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    Jurnal 18

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    Zella Zakya
    This document describes a case of non-aneurysmal perimesencephalic subarachnoid haemorrhage in a 51-year-old male patient. Imaging including non-contrast CT, CT angiography, digital subtraction angiography, and MRI showed subarachnoid bleeding localized to the perimesencephalic cisterns with no evidence of an aneurysm. Perimesencephalic haemorrhage is a subtype of non-traumatic subarachnoid haemorrhage that typically has a benign clinical course. The cause is thought to be venous rupture or abnormal drainage of veins in this region.

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    Jurnal 18

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    Zella Zakya
    27 views9 pages
    This document describes a case of non-aneurysmal perimesencephalic subarachnoid haemorrhage in a 51-year-old male patient. Imaging including non-contrast CT, CT angiography, digital subtraction angiography, and MRI showed subarachnoid bleeding localized to the perimesencephalic cisterns with no evidence of an aneurysm. Perimesencephalic haemorrhage is a subtype of non-traumatic subarachnoid haemorrhage that typically has a benign clinical course. The cause is thought to be venous rupture or abnormal drainage of veins in this region.

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    This document describes a case of non-aneurysmal perimesencephalic subarachnoid haemorrhage in a 51-year-old male patient. Imaging including non-contrast CT, CT angiography, digital subtraction angiography, and MRI showed subarachnoid bleeding localized to the perimesencephalic cisterns with no evidence of an aneurysm. Perimesencephalic haemorrhage is a subtype of non-traumatic subarachnoid haemorrhage that typically has a benign clinical course. The cause is thought to be venous rupture or abnormal drainage of veins in this region.

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    © All Rights Reserved
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    27 views9 pages

    Jurnal 18

    Uploaded by

    Zella Zakya
    This document describes a case of non-aneurysmal perimesencephalic subarachnoid haemorrhage in a 51-year-old male patient. Imaging including non-contrast CT, CT angiography, digital subtraction angiography, and MRI showed subarachnoid bleeding localized to the perimesencephalic cisterns with no evidence of an aneurysm. Perimesencephalic haemorrhage is a subtype of non-traumatic subarachnoid haemorrhage that typically has a benign clinical course. The cause is thought to be venous rupture or abnormal drainage of veins in this region.

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    net/publication/349238885

    Non-aneurysmal perimesencephalic subarachnoid haemorrhage

    Poster · April 2020


    DOI: 10.13140/RG.2.2.17848.06408

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    Anca Oprisan Eduardo Baettig Arriagada


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    Case 16730

    Non-aneurysmal
    perimesencephalic subarachnoid
    haemorrhage
    Published on 22.04.2020

    ISSN: 1563-4086
    Section: Neuroradiology
    Area of Interest: Emergency Interventional vascular
    Neuroradiology brain
    Procedure: Diagnostic procedure
    Imaging Technique: CT-Angiography
    Imaging Technique: Digital radiography
    Special Focus: Aneurysms Haemorrhage Case Type:
    Clinical Cases
    Authors: Anca Oprisan1, Eduardo Baettig-Arriagada1,
    Viktoria Pozdniakova2, Macarena Barreda-Solana1,
    Fernando Aparici-Robles1
    Patient: 51 years, male

    Clinical History:

    A 51-year-old man admitted to the emergency department with acute headache and nausea for two days that would
    not ease using normal medication. He is a smoker with dyslipemia and lower limb chronic ischemia. His neurological
    exam was unexceptional.

    Imaging Findings:

    Initial imaging with non-contrast CT was done. It showed an acute subarachnoid haemorrhage (SAH) in the
    perimesencephalic and prepontine cisterns with extension to the proximal segment of left Sylvian fissure (Figure 1).
    The cerebral CT angiogram (CTA) and digital subtraction angiography (DSA) were normal (Figure 2). Subsequent
    3D TOF magnetic resonance angiography (MRA) showed no signs of aneurism (Figure 3). The susceptibility
    sequence detected siderotic remains in prepontomesencephlic cisterns and mild superficial siderosis in vermis folds
    (Figure 4).

    Discussion:

    Perimesencephalic haemorrhage is a clinical-radiological entity that represents a subtype of nontraumatic


    subarachnoid haemorrhage. It has a benign clinical presentation and course with a low rate of vasospasm,
    hydrocephalus and rebleeding [1]. The aetiology is not clear but is thought to be a venous rupture of superficial
    pontine or perimesencephalic veins [1]. Abnormal drainage of the basal vein of Rosenthal is another possible reason
    [4]. Studies show that a ‘primitive’ drainage pattern of this vein directly into the dural sinuses instead of the Galenic
    system is a risk factor for unilateral nontraumatic perimesencephalic SAH. Pathophysiological explanation can be
    vein rupture due to sudden increase in venous pressure, intracranial venous congestion and vein torsion or friction
    when it crosses over the tentorial margin [4].

