Desfechos clínicos e funcionais de pacientes com hemorragia subaracnóidea aneurismática em UTI / Clinical and functional outcomes of patients with aneurysmatic subarachnoid hemorrhage in the ICU

INTRODUCTION: Rehabilitation has recently been discussed in patients with subarachnoid hemorrhage (SAH) caused by a ruptured aneurysm. OBJECTIVE: To compare clinical and functional outcomes of surviving and non-surviving patients with aneurysmal SAH in a neurosurgical ICU. METHODS: This is a retrospective documentary study. Medical records of patients with SAH admitted to the neurosurgical ICU of a teaching hospital between July 2014 and July 2019 were analyzed. Data were divided according to the outcomes into survivors group (SG) and non-survivors group (NG). RESULTS: 103 patients were analyzed, 72% female, mean age 55 years, 62% had high ICU outcome. The SG had significantly lower age, SAPS III score, Fisher and Hunt-Hess scales and time on mechanical ventilation (MV) than the NG, in addition, they had a Glasgow Coma Scale (GCS), on admission and discharge from the ICU and length of hospital stay, significantly higher (p≤0.05) than NG. The SG showed significantly higher functionality (p≤0.05) than the NG on admission and a significant increase (p≤0.05) in functionality between admission and discharge from the ICU. CONCLUSION: Surviving patients with aneurysmal SAH had lower age, SAPS III score, neurological scales and time on MV, higher GCS scores at ICU admission and discharge, and longer hospital stay than non-survivors. Surviving patients had better functionality than non-survivors on admission, and, evolved with functional improvement from admission to discharge from the ICU.

INTRODUÇÃO: Recentemente tem sido discutido quanto à reabilitação em pacientes com hemorragia subaracnóidea (HSA) causada pelo rompimento de um aneurisma. OBJETIVO: Comparar desfechos clínicos e funcionais de pacientes com HSA aneurismática, sobreviventes e não sobreviventes em uma UTI neurocirúrgica. MÉTODOS: Trata-se de um estudo documental retrospectivo. Foram analisados prontuários de pacientes com HSA internados na UTI neurocirúrgica de um hospital escola, entre julho de 2014 e julho de 2019. Os dados foram divididos de acordo com os desfechos em grupo sobreviventes (GS) e grupo não sobreviventes (GN). RESULTADOS: Foram analisados 103 pacientes, 72% do sexo feminino, idade média de 55 anos, 62% apresentaram alta da UTI como desfecho. O GS apresentou idade, escore SAPS III, escalas de Fisher e Hunt-Hess e tempo de ventilação mecânica (VM) significativamente menores (p≤0,05) que o GN, além disso, apresentaram escala de coma de Glasgow (ECG), na admissão e na alta da UTI e tempo de internação hospitalar, significativamente maiores (p≤0,05) que o GN. O GS apresentou funcionalidade significativamente maior (p≤0,05) que o GN na admissão e incremento significativo (p≤0,05) da funcionalidade entre a admissão e alta da UTI. CONCLUSÃO: Pacientes com HSA aneurismática sobreviventes apresentaram menores idades, escore SAPS III, escalas neurológicas e tempo de VM, maiores escores de ECG, na admissão e na alta da UTI e maior tempo de internação hospitalar que os não sobreviventes. Os pacientes sobreviventes apresentaram melhor funcionalidade que os não sobreviventes na admissão, e, evoluíram com melhora funcional da admissão até a alta da UTI.

Cefaleia sentinela: um quadro presente, mas pouco lembrad / Sentinel headache: present, but poorly remembered

Esta revisão narrativa da literatura tratou da cefaleia sentinela. A cefaleia é um acometimento de alta prevalência mundial, sobretudo em mulheres. São várias as condições que podem levar à sua ocorrência, destacando-se, entre elas, a hemorragia subaracnóidea, que é sabidamente a terceira maior causa de acidente vascular encefálico. No âmbito da hemorragia subaracnóidea, existe um sintoma que, por vezes, é ignorado na investigação clÍnica do acidente vascular encefálico: é a cefaleia sentinela. Ela é conceituada como sendo cefaleia súbita, não usual, do tipo explosiva, persistente e de menor intensidade que a dor de cabeça da hemorragia subaracnóidea. Geralmente precede a hemorragia subaracnóidea por dias ou semanas. Este manuscrito traz uma revisão narrativa da literatura sobre cefaleia sentinela, usando as bases de dados PubMed® e Literatura Latino-Americana e do Caribe em Ciências da Saúde. A prevalência dessa condição é de 10% a 43% na hemorragia subaracnóidea, podendo ser fator preditor na identificação precoce do paciente com risco para sangramento aneurismático. Torna-se, então, necessária tanto a educação médica como a atuação precisa acerca do tema, a fim de mudar os desfechos da hemorragia subaracnóidea.

