- Email: [email protected]
Evaluation of subarachnoid hemorrhage and cerebral vasospasm by computed tomography
MATERIALS *ND METMODS
conditions. its wefuulnessin p>mary vascular le;io& is still unclear. The role of CI’in the workuo of intrac:n:hral ~nwrysms and asliociated subarachnnid hi’morrhaae is still cvoivinza.Previous rcoort$ have demonstr&d ti:c ability oi CT to show large aneurisnns (L-3). blood fro,,, hemorrhage (1. 3-7). arid hydroccphalns(I, there is little previous informxion or. the cvsluation by CT of cerebrovascular spasm wondary 10 subarachnoid hemotrhage (MH). The purpose of this paper is to show!!.:. useiulrxss of CT in SAH secondary w z;eurysm. with parricutar ancntion to the *. i.;uation of vasospssm.
4).However,
P&ntr with the diagnosis of suberachn&d hemorrhasa who were admitted from Oclober KW. 10 June 197? were reviewzd. All cases iduded in this study had I rbaraehnoid hemorrhage sew&r; :o an intocerebral aoeurysm and 81~0had a do&\ spDcMICT scan and eerebmt angio#rsm. Subjew had a clinical higory indicative of SAN and bIood in their spinal fluid. All had four vesselcerebral anglo.qaphy that demonslratd an aneurynn accwnting L-r the hemorrhage. CT scanswere periotmcd within ‘Wee days of the muziomam. Some oaticnts had muitxrle Cl 8cn.m and a&&ams.wldch will be included in wme of the nnslysia. The findings in 4G patients with all of the above criteria are reported. The CT scanswere ~rforrxd ORan EM1 Mark 1 Scanner with 160x 160 matrix. Twenty-three of the oatients were initially scanned and awiorrsmmed &thin five days of thi hemorrhage. Tbc &&niog 23 were initially s!r,died up to 14 days after hemorrhage. Thirty patients had scanrbefore and aftercontrastinjstion (125 cc of Kenografin-76 in n bolos injeaion) while 16 paxients bad only nonsontras~.enh SEBIIF.The CT scanswere evaluated for the praence or t Iood, “as effect, hydrc:;halus, and areas of “ischemic” loccnc~. “:schemic’ luccncy is&fined as an arw ofnbnormaJly low absorption mefficiat in a w xlnr distribution lhat has little or no mass effect and that may not enhance after umtra.sl injection. liydrocephalus was empirically judged to be absent CO), mild ( + ), moderate Associated perivcntricular tucewy wan also noted, ii **e?.ent. Cerebral snf$ograms were evaluated for size and locations of anenryamn and de:ree of v~~~~. Vasospasm II ~7 , .piricaUy judged to bc absent (0). mild(+), or scverc(++). Anynwseffwtor hydrocephalus was also noted.
(++) or severe (+++1.
Tk patient ci~ were reviewed and the ci oical wndition at the time of CT and angiownpby gtadcd on a scale of five using Botterail’s criteria W.
CTanolo tlndlnqs t_ucancy-
Spasm
No !ucency h,Pll
!:Ecsm
oases 9 19
a+ 1.8 1.2
gwm It 3
28
CASE IEPOWT! G?w 1: A. w.
T&te 1. CT oi subarachnoid hemorfhape (48 ca?+rg! di ,,~~~~~~~~~~~~ Number01
hcmabagc wrc can in 20 cues. but thls only occurred in thoac ptkols scanned within five days of
mJtNlr;rbnoid wd,or 1 be mrrclutiru
bllravenvicular. of CT fiii of lscbcmia with
This 41.year-old female wu admiltc5 with suddrn lon%t of hc.adeche, MUKIL, and vomiting. whb:h ,;larr~d four days prior to admission. On phvsicnl exdmination she had marked nuchnl riSidity and a left ruperior nasal fidd cul. Cerebral argiography revmkd a multilobed left poslerior ccinnunicaring i.rkry aneurysm measuring 8 x 6 mm srsociakd with marked spasmof the left wpraclinoid bamat carotid nrlery ,md the horirontat s~meots of It c a”t”ior and middle cerebral arteries. Thm wzu no focal mssr cffca. llx lateral venwicta were of nowmt sire. A CT scan following. angbgraphy demonstrxed moderate vcnvicular dilation and “ixbemic” luoacy in the lefl fwantotemporal area that enhanced uirh con~~t (Figure I). Ovn rhc course of the nen I5 days, she developed a denseright facml and arm caresis. global aphasia. end rt< homonymous hcmimnopsta.Tbe clinical condition remained unchanged and the patient WE dirhargej four recks laln tor nursing home CM:.
