Hemorragia subaracnoidea angio negativadiagnóstico, complicaciones y utilidad de las escalas clínico radiológicas para su valoración

Laburpena

Introduction. Angio negative subarachnoid hemorrhage comprises almost 15% of subarachnoid hemorrhages. While the number of patients suffering this special type of hemorrhage are increasing in the last years, there is also a meaningful proliferation of papers that intensify the debate about how the diagnostic approach should be performed in these cases. On the other hand, the clinical and physiopathological differences between angio negative SAH and aneurysmal subarachnoid hemorrhage (aSAH) suggest that scales applied for the evaluation of aSAH are not pertinent for the assessment of patients with SAH without identifiable vascular lesions. The principal objectives of this investigation are to assess the results obtained in the radiological tests performed to patients with SAH and negative angio-CT (ACT) so that we can propose a diagnostic algorithm, and to value the applicability of Modified Fisher Scale (MFS) and Hunt and Hess (HH) scale in cases of angio negative SAH. Materials and Methods. We retrospectively reviewed the radiology database and the medical records of all the patients who presented to the Arrixaca University Hospital during a 9-year period. The inclusion criteria were patients with spontaneous SAH (perimesencephalic or diffuse) with negative ACT, and at least one control performed by digital subtraction angiography (DSA) of cerebral vessels. Subsequently, we calculated the diagnostic yield of the diagnostic procedures based on the distribution of the blood in the initial cranial CT (perimesencephalic or diffuse), and evaluate the number and type of neurological complications in each group, studying which are the factors related to its development. Results. A total of 125 patients fulfilled the aforementioned criteria. In 9 cases, vascular lesions related to the hemorrhage, that were hidden to the ACT, were detected in the DSA (1 from the perimesencephalic group and 8 from the diffuse group). The diagnostic yield of the first DSA (indicated after a negative angio CT) was of 1,6% in the perimesencephalic group and 10,7% in the group of patients with diffuse SAH. The succeeding studies did not obtain a diagnostic yield. When we discarded these cases, the cohort comprised 116 patients. The most common complication in cases of angio negative SAH was hydrocephalus. This entity, statically significant predominated in the diffuse bleeding group (p<0.001). The main factors related to the development of neurological complications were a high score in HH scale (p<0.001) and worse values in MFS (p0.025), as well as the diffuse bleeding pattern (p0.028). Conclusion. The results take us to conclude that the diagnostic approach of patients with SAH and negative angio-CT should be individualized based on the distribution of the blood in the cranial CT performed at admission, and the availability of the diagnostic techniques. The incidence and type of neurological complications in cases of angio negative SAH differ compared to aSAH, and despite MFS could be used to predict the development mainly of hydrocephalus, patients with grade IV hemorrhages are specially exposed. A more pronounced clinical affectation, valuated with the HH scale, was an independent predictor of neurological complications in patients with angio negative SAH.