Hemorragia subaracnoídea com tomografia de crânio sem sinais de sangramento

Francisco, Silvio; Reis-Filho, João Baptista dos; Neves, Afonso Carlos

doi:10.1590/S0004-282X1997000300010

Resumos

Foram observados 23 casos de pacientes com suspeita clínica de hemorragia subaracnoídea (HSA), com tomografia de crânio (CT) sem sinais de sangramento, com diagnóstico definitivo realizado por exame de líquido cefalorraquiano(LCR). Desses, 20 casos foram submetidos a angiografia cerebral. Estabeleceu-se a classificação clínica de Hunt & Hess. Os principais achados neste estudo foram:1) um terço dos pacientes apresentou intervalo de tempo entre o ictus e a realização da CT e do LCR entre 24 e 48 horas, período de maior sensiblidade da CT; 2) dos pacientes estudados com angiografia cerebral, 55% tiveram o diagnóstico de aneurisma com predomínio no território de carótida e cerebral anterior; 3) o grau clínico dominante foi Hunt & Hess I e II. Todos os achados encontrados demonstraram a necessidade da realização de LCR em suspeita de HSA sem sinais de sangramento na CT.

hemorragia subaracnoídea; líquido cefalorraquiano; tomografia computadorizada

We observed 23 pacients with clinical hypothesis of subarachnoidal hemorrhage (SAH) having cranial tomography (CT) without bleeding signals. The final diagnosis of SAH was made upon the cerebrospinal fluid (CSF) results. Twenty cases were submitted to brain angiography. They were focused under the clinical classification of Hunt & Hess. The main results were: 1) 1/3 of patients had interval time between 24 and 48 hours after ictus and before CT and CSF making; this was the most sensitive CT time; 2) 55% of patients with brain angiography had aneurysm predominantly in the carotid and anterior cerebral artery territory; 3) the dominant clinical degree was Hunt & Hess I e II. Conclusion: the results demonstrate the need of CSF test in case of SAH clinical diagnosis with CT showing no bleeding signals.

subarachnoidal hemorrhage; cerebrospinal fluid; computerized tomography

Hemorragia subaracnoídea com tomografia de crânio sem sinais de sangramento

Subarachnoidal hemorrhage with cranial tomography without bleeding signals

Silvio Francisco^I; João Baptista dos Reis-Filho^II; Afonso Carlos Neves^III

^ISetor de LCR da Disciplina de Neurologia da UNIFESP - Escola Paulista de Medicina: Pós-Graduando da Disciplina de Neurologia

^IISetor de LCR da Disciplina de Neurologia da UNIFESP - Escola Paulista de Medicina: Professor Adjunto da Disciplina de Neurologia e Chefe do Setor de LCR

^IIISetor de LCR da Disciplina de Neurologia da UNIFESP - Escola Paulista de Medicina: Médico da Disciplina de Neurologia e Chefe do PS de Neurologia

RESUMO

Foram observados 23 casos de pacientes com suspeita clínica de hemorragia subaracnoídea (HSA), com tomografia de crânio (CT) sem sinais de sangramento, com diagnóstico definitivo realizado por exame de líquido cefalorraquiano(LCR). Desses, 20 casos foram submetidos a angiografia cerebral. Estabeleceu-se a classificação clínica de Hunt & Hess. Os principais achados neste estudo foram:1) um terço dos pacientes apresentou intervalo de tempo entre o ictus e a realização da CT e do LCR entre 24 e 48 horas, período de maior sensiblidade da CT; 2) dos pacientes estudados com angiografia cerebral, 55% tiveram o diagnóstico de aneurisma com predomínio no território de carótida e cerebral anterior; 3) o grau clínico dominante foi Hunt & Hess I e II. Todos os achados encontrados demonstraram a necessidade da realização de LCR em suspeita de HSA sem sinais de sangramento na CT.

Palavras-chave: hemorragia subaracnoídea, líquido cefalorraquiano, tomografia computadorizada.

ABSTRACT

We observed 23 pacients with clinical hypothesis of subarachnoidal hemorrhage (SAH) having cranial tomography (CT) without bleeding signals. The final diagnosis of SAH was made upon the cerebrospinal fluid (CSF) results. Twenty cases were submitted to brain angiography. They were focused under the clinical classification of Hunt & Hess. The main results were: 1) 1/3 of patients had interval time between 24 and 48 hours after ictus and before CT and CSF making; this was the most sensitive CT time; 2) 55% of patients with brain angiography had aneurysm predominantly in the carotid and anterior cerebral artery territory; 3) the dominant clinical degree was Hunt & Hess I e II. Conclusion: the results demonstrate the need of CSF test in case of SAH clinical diagnosis with CT showing no bleeding signals.

