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

Clinical article

Kimon Bekelis M.D.1, Atman Desai M.D.1, Wenyan Zhao Ph.D.4, Dan Gibson M.D.2, Daniel Gologorsky4, Clifford Eskey M.D., Ph.D.1,2,3,4, and Kadir Erkmen M.D.1,3,4
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  • 1 Section of Neurosurgery,
  • | 2 Department of Radiology, and
  • | 3 Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon; and
  • | 4 Dartmouth Medical School, Hanover, New Hampshire
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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.

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