This 55.war.old icmak was admitral with a history of head&he. nawcn. and vomiting of stx days’ d&lion. Or admission. oh.5had ouchal r&idly hut no fowl ncunlopical defiuil. The spinal t%ic was grossly bloody. Cerebral nnglopraphy revcal:d multiple nncurytms at tbc following locaionr: left suprwlinoid inkrnal carotid. portnior canmu~licaling and >nhrior communiutbu marks, and linhr middle cerebral and internal carorid near the origin of the pr~tcriorcommunicatiagnnm,(Fiaure2t. Thnewac mukcd spasmof the borkonlal scgmentrof the lghl wxerlor and middl~:cnclmlartnin. CT:can showed no bcmorrlmuic blood.Thnewu a riabl Iromowric-
I
leehwnk
hwnoy
r3l
No Iwhrmlc Iwwwy (37) Total _.---..
0
9 10 ..-..28
_
18 18__ _._._..
left hemiparcsis and hcmlxnsory &fcFt. Tlwe WC> clinical improvement over tbc rubxquont month and a repcal an9ioSrvm sbowd re‘olvtima of sppun and rcdcmonslrarion of the multiple awurysn~s The paticm wes then operated on. with clipping ,,f the right middle cerebral, righr poc~erior commonk~ inp. and
antetior communicating artery ;meurysms. AI sur. rhe right middle cerebral a-tery aneurysm had evidence of rupture. Tbe patient continued to im prove nz?xalogically and was discharged. A foliowup CT ccan four months later showec!only pastol;erative changes in the right frontal regic’n and mild hydroClZPb?dUS. The presenceof subaracbnoid blood did not significantly correlate with vasospasm. In fact, one of the mo,l florid casesof subarachnoid blood on CT had no associatedvasospasm.
gery,
Case 3: C. C. This 46.year-old hypertensive female was admitted with sudden onsef of headache, nausea, vomiting, dizziness, and lossofconsciousnes;. On examination sheuas found to be stuporousand responsiveto painful uimuli only, and she had nuchal rigidity and bilateral Babinski responses.Retinal hemorrhage was deIectrJ on the left side. Clinical impression was subarailrnoid hemorrhage secondaryto anterior communicolinp artery aneurysm. CT scan on the same day showed extensive subaracbnoid blood and acute hydruccphalur. A cerebral angiogram demonstrated an anterior cummunicating artery aneurysm measuring 6 X 4 mm, with no associatedrpasm or focal masseffect (Figure 3). There was moderate dilation of the lateral ventricles. A repeat CT scan five days later
Flgurs 1. b: Pm-contrast CT scan show ~,eae. of dl. minishad absorption coelflclenls indicative of iache“,,a in flu? le‘t tronla, and temporal ,e@ons.
showed
considentblv
resorption
of
!uberacbnnid
blood. The ventricles were smaller. Clinically. the relatively
benign appearance
nod CT scan. the pati :nt continued she died a week later The presence of “ischemic”
to dcrerior?!e
luccocin
associated with B poor climcal condition. these patients wrc
desoite
of ihc angiograms and
on CT ws All nine of
Cl;nical Grede 111 or worse (Tab!e
4). Patiems without
spasm or ivilb spasm but no CT
lucency usually had B more bcnigli clinical condition. The most com~non abnurmality tients with SAH was acuteobsrroclive Twenry-five
patients (54%)
casts the bydracephahls
or
CT
in pa-
hydrocephalur.
had this finding.
In most
resolved. but in three cases it
progressed and required shunting. Table 4.
CT-angio
Clinical-radiographic
findings
Lucency -
corr~latlon *v&moo olini& grade
Grade Ill-V
9
3.7
9
Number cases
Spasm
of
NO ,ucency -
Spasm
19
2.2
5
NO tuconcy -
No soarm
18
2.0
2
Total
case4:
46
Ii.
w.
This 46.year-old
female was admitted
with a sudden
loss of consciousness. On admission there uere no focal neurological delicits. The spinal fluid was grossly bloody. Cerebral angiography showed ar anterior communicating artery aneurysm measuring 5 x 4 mm that WRS associated with mild spasm (Figure 4). There was no focal mass eifect. A CT !ican on the EQ~O day showed hemorrhagic
blood io the septum pr,lucidum,
foramina of Monro. rinhl temooral horn. and subarachnoid spaces. iher; WE mild ventricular dil;?lion. Clinically. the parient remained lethnrgc. .4 fo!lowup scan B week later showed ieanlving hcnimomn in Ihe semoro peltucidum. and s&rach~oid
The b!aqd in the !eotricles
spaceshadcleared.
tricles were unchanged.
