Angiography In High-risk Patients Research Articles

European practice patterns for antiplatelet management in NSTE-ACS patients: Results from the REal-world ADoption survey focus on Acute antiPlatelet Treatment (READAPT) survey

BackgroundThe 2020 European Society of Cardiology (ESC) guidelines for the diagnosis and management of patients with non-ST elevation-acute coronary syndrome (NSTE-ACS) recommend early invasive coronary angiography in high-risk patients and no routine pre-treatment with oral P2Y12 receptor inhibitor in NSTE-ACS patients prior to defining coronary anatomy. ObjectiveTo assess the implementation of this recommendation in the real-life setting. MethodsA web-survey in 17 European countries collected physician profiles and their perceptions of the diagnosis, medical and invasive management of NSTE-ACS patients at their hospital. A sample size of at least 1100 responders permitted the estimation of proportions with a precision of at least ±3.0%. ResultsAmong the 3024 targeted participants, 1154 provided valid feedback defined as a 50% response rate of answers to the survey questions. Overall, >60% of the participants declared full implementation of the guidelines at their institution. The time delay from admission to coronary angiography and PCI was reported to be <24 h in over 75% of the hospitals while pre-treatment was intended in >50% of NSTE-ACS patients. Ad-hoc percutaneous coronary intervention (PCI) was performed in >70% of the cases while intravenous platelet inhibition was rarely used (<10%). Between countries differences in practice patterns for antiplatelet management for NSTE-ACS were observed, suggesting heterogeneous implementation of the guidelines. ConclusionsThis survey indicates that the implementation of 2020 NSTE-ACS guidelines on early invasive management and pre-treatment is heterogeneous, potentially due by local logistical constraints.

Increased serum IL-6 is predictive of long-term cardiovascular events in high-risk patients submitted to coronary angiography: an observational study

BackgroundInterleukin-6 (IL-6) is an inflammation-related cytokine associated with an elevated risk of cardiovascular events. In a previous study, we demonstrated that increased IL-6 was predictive of sub-clinical atherosclerotic coronary disease in intermediate-risk patients undergoing coronary angiography. In the present study, we investigated whether increased serum IL-6 is predictive of cardiovascular events in high-risk patients.MethodsIn this observational study, consecutive patients referred for elective coronary angiography due to stable chest pain/myocardial ischemia had IL-6 measured immediately before the procedure. Long-term follow-up was performed by phone call or e-mail, and their clinical registries were revised. The primary outcome was a composite of new myocardial infarction, new ischemic stroke, hospitalization due to heart failure, new coronary revascularization, cardiovascular death, and death due to all causes.ResultsFrom 141 patients submitted to coronary angiography and IL-6 analysis, 100 had complete follow-up data for a mean of 5.7 years. The median age was 61.1 years, 44% were men, and 61% had type-2 diabetes. The median overall time-to-event for the primary outcome was 297 weeks (95% confidence interval [CI] 266.95–327.16). A receiver operator characteristic curve defined the best cut-off value of baseline serum IL-6 (0.44 pg/mL) with sensitivity (84.37%) and specificity (38.24%) to define two groups. High (> 0.44 pg/mL) IL-6 levels were predictive of cardiovascular events. (p for interaction = 0.015) (hazard ratio = 2.81; 95% CI 1.38–5.72, p = 0.01). Subgroup analysis did not find interactions between patients with or without diabetes, obesity, or hypertension.ConclusionIn conclusion, an interleukin-6 level higher than 0.44 pg/mL, obtained just before elective coronary angiography, was associated with a poorer prognosis after a mean of 5,7-year. A pre-procedure IL-6 below 0.44 pg/mL, on the other hand, has a very good negative predictive value, suggesting a good prognosis, and may be useful to better indicate coronary angiography in high-risk patients..

Computed Tomography-Derived Fractional Flow Reserve in Patients With Chronic Coronary Syndrome: A Real-World Cohort Study.

