Subpial haemorrhage: clinical presentation, neuroradiological findings and therapeutic consequences

Cerebral haemorrhage is a frequent neurological condition, usually classified into epidural and subdural hematoma, subarachnoid haemorrhage and parenchymal hemorrhage. Here, we present data of 10 patients, from 53 to 80 years of age, with the rare diagnosis of subpial haemorrhage. Concerning the clinical picture, 5 patients had symptoms that were interpreted as recurrent focal seizures. The second most frequent symptom (4 patients) was headache, 3 patients presented with hemiparesis. The diagnosis was made by radiological criteria with magnetic resonance imaging (MRI) of the brain, showing blood deposits in the superficial layers of the cortex. 7 patients underwent lumbar puncture. None of the cerebrospinal fluid (CSF) samples showed fresh blood or xanthochromia. This finding is imperative for the diagnosis of a subpial haemorrhage as erythrocytes do not cross the pia mater.

Thrombosis of cortical veins is considered a possible reason for subpial haemorrhage. Therefore, digital subtraction angiography (DSA) or MR angiography (MRA) were performed in all patients, but no clear thrombosis or aneurysm were detected in any of our patients. Consequently, other reasons for a subpial bleeding than cortical vein thrombosis have to be considered.

All patients recovered completely from their symptoms, indicating an excellent prognosis. As a summery, the origin of subpial haemorrhage remains unclear and its treatment should be symptomatic with particular attention to anticonvulsant medication. Anticoagulation therapy might be restriced to patients with a confirmed diagnosis of cortical vein thrombosis by neuroimaging.