Focal Cortical Subarachnoid Hemorrhage Revealed by Recurrent Paresthesias: A Clinico-Radiological Syndrome Strongly Associated with Cerebral Amyloid Angiopathy

Abstract

Background: Focal subarachnoid hemorrhage (SAH) is often revealed by transient and recurrent focal neurological episodes. This cause is important to identify because it carries a high risk of intracerebral hemorrhage (ICH). We report the clinical, imaging and prognostic data of 17 patients with focal SAH revealed by short episodes of paresthesias mimicking transient ischemic attacks. Methods: The medical records and imaging data of patients with focal acute SAH at the cerebral convexity and at least one episode of focal paresthesia having attended the Neurology Department of Caen University Hospital in the last 10 years were retrospectively reviewed. Hemorrhagic lesions, ischemic lesions, cerebral microbleeds (CMBs), superficial siderosis, white matter changes (leukoaraiosis) and modified Boston criteria for cerebral amyloid angiopathy (CAA) were assessed. All patients or relatives were contacted after a median delay of 16 months in order to seek for new events (death, stroke, recurrent focal symptoms, ICH and dementia) that occurred since hospital discharge. Results: Seventeen patients (12 men) aged 69-96 years were identified. All but 1 had multiple, repeated, stereotyped and brief attacks of paresthesias, associated in some of them with motor and/or speech difficulties, but only 1 had a headache. SAHs were seen on CT scans in 15/17 patients and on T2* gradient-echo magnetic resonance imaging (MRI) in all patients. They were multiple SAHs in 14/17 patients, including at least 1 SAH in the central or pre- or postcentral sulcus contralateral to the symptoms in all patients. Five patients had punctate cortical hyperintensities on diffusion-weighted MRI. Eleven patients had CMBs, and 4 of them had more than 5 CMBs. Seven patients met the modified Boston criteria for probable and 10 for possible CAA. At follow-up, 5 patients had a subsequent ICH, 4 of whom had received antithrombotic treatments. Five patients died (1 from ICH). Six patients developed dementia. Conclusion: The combination of transient, repeated and stereotyped attacks of unilateral paresthesias with a contralateral sulcal SAH seems to preferentially occur in elderly people and is often indicative of CAA.

The Characteristics of Superficial Siderosis and Convexity Subarachnoid Hemorrhage and Clinical Relevance in Suspected Cerebral Amyloid Angiopathy

“…A previous study has correlated TFNE with SS in CAA patients who had suffered lobar ICH [7]. Several case series have suggested that CAA could be common cause of cSAH in the elderly [11,12]. Additionally, two recent studies in CAA with lobar ICH demonstrated that those with SS/cSAH had a higher risk of recurrent ICH compared with those without [13,14].…”

Focal subarachnoid haemorrhage mimicking transient ischaemic attack - do we really need MRI in the acute stage?

“…Similar to this 2 out of 17 CT scans were negative for fSAH compared to MRI in the series of Apoil et al, but also in this publication no detailed information on timing and physical acquisition parameters of the CT examination was given [15]. …”

“…The small number of cases acquired and the retrospective design of our study limits general recommendations from our data and does not allow a statistically valuable sensitivity/specificity analysis, as in previously published works [2,3,5,9,15]. Due to the short period between clinical onset and CT examination, we might have not missed one of the fSAH in CT.…”

Neuropsychological Effects of Cerebral Amyloid Angiopathy

“…This phenomenon is most closely associated with the neuroimaging finding of superifical siderosis on susceptibility-weighted sequences on MRI (see Fig. 1) [18]. This is most likely a focal epileptiform process, although others have suggested it is related to cortical spreading depression [19].…”