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

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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.


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.


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.


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:

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.



  • View in gallery

    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.


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