Risk of rebleeding

Overall rebleed rate is 0,5%/yr, which is lower then with aneurysmal SAH or
rebleeding from AVMs. There also a small risk of delayed cerebral ischemia
(vasospasm). Neurological outcome is likewise better.
MANAGEMENT
General measures
These patients are still at risk for the same complications of SAH as with
aneurysmal SAH: Vasospasm, hydrocephalus, hyponatremia, rebleeding, etc.(see
page 1040) and should be managed as any SAH (see page 1040). Some
subgroups may be at lower risk for complications and may be managed
accordingly (e.g. see Pretruncal nonaneurysm SAH (PNSAH) below.
Repeat angiography
Yield of positive second angiogram after technically adequate negative study:
1.8-9.8 %)370 in early (pre-CT) studies, 2-24% quoted more recently
369,371,372 . CT scan findings are helpful in the decision to repeat
angiography373. 70% of cases with diffuse SAH and thick layering of blood in the
anterior interhemispheric fissure were associated with an AcoA aneurysm that
show up on repeat angiography 367. The absence of blood on CT (performed
within 4 days of SAH), or thick blood in the perimesencephalic cisterns alone (see
below) were unlikely to be associated with a missed aneurysm.
Recomendations regarding repeat angio :
1. repeat angio after = 10 -14 days ( allow pasospasm & some clot to
resolve) A
A. Technically adequate 4 vessel angiogram is negative, and evidence for
SAH is strong
B. Original angio was incomplete or if there are suspicious findings
2. If CT localizes blood clot to particular area, place special attention to this
area on repeat angio
3. Do not repeat angio for classic pretruncal SAH (see below) or if no blood
on CT
4. Patients are usually kept in the hospital 10-14 days while waiting for
repeat angio (to watch for and manage complication of SAH or bleeding)
Other studies
1. imaging studies of the brain: MRI (with MRA if avaliable) or CT (with
angio-CT if avaliable). This may visualize an aneurysm that fails to
show up on angiography, and may identify other sources of SAH such
as angiographically occult vascular information ( see page 1105),
tumor......
2. tests to rule-out spinal AVM: a rare cause of intracebral SAH (see page
507)
A. spinal MRI: cervical, thoracic and lumbar

B. spinal angiography : too difficult and risky to be justified in most

cases of angio negative SAH. Consider in cases with high suspicion
of spinal source.
Surgical exploration
Advocated by some for cases of SAH with CT findings compatible with
an aneurysmal source in which a suspicious area is demonstrated
angiographically 369 with carefull explanation to the patient and family of the
possibility of negative operative findings.

30.19. Nonaneurysmal SAH

For etiologies of SAH other aneurysm, see page 1034
PRETRUNCAL NONANEURYSMAL SAH (PNSAH)
Nee perimesencephalic nonaneurysmal SAH 374. The suggestion to change the

name to pretruncal non aneurysmal SAH was proposed because improved

neuroimaging techniques have shown the true anatomic localization of the blood
to be in front of the brain stem (truncus cerebri) centered in front of the pons
rather than perimesencephalic 375.
A distinct entity considered to be a benign condition with good outcome and less risk of
bleeding and vasospasm than other patients with SAH of unknown etiology 376 (no
rebleeding occured in 37 patients with PNSAH and 45 months mean follow-up377 , nor in
169 patients with 8-51 months follow-up372, vasospasm has been reported in only 3
patients and may have been related to cerebral angiography rather than the PNSAH,
and although it is slow, the incidence of angiographic vasospasm may be higher than
oroginally though378).
The actual etiology has yet to be determined, but iy may be secondary to rupture of a
small perimesencephalic vein or capillary378.
Presentation
Patients may present with severe paroxysmal HA, meningismus, photophobia, and
nausea. Loss of consciousness is rare. These patients are usually not critically ill ( all
were grade 1 or 2), however, complications such as hyponatremia or cardiac
abnormalities may occur. Preretinal Hemorrhages and sentinel H/A have not occured.