Key words: subarachnoidal hemorrhage, cerebrospinal fluid, computerized tomography.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Aceite: 5-março-1997.

Dr. Silvio Francisco - Rua Itapeva 500 conj 3B - 01332-900 São Paulo SP - Brasil.

1. Adams HP, Jergenson DD, Kassel NF, Sahs AL. Pitfalls in the recognition of subarachnoid haemorrhage. JAMA 1980;244:794-796
2. Adams HP, Kassel] NF, Torner JC, Sahs AL. CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study. Neurology 1983;33:981-988.
3. Alexander MSM, Dias PS, Uttley D. Spontaneous subarachnoid haemorrhage and negative cerebral panangiography: review of 140 cases. J Neurosurg 1986;64:537-542.
4. American Heart Association Stroke Council. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke 1994;25:2314-2324.
5. Barrows U, Hunter FT, Banker BQ. The nature and clinical significance of pigments in the cerebrospinal fluid. Brain 1955;78:59-80.
6. Beetham R. Spectrophotometry examination of CSF for xanthochomia. Lancet 1992;339:1492.
7. Bell BA, Kendall BE, Symon L. Computed tomography in aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1980;43:522-524.
8. Bernhein AR. The icterus index. JAMA 1924,82:291.
9. Bonita R, Thomsom S. Subarachnoid haemorrhage: epidemiology, diagnosis, management and outcome. Stroke 1985; 16:591 -594.
10. Borri ML. A tomografia computadorizada do crânio na hemorragia subaracnoídea por aneurisma: análise de 100 casos. Tese de Mestrado, UNIFESP - EPM. São Paulo, 1990.
11. Cioffi F, Pasqualine A, Cacazzani P, Dapian R. Subarachnoid haemorrhage of unknown origin: clinical and tomographical aspects. Acta Neurochir. (Wien) 1989;97:31-39.
12. Davis KR, New PFJ, Ojemann RG, Crowell RM, Morawetz RB, Roberson GH. Computed tomographic evaluation of haemorrhage secondary to intracranial aneurysm. Am J Roentgenol 1976;127:143-153.
13. Duffy G. P.Lumbar puncture in spontaneous subarachnoid haemorrhage. Br Med J 1982,285:1163-1164.
14. Duffy GP. The"Warning leak"in spontaneous subarachnoid haemorrhage. Med J Aust 1983 ;1:514-516.
15. Eclache V, Vu T, Le Roux G. D-dimers levels in the cerebrospinal fluid: a marker of central nervous system involvement in neoplastic disease. Nouv Rev Fr Hematol 1994;36:321-324.
16. Greenberg CS, Devine DV, McCrae KM. Measurement of plasma fibrin D- dimer levels with the use of a monoclonal antibody coupled to latex beads. A J C P 1987;87:94-99.
17. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysm. J Neurosurg 1968;28:14-20.
18. Ivan LP. Computed tomographys and the early diagnostic lumbar puncture. Can Med Assoc J 1979; 121:1442.
19. Kendall BE, Lee BCP, Claveria E. Computerized tomography and angiography in subarachnoid haemorrhage. Br J Radiol 1976;49:483-501.
20. Lang DT, Berberian LB, Stephein L, Ault M. Rapid differentiation of subarachnoid hemorrhage from traumatic lumbar puncture using the D-dimer assay. A J C P 1990;93: 403-405.
21. Leblanc R. The minor leak preceding subarachnoid hemorrhage. J.Neurosurg. 1987;66:35-39.
22. Leblanc R, Winfield DJA. The warning leak in subarachnoid hemorrhage and the importance of its early diagnosis. Can Med Assoc J 1984;131:1235-1236.
23. Liliequist B, Lindquist M.Valdimarsson E. Computed tomography and subarachnoid hemorrhage. Neuroradioloy 1977;14:21-26.
24. Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. J Neurosurg 1966;24:779-780.
25. MacDonald A, Mendelow AD. Xanthochromia revisited: a re-evaluation of lumbar puncture and CT scanning in the diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1988;51:342-344.
26. Marton KI, Gean AD. The spinal tap: a new look at an old test. Ann Intern Med 1986;104:840-848.
27. Mendelow AD, Cartlidge N. Xanthochromia in subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1990;53:270-271.
28. Okawara SH. Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg 1973;38:575-580.
29. Ostergaard JR. Headache as a warning symptom of impending aneurysmal subarachnoid haemorrhage. Cephalalgia 1991;11:53-55.
30. Page KB, Howell SJ, Smith CML, Dabbs DJW, Malia RG, Porter NR, Thickett KJ, Wilkinson GM. Bilirubin, ferritin, D-dimers and erythrophages in the cerebrospinal fluid of patients with suspected subarachnoid haemorrhage but negative computed tomography scans. J Clin Pathol 1994;47:986-989.
31. Rinkel GJE, Wijdicks EFM, Vermeulen M, Ramos LMP, Tanghe HLJ, Hasan D, Meiners LC, Van Gijn J. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that diifer from aneurysmal rupture. A J N R 1991; 12:829-834.
32. Sadato N, Numaguchi Y, Rigamonti D, Salcman M, Gellad RE, Kishikawa T. Bleeding patterns in ruptured posterior fossa aneurysms: a CT study. J Comput Assist Tomogr 1991;15:612-617.
33. Scott WR, New PFJ, Davis KR. Computerized axial tomography of intracerebral and intraventricular hemorrhage. Radiology 1974;122:73-80.
34. Van Der Wee N, Rinkel GJE, Hasan D, Van Gijn J. Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan? J Neurol Neurosurg Psychiatry 1995;58:357-359.
35. Van Gijn J, Van Dongen KJ. The time course of aneurysmal haemorrhage on computed tomograns. Neuroradiology 1982;23:153-156.
36. Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, Van Gijn J. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989;52:826-828.
37. Vermeulen M, Van Gijn J. The diagnosis of subarachnoid haemorrhage. J. Neurol. Neurosurg. Psychiatry 1990;53:365-372.
38. Vermeulen M, Vavliet HHDM, Lindsay KW, Hijdra A, Van Gijn J. Source of fibrin I fibrinogen degradation products in the CSF after subarachnoid hemorrhage. J Neurosurg 1985;63:573-577.
39. Walton JN. Subarachnoid haemorrhage. Edinburgh: Livingstone, 1956.
40. Weisberg LA. Computed tomography in aneurysmal subarachnoid hemorrhage. Neurology 1979;29:802-808.

