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Amantakul A, Vuthiwong W, Khiawsa N. The diagnostic yield of repeat computed tomography angiography in cases of spontaneous subarachnoid haemorrhage after negative initial digital subtraction angiography. Pol J Radiol 2024; 89:e179-e186. [PMID: 38783910 PMCID: PMC11112413 DOI: 10.5114/pjr.2024.138787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 02/12/2024] [Indexed: 05/25/2024] Open
Abstract
Purpose It is currently unclear how useful repeat computed tomography angiography (CTA) is in spontaneous subarachnoid haemorrhage (SAH) patients after negative initial digital subtraction angiography (DSA). The purpose of this study is to assess the yield of repeat CTA for the detection of causative vascular lesions in patients with SAH in whom there has been a negative initial DSA. Material and methods This observational retrospective study was carried out from January 2013 to July 2022 at a single institution. Analysis of the SAH pattern on unenhanced CT showed that patients were divided into perimesencephalic SAH and diffuse SAH groups. A repeat CTA was performed on all spontaneous SAH patients who had a nega-tive initial CTA and DSA within a 2-week period. An interventional neuroradiologist and a diagnostic radiologist examined all images to search for causative vascular abnormalities. Results Forty-seven patients were included in our study, with a median age of 55 years and a range of 28-81 years. Thirty-seven had diffuse SAH (66%), and 16 had perimesencephalic SAH (34%). The repeat CTA revealed 2 causa-tive vascular lesions (a right PICA aneurysm and a mycotic aneurysm) in 2 separate patients (yield of 4.3%), both of whom had diffuse SAH (yield of 6.5%). In retrospect, none of these vascular lesions were evident in the initial CTA and DSA. No evidence of re-bleeding was observed in the follow-up period. Conclusions It is beneficial to repeat CTA when evaluating patients with diffuse SAH who initially present with nega-tive initial DSA. For occult aneurysms, the diagnostic yield of the follow-up CTA is 6.5%.
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Affiliation(s)
- Amonlaya Amantakul
- Department of Radiology, Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Withawat Vuthiwong
- Department of Radiology, Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Natthapong Khiawsa
- Department of Radiology, Maharaj Nakorn Chiang Mai Hospital, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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Nakajima H, Tsuchiya T, Shimizu S, Suzuki H. Contrast extravasation from basilar artery without aneurysm formation on digital subtraction angiography in computed tomography angiogram-negative subarachnoid hemorrhage: A case report. Surg Neurol Int 2021; 12:498. [PMID: 34754548 PMCID: PMC8571361 DOI: 10.25259/sni_713_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 09/21/2021] [Indexed: 11/20/2022] Open
Abstract
Background: The causes of angiogram-negative subarachnoid hemorrhage (SAH) on initial angiography, which accounts for 10–30% of spontaneous SAH, are heterogeneous and still unclear. We report a case of nonaneurysmal SAH, in which initial computed tomographic angiography (CTA) showed no source of bleeding, but the subsequent digital subtraction angiography (DSA) revealed contrast extravasation from the basilar artery without aneurysms. Case Description: A 67-year-old woman with a medical history of hypertension presented as SAH of World Federation of Neurological Surgeons Grade II. CTA on admission did not show any cause of bleeding and DSA was subsequently performed to show contrast extravasation from a perforator of the middle third of the basilar artery without aneurysms during the subsequent DSA, resulting in profound deterioration SAH and neurological status. The patient was conservatively treated. Follow-up DSAs on days 2 and 16 showed no source of bleeding as well. Conclusion: Although the precise cause of bleeding in this case is uncertain, SAH might be caused by local dissection of the basilar artery perforator, and the bleeding site might heal spontaneously without forming of a pseudoaneurysm.
