Computed tomography angiography: improving diagnostic yield and cost effectiveness in the initial evaluation of spontaneous nonsubarachnoid intracerebral hemorrhage

Clinical article

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Object

Computed tomography angiography (CTA) is increasingly used as a screening tool in the investigation of spontaneous intracerebral hemorrhage (ICH). However, CTA carries additional costs and risks, necessitating its judicious use. The authors hypothesized that subsets of patients with nontraumatic, nonsubarachnoid ICH are unlikely to benefit from CTA as part of the diagnostic workup and that particular patient risk factors may be used to increase the yield of CTA in the detection of vascular sources.

Methods

The authors performed a retrospective analysis of 1376 patients admitted to Dartmouth-Hitchcock Medical Center with ICH over an 8-year period. Patients with subarachnoid hemorrhage, hemorrhagic conversion of ischemic infarcts, trauma, and known prior malignancy were excluded from the analysis, resulting in 257 patients for final analysis. Records were reviewed for medical risk factors, hemorrhage location, and correlation of CTA findings with final diagnosis. Multiple logistic regression analysis was used to investigate the combined effects of baseline variables of interest. Model selection was conducted using the stepwise method with p = 0.10 as the significance level for variable entry and p = 0.05 the significance level for variable retention.

Results

Computed tomography angiography studies detected vascular pathology in 34 patients (13.2%). Patient characteristics that were associated with a significantly higher likelihood of identifying a structural vascular lesion as the source of hemorrhage included patient age younger than 65 years (OR = 16.36, p = 0.0039), female sex (OR = 14.9, p = 0.0126), nonsmokers (OR = 103.8, p = 0.0008), patients with intraventricular hemorrhage (OR = 9.42, p = 0.0379), and patients without hypertension (OR = 515.78, p < 0.0001). Patients who were older than 65 years of age, with a history of hypertension, and hemorrhage located in the cerebellum or basal ganglia were never found to have an identified structural source of hemorrhage on CTA.

Conclusions

Patient characteristics and risk factors are important considerations when ordering diagnostic tests in the workup of nonsubarachnoid, nontraumatic spontaneous ICH. Although CTA is an accurate diagnostic examination, it can usually be omitted in the workup of patients with the described characteristics. The use of this algorithm has the potential to increase the yield, and thus the safety and cost effectiveness, of this diagnostic tool.

Abbreviations used in this paper:AVM = arteriovenous malformation; CTA = computed tomography angiography; DSA = digital subtraction angiography; ICH = intracerebral hemorrhage; SAH = subarachnoid hemorrhage.

Article Information

Address correspondence to: Kadir Erkmen, M.D., Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, New Hampshire 03756. email: kadir.erkmen@hitchcock.org.

Please include this information when citing this paper: published online August 10, 2012; DOI: 10.3171/2012.7.JNS12281.

© AANS, except where prohibited by US copyright law.

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Figures

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    Axial images obtained in a 58-year-old woman presenting with progressively severe headache and depressed mental status. Left: Noncontrast head CT scan demonstrating extensive (4 × 4 × 7 cm) left temporoparietal ICH with intraventricular extension. Right: Computed tomography angiogram demonstrating a 5 × 4 × 4–cm AVM in the left parietal and temporal lobes supplied by the left posterior cerebral, anterior cerebral artery, and middle cerebral artery branches, and mainly draining in the superior sagittal sinus.

  • View in gallery

    Axial images obtained in a 57-year-old woman who presented after having been found unresponsive by her husband at home. Left: Noncontrast head CT scan demonstrating left ICH extending into the left temporal role and the lateral ventricles. Right: Computed tomography angiogram demonstrating nonopacification of the distal supraclinoid segments of the internal carotid arteries and M1 segments of the middle cerebral arteries bilaterally, with numerous lenticulostriate collateral vessels consistent with Moyamoya disease.

