Spontaneous subarachnoid hemorrhage: patients investigation in initial angiogram-negative cases

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1 976 Spontaneous subarachnoid hemorrhage: patients investigation in initial angiogram-negative cases Gintautas Vaitkevičius, Antanas Romas Gvazdaitis, Saulius Lukoševičius 1 Department of Neurosurgery, Kaunas University of Medicine, 1 Department of Radiology, Kaunas University of Medicine, Lithuania Key words: subarachnoid hemorrhage, cerebral aneurysms, angiography, computed tomography angiography. Summary. Aim of the study. To find out, which patients in case of subarachnoid hemorrhage and negative initial angiograms need a repeated investigation, when it should be repeated and what kind of angiographic investigation should be performed. Materials and methods. Fifty sevent patients with subarachnoid hemorrhage and negative initial angiograms were investigated in Department of Neurosurgery of Kaunas University of Medicine Hospital from January 2001 to August They underwent a repeated angiography (digital subtraction or computed tomography angiography) generally in the period of 10 days. Results. Repeated cerebral angiography revealed saccular aneurysms of various locations in 23 patients. Perimesencephalic hemorrhage was present in 24 cases and no aneurysms were detected in these cases. Aneurysm was suspected in initial angiography in 14 cases and 10 of them were confirmed after second angiography. In all cases of application computed tomography angiography provided equal or more information for neurosurgeon compared to digital subtraction angiography. Nearly half of the detected aneurysms (n=11) were small (<5 mm). Conclusions. Repeated angiography is not recommended in case of perimesencephalic pattern of spontaneous subarachnoid hemorrhage. In case of suspicion of aneurysm in initial angiography, computed tomography angiography could be a method of choice performed immediately. Introduction Spontaneous subarachnoid hemorrhage (SAH) according to etiology, clinical course, diagnostic findings and outcome could be divided into two groups: perimesencephalic and aneurysmatic (1). Perimesencephalic SAH occurs in case of rupture of small veins or capillaries. Status of these patients is usually satisfactory, outcome is more favorable, less complications, as well as negative angiographic findings. In case of aneurysmatic SAH status of the patient is usually worse, with more complications and high mortality rate (2). Cerebral aneurysms are detected by means of cerebral angiography, applying contrast media, however in 15-20% of such cases no vascular abnormalities are detected angiographically (3). In such cases further tactics of patient management differs: some authors recommend 2 nd and 3 rd angiography (4-6). Other authors report that single angiography but of high quality is enough (7). Though aneurysms are detected after repeated angiography in 2-24% of cases (8,9) and it is agreed that an untreated aneurysm may re-bleed, what will significantly deteriorate patients status and outcome (10). The traditional and golden standard tool for investigation of patients with suspected cerebral aneurysms has been catheter subtraction angiography (DSA). This method of investigation is quite expensive, sometimes long-lasting and of course, involves some risk (1-2%) of complications (11). In recent decade less invasive imaging techniques were implemented into practice. One of such methods computed tomography angiography (CTA) a quick, providing sufficient information, less invasive and safer imaging modality (12). Nevertheless possibilities of diagnosis of spontaneous SAH are increasing, the discussion on tactics after negative initial Correspondence to G. Vaitkevičius, Department of Neurosurgery, Kaunas University of Medicine, Eivenių 2, 3007 Kaunas slu@delfi.lt

