Negative Digital Subtraction Angiography Research Articles

The predictive value of contrast-enhanced ultrasonography combined with aspartate aminotransferase-to-lymphocyte ratio in predicting therapeutic efficacy and prognosis of post-transarterial chemoembolization in primary liver cancer

ObjectiveTo investigate the predictive value of contrast-enhanced ultrasonography (CEUS) combined with the aspartate aminotransferase-to-lymphocyte ratio (ALRI) in predicting the therapeutic efficacy and prognosis of primary liver cancer after transarterial chemoembolization (TACE). MethodsWe included 75 patients with hepatocellular carcinoma (HCC) who underwent TACE in our oncology department between January 2019 and December 2021. The patients' clinical data, preoperative ALRI, and postoperative CEUS results were analyzed. ResultsThe optimal cutoff value of ALRI for predicting residual tumor lesions using digital subtraction angiography (DSA) was 42.50. CEUS had a specificity of 0.92, sensitivity of 0.96, and area under the curve (AUC) of 0.940 for determining residual tumor lesions, while ALRI had a specificity of 0.88, sensitivity of 0.70, and AUC of 0.825. The combination of CEUS and ALRI provided a specificity of 0.92, sensitivity of 0.98, and AUC of 0.985 for determining residual tumor lesions. All patients were followed up continuously after the operation. The optimal cutoff value of ALRI for predicting residual tumor lesions in relation to 3-year survival was 41.50. In terms of 3-year survival prediction, DSA showed a specificity of 0.559, sensitivity of 0.889, and AUC of 0.724, CEUS exhibited a specificity of 0.500, sensitivity of 0.852, and AUC of 0.676, and ALRI had a specificity of 0.618, sensitivity of 0.704, and AUC of 0.611. Combined detection of CEUS and ALRI resulted in a specificity of 0.500, sensitivity of 0.889, and AUC of 0.662 for predicting 3-year survival. Patients with negative DSA results, CEUS-negative patients, and those with ALRI ≤41.5 exhibited significantly better survival outcomes compared to their positive counterparts. ConclusionCEUS combined with ALRI yields a higher predictive value in predicting residual tumor lesions and death in patients with HCC after TACE.

322 Clinical Factors Predictive of Both Successful and Unsuccessful Arterial Embolization in The Management of Lower Gastrointestinal Bleeding

Abstract Aim To develop a model of clinical factors that may predict: (1) technically and clinically successful embolization of a bleeding vessel at Digital Subtraction Angiography (DSA) for lower gastrointestinal bleed (LGIB); (2) a negative DSA in the presence of positive CT-mesenteric angiography (CTMA) for LGIB. Method A retrospective cohort study of all DSAs conducted with intent for embolization for acute LGIB over a 10-year period was undertaken. Pre-procedural and intra-procedural clinical variables were evaluated using uni- and multi-variate analysis. Results 123 DSAs were evaluated. Technical success was 81% (64/78) with clinical success 78%. Technical success was associated with super-selective approach, contrast extravasation on CT, haemoglobin drop, anatomical source and time from CT to DSA on univariate analysis. On multivariate analysis time from CT to DSA was significant with a higher success probability within 120 minutes with different factors being salient depending on degree of delay. Clinical success was only associated with APTT (<27.5s). Technical failure from a negative DSA following a positive CTMA was associated with anatomical source, haemodynamic stability, platelet count and time from CT to DSA on univariate analysis. The latter three remained so on multivariate analysis. Conclusions A triaging approach to utilising emergency DSA may be helpful. If prolonged delay between a positive CT and DSA is anticipated, with haemodynamic stability and a near normal platelet count, the DSA may not be fruitful. Technical success may be more likely if DSA occurs within 120mins. Clinical success may be more likely if APTT is within normal range.

Reader Response: Pearls & Oy-sters: Isolated Oculomotor Nerve Palsy due to Pituitary Apoplexy Missed on CT Scan

We read with interest the case presented by Marzoughi et al.1 describing a patient with pituitary apoplexy and isolated oculomotor nerve palsy. This case demonstrated that pituitary apoplexy was an important differential diagnosis for acute headache and cranial nerve palsies, with which we totally agree. Meanwhile, there are several tips we think would be helpful to pile on. First, for patients with acute headache and cranial nerve palsy, a negative CT scan cannot rule out the possibility of subarachnoid hemorrhage (SAH). Previous studies confirmed the superiority in detecting SAH by susceptibility-weighted imaging (SWI) than CT.2 In addition, uniform and consistent blood from lumbar puncture can help with the diagnosis.3 Second, previous studies reported that a negative CT angiography (CTA) or even digital subtraction angiography (DSA) cannot rule out the possibility of intracranial aneurysm.4 Besides, the guidelines recommended that for SAH patients with negative DSA, a repeated DSA was still recommended.5 Back to this case, if the CT/MRI did not show the abnormality in pituitary, it is still possible for the patient to have SAH and intracranial aneurysm, even with negative CT/CTA/MRI.