References

  • 1

    Arteriovenous Malformation Study Group: Arteriovenous malformations of the brain in adults. N Engl J Med 340:181218181999

  • 2

    Badjatia NRosand J: Intracerebral hemorrhage. Neurologist 11:3113242005

  • 3

    Broderick JConnolly SFeldmann EHanley DKase CKrieger D: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update. Stroke 38:200120232007

    • Search Google Scholar
    • Export Citation
  • 4

    Delgado Almandoz JEJagadeesan BDMoran CJCross DT IIIZipfel GJLee JM: Independent validation of the secondary intracerebral hemorrhage score with catheter angiography and findings of emergent hematoma evacuation. Neurosurgery 70:1311402012

    • Search Google Scholar
    • Export Citation
  • 5

    Delgado Almandoz JESchaefer PWForero NPFalla JRGonzalez RGRomero JM: Diagnostic accuracy and yield of multidetector CT angiography in the evaluation of spontaneous intraparenchymal cerebral hemorrhage. AJNR Am J Neuroradiol 30:121312212009

    • Search Google Scholar
    • Export Citation
  • 6

    Goddard AJTan GBecker J: Computed tomography angiography for the detection and characterization of intra-cranial aneurysms: current status. Clin Radiol 60:122112362005

    • Search Google Scholar
    • Export Citation
  • 7

    Griffiths PDBeveridge CJGholkar A: Angiography in nontraumatic brain haematoma. An analysis of 100 cases. Acta Radiol 38:7978021997

    • Search Google Scholar
    • Export Citation
  • 8

    Halpin SFBritton JAByrne JVClifton AHart GMoore A: Prospective evaluation of cerebral angiography and computed tomography in cerebral haematoma. J Neurol Neurosurg Psychiatry 57:118011861994

    • Search Google Scholar
    • Export Citation
  • 9

    Jane JAKassell NFTorner JCWinn HR: The natural history of aneurysms and arteriovenous malformations. J Neurosurg 62:3213231985

    • Search Google Scholar
    • Export Citation
  • 10

    Kim JSmith AHemphill JC IIISmith WSLu YDillon WP: Contrast extravasation on CT predicts mortality in primary intracerebral hemorrhage. AJNR Am J Neuroradiol 29:5205252008

    • Search Google Scholar
    • Export Citation
  • 11

    Laissy JPNormand GMonroc MDuchateau CAlibert FThiebot J: Spontaneous intracerebral hematomas from vascular causes. Predictive value of CT compared with angiography. Neuroradiology 33:2912951991

    • Search Google Scholar
    • Export Citation
  • 12

    Leffers AMWagner A: Neurologic complications of cerebral angiography. A retrospective study of complication rate and patient risk factors. Acta Radiol 41:2042102000

    • Search Google Scholar
    • Export Citation
  • 13

    Linn JErtl-Wagner BSeelos KCStrupp MReiser MBrückmann H: Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses. AJNR Am J Neuroradiol 28:9469522007

    • Search Google Scholar
    • Export Citation
  • 14

    Loes DJSmoker WRBiller JCornell SH: Nontraumatic lobar intracerebral hemorrhage: CT/angiographic correlation. AJNR Am J Neuroradiol 8:102710301987

    • Search Google Scholar
    • Export Citation
  • 15

    Matsumoto KSakaki SAbekura MYoshimine T: Co-existence of unruptured cerebral aneurysms in patients with hypertensive intracerebral hemorrhage. Acta Neurochir (Wien) 146:108510892004

    • Search Google Scholar
    • Export Citation
  • 16

    Ohtani RKazui STomimoto HMinematsu KNaritomi H: Clinical and radiographic features of lobar cerebral hemorrhage: hypertensive versus non-hypertensive cases. Intern Med 42:5765802003

    • Search Google Scholar
    • Export Citation
  • 17

    Ondra SLTroupp HGeorge EDSchwab K: The natural history of symptomatic arteriovenous malformations of the brain: a 24-year follow-up assessment. J Neurosurg 73:3873911990

    • Search Google Scholar
    • Export Citation
  • 18

    Qureshi AITuhrim SBroderick JPBatjer HHHondo HHanley DF: Spontaneous intracerebral hemorrhage. N Engl J Med 344:145014602001

    • Search Google Scholar
    • Export Citation
  • 19

    Ruíz-Sandoval JLCantú CBarinagarrementeria F: Intracerebral hemorrhage in young people: analysis of risk factors, location, causes, and prognosis. Stroke 30:5375411999

    • Search Google Scholar
    • Export Citation
  • 20

    Singh TChakera T: Dural sinus thrombosis presenting as unilateral lobar haematomas with mass effect: an easily misdiagnosed cause of cerebral haemorrhage. Australas Radiol 46:3513652002

    • Search Google Scholar
    • Export Citation
  • 21

    Toffol GJBiller JAdams HPJ JrSmoker WR: The predicted value of arteriography in nontraumatic intracerebral hemorrhage. Stroke 17:8818831986

    • Search Google Scholar
    • Export Citation
  • 22

    Zhu XLChan MSPoon WS: Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke 28:140614091997

    • Search Google Scholar
    • Export Citation

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