2 Spontaneous subarachnoid hemorrhage 977 angiogram in case of SAH is still on. Aim of the study. To find out, which patients in case of subarachnoid hemorrhage and negative initial angiograms need a repeated investigation, when it should be repeated and what kind of angiographic investigation should be performed. Clinical material and methods Between January 2001 and August 2002, 246 patients with SAH, detected on CT and/or verified by lumbar puncture, were treated in Department of Neurosurgery of Kaunas University of Medicine Hospital. Patients with ruptured arterio-venous malformations or stroke were not included. DSA was performed in 235 patients (95.5%) during the first day of admission, in 10 patients (4.1%) later due to bad condition or technical reasons. In 1 case (0.4%) DSA was not performed the patient died and cerebral aneurysm was detected at autopsy. Aneurysms of different locations were detected in 160 patients (65%). The rest 86 (35%) possessed no vascular abnormalities, thus cause of SAH remained unclear. 57 patients (66.3%) underwent a repeated cerebral angiography (37 female, 20 males, with age ranging from 19 to 82 y., average 52.2 y.). In 37 cases DSA was repeated in the period of days after the initial procedure, 1 patient had two repeated DSAs. CTA was performed in 9 cases usually in the period of 7 days after initial DSA with suspicion of an aneurysm. CTA and DSA both were performed in 11 patients 3 rd angiography during 7 days after the 2 nd procedure with suspected aneurysm, and during 1-3 week period after 2 nd procedure, if no suspicion of aneurysm was present. Angiography was not repeated in 29 cases (33.7%), including 19 cases of perimesencephalic hemorrhage, 6 cases of absence of SAH on CT and 4 cases of diffuse SAH on CT (1 patient died before repeated angiography, 1- refused to undergo the procedure, 1- pregnant woman and 1 was admitted 2 months later after repeated SAH). DSA was performed in Interventional radiology department of Radiology clinic of Kaunas University of Medicine Hospital, by using the Seldinger technique and femoral percutaneous catheterization, employing Advantx (GE) angiography unit. The patients underwent four-vessel, multiple projection angiography with 4-6 ml of high-density contrast media, injected into each vessel. CTA was performed in Tomography department of Radiology clinic of Kaunas University of Medicine Hospital, employing Siemens Somatom Plus 4 (Siemens AG) CT unit. 100 ml of contrast media were injected via antecubital vein by means of power injector with the injection rate of 2,8 ml/s. Images were postprocessed applying MIP, SSD and VRT techniques. DSA and CTA images were evaluated by radiologists and neurosurgeons. Results Fifty-seven patients (66.3%) with absence or suspicion of aneurysms on initial angiograms underwent repeated cerebral angiography. In 3 cases of initial DSA four-vessel catheterization was not possible due to anatomical reasons, in 4 cases severe vasospasm was observed, in 14 cases cerebral aneurysm was suspected (in 10 cases aneurysms were detected during repeated examinations). Twenty-three patients harbored saccular aneurysms of different location mostly of ACoA, ACA, ACI (Table 1). This makes up to 40.4% of all repeatedly investigated patients (9.3% of all patients Table 1. Comparison of the most intensive SAH site on CT and repeated angiography results The most intensive SAH site Ruptured aneurysm detected No aneurysm ACoA ACA ACI ACM AB AV detected Anterior interhemispheric fissure Sylvian fissure 2 Posterior fossa 1 Diffuse SAH Perimesencephalic pattern 24 No SAH signs Total ACoA a. communicans anterior, ACA a. cerebri anterior, ACM a. cerebri media, ACI a. carotis interna, AB a. basilaris, AV a. vertebralis.

