Angiographically Occult Subarachnoid Hemorrhage: Yield of Repeat Angiography, Influence of Initial CT Bleed Pattern, and Sources of Diagnostic Error in 242 Consecutive Patients.
Journal
AJNR. American journal of neuroradiology
ISSN: 1936-959X
Titre abrégé: AJNR Am J Neuroradiol
Pays: United States
ID NLM: 8003708
Informations de publication
Date de publication:
05 2022
05 2022
Historique:
received:
13
12
2021
accepted:
09
02
2022
pubmed:
2
4
2022
medline:
14
5
2022
entrez:
1
4
2022
Statut:
ppublish
Résumé
Nearly 20% of patients with spontaneous SAH have no definitive source on initial DSA. The purpose of this study was to investigate the timing and yield of repeat DSA, to clarify the influence of initial CT bleed pattern, and to characterize sources of diagnostic error in this scenario. We evaluated the yield of repeat DSA and clinical outcomes stratified by hemorrhage pattern on CT in consecutive patients with nontraumatic SAH with negative initial DSA findings at a referral center. Cases in which the culprit lesion was subsequently diagnosed were classified as physiologically occult (ie, undetectable) on the initial DSA, despite adequate technique and interpretation or misdiagnosed due to operator-dependent error. Two hundred forty-two of 1163 (20.8%) patients with spontaneous SAH had negative initial DSA findings between 2009 and 2018. The SAH CT pattern was nonperimesencephalic (41%), perimesencephalic (36%), sulcal (18%), and CT-negative (5%). Repeat DSA in 135/242 patients (55.8%) revealed a source in 10 patients (7.4%): 4 saccular aneurysms, 4 atypical aneurysms, and 2 arteriovenous shunts. The overall yield of repeat DSA was 11.3% with nonperimesencephalic and 2.2% for perimesencephalic patterns. The yield of the second and third DSAs with a nonperimesencephalic pattern was 7.7% and 12%, respectively. Physiologically occult lesions accounted for 6/242 (2.5%) and operator-dependent errors accounted for 7/242 (2.9%) of all angiographically occult lesions on the first DSA. Atypical aneurysms and small arteriovenous shunts are important causes of SAH negative on angiography. Improving DSAs technique can modestly reduce the need for repeat DSA; however, a small fraction of SAH sources remain occult despite adequate technique. These findings support the practice of repeating DSA in patients with a nonperimesencephalic SAH pattern.
Sections du résumé
BACKGROUND AND PURPOSE
Nearly 20% of patients with spontaneous SAH have no definitive source on initial DSA. The purpose of this study was to investigate the timing and yield of repeat DSA, to clarify the influence of initial CT bleed pattern, and to characterize sources of diagnostic error in this scenario.
MATERIALS AND METHODS
We evaluated the yield of repeat DSA and clinical outcomes stratified by hemorrhage pattern on CT in consecutive patients with nontraumatic SAH with negative initial DSA findings at a referral center. Cases in which the culprit lesion was subsequently diagnosed were classified as physiologically occult (ie, undetectable) on the initial DSA, despite adequate technique and interpretation or misdiagnosed due to operator-dependent error.
RESULTS
Two hundred forty-two of 1163 (20.8%) patients with spontaneous SAH had negative initial DSA findings between 2009 and 2018. The SAH CT pattern was nonperimesencephalic (41%), perimesencephalic (36%), sulcal (18%), and CT-negative (5%). Repeat DSA in 135/242 patients (55.8%) revealed a source in 10 patients (7.4%): 4 saccular aneurysms, 4 atypical aneurysms, and 2 arteriovenous shunts. The overall yield of repeat DSA was 11.3% with nonperimesencephalic and 2.2% for perimesencephalic patterns. The yield of the second and third DSAs with a nonperimesencephalic pattern was 7.7% and 12%, respectively. Physiologically occult lesions accounted for 6/242 (2.5%) and operator-dependent errors accounted for 7/242 (2.9%) of all angiographically occult lesions on the first DSA.
CONCLUSIONS
Atypical aneurysms and small arteriovenous shunts are important causes of SAH negative on angiography. Improving DSAs technique can modestly reduce the need for repeat DSA; however, a small fraction of SAH sources remain occult despite adequate technique. These findings support the practice of repeating DSA in patients with a nonperimesencephalic SAH pattern.
Identifiants
pubmed: 35361576
pii: ajnr.A7483
doi: 10.3174/ajnr.A7483
pmc: PMC9089267
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
731-735Informations de copyright
© 2022 by American Journal of Neuroradiology.
Références
Emerg Radiol. 2011 Oct;18(5):403-8
pubmed: 21786138
Neurology. 1985 Apr;35(4):493-7
pubmed: 3982634
Lancet. 1991 Oct 19;338(8773):964-8
pubmed: 1681340
J Clin Neurosci. 2009 Jul;16(7):904-8
pubmed: 19362482
J Neuroimaging. 2020 May;30(3):286-296
pubmed: 32072719
Neurology. 2019 May 14;92(20):e2385-e2394
pubmed: 30996058
Clin Radiol. 2014 Apr;69(4):350-6
pubmed: 24360513
Radiology. 1992 Apr;183(1):145-50
pubmed: 1549661
Clin Neuroradiol. 2021 Dec;31(4):1071-1081
pubmed: 33974086
Stroke. 1997 Jun;28(6):1278-82
pubmed: 9183362
Neurosurgery. 2013 Apr;72(4):646-52; discussion 651-2
pubmed: 23277373
Acad Radiol. 2019 Jun;26(6):833-845
pubmed: 30559033
Eur J Radiol. 2014 Jan;83(1):197-205
pubmed: 24231267
J Neurosurg. 2011 Apr;114(4):1003-7
pubmed: 20672895
Stroke. 1993 Sep;24(9):1403-9
pubmed: 8362440
AJNR Am J Neuroradiol. 2021 Aug;42(8):1486-1491
pubmed: 33958333
Neurosurg Focus. 2017 Jun;42(6):E12
pubmed: 28565977
AJR Am J Roentgenol. 2014 Mar;202(3):465-70
pubmed: 24555582
J Neurosurg. 2003 Jun;98(6):1235-40
pubmed: 12816270
Handb Clin Neurol. 2021;176:107-119
pubmed: 33272391
Stroke. 1998 Dec;29(12):2514-6
pubmed: 9836761
AJR Am J Roentgenol. 1999 Jan;172(1):201-6
pubmed: 9888768
Radiographics. 2015 Oct;35(6):1668-76
pubmed: 26466178
Neurosurgery. 2008 May;62(5):1040-6; discussion 1047
pubmed: 18580801
J Neurosurg. 1998 Sep;89(3):419-24
pubmed: 9724116
Acta Neurochir (Wien). 2019 Oct;161(10):2013-2026
pubmed: 31410556
Neurol Res. 2012 Jan;34(1):91-7
pubmed: 22196868