International Journal of Health and Clinical Research, 2021;4(7):1-3 e-ISSN: 2590-3241, p-ISSN: 2590-325X

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Original Research Article
A Prospective Clinical Analysis of Subarachnoid Haemorrhage of Unknown Etiology in a
Secondary Referral Hospital
G.V. Murali*

MBBS, MS (Gen) Mch (Neurosurgery), Telangana Hospitals, Khammam, India

Received: 27-01-2021/ Revised: 28-02-2021 / Accepted: 23-03-2021

Abstract
Introduction: Spontaneous subarachnoid haemorrhage (SAH) accounts for 15 per lakh population. In 1985, SAH was identified as the pattern of
haemorrhage anterior to the midbrain without intraparenchymal or intra ventricular extension without any bleeding on digital subtraction
angiography (DSA) and a benign clinical condition. SAH is usually caused by the rupture of an intracranial aneurysm. But only 13 % was found
to be negative for any intracranial aneurysms. Such patients with angiography negative SAH have lower risk of rebleeding and their blood
distribution is termed as perimesencephalic or Prepontine.Aims and Objectives: The aim of the present study was to investigate the clinical
course and outcome in patients with SAH.Materials and Methods: Quantitative research approach was used to assess the Clinical Analysis of
Subarachnoid Haemorrhage of Unknown Origin (SAHUE) at Telangana hospitals, Khammam. Purposive sampling technique was used to select
samples. During the study period, 55 samples were selected based on the inclusion and exclusion criteria.Results: Totally, we identified 55 cases
of spontaneous subarachnoid haemorrhage during the study period. All the cases of subarachnoid haemorrhage were identified by CT and clinical
evaluation of the patients. The mean age of the 55 patients was 27.5±1.3 (25 men and 30 women). 47 patients had Glasgow Coma Scale (GCS)
between 13-14 both after admission and on discharge. Original CT films that were used to measure the volume of subarachnoid, intraventricular,
and intraparenchymalhaemorrhage were available for all the 55 patients included in this study. The patient results have been tabulated and the
factors studied have been analysed. Results of radiological assessment of haematoma showed that majority of them had local haematoma, and
other members had hypertension as reason of haematoma.Conclusion: Each patient with subarachnoid haemorrhage should be monitored as an
individual case and to prevent death it is important to identify patients to reduce the aneurysms and modify the risk factors associated with it.
Keywords: Spontaneous subarachnoid haemorrhage, Glasgow Coma Scale, CT, Subarachnoid Haemorrhage of Unknown Origin
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original work is properly credited.

Introduction
Spontaneous subarachnoid haemorrhage (SAH) accounts for 15 per of the present study was to investigate the clinical course and
lakh population. In 1985, SAH was identified as the pattern of outcome in patients with SAH[7]
haemorrhage anterior to the midbrain without intraparenchymal or Aims and Objectives
intra ventricular extension without any bleeding on digital subtra- The aim of the present study was to investigate the clinical course
ction angiography (DSA) and a benign clinical condition[1]. SAH is and outcome in patients with SAH.
usually caused by the rupture of an intracranial aneurysm. But only Materials and Methods
13 % was found to be negative for any intracranial aneurysms. Such Quantitative research approach was used to assess the Clinical
patients with angiography negative SAH have lower risk of Analysis of Subarachnoid Haemorrhage of Unknown Origin
rebleeding and their blood distribution is termed as primes- (SAHUE) at Telangana hospitals, Khammam. Purposive sampling
encephalic or Prepontine[2].Perimesencephalic haemorrhage is a technique was used to select samples. During the study period, 55
subset of subarachnoid haemorrhage. It has been identified in recent samples were selected based on the inclusion and exclusion criteria.
years that patients with an aneurysmal subarachnoid haemorrhage In our study, we identified a total of 55 patients admitted to the
have a reduced life expectancy[3].Spontaneous subarachnoid Neurosurgery department of Telangana hospitals, Khammam who
haemorrhage occurs by sudden onset headache which is usually presented with subarachnoid haemorrhage between 2019 and 2020.
described as the worst ever headache explained by the patient. The Subarachnoid haemorrhage was confirmed radiologically via urgent
patient presents with neck pain along with headache and usually it computed tomography (CT) scan without contrast. Traditionally, a
may be associated with vomiting also. The patient also has loss of negative CT scan is followed with lumbar puncture. However, non-
consciousness based on the severity of haemorrhage[4].Based on the contrast CT followed by CT angiography (CTA) of the brain can rule
associated intra-parenchymal haemorrhage there may even be out SAH with greater than 99% sensitivity. The patients were
neurological deficits associated with blurring of vision. Bleeding subjected to four-vessel 3D digital subtraction angiography (DSA)
cannot be demonstrated in the spontaneous SAH patients [5]. Patients within 24 hours of admission and repeat DSA done at an interval of 2
with peri-mesencephalic SAH are believed to attain a good outcome weeks. IV 3D DSA was obtained with rotational angiographies
and they are found to have a lower risk of rebleeding. There are few which was performed on a C-Arm (InfinixCeleve VS; Toshiba,
reports on the patients with perimesencephalic haemorrhage and few Tokyo, Japan). This covers a total angular range of 200°, with a first
reports with limited number of patients. Therefore, the aim rotation of 40°/s to acquire the mask images, a second rotation to
return to the starting position, and a third rotation of 40°/s to acquire
*Correspondence the opacified images. The type of detector in this system was an
Dr G.V. Murali image intensifier (RTP12303J-G9E; Toshiba). An 18-gauge
MBBS,MS (Gen) Mch (Neurosurgery),Telangana Hospitals, angiocatheter was inserted into the right antecubital vein and linked
Khammam, India. with a connective tube for power injection. First, 15 mL of nonionic
E-mail: hospitalstelangana@gmail.com contrast medium (Omnipaque 350; Daiichi Seiyaku, Tokyo, Japan)
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International Journal of Health and Clinical Research, 2021;4(7):1-3 e-ISSN: 2590-3241, p-ISSN: 2590-325X