This narrative review of the literature addressed the sentinel headache. headaches are of high prevalence worldwide, especially in women. Several conditions can lead to its occurrence, such as the subarachnoid hemorrhage (known to be the third main cause of stroke). In the context of subarachnoid hemorrhage, there is a symptom that is sometimes overlooked in the clinical investigation of stroke: the sentinel headache. It is conceptualized as sudden, unusual, of explosive nature, persistent and of lesser intensity than the subarachnoid hemorrhage headache. It usually precedes the subarachnoid hemorrhage by days or weeks. This study provides a narrative review of the literature on sentinel headache, using the PubMed® and Latin American and Caribbean Health Sciences Literature databases. The prevalence of this condition in subarachnoid hemorrhage is 10 - 43%, and may be a predictive factor in the early identification of the patient with risk for aneurysmal bleeding. Both medical education and accurate action on this issue are necessary to change the outcomes of subarachnoid hemorrhage.

Prognosis of Patients Victim of Spontaneous Subarachnoid Hemorrhage: A Comparison between Radiologic Scales

Objective To analyze the population and the earlymortality rate (up to thirty days) of patients victim of spontaneous subarachnoid hemorrhage (SAH) according to the Hunt-Hess clinical scale and the Fisher and modified Fisher radiological scales. Materials and Methods We analyzed 46 medical records and skull computed tomography (CT) scans of patients with spontaneous SAH admitted between February 2014 and December 2017 at Hospital Universitário Evangélico Mackenzie, in the city of Curitiba, state of Paraná, Brazil. The method of the study was exploratorydescriptive, transversal and retrospective, with a quantitative approach. We analyzed epidemiological (gender, age), clinical (life habits, pathologies, Glasgow coma scale and Hunt-Hess scale) and radiological (Fisher and modified Fisher scales) variables, and the Hunt-Hess and the Fisher scales were correlated with risk of death. The data was submitted to statistical analysis considering values of p<0.05. Result There was a higher prevalence of spontaneous SAH among women (69.5%), as well as among patients aged between 51 and 60 years (34.7%). Regarding the grades on the scales, there was higher prevalence of Fisher 4, Modified Fisher 4 and Hunt-Hess 2. Evolution to death was higher among women (76.4%) and patients aged between 61 and 70 years (35,2%). Conclusion Mortality was higher among patients classified as Fisher 3, Modified Fisher 4 and Hunt-Hess > 3. The Fisher scale is better than the modified Fisher scale to assess the risk of mortality.

Hemorragia intramedular y hemorragia subaracnoidea occipital concurrente. presentación de un caso / Hemorragia intramedular e hemorragia subaracnóidea occipital concomitante. apresentação de caso / Intramedullary hemorrhage and concurrent occipital subarachnoid hemorrhage. Case presentation

Se presentó una paciente de 62 años, con antecedente de hipertensión arterial sistémica e infarto cerebral. Acudió al cuerpo de guardia porque 24 horas después de un esfuerzo físico intenso presentó cefalea y dolor cervical intenso, vómitos no precedidos de náuseas y pérdida de la conciencia y al despertar no podía mover las piernas. El examen físico reveló signos meníngeos, paraplejia flácida, perdida de la sensibilidad táctil, térmica y dolorosa hasta el nivel de la segunda costilla y del tono de los esfínteres vesical y anal. La tomografía axial computarizada de cráneo mostró la presencia de hemorragia subaracnoidea occipital bilateral Fisher 3 y la resonancia magnética de columna dorsal contrastada reveló una hemorragia intramedular subaguda tardía. Se pondera la relevancia de la anamnesis, el examen físico y de los medios diagnósticos, sobre todo de la resonancia magnética para el diagnóstico clínico de hemorragia intramedular(AU)

