Neaneurizminės kilmės spontaninės subarachnoidinės hemoragijos stebėjimo strategija

Karla Margarete Hennigs. Follow-up Strategy of Non-aneurysmal Subarachnoid Hemorrhage. Aim. To investigate the rationale of follow-up strategy of non-aneurysmal subarachnoid hemorrhages. Objectives. 1) To determine the distribution of blood in a subarachnoid hemorrhage on initial non-contrast CT and its correlation of unfavorable outcome for patients with non-aneurysmal subarachnoid hemorrhage; 2) To identify the occurrence of intracranial aneurysms on follow-up imaging for patients with non-aneurysmal subarachnoid hemorrhage; 3) To compare different neurovascular imaging modalities by its ability to detect aneurysms on follow-up as the cause of previously detected subarachnoid hemorrhage with negative angiography; 4) To determine the accurate timing for follow-up investigations to detect intracranial aneurysm for patients with non-aneurysmal subarachnoid hemorrhage. Methods. A systematic literature review was conducted following the PRISMA guidelines. A systematic data search on PubMed was performed, guided by inclusion criteria structured around the PICO paradigm, leading to the inclusion of 26 reports. The Newcastle-Ottawa Quality Assessment Scale was employed to assess the quality of scientific articles with a control group, while the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses was utilized for systematic reviews. Results. The most employed classification is the differentiation between PM-SAH and NP-SAH subarachnoid hemorrhage. NP-SAH is associated with increased rates of complications, mortality, and unfavorable outcomes, necessitating more comprehensive management strategies. Studies show variable rates of aneurysm detection on follow-up imaging, with a mean of 9.7%. The predominant imaging modality employed was DSA, utilized in 13 out of 16 studies, identifying an aneurysm in 9.1% of cases. MRI/A was the second most frequently employed modality, featured in 7 out of 16 studies, with an aneurysm detection rate of 1.9%. Follow-up imaging within the initial two weeks had the highest likelihood of detecting an aneurysm, with a mean diagnostic yield of 14.65%, compared to 10.53% between 2 – 8 weeks and 1.23% after eight weeks. Conclusions. 1) There is significant heterogeneity in the classification of blood distribution patterns on initial CT scans. A standardized classification system could aid in the detection of aneurysms in highly suspicious bleeding patterns while also reducing the need for unnecessary imaging in cases where the probability of identifying a bleeding source is minimal.; 2) Idiopathic SAH causes remain uncertain, with theories suggesting microaneurysm self-repair, venous hemorrhage, and occult aneurysms. Detecting occult aneurysms through follow-up imaging is crucial for preventing recurrent hemorrhage and improving outcomes.; 3) Despite its gold standard status, concerns about DSA's invasiveness prompt exploration of non-invasive options like CTA and MRI/A. Size considerations for aneurysms are crucial, as some modalities may have lower sensitivity. While 3D imaging techniques show potential, complications and risk-benefit ratios of repeat DSA should be considered.; 4) Many studies lack clarity on imaging timing, with a trend towards repeating angiographic exams after a 14-day interval. However, recent studies suggest an earlier follow-up within one to two weeks after the initial event, as supported by our results.

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