This study aimed to investigate the outcome of computed tomography (CT) angiography with optional CT-derived fractional flow reserve (FFRCT) of intermediate-range coronary artery disease in non-emergent patients referred on a suspicion of chronic coronary syndrome. Patients were classified as high risk and low-intermediate risk according to the presence of typical angina or either atypical or nonangina chest pain. Outcome was assessed as the cumulative incidence proportion of a composite end point of unstable angina pectoris, unplanned revascularization, nonfatal myocardial infarction, and all-cause mortality. The study included 743 patients. Mean follow-up was 2.2 (range, 0.1-2.5) years. Low-intermediate-risk and high-risk patients who had invasive coronary angiography deferred had comparable proportions of adverse events (1.4% vs 2.6% [P = 0.27]). Adverse events in high-risk patients with FFRCT >0.80 was 3.3% versus 1.4% in patients where no additional testing was performed (P = 0.79). Computed tomography-derived fractional flow reserve >0.8 conveys an excellent prognosis. Computed tomography angiography with optional FFRCT allows for the safe cancellation of invasive coronary angiography in high-risk patients.

S0983 Coronary Artery Calcium Score and All-Cause Mortality in Liver Transplant Recipients: A Retrospective Analysis

INTRODUCTION: Cardiovascular disease is a major cause of death after liver transplantation. Pre-transplant cardiac risk stratification generally involves pharmacologic stress testing, as well as coronary artery angiography in high-risk patients. Coronary artery calcium (CAC) score is a non-invasive estimation of total calcified plaque in coronary arteries. CAC score has been shown to be associated with 1-month post-transplant mortality; however, it has not been studied as a predictor of long-term outcomes in liver transplant recipients. METHODS: We retrospectively studied patients who underwent liver transplantation at Johns Hopkins Hospital between 1/1/2015 and 12/31/2018 who had a pre-transplant CAC score measured. Patients were divided into 3 groups: CAC score 0 (group 1), CAC score 1–400 (group 2) and CAC score >400 (group 3). All-cause mortality in the 3 groups was compared using Kaplan-Meier curves and the log-rank test, with statistical significance defined as P < 0.05. RESULTS: A total of 412 adult patients underwent liver transplantation, of which 155 patients had a CAC score measured as part of pre-transplant cardiovascular evaluation. CAC group 1, 2, and 3 and 37, 82, and 36 patients, respectively. The median age was 60, median body mass index (BMI) was 28.6, and median model for end-stage liver disease (MELD) score was 19, with no significant difference between groups (Table 1). The cohort was 38.1% female, with significantly lower proportion of females in higher CAC score groups (P = 004). At 1 year, death occurred in 3 (8.1%), 7 (8.5%) and 2 (5.6%) patients in groups 1, 2, and 3, respectively (Table 2). At 2 years, there were 5 (15.2%), 12 (16.9%), and 6 (20.7%) deaths in the three groups, respectively. At 3 years, there were 6 (23.1%), 13 (24.5%), and 8 (32.0%) deaths in the 3 groups, respectively. There was no significant difference in all-cause mortality between CAC score groups (Figure 1). CONCLUSION: CAC score may be useful in cardiac risk stratification prior to liver transplantation. In this study, there was no significant difference in 1-, 2-, or 3-year all-cause mortality between CAC score groups. However, there was a non-significant trend towards increased all-cause mortality with higher calcium scores at 2 and 3 years of follow up. Further research is needed with a larger sample size and examination of cardiac risk factors to better evaluate the prognostic utility of CAC score in this population.Table 1.: Baseline characteristics by coronary artery calcium score groups. Continuous variables in this table were assumed to be skewed in the population, thus nonparametric k-test for equality of medians was used to compare medians between groups. Fisher’s exact test was used to compare categorical variables. a. body mass index (BMI) b. model for end-stage liver disease (MELD) c. coronary artery calcium (CAC)Table 2.: All-cause mortality at 1, 2, and 3 years after liver transplant, stratified by coronary artery calcium score groups. a. coronary artery calcium (CAC)Figure 1.: Three-year Kaplan-Meier survival curves stratified by coronary artery calcium score groups. No significant difference between groups (P = 0.71). Abbreviations: coronary artery calcium (CAC).

