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

Abstract

BackgroundAcute non-traumatic focal subarachnoid haemorrhage (fSAH) is a rare transient ischaemic attack (TIA)-mimic. MRI is considered to be indispensable by some authors in order to avoid misdiagnosis, and subsequent improper therapy. We therefore evaluated the role of CT and MRI in the diagnosis of fSAH patients by comparing our cases to those from the literature.MethodsFrom 01/2010 to 12/2012 we retrospectively identified seven patients with transient neurological episodes due to fSAH, who had received unenhanced thin-sliced multiplanar CT and subsequent MRI within 3 days on a 1.5 T scanner. MRI protocol included at least fast-field-echo (FFE), diffusion-weighted imaging (DWI), T2-weighted fluid-attenuated inversion recovery (FLAIR) and time-of-flight (TOF) MRA sequences. By using MRI as gold-standard, we re-evaluated images and data from recent publications regarding the sensitivity to detect fSAH in unenhanced CT.ResultsfSAH was detected by CT and by FFE and FLAIR on MRI in all of our own cases. However, DWI and T2w-spin-echo sequences revealed fSAH in 3 of 7 and 4 of 6 cases respectively. Vascular imaging was negative in all cases. FFE-MRI revealed additional multiple microbleeds and superficial siderosis in 4 of 7 patients and 5 of 7 patients respectively. Including data from recently published literature CT scans delivered positive results for fSAH in 95 of 100 cases (95%), whereas MRI was positive for fSAH in 69 of 69 cases (100%).ConclusionsThin-sliced unenhanced CT is a valuable emergency diagnostic tool to rule out intracranial haemorrhage including fSAH in patients with acute transient neurological episodes if immediate MRI is not available. However, MRI work-up is crucial and mandatorily has to be completed within the next 24–72 hours.

Cerebral Microbleeds and Cortical Superficial Siderosis in Patients Presenting With Minor Cerebrovascular Events

“…27 Strengths of our study are the prospective data acquisition and enrollment of a typical patient cohort presenting emergently with minor ischemic stroke and TIA symptoms. Limitations include the relatively few number of patients with CMB and a short follow-up period.…”

Cortical superficial siderosis predicts early recurrent lobar hemorrhage

“…9 The interrater agreement for cSS presence and severity was 90% (Cohen k 5 0.79) and 85% (Cohen k 5 0.74), respectively, as described previously. 21 cSAH was defined as evidence of acute blood in the subarachnoid space localized in the superficial layer of the cerebral cortex, which showed linear hyperintensity on FLAIR images with corresponding linear hypointensity on T2*GRE images 22 or SWI. We did not include cSS and cSAH adjacent to any ICH or due to ICH extension into the interhemispheric fissure, sylvian fissure, basal cistern, or ventricles.…”

Diagnostik und Differenzialdiagnosen der nicht traumatischen Subarachnoidalblutung

“…u.). Häufig sind der Sulcus centralis und/oder die benachbarten Sulci pre-und postcentralis unilateral supraventrikulär von fSAB betroffen, sodass eine sorgfältige Durchmusterung der akut durchgeführten, dünnschichtigen CT in allen 3 Ebenen obligatorisch ist und die Indikation zur MRT großzügig gestellt werden sollte [15].…”