Clinical factors associated with successful embolization of lower gastrointestinal bleeding.

To develop a model of clinical factors that may predict: (1) technically and clinically successful embolization of a bleeding vessel at digital subtraction angiography (DSA) for lower gastrointestinal bleed (LGIB); (2) a negative DSA in the presence of positive CT-mesenteric angiography (CTMA) for LGIB. A retrospective cohort study of all DSAs conducted with intent for embolization for acute LGIB over a 10-year period was undertaken. Pre-procedural and intra-procedural clinical variables were evaluated using uni- and multi-variate analysis. One hundred and twenty-three DSAs were evaluated. Technical success was 81% and clinical success 78% where DSA was positive. Technical success was associated with super-selective approach, contrast extravasation on CT, haemoglobin drop, anatomical source and time from CT to DSA on univariate analysis. On multivariate analysis, time from CT to DSA was significant with a higher success probability within 120 min with different factors being salient depending on degree of delay. Clinical success was only associated with activated partial thromboplastin time (<27.5s). A negative DSA was associated with anatomical source, haemodynamic stability, platelet count and time from CT to DSA on univariate analysis. The latter three remained so on multivariate analysis. A triaging approach to utilizing emergency DSA may be helpful. If prolonged delay between CT and DSA is anticipated, with haemodynamic stability and a near-normal platelet count, the DSA may not be fruitful. Technical success may be more likely if DSA occurs within 120 min. Clinical success may be more likely if activated partial thromboplastin time is within normal range.

Familial Predisposition and Differences in Radiographic Patterns in Spontaneous Nonaneurysmal Subarachnoid Hemorrhage.

Subarachnoid hemorrhage (SAH) from an intracranial aneurysmal rupture is the most common nontraumatic etiology for SAH, but up to 15% of patients with SAH have no identifiable source. To assess familial predisposition to spontaneous nonaneurysmal SAH (naSAH) and to evaluate whether family history affects the severity of presentation and prognosis of this condition. We conducted a retrospective analysis of all spontaneous SAH with negative digital subtraction angiography from 2004 to 2018. Patients were divided into 2 groups: patients with first- or second-degree relatives with intracranial aneurysms and patients with no family history. Univariate and multivariate regression analyses were used to study patient presentation, radiographic patterns of hemorrhage, and clinical outcome. A total of 100 patients met the inclusion criteria. There were no individuals with family history of naSAH. A total of 15 patients (15%) had at least one family member with an intracranial aneurysm, of which 12 (12%) presented as SAH. Patients without family history had a higher percentage of perimesencephalic presentation, whereas those with family history had a higher percentage of nonperimesencephalic SAH presentation (47%vs 13%, odds ratio [OR] 0.17 [95% CI 0.04, 0.81]). We found a high rate of family history of intracranial aneurysms in patients who presented with naSAH. Although there was no difference in clinical outcome in patients with and without family history, there appears to be a higher percentage of nonperimesencephalic radiographic patterns of SAH in those with family history, suggesting possible different etiologies of these hemorrhages.

Non-traumatic non-aneurysmal subarachnoid haemorrhage: Single institutional experience

