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


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.


CONCLUSIONS
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.
Pôle des neurosciences cliniques, CHU de Bordeaux, Université Bordeaux Segalen, Bordeaux, France. pauline.renou@chu-bordeaux.fr
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Renou
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Tourdias
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Fleury
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Debruxelles
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Rouanet
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D000368:Aged; D016657:Cerebral Amyloid Angiopathy / Q000150:complications / Q000175:diagnosis; D002543:Cerebral Hemorrhage / Q000150:complications; D004829:Epilepsy, Generalized / Q000209:etiology; D005260:Female; D005602:France / Q000453:epidemiology; D006261:Headache / Q000209:etiology; D006486:Hemosiderosis / Q000209:etiology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D054038:Posterior Leukoencephalopathy Syndrome / Q000150:complications / Q000175:diagnosis; D012008:Recurrence; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000209:etiology / Q000473:pathology; D014057:Tomography, X-Ray Computed; D020301:Vasospasm, Intracranial / Q000150:complications; D020246:Venous Thrombosis / Q000150:complications