiology.

Copyright © 2012 S. Karger AG, Basel.

DOI: 10.1159/000339685
PMID: 22890017 [Indexed for MEDLINE]

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