    Clinical manifestations of nontraumatic subarachnoid haemorrhage are an acute headache, nausea, vomiting and
    neck stiffness. Patients with perimesencephalic SAH are usually in a good condition with a favourable long-term
    evolution and prognosis. Cerebral angiogram is normal in approximately 95% of cases, and a 6- month follow up
    with cerebral DSA is recommended [2]. Vertebrobasilar aneurysms are responsible of only 5% of the nontraumatic
    SAH with perimesencephalic distribution. Other rare causes include cervical arteriovenous malformations and dural
    fistula [3].
    To raise perimesencephalic SAH diagnosis, patients must be in good clinical condition (GCS 15) with a non-contrast
    CT performed in the first 72 hours of the onset of symptoms and a negative angiographic study [2]. Non-traumatic
    SAH has the following characteristics on CT: (1) It is centred anteriorly to the pons and midbrain, (2) it may extend
    into the basal cisterns and proximal/basal Sylvian fissure and interhemispheric fissure, (3) it may settle as sediment
    in the occipital horns of the lateral ventricles, but there is no intraventricular haemorrhage. Following criteria
    indicates need for conventional angiography (DSA) in case of negative CTA: (1) SAH in perimesencephalic cisterns
    anterior to midbrain Main Document, (2) SAH extension only into the anterior interhemispheric fissure, (3) SAH
    extension into the medial Sylvian fissures, (4) interventricular extension, no frank intraventricular haemorrhage, (5)
    No intraparenchymal haemorrhage.

    Written informed patient consent for publication has been obtained.

    Differential Diagnosis List: Non-aneurysmal perimesencephalic subarachnoid haemorrhage. , SAH from a


    ruptured vetebrobasilar aneurysm, Spinal dural arteriovenous fistula , Vascular tumour (hemangioblastoma)

    Final Diagnosis: Non-aneurysmal perimesencephalic subarachnoid haemorrhage.

    References:

    Marder C, Narla V, Fink R, Tozer Fink K. Subarachnoid Hemorrhage: Beyond Aneurysms. AJR:202, January 2014.
    (PMID: 24370126)
    Flaherty M et al. Perimesencephalic Subarachnoid Hemorrhage: Incidence, Risk Factors, and Outcome. J Stroke
    Cerebrovasc Dis. 2005; 14(6): 267–271. (PMID: 16518463)
    Zerega Ruiz et al. Non-Traumatic Subarachnoid Hemorrhage with “Negative” Initial Computed Tomography
    Angiography. Rev Chil Radiol 2018; 24(3): 94-104.
    Rouchaud A et al. Nonaneurysmal Perimesencephalic Hemorrhage Is Associated with Deep Cerebral Venous
    Drainage Anomalies: A Systematic Literature Review and Meta-Analysis. AJNR Am J Neuroradiol. 2016
    Sep;37(9):1657-63. (PMID: 27173362)
    Figure 1
    a

    Description: Non-contrast head CT showing acute subarachnoid haemorrhage (white arrow) in the
    perimesencephalic cisterns with extension to the proximal segment of the left sylvian valley.Origin:
    Área Clínica de Imagen Médica, Hospital Universitario y Politécnico La Fe Valencia, España 2020
    b

    Description: Non-contrast head CT showing acute subarachnoid haemorrhage (white arrow) in the
    perimesencephalic cisterns with extension to the proximal segment of the left sylvian valley.Origin:
    Área Clínica de Imagen Médica, Hospital Universitario y Politécnico La Fe Valencia, España 2020
    c

    Description: Non-contrast head CT showing acute subarachnoid haemorrhage (white arrow) in the
    perimesencephalic cisterns with extension to the proximal segment of the left sylvian valley.Origin:
    Área Clínica de Imagen Médica, Hospital Universitario y Politécnico La Fe Valencia, España 2020
    Figure 2
    a

    Description: Normal cerebral DSA. Origin: Área Clínica de Imagen Médica, Hospital Universitario y
    Politécnico La Fe Valencia, España 2020
    Figure 3
    a

    Description: MRA 3DToF sequence with no evidence of intracranial aneurysm. Origin: Área Clínica
    de Imagen Médica, Hospital Universitario y Politécnico La Fe Valencia, España 2020
    Figure 4
    a

    Description: Susceptibility-weighted sequence shows siderotic remains in prepontomesencephalic


    cisterns and mild superficial siderosis in vermis folds. Origin: Área Clínica de Imagen Médica, Hospital
    Universitario y Politécnico La Fe Valencia, España 2020

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