The role of computed tomography angiography as initial imaging tool for acute hemorrhage in the head and neck.

Acute hemorrhage in the head and neck (AHNH) is life-threatening due to asphyxiation and hemorrhagic shock. When conservative measures fail, some patients benefit from endovascular therapy (EVT). While CTA is routinely used to localize bleeding and plan EVT in gastrointestinal hemorrhage, the diagnostic value of CTA in AHNH and role of CTA in treatment-planning are uncertain. We retrospectively reviewed neck CTAs from June 2015 to October 2018 indicated for AHNH. When performed, digital subtraction angiography (DSA) findings and EVT were documented. Extravasation or pseudoaneurysm on DSA was considered positive for bleed localization. Thirty CTA exams were performed for AHNH in 18 patients (mean age = 56.6, male% = 55.6%). Eleven out of 30 exams (36.7%) had immediate DSA follow-up within 24h. Etiologies of hemorrhage included malignancy 11/18 (61.1%) and coagulopathy (4/18, 22.2%) among others. CTA reports identified definite or possible source of bleeding in 7/30 (23.3%) exams. Seven out of 7 (100%) patients with definite or possible source of bleeding on CTA underwent DSA and 4/23 (17.4%) patients underwent DSA despite negative CTA. With DSA as the gold standard, CTA had a sensitivity of 70% and a specificity of 100%. CTA has high specificity and reasonable sensitivity for detecting arterial source of bleeding in patients presenting with AHNH. Patients with negative CTA may avoid catheter angiography in most cases; however, false-negative CTA should not preclude angiography in high-risk patients.

Serum levels of neutrophil Gelatinase associated Lipocalin (NGAL) predicts hemodialysis after coronary angiography in high risk patients with acute coronary syndrome

BackgroundContrast-induced nephropathy (CIN) following a percutaneous coronary intervention (PCI) is the third most common cause of acute kidney injury (AKI) worldwide. Patients who require hemodialysis secondary to CIN have an elevated mortality rate as high as 55%. The current definition of CIN is based on an elevation of creatinine and decrease in urinary output. Creatinine typically increases 48 h after the contrast exposure, which delays the diagnosis and treatment of CIN. The neutrophil gelatinase associated lipocalin (NGAL) has emerged as a sensitive and specific biomarker of renal injury. Limited data exists about the effectiveness of NGAL to predict CIN in high-risk patients with acute coronary syndrome (ACS) that underwent PCI. The primary aim of this study was to determine the association of serum NGAL levels and the need for hemodialysis after PCI.MethodsThis is a prospective, observational study. NGAL levels were measured using ELISA. Blood samples were obtained within the first 6 h of hospital admission, and 12 and 24 h after contrast exposure from angiography. The primary outcome was the requirement of hemodialysis. The non-parametric Mann-Whitney U test was used to test for differences in median serum levels of NGAL. A receiver operating characteristic (ROC) curve was developed to assess the accuracy of NGAL to predict the need for hemodialysis after PCI.ResultsA total of 2875 were screened; however, 45 patients with ACS that underwent PCI were included. All patients were at high risk of developing CIN defined by Mehran score > 11 points. The median (IQR) serum concentration of NGAL was significantly higher in patients that required versus did not require hemodialysis (340 [83–384] vs. 169 [100–210], p = 0.01). Elevated serum levels of NGAL with a cut-off at 6 h post PCI of 281 mg/dL predicted the need for hemodialysis with an area under the curve of 0.86 (95% CI, 0.66–1.00).ConclusionsIn patients with ACS undergoing PCI; and high risk of developing CIN, an elevated serum level of NGAL 6 h after contrast exposure predicts the development of acute kidney injury requiring hemodialysis.

