Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture

Abstract

We describe a characteristic distribution of cisternal blood in 52 patients with nonaneurysmal subarachnoid hemorrhage proved by a normal angiogram. On CT, the center of the bleeding was located immediately anterior to the brainstem in all patients, which was confirmed in four patients who were studied with MR imaging. Extension to the ambient cisterns or to the basal parts of the sylvian fissures was common, but the lateral sylvian or anterior interhemispheric fissures were never completely filled with blood. Rupture into the ventricular system did not occur. MR demonstrated downward extension of the blood anterior to the brainstem as far as the medulla, but failed to detect the source of hemorrhage. Our aim was to determine whether this so-called nonaneurysmal perimesencephalic hemorrhage could be distinguished from aneurysmal subarachnoid hemorrhage on early CT scans. Two neuroradiologists were shown a consecutive series of 221 CT scans of patients with subarachnoid hemorrhage who subsequently underwent angiography. Only one patient with a basilar artery aneurysm on angiography was incorrectly labeled by both observers as having a nonaneurysmal perimesencephalic pattern of hemorrhage. The high predictive value of the perimesencephalic pattern of hemorrhage for a normal angiogram (0.95 and 0.94, respectively, for the two observers) and the excellent interobserver agreement (kappa 0.87) demonstrate that nonaneurysmal perimesencephalic hemorrhage can be distinguished on CT in the majority of patients. Recognition of this pattern of hemorrhage is important as patients with this subset of subarachnoid hemorrhage have an excellent prognosis.