3 978 Gintautas Vaitkevičius, Antanas Romas Gvazdaitis, Saulius Lukoševičius Fig. 1. Characteristic CT image after rupture of ACoA aneurysm Fig. 2. DSA of the same patient (suspicion of ACoA aneurysm). Fig. 3. Repeated DSA of the same patient (ACoA aneurysm is seen slightly better) with SAH). In 22 cases of detected aneurysms repeated angiography was performed during 10 days after initial DSA, in 1 case during 16 days. Aneurysm was evident in 18 patients (31.6%) after second angiography, while in 4 (7%) it was only suspected again: 1 patient was operated after two DSA, the suspected region accessed and aneurysm confirmed, 3 patients underwent 3 rd angiography by Fig. 4. CTA of the same patient. ACoA aneurysm is evident. means of CTA. CTA confirmed aneurysms in all this cases and provided more diagnostic information compared to both previous DSA (Figures 1-4). One patient (1.8%) underwent 3 rd DSA aneurysm, which was not seen on previous DSA images, was revealed (Table 2). Aneurysm was confirmed after second angiography (CTA) in 3 cases, but a repeated DSA was

4 Spontaneous subarachnoid hemorrhage 979 Table 2. Value of repeated angiography in the group of patients with detected aneurysms Information value 2nd angiogrphy 3rd angiogrphy DSA CTA DSA CTA Enough information Not enough information 4 No valuable information 1 Total performed in these cases diagnostic information was similar and sufficient. Nearly half of all detected aneurysms (n=11) were small (<0.5 cm). The site of most intense bleeding on CT and the site of detected aneurysm coincided in 14 cases (60.9%), in other cases SAH was diffused or absent on CT. In 34 cases (59.6%) the cause of SAH remained unclear even after 2 nd and 3 rd angiography, including 24 cases (42.1% of all repeatedly investigated patients), which were regarded as perimesencephalic pattern of SAH. One patient showed perimesencephalic pattern of SAH on CT. ACI aneurysm was suspected on DSA image, while infundibular dilatation of ACI on CTA image. The suspected site was accessed at surgery, but no aneurysm detected. Thus, CTA provided a true negative result. One patient was present with intensive SAH in the right Sylvian fissure on CT, but no vascular abnormalities on DSA. The suspected site was accessed at surgery, and ACM aneurysm was detected. Four patients after negative initial angiography had re-bleeding: 1 patient died without repeated angiography (no autopsy performed), 3 patients underwent repeated angiography and aneurysms were detected in all cases. Two patients developed signs of cerebral ischemia due to vasospasm immediately after repeated DSA this was regarded as DSA complication. No complications appeared after CTA. Discussion Angiogram-negative spontaneous SAH appears in 15-20% of cases. Aneurysms are detected after repeated angiography in 2-24% of cases. We detected aneurysms in 23 cases 40.4% of all repeatedly investigated patients. Aneurysms may thrombose after rupture or even destruct (in case of microaneurysms), as well as become angiographically occult due to severe vasospasm or compression from hematoma (4 patients from our study presented with severe vasospasm on angiograms, while large hematomas were absent). Many authors suggest performance of the 2 nd angiography after days and performance of the 3 rd one after 4-8 weeks (13,14). We suspected aneurysms in 14 cases, and in 10 cases aneurysms were confirmed by repeated DSA or CTA. Thus, based on our results, in case of suspicion of aneurysm on initial angiograms and absence of vasospasm, angiography could be repeated as soon as possible during several days, as undetected and untreated aneurysm could re-rupture. The chance of re-bleeding is 4-5% in the first twenty-four hours, 20% in two weeks and even 50% in 6 months (10). In our study group 4 patients (7%) with negative initial angiograms had re-rupture in 1-9 days, 1 patient (1.8%) with diffuse SAH on CT and negative initial angiograms was admitted to the department again because of rebleeding after 2 months (ACI