Subarachnoid hemorrhage other imaging findings

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Differentiating Subarachnoid Hemorrhage from other Diseases

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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)

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Cerebral Vasospasm and DCI
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Seizures Associated With aSAH
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Sara Mehrsefat, M.D. [2]

Overview

Other imaging studies for subarachnoid hemorrhage include digital-subtraction cerebral angiography and CT/MR angiography. Once the diagnosis of subarachnoid hemorrhage is confirmed, the next question is about its origin. CT angiography (using radiocontrast) to identify aneurysms is generally the first step, as invasive angiography (injecting radiocontrast through a catheter advanced to the brain arteries) has a small rate of complications but is useful if there are plans to obliterate the source of bleeding, such as an aneurysm, at the same time.[1][2]

Other imaging findings

Once the diagnosis of subarachnoid hemorrhage is confirmed, the next question is about its origin. CT angiography (using radiocontrast) to identify aneurysms is generally the first step, as invasive angiography (injecting radiocontrast through a catheter advanced to the brain arteries) has a small rate of complications but is useful if there are plans to obliterate the source of bleeding, such as an aneurysm, at the same time.

Digital-subtraction cerebral angiography

Digital-subtraction cerebral angiography is used in the following conditions:[1][3][4]

  • Uncertain diagnosis after CT scan and LP
  • In patients with septic endocarditis and SAH to search for mycotic aneurysms
  • To provide surgical information such as:
    • Cerebrovascular anatomy
    • Aneurysm location and source of bleeding
    • Aneurysm size and shape
    • Relation of the aneurysm to the parent artery and perforating arteries
    • Presence of multiple or mirror aneurysms

CT angiography

CT angiography of the intracranial vessels is noninvasive test which is routinely performed in patients presenting with acute subarachnoid hemorrhage.[2][5]

  • Useful for screening and pre surgical planning
  • Identifying aneurysms 3 to 5 mm or larger with a high degree of sensitivity

Advantages of CTA may include:[6]

  • The speed and ease by which it can be obtained
  • Usefulness in the acute setting in a rapidly declining patient who needs emergent craniotomy
  • Offers a more practical approach to acute diagnosis
Large aneurysm at the branching M1 segment of the right middle cerebral artery, giving off superior middle and inferior vessels (MCA trifurcation)[7]

MR angiography

MR angiography of the intracranial vessels is noninvasive test which is routinely performed in patients presenting with acute subarachnoid hemorrhage.[2]

  • Useful for screening and pre surgical planning
  • Identifying aneurysms 3 to 5 mm or larger with a high degree of sensitivity

Indications for magnetic resonance angiography in aSAH are still few because of the limitations, such as:

  • Difficulty in scanning acutely ill patients
  • predisposition to motion artifact
  • Patient compliance
  • Longer study time
  • Cost

Repeat angiography

Around 25% all cases of subarachnoid hemorrhage (SAH) with initial negative angiography may have positive result on repeat angiogram. It is necessary to repeat digital subtraction angiography within 4 to 14 days in all cases of subarachnoid hemorrhage with negative initial angiogram.[8][9][10]

False negative angiography may result from:[9][10][11][12]

  • Technical or reading errors
  • Small aneurysm size
  • Obscuration of the aneurysm secondary to thrombosis, vasospasm,or hematoma
  • Patients with perimesencephalic SAH

References

  1. 1.0 1.1 Lu L, Zhang LJ, Poon CS, Wu SY, Zhou CS, Luo S; et al. (2012). "Digital subtraction CT angiography for detection of intracranial aneurysms: comparison with three-dimensional digital subtraction angiography.". Radiology. 262 (2): 605–12. PMID 22143927. doi:10.1148/radiol.11110486. 
  2. 2.0 2.1 2.2 Li MH, Cheng YS, Li YD, Fang C, Chen SW, Wang W; et al. (2009). "Large-cohort comparison between three-dimensional time-of-flight magnetic resonance and rotational digital subtraction angiographies in intracranial aneurysm detection.". Stroke. 40 (9): 3127–9. PMID 19556531. doi:10.1161/STROKEAHA.109.553800. 
  3. Li Q, Lv F, Li Y, Luo T, Li K, Xie P (2009). "Evaluation of 64-section CT angiography for detection and treatment planning of intracranial aneurysms by using DSA and surgical findings.". Radiology. 252 (3): 808–15. PMID 19508992. doi:10.1148/radiol.2523081911. 
  4. Cloft HJ, Joseph GJ, Dion JE (1999). "Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis.". Stroke. 30 (2): 317–20. PMID 9933266. 
  5. Chappell ET, Moure FC, Good MC (2003). "Comparison of computed tomographic angiography with digital subtraction angiography in the diagnosis of cerebral aneurysms: a meta-analysis.". Neurosurgery. 52 (3): 624–31; discussion 630–1. PMID 12590688. 
  6. Papke K, Kuhl CK, Fruth M, Haupt C, Schlunz-Hendann M, Sauner D; et al. (2007). "Intracranial aneurysms: role of multidetector CT angiography in diagnosis and endovascular therapy planning.". Radiology. 244 (2): 532–40. PMID 17641372. doi:10.1148/radiol.2442060394. 
  7. Radiopedia, CT angiphraphy in subarachnoid hemorrhage https://radiopaedia.org/cases/mca-trifurcation-aneurysm-cta-1
  8. Rinkel GJ, van Gijn J, Wijdicks EF (1993). "Subarachnoid hemorrhage without detectable aneurysm. A review of the causes.". Stroke. 24 (9): 1403–9. PMID 8362440. 
  9. 9.0 9.1 Tatter SB, Crowell RM, Ogilvy CS (1995). "Aneurysmal and microaneurysmal "angiogram-negative" subarachnoid hemorrhage.". Neurosurgery. 37 (1): 48–55. PMID 8587690. 
  10. 10.0 10.1 Urbach H, Zentner J, Solymosi L (1998). "The need for repeat angiography in subarachnoid haemorrhage.". Neuroradiology. 40 (1): 6–10. PMID 9493179. 
  11. Rinkel GJ, Wijdicks EF, Hasan D, Kienstra GE, Franke CL, Hageman LM; et al. (1991). "Outcome in patients with subarachnoid haemorrhage and negative angiography according to pattern of haemorrhage on computed tomography.". Lancet. 338 (8773): 964–8. PMID 1681340. 
  12. Schwartz TH, Solomon RA (1996). "Perimesencephalic nonaneurysmal subarachnoid hemorrhage: review of the literature.". Neurosurgery. 39 (3): 433–40; discussion 440. PMID 8875472. 

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