Diagnostic value of magnetic resonance imaging in perimesencephalic and nonperimesencephalic subarachnoid hemorrhage of unknown origin

Abstract

Object The aim of this study was to evaluate the diagnostic value of MR imaging in perimesencephalic (PM) and nonperimesencephalic (non-PM) subarachnoid hemorrhage (SAH) of unknown origin. Methods The authors conducted a retrospective review of all patients with SAH (1226 patients) in their department between January 1991 and December 2008. Included in the study were cases of spontaneous SAH diagnosed using CT scans obtained within 24 hours of the initial symptoms and initially negative digital subtraction (DS) angiograms. Patients with traumatic SAH and an unknown history were excluded from the study. Patients with initially negative DS angiograms were divided into 2 groups: Group 1, a typically PM bleeding pattern (PM SAH); and Group 2, a non-PM bleeding pattern (non-PM SAH) such as hemorrhage in the sylvian or interhemispheric fissure. Cranial MR imaging including the craniocervical region was performed within 72 hours after SAH was diagnosed in all patients in Groups 1 and 2. Results One thousand sixty-eight patients underwent DS angiography, and among them were 179 (16.7%) with negative angiograms—47 patients (26.3%) from Group 1 and 132 patients (73.7%) from Group 2. Magnetic resonance imaging demonstrated no bleeding sources in any case (100% negative). Thirty-four patients in Group 1 and 120 patients in Group 2 underwent a second DS angiography study. Digital subtraction angiography revealed an aneurysm as the bleeding source in 1 case in Group 1 and in 13 cases in Group 2. Conclusions Magnetic resonance imaging of the brain and craniocervical region did not produce additional benefit for the detection of a bleeding source and the therapy administered for PM SAH and non-PM SAH (100% negative). The costs of this examination exceeded the clinical value. Despite the results of this study, MR imaging should be discussed on a case-by-case basis because rare bleeding sources are periodically diagnosed in cases of non-PM SAH. A second-look DS angiogram is necessary because aneurysmal hemorrhage occasionally produces PM SAH as well as non-PM SAH. Further prospective studies are needed to verify the authors' results in the future.