Datas de Publicação

Publicação nesta coleção
18 Out 2010
Data do Fascículo
Set 1997

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Adams HP, Jergenson DD, Kassel NF, Sahs AL. Pitfalls in the recognition of subarachnoid haemorrhage. JAMA 1980;244:794-796

[2] 2. Adams HP, Kassel] NF, Torner JC, Sahs AL. CT and clinical correlations in recent aneurysmal subarachnoid hemorrhage: a preliminary report of the Cooperative Aneurysm Study. Neurology 1983;33:981-988.

[3] 3. Alexander MSM, Dias PS, Uttley D. Spontaneous subarachnoid haemorrhage and negative cerebral panangiography: review of 140 cases. J Neurosurg 1986;64:537-542.

[4] 4. American Heart Association Stroke Council. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke 1994;25:2314-2324.

[5] 5. Barrows U, Hunter FT, Banker BQ. The nature and clinical significance of pigments in the cerebrospinal fluid. Brain 1955;78:59-80.

[6] 6. Beetham R. Spectrophotometry examination of CSF for xanthochomia. Lancet 1992;339:1492.

[7] 7. Bell BA, Kendall BE, Symon L. Computed tomography in aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1980;43:522-524.

[8] 8. Bernhein AR. The icterus index. JAMA 1924,82:291.

[9] 9. Bonita R, Thomsom S. Subarachnoid haemorrhage: epidemiology, diagnosis, management and outcome. Stroke 1985; 16:591 -594.

[10] 10. Borri ML. A tomografia computadorizada do crânio na hemorragia subaracnoídea por aneurisma: análise de 100 casos. Tese de Mestrado, UNIFESP - EPM. São Paulo, 1990.

[11] 11. Cioffi F, Pasqualine A, Cacazzani P, Dapian R. Subarachnoid haemorrhage of unknown origin: clinical and tomographical aspects. Acta Neurochir. (Wien) 1989;97:31-39.

[12] 12. Davis KR, New PFJ, Ojemann RG, Crowell RM, Morawetz RB, Roberson GH. Computed tomographic evaluation of haemorrhage secondary to intracranial aneurysm. Am J Roentgenol 1976;127:143-153.

[13] 13. Duffy G. P.Lumbar puncture in spontaneous subarachnoid haemorrhage. Br Med J 1982,285:1163-1164.

[14] 14. Duffy GP. The"Warning leak"in spontaneous subarachnoid haemorrhage. Med J Aust 1983 ;1:514-516.

[15] 15. Eclache V, Vu T, Le Roux G. D-dimers levels in the cerebrospinal fluid: a marker of central nervous system involvement in neoplastic disease. Nouv Rev Fr Hematol 1994;36:321-324.

