Date Published: April 3, 2017
Publisher: Public Library of Science
Author(s): Sepide Kashefiolasl, Nina Brawanski, Johannes Platz, Markus Bruder, Christian Senft, Gerhard Marquardt, Volker Seifert, Stephanie Tritt, Juergen Konczalla, Stephan Meckel.
Up to 15% of all spontaneous subarachnoid hemorrhages (SAH) have a non-aneurysmal SAH (NASAH). The evaluation of SAH patients with negative digital subtraction angiography (DSA) is sometimes a diagnostic challenge. Our goal in this study was to reassess the yield of standard MR-imaging of the complete spinal axis to rule out spinal bleeding sources in patients with NASAH.
We retrospectively analyzed the spinal MRI findings in 190 patients with spontaneous NASAH, containing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH, diagnosed by computer tomography (CT) and/or lumbar puncture (LP), and negative 2nd DSA.
190 NASAH patients were included in the study, divided into PM-SAH (n = 87; 46%) and NPM-SAH (n = 103; 54%). Overall, 23 (22%) patients had a CT negative SAH, diagnosed by positive LP. MR-imaging of the spinal axis detected two patients with lumbar ependymoma (n = 2; 1,05%). Both patients complained of radicular sciatic pain. The detection rate raised up to 25%, if only patients with radicular sciatic pain received an MRI.
Routine radiological investigation of the complete spinal axis in NASAH patients is expensive and can not be recommended for standard procedure. However, patients with clinical signs of low-back/sciatic pain should be worked up for a spinal pathology.
Subarachnoid hemorrhage (SAH) is normally due to intracranial lesions, mostly aneurysms or vascular malformations. In up to 15% of all spontaneous subarachnoid hemorrhages, there is no evidence of an intracranial vascular pathology . Recently published data showed increasing numbers of patients with non-aneurysmal SAH (NASAH) . The evaluation of patients with subarachnoid hemorrhage with negative digital subtraction angiography (DSA) is therefore important and furthermore sometimes a diagnostic challenge.
The vast majority of patients with SAH are found to have intracranial lesions, most often vascular pathology like aneurysms or arteriovenous malformations, and in other cases brain tumors, vasculitis or secondary to infarction . Missing intracranial bleeding source is obvious in about 15% of all spontaneous subarachnoid hemorrhages . SAH due to spinal cord masses like ependymomas, nerve sheet tumors, paragangliomas, hemangioblastomas, metastases or meningiomas, however, is a very rare entity. Low-back/sciatic pain and severe headache are often the leading clinical features . In relation to SAH of spinal origin, ependymoma is the most frequent (60%) pathology .
SAH caused by spinal pathology is very rare. According to this study, lumbar ependymoma has an incidence of 1,05% in NASAH. Routine radiological investigation of the spinal axis in every NASAH patient is therefore not recommended and should be done symptom-orientated. However, MR-imaging of the complete spinal axis in patients with a CT-negative NPM-SAH, positive lumbar puncture and leading clinical symptoms such as low-back/sciatic pain can be useful and reasonable to detect this rare entity of SAH.