Aim: Despite the advanced diagnostic methods we use today, the rate of negative digital subtraction angiography (DSA) is 15% in patients diagnosed with subarachnoidal hemorrhage (SAH), and these types of hemorrhages are named as non-aneurysmal (NASAH). Various factors such as inadequate interpretation of the beginning angiography, vasospasm, thrombosis, intra-cerebral hematoma pressure may cause DSA to be negative. This study aims to determine the causes of bleeding in patients who were suffered from NASAH.Materials and Methods: The study evaluated 664 patients with SAH from 2010 to 2016. DSA was performed on these patients within the first 3 or 6 hours. Sixty-seven patients with DSA negative were included in the study group. The patients were divided into three groups as perimesencephalic subarachnoidal hemorrhage (PMSAH), non-perimesencephalic subarachnoidal hemorrhage (nPMSAH), CT negative subarachnoidal hemorrhage (CT negative SAH). These three groups were evaluated based on age, gender, Glascow coma scale (GCS), World Federation of Neurosurgical Societies (WFNS) grade, Hunt and Hess Classification and Fisher’s scale, hospitalization time duration, complications and computerized tomography (CT), and cervical and cranial MRI was performed on patients without correlation between DSA results if needed.Results: Of the 664 patients diagnosed with SAH, 67 (10.09%) had NASAH. Statistically significant differences were found between CT Negative SAH and PMSAH and CT Negative SAH and nPMSAH in terms of the variables of GCS during hospital admission and total duration of hospitalization. Statistically significant differences were found between CT Negative SAH and PMSAH and nPMSAH in terms of the variables of GCS during hospital discharge. There were statistically significant differences between the types in terms of WFNS Classification, Hunt and Hess Classification and Fisher’s Scala.Conclusion: We believe that this study will contribute to the literature about the necessity of performing additional radiologic imaging during clinical follow-up since belated diagnosis in patients with NASAH may increase mortality.

Empiric cone-beam CT-guided embolization in acute lower gastrointestinal bleeding.

To evaluate the clinical effect and safety of cone-beam CT (CBCT)-guided empirical embolization for acute lower gastrointestinal bleeding (LGIB) in patients with a positive CT angiography (CTA) but subsequent negative digital subtraction angiography (DSA). A retrospective study of consecutive LGIB patients with a positive CTA who received a DSA within 24h from January 2008 to July 2019. Patients with a positive DSA were treated with targeted embolization (TE group). Patients with a negative DSA underwent an empiric CBCT-guided embolization of the assumed ruptured vas rectum (EE group) or no embolization (NE group). Recurrent bleeding, major ischemic complications, and in-hospital mortality were compared by means of Fisher's exact test. Further subgroup analysis was performed on hemodynamic instability. Eighty-five patients (67.6years ± 15.7, 52 men) were included (TE group, n = 47; EE group, n = 19; NE group, n= 19). If DSA was positive, technical success of targeted embolization was 100% (47/47). If DSA was negative and the intention to treat by empiric CBCT-guided embolization, technical success was 100% (19/19). Recurrent bleeding rates in the TE group, EE group, and NE group were 17.0% (8/47), 21.1% (4/19), and 52.6% (10/19) respectively. Empiric CBCT-guided embolization reduced rebleeding significantly in patients with a negative DSA and hemodynamic instability (EE group, 3/10 vs NE group, 10/12, p = .027). Major ischemic complications occurred in one patient (TE group). Overall, the in-hospital mortality rate was 7.1% (6/85). Empiric cone-beam CT-guided embolization proved to be a feasible, effective, and safe treatment strategy to reduce rebleeding and improve clinical success in hemodynamically unstable patients with acute LGIB, positive CTA but negative DSA. • A novel transarterial embolization technique guided by cone-beam CT could be developed extending the "empiric" embolization strategy to lower gastrointestinal bleeding. • By implementing the empiric treatment strategy, nearly all patients with an active lower gastrointestinal bleeding on CTA will be eligible for a superselective empiric embolization, even if subsequent catheter angiography is negative. • In patients with a negative catheter angiography, empiric embolization reduces the rebleeding rate and, particularly in hemodynamically unstable patients, improves clinical success compared with a conservative "wait-and-see" management.

The Yield of Repeat Angiography in Angiography-Negative Spontaneous Subarachnoid Hemorrhage.

Objective Despite the technological advancement in imaging, digital subtraction angiography (DSA) remains gold standard imaging modality for spontaneous subarachnoid hemorrhage (SAH). But even after DSA, around 15% of SAH remains elusive for the cause of the bleed. This is an institutional review to solve the mystery, “when is second DSA really indicated?” Methods In a retrospective review from January 2015 to December 2017, we evaluated cases of spontaneous SAH with initial negative DSA with repeat DSA after 6 weeks to rule out vascular abnormality. The spontaneous SAH was confirmed on noncontrast computed tomography (NCCT) and divided into two groups of perimesencephalic SAH (PM-SAH) or nonperimesencephalic SAH (nPM-SAH). The outcome was assessed by a modified Rankin’s score (mRS) at 6 months postictus. Results During the study period, we had 119 cases of initial negative DSA and 98 cases (82.3%) underwent repeat DSA after 6 weeks interval. A total of 53 cases (54.1%) had PM-SAH and 45 cases (45.9%) had nPM-SAH. Repeat DSA after 6 weeks showed no vascular abnormality in 53 cases of PM-SAH and in 2 (4.4%) out of 45 cases of nPM-SAH. At 6 months postictus, all cases of PM-SAH and 93% of nPM-SAH had mRS of 0. Conclusion We recommend, a repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH. Although the overall outcome for nonaneurysmal spontaneous SAH is better than aneurysmal SAH, nPM-SAH has poorer eventual outcome compared to PM-SAH.