A 62-year-old patient was presented, with a history of systemic arterial hypertension and cerebral infarction. He went to the guard because 24 hours after intense physical exertion, he had headache and severe cervical pain, vomiting not preceded by nausea and loss of consciousness and when he woke up he could not move his legs. The physical examination revealed meningeal signs, flaccid paraplegia, loss of tactile, thermal and painful sensitivity to the level of the second rib and the tone of the bladder and anal sphincters. Computed axial tomography of the skull showed the presence of Fisher 3 bilateral occipital subarachnoid hemorrhage and the contrasted dorsal spine magnetic resonance revealed late subacute intramedullary hemorrhage. The relevance of the history, physical examination and diagnostic means, especially magnetic resonance imaging for the clinical diagnosis of intramedullary hemorrhage, is considered(AU)

Apresentou-se um paciente de 62 anos de idade, com história de hipertensão arterial sistêmica e infarto cerebral. Ele foi para a guarda porque, 24 horas após intenso esforço físico, estava com dor de cabeça e forte dor cervical, vômito não precedido de náusea e perda de consciência e, quando acordou, não conseguiu mexer as pernas. O exame físico revelou sinais meníngeos, paraplegia flácida, perda de sensibilidade tátil, térmica e dolorosa ao nível da segunda costela e ao tom da bexiga e dos esfíncteres anais. A tomografia axial computadorizada do crânio mostrou a presença de hemorragia subaracnóidea occipital bilateral de Fisher 3 e a ressonância magnética contrastada da coluna dorsal revelou hemorragia intramedular subaguda tardia. Considera-se a relevância da história, exame físico e meios de diagnóstico, especialmente ressonância magnética para o diagnóstico clínico de hemorragia intramedular(AU)

Subarachnoid hemorrhage: clinical presentation, causes and outcome in 52 Ethiopian patients

Introduction: Subarachnoid hemorrhage is a devastating neurological emergency associated with high mortality and disability. Little is known about its occurrence and clinical profile in Ethiopia. We, therefore, studied the clinical presentation, causes and outcome of the condition among in a tertiary facility.Methods: A retrospective analysis of records of patients admitted with the diagnosis of subarachnoid hemorrhage to Tikur Anbassa Specialized Hospital over a period of 12 years, January 2001 to January 2012, was undertaken.Results: Of 725 patients admitted with the diagnosis of stroke 52 (7.1%) patients were diagnosed to have subarachnoid hemorrhage. Death was registered in 18(34.6%) and disability in seven (13.4%).Hypertension was the most common risk factor, observed in 36 (69.21 %) of the patients, and seizure disorder and electrolyte abnormalities-hyponatremia were the most common complications. Conclusion: The outcome of subarachnoid hemorrhage in this study is comparable with reports from elsewhere. A prospective and well-designed epidemiological study is recommended. There is a need to improve the diagnostic and interventional capacity of the hospital

Terapia endovascular y hemorragia subaracnoidea: experiencia en el Hospital Central de Maracay / Endovascular therapy and subarachnoid hemorrhage: experience in the Hospital Central of Maracay

La ruptura aneurismática es la causa más frecuente de hemorragia subaracnoidea y la embolización endovascular es un procedimiento neuroradiológico eficiente que minimiza la posibilidad de una nueva ruptura y sangrado a corto y largo plazo. Investigación de casos, descriptiva, retrospectiva, sin experimentación, de 78 historias clínicas de pacientes con diagnóstico de hemorragia subaracnoidea tratados en el servicio de medicina interna del Hospital Central de Maracay en el período enero 2011 – junio 2012. Predominó el género femenino, provenientes en su mayoría del centro del país, la edad promedio fue de 49 años, el mayor porcentaje recibió tratamiento electivo, con una estancia hospitalaria menor de 3 días. Las arterias afectadas pertenecieron especialmente al circuito anterior del Polígono de Willis. No se reportaron complicaciones fatales. La embolización es un instrumento terapéutico altamente eficaz, con pocas complicaciones perioperatorias y estancia hospitalaria corta.

Aneurysmal rupture is the most common cause of subarachnoid hemorrhage. Embolization is an efficient neuroradiological procedure that minimizes the possibility of a new rupture and bleeding. This is a descriptive case review, retrospective, not experimental, of the medical records of 78 patients with non-traumatic subarachnoid hemorrhage treated at the department of internal medicine of the Hospital Central Maracay, Venezuela from January 2011 to June 2012. Female gender predominated, the average age was 49 years; the highest percentage received elective treatment, with a hospital stay of less than 3 days. The affected arteries were mostly from the anterior circuit of Willis poligon. There were no fatal complications. Embolization is a highly effective therapeutic instrument, with few complications and shorter hospital stay.

