Perimesencephalic subarachnoid hemorrhage
Perimesencephalic subarachnoid hemorrhage (PMSAH) is a distinct pattern of subarachnoid hemorrhage (SAH), which is centered on the basal cisterns around the midbrain.
Epidemiology
Classification
Etiology
Clinical features
Diagnosis
Treatment
A survey aimed to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding 1)
Blood pressure control: It is important to maintain stable blood pressure levels in patients with perimesencephalic SAH. Hypertension (high blood pressure) can increase the risk of rebleeding. Medications may be administered to manage blood pressure, if necessary.
Observation and monitoring: In perimesencephalic SAH, there is usually no need for aneurysm repair or invasive treatments. Patients are typically admitted to an intensive care unit or a specialized neurology unit for close monitoring of their neurological status, blood pressure, and other vital signs. Serial imaging studies, such as repeat CT scans or angiography, may be performed to assess the stability of the hemorrhage.
Symptom management: Patients may experience symptoms such as headaches or neck stiffness following the SAH. Appropriate pain management and supportive measures, including bed rest and fluid management, are provided to alleviate symptoms and facilitate recovery.
Follow-up and surveillance: After the acute phase, patients with perimesencephalic SAH are usually discharged from the hospital and advised to follow up with their healthcare provider. Regular follow-up visits and imaging studies are recommended to monitor their progress and ensure the absence of complications or rebleeding.