title: Spontaneous subarachnoid hemorrhage of unknown origin: hospital course and long-term clinical and angiographic follow-up.
abstract: OBJECTIVE
  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.
authors.affiliation: Division of Neurological Surgery;
authors.forename: Ali M
authors.initials: AM
authors.lastname: Elhadi
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Zabramski
authors.forename: Kaith K
authors.initials: KK
authors.lastname: Almefty
authors.forename: George A C
authors.initials: GA
authors.lastname: Mendes
authors.forename: Peter
authors.initials: P
authors.lastname: Nakaji
authors.forename: Cameron G
authors.initials: CG
authors.lastname: McDougall
authors.forename: Felipe C
authors.initials: FC
authors.lastname: Albuquerque
authors.forename: Mark C
authors.initials: MC
authors.lastname: Preul
authors.forename: Robert F
authors.initials: RF
authors.lastname: Spetzler
mesh_terms: D000328:Adult; D000368:Aged; D017542:Aneurysm, Ruptured / Q000601:surgery; D002545:Brain Ischemia / Q000209:etiology; D002533:Cerebral Angiography; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D023261:Glasgow Outcome Scale; D006801:Humans; D006849:Hydrocephalus / Q000150:complications; D008136:Longevity; D008297:Male; D008875:Middle Aged; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000601:surgery*; D016896:Treatment Outcome; D017287:Ventriculoperitoneal Shunt; D055815:Young Adult
keywords: AVM = arteriovenous malformation; BRAT; BRAT = Barrow Ruptured Aneurysm Trial; CTA = CT angiography; CTN = CT negative; DSA = digital subtraction angiography; EVD = external ventricular drain; GOS = Glasgow Outcome Scale; HH = Hunt and Hess; IQR = interquartile range; IVH = intraventricular hemorrhage; LOS = length of hospital stay; MRA = MR angiography; PMH = perimesencephalic hemorrhage; SAH = subarachnoid hemorrhage; SAH of unknown origin; VP = ventriculoperitoneal; angiographic follow-up; angiographically negative; hospital stay; mRS = modified Rankin Scale; subarachnoid hemorrhage; vascular disorders