Avoidance of Coronary Angiography in High-Risk Patients With Acute Coronary Syndromes: The ACSIS Registry Findings

Background/purposePatients with acute coronary syndrome (ACS) are at high-risk for recurrent coronary syndromes, heart failure and death. Early coronary intervention combined with medications reduces these risks. The ACS Israeli Survey (ACSIS) is conducted over a 2-month period, every 2–3 years. ACSIS includes all patients discharged with a diagnosis of ACS from the 24 coronary care units and cardiology departments in Israel. We compared clinical profiles and 1-year survival between ACS patients who did and did not undergo coronary angiography. Methods/materialsWe reviewed ACSIS for the period 2002–2013. ResultsThe prognosis of patients who did not undergo coronary angiography during hospitalization (N = 2078) was significantly worse than for patients who underwent angiography (N = 9550). Avoidance of angiography was less common in ST-elevation myocardial infarction (STEMI) patients than in non-STEMI/unstable angina (NSTEMI/UAP) patients (13% vs. 22%, p < 0.001). Among NSTEMI/UAP patients, those who did not undergo angiography were older (mean: 71 vs. 64 years, p < 0.001), had higher incidences of diabetes (47% vs. 38%, p < 0.001), and renal (55% vs. 27%, p < 0.001) and heart failure (35% vs. 13%, p < 0.01) on admission, compared to those who underwent angiography. Even patients that underwent only diagnostic angiography had had a better prognosis than patients who did not undergo angiography. After propensity score matching for the major differences mentioned above, survival was still significantly better for patients who underwent angiography. ConclusionACS patients who did not undergo coronary angiography had higher-risk clinical profiles and worse 1-year survival than ACS patients who underwent angiography. After propensity score matching, the absence of angiography was independently associated with higher mortality. SummaryData over 10 years were reviewed from a national registry of acute coronary syndrome. Patients who did not undergo coronary angiography during hospitalization were older and with more comorbidities than patients who underwent angiography. After propensity score matching, the absence of angiography remained independently associated with 1-year mortality.

Preventive Effect of Atorvastatin (80 mg) on Contrast-Induced Nephropathy After Angiography in High-Risk Patients: Double-Blind Randomized Clinical Trial.

BackgroundContrast-induced nephropathy (CIN) is one of the most important complications of angiography in patients with chronic kidney disease (CKD) or diabetes mellitus. The prevention of CIN can decrease therapeutic costs and hospital stays. There is controversy in the literature over the preventive effect of statins on CIN.ObjectivesThis study was designed to evaluate the preventive effect of atorvastatin on CIN after angiography in CKD and diabetic patients.Patients and MethodsIn this placebo-controlled, double-blind clinical trial, patients with diabetes mellitus or CKD (15 < GFR < 60 mL/min, Cr > 1.5 mg/dL) and an age range of 55 - 75 years candidated for angiography were included. The patients were randomized to 2 groups: one group receiving atorvastatin (80 mg/d from 48 h before angiography) and the other one receiving a placebo. All the patients received intravenous isotonic saline and N-acetylcysteine. CIN was defined as an increase in serum creatinine more than 0.5 mg/dL or more than 25% from the baseline values.ResultsTotally, 220 patients at a mean age of 63.85 ± 8.89 years and a mean body mass index of 31.41 ± 5.99 kg/m2 were evaluated. In comparison of before-after values, there was a significant increase in serum creatinine in the placebo group (P = 0.000). The incidence of CIN was significantly higher in the control group 24 hours after angiography (P = 0.010); however, at a 48-hour interval, there was no significant difference in CIN between the 2 groups.ConclusionsStandard hydration and N-acetylcysteine and atorvastatin (80 mg) reduced the incidence of CIN, and this regimen was more effective than was the regimen of hydration and N-acetylcysteine (without atorvastatin) in decreasing CIN. Accordingly, it is reasonable to prescribe atorvastatin before angiography in high-risk patients.

