Nontraumatic convexal subarachnoid hemorrhage: A case report

lNTRODUCTlON

Nontraumatic convexal subarachnoid hemorrhage (cSAH) is a subtype of atypical SAH. Its bleeding site is mainly confined to one or more cerebral hemisphere convexocortical sulci with high incidence in the central sulcus. It does not affect the brain parenchyma, basal cistern, or interhemispheric fissure. It is characterized by low hemorrhage, and only the local cerebral cortex is involved. In addition, it is not associated with typical symptoms such as severe headache and meningeal irritation. In the present study, a case of a cSAH patient with transient ischemic attack (TIA) and a summary of relevant literature are presented.

CASE PRESENTATlON

Chief complaints

A 64-year-old male was admitted to the hospital after experiencing paroxysmal left-sided numbness and weakness for 4 d.

History of present illness

These symptoms occurred 2-3 times a day and lasted approximately 20 min each time.

History of past illness

The complete evidence supported the final diagnosis of cSAH.

Personal and family history

The patient had no history of smoking or drinking, and no family history.

實際操作中應在軟件確認排列的順序：①需要保證排水管與電纜橋架的之間的距離。若管線與電纜平行，需要保證其最短距離為0.4m；若管線與電纜不平行，需要保證其最短距離為0.3m。②對于線槽和暖通及通風的管道設計，需要保證其弱電結構之間距離為0.3m[1]。③對于給水和消防管道的設計，需要保證線槽位置處于建筑物的高位，其他管道需要控制在建筑物的中位。

Physical examination

The systolic and diastolic blood pressure of the patient during admission was 130/80 mmHg. The patient presented with paroxysmal left hemiplegia without obvious inducement. The left limb could not move during the attack and was accompanied by numbness and discomfort on the left face, trunk,upper, and lower limbs; and the patient presented with dizziness. The National Institute of Health Stroke Scale score of the patient was 0.

⑦Hill H，Neue Organisationsformen in der Staats－und Kommunalverwaltung，Verwaltungsorganisationsrecht als Steuerungsressource，Baden － Baden，1997，S．69．

Laboratory examinations

Routine clinical biochemistry showed normal results.

Imaging examinations

Computed tomography (CT) examination was performed during admission and showed a high-density image of the right frontal-parietal sulcus. Magnetic resonance imaging examination showed a slight increase in the T1 flair and a high T2 flair. Diffusion-weighted imaging (DWI) revealed high signal intensity, whereas susceptibility weighted imaging (SWI) showed slightly increased signal intensity in the right frontal lobe. Machine records activity results indicated short local stenosis of the right anterior cerebral artery of the A3 segment, and magnetic resonance venography revealed a thin contrast in the left transverse sinus and left sigmoid sinus (Figure 1). Severe stenosis was observed in the right anterior cerebral artery A2-A3 junction (stenosis rate approximately 70%), and mild stenosis was observed in the distal end of A3 (stenosis rate approximately 30%) through digital subtraction angiography (DSA)(Figure 2).

MULTlDlSClPLlNARY EXPERT CONSULTATlON

There is no multidisciplinary expert consultation.

FlNAL DlAGNOSlS

The patient had a clinical history of ischemic stroke and no history of hypertension, diabetes, coronary heart disease, or major trauma.

TREATMENT

The patient was given blood pressure monitoring, cerebrovascular spasm prevention (nimodipine),cerebral protection, and other treatments.

Research Fund of the Department of Science and Technology of Shandong Province, China, No.2019WS328.

OUTCOME AND FOLLOW-UP

Ma WB conceived the study, participated in its design and draft the manuscript; Li B, Chen C and Fan XX collected data; Chen HL helped to draft the manuscript; all authors read and approved the final manuscript.