Role of digital subtraction angiography in detection of intracranial aneurysms compared with computed tomographic angiography

Objective To evaluate the role of digital subtraction angiography (DSA) in the detection of intracranial aneurysms among patients with spontaneous subarachnoid hemorrhage (SAH) compared with computed tomographic angiography (CTA) in a single center, Sri Lanka. Methods A total of 123 patients clinically and CT proven SAH were evaluated with CT angiography and DSA with a median interval of 3 days. The sensitivity, specificity and accuracy of CT angiography in detecting aneurysms were analyzed compared to DSA on a per-patient, per-size, per-site and per morphological basis. All data were analyzed using SPSS analytical package (version 18). Ethical approval for the study was from the institutional ethical review board. Results Among 123 patients with clinically and CT proven SAH, 51 (41.5%) patients showed aneurysms on CT angiography. 72 were negative for aneurysms in CTA. In 13 out of 72 (18%) CTA negative patients subsequent DSA demonstrated aneurysms. Number of CTA negative but DSA positive aneurysm were 15 as two of the patients had two aneurysms each. Four CTA detected aneurysms could not be appreciated in the subsequent DSAs. Aneurysms (47)detected by both CT angiography and DSA were more than 6mm in size (56.7%) , sacculartype (96.5%) and were located in the anterior circulation system (92.4%). Most CTA negative aneurysms detected by DSA were less than 6mm in size (80%), saccular type (60%) and were located in anterior (53.8%) and posterior (46.7%) circulation system. The sensitivity, specificity, positive predictive value and negative predictive value of CT angiography compared to DSA per patient basis were 78.3%, 93.7%, 92.2% and 81.9% respectively. CT angiography has a low sensitivity to detect aneurysms less than 6mm size (65.7%%), in posterior circulation (36.4%) and other morphological types (0%) compared to aneurysms more than 6mm size (90.9%), in anterior circulation (85.9%) and saccular type (85.5%). Conclusion Digital subtraction angiography (DSA) has a significant role in detecting intracranial aneurysms which are less than 6mm in size, are located in posterior circulation system and of non-saccular morphological type.

Interval angioarchitectural evolution of brain arteriovenous malformations following rupture.

The goal of this study was to describe changes in the angioarchitecture of brain arteriovenous malformations (bAVMs) between acute and delayed cerebral digital subtraction angiography (DSA) obtained after hemorrhage, and to examine bAVM characteristics predicting change. This is a retrospective study of a prospective institutional bAVM database. The authors included all patients with ruptured bAVMs who had DSA in both acute and delayed phases, with no interval treatment of their bAVM, between January 2000 and April 2017. The authors evaluated the existence or absence of angioarchitectural changes. Demographic data, radiological characteristics of hemorrhages, and angioarchitectural features of the bAVMs of the two patients' groups were analyzed. Univariate and multivariate logistic analyses were performed to identify predictors of angioarchitectural change. A total of 42 patients were included in the series. Seventeen (40.5%) patients had angioarchitectural changes including bAVM only visible on the delayed DSA study (n = 8), spontaneous thrombosis of the AVM (n = 3), or alteration of the size or the opacification of the nidus (n = 6). The factors associated with angioarchitectural changes were a small nidus (3.8 ± 7.9 ml vs 6.1 ± 9.5 ml, p = 0.046), a superficial location (94.1% vs 5.9%, p = 0.016), and a single superficial draining vein (58.8% vs 24.0%, p = 0.029). Angioarchitectural changes can be seen in 40% of ruptured bAVMs between the acute- and delayed-phase DSA. A small nidus, a superficial location, and a single superficial draining vein were statistically associated with the occurrence of angioarchitectural changes. These changes included either enlargement or spontaneous occlusion of the bAVM, as well as subsequent diagnosis of a bAVM following an initial negative DSA study.