Diagnostic accuracy of high-definition CT coronary angiography in high-risk patients

To assess the diagnostic accuracy of computed tomography coronary angiography (CTCA) using a combination of high-definition CT (HD-CTCA) and high level of reader experience, with invasive coronary angiography (ICA) as the reference standard, in high-risk patients for the investigation of coronary artery disease (CAD). Three hundred high-risk patients underwent HD-CTCA and ICA. Independent experts evaluated the images for the presence of significant CAD, defined primarily as the presence of moderate (≥ 50%) stenosis and secondarily as the presence of severe (≥ 70%) stenosis in at least one coronary segment, in a blinded fashion. HD-CTCA was compared to ICA as the reference standard. No patients were excluded. Two hundred and six patients (69%) had moderate and 178 (59%) had severe stenosis in at least one vessel at ICA. The sensitivity, specificity, positive predictive value, and negative predictive value were 97.1%, 97.9%, 99% and 93.9% for moderate stenosis, and 98.9%, 93.4%, 95.7% and 98.3%, for severe stenosis, on a per-patient basis. The combination of HD-CTCA and experienced readers applied to a high-risk population, results in high diagnostic accuracy comparable to ICA. Modern generation CT systems in experienced hands might be considered for an expanded role.

238 Is waiting for a coronary angiogram on the weekend safe for NSTEMI patients? Insights from the Canadian Global Registry of acute coronary events

238 Is waiting for a coronary angiogram on the weekend safe for NSTEMI patients? Insights from the Canadian Global Registry of acute coronary events

Prevalence of Cardiovascular Disease in Kidney Transplant Candidates: Outpatient Cardiac Evaluation

Background Cardiovascular disease is the most common cause of death after kidney transplantation. Pretransplant cardiovascular screening is an integral part of the assessment of patients with end-stage renal disease in most transplantation centers. Through this descriptive study we sought to highlight the major cardiovascular diseases that cause the high mortality rate before and after renal transplantation. Methods Between November 2005 and December 2009 we screened 356 patients for cardiovascular disease before inclusion in the renal transplant waiting list. All candidates underwent an analytical study, chest radiography, electrocardiogram, and echocardiography, as well as coronary angiography in high-risk patients. Results Clinical evaluations were performed in 356 patients (63% men) of mean age 54.3 ± 11 years. They had been on renal replacement treatment for a median 13.2 months. Risk factors included hypertension (95.8%), dyslipidemia (56.5%), smoking (53.4%), and diabetes (27.2%). Cardiovascular disease included peripheral artery disease (15%), coronary artery disease (CAD; 12.1%), and stroke (9.8%). Significant CAD was found in 89 individuals (38.4%), 73 (82%) of whom were asymptomatic. Peripheral artery disease ( P = .02), high levels of total cholesterol ( P = .03), triglycerides ( P = .03), and C-reactive protein ( P = .03) were associated with the presence of severe CAD. The main diagnoses were hypertensive heart disease (70.8%), ischemic heart disease (33.1%), aortic valve disease (24.4%), and mitral valve disease (30.1%). Conclusions Patients with chronic kidney disease show a high prevalence of cardiovascular risk factors and ischemic heart disease, principally occult coronary artery stenosis, which could explain their high cardiovascular mortality after renal transplantation.