aneurysm was detected in this case). Some authors presume that SAH pattern on CT could indicate when it is possible to detect aneurysm by means of repeated angiography. In case of perimesencephalic pattern of SAH and thorough four-vessel catheterization there is no need of repeated angiography (15). In our study 24 patients (42.1%) with perimesencephalic pattern of SAH on CT underwent repeated angiography and no aneurysm was confirmed in this group. In case of diffuse SAH or site of intensive SAH (especially with intracerebral hematoma) the chance of detecting of an aneurysm is high. The most intensive SAH in the anterior interhemispheric fissure was seen in 11 cases in our study, 6 ACoA and 5 ACA aneurysms were detected after repeated angiography. The most intensive SAH in the site of Sylvian fissure was seen in 2 cases and ACM aneurysms were confirmed in both. Some authors indicate uselessness of repeated

5 980 Gintautas Vaitkevičius, Antanas Romas Gvazdaitis, Saulius Lukoševičius angiography in case of coincidence of intensive SAH site and suspected aneurysm location (14), as surgical intervention is favored in such case. One patient from our study group was operated without repeated angiography and ACM aneurysm was confirmed. If intensive SAH site and suspected aneurysm location do not coincide, there is a chance of not detecting of any ruptured aneurysm at surgery (13). In recent time some authors propose CTA as repeated angiography procedure in case of negative initial angiography: CTA is quicker, less invasive, cheaper and involves smaller risk of complications (16-18). Based on our results, there were no complications after CTA, while 2 patients developed cerebral ischemia due to vasospasm after DSA. CTA is capable to detect even 3 mm aneurysms that were missed on initial angiography (16,18), though other authors indicate that the majority of all CTA missed aneurysms are 2-3 mm or smaller (19). Eleven patients from our study group with negative initial DSA underwent repeated DSA and CTA both. Aneurysms were confirmed in 6 cases: in 3 cases CTA was superior providing information regarding aneurysm location and anatomy, in the rest 3 cases both modalities provided sufficient information. Thus, in case of insufficient information on DSA angiograms, CTA could be the method of choice, especially if intensive SAH site on CT and suspected aneurysm location coincide. Conclusions 1. There is no need of repeated angiography in case of perimesencephalic pattern of spontaneous subarachnoid hemorrhage and negative initial angiography. Angiography must be repeated in all other cases. 2. Repeated angiography could be performed immediately in case of aneurysm suspicion on initial angiograms and absence of vasospasm, while if there is no suspicion of aneurysm in the period of days. 3. CTA could be the method of choice as repeated angiography, especially if intensive SAH site on CT and suspected aneurysm location coincide. Spontaninė subarachnoidinė hemoragija. Ligonio tyrimo taktika neradus aneurizmos pirminėse angiogramose Gintautas Vaitkevičius, Antanas Romas Gvazdaitis, Saulius Lukoševičius 1 Kauno medicinos universiteto Neurochirurgijos klinika, 1 Kauno medicinos universiteto Radiologijos klinika Raktažodžiai: subarachnoidinė hemoragija, galvos smegenų arterinės aneurizmos, angiografija, kompiuterinės tomografijos angiografija. Santrauka. Darbo tikslas. Nustatyti, kuriems ligoniams po įvykusios spontaninės subarachnoidinės hemoragijos ir neradus aneurizmos pirminėse angiogramose reikia kartoti angiografiją, kada ją kartoti ir kokį angiografijos metodą parinkti. Tyrimo medžiaga ir metodai. Ištirti Kauno medicinos universiteto Neurochirurgijos klinikoje 2001 m. sausio 2002 m. rugpjūčio mėn. gydyti 57 ligoniai po įvykusios subarachnoidinės hemoragijos ir pirminės angiografijos be pakitimų. Šiems ligoniams buvo kartojama skaitmeninė subtrakcinė angiografija ir (arba) kompiuterinės tomografijos angiografija (dažniausiai per 10 dienų nuo pirmosios angiografijos). Rezultatai. Pakartotinai