Detection of Gnathostoma spinigerum Antibodies in Sera of Non-Traumatic Subarachnoid Hemorrhage Patients in Thailand

Gnathostoma spinigerum can cause subarachnoid hemorrhage (SAH). The detection of specific antibodies in serum against G. spinigerum antigen is helpful for diagnosis of neurognathostomiasis. There is limited data on the frequency of G. spinigerum infection in non-traumatic SAH. A series of patients diagnosed as non-traumatic SAH at the Srinagarind Hospital, Khon Kaen University, Thailand between January 2011 and January 2013 were studied. CT or MR imaging of the brain was used for diagnosis of SAH. Patients were categorized as aneurysmal subarachnoid hemorrhage (A-SAH) or non-aneurysmal subarachnoid hemorrhage (NA-SAH) according to the results of cerebral angiograms. The presence of specific antibodies in serum against 21- or 24-kDa G. spinigerum antigen was determined using the immunoblot technique. The detection rate of antibodies was compared between the 2 groups. Of the 118 non-traumatic SAH patients for whom cerebral angiogram and immunoblot data were available, 80 (67.8%) patients had A-SAH, whereas 38 (32.2%) had NA-SAH. Overall, 23.7% were positive for specific antibodies against 21- and/or 24-kDa G. spinigerum antigen. No significant differences were found in the positive rate of specific antibodies against G. spinigerum in both groups (P-value=0.350).

Síndrome de takotsubo após hemorragia subaracnoidea / Takotsubo cardiomyopathy following subarachnoid hemorrhage

A síndrome de takotsubo corresponde a uma cardiomiopatia caracterizada por uma disfunção miocárdica transitória afetando ápice do ventrículo esquerdo, que classicamente ocorre após grande estresse físico ou emocional (também chamada "síndrome do coração partido" ou "cardiomiopatia induzida por estresse"). Descrevemos a ocorrência de síndrome de takotsubo em uma paciente induzida por hemorragia subaracnoidea.

Takotsubo cardiomyopathy corresponds to a syndrome characterized by a transient myocardial dysfunction affecting the left ventricular apex that classically occurs after major physical or emotional stress (also called "broken heart syndrome" or "stress-induced cardiomyopathy"). The author describes the case of a patient with takotsubo cardiomyopathy induced by subarachnoid hemorrhage.

Subarachnoid hemorrhage as a rare presentation of cerebral venous sinus thrombosis

Cerebral [Dural] venous thrombosis can present with a variety of symptoms ranging from mild headache to altered level of consciousness and coma. Cerebral venous thrombosis is an uncommon clinical condition. It often affects young to middle aged patients and more commonly women. Subarachnoid hemorrhage is a rare presentation. In this report, we describe a case of cerebral venous thrombosis presenting with Subarachnoid hemorrhage

Hemorragia subaracnoídea por aneurisma cerebral roto: guías de manejo clínico actualizadas 2010: una propuesta al capítulo vascular de la FLANC / Cortical spreading depressions and their role in the pathophysiology of neuronal damage subsequent to aneurysmal subarachnoid hemorrhage

El vasoespasmo cerebral es la principal causa potencialmente tratable de mortalidad e incapacidad en pacientes que sufren hemorragia subaracnoidea aneurismática (HSA). Sin embargo, a la fecha no existe un tratamiento eficaz para el mismo. La reciente demostración de la falta de respuesta clínica a la reversión farmacológica del espasmo arterial a consecuencia de HSA ha obligado un replanteo de los fundamentos fisiopatológicos de los déficits neurológicos isquémicos tardíos (“delayed ischemic neurologic déficit”, DIND) a consecuencia de HSA, los cuales se creían en relación al espasmo arterial observado en pacientes con HSA. Desde la demostración de hallazgos electrocorticográficos de depresión cortical propagada (“cortical spreading depression”, CSD) en pacientes con HSA, un interés creciente se ha despertado respecto del rol de estos fenómenos en la fisiopatologíade los DIND observados en pacientes con HSA. Cuando inducidas en un cerebro saludable, las CSD se asocian con un aumento del flujo sanguíneo cerebral, facilitando la entrega del cerebro de los sustratos energéticos necesarios. En un cerebro que ha sido lesionado, sin embargo, la CSD se asocia con una reducción en flujo sanguíneo cerebral, lo cual, en el contexto deun aumento de las necesidades de energía, conduce a la insuficiencia energética y la hipoxia, empeorando así el daño cerebral. Estas observaciones sugieren que el déficit de energía producida por la CSD es un factor clave en la patogénesis de los DINDobservados a consecuencia de HSA. Este resumen detalla características sobresalientes de las CSD y su potencial relevancia en la fisiopatología del vasoespasmo.

