Cerebral Microbleeds in Patients With Acute Subarachnoid Hemorrhage

Sang-Beom Jeon, Gunjan Parikh, H. Alex Choi, Neeraj Badjatia, Kiwon Lee, J. Michael Schmidt, Hector Lantigua, E. Sander Connolly, Stephan A. Mayer, Jan Claassen
2014 Neurosurgery  
Cerebral microbleeds (CMBs) are commonly found after stroke, but have not been previously studied in patients with subarachnoid hemorrhage (SAH). Objective: To study the prevalence, radiographic patterns, predictors, and impact on outcome of CMBs in patients with SAH. Methods: We analyzed retrospectively 39 consecutive patients who underwent T2 * -weighted gradient-echo imaging within seven days after onset of spontaneous SAH. We report frequency and location of CMBs and show their association
more » ... their association with demographics, vascular risk factors, the Hunt-Hess grade, the modified Fisher Scale, the Acute Physiologic and Chronic Health Evaluation II, MRI findings including diffusion-weighted imaging lesions (DWILs), and laboratory data, as well as data on rebleeding, global cerebral edema, delayed cerebral ischemia, seizures, the Telephone Interview for Cognitive Status, and the modified Rankin Scale. Results: Eighteen (46%) patients had CMBs. Of these patients, nine had multiple CMBs, and overall a total of 50 CMBs were identified. The most common locations of CMBs were lobar (n=23), followed by deep (n=15) and infratentorial (n=12). After adjustment for age and history of hypertension, CMBs were related to the presence of DWILs (OR, 5.24; 95% CI, 1.14 to 24.00; p = 0.033). Three months after SAH, patients with CMBs had non-significantly higher modified Rankin Scale scores (OR, 2.50; 95% CI, 0.67 to 9.39; p = 0.175). Conclusion: This study suggests that CMBs are commonly observed and associated with DWILs in patients with SAH. Our findings may represent a new mechanism of tissue injury in SAH. Further studies are needed to investigate CMBs' clinical implications. CMBs were seen in 18 (46%) patients. Of these, nine had multiple (≥ 2) CMBs. DWILs were found in 25 (64%) patients ( Figure) . The presence of DWILs was associated with the presence of CMBs (odds ratio [OR], 5.50; 95% confidence interval [CI], 1.22 to 24.81; p=0.027) (Table 1). Logistic regression analysis controlling for age and hypertension showed that DWILs were independently associated with CMBs (OR = 5.24, 95% CI = 1.14 to 24.00, p = 0.033; and OR = 5.61, 95% CI = 1.21 to 25.98, p = 0.028). Of 50 CMBs, 23 were found in the lobar (8 frontal, 4 parietal, 9 temporal, 1 occipital, and 1 insular), 15 in the deep (3 basal ganglia, 7 thalamus, 4 internal capsule, and 1 corpus callosum), and 12 in the infratentorial (2 brainstem and 10 cerebellum) location. Patients with CMBs in the deep location had a larger amount of subarachnoid blood in the basal Sylvian fissure and suprasellar cistern (median, 6.0; interquartile range, 2.0 to 8.0) than those without CMBs in this location (median, 11.5; interquartile range, 8.8 to 12.0; p = 0.006) (see Table, Supplemental Content 2, which illustrates locational relationship between the presence of CMBs and the amount of subarachnoid blood). DWILs' patterns were punctate in 11 patients, territorial in 4 patients, and mixed (both punctate and territorial) in 10 patients. These patterns were not associated with the presence of CMBs (punctate, p = 0.956; territorial, p = 0.250; and mixed, p = 0.090). Among 15 patients who had both CMBs and DWILs, locational (lobar, deep or infratentorial) associations between CMBs and DWILs were not significant. Patients with CMBs were more likely to have a higher mRS on discharge (OR = 2.10) and at three months after SAH (OR = 2.50), and lower TICS on discharge (OR = 5.06) and at three months (OR = 1.50) after SAH, but the associations were not statistically significant (Table 3) . DISCUSSION CMBs were found in approximately half of patients with acute SAH. The most common locations were lobar followed by deep and infratentorial regions. The presence of CMBs was significantly associated with the occurrence of DWILs. CMBs were not significantly related to acute complications of SAH, such as rebleeding, global cerebral edema, delayed cerebral ischemia or seizures. In patients with CMBs, poor functional outcome measured by mRS and cognitive impairment measured by TICS tended to be high at discharge and at three months after SAH, but this association was not statistically significant. In other populations, CMBs have been independently associated with variable neurological deficits: cognitive impairment, depression, gait instability, poor quality of life, and future hemorrhagic risk. [1] [2] [3] [4] [5] 11,12 Given that SAH survivors also have the aforementioned A C C E P T E D
doi:10.1227/neu.0000000000000244 pmid:24176956 fatcat:jlvjdnpffjhgxmvvuj5uiqnzfe