Non-aneurysmal perimesencephalic subarachnoid hemorrhage

In 1985 Van Gijn and co-workers were the first to describe a particular subgroup of patients who presented with an acute subarachnoid hemorrhage with the clot seen on computed tomography (CT) confined to the perimesencephalic cisterns and adjacent subarachnoid spaces 1).

Nonaneurysmal perimesencephalic subarachnoid hemorrhage has become well recognized as a distinct type of subarachnoid hemorrhage and may account for up to two-thirds of all SAHs unknown cause 2) 3) 4)

95% of cases of perimesencephalic subarachnoid hemorrhage have a normal cerebral angiography and the source of bleeding is not identified; the cause is thought to be a venous bleed. This is referred to as non-aneurysmal perimesencephalic subarachnoid hemorrhage.

The etiology is unknown, but many explanations have been proposed, including venous injury or rupture followed by thrombosis of a ruptured microaneurysm.

Non-aneurysmal perimesencephalic subarachnoid hemorrhage is characterized by an accumulation of blood in the perimesencephalic and prepontine cisterns identified on sectional imaging together with persistently negative cerebral angiography. Magnetic resonance imaging usually contributes no further information on the possible cause of the bleed but may occasionally show further features including associated parenchymal infarcts such as the pontine haemorrhagic infarct seen in a case described by Duncan et al. 5).

All of the 13 patients in the series of van Gijn et al. had negative cerebral angiograms and followed a benign clinical course with excellent outcome 6)

Other authors have independently confirmed this as a distinct entity with consistent imaging findings and a universally benign clinical course and good outcome 7) 8).

A 48-year-old man on apixaban for multiple venous thromboembolisms presented with the worst headache of his life associated with blurry vision, nausea, and neck stiffness. Computed tomography demonstrated a perimesencephalic pattern of blood (Hunt and Hess grade 2, Fisher grade 3). Computed tomography angiography and 6-vessel digital subtraction angiography demonstrated no precipitating cause. Systemic tissue plasminogen activator (tPA) was administered on postbleed day 8 owing to obstructive shock from saddle pulmonary embolism and pulseless electrical activity. He was safely discharged to rehabilitation with moderate neurological deficits attributed to ischemic effects of his cardiac arrest.

Conclusions: Symptomatic saddle pulmonary embolism in the setting of intracranial hemorrhage creates conflicting risks of medical intervention. There are no case reports or evidence of the use of systemic thrombolysis in the setting of SAH. Owing to the benign natural history of PNSH, tPA may be a safe intervention. Neurointensivists and neurosurgeons should be aware that intravenous tPA was used safely for life-threatening pulmonary embolism in the setting of PNSH. Additionally, the use of tPA without resultant rebleeding in this case opposes the theory of the presence of a thrombosed ruptured microaneurysm 9).

1) , 6)
van Gijn J, van Dongen KJ, Vermeulen M, Hijdra A. Perimesencephalic hemorrhage: a nonaneurysmal and benign form of subarachnoid hemorrhage. Neurology. 1985 Apr;35(4):493-7. doi: 10.1212/wnl.35.4.493. PMID: 3982634.
Schievink WI, Wijdicks EF, Piepgras DG, Nichols DA, Ebersold MJ. Perimesencephalic subarachnoid hemorrhage. Additional perspectives from four cases. Stroke. 1994;25:1507–11.
Van Calenbergh F, Plets C, Goffin J, Velghe L. Nonaneurysmal subarachnoid hemorrhage: Prevalence of perimesencephalic hemorrhage in a consecutive series. Surg Neurol. 1993;39:320–3.
Rinkel GJ, Wijdicks EF, Hasan D, Kienstra GE, Franke CL, Hageman LM, et al. Outcome in patients with subarachnoid haemorrhage and negative angiography according to pattern of haemorrhage on computed tomography. Lancet. 1991;338:964–8.
Duncan IC, Terblanche JM, Fourie PA. Non-aneurysmal perimesencephalic subarachnoid haemorrhage with associated pontine haemorrhagic infarction. A case report and subject review. Interv Neuroradiol. 2003 Jun 30;9(2):177-84. doi: 10.1177/159101990300900207. Epub 2004 Oct 22. PMID: 20591268; PMCID: PMC3547513.
Canhao P, Ferro JM, et al. Perimesencephalic and nonperimesencephalic subarachnoid haemorrhages with negative angiograms. Acta neurochir. 1995;132:14–19.
Goergen SK, Barrie D, et al. Perimensencephalic subarachnoid haemorrhage: Negative angiography and favourable prognosis. Australas Radiol. 1993;37:156–160.
Porche K, Robinson C, Polifka A. Successful Use of Tissue Plasminogen Activator for Saddle Pulmonary Embolism in Perimesencephalic Nonaneurysmal Subarachnoid Hemorrhage. World Neurosurg. 2020 Dec;144:209-212. doi: 10.1016/j.wneu.2020.09.089. Epub 2020 Sep 22. PMID: 32971282.
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