Analysis of negative DSA findings in patients with acute nonvariceal gastrointestinal bleeding: A retrospective study of 133 patients

PurposeTo analyze causes of acute nonvariceal gastrointestinal bleeding (GIB) with negative digital subtraction angiography (DSA) results. Materials and methodsThe clinical and follow-up data of 133 patients - recruited between February 2008 and November 2016 - with acute nonvariceal GIB and negative DSA results were included in this study. DSA results, diagnoses, and clinical outcomes were recorded. ResultsThe DSA results were negative in all 133 patients. Of the total, 55 patients (41.4%) chose to undergo surgery and 78 (58.6%) opted for conservative treatment. Within 30 days, there was no significant difference in the rebleeding or mortality rates between the two groups (P < .05). Of all 133 patients, 76 (57.1%) had upper GIB and 57 (42.9%) had lower GIB; within 30 days, the rebleeding rate in the upper GIB group (44.7%, 34/76) was significantly higher than that in the lower GIB group (26.3%, 15/57). There was no significant statistical difference (P < .05) within 30 days in the mortality rates between the two groups.Among patients with upper GIB, 26 (34.2%, 26/76) opted to undergo surgery and 50 (65.8%, 50/76) chose conservative treatment; within 30 days, the rebleeding rate in the group that chose surgery (61.5%, 16/26) was higher than that in the conservative treatment group (36%, 18/50). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups.Among the patients with lower GIB, 29 (50.9%, 29/57) chose to undergo surgery and 28 (49.1%, 28/57) opted for conservative treatment. Within 30 days, the rebleeding rate in the surgery group (13.8%, 4/29) was lower than that in conservative treatment group (39.3%, 11/28). There was no significant difference (P < .05) within 30 days in the mortality rate between the two groups.Sixteen patients underwent prophylactic arterial embolization; in 6 of these, bleeding was stopped for 30 days. DSA was then repeated in these 16 patients after a median interval of 1 day, and a positive bleeding site was found in 9 of the 16. Causes of bleeding were found in 111 patients by surgery or endoscopy, whereas the causes remained unknown in 22 patients. ConclusionsUpper GIB with negative DSA results was stopped by conservative treatment, whereas lower GIB required surgery to detect the culprit bleeding site. Rare causes of GIB should be considered and appropriate management selected in a timely manner in order to detect unusual causes.

Diagnosis and treatment efficacy of digital subtraction angiography and transcatheter arterial embolization in post-pancreatectomy hemorrhage: A single center retrospective cohort study

BackgroundTo evaluate the diagnostic and treatment efficacy of digital subtraction angiography (DSA), transcatheter arterial embolization (TAE) in post-pancreatectomy hemorrhage (PPH). Materials and methodsThis is a single-center retrospective cohort study. Clinicopathological data of 23 patients with PPH from August 2009 to November 2016 were collected. We observed (1) DSA procedures and hemorrhagic sites (2) TAE: successful rate and complications (3) Follow-up. Results(1) 30 procedures of DSA were conducted in 23 patients, 20 (66.7%) procedures of contrast medium extravasation were observed. Among 20 procedures of positive DSA, hemorrhagic site located 5 times in gastroduodenal artery,4 times in common hepatic artery, 3 times in superior mesenteric artery, 3 times in splenic artery, 1 time in left gastric artery, right gastric artery, left hepatic artery, right hepatic artery and inferior mesenteric artery respectively. (2) Besides 4 failure procedures of TAE managed by surgery, 16 procedures of TAE were conducted, with 14 successful hemostasis. 2 procedures of post-TAE re-hemorrhage were managed by surgery. In 9 patients with 10 procedures of negative DSA, 9 had conservative treatment and 1 was managed by surgery. (3) 6 patients died because of the metastasis, median survival time was 7.5 months. ConclusionsDSA is minimal invasive in the diagnosis of PPH, and TAE is safe and effective for patients with positive DSA.

Non-aneurysmal subarachnoid hemorrhage: When is a second angiography indicated?