[16] 16. Greenberg CS, Devine DV, McCrae KM. Measurement of plasma fibrin D- dimer levels with the use of a monoclonal antibody coupled to latex beads. A J C P 1987;87:94-99.

[17] 17. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysm. J Neurosurg 1968;28:14-20.

[18] 18. Ivan LP. Computed tomographys and the early diagnostic lumbar puncture. Can Med Assoc J 1979; 121:1442.

[19] 19. Kendall BE, Lee BCP, Claveria E. Computerized tomography and angiography in subarachnoid haemorrhage. Br J Radiol 1976;49:483-501.

[20] 20. Lang DT, Berberian LB, Stephein L, Ault M. Rapid differentiation of subarachnoid hemorrhage from traumatic lumbar puncture using the D-dimer assay. A J C P 1990;93: 403-405.

[21] 21. Leblanc R. The minor leak preceding subarachnoid hemorrhage. J.Neurosurg. 1987;66:35-39.

[22] 22. Leblanc R, Winfield DJA. The warning leak in subarachnoid hemorrhage and the importance of its early diagnosis. Can Med Assoc J 1984;131:1235-1236.

[23] 23. Liliequist B, Lindquist M.Valdimarsson E. Computed tomography and subarachnoid hemorrhage. Neuroradioloy 1977;14:21-26.

[24] 24. Locksley HB. Natural history of subarachnoid hemorrhage, intracranial aneurysms and arteriovenous malformations. J Neurosurg 1966;24:779-780.

[25] 25. MacDonald A, Mendelow AD. Xanthochromia revisited: a re-evaluation of lumbar puncture and CT scanning in the diagnosis of subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1988;51:342-344.

[26] 26. Marton KI, Gean AD. The spinal tap: a new look at an old test. Ann Intern Med 1986;104:840-848.

[27] 27. Mendelow AD, Cartlidge N. Xanthochromia in subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1990;53:270-271.

[28] 28. Okawara SH. Warning signs prior to rupture of an intracranial aneurysm. J Neurosurg 1973;38:575-580.

[29] 29. Ostergaard JR. Headache as a warning symptom of impending aneurysmal subarachnoid haemorrhage. Cephalalgia 1991;11:53-55.

[30] 30. Page KB, Howell SJ, Smith CML, Dabbs DJW, Malia RG, Porter NR, Thickett KJ, Wilkinson GM. Bilirubin, ferritin, D-dimers and erythrophages in the cerebrospinal fluid of patients with suspected subarachnoid haemorrhage but negative computed tomography scans. J Clin Pathol 1994;47:986-989.

[31] 31. Rinkel GJE, Wijdicks EFM, Vermeulen M, Ramos LMP, Tanghe HLJ, Hasan D, Meiners LC, Van Gijn J. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that diifer from aneurysmal rupture. A J N R 1991; 12:829-834.

[32] 32. Sadato N, Numaguchi Y, Rigamonti D, Salcman M, Gellad RE, Kishikawa T. Bleeding patterns in ruptured posterior fossa aneurysms: a CT study. J Comput Assist Tomogr 1991;15:612-617.

[33] 33. Scott WR, New PFJ, Davis KR. Computerized axial tomography of intracerebral and intraventricular hemorrhage. Radiology 1974;122:73-80.

[34] 34. Van Der Wee N, Rinkel GJE, Hasan D, Van Gijn J. Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan? J Neurol Neurosurg Psychiatry 1995;58:357-359.

[35] 35. Van Gijn J, Van Dongen KJ. The time course of aneurysmal haemorrhage on computed tomograns. Neuroradiology 1982;23:153-156.

[36] 36. Vermeulen M, Hasan D, Blijenberg BG, Hijdra A, Van Gijn J. Xanthochromia after subarachnoid haemorrhage needs no revisitation. J Neurol Neurosurg Psychiatry 1989;52:826-828.

[37] 37. Vermeulen M, Van Gijn J. The diagnosis of subarachnoid haemorrhage. J. Neurol. Neurosurg. Psychiatry 1990;53:365-372.

[38] 38. Vermeulen M, Vavliet HHDM, Lindsay KW, Hijdra A, Van Gijn J. Source of fibrin I fibrinogen degradation products in the CSF after subarachnoid hemorrhage. J Neurosurg 1985;63:573-577.

[39] 39. Walton JN. Subarachnoid haemorrhage. Edinburgh: Livingstone, 1956.

[40] 40. Weisberg LA. Computed tomography in aneurysmal subarachnoid hemorrhage. Neurology 1979;29:802-808.