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Review
. 2021 Jan 20:12:29.
doi: 10.25259/SNI_905_2020. eCollection 2021.

Pseudosubarachnoid hemorrhage: A systematic review of causes, diagnostic modalities, and outcomes in patients who present with pseudosubarachnoid hemorrhage

Andrew Platt  1 , John Collins  2 , Edwin Ramos  1 , Fernando D Goldenberg  3
Affiliations
Review

Pseudosubarachnoid hemorrhage: A systematic review of causes, diagnostic modalities, and outcomes in patients who present with pseudosubarachnoid hemorrhage

Andrew Platt et al. Surg Neurol Int. .

Abstract

Background: Patients with computed tomography (CT) findings consistent with subarachnoid hemorrhage without evidence of hemorrhage following autopsy or cerebrospinal fluid testing are termed to have pseudosubarachnoid hemorrhage (pSAH).

Methods: A systematic review of literature was conducted based on the preferred reporting items for systematic reviews and meta-analysis statement. Studies were evaluated for associated cause of pSAH, imaging modality used in assessment, method of confirmatory testing, and clinical outcome.

Results: Fifty studies were included in qualitative analysis including 197 cases of pSAH. Systematic review revealed 23 studies including 110 patients with pSAH attributed to hypoxic-ischemic brain injury following cardiac arrest. Three studies were included in meta-analysis that quantitatively analyzed differences in CT densities in patients with pSAH and true subarachnoid hemorrhage (true SAH). A random effects model meta-analysis showed a statistically significant decrease in densities in the Sylvian fissure in patients with pSAH compared to true SAH and a statistically significant decrease in densities in adjacent parenchyma in patients with pSAH compared to true SAH. Systematic review further revealed 32 patients with pSAH associated with spontaneous intracranial hypotension, 11 patients with pSAH related to infectious etiologies, 15 patients with pSAH associated with subdural hemorrhage, 20 cases of pSAH related to hyperhemoglobinemia, 2 cases related to valproate toxicity, and individual cases related to hyponatremia, diabetic ketoacidosis, sudden infant death syndrome, cerebellar infarction, and dialysis disequilibrium syndrome.

Conclusion: This study is the first systematic review of causes, diagnostic modalities, and outcomes in patients who present with pSAH. A diagnosis of pSAH may be considered following assessment of CT densities following cardiac arrest.

Keywords: Cardiac arrest; False subarachnoid hemorrhage; Pseudosubarachnoid hemorrhage; Systematic review.

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Conflict of interest statement

There are no conflicts of interest.

Figures

Figure 1:
Figure 1:
Computed tomography demonstrating diffuse hyperdensity within the subarachnoid space in a patient with pseudosubarachnoid hemorrhage.
Figure 2:
Figure 2:
A flowchart of study inclusion and exclusion.
Figure 3:
Figure 3:
A random effects model meta-analysis comparing densities in high-density areas in patients with pseudosubarachnoid hemorrhage and true subarachnoid hemorrhage. IV: Inverse variance, CI: Confidence interval, SD: Standard deviation.
Figure 4:
Figure 4:
A random effects mode meta-analysis comparing densities in adjacent parenchyma in patients with pseudosubarachnoid hemorrhage and true subarachnoid hemorrhage. IV: Inverse variance, CI: Confidence interval, SD: Standard deviation.
Figure 5:
Figure 5:
A flowchart of a theoretical diagnostic protocol to differentiate cases of pseudosubarachnoid hemorrhage from aneurysmal subarachnoid hemorrhage in patients who present following cardiac arrest with high-density areas on computed tomography. *Ruling out subarachnoid hemorrhage to be done per individual hospital policy which may include further vascular imaging or confirmatory testing, HAD: High-density areas, HA: Headache, LOC: Loss of consciousness, IPH: Intraparenchymal hemorrhage, IVH: Intraventricular hemorrhage.
See this image and copyright information in PMC

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