Purpose Repeat imaging in patients with non-aneurysmal subarachnoid hemorrhage (NASAH) remains controversial. We aim to report our experience with NASAH with different hemorrhage patterns, and to investigate the need for further diagnostic workup to determine the underlying cause of hemorrhage. Method We conducted a retrospective analysis of all spontaneous SAH with an initial negative computed tomography (CT) with angiography (CTA) and/or digital subtraction angiography (DSA) from October 2011 through May 2017. According to the bleeding pattern on the admission CT scan, NASAH was divided into two subgroups: (1) perimesencephalic SAH (PMSAH) and (2) non-perimesencephalic SAH (nPMSAH). Radiological data included the admission CT, CTA, DSA, and magnetic resonance imaging (MRI) with angiography (MRA). Results Seventy-four patients met the inclusion criteria. Thirty-nine (52.7%) patients had PMSAH on the initial CT scan, and 35 (47.3%) had nPMSAH. All underwent CTA and/or DSA revealing no vascular abnormalities. Forty-seven (63.5%) patients underwent subsequent diagnostic workup. DSA was performed in all patients at least once. No abnormalities were found on the repeat DSA or other radiological follow-up studies except in one (1.4%) patient with nPMSAH, in whom a follow-up DSA revealed a small saccular anterior choroidal artery aneurysm, considered to be the source of hemorrhage. Conclusion A repeat DSA may not be needed in case of PMSAH, if the initial negative DSA is technically adequate with absence of hematoma and vasospasm. In contrast, a follow-up DSA should be mandatory for confirming or excluding vascular pathology in case of nPMSAH in order to prevent rebleeding.

Diagnosis and interventional treatment value of digital subtraction angiography for post pancreatectomy hemorrhage

Objective To investigate the diagnosis and treatment value of digital subtraction angiography (DSA) and transcatheter arterial embolization (TAE) for post pancreatectomy hemorrhage (PPH), and influencing factors of severity of PPH. Methods The retrospective case-control study was conducted. The clinicopathological data of 20 patients with PPH who were admitted to the Zhongshan Hospital of Fudan University from August 2009 to November 2016 were collected. Patients with PPH in the early stage underwent reoperations for hemostasis; patients with PPH in the later stage received conservative treatment, and then DSA and TAE were considered when patients had the stable vital signs. Observation indicators: (1) DSA situations: overall times, positive rate and bleeding sites; (2) TAE situations: successful rate of hemostasis, operating time and postoperative complications; (3) follow-up situations; (4) influencing factors analysis of severity of PPH. Follow-up using outpatient examination and telephone interview was performed to detect occurrence of complications after discharging from hospital up to April 2017. Measurement data with skewed distribution were described as M (range). Count data were evaluated by the ratio and proportion. The univariate analysis was done using the Fisher exact probability. Results (1) DSA situations: all the 20 patients underwent DSA, with overall times of 27. The direct sign was 18 times extravasation of the contrast medium, with a positive rate of 66.7% (18/27). Of 18 times positive DSA, clear bleeding sites were located in 5 times gastroduodenal artery (3 times with pseudoaneurysm of gastroduodenal artery stump), in 4 times common hepatic artery (3 times with pseudoaneurysm of common hepatic artery), in 3 times superior mesenteric artery, in 2 times splenic artery, in 1 time left gastric artery, in 1 time right gastric artery, in 1 time left hepatic artery (pseudoaneurysm of left hepatic artery) and in 1 time inferior mesenteric artery. (2) TAE situations: of patients with 18 times positive DSA, patients with 15 times positive DSA received TAE, with a successful rate of hemostasis of 13/15, and patients with 5 times positive DSA received successful hemostasis by reoperation. A median operating time of TAE for patients with 15 times positive DSA was 30 minutes. There was no occurrence of adverse reaction, including fever, abdominal pain, melena, elevated aminotransferase and liver abscess. One patient complicated with splenic abscess after transcatheter splenic arterial embolization underwent puncture drainage and then had a good recovery. Of patients with 9 times negative DSA, patients with 8 times negative DSA were cured by conservative treatment and patient with 1 time negative DSA received successful hemostasis by operation. All the 20 patients were cured and then discharged from hospital. (3) Follow-up situations: 20 patients were followed up for 4-92 months, with a median time of 24 months. During the follow-up, 20 patients recovered well, without long-term complications. (4) Influencing factors analysis of severity of PPH: the results of univariate analysis showed that gender, age, preoperative blood sugar, preoperative combined jaundice, preoperative albumin (Alb), preoperative prothrombin time (PT) extended, preserving pylorus, pancreatic duct stent placement, pancreatic operation time, volume of intraoperative blood loss, intraoperative blood transfusion, property of tumor, postoperative pancreatic fistula and time of PPH were not factors affecting the severity of PPH (P>0.05). Conclusion DSA is minimal-invasive in the diagnosis for PPH, and TAE is safe and effective for patients with positive DSA. Key words: Post pancreatectomy hemorrhage; Digital subtraction angiography; Transcatheter arterial embolization; Outcomes

Epidemiological Features of Nontraumatic Spontaneous Subarachnoid Hemorrhage in China: A Nationwide Hospital-based Multicenter Study.

