The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

/pdf/subarachnoid-haemorrhage-diagnosis-causes-and-management-2bxfcfscjw.pdf

Subarachnoid haemorrhage: diagnosis, causes and management

Study design. Spinal subarachnoid hematomas are unusual and difficult to diagnose and the outcome of treatment is influenced by the lesions that frequently accompany them.

Spinal subarachnoid hematomas: our experience and literature review.

Study design The clinical data of five patients with spontaneous spinal epidural hematoma (SSEH) were reviewed. Objectives To assess the clinical outcome of patients with SSEH after surgical decompression. Summary of background data The outcome in SSEH is essentially determined by the timing of the operation. Therefore, early and precise diagnosis is necessary. Methods A retrospective analysis of five patients with SSEH was performed. The clinical data were stratified according to the Frankel Score. Special interest was given to the relevance of rapid and exact diagnosis and immediate therapeutic intervention. Results Diagnosis of SSEH was established preoperatively by means of computed tomography (one case) or magnetic resonance imaging (three patients) and intraoperatively in one case. Lumbar myelography had been false negative in one patient, computed tomography false-negative in two patients. Surgical decompression was performed in four patients within 24 hours after the onset of symptoms. Favorable postoperative functional results were found only in one patient whose symptoms had been present for less than 12 hours and in the case of an incomplete cauda equina syndrome. Conclusions The results of the current series demonstrate both the superiority of magnetic resonance imaging for diagnosis of SSEH as well as the necessity of early decompressive surgery in cases of sensorimotor paralysis after SSEH.

Acute nontraumatic spinal epidural hematomas. An important differential diagnosis in spinal emergencies.

Study design The clinical data, magnetic resonance imaging, intraoperative findings, and functional outcome were reviewed for three patients under anticoagulant therapy who experienced acute nontraumatic spinal subdural hematoma. Objectives To draw attention to this rare complication of anticoagulant therapy and to assess the magnetic resonance findings and clinical outcome of patients with spinal subdural hematoma after surgical evacuation. Summary of background data Among intraspinal hematomas, spinal subdural hematomas are by far the least common. Magnetic resonance findings have been demonstrated in only a few cases of spinal subdural hematomas. The timing of the operation and the anatomic location of the hematoma essentially determine the functional outcome. Methods Three case reports of spinal subdural hematomas in patients receiving anticoagulant therapy are presented. Particular interest was given to the clinical and magnetic resonance data, the intraoperative findings, and the functional outcome. Results The three patients each had a complete preoperative neurologic deficit. Sagittal T1- and T2-weighted magnetic resonance images of the spine proved to have high sensitivity for defining the type of bleeding and delineating the craniocaudal extension of the hematoma. Surgical evacuation was performed within 26 hours after the onset of symptoms. Intraoperative findings showed the hematoma to be confined between the dura and the arachnoid in two patients, and to be associated with rupture into the subarachnoid space in one patient. Postoperative recovery was incomplete in two patients, and did not improve in the remaining patient. Conclusions Spinal subdural hematoma must be considered in patients under anticoagulant therapy with spontaneous signs of acute spinal cord or cauda equina compression. Magnetic resonance imaging with sagittal T1- and T2-weighted images were adequate and reliable for diagnosis of spinal subdural hematoma. On the basis of previous studies and the authors' intraoperative findings, spinal subdural hematomas could be viewed as spinal dural border hematomas. The level of preoperative neurologic deficit seemed to be critical for recovery despite prompt surgical evacuation.

Acute nontraumatic spinal subdural hematomas in three patients.