Followup
The lalrral
vcn-
scaw at tvee
and
five reeks post-hemorrhage showed cnlarsins ventricles with development of distinctive periwlfriculnr lucency. The patient was shunted. improved, discharged for pnsrible subsequent surgery.
The infrequent with
viswdization
subarachnoid
and war
of aneurysms in pnlients
hemorrhage
is to be c> pecred.
Most “berry” aocuryams that ruprure are small. less dun 5 mm in diameter. Normal adjacent vessels may
Figure 4. Csso 4. a: Right brachial anglogram with crow compre8Slon Shows an anterior communical~ ing anaurysm with mild spasm of the horizontal seg me”, of the lsit anterio: cerebral artery. The frequency of our visualization of blood on CT after suharachnoid hemorrhage is comparable 13 that reported hy prewous aurhorr ,I, 3.4, 5,. CT i\ I VW reliahlr method of dcmonrtratinr. SAH if rh:
cu1z.r rhrombwis mfa mlon.
and mfarnion.
bloody
or ~pavn producing
The pre;?nce of a lucent “ischemic”
re-
fluid.
municaring
Angiography
showed an anterix
artery aneurysm
was transferred
5). i?x
to the Neuroiwdcal
days later. On admission, nuchal rigidity
(Figure
Institute
he wasiethargic
dilation
distribution Cerebral
uf
seven
but had no
and a mild right !wniparesis.
scan performedonadmiasiondemrjnstratpd veniricular
compatient
and “ischemic”
the
;npiography
left
anterior
A CT
moderate lucency in the
cerebral
showed the awerior
artery.
cornmuni-
eating aneurysm measuring 9 x 6 mm associated with spasm of the supraclinoid
segment of the left internal
carotid artery and horizontal
segm~ntsofilleanterior
and middie cerebral arteries. There was no foal and the ventricles were moderately tient remained lethargic, aped nuchal rigidity
dilated.
mass
The pa-
but nine dass later he dewl-
without
new fwal
neurological
deficits. He wa5 thought to have bled again and repeat CT scan showed blood density in the septum cellucidum and venl?icles. The w&es periventricular
“fuzz.”
the patient remainedcritically confused. Ihc owrall
clinical aitwtion.
The prescuce of hydrocephal~ur sfter SAIH i%well hnow. but the frequency ill our results is higher than prwious reports (1%). ‘Thi- I% probshly due to tlmeincre;wd accuracy 01 CT when wr-qxmd with ~:tber techmqocs. The hydroceph;dus is ~ssally communicating and self-limitmg. Howcvcr. in three of our patients the hydrocephalix progressed and became the most significant aspect of 1111: di5eae. CT isextremely hr-;pful in these casts. particularly BIlICriOrCOlllm,llliCafin6
if the patient has as
anewysn!.
It may bedifficulr
cli.lic;lllglodiffcrenli;~iethe,~hysical my to hydroccf~halur lobe ixhcmia.
findings,;econd-
irom lhore secondary to fru~~tal
7 Ihc findins on CT’correlate well with the clinicai wndition of the patiem. Sixteen paliemn were Grade lil to V. Nine of rhere palientr Cl’
evidence of
Four additional
an ;nsociaied
had spwn
“ischemic”
patients had an infracerebral
and
wgios. hema-
tmnn nrcounliog for thv poor clinical picture. Two palienis hnd severe hydrocephalus. Only one patiem was in poor clinical condition wirhoul an obvious rcaSO” on CT.
Cnse 5: w:. II. This ~1%ycwold hypcrten,ivc diabetic male was admitted to an outside hospital with a sudden onw of hri~dacbe.
nausc~, and vomilmg.
On admission,
w:i i pha!,ic and had a right hemiparcsis.
he
LP showd
Another
had &la&d.
with
The hemipareeis cleared. but ill. beingstuporwsand
CT scan showed enlarging
\.entri-
?b.
J.
6.
7.
e. 9. 10. II. 12. 13.