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Affiliation(s)
| | | | | | - Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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3
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Atiles JL, Marrero-González AP, Labat EJ. Delayed Spontaneous Resolution of a Traumatic Middle Meningeal Artery Pseudoaneurysm. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e926852. [PMID: 33744907 PMCID: PMC7990124 DOI: 10.12659/ajcr.926852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Patient: Male, 42-year-old Final Diagnosis: Middle meningeal artery pseudoaneurysm Symptoms: Migraine Medication:— Clinical Procedure: — Specialty: Radiology
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Affiliation(s)
- Jaime L Atiles
- Department of Diagnostic Radiology, University of Puerto Rico - School of Medicine, San Juan, Puerto Rico
| | - Amanda P Marrero-González
- Department of Diagnostic Radiology, University of Puerto Rico - School of Medicine, San Juan, Puerto Rico
| | - Eduardo J Labat
- Department of Diagnostic Radiology, University of Puerto Rico - School of Medicine, San Juan, Puerto Rico
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Sadigh G, Menon RK, Bhojak M, Aladi A, Mossa-Basha M, Wu L, Lehman VT, Brinjikji W, Dehkharghani S, Derakhshani A, Mossa-Basha F, Allen JW. Radiological Management of Angiographically Negative, Spontaneous Intracranial Subarachnoid Hemorrhage: A Multicenter Study of Utilization and Diagnostic Yield. Neurosurgery 2019; 85:126-133. [DOI: 10.1093/neuros/nyy225] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 04/30/2018] [Indexed: 01/04/2023] Open
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Cho WH, Choi HJ, Nam KH, Lee JI. Contrast Extravasation on Computed Tomography Angiography Imitating a Basilar Artery Trunk Aneurysm in Subsequent Conventional Angiogram-Negative Subarachnoid Hemorrhage: Report of Two Cases with Different Clinical Courses. J Cerebrovasc Endovasc Neurosurg 2016; 17:324-30. [PMID: 27066442 PMCID: PMC4823430 DOI: 10.7461/jcen.2015.17.4.324] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/12/2014] [Accepted: 12/31/2014] [Indexed: 11/23/2022] Open
Abstract
Contrast extravasation on computed tomography angiography (CTA) is rare but becoming more common, with increasing use of CTA for various cerebral vascular diseases. We report on two cases of spontaneous subarachnoid hemorrhage (SAH) in which the CTA showed an upper basilar trunk saccular lesion suggesting ruptured aneurysm. However, immediate subsequent digital subtraction angiography (DSA) failed to show a vascular lesion. In one case, repeated follow up DSA was also negative. The patient was treated conservatively and discharged without any neurologic deficit. In the other case, the patient showed sudden mental deterioration on the third hospital day and her brain CT showed rebleeding. The immediate follow up DSA showed contrast stagnation in the vicinity of the upper basilar artery, suggestive of pseudoaneurysm. Double stents deployment at the disease segment was performed. Due to the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.
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Affiliation(s)
- Won Ho Cho
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
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Canneti B, Mosqueira AJ, Nombela F, Gilo F, Vivancos J. Spontaneous Subarachnoid Hemorrhage with Negative Angiography Managed in a Stroke Unit: Clinical and Prognostic Characteristics. J Stroke Cerebrovasc Dis 2015; 24:2484-90. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.06.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 05/18/2015] [Accepted: 06/14/2015] [Indexed: 11/26/2022] Open
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Cho WH, Choi HJ, Nam KH, Lee JI. Contrast extravasation on computed tomography angiography imitating a basilar artery trunk aneurysm in subsequent conventional angiogram-negative subarachnoid hemorrhage: report of two cases with different clinical courses. J Cerebrovasc Endovasc Neurosurg 2015; 17:20-6. [PMID: 25874181 PMCID: PMC4394115 DOI: 10.7461/jcen.2015.17.1.20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Revised: 08/23/2014] [Accepted: 12/31/2014] [Indexed: 11/23/2022] Open
Abstract
Contrast extravasation on computed tomography angiography (CTA) is rare but becoming more common, with increasing use of CTA for various cerebral vascular diseases. We report on two cases of spontaneous subarachnoid hemorrhage (SAH) in which the CTA showed a saccular lesion of the upper basilar trunk suggesting a ruptured aneurysm. However, no vascular lesion was observed on immediate subsequent digital subtraction angiography (DSA). In one case, repeated follow up DSA was also negative. The patient was treated conservatively and discharged with no neurologic deficit. In the other case, the patient showed sudden mental deterioration on the third hospital day and her brain CT showed rebleeding. The immediate follow up DSA showed contrast stagnation in the vicinity of the upper basilar artery, suggestive of pseudoaneurysm. Double stent deployment at the disease segment was performed. Due to the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.
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Affiliation(s)
- Won Ho Cho
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
| | - Hyuk Jin Choi
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
| | - Kyoung Hyup Nam
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
| | - Jae Il Lee
- Department of Neurosurgery, Medical Research Institute, Pusan National University College of Medicine and Hospital, Busan, Korea
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8
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Dalyai R, Chalouhi N, Theofanis T, Jabbour PM, Dumont AS, Gonzalez LF, Gordon DS, Thakkar V, Rosenwasser RH, Tjoumakaris SI. Subarachnoid hemorrhage with negative initial catheter angiography: a review of 254 cases evaluating patient clinical outcome and efficacy of short- and long-term repeat angiography. Neurosurgery 2013; 73:E913. [PMID: 23277373 DOI: 10.1227/neu.0b013e3182846de8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial. OBJECTIVE To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging. METHODS Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram. RESULTS Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of short-term and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients. CONCLUSION Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH.
