How is non-aneurysmal perimesencephalic hemorrhage (non-aneurysmal perimesencephalic bleed) managed and do they require daily Transcranial Doppler (TCD) monitoring?

From the Guidelines

Non-aneurysmal perimesencephalic hemorrhage is typically managed conservatively without surgical intervention, and daily Transcranial Doppler (TCD) monitoring is not routinely required for these patients. The management includes a short observation period in the intensive care unit (usually 24-48 hours), bed rest, blood pressure control (maintaining systolic blood pressure below 140-160 mmHg), pain management, and symptomatic treatment. According to the American College of Radiology 1, TCD is a quick and noninvasive modality to evaluate for increased arterial velocities in the setting of vasospasm, but prolonged TCD screening past day 10 post-SAH does not appear to increase detection of delayed cerebral ischemia.

Key Management Points

• A short observation period in the intensive care unit (usually 24-48 hours)
• Bed rest
• Blood pressure control (maintaining systolic blood pressure below 140-160 mmHg)
• Pain management
• Symptomatic treatment
• Initial vascular imaging with CT angiography or digital subtraction angiography to confirm the absence of an aneurysm
• A repeat angiogram is typically performed after 7-14 days to definitively rule out an aneurysm if the initial angiogram is negative

Use of TCD

• A baseline TCD may be performed
• Follow-up studies only if clinically indicated
• Daily TCD monitoring is not necessary due to the low risk of vasospasm (less than 5%) in non-aneurysmal perimesencephalic hemorrhages, as stated in the study 1

Prognosis and Recovery

• The prognosis for non-aneurysmal perimesencephalic hemorrhage is excellent, with most patients making a complete recovery
• Very low risk of rebleeding (less than 1%)
• Patients can usually resume normal activities after discharge, with gradual return to full activity over 4-6 weeks

From the Research

Management of Non-Aneurysmal Perimesencephalic Hemorrhage

• Non-aneurysmal perimesencephalic hemorrhage (non-aneurysmal perimesencephalic bleed) is typically managed conservatively, with a focus on supportive care and monitoring for potential complications 2, 3.
• The use of Nimodipine, a calcium channel blocker, is not well established in the management of non-aneurysmal perimesencephalic hemorrhage, and its effectiveness in preventing complications is unclear 2.
• Patients with non-aneurysmal perimesencephalic hemorrhage are at risk of developing vasospasm, although the clinical significance of this complication is debated 3.

Role of Transcranial Doppler (TCD) Monitoring

• Transcranial Doppler (TCD) monitoring is used to detect vasospasm in patients with subarachnoid hemorrhage, including those with non-aneurysmal perimesencephalic hemorrhage 3.
• However, the necessity of daily TCD monitoring in patients with non-aneurysmal perimesencephalic hemorrhage is not well established, and the decision to use TCD monitoring should be individualized based on the patient's clinical course and risk factors for vasospasm 3, 4.
• One study suggested that vasospasm in non-aneurysmal perimesencephalic hemorrhage is not as rare as previously believed, but its clinical significance is limited, which may argue against the need for intensive TCD monitoring 3.

Predictive Factors and Outcomes

• The clinical outcome of patients with non-aneurysmal perimesencephalic hemorrhage is generally favorable, with a low risk of complications and good long-term prognosis 5, 6.
• The initial clinical status, as assessed by the Hunt and Hess score, is an important predictor of outcome in patients with non-aneurysmal perimesencephalic hemorrhage 5.
• Patients with perimesencephalic non-aneurysmal subarachnoid hemorrhage tend to have a more benign course than those with aneurysmal subarachnoid hemorrhage or non-perimesencephalic non-aneurysmal subarachnoid hemorrhage 5, 6.