• Bertie Geng, Xiao Wu, Alexandria Brackett, and Ajay Malhotra.
• Department of Radiology and Biomedical Imaging, Yale School of Medicine, Box 208042, Tompkins East 2, 333 Cedar St, New Haven, CT, 06520-8042, United States. Electronic address: bertie.geng@yale.edu.
• Clin Neurol Neurosurg. 2019 May 1; 180: 111-116.

ObjectivesIsolated perimesencephalic subarachnoid hemorrhage is an uncommon, distinct subtype of subarachnoid hemorrhage with a more benign prognosis. A negative computed tomographic angiogram has been shown to be reliable in excluding aneurysmal rupture as the underlying etiology. However, some studies continue advocating for more imaging to determine a vascular cause in perimesencephalic subarachnoid hemorrhage. The objective of this study is to evaluate the evidence for use and utility of repeat angiographic imaging after a negative computed tomographic angiogram in patients with perimesencephalic subarachnoid hemorrhage.Patients And MethodsRetrospective institutional analysis of patients with perimesencephalic subarachnoid hemorrhage was performed from 2014 to 2017 for number and types of follow-up angiographic imaging studies performed. Updated meta-analysis of literature was performed from 2014 onwards to assess the utility of follow-up imaging after a negative initial angiographic study.ResultsThe institutional review revealed no utility of additional imaging after a negative computed tomographic angiogram in 6 patients with isolated perimesencephalic subarachnoid hemorrhage. Literature review and metaanalysis of 13 studies with 588 patients revealed a vascular etiology in 3 patients with isolated perimesencephalic subarachnoid hemorrhage from a single study- 2 aneurysms and 1 patient with vasculitis.ConclusionsUse of repeat angiographic imaging after a negative computed tomographic angiogram for perimesencephalic subarachnoid hemorrhage patients remains not uncommon, despite previous meta-analysis. Review of the more recent literature is consistent with previously published meta-analysis and shows limited benefits despite frequent use. In patients with a strictly defined perimesencephalic subarachnoid hemorrhage pattern and clinical picture consistent with perimesencephalic subarachnoid hemorrhage, an initial negative computed tomographic angiogram should be adequate and repeated follow-up studies can be avoided.Copyright © 2019 Elsevier B.V. All rights reserved.

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