PubMed · 8043134
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D W Cahill. 1994. Surgery for occult aneurysms.. https://pubmed.ncbi.nlm.nih.gov/8043134/
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BACKGROUND AND PURPOSE: In perimesencephalic nonaneurysmal hemorrhage (PMH), subarachnoid blood accumulates around the midbrain. Clinical and radiological characteristics suggest a venous origin of PMH. We compared the venous drainage of the midbrain between patients with PMH and aneurysmal subarachnoid hemorrhage (aSAH) by means of computed tomography angiography (CTA). METHODS: CTAs of 55 PMH patients and 42 aSAH patients with a posterior circulation aneurysm were reviewed. Venous drainage was classified into: (1) normal continuous: the basal vein of Rosenthal is continuous with the deep middle cerebral vein and drains mainly to the vein of Galen (VG); (2) normal discontinuous: drainage anterior to uncal veins and posterior to VG; and (3) primitive variant: drainage to other veins than VG. Additionally, we compared in PMH patients the side of the primitive variant and side of the bleeding. RESULTS: A primitive variant was present on one or both hemispheres in 53% of PMH patients with PMH (95% CI, 40% to 65%) and in 19% of aSAH patients (95% CI, 10% to 33%). In all 16 PMH patients with a unilateral primitive drainage, blood was seen on the side of the primitive drainage (100%; 95% CI, 81% to 100%); blood was never found mainly on the side with normal drainage. CONCLUSIONS: Patients with PMH have a primitive venous drainage directly into dural sinuses instead of via the vein of Galen more often than do controls. Moreover, the side of the perimesencephalic hemorrhage relates to the side of the primitive drainage. These results further support a venous origin of PMH.
BACKGROUND AND PURPOSE: Collateral flow plays an important role in maintaining tissue viability in proximal large vessel occlusion. We developed and tested a regional angiographic collateral grading system for patients with angiographically confirmed acute symptomatic middle cerebral artery occlusion to predict regional infarction. METHODS: A subset of 42 patients was selected from 180 patients enrolled in the Prolyse in Acute Cerebral Thromboembolism II (PROACT II) trial. Readers evaluated baseline cerebral angiograms in a blinded fashion for the degree of regional collateral circulation, which was graded on a 4-point scale in each of 15 anatomic regions. Regional and total collateral flow scores were compared with the presence or absence of infarction on 7- to 10-day follow-up computed tomography (CT), as well as clinical outcome as assessed by National Institute of Health Stroke Scale (NIHSS) scores. RESULTS: The collateral flow score on baseline angiography accurately predicted infarction, demonstrating a receiver operating characteristic curve of 0.87 (95% CI: 0.83 to 0.91) for all regions. Collateral grades on baseline angiography correlated moderately with infarct volume on follow-up CT scan at 7 to 10 days (R=0.61; P=0.0001). Collateral grades also correlated with follow-up NIHSS scores for patients who received thrombolysis (R=0.36 to 0.49, P<0.05), but not for control patients. CONCLUSIONS: An angiographic grading system for regional collateral flow accurately predicts the extent and location of cerebral infarction. This study corroborates the correlation between the presence of collateral flow, infarction volume, and clinical outcome, and it reinforces the need to control for collateral flow in clinical trials.
Meningeal carcinomatosis remains a challenging diagnosis to make, with both cerebrospinal fluid (CSF) analysis and radiological methods having a limited sensitivity. We aimed at describing a possible diagnostic sign of multislice CT angiography (MS-CTA) in the diagnosis of meningeal carcinomatosis. Upon retrospective analysis of MSCT angiographies of the brain, a conspicuous sign of the vessels of the interhemispheric fissure was noted in five patients. Cranial MSCT angiographies were performed with a standardized protocol (120 kV, 200 mA s, collimation of 4x1 mm, table feed per rotation 4 mm). We injected 120 ml of nonionic contrast medium as a bolus, and data acquisition was started after a fixed delay of 35 s. In order to elucidate the finding, correlation with clinical follow-up and/or CSF findings was performed for all patients. In five patients there was a blurring, an increased number, and a pathologic configuration of the vessels of the interhemispheric fissure. All five patients with this sign had clinical signs and symptoms of meningeal carcinomatosis. Three patients had positive CSF cytology, one further patient had follow-up spinal MRI 6 weeks later demonstrating meningeal carcinomatosis. One patient declined lumbar puncture. MS-CTA has the capacity to demonstrate a pathologic configuration of the vessels of the interhemispheric fissure in patients with meningeal carcinomatosis. This sign may serve as an indicator of meningeal carcinomatosis and should raise the suspicion of this disease entity.