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Cerebral vasospasm and delayed cerebral infarctions in 225 patients with non-aneurysmal subarachnoid hemorrhage: the underestimated risk of Fisher 3 blood distribution
  1. Juergen Konczalla1,
  2. Sepide Kashefiolasl1,
  3. Nina Brawanski1,
  4. Stephanie Lescher2,
  5. Christian Senft1,
  6. Johannes Platz1,
  7. Volker Seifert1
  1. 1Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
  2. 2Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
  1. Correspondence to Dr Juergen Konczalla, Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, Frankfurt am Main 60528, Germany; J.Konczalla{at}


Objective Recent data have shown increasing numbers of non-aneurysmal subarachnoid hemorrhage (NASAH). However, data are limited and often only small series have been published. Our objective was to analyze the rate of cerebral vasospasm (CVS), delayed cerebral infarction (DCI), and their influence on the clinical outcome, especially in patients with diffuse Fisher 3 bleeding pattern NASAH (Fi3).

Methods Between 1999 and 2014, 225 patients had NASAH. CVS, DCI, and outcome (according to the modified Rankin Scale at 6 months) were analyzed retrospectively. Patients were stratified according to the bleeding type. After univariate analysis a multivariate analysis was performed and NASAH Fi3 was also compared with aneurysmal SAH Fi3.

Results Patient characteristics and the outcome of perimesencephalic (PM) and non-PM (NPM) SAH were similar. Excluding Fi3, PM and NPM without Fi3 had similar patient characteristics, clinical course, and outcome. In particular, the Fi3 subgroup had a significantly increased risk of CVS, DCI, unfavorable outcome, hydrocephalus, and death. Early hydrocephalus was associated with Fi3 and intraventricular hemorrhage. The multivariate regression model showed the variables elderly patients, Fi3, and early hydrocephalus as independent and significant predictors for an unfavorable outcome. A further comparison of NASAH Fi3 with aneurysmal SAH Fi3 showed similar characteristics, CVS rate, and mortality.

Conclusions Patients with NASAH without a Fi3 bleeding pattern had a similar excellent outcome to patients with PM-SAH. Patients with Fi3 had a high risk for early hydrocephalus, CVS, DCI, and an unfavorable outcome, similar to patients with aneurysmal SAH. After multivariate analysis, early hydrocephalus, elderly patients, and Fi3 were identified as negative prognostic factors. Therefore, patients with Fi3 are at risk and need careful clinical observation.

  • Subarachnoid
  • Hemorrhage

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  • Contributors JK, JP, NB, SK and SL acquired and analyzed the data. JK performed the statistical analysis and drafted the manuscript. CS, JK, SL and VS interpreted the data and contributed to critical revision of the manuscript for important intellectual content. VS performed critical supervision of the manuscript. All authors read and approved the final manuscript.

  • Competing interests None declared.

  • Ethics approval The study was approved by the local ethics committee of Frankfurt University Hospital.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement All data is included in the study.