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Affiliation(s)
- Richard Dalyai
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
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Chen M. Detection of angiographically occult, ruptured cerebral aneurysms: case series and literature review. J Neurointerv Surg 2013; 6:744-7. [DOI: 10.1136/neurintsurg-2013-010988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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10
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Benefit of Second Catheter Angiography in Patients with Nontraumatic Subarachnoidal Hemorrhage. Clin Neuroradiol 2013; 25:13-7. [DOI: 10.1007/s00062-013-0271-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/18/2013] [Indexed: 10/26/2022]
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Delgado Almandoz JE, Kadkhodayan Y, Crandall BM, Scholz JM, Fease JL, Anderson RE, Tubman DE. Diagnostic yield of delayed neurovascular imaging in patients with subarachnoid hemorrhage, negative initial CT and catheter angiograms, and a negative 7 day repeat catheter angiogram. J Neurointerv Surg 2013; 6:637-42. [DOI: 10.1136/neurintsurg-2013-010896] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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12
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Angiogram negative subarachnoid haemorrhage: Outcomes and the role of repeat angiography. Clin Neurol Neurosurg 2013; 115:1470-5. [DOI: 10.1016/j.clineuro.2013.02.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Revised: 12/19/2012] [Accepted: 02/01/2013] [Indexed: 11/23/2022]
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Ringelstein A, Mueller O, Timochenko O, Moenninghoff C, Sure U, Forsting M, Schlamann M. Reangiographie nach perimesenzephaler Subarachnoidalblutung. DER NERVENARZT 2013; 84:715-9. [DOI: 10.1007/s00115-013-3803-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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14
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Steiner T, Juvela S, Unterberg A, Jung C, Forsting M, Rinkel G. European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage. Cerebrovasc Dis 2013; 35:93-112. [PMID: 23406828 DOI: 10.1159/000346087] [Citation(s) in RCA: 707] [Impact Index Per Article: 64.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Accepted: 11/22/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Intracranial aneurysm with and without subarachnoid haemorrhage (SAH) is a relevant health problem: The overall incidence is about 9 per 100,000 with a wide range, in some countries up to 20 per 100,000. Mortality rate with conservative treatment within the first months is 50-60%. About one third of patients left with an untreated aneurysm will die from recurrent bleeding within 6 months after recovering from the first bleeding. The prognosis is further influenced by vasospasm, hydrocephalus, delayed ischaemic deficit and other complications. The aim of these guidelines is to provide comprehensive recommendations on the management of SAH with and without aneurysm as well as on unruptured intracranial aneurysm. METHODS We performed an extensive literature search from 1960 to 2011 using Medline and Embase. Members of the writing group met in person and by teleconferences to discuss recommendations. Search results were graded according to the criteria of the European Federation of Neurological Societies. Members of the Guidelines Committee of the European Stroke Organization reviewed the guidelines. RESULTS These guidelines provide evidence-based information on epidemiology, risk factors and prognosis of SAH and recommendations on diagnostic and therapeutic methods of both ruptured and unruptured intracranial aneurysms. Several risk factors of aneurysm growth and rupture have been identified. We provide recommendations on diagnostic work up, monitoring and general management (blood pressure, blood glucose, temperature, thromboprophylaxis, antiepileptic treatment, use of steroids). Specific therapeutic interventions consider timing of procedures, clipping and coiling. Complications such as hydrocephalus, vasospasm and delayed ischaemic deficit were covered. We also thought to add recommendations on SAH without aneurysm and on unruptured aneurysms. CONCLUSION Ruptured intracranial aneurysm with a high rate of subsequent complications is a serious disease needing prompt treatment in centres having high quality of experience of treatment for these patients. These guidelines provide practical, evidence-based advice for the management of patients with intracranial aneurysm with or without rupture. Applying these measures can improve the prognosis of SAH.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Heidelberg University, Heidelberg, Germany.