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was injected with a pump at a rate of 9 ml/s. The delay time from the criteria of the scale, and the resulting points give a person's score
start of contrast injection to the time when the common carotid between 3 (indicating deep unconsciousness) and either 14 (original
arteries were filled with contrast was measured with DSA. Then 50 scale) or 15 (more widely used, modified or revised scale). GCS was
mL of the contrast medium was injected at a rate of 9 ml/s. The used to assess a person's level of consciousness after a head injury,
acquisition of source images was started immediately after the and the scale is widely used by emergency medical services, nurses,
injection of contrast. The acquisition matrix was 512 × 512. This and physicians as being applicable to all acute medical and trauma
protocol resulted in a rotational series of 200 subtracted images. patients. In these hospitals, it is also used in monitoring patients in
Rotational angiography data were automatically transferred to a intensive care units. The score is expressed in the form "GCS 9 = E2
personal computer (XIDF- 100A; Toshiba), which reconstructed 3D V4 M3 at 07:35". Generally, brain injury is classified as: Severe;
volume data. The matrix of transferred data were transformed from GCS < 8–9; Moderate; GCS 8 or 9–12 (controversial); Minor; GCS ≥
512 × 512 to 256 × 256 by voxel addition. The 3D volume data were 13.
transferred to a commercially available multimodality 3D work Statistical Analysis
station(ZIO M900TXA; ZIO Software, Tokyo, Japan), processed, The collected data were grouped and analyzed based on percentage,
and presented. Available visualization of algorithms included mean and standard deviation.
maximum intensity projection (MIP) and volume rendering. A Results
computed tomography scan was performed within 72 hours after the Totally, we identified 55 cases of spontaneous subarachnoid
onset of headache showing a perimesencephalic pattern of haemorrhage during the study period. All the cases of subarachnoid
haemorrhage. The initial CT scan of the patient’s brain revealed haemorrhage were identified by CT and clinical evaluation of the
blood either in peri-mesencephalic cisterns which was called as patients. The mean age of the 55 patients was 27.5±1.3 (25 men and
localized blood and people who had blood in both peri- 30 women) (Table 1). 47 patients had Glasgow Coma Scale (GCS)
mesencephalic cisterns and in the lateral cisterns were classified as between 13-14 both after admission and on discharge. Original CT
diffuse collection of blood radiologically. The absence of a saccular films that were used to measure the volume of subarachnoid,
aneurysm on computed tomographic angiography or conventional intraventricular, and intraparenchymalhaemorrhage were available
angiography was noted. The patients who had initial angiogram for all the 55 patients included in this study. The patient results have
negative finding for aneurysm were taken into study. been tabulated below and the factors studied have been analysed.
The Glasgow Coma Scale (GCS) Results of radiological assessment of haematoma showed that
It is a neurological scale which aims to give a reliable and objective majority of them had local haematoma, and other members had
way of recording the state of a person's consciousness for initial as hypertension as reason of haematoma.
well as subsequent assessment. A person is assessed against the
Table 1: Characteristics of Patients Studied and the Factors Analysed
Characteristics Studied Number of Patients Percentage
1.Sex
Male 25 45%
Female 30 55%
2.Glasgow Coma Scale (GCS) on Admission
13-14 47 85%
3-4 8 15%
3.Hypertension
Yes 47 85%
No 8 15%
4.Radiology of Haematoma
Diffuse 8 15%
Local 47 85%
5.Associated severe risk factors
Diabetes 12 22%
Hypertension 13 23%
Anticoagulants 3 5%
None 27 50%
6.Glasgow Coma Scale (GCS) on Discharge
14 47 85%
8 8 15%
7.Repeat DSA
Positive 7 14.30%
Negative 48 85.70%