CONTINUlNG MEDICAL ‘:DIJCAT!ON QUFS WNS WVALUATlON OF HJMRACIINOID HFZhlORRHAGE AND CW HIltAL VASOSPAA1M BY COMPIJYED TOMOCRAPHY)
conditions. its wefuulnessin p>mary vascular le;io& is still unclear. The role of CI’in the workuo of intrac:n:hral ~nwrysms and asliociated subarachnnid hi’morrhaae is still cvoivinza.Previous rcoort$ have demonstr&d ti:c ability oi CT to show large aneurisnns (L-3). blood fro,,, hemorrhage (1. 3-7). arid hydroccphalns(I, there is little previous informxion or. the cvsluation by CT of cerebrovascular spasm wondary 10 subarachnoid hemotrhage (MH). The purpose of this paper is to show!!.:. useiulrxss of CT in SAH secondary w z;eurysm. with parricutar ancntion to the *. i.;uation of vasospssm.
4).However,
P&ntr with the diagnosis of suberachn&d hemorrhasa who were admitted from Oclober KW. 10 June 197? were reviewzd. All cases iduded in this study had I rbaraehnoid hemorrhage sew&r; :o an intocerebral aoeurysm and 81~0had a do&\ spDcMICT scan and eerebmt angio#rsm. Subjew had a clinical higory indicative of SAN and bIood in their spinal fluid. All had four vesselcerebral anglo.qaphy that demonslratd an aneurynn accwnting L-r the hemorrhage. CT scanswere periotmcd within ‘Wee days of the muziomam. Some oaticnts had muitxrle Cl 8cn.m and a&&ams.wldch will be included in wme of the nnslysia. The findings in 4G patients with all of the above criteria are reported. The CT scanswere ~rforrxd ORan EM1 Mark 1 Scanner with 160x 160 matrix. Twenty-three of the oatients were initially scanned and awiorrsmmed &thin five days of thi hemorrhage. Tbc &&niog 23 were initially s!r,died up to 14 days after hemorrhage. Thirty patients had scanrbefore and aftercontrastinjstion (125 cc of Kenografin-76 in n bolos injeaion) while 16 paxients bad only nonsontras~.enh SEBIIF.The CT scanswere evaluated for the praence or t Iood, “as effect, hydrc:;halus, and areas of “ischemic” loccnc~. “:schemic’ luccncy is&fined as an arw ofnbnormaJly low absorption mefficiat in a w xlnr distribution lhat has little or no mass effect and that may not enhance after umtra.sl injection. liydrocephalus was empirically judged to be absent CO), mild ( + ), moderate Associated perivcntricular tucewy wan also noted, ii **e?.ent. Cerebral snf$ograms were evaluated for size and locations of anenryamn and de:ree of v~~~~. Vasospasm II ~7 , .piricaUy judged to bc absent (0). mild(+), or scverc(++). Anynwseffwtor hydrocephalus was also noted.
(++) or severe (+++1.
Tk patient ci~ were reviewed and the ci oical wndition at the time of CT and angiownpby gtadcd on a scale of five using Botterail’s criteria W.
CTanolo tlndlnqs t_ucancy-
Spasm
No !ucency h,Pll
!:Ecsm
oases 9 19
a+ 1.8 1.2
gwm It 3
28
CASE IEPOWT! G?w 1: A. w.
T&te 1. CT oi subarachnoid hemorfhape (48 ca?+rg! di ,,~~~~~~~~~~~~ Number01
hcmabagc wrc can in 20 cues. but thls only occurred in thoac ptkols scanned within five days of
mJtNlr;rbnoid wd,or 1 be mrrclutiru
bllravenvicular. of CT fiii of lscbcmia with
This 41.year-old female wu admiltc5 with suddrn lon%t of hc.adeche, MUKIL, and vomiting. whb:h ,;larr~d four days prior to admission. On phvsicnl exdmination she had marked nuchnl riSidity and a left ruperior nasal fidd cul. Cerebral argiography revmkd a multilobed left poslerior ccinnunicaring i.rkry aneurysm measuring 8 x 6 mm srsociakd with marked spasmof the left wpraclinoid bamat carotid nrlery ,md the horirontat s~meots of It c a”t”ior and middle cerebral arteries. Thm wzu no focal mssr cffca. llx lateral venwicta were of nowmt sire. A CT scan following. angbgraphy demonstrxed moderate vcnvicular dilation and “ixbemic” luoacy in the lefl fwantotemporal area that enhanced uirh con~~t (Figure I). Ovn rhc course of the nen I5 days, she developed a denseright facml and arm caresis. global aphasia. end rt< homonymous hcmimnopsta.Tbe clinical condition remained unchanged and the patient WE dirhargej four recks laln tor nursing home CM:.