Cerebral vasospasm is the leading potentially treatable cause of mortality and disability in patients with aneurysmatic subarachnoid hemorrhage (SAH). However, to date there is no effective treatment for this entity. The recently demonstrated lack of clinical response to pharmacologic reversal of arterial spasm as a result of SAH has spurred a reassessment of the pathophysiological concepts on delayed ischemic neurologic deficits (DIND) that follow SAH, which were long believed the effect of the arterial spasm observed in patients with SAH. Since the discovery of electrocorticographic cortical spreading depressions (CSD) in patients with SAH, increasing interest has been shown on the role of these phenomena in the pathophysiology of DIND observed in patients with HSA. When induced in a healthy brain, CSD are associated with an increase in cerebral blood flow by facilitating the delivery of the necessary energy substrates. In a brain that has been injured, however, CSD are associated with a reduction in cerebral blood flow, which, in the context of increased energy requirements leads to energy shortage and hypoxia, thus worsening brain damage. These observations suggest that the energetic deficit produced by the CSD is a key factor inthe pathogenesis of DIND observed as a result of HSA. This review details striking characteristics of CSD and their potential relevance in the pathophysiology of vasospasm.

Subarachnoid hemorrhage with transient ischemic attack: Another masquerader in cerebral venous thrombosis.

Cerebral venous thrombosis has a wide spectrum of clinical manifestations that may mimic many other neurological disorders and lead to frequent misdiagnoses or delay in diagnosis. The most frequent symptoms and signs are headache, seizures, focal deficits, and papilledema. A number of rare atypical manifestations have been described. Cerebral venous thrombosis may present with an isolated intracranial hypertension type picture, thunderclap headache, attacks of migraine with aura, isolated psychiatric disturbances, pulsatile tinnitus, isolated or multiple cranial nerve involvement, and occasionally as subarachnoid hemorrhage (SAH) or transient ischemic attack. Our patient presented with thunderclap headache and transient ischemic attack like episode with obvious SAH on CT scan. Acute SAH suggests the presence of a vascular lesion, such as ruptured aneurysm, and CVT is not generally considered in the diagnostic workup of SAH. The case emphasizes the importance of cerebral venous study in nonaneurysmal cases of SAH. It is important to have a high index of suspicion in such atypical cases to avoid delay in diagnosis.

Stroke subtypes on imaging in a Jamaican population a hospital-based study: estudio en un hospital / Subtipos de accidente cerebrovascular en la imagen médica en una población Jamaicana

OBJECTIVE: To examine the pattern of stroke subtypes found on Computed Tomography (CT), Magnetic Resonance Imaging (MRI) at the University Hospital of the West Indies (UHWI), Kingston, Jamaica. METHOD: A retrospective review was conducted for all patients diagnosed with stroke and who were subjected to CT or MRI evaluation at UHWI between January 2001 and December 2004. Data were collected for patient age and gender and type of stroke. RESULTS: Four hundred and thirty-three patients were identified and classified as having cerebral infarct, intra-parenchymal haemorrhage or subarachnoid haemorrhage. There were 414 patients who had CT scans and 19 had MRI scans. Within and across genders, over 80% suffered infarcts with no significant statistical difference between male and female patients. Subarachnoid haemorrhage was the least frequent subtype and occurred in younger patients. CONCLUSION: The pattern of stroke subtypes seen in this population was similar to that of Australian and European cohorts of patients but differed from that reported in Asians. Ischaemic infarct was the most frequent stroke subtype followed by intra- parenchymal haemorrhage and subarachnoid haemorrhage. There was no gender predilection for any specific type of stroke.

