Cerebral Angiography for Evaluation of Patients with CT Angiogram-Negative Subarachnoid Hemorrhage: An 11-Year Experience.

J.J Heit,J.A Hirsch,T.M Leslie-Mazwi,A.J Yoo,G.T Pastena,R.G Nogueira,J.D Rabinov

doi:10.3174/ajnr.a4503

Abstract

CT angiography is increasingly used to evaluate patients with nontraumatic subarachnoid hemorrhage given its high sensitivity for aneurysms. We investigated the yield of digital subtraction angiography among patients with SAH or intraventricular hemorrhage and a negative CTA. An 11-year, single-center retrospective review of all consecutive patients with CTA-negative SAH was performed. Noncontrast head CT, CTA, DSA, and MR imaging studies were reviewed by 2 experienced interventional neuroradiologists and 1 neuroradiologist. Two hundred thirty patients (mean age, 54 years; 51% male) with CTA-negative SAH were identified. The pattern of SAH was diffuse (40%), perimesencephalic (31%), sulcal (31%), isolated IVH (6%), or identified by xanthochromia (7%). Initial DSA yield was 13%, including vasculitis/vasculopathy (7%), aneurysm (5%), arteriovenous malformation (0.5%), and dural arteriovenous fistula (0.5%). An additional 6 aneurysms/pseudoaneurysms (4%) were identified by follow-up DSA, and a single cavernous malformation (0.4%) was identified by MRI. No cause of hemorrhage was identified in any patient presenting with isolated intraventricular hemorrhage or xanthochromia. Diffuse SAH was due to aneurysm rupture (17%); perimesencephalic SAH was due to aneurysm rupture (3%) or vasculitis/vasculopathy (1.5%); and sulcal SAH was due to vasculitis/vasculopathy (32%), arteriovenous malformation (3%), or dural arteriovenous fistula (3%). DSA identifies vascular pathology in 13% of patients with CTA-negative SAH. Aneurysms or pseudoaneurysms are identified in an additional 4% of patients by repeat DSA following an initially negative DSA. All patients with CT-negative SAH should be considered for DSA. The pattern of SAH may suggest the cause of hemorrhage, and aneurysms should specifically be sought with diffuse or perimesencephalic SAH.

Highlights

BACKGROUND AND PURPOSECT angiography is increasingly used to evaluate patients with nontraumatic subarachnoid hemorrhage given its high sensitivity for aneurysms
The pattern of SAH may suggest the cause of hemorrhage, and aneurysms should be sought with diffuse or perimesencephalic SAH
Nontraumatic subarachnoid hemorrhage occurs in 30,000 patients per year in the United States, which accounts for 5% of strokes

Summary

Methods

An 11-year, single-center retrospective review of all consecutive patients with CTA-negative SAH was performed. Noncontrast head CT, CTA, DSA, and MR imaging studies were reviewed by 2 experienced interventional neuroradiologists and 1 neuroradiologist. Patient Selection We retrospectively reviewed the radiology data base and medical records of all patients who presented to our hospital (Massachusetts General Hospital) during an 11-year period (January 1, 2002, through December 31, 2012) with the following: 1) nontraumatic subarachnoid hemorrhage or isolated intraventricular hemorrhage identified by noncontrast head CT or xanthochromia on lumbar puncture, 2) initial evaluation with a CTA that failed to identify a cause of SAH, and 3) at least 1 cerebral DSA. If an initial cerebral DSA was negative for SAH, patients underwent additional studies. Additional selective injection of the internal, external, or contralateral vertebral artery was performed at the discretion of the neurointerventionalist. Standard views typically included frontal, lateral, and oblique views of each selected vessel

Results

Discussion

Conclusion