This 55.war.old icmak was admitral with a history of head&he. nawcn. and vomiting of stx days’ d&lion. Or admission. oh.5had ouchal r&idly hut no fowl ncunlopical defiuil. The spinal t%ic was grossly bloody. Cerebral nnglopraphy revcal:d multiple nncurytms at tbc following locaionr: left suprwlinoid inkrnal carotid. portnior canmu~licaling and >nhrior communiutbu marks, and linhr middle cerebral and internal carorid near the origin of the pr~tcriorcommunicatiagnnm,(Fiaure2t. Thnewac mukcd spasmof the borkonlal scgmentrof the lghl wxerlor and middl~:cnclmlartnin. CT:can showed no bcmorrlmuic blood.Thnewu a riabl Iromowric-
I
leehwnk
hwnoy
r3l
No Iwhrmlc Iwwwy (37) Total _.---..
0
9 10 ..-..28
_
18 18__ _._._..
left hemiparcsis and hcmlxnsory &fcFt. Tlwe WC> clinical improvement over tbc rubxquont month and a repcal an9ioSrvm sbowd re‘olvtima of sppun and rcdcmonslrarion of the multiple awurysn~s The paticm wes then operated on. with clipping ,,f the right middle cerebral, righr poc~erior commonk~ inp. and
antetior communicating artery ;meurysms. AI sur. rhe right middle cerebral a-tery aneurysm had evidence of rupture. Tbe patient continued to im prove nz?xalogically and was discharged. A foliowup CT ccan four months later showec!only pastol;erative changes in the right frontal regic’n and mild hydroClZPb?dUS. The presenceof subaracbnoid blood did not significantly correlate with vasospasm. In fact, one of the mo,l florid casesof subarachnoid blood on CT had no associatedvasospasm.
gery,
Case 3: C. C. This 46.year-old hypertensive female was admitted with sudden onsef of headache, nausea, vomiting, dizziness, and lossofconsciousnes;. On examination sheuas found to be stuporousand responsiveto painful uimuli only, and she had nuchal rigidity and bilateral Babinski responses.Retinal hemorrhage was deIectrJ on the left side. Clinical impression was subarailrnoid hemorrhage secondaryto anterior communicolinp artery aneurysm. CT scan on the same day showed extensive subaracbnoid blood and acute hydruccphalur. A cerebral angiogram demonstrated an anterior cummunicating artery aneurysm measuring 6 X 4 mm, with no associatedrpasm or focal masseffect (Figure 3). There was moderate dilation of the lateral ventricles. A repeat CT scan five days later
Flgurs 1. b: Pm-contrast CT scan show ~,eae. of dl. minishad absorption coelflclenls indicative of iache“,,a in flu? le‘t tronla, and temporal ,e@ons.
showed
considentblv
resorption
of
!uberacbnnid
blood. The ventricles were smaller. Clinically. the relatively
benign appearance
nod CT scan. the pati :nt continued she died a week later The presence of “ischemic”
to dcrerior?!e
luccocin
associated with B poor climcal condition. these patients wrc
desoite
of ihc angiograms and
on CT ws All nine of
Cl;nical Grede 111 or worse (Tab!e
4). Patiems without
spasm or ivilb spasm but no CT
lucency usually had B more bcnigli clinical condition. The most com~non abnurmality tients with SAH was acuteobsrroclive Twenry-five
patients (54%)
casts the bydracephahls
or
CT
in pa-
hydrocephalur.
had this finding.
In most
resolved. but in three cases it
progressed and required shunting. Table 4.
CT-angio
Clinical-radiographic
findings
Lucency -
corr~latlon *v&moo olini& grade
Grade Ill-V
9
3.7
9
Number cases
Spasm
of
NO ,ucency -
Spasm
19
2.2
5
NO tuconcy -
No soarm
18
2.0
2
Total
case4:
46
Ii.
w.
This 46.year-old
female was admitted
with a sudden
loss of consciousness. On admission there uere no focal neurological delicits. The spinal fluid was grossly bloody. Cerebral angiography showed ar anterior communicating artery aneurysm measuring 5 x 4 mm that WRS associated with mild spasm (Figure 4). There was no focal mass eifect. A CT !ican on the EQ~O day showed hemorrhagic
blood io the septum pr,lucidum,
foramina of Monro. rinhl temooral horn. and subarachnoid spaces. iher; WE mild ventricular dil;?lion. Clinically. the parient remained lethnrgc. .4 fo!lowup scan B week later showed ieanlving hcnimomn in Ihe semoro peltucidum. and s&rach~oid
The b!aqd in the !eotricles
spaceshadcleared.
tricles were unchanged.