Background:Nontraumatic spontaneous subarachnoid hemorrhage (SAH) is associated with a high mortality. This study was conducted to investigate the epidemiological features of nontraumatic spontaneous SAH in China.Methods:From January 2006 to December 2008, the clinical data of patients with nontraumatic SAH from 32 major neurosurgical centers of China were evaluated. Emergent digital subtraction angiography (DSA) was performed for the diagnosis of SAH sources in the acute stage of SAH (≤3 days). The results and complications of emergent DSA were analyzed. Repeated DSA or computed tomography angiography (CTA) was suggested 2 weeks later if initial angiographic result was negative.Results:A total of 2562 patients were enrolled, including 81.4% of aneurysmal SAH and 18.6% of nonaneurysmal SAH. The total complication rate of emergent DSA was 3.9% without any mortality. Among the patients with aneurysmal SAH, 321 cases (15.4%) had multiple aneurysms, and a total of 2435 aneurysms were detected. The aneurysms mostly originated from the anterior communicating artery (30.1%), posterior communicating artery (28.7%), and middle cerebral artery (15.9%). Among the nonaneurysmal SAH cases, 76.5% (n = 365) had negative initial DSA, including 62 cases with peri-mesencephalic nonaneurysmal SAH (PNSAH). Repeated DSA or CTA was performed in 252 patients with negative initial DSA, including 45 PNSAH cases. Among them, the repeated angiographic results remained negative in 45 PNSAH cases, but 28 (13.5%) intracranial aneurysms were detected in the remaining 207 cases. In addition, brain arteriovenous malformation (AVM, 7.5%), Moyamoya disease (7.3%), stenosis or sclerosis of the cerebral artery (2.7%), and dural arteriovenous fistula or carotid cavernous fistula (2.3%) were the major causes of nonaneurysmal SAH.Conclusions:DSA can be performed safely for pathological diagnosis in the acute stage of SAH. Ruptured intracranial aneurysms, AVM, and Moyamoya disease are the major causes of SAH detected by emergent DSA in China.

MRI-detection rate and incidence of lumbar bleeding sources in 190 patients with non-aneurysmal SAH.

BackgroundUp to 15% of all spontaneous subarachnoid hemorrhages (SAH) have a non-aneurysmal SAH (NASAH). The evaluation of SAH patients with negative digital subtraction angiography (DSA) is sometimes a diagnostic challenge. Our goal in this study was to reassess the yield of standard MR-imaging of the complete spinal axis to rule out spinal bleeding sources in patients with NASAH.MethodsWe retrospectively analyzed the spinal MRI findings in 190 patients with spontaneous NASAH, containing perimesencephalic (PM) and non-perimesencephalic (NPM) SAH, diagnosed by computer tomography (CT) and/or lumbar puncture (LP), and negative 2nd DSA.Results190 NASAH patients were included in the study, divided into PM-SAH (n = 87; 46%) and NPM-SAH (n = 103; 54%). Overall, 23 (22%) patients had a CT negative SAH, diagnosed by positive LP. MR-imaging of the spinal axis detected two patients with lumbar ependymoma (n = 2; 1,05%). Both patients complained of radicular sciatic pain. The detection rate raised up to 25%, if only patients with radicular sciatic pain received an MRI.ConclusionRoutine radiological investigation of the complete spinal axis in NASAH patients is expensive and can not be recommended for standard procedure. However, patients with clinical signs of low-back/sciatic pain should be worked up for a spinal pathology.

