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Subarachnoid Hemorrhage


KEY FACTS

Terminology

  • Hemorrhage into spinal subarachnoid space from variety of etiologies

    • Trauma (> 50%)

    • Aneurysmal subarachnoid hemorrhage (SAH) with spinal extension

    • Spinal arteriovenous malformations

      • –

        Mainly types II, III, IVc, conus malformations

    • Tumor

    • Anticoagulant therapy

    • Infection (pneumococcal meningitis, herpes)

    • Systemic disease

    • Spinal artery aneurysm (rare)

Imaging

  • Fluid-fluid level within thecal sac

  • Variable depending on stage of blood breakdown and byproducts

  • Dynamic enhanced MRA useful as screen for spinal vascular malformation

Top Differential Diagnoses

  • Epidural hemorrhage

  • Subdural hemorrhage

  • Intramedullary hemorrhage

Pathology

  • Rare reports of cervical/thoracic arachnoiditis developing following spinal SAH

Clinical Issues

  • Acute back or radicular pain ± signs of cord compression (numbness, weakness)

  • Massive spinal SAH may give acute cord compression, paraplegia, fecal and urinary incontinence

Sagittal T1WI MR of subarachnoid blood following epidural blood patch, presumably related to incorrect needle position, shows oblong focus of T1 hyperintensity within distal thecal sac at the L5-S1 level due to methemoglobin
. No epidural lesion is present.

Sagittal T2WI MR in the same patient shows the blood is low signal intensity
. The epidural space is normal
.

Axial T1WI MR (same patient) of subarachnoid blood following epidural blood patch shows focus of T1 hyperintensity
within distal thecal sac at the L5-S1 level.

Axial T2WI MR shows diffuse subarachnoid blood in the distal thecal sac as hypointensity
.

TERMINOLOGY

Abbreviations

  • Subarachnoid hemorrhage (SAH)

Definitions

  • Hemorrhage into spinal subarachnoid space from variety of etiologies

    • Trauma (> 50%)

      • –

        MVA, occupational, etc.

      • –

        Postoperative

      • –

        Lumbar puncture, epidural or intradural catheter placement

    • Related to brain pathology

      • –

        Aneurysmal SAH with spinal extension

    • Spinal arteriovenous malformations

      • –

        Mainly types II, III, IVc, conus malformations

      • –

        Intradural extramedullary cavernous malformation (very rare)

    • Tumor

      • –

        Spinal ependymoma

      • –

        Spinal schwannoma (rare)

      • –

        Hemangioblastoma (rare)

      • –

        Astrocytoma (rare)

      • –

        Endometriosis (rare)

    • Bleeding diatheses

    • Anticoagulant therapy

    • Infection (pneumococcal meningitis, herpes)

    • Systemic disease

      • –

        Lupus erythematosus, polyarteritis nodosa

    • Spinal artery aneurysm (rare)

      • –

        High flow varieties associated with AVM, or coarctation of aorta

      • –

        Congenital type seen with collagen gene mutations; connective tissue disorders

    • Spontaneous idiopathic (rare)

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