| Objective:This study was performed to analyze the clinical and imaging characteristics, discuss the etiologies and pathogenesis, and describe the treatment and prognosis in patients with c SAH.Methods:115 cases of c SAH was collected from 28 articles, searched in the Pub Med, CNKI, WAGFANG DATA and VIP between 2005 and 2015. Meanwhile, 22 cases of c SAH was collected from The Second Hospital of Ji Lin University between Jan.2009 and Aug.2015. A total of 137 cases of c SAH was identified and analyzed, including their clinical presentation, imaging findings, etiologies, pathogenesis, treatment and prognosis. We use SPSS 16.0 software and analyze the data.Results:1. General information: 137 patients(80 men and 57 women) were identified. Age of onset distributed in 12-96 years. Median age was 65 years. There were 79 patients >60 years and 58 patients ≤60 years.2. Clinical presentation: The main clinical symptoms of 137 patients were focal neurological deficits(n=96), 69 patients of them were >60 years old(71.9%). The most common form of c SAH was TIA like symptoms. Headache was another important clinical symptoms(n=58), mainly presented mild headache(n=59, 69.4%) and seen ≤60 years(n=57, 67.1%). 13 patients had altered mental status. 11 patients had epileptic seizures. 5 patients had dizzy. 1 patient had syncope.3. Imaging findings: 135 patients were detected on cranial CT scan and 111 patients had a brain MRI FLAIR sequence. The positive rate of CT was 94.1%, while FLAIR sequence was 100%. c SAH was localized in the right hemisphere in 70 patients, left hemisphere in 50 patients, and bilaterally in 17 patients. The hemorrhage of c SAH was located in one or a few cortical sulci of the brain, and this study mainly seen in one cortical sulci of brain(n=91, 66.4%). The bleeding was predominantly located in parietal lobe、frontal lobe and central sulci. Abnormal vascular imaging results were obtained in 71 patients(51.8%). The most common vascular abnormalities were cerebral artery stenosis or occlusion(n=40, 56.3%), followed by cerebral venous thrombosis(n=10, 14.1%), extensive cerebrovascular segmental stricture(n=9, 12.7%), cerebral artery dissection(n=6, 8.5%), vascular malformation(n=4, 5.6%) and moyamoya disease(n=2, 2.8%). The onset age of cerebral artery stenosis or occlusion concentrated in the 51-70 years of age(n=25, 62.5%). There were 9 patients showed middle cerebral artery stenosis, 6 patients showed middle cerebral artery occlusion, 11 patients showed internal carotid artery stenosis and 14 patients showed internal carotid artery occlusion. Cerebral artery stenosis or occlusion and c SAH were on the same side in 36 patients(90%).4. Etiologies: An underlying cause of the hemorrhage was identified in 112 patients, whereas the remaining 25 patients went unresolved. Of the known patients, 38 were due to cerebral amyloid angiopathy, 31 were caused by cerebral artery stenosis or occlusion, and the remainder were cerebral venous thrombosis(n=10), reversible cerebral vasoconstriction syndrome(n=9), cerebral artery dissection(n=6), posterior reversible encephalopathy syndrome(n=6), cerebral vascular malformation(n=4), moyamoya disease(n=2), thrombocytopenia(n=2), drug-induced vasculopathy(n=1), hypertension microangiopathy(n=1), lupus vasculitis(n=1), and cerebral hyperperfusion syndrome(n=1). The most common etiology among the >60 years old was cerebral amyloid angiopathy(n=38, 48.1%), followed by cerebral artery stenosis or occlusion(n=12, 15.2%). While among the ≤60 years old, the main etiology was cerebral artery stenosis or occlusion(n=19, 32.8%), followed by reversible cerebral vasoconstriction syndrome(n=8, 13.8%), cerebral venous thrombosis(n=6, 10.3%), and posterior reversible encephalopathy syndrome(n=6, 10.3%).5. Prognosis: Follow-up data could be obtained in 81 patients of 137 patients with follow-up time of 12 days to 96 months. 60 patients(74.1%) had a favorable outcome(m RS 0-3) and 21(25.9%) had an unfavorable outcome with 4 had dementia, 8 had a severe disability(m RS 4-5), 9 had died due to cancer(n=3), septicemia(n=2), intracranial hemorrhage(n=2), brain hernia(n=1), and unknown reason(n=1). 2 patients among ≤60 years(n=27) died due to cancer, the other of them had a favorable outcome and none of them had a severe disability. 19 patients among >60 years(n=54) had an unfavorable outcome and all of their etiology was cerebral amyloid angiopathy.Conclusion:1. Clinical characteristics: c SAH is predominantly seen in >60 years old. The main clinical symptoms of c SAH are focal neurological deficits and the most common form is TIA like symptoms. Headache is another important clinical symptom.2. Imaging characteristics: c SAH is commonly localized in the unilateral hemisphere, mainly seen in a cortical sulci of brain, and predominantly observed in parietal lobe、frontal lobe and central sulci. The positive rate of cranial CT is 94% in acute stage. The positive rate of MRI FLAIR sequence is 100%, but this is not the specific of c SAH. We can further determinate the etiology with combination of various imaging study(DWI, GRE-T2*WI, SWI, and cerebral vascular examination).3. Etiology: The most common etiology of c SAH is cerebral amyloid angiopathy followed by cerebral artery stenosis or occlusion. Cerebral amyloid angiopathy is frequent in patients >60 years, whereas, cerebral artery stenosis or occlusion appear to be a common cause in patients ≤60 years.4. The patients with the first episode c SAH need have comprehensive cerebral vascular examination, including artery and vein with intracranial and extracranial and have to eliminate the other systemic diseases, such as autoimmune disease, infection, tumor and so on. The patients without identified etiology need long-term follow up to avoid misdiagnosis, especially for the old patients, we should pay attention to cerebral amyloid angiopathy.5. Prognosis: The prognosis of c SAH is closely related to etiology, correct diagnosis and treatment. Generally, the cerebral amyloid angiopathy has a poor outcome whereas, the cerebral artery stenosis or occlusion and reversible cerebral vasoconstriction syndrome has a relatively good outcome. Therefore, the patients of cerebral amyloid angiopathy require long-term follow up in order to avoid adverse events. |
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