Clinical effects of preventive interventional therapy in gastrointestinal bleeding patients with negative digital subtraction angiography findings

Clinical effects of preventive interventional therapy in gastrointestinal bleeding patients with negative digital subtraction angiography findings

Benefit of Second Catheter Angiography in Patients with Nontraumatic Subarachnoidal Hemorrhage

This study aimed to determine the yield of repetitive catheter angiography (digital subtraction angiography (DSA)) for the detection of causative vascular lesions in patients with nontraumatic subarachnoidal hemorrhage (SAH) and negative initial DSA. We hypothesize that a second DSA might be helpful to detect an initially occult bleeding source. We retrospectively evaluated 649 patients with acute SAH and invasive catheter angiographies between 2004 and 2012. In 90 SAH patients initial imaging was negative concerning a causative bleeding source. A total of 113 repetitive DSA were performed. Two neuroradiologists reanalyzed the initial imaging and the result of the reangiography independently. In 4/90 patients (4.5 %) bleeding source was first detected in the second or third DSA. In all other patients, no causative vascular lesion was found. Reasons for the initially false negative diagnostics were one dissecting aneurysm and thrombosis of three aneurysms within the acute phase of SAH. Repetitive DSA revealed the cause of SAH in 4.5 % of the cases. These findings have a therapeutic and prognostic impact. We think that at least a second DSA should be part of diagnostic work-up in patients with SAH and missing bleeding source, even considering the risk of an additional invasive angiography itself.

Repeat digital subtraction angiography after a negative baseline assessment in nonperimesencephalic subarachnoid hemorrhage: a pooled data meta-analysis

A repeat digital subtraction angiography (DSA) study of the cranial vasculature is routinely performed in patients with diffuse nonperimesencephalic subarachnoid hemorrhage (SAH) after negative baseline CT angiography (CTA) and DSA studies. However, DSA carries a low but substantial risk of neurological complications. Therefore, the authors evaluated the added value of repeat DSA in patients with initial angiographically negative diffuse nonperimesencephalic SAH. A systematic review of the contemporary literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies from January 2000 onward were reviewed since imaging modalities have much improved over the last decade. A pooled analysis was conducted to identify the detection rate of repeat DSA. In addition, the diagnostic yield of repeat DSAs in a prospectively maintained single-center series of 1051 consecutive patients with SAH was added to the analysis. An initial search of the literature yielded 179 studies, 8 of which met the selection criteria. Another 45 patients from the authors' institution were included in the study, providing 368 patients eligible for the pooled analysis. In 37 patients (10.0%, 95% CI 7.4%-13.6%) an aneurysm was detected on repeat DSA. The timing of the repeat DSA varied from 1 to 6 weeks after the initial DSA. The use of 3D techniques was poorly described among these studies, and no direct comparisons between CTA and DSA were made. Repeat DSA is still warranted in patients with a diffuse nonperimesencephalic SAH and negative initial assessment. However, the exact timing of the repeat DSA is subject to debate.

Clinical relevance of negative initial angiogram in spontaneous subarachnoid hemorrhage

Background: We aimed to compare the presentation, management, and clinical course in patients with perimesencephalic and nonperimesencephalic (aneurysmal) bleeding patterns on noncontrast CT, but negative initial 4-vessel digital subtraction angiography (DSA).Methods: We retrospectively reviewed clinical and imaging data for 280 patients presenting with spontaneous SAH admitted between 2005 and 2011. We identified 56 patients (20%) with SAH diagnosed on high resolution head CT performed within 48 hours of admission, and negative initial DSA, and divided them into perimesencephalic and non-perimesencephalic groups based on hemorrhage patterns. Patients with traumatic subarachnoid bleeding and those with initial positive DSA were excluded from this analysis.Results: Perimesencephalic SAH was seen in 25 patients (45%); non-perimesencephalic bleeding patterns were seen in 31 (55%). All patients with perimesencephalic SAH presented with Hunt and Hess (HH) I, versus 45% HH I and 55% HH II–IV in those with non-perimecenphalic SAH. All patients with perimesencephalic SAH achieved modified Rankin score (mRS) 0 at discharge and 6-month follow-up, compared with 45% mRS 0 at discharge and 68% at 6-month follow-up in non-perimesencephalic SAH. Patients with perimesencephalic SAH presented a uniformly uncomplicated clinical course. Among non-perimesencephalic SAH patients there were 19 neurological/neurosurgical and 10 medical complications, two small aneurysms diagnosed at follow-up DSA, and one death.Conclusions: In this series, perimesencephalic SAH was associated with good clinical grades, consistently negative initial and follow-up angiograms, and an excellent prognosis. In contrast, non-perimesencephalic SAH was associated with a worse clinical presentation, higher complication rates, higher rates of true aneurysm detection on follow-up angiogram, and a poorer outcome.