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Open Access Research article

Focal subarachnoid haemorrhage mimicking transient ischaemic attack - do we really need MRI in the acute stage?

Lorenz Ertl12*, Dominik Morhard1, Maria Deckert-Schmitz3, Jennifer Linn2 and Gernot Schulte-Altedorneburg1

Author Affiliations

1 Department of Radiology, Nuclear Medicine & Neuroradiology, Klinikum München-Harlaching, Sanatoriumsplatz 2, Munich D-81545, Germany

2 Department of Neuroradiology, University of Munich, Marchioninistr 15, Munich D-81377, Germany

3 Department of Neurology, Klinikum München-Harlaching, Sanatoriumsplatz 2, Munich D-81545, Germany

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BMC Neurology 2014, 14:80  doi:10.1186/1471-2377-14-80

Published: 10 April 2014

Abstract

Background

Acute non-traumatic focal subarachnoid haemorrhage (fSAH) is a rare transient ischaemic attack (TIA)-mimic. MRI is considered to be indispensable by some authors in order to avoid misdiagnosis, and subsequent improper therapy. We therefore evaluated the role of CT and MRI in the diagnosis of fSAH patients by comparing our cases to those from the literature.

Methods

From 01/2010 to 12/2012 we retrospectively identified seven patients with transient neurological episodes due to fSAH, who had received unenhanced thin-sliced multiplanar CT and subsequent MRI within 3 days on a 1.5 T scanner. MRI protocol included at least fast-field-echo (FFE), diffusion-weighted imaging (DWI), T2-weighted fluid-attenuated inversion recovery (FLAIR) and time-of-flight (TOF) MRA sequences. By using MRI as gold-standard, we re-evaluated images and data from recent publications regarding the sensitivity to detect fSAH in unenhanced CT.

Results

fSAH was detected by CT and by FFE and FLAIR on MRI in all of our own cases. However, DWI and T2w-spin-echo sequences revealed fSAH in 3 of 7 and 4 of 6 cases respectively. Vascular imaging was negative in all cases. FFE-MRI revealed additional multiple microbleeds and superficial siderosis in 4 of 7 patients and 5 of 7 patients respectively. Including data from recently published literature CT scans delivered positive results for fSAH in 95 of 100 cases (95%), whereas MRI was positive for fSAH in 69 of 69 cases (100%).

Conclusions

Thin-sliced unenhanced CT is a valuable emergency diagnostic tool to rule out intracranial haemorrhage including fSAH in patients with acute transient neurological episodes if immediate MRI is not available. However, MRI work-up is crucial and mandatorily has to be completed within the next 24–72 hours.

Keywords:
Transient ischaemic attack; Subarachnoid haemorrhage; Computed tomography; Magnetic resonance imaging; Emergency care