Spinal Subdural Haematoma: A Study of Three Cases

Spinal cord compression due to extradural and subdural haemorrhage is a neurosurgical emergency. Differences in clinical presentation in relation to localisation of the haematoma, value of MRI as a diagnostic tool, surgical treatment, and prognosis were investigated in a retrospective case series of eight patients with extradural (n = four) and subdural (n = four) haematomas. Results of MRI were compared with operative findings and proved to be of high sensitivity in defining the type of bleeding and delineating craniocaudal extension and ventrodorsal location. Surgical treatment by decompressive laminectomy, haematoma evacuation, and postoperative high dose corticosteroids resulted in resolution of symptoms in five patients and improvement in the clinical situation in two patients. One patient with a chronic subdural haematoma had a second operation because of arachnoidal adhesions. One patient presented with a complete cord transection syndrome due to an acute subdural haematoma and remained paraplegic. It is concluded that prompt, reliable, and non-invasive diagnosis by MRI leads to efficient surgical treatment and a favourable outcome in this rare condition.

https://jnnp.bmj.com/content/jnnp/59/4/442.full.pdf

Management of spontaneous extramedullary spinal haematomas: results in eight patients after MRI diagnosis and surgical decompression.

This was a prospective study. The study evaluated the use of Preclude Spinal Membrane to inhibit peridural fibrosis and reduce fibroses-related problems after first-time lumbar discectomy. Peridural scarring causes tethering of dura and nerve roots. Following discectomy Preclude Spinal Membrane was applied to patients of first group (10 patients). The second group (10 patients) was operated on without Preclude Spinal Membrane. Outcome was evaluated with MRI, 3 and 6 month after operation for all patients. No peridural or epidural scar tissue could be found in patients with Preclude Spinal Membrane, in the control group who were operated on without the preclude Spinal Membrane scar tissue of varying degree with complete enclosure of the nerve roots and dura was found.

Prevention of local scar formation after operative discectomy for lumbar disc herniation.

abilities quickly returned to their previous level, he continued to need cuing to initiate his self care. The patient was discharged home under 24 hour supervision of relatives. The neuropsychological testing completed after the operation revealed average intellectual skills but slow performance on the timed visual perceptual tasks. Although his intellectual performance was significantly better than the initial testing, intelligence level was slightly below that expected given his educational history and age. The patient's slow processing on the timed visual perceptual tasks probably resulted in a decline in his intelligence score. On a problem solving task his performance was mildly perseverative and, most likely because of his memory disturbance, the patient had difficulty maintaining a strategy over time. The neuropsychological testing also revealed a long-term memory dysfunction (figure). Although immediate recall of verbal material was more accurate than before the operation, the patient's ability to recall material after a significant delay was severely impaired. When a list of seven words was presented verbally, he was able to repeat six (immediate or working memory). When asked to recall the words after a delay, no words were recalled spontaneously, semantic clues were not helpful, and recognition memory was also found to be severely impaired. A brief assessment took place two months after the operation. Again, the patient was not able to provide the date, his own age, or recall recent significant events. Formal testing of verbal memory again revealed a severely impaired long-term memory. Our patient has many symptoms consistent with a diagnosis of an amnestic syndrome. He was unable to acquire new visual or verbal information efficiently and was only able to learn procedures with much repetition and numerous cues. Memory difficulties influenced his ability to perform efficiently on a problem solving task. Neuropsychological testing revealed particularly severe deficits in encoding new information and retrieval after a delay or distraction. Testing completed before operation showed adequate long-term memory functioning, so it is umlikely that alcohol abuse itself caused pre-existing deficits. The patient's drinking history, however, may have compromised diencephalic structures so that no alternative limbic memory pathways were available after surgical intervention on fornices compressed by the tumour. This would explain the apparent contradiction between our results and Apuzzo's suggestion that the fornix is not required for normal memory functioning.1 This is the second published case of surgery in which a transcallosal approach was associated with the development of a non-transient amnestic syndrome as Berti et al also presented a patient who demonstrated amnesia after similar surgery.2 The results from our patient indicate possible interactions between alcohol abuse and outcome from particular neurosurgical approaches. LINDA LAATSCH

https://jnnp.bmj.com/content/jnnp/57/6/767.full.pdf

Isolated aneurysm of a spinal radicular artery presenting as spinal subarachnoid haemorrhage.

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Management of spontaneous extramedullary spinal haematomas: results in eight patients after MRI diagnosis and surgical decompression.

Prevention of local scar formation after operative discectomy for lumbar disc herniation.

Isolated aneurysm of a spinal radicular artery presenting as spinal subarachnoid haemorrhage.