DlSCUSSlON

cSAH is a subtype of atypical SAH. Approximately 49% of patients with SAH present with TIA-like symptoms; therefore, the actual annual incidence is more than 5.1 cases in every 100000 people[1]. The etiology of cSAH is highly correlated with age, hypertension, coronary heart disease, and diabetes.Common causes of cSAH include cerebral amyloidosis (CAA), reversible cerebral vasoconstriction syndrome (RCVS), cortical vein thrombosis (CoVT), intracranial large artery atherosclerosis stenosis or occlusion, moyamoya disease, and vasculitis. Notably, CAA is the main cause, accounting for approximately 39% of all cSAH cases[1]. Transient sensorimotor dysfunction (TFNE) is the main symptom in cSAH patients above 60 years of age, and CAA is the common cause of disease, followed by intracranial atherosclerosis stenosis or occlusion[2,3]. In contrast, headache is the main clinical manifestation in patients under 60 years of age, whereas rCVS and CoVT are the main causes of cSAH in these patients[3]. Nakajima[4-5] reported that more than half of patients with cSAH presented with cerebral vascular occlusion and TFNE and were often misdiagnosed with transient cerebral ischemia. Notably,CAA is a progressive age-related cerebrovascular disease. The severity of the disease increases with age due to deposition of amyloid beta protein in the cortex and leptomeningeal vessels, which is the main cause of cSAH. A previous study reported that TFNE is the main characteristic clinical manifestation of CAA-induced cSAH, followed by cortical superficial siderosis (CSS) and rebleeding[6]. The incidence of hypercholesterolemia is lower in patients with CAA-induced cSAH than in patients with TIA.Cholesterol is negatively correlated with the incidence of nontraumatic intracerebral hemorrhage and aneurysmal hemorrhage[5]. Symptoms of cSAH are paroxysmal and include TIA attacks, seizures, and TFNE. This indicates that TIA attacks can occur as a result of ischemic infarction or may occur as a clinical manifestation of hemorrhagic stroke.

A previous study reported that hyperacute arterial ischemic stroke occurs in patients within 4.5 h and 6 days after a concurrent rate of cSAH 0.5%[4]. Acute changes in hemodynamics and damage to the blood brain barrier may be important mechanisms for the occurrence of cSAH. The incidence of SAH is associated with cerebrovascular disease risk factors such as hypertension, coronary heart disease, and diabetes, and this relationship can be explained by collateral circulation. ICA stenosis or occlusion and MCA stenosis or occlusion can promote the formation of Willis circle and the opening of PIA meningostomy vessels, respectively[7-8].

The authors declare no conflict of interest.

一級平臺可作為親水平臺，高程取值應略高于平均高潮位、略低于高高潮位為宜，以滿足親水的需求，同時避免經常受淹。該區域多年平均高潮位為5.0m（廣州城建高程，下同），200年一遇潮位為7.93m，故一級親水平臺高程取6.5m～6.8m，允許一年內親水平臺短時間過水，同時又滿足親水、休閑、觀景要求。

A 50mm定焦鏡頭可以說是一支玩攝影的人不能錯過的經典焦段鏡頭。50mm鏡頭又稱標準鏡頭，指視角大約為50度左右的定焦鏡頭，拍攝照片所表現的景物透視與目視較為接近而得名。50mm鏡頭給人以紀實性的視覺效果畫面，所以在實際使用頻率上非常高。接下來有幾個原因告訴你為什么這是一支值得擁有的鏡頭。

cSAH is treated using different treatment strategies depending on the cause of the disease.Antiplatelet therapy is used for intracranial artery stenosis or occlusion caused by arteriosclerosis,nimodipine is administered for reversible cerebral vasoconstriction syndrome, and steroid hormone is given for the treatment of vasculitis. Symptomatic therapy for cSAH includes reduction of intracranial pressure, anti-epilepsy drugs, and administration of drugs for lowering blood pressure. The prognosis of cSAH depends on the cause, and most patients present with good prognosis. However, CAA-induced intracranial hemorrhage is recurrent and associated with poor prognosis[12].

CONCLUSlON

Symptoms of cSAH are complex and not easily detected during clinical investigations. The cause of the disease should be explored to minimize missed diagnosis and misdiagnosis.