Arterial imaging in patients with lower extremity ischemia and diabetes mellitus

Precise, comprehensive imaging of the arterial circulation is the cornerstone of successful revascularization of the ischemic extremity in patients with diabetes mellitus. Arterial imaging is challenging in these patients because the disease is often multisegmental with a predilection for the distal tibial and peroneal arteries. Occlusive lesions and the arterial wall itself are often calcified and patients presenting with ischemic complications frequently have underlying renal insufficiency. Intra-arterial digital subtraction angiography (DSA), contrast enhanced magnetic resonance angiography (MRA), and more recently, computerized tomographic angiography (CTA) have been used as imaging modalities in lower extremity ischemia. Each has specific advantages and shortcomings in this patient population, which will be summarized and contrasted in this review. DSA is an invasive technique most often performed from a femoral arterial puncture and requires the injection of arterial contrast, which can occasionally cause allergic reactions. In patients with pre-existing renal insufficiency, contrast infusion can result in worsening renal failure; although usually self-limited, it may occasionally require hemodialysis, especially in patients with diabetes. However, DSA provides the highest degree of spatial resolution and image quality. It is also the only modality in which the diagnosis and treatment of arterial disease can be performed simultaneously. MRA is noninvasive, and when enhanced with gadolinium contrast injection provides arterial images of comparable quality to DSA and in some circumstances may uncover distal arterial targets not visualized on DSA. However, spatial resolution is inferior to DSA and erroneous interpretations due to acquisition artifacts are common. Specialized equipment and imaging techniques are necessary to minimize their occurrence in the distal lower extremity. In addition, due to the risk of inducing nephrogenic systemic fibrosis, gadolinium-enhanced MRA cannot be used in patients with renal insufficiency. CTA is noninvasive and rapidly performed, with better spatial resolution than MRA, but requires the largest volume of contrast infusion, exposes patients to high-doses of radiation, and is subject to interpretive error due to reconstruction artifacts especially in heavily calcified arteries, limiting its usefulness in many patients with diabetes. For patients in whom the planned intervention is a surgical bypass, DSA and MRA will provide high quality images of the lower extremity arterial anatomy. For patients in whom a catheter-based intervention is the likely treatment, a diagnostic DSA immediately followed by a catheter-based treatment in the same procedure is the preferred approach. In patients with pre-existing renal dysfunction, in which gadolinium-enhanced MRA is contraindicated, DSA or CTA can be performed. However, patients should have an infusion of intravenous normal saline solution or sodium bicarbonate before the procedure to reduce the incidence of contrast-induced nephropathy.

Influence of Implementation of a Chest Pain Unit on Acute Coronary Syndrome Outcomes

Different strategies have been described to increase promptness and efficiency in the assessment and management of patients with acute chest pain and acute coronary syndrome (ACS) in the emergency department (ED). The objective of this study is to evaluate the results of implementing a Chest Pain Unit (CPU) to assist patients with ACS, and to determine its impact on quality of health care indexes and clinical outcomes. A study was conducted with a prospective cohort of patients admitted to the ED with a chief complaint of acute chest pain or suspected ACS at two different time periods: before (n = 663) and after (n = 450) introducing a CPU as part of the ED. Quality-of-care indexes analyzed in this study were adherence to a critical pathway, length of hospital stay, and hospital mortality. There was increased adherence to a critical pathway during the CPU period compared to the period with no designated CPU area, including compliance with prescribing aspirin, beta-blockers, and angiotensin-converting enzyme inhibitor, and performing coronary angiography in high-risk patients. After adjustment to baseline characteristics, admissions to a CPU resulted in a 65% reduction in mortality (odds ratio 0.35; 95% confidence interval 0.14-0.88; p = 0.03). There was no difference in median length of hospital stay, 7 days (interquartile range [IQR] 4-12) before CPU and 6 days (IQR 4-11) after introducing the CPU (p = 0.10). In the scenario of a crowded ED, implementation of a CPU was associated with greater adherence to a critical pathway for patients with ACS, with a concomitant reduction in mortality rates.

Optimized diagnostic angiography in high-risk patients with severe peripheral vascular disease.