OBJETIVO: Examinar el patrón de los subtipos de accidente cerebrovascular encontrados en las imágenes de TAC y MRI en el Hospital Universitario de West Indies (HUWI), Kingston, Jamaica. MÉTODO: Se realizó un examen retrospectivo de todos los pacientes con diagnóstico de accidente cerebrovascular, sometidos a evaluación mediante TAC o MRI, entre enero 2001 y diciembre 2004. Los datos fueron recogidos teniendo en cuenta la edad y el género del paciente, así como el tipo de accidente. RESULTADOS: Cuatrocientos treinta y tres (433) pacientes fueron identificados y clasificados como pacientes con un infarto cerebral, hemorragia intraparenquimal o hemorragia subaracnoidea (HSA). Hubo 414 pacientes examinados con TAC y 19 con MRI. Dentro de ellos, ambos géneros incluidos, más del 80% sufrió infartos sin que hubiese diferencias estadísticas significativas entre hombres y mujeres. La hemorragia subaracnoidea fue el tipo menos frecuente, y se produjo en pacientes jóvenes. CONCLUSIÓN: El patrón de subtipos de accidente cerebrovascular en esta población fue similar al de cohortes de pacientes australianos y europeos, pero diferente al reportado para los asiáticos. El infarto isquémico fue el subtipo de accidente cerebrovascular más frecuente, seguido por la hemorragia intraparenquimal y la hemorragia subaracnoidea. No hubo preferencia de géneros en relación con ninguno de los tipos específicos de accidente cerebrovascular.

Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II in Predicting Hospital Mortality of Neurosurgical Intensive Care Unit Patients

We study the predictive power of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) in neurosurgical intensive care unit (ICU) patients. Retrospective investigation was conducted on 672 consecutive ICU patients during the last 2 yr. Data were collected during the first 24 hours of admission and analyzed to calculate predicted mortality. Mortality predicted by two systems was compared and, multivariate analyses were then performed for subarachnoid hemorrhage (SAH) and traumatic brain injury (TBI) patients. Observed mortality was 24.8% whereas predicted mortalities were 37.7% and 38.4%, according to APACHE II and SAPS II. Calibration curve was close to the line of perfect prediction. SAPS II was not statistically significant according to a Lemeshow-Hosmer test, but slightly favored by area under the curve (AUC). In SAH patients, SAPS II was an independent predictor for mortality. In TBI patients, both systems had independent prognostic implications. Scoring systems are useful in predicting mortality and measuring performance in neurosurgical ICU setting. TBI patients are more affected by systemic insults than SAH patients, and this discrepancy of predicting mortality in each neurosurgical disease prompts us to develop a more specific scoring system targeted to cerebral dysfunction.

Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II in Predicting Hospital Mortality of Neurosurgical Intensive Care Unit Patients

We study the predictive power of Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) in neurosurgical intensive care unit (ICU) patients. Retrospective investigation was conducted on 672 consecutive ICU patients during the last 2 yr. Data were collected during the first 24 hours of admission and analyzed to calculate predicted mortality. Mortality predicted by two systems was compared and, multivariate analyses were then performed for subarachnoid hemorrhage (SAH) and traumatic brain injury (TBI) patients. Observed mortality was 24.8% whereas predicted mortalities were 37.7% and 38.4%, according to APACHE II and SAPS II. Calibration curve was close to the line of perfect prediction. SAPS II was not statistically significant according to a Lemeshow-Hosmer test, but slightly favored by area under the curve (AUC). In SAH patients, SAPS II was an independent predictor for mortality. In TBI patients, both systems had independent prognostic implications. Scoring systems are useful in predicting mortality and measuring performance in neurosurgical ICU setting. TBI patients are more affected by systemic insults than SAH patients, and this discrepancy of predicting mortality in each neurosurgical disease prompts us to develop a more specific scoring system targeted to cerebral dysfunction.

Spontaneous intracystic hemorrhage of the arachnoid cyst: a case report and review of literature.

Arachnoid cysts represent benign cysts that occur in the cerebrospinal axis in relation to the arachnoid membrane and do not communicate with the ventricular system. We report a case of a years right handed lady, who presented to the emergency department with the complaints of headache and vomiting for one week CT scan showed extraaxial cystic lesion in the left fronto-parietal region. On the fifth day of admission, patient had sudden onset of severe headache associated with loss of consciousness for about 3-4 minutes with neck rigidity. A CT scan of head was repeated, which showed left fronto-parietal cystic lesion with intracystic bleed and SAH. Intraoperatively, there was intradural cystic lesion containing xanthochromic fluid with normal brain surface and there were no evidence of any vascular malformations. Marsupilization of the cystic lesion was carried out and she improved. The literature regarding arachnoid cyst with spontaneous intracranial haemorrhage is reviewed.