陸軍越是現代化、越是信息化，越要法治化。建設強大現代化新型陸軍，離不開健全的法律、嚴明的紀律、正規的秩序，必須充分發揮法治的引導、推動、規范、保障作用，為建強陸軍夯實法治根基。

FOOTNOTES

The range of brain CT-showed bleeding was significantly reduced compared to the previous range after 9 d. The patient had no recurrence of paroxysmal left-sided numbness and weakness.

現階段，一些能源企業在環保工程施工過程中，其工藝流程的規范性嚴重缺失，很難取得良好的環保效果。對于科學、合理的工藝流程來說，可以節省諸多成本，并確保回收利用效率的穩步提升[3]。比如，在環保工程建設中，出現了大量的重金屬污染土壤，進而急需處理，然而在固廢處理中心中，處理費用約為2500元/t，但是如果企業將產生的重金屬污染土壤摻入進固化劑，形成路基填充材料，其處理成本僅需要原方案的1/5。所以在這種工藝流程安排的影響下，可以將處理廢料成本保持在合理范圍內，并提高廢棄材料的回收利用效率，進而對環保工程理念進行有效落實。

The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).

CT scan is important for the diagnosis of cSAH. However, the sensitivity of CT decreases after a period of time. Notably, flair is highly sensitive to hemorrhage in the cerebral convexity cortex sulcus and is more effective in the diagnosis of acute and subacute SAH than plain CT scans. DWI and SWI are characterized by high sensitivity and accuracy in the diagnosis of SAH. Cerebrospinal fluid examination cannot confirm the diagnosis of cSAH; however, it helps in determining the etiology of the disease[9].Notably, DSA is performed to further confirm the diagnosis when the cause of disease cannot be determined through noninvasive examination. Studies report that cSAH may be a marker of vascular fragility and a major risk factor for future lobar hemorrhage[10]. Cortical or watershed subarachnoid hemorrhage may be the result of excessive cerebral perfusion. High-grade stenosis is always a sign of hemodynamic compromise, and collateral circulation might be a predictor of excessive cerebral perfusion[11]. The clinical and imaging findings of the patient in the present study indicate a positive diagnosis of cSAH and rule out the possibility of CAA. The cause of the disease was initially considered to be atherosclerotic stenosis of the large cerebral artery; however, later severe stenosis of the anterior cerebral artery was considered the cause of the present case. It is speculated that the pathogenesis may be severe stenosis of the anterior cerebral artery, which can cause compensatory dilation and vulnerability of cortical lateral branch vessels in the corresponding region, when hemodynamic changes occur,such as a sudden increase in intracranial perfusion pressure, resulting in the rupture of the leptic lateral branch circulation vessels that have already undergone expansion or increased permeability, resulting in bleeding, or the arrival of embolus to the fragile collateral vessels causing blood vessel rupture and causing a small amount of bleeding, which as indicated by DSA examination. Intracranial artery stenosis/occlusion caused by cSAH is common in MCA. In summary, the findings of the present study indicate that ACA stenosis may lead to the occurrence of cSAH.

Written informed consent was obtained from the patient for publication of this case report.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

Hong-Liang Chen 0000-0001-9434-9796; Bin Li 0000-0002-8721-4356; Chao Chen 0000-0003-0417-3809;Xiao-Xuan Fan 0000-0003-4912-6774; Wen-Bin Ma 0000-0001-5030-0093.

錢多多在歐陽鋒肩上重重地拍了一巴掌，笑道：嗬，嗬嗬，你小子一不留神就交上了桃花運，艷福不淺哪！不就5萬塊錢嗎？值！

Xing YX

A

隨著互聯網技術的發展，利用互聯網宣傳是提高潛山市的知名度極其有效的渠道。政府可以通過建立智慧型公共服務平臺、微信微博公眾號以及新聞客戶端進行網絡宣傳，開通線上旅游產品的預定銷售服務，也可以通過電商平臺、節慶推廣、主題活動等方式開展旅游扶貧公益宣傳，并加強與省內外及周邊景區合作聯動，積極融入省內外精品旅游線路，在重要客源地設置旅游營銷機構或代理門店，實現與省內外知名景區和旅游目的地聯合推介、捆綁營銷。

Xing YX