Clinical Characteristics And Prognosis Of Spontaneous Subarachnoid Hemorrhage With Negative Angiography

Objective: This study was to explore the clinical characteristics and prognosis of patients with angiographically negative subarachnoid hemorrhage(SAH),guiding the clinical therapy.Methods: Patients with angiographically negative SAH and aneurysmal subarachnoid hemorrhage(aSAH)through operative treatment from April 2009 to September 2017 were retrospectively reviewed.We compared the clinical features,outcomes and prognosis of patients with angiography-negative SAH and aSAH.Angiographically negative SAH was categorized as either perimesencephalic nonaneurysmal subarachnoid hemorrhage(PNSH)or n-PNSH according to the Rinkel criteria,and the clinical features,outcomes and prognosis of patients were compared between the two groups.All patients with angiographically negative SAH conducted at least 1 digital subtraction angiography(DSA)examination,performing computed tomography angiography(CTA)or DSA when reviewing.The follow-up period was between 3 months to 91 months.The average follow-up period was 33 months.Glasgow outcome scale was used to evaluate the clinical outcomes at discharge.Modified Rankin Scale was used to evaluate the clinical outcomes after discharge.Results: A total of 65 initial angiographically negative SAH patients were enrolled,25 patients received follow-up DSA.19 cases remained negative and aneurysms were found in 6 n-PNSH patients.Eventually,59 patients were enrolled in group of angiographically negative SAH.203 patients with SAH found aneurysms at the first angiography.Plus 6 patients who found aneurysms at the second DSA,a total of 209 cases were included in group of aSAH.Compared with aSAH group,the proportion of hospitalized Hunt-Hess Grade III and IV level,WFNS Grade IV-V level and deaths after discharge was lower in DSA-negative SAH group.At the same time,the proportion of hospitalized Hunt-Hess Grade I level,WFNS Grade I-III level and discharge GOS score 4-5 points was higher in DSA-negative SAH group(P<0.05,P<0.01).There were 19 PNSH patients and 40 n-PNSH patients.Compared with n-PNSH group,the average admission blood glucose level was lower and the proportion of hospitalized Hunt-Hess Grade II level was higher in PNAH group(P<0.05).All patients from the PNSH group and 34 patients(85.0%)from n-PNSH group were with normal consciousness(GCS=15)on admission.In terms of the WFNS scale on admission,the majority of patients in both groups scored between I and III(100.0% of PNSH and 95.0% of n-PNSH).There were no cases with rebleeding and advanced hydrocephalus in both groups and no patients died during hospitalization.2 patients had early hydrocephalus and 2 patients had cerebral ischemia who were all in the n-PNSH group.At discharge,all PNSH patients and 37 n-PNSH patients(92.5%)had GOS scores between 4 and 5.As far as the modified Rankin Scale(mRS)beyond three months after discharge,all PNSH patients and 36 n-PNSH patients(90.0%)had favorable outcome(mRS 0-2),three patients died were from the n-PNSH group.All patients with negative DSA had no events occurred such as cerebral infarction or cerebral hemorrhage after discharge.Conclusions: 1.DSA-negative SAH was often associated with lighter clinical symptoms,lower rate of complications and better prognosis compared with aSAH.2.The majority of patients with negative DSA findings were n-PNSH,which was associated with higher fasting blood glucose level,poorer clinical course and outcome compared to PNSH.Due to the high rates of finding aneurysms during the following angiography,we should conduct follow-up studies in n-PNSH patients to avoid misdiagnosis.PNSH patients had more severe headache,but they own good clinical course and prognosis.