Spontaneous subarachnoid hemorrhage of unknown origin

Hospital course and long-term clinical and angiographic follow-up

Ali M. Elhadi, Joseph M. Zabramski, Kaith K. Almefty, George A.C. Mendes, Peter Nakaji, Cameron McDougall, Felipe C. Albuquerque, Mark C. Preul, Robert F. Spetzler

Research output: Contribution to journalArticle

Abstract

Object Hemorrhagic origin is unidentifiable in 10%-20% of patients presenting with spontaneous subarachnoid hemorrhage (SAH). While the patients in such cases do well clinically, there is a lack of long-term angiographic followup. The authors of the present study evaluated the long-term clinical and angiographic follow-up of a patient cohort with SAH of unknown origin that had been enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). Methods The BRAT database was searched for patients with SAH of unknown origin despite having undergone two or more angiographic studies as well as MRI of the brain and cervical spine. Follow-up was available at 6 months and 1 and 3 years after treatment. Analysis included demographic details, clinical outcome (Glasgow Outcome Scale, modified Rankin Scale [mRS]), and repeat vascular imaging. Results Subarachnoid hemorrhage of unknown etiology was identified in 57 (11.9%) of the 472 patients enrolled in the BRAT study between March 2003 and January 2007. The mean age for this group was 51 years, and 40 members (70%) of the group were female. Sixteen of 56 patients (28.6%) required placement of an external ventricular drain for hydrocephalus, and 4 of these subsequently required a ventriculoperitoneal shunt. Delayed cerebral ischemia occurred in 4 patients (7%), leading to stroke in one of them. There were no rebleeding events. Eleven patients were lost to followup, and one patient died of unrelated causes. At the 3-year follow-up, 4 (9.1%) of 44 patients had a poor outcome (mRS > 2), and neurovascular imaging, which was available in 33 patients, was negative. Conclusions Hydrocephalus and delayed cerebral ischemia, while infrequent, do occur in SAH of unknown origin. Long-term neurological outcomes are generally good. A thorough evaluation to rule out an etiology of hemorrhage is necessary; however, imaging beyond 6 weeks from ictus has little utility, and rebleeding is unexpected.

Original languageEnglish (US)
Pages (from-to)663-670
Number of pages8
JournalJournal of Neurosurgery
Volume122
Issue number3
DOIs
StatePublished - Mar 1 2015
Externally publishedYes

Fingerprint

Subarachnoid Hemorrhage
Ruptured Aneurysm
Hydrocephalus
Brain Ischemia
Glasgow Outcome Scale
Ventriculoperitoneal Shunt
Blood Vessels
Spine
Age Groups
Stroke
Demography
Databases
Hemorrhage

Keywords

  • Angiographic follow-up
  • Angiographically negative
  • BRAT
  • Hospital stay
  • SAH of unknown origin
  • Subarachnoid hemorrhage
  • Vascular disorders

ASJC Scopus subject areas

  • Surgery
  • Clinical Neurology

Cite this

Spontaneous subarachnoid hemorrhage of unknown origin : Hospital course and long-term clinical and angiographic follow-up. / Elhadi, Ali M.; Zabramski, Joseph M.; Almefty, Kaith K.; Mendes, George A.C.; Nakaji, Peter; McDougall, Cameron; Albuquerque, Felipe C.; Preul, Mark C.; Spetzler, Robert F.

In: Journal of Neurosurgery, Vol. 122, No. 3, 01.03.2015, p. 663-670.

Research output: Contribution to journalArticle

Elhadi, AM, Zabramski, JM, Almefty, KK, Mendes, GAC, Nakaji, P, McDougall, C, Albuquerque, FC, Preul, MC & Spetzler, RF 2015, 'Spontaneous subarachnoid hemorrhage of unknown origin: Hospital course and long-term clinical and angiographic follow-up', Journal of Neurosurgery, vol. 122, no. 3, pp. 663-670. https://doi.org/10.3171/2014.10.JNS14175
Elhadi, Ali M. ; Zabramski, Joseph M. ; Almefty, Kaith K. ; Mendes, George A.C. ; Nakaji, Peter ; McDougall, Cameron ; Albuquerque, Felipe C. ; Preul, Mark C. ; Spetzler, Robert F. / Spontaneous subarachnoid hemorrhage of unknown origin : Hospital course and long-term clinical and angiographic follow-up. In: Journal of Neurosurgery. 2015 ; Vol. 122, No. 3. pp. 663-670.
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title = "Spontaneous subarachnoid hemorrhage of unknown origin: Hospital course and long-term clinical and angiographic follow-up",
abstract = "Object Hemorrhagic origin is unidentifiable in 10{\%}-20{\%} of patients presenting with spontaneous subarachnoid hemorrhage (SAH). While the patients in such cases do well clinically, there is a lack of long-term angiographic followup. The authors of the present study evaluated the long-term clinical and angiographic follow-up of a patient cohort with SAH of unknown origin that had been enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). Methods The BRAT database was searched for patients with SAH of unknown origin despite having undergone two or more angiographic studies as well as MRI of the brain and cervical spine. Follow-up was available at 6 months and 1 and 3 years after treatment. Analysis included demographic details, clinical outcome (Glasgow Outcome Scale, modified Rankin Scale [mRS]), and repeat vascular imaging. Results Subarachnoid hemorrhage of unknown etiology was identified in 57 (11.9{\%}) of the 472 patients enrolled in the BRAT study between March 2003 and January 2007. The mean age for this group was 51 years, and 40 members (70{\%}) of the group were female. Sixteen of 56 patients (28.6{\%}) required placement of an external ventricular drain for hydrocephalus, and 4 of these subsequently required a ventriculoperitoneal shunt. Delayed cerebral ischemia occurred in 4 patients (7{\%}), leading to stroke in one of them. There were no rebleeding events. Eleven patients were lost to followup, and one patient died of unrelated causes. At the 3-year follow-up, 4 (9.1{\%}) of 44 patients had a poor outcome (mRS > 2), and neurovascular imaging, which was available in 33 patients, was negative. Conclusions Hydrocephalus and delayed cerebral ischemia, while infrequent, do occur in SAH of unknown origin. Long-term neurological outcomes are generally good. A thorough evaluation to rule out an etiology of hemorrhage is necessary; however, imaging beyond 6 weeks from ictus has little utility, and rebleeding is unexpected.",
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author = "Elhadi, {Ali M.} and Zabramski, {Joseph M.} and Almefty, {Kaith K.} and Mendes, {George A.C.} and Peter Nakaji and Cameron McDougall and Albuquerque, {Felipe C.} and Preul, {Mark C.} and Spetzler, {Robert F.}",
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T1 - Spontaneous subarachnoid hemorrhage of unknown origin