Fig 1:DSA Showing a Normal Study

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International Journal of Health and Clinical Research, 2021;4(7):1-3 e-ISSN: 2590-3241, p-ISSN: 2590-325X

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Fig 2:DSA Normal with CT Scan Showing Diffuse SAH

The image shows the preliminary illustration of a patient with mesencephalic haemorrhage. Five per cent of patients in our study
subarachnoid haemorrhage and a normal DSA (Fig 2 & 3). Non- were under anticoagulant therapy but the adequate risk of
contrast head CT; Examples of SAH.Perimesencephalic SAH: axial anticoagulant therapy on patients with peri-mesencephalic
image from a non-contrast head CT demonstrates acute SAH in the haemorrhage is not available[10]The prognosis of patient varies
prepontine and interpeduncular cistern, consistent with a based on the thickness of hematoma and people with hydrocephalus
perimesencephalic pattern of SAH (A). Sulcal SAH: axial image had poor prognosis. Hydrocephalus developed in 7 of our patients for
from a non-contrast head CT demonstrates acute SAH in the left which intervention in the form of External Ventricular Drain (EVD)
precentral sulcus and in the sulci overlying the left middle frontal was done in 4 patients and 2 patients underwent permanent
gyrus, consistent with a sulcal pattern of SAH (B). Diffuse SAH: ventriculoperitoneal (V.P) shunt. Blood in localized basal cisterns
axial image from a non-contrast head CT demonstrates acute SAH in had a good prognosis than patients with diffuse blood in all the
the bilateral Sylvian fissures, overlying the sulci of the bilateral cisterns. Each patient with subarachnoid haemorrhage should be
temporal lobes, consistent with a diffuse pattern of SAH. Note also monitored and treated since the mortality of patients with
intraventricular haemorrhage within the third ventricle (C). Isolated subarachnoid haemorrhage may not be reduced due to any therapy.
IVH: axial image from a non-contrast head CT demonstrates acute Conclusion
intraventricular haemorrhage casting the right lateral ventricle (D). Perimesencephalic haemorrhagic pattern is due to posterior
Discussion circulation aneurysm rupture, which becomes mandatory to visualise.
A perimesencephalic haemorrhagic pattern is actually due to the Study suggested that negative sub-arachnoid haemorrhage angiogram
rupture of a posterior circulation aneurysm. Thus, the viewing of the exhibited very mild prognosis than with aneurysmal sub-arachnoid
intracranial vessels becomes mandatory. The use of CTA as a haemorrhage. Here, We studied perimesencephalic haemorrhage
primary imaging and triage technique in patients presenting with disease due to causes other than intracranial aneurysm., which
SAH results in decreased time to diagnosis and reduced medical showed that all the patients had presence of blood either in
costs. At our tertiary care center, all patients presenting with SAH perimesencephalic cisterns and in the lateral cisterns. This study
undergo a CTA of the head, and this technique identified an concludes that each patient with subarachnoid haemorrhage should
aneurysm as the cause of SAH. For much of this period, the bulk of be monitored as an individual case and to prevent death it is
patients who underwent subsequent craniotomy for ruptured important to identify patients to reduce the aneurysms and modify the
aneurysms did not undergo preoperative DSA examination[8].In our risk factors associated with it.
study, population with perimesencephalic haemorrhage, there was no References
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Conflict of Interest: Nil Source of support:Nil
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