Case ReportRecurrent Bleeding After Perimesencephalic Hemorrhage
Introduction
Perimesencephalic hemorrhage (PMH) is a benign form of subarachnoid hemorrhage.1 In contrast to aneurysmal subarachnoid hemorrhage, complications during hospital admission and after discharge are rare. In 7 previous studies, recurrent bleeding was reported after PMH, including 3 patients with in-hospital rebleeding.2, 3, 4, 5, 6, 7, 8 In 1 case, rebleeding occurred 5 days after the initial hemorrhage and shortly after initiating antithrombotic treatment because of myocardial ischemia.4 We describe a patient with PMH, without antithrombotic treatment, who had 2 episodes of recurrent bleeding within 9 hours after the initial hemorrhage. Informed consent was obtained. To validate the radiologic findings, we conducted an additional case-control study.
Section snippets
Case-Control Study
This study was approved by the Research Ethics Board of the University Medical Center Utrecht. To avoid bias in reading the subsequent head computed tomography (CT) scans of this patient, we retrieved from our database 8 patients admitted between 2006 and 2015 with serial CT scans after a perimesencephalic bleeding pattern (which included the index patient, 6 patients with PMH, and 1 patient with a perimesencephalic bleeding pattern and a basilar artery aneurysm). All patients had 2 CT scans
Case Description
A 56-year-old woman presented to the emergency department of a regional hospital because of acute onset of severe headache (visual analog scale score 10/10), nausea, and vomiting, which started while she was peeling potatoes. Past medical history was unremarkable, and she did not use any medication. She stopped smoking 30 years earlier and did not use alcohol or drugs. Neurologic examination was unremarkable. A head CT scan performed 2.5 hours after symptom onset showed a subarachnoid
Results of Case-Control Study
In both observation rounds, all raters found the CT scans of sufficient quality to assess the pattern of hemorrhage and changes in amount of blood (Supplementary Tables 1 and 2). All observers identified the head CT scan of the index patient after the first episode of suspected rebleeding to have an increased amount of subarachnoid blood compared with the admission head CT scan, and 6 radiologists reported an increased amount of subarachnoid blood for the index patient on the third CT scan
Discussion
We described a patient with PMH who had 2 episodes of recurrent bleeding within 24 hours after ictus, of which we consider the first to be certain, as all observers found an increased amount of blood, and the second likely but not definite, as 2 of the 8 observers found no increase in blood compared with the second scan. In the literature, 7 other patients with PMH and rebleeding have been reported, including 3 patients with in-hospital rebleeding.2, 3, 4, 5, 6, 7, 8 Of the 3 patients reported
Conclusions
Spontaneous rebleeding may occur shortly after PMH. In this patient, even after 3 episodes of bleeding, all with a perimesencephalic pattern, the prognosis was good. Rebleeding as a complication should be kept in mind if a patient with a perimesencephalic bleeding pattern on the initial CT scan complains of a sudden increase in headache.
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Cited by (2)
Recurrent Bleeding After Perimesencephalic Hemorrhage: Case Report and Review of the Literature
2019, World NeurosurgeryCitation Excerpt :They had undergone conservative treatment with complete recovery and without any complications. In the literature, 9 other patients with PMH and rebleeding have been reported (Table 1),5-13 including 4 patients with in-hospital rebleeding.5-8 The first patient experienced an increase of headache 5 days after the hemorrhage and 3 days after starting treatment with aspirin and intravenous heparin for an acute coronary syndrome, with a head CT showing an increased amount of extravasated blood compatible with recurrent PMH.7
Angiogram-negative subarachnoid haemorrhage - case report, retreospective analysis and literature review
2021, Journal fur Neurologie, Neurochirurgie und Psychiatrie
Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Supplementary digital content available online.