atlikus angiografiją, 23 ligoniams nustatyta įvairios lokalizacijos galvos smegenų maišinė arterinė aneurizma. Perimezencefalinis pakraujavimo pobūdis nustatytas 24 ligoniams ir nė vienam iš jų aneurizmos nerasta. Pirminėse angiogramose 14 ligonių įtarta aneurizma, pakartojus angiografiją, aneurizma rasta 10. Visais atvejais, kai pakartotinės angiografijos metodu pasirinkta kompiuterinės tomografijos angiografija, tyrimas buvo pakankamai informatyvus. Beveik pusė visų nustatytų aneurizmų (n=11) buvo mažos (<5 mm). Išvados. Perimezencefalinės subarachnoidinės hemoragijos atveju kartoti angiografiją nerekomenduojama. Pirminėse angiogramose įtarus aneurizmą, tyrimą reikia kartoti nedelsiant, pirmiausia pasirenkant kompiuterinės tomografijos angiografiją. Adresas susirašinėjimui: G. Vaitkevičius, KMU Neurochirurgijos klinika, Eivenių 2, 3007 Kaunas El. paštas: slu@delfi.lt

6 Spontaneous subarachnoid hemorrhage 981 References 1. Jeelani NUO, Sekhar LN. Angiogram-negative subarachnoid hemorrhage: a current perspective. Crit Rev Neurosurg 1997;7: Tamasauskas A, Tamasauskas J, Bernotas G, Inao S and Yoshida J. Management of Patients with Ruptured Cerebral Aneurysms in Hospital Population of Lithuania. Acta Neurochir (Wien) 2000;142: Kassell NF, Torner JC, Jane JA, Haley EC Jr, Adams HP. The International Cooperative Study on the Timing of Aneurysm Surgery II: Surgical results. J Neurosurg 1990;73: Duong H, Melancon D, Tampieri D, Ethier R. The negative angiogram in subarachnoid hemorrhage. Neuroradiology 1996;38: Jafar JJ, Weiner HL. Surgery for angiographically occult cerebral aneurysms. J Neurosurg 1993;79: Gvazdaitis AR, Bernotas G. Angiografinė galvos smegenų ligų diagnostika. Intrakranijinė hemoragija. (Angiographic Diagnosis of Cerebral Disease. Intracranial Hemorrhage.) Neurologijos seminarai 1998;2: Ronkainen A, Hernesniemi J. Subarachnoid hemorrhage of unknown aethiology. Acta Neurochir 1992;119: Iwanaga H, Wakai S, Ochiai C, Narita J, Inoh S, Nagai M. Ruptured cerebral aneurysm missed by initial angiographic study. Neurosurgery 1990;27: Rinkel GJ, Wijdicks EF, Hasan D, Kienstra GEM, Franke CL, Hageman LM, et al. Outcome in patients with subarachnoid hemorrhage and negative angiography according to pattern of hemorrhage on computed tomography. Lancet 1991;338: Kassel NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery 1983;13: Heiserman JE, Dean BL, Hodak JA, Flom RA, Bird CR, Drayer BP, Fram EK. Neurologic complications of cerebral angiography. Am J Neuroradiol 1994;15: Katz DA, Marks MP, Napel SA, Bracci PM, Roberts SL. Circle of Willis: evaluation with spiral CT angiography, MR angiography and conventional angiography. Radiology 1995;195: Bradac GB, Bergui M, Ferrio MF, Fontanella M, Stura G. False-negative angiograms in subarachnoid hemorrhage due to intracranial aneurysms. Neuroradiology 1997;39: Tatter SB, Crowell RB, Ogilvy CS. Aneurysmal and microaneurysmal angiogram-negative subarachnoid hemorrhage. Neurosurgery 1995;37: Rinkel GJE, Wijdicks EFM, Vermeulen M, Ramos LMP, Tanghe HLJ, Hasan D, et al. Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysm rupture. Am J Neuroradiol 1991;12: Hashimoto H, Iida J-I, Hironaka Y, Okada M and Sakaki T. Use of spiral computerized tomography in patients with subarachnoid hemorrhage in whom subtraction angiography did not reveal cerebral aneurysms. J Neurosurg 2000;92: Zouaoui A, Sahel M, Marro B, Clemenceau S, Dargent N, Bitar A, et al. Three-dimensional computed tomographic angiography in detection of cerebral aneurysms in acute subarachnoid hemorrhage. Neurosurgery 1997;41: Young N, Dorsch NW, Kingston RJ, Soo MY, Robinson A. Spiral scanning in the detection and evaluation of aneurysms of the circle of Willis. Surg Neurol 1998;50: Anderson GB, Steinke DE, Petruk KC, Ashforth R, Findlay JM. Computed Tomographic Angiography versus Digital Substraction Angiography for the Diagnosis and Early Treatment of Ruptured Intracranial Aneurysms. Neurosurgery 1999; 45: Received 16 September 2002, accepted 15 October 2002