T2 - Hospital course and long-term clinical and angiographic follow-up

AU - Elhadi, Ali M.

AU - Zabramski, Joseph M.

AU - Almefty, Kaith K.

AU - Mendes, George A.C.

AU - Nakaji, Peter

AU - McDougall, Cameron

AU - Albuquerque, Felipe C.

AU - Preul, Mark C.

AU - Spetzler, Robert F.

PY - 2015/3/1

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N2 - Object Hemorrhagic origin is unidentifiable in 10%-20% of patients presenting with spontaneous subarachnoid hemorrhage (SAH). While the patients in such cases do well clinically, there is a lack of long-term angiographic followup. The authors of the present study evaluated the long-term clinical and angiographic follow-up of a patient cohort with SAH of unknown origin that had been enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). Methods The BRAT database was searched for patients with SAH of unknown origin despite having undergone two or more angiographic studies as well as MRI of the brain and cervical spine. Follow-up was available at 6 months and 1 and 3 years after treatment. Analysis included demographic details, clinical outcome (Glasgow Outcome Scale, modified Rankin Scale [mRS]), and repeat vascular imaging. Results Subarachnoid hemorrhage of unknown etiology was identified in 57 (11.9%) of the 472 patients enrolled in the BRAT study between March 2003 and January 2007. The mean age for this group was 51 years, and 40 members (70%) of the group were female. Sixteen of 56 patients (28.6%) required placement of an external ventricular drain for hydrocephalus, and 4 of these subsequently required a ventriculoperitoneal shunt. Delayed cerebral ischemia occurred in 4 patients (7%), leading to stroke in one of them. There were no rebleeding events. Eleven patients were lost to followup, and one patient died of unrelated causes. At the 3-year follow-up, 4 (9.1%) of 44 patients had a poor outcome (mRS > 2), and neurovascular imaging, which was available in 33 patients, was negative. Conclusions Hydrocephalus and delayed cerebral ischemia, while infrequent, do occur in SAH of unknown origin. Long-term neurological outcomes are generally good. A thorough evaluation to rule out an etiology of hemorrhage is necessary; however, imaging beyond 6 weeks from ictus has little utility, and rebleeding is unexpected.

AB - Object Hemorrhagic origin is unidentifiable in 10%-20% of patients presenting with spontaneous subarachnoid hemorrhage (SAH). While the patients in such cases do well clinically, there is a lack of long-term angiographic followup. The authors of the present study evaluated the long-term clinical and angiographic follow-up of a patient cohort with SAH of unknown origin that had been enrolled in the Barrow Ruptured Aneurysm Trial (BRAT). Methods The BRAT database was searched for patients with SAH of unknown origin despite having undergone two or more angiographic studies as well as MRI of the brain and cervical spine. Follow-up was available at 6 months and 1 and 3 years after treatment. Analysis included demographic details, clinical outcome (Glasgow Outcome Scale, modified Rankin Scale [mRS]), and repeat vascular imaging. Results Subarachnoid hemorrhage of unknown etiology was identified in 57 (11.9%) of the 472 patients enrolled in the BRAT study between March 2003 and January 2007. The mean age for this group was 51 years, and 40 members (70%) of the group were female. Sixteen of 56 patients (28.6%) required placement of an external ventricular drain for hydrocephalus, and 4 of these subsequently required a ventriculoperitoneal shunt. Delayed cerebral ischemia occurred in 4 patients (7%), leading to stroke in one of them. There were no rebleeding events. Eleven patients were lost to followup, and one patient died of unrelated causes. At the 3-year follow-up, 4 (9.1%) of 44 patients had a poor outcome (mRS > 2), and neurovascular imaging, which was available in 33 patients, was negative. Conclusions Hydrocephalus and delayed cerebral ischemia, while infrequent, do occur in SAH of unknown origin. Long-term neurological outcomes are generally good. A thorough evaluation to rule out an etiology of hemorrhage is necessary; however, imaging beyond 6 weeks from ictus has little utility, and rebleeding is unexpected.

KW - Angiographic follow-up

KW - Angiographically negative

KW - BRAT

KW - Hospital stay

KW - SAH of unknown origin

KW - Subarachnoid hemorrhage

KW - Vascular disorders

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