Conventional arteriography remains the usual method for preoperative assessment of severe peripheral vascular disease (PVD). Unfortunately, many peripheral arteriograms are still performed with a suboptimal technique, which can cause significant diagnostic errors in patients with severe PVD. A suboptimal technique may be due to poor collimation (causing incorrect exposure and incorrect gray scale), excessive patient-film distance (magnification unsharpness), inadequate volume or density of contrast material, poor contrast resolution (screen-film arteriography), nonselective injection, patient movement, and pressure from restraints or incorrect patient position (failure to profile lesions, pseudo-occlusion from external pressure or plantar flexion). The technique of selective digital subtraction arteriography (DSA) allows one to avoid these errors. The superior contrast resolution of DSA allows use of lower concentrations of contrast material. Selective injection into the external iliac artery allows proper positioning and improves image quality. Demonstration of distal vessels is best achieved by using biplane arteriography. For patients with severe resting ischemia, especially those with diabetes, high-quality selective DSA is essential to ensure that all distal vessels suitable for distal bypass grafting are identified. When properly performed, selective DSA remains the investigation of choice for reliably demonstrating arterial anatomy in high-risk patients with severe PVD.

Invited Commentary

HomeRadioGraphicsVol. 20, No. 1 PreviousNext Invited CommentaryInvited CommentaryRichard A. BaumRichard A. BaumAuthor Affiliations1Department of Radiology, University of Pennsylvania Medical Center, Philadelphia, PennsylvaniaRichard A. BaumPublished Online:Jan 1 2000https://doi.org/10.1148/radiographics.20.1.g00ja10152MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In References 1 Gates J, Hartnell GG. Optimized diagnostic angiography in high-risk patients with severe peripheral vascular disease. RadioGraphics 2000; 20:121-133. Link, Google Scholar2 Watanabe Y, Dohke M, Okumura A, et al. Dynamic subtraction contrast-enhanced MR angiography: technique, clinical applications, and pitfalls. RadioGraphics 2000; 20:135-152. Link, Google Scholar3 Levy MM, Baum RA, Carpenter JP. Endovascular surgery based solely on noninvasive preprocedural imaging. J Vasc Surg 1998; 28:995-1005. Crossref, Medline, Google ScholarArticle HistoryPublished in print: Jan 2000 FiguresReferencesRelatedDetailsCited BySSRN Electronic JournalTechniques of Dynamic Subtraction Contrast-enhanced MR AngiographyTim Leiner, , Kai Yiu J.A.M. Ho, , Jos M.A. van Engelshoven, , and 1 July 2000 | RadioGraphics, Vol. 20, No. 4Recommended Articles RSNA Education Exhibits RSNA Case Collection Vol. 20, No. 1 Metrics Altmetric Score PDF download

The Significance of Subarachnoid Hemorrhage after Penetrating Craniocerebral Injury

Certain clinical factors are considered to have an effect on patient outcome after penetrating missile injury. These include bilateral hemispheric injury, ventricular hemorrhage, intracerebral hemorrhage, mass effect, and missile or bony fragmentation. The relationship of subarachnoid hemorrhage (SAH) after penetrating craniocerebral injury and outcome is unknown. In addition, controversy exists regarding the role of angiography and the incidence of traumatic intracranial aneurysm in this population. Finally, can we assume that the incidence of traumatic intracranial aneurysm is equal in military and civilian populations, given the absence of penetrating shrapnel injury in civilian populations? Now that computed tomography has supplanted angiography as the primary diagnostic modality, increasing vigilance on the part of the physician and examination of angiography in high-risk patients should allow for enhanced outcome. We evaluated 100 patients with a diagnosis of cerebral gunshot wound over a 12-month period. All patients were evaluated neurologically at the time of admission and had imaging studies. Thirty-one patients with radiological evidence of SAH on computed tomography underwent angiography. Angiograms were limited to the side of the injury in patients with single-lobe or unilateral multilobe injuries and were bilateral in patients with bilateral hemispheric involvement. One intracranial aneurysm (3.2%) was documented and treated surgically. In those patients who died within 48 hours of admission, 68% had SAH as compared with only 17% of those surviving. Outcome was based upon neurological evaluation at the time of discharge and at the time of clinical follow-up at 3 and 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)