Followup
The lalrral
vcn-
scaw at tvee
and
five reeks post-hemorrhage showed cnlarsins ventricles with development of distinctive periwlfriculnr lucency. The patient was shunted. improved, discharged for pnsrible subsequent surgery.
The infrequent with
viswdization
subarachnoid
and war
of aneurysms in pnlients
hemorrhage
is to be c> pecred.
Most “berry” aocuryams that ruprure are small. less dun 5 mm in diameter. Normal adjacent vessels may
Figure 4. Csso 4. a: Right brachial anglogram with crow compre8Slon Shows an anterior communical~ ing anaurysm with mild spasm of the horizontal seg me”, of the lsit anterio: cerebral artery. The frequency of our visualization of blood on CT after suharachnoid hemorrhage is comparable 13 that reported hy prewous aurhorr ,I, 3.4, 5,. CT i\ I VW reliahlr method of dcmonrtratinr. SAH if rh:
cu1z.r rhrombwis mfa mlon.
and mfarnion.
bloody
or ~pavn producing
The pre;?nce of a lucent “ischemic”
re-
fluid.
municaring
Angiography
showed an anterix
artery aneurysm
was transferred
5). i?x
to the Neuroiwdcal
days later. On admission, nuchal rigidity
(Figure
Institute
he wasiethargic
dilation
distribution Cerebral
uf
seven
but had no
and a mild right !wniparesis.
scan performedonadmiasiondemrjnstratpd veniricular
compatient
and “ischemic”
the
;npiography
left
anterior
A CT
moderate lucency in the
cerebral
showed the awerior
artery.
cornmuni-
eating aneurysm measuring 9 x 6 mm associated with spasm of the supraclinoid
segment of the left internal
carotid artery and horizontal
segm~ntsofilleanterior
and middie cerebral arteries. There was no foal and the ventricles were moderately tient remained lethargic, aped nuchal rigidity
dilated.
mass
The pa-
but nine dass later he dewl-
without
new fwal
neurological
deficits. He wa5 thought to have bled again and repeat CT scan showed blood density in the septum cellucidum and venl?icles. The w&es periventricular
“fuzz.”
the patient remainedcritically confused. Ihc owrall
clinical aitwtion.
The prescuce of hydrocephal~ur sfter SAIH i%well hnow. but the frequency ill our results is higher than prwious reports (1%). ‘Thi- I% probshly due to tlmeincre;wd accuracy 01 CT when wr-qxmd with ~:tber techmqocs. The hydroceph;dus is ~ssally communicating and self-limitmg. Howcvcr. in three of our patients the hydrocephalix progressed and became the most significant aspect of 1111: di5eae. CT isextremely hr-;pful in these casts. particularly BIlICriOrCOlllm,llliCafin6
if the patient has as
anewysn!.
It may bedifficulr
cli.lic;lllglodiffcrenli;~iethe,~hysical my to hydroccf~halur lobe ixhcmia.
findings,;econd-
irom lhore secondary to fru~~tal
7 Ihc findins on CT’correlate well with the clinicai wndition of the patiem. Sixteen paliemn were Grade lil to V. Nine of rhere palientr Cl’
evidence of
Four additional
an ;nsociaied
had spwn
“ischemic”
patients had an infracerebral
and
wgios. hema-
tmnn nrcounliog for thv poor clinical picture. Two palienis hnd severe hydrocephalus. Only one patiem was in poor clinical condition wirhoul an obvious rcaSO” on CT.
Cnse 5: w:. II. This ~1%ycwold hypcrten,ivc diabetic male was admitted to an outside hospital with a sudden onw of hri~dacbe.
nausc~, and vomilmg.
On admission,
w:i i pha!,ic and had a right hemiparcsis.
he
LP showd
Another
had &la&d.
with
The hemipareeis cleared. but ill. beingstuporwsand
CT scan showed enlarging
\.entri-
?b.
J.
6.
7.
e. 9. 10. II. 12. 13.
CONTINUlNG MEDICAL ‘:DIJCAT!ON QUFS WNS WVALUATlON OF HJMRACIINOID HFZhlORRHAGE AND CW HIltAL VASOSPAA1M BY COMPIJYED TOMOCRAPHY)