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Hudák I, Lenzsér G, Lunenkova V, Dóczi T. Cerebral arterial fenestrations: a common phenomenon in unexplained subarachnoid haemorrhage. Acta Neurochir (Wien) 2013; 155:217-22. [PMID: 23275070 DOI: 10.1007/s00701-012-1587-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 12/05/2012] [Indexed: 12/30/2022]
Abstract
BACKGROUND Fenestrations of intracranial arteries are variants resulting from incomplete fusion of vessels during development with unknown clinical significance. They are best visualised with 3D rotational angiography (3DRA). OBJECTIVE In a prospective consecutive series of patients with suspected aneurysms, 3DRA was performed to identify not only the potential bleeding source but also to assess the frequency and location of any fenestrations of intracranial arteries. METHODS In 287 consecutive patients with possible intracranial aneurysms (accidental discovery or previous history of SAH), 3DRAs were prospectively performed, and the location of subarachnoid haemorrhage was assessed by CT. RESULTS Of 174 patients presenting with SAH, 153 had saccular aneurysms, and in 21 cases (12.1 %), no source of bleeding was found. In 20 of these 21 patients with "unexplained SAH" (95.2 %) an arterial fenestration was detected in the neighbourhood of the clot. The incidence of fenestration in the 153 aneurysmal SAH patients was 22.9 %, and it was 23.3 % in 266 patients with intracranial aneurysms (113 accidental and 153 ruptured). CONCLUSIONS Arterial fenestration was detected in 22.9 % of ruptured cerebral aneurysms, in contrast with 95.2 % in patients with unexplained SAH, the difference being statisctically significant (p < 0.01). Fenestration is a developmental defect, a structural wall weakness possibly making the vessel prone to rupture. Its incidence of nearly 100 % may suggest a connection with idiopathic SAH. The presented data indicate that arterial fenestrations are generally overlooked, and they can be considered as one of the candidates for the source of idiopathic SAH.
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Affiliation(s)
- Istvan Hudák
- Department of Neurosurgery, University of Pécs, 2 Ret str, 7623, Pécs, Hungary
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Delgado Almandoz JE, Crandall BM, Fease JL, Scholz JM, Anderson RE, Kadkhodayan Y, Tubman DE. Diagnostic yield of catheter angiography in patients with subarachnoid hemorrhage and negative initial noninvasive neurovascular examinations. AJNR Am J Neuroradiol 2012; 34:833-9. [PMID: 23019174 DOI: 10.3174/ajnr.a3291] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE The yield of DSA in patients with SAH and negative initial noninvasive neurovascular examinations (CTA or MRA) is not well-understood. This study aimed to determine the yield of DSA for the detection of causative vascular lesions in this clinical scenario. MATERIALS AND METHODS We examined the yield of DSA for the detection of causative vascular lesions in a cohort of patients presenting to our institution with SAH and negative initial noninvasive neurovascular examinations during a 5-year period. Two experienced neuroradiologists independently evaluated the NCCT to determine the SAH pattern (diffuse, perimesencephalic, or peripheral sulcal) and the catheter angiograms to assess the presence of a causative vascular lesion. RESULTS Fifty-five patients were included in the study, with a mean age of 58.2 years (median, 58 years; range, 25-88 years). Twenty-eight patients were men (50.9%), and 27 were women (49.1%). The initial noninvasive examination was a CTA in 47 patients (85.5%) and an MRA in 8 patients (14.5%). Thirty-three patients had diffuse SAH (60%); 11, perimesencephalic SAH (20%); and 11, peripheral sulcal SAH (20%). DSA demonstrated a causative vascular lesion in 6 patients (10.9%), 5 of whom had diffuse SAH (yield of 15.2%) and 1 of whom had peripheral sulcal SAH (yield of 9.1%). No causative vascular lesions were found in patients with perimesencephalic SAH. CONCLUSIONS DSA is a valuable tool in the evaluation of patients with diffuse and peripheral sulcal SAH who have negative initial noninvasive neurovascular examinations, demonstrating a causative vascular lesion in 15.2% and 9.1% of patients, respectively.
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Affiliation(s)
- J E Delgado Almandoz
- Division of Interventional Neuroradiology, Abbott Northwestern Hospital, Minneapolis, Minnesota 55407, USA.
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Delgado Almandoz JE, Jagadeesan BD, Refai D, Moran CJ, Cross DT, Chicoine MR, Rich KM, Diringer MN, Dacey RG, Derdeyn CP, Zipfel GJ. Diagnostic yield of computed tomography angiography and magnetic resonance angiography in patients with catheter angiography-negative subarachnoid hemorrhage. J Neurosurg 2012; 117:309-15. [PMID: 22680242 DOI: 10.3171/2012.4.jns112306] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The yield of CT angiography (CTA) and MR angiography (MRA) in patients with subarachnoid hemorrhage (SAH) who have a negative initial catheter angiogram is currently not well understood. This study aims to determine the yield of CTA and MRA in a prospective cohort of patients with SAH and a negative initial catheter angiogram. METHODS From January 1, 2005, until September 1, 2010, the authors instituted a prospective protocol in which patients with SAH-as documented by noncontrast CT or CSF xanthochromia and a negative initial catheter angiogram- were evaluated using CTA and MRA to assess for causative cerebral aneurysms. Two neuroradiologists independently evaluated the noncontrast CT scans to determine the SAH pattern (perimesencephalic or not) and the CT and MR angiograms to assess for causative cerebral aneurysms. RESULTS Seventy-seven patients were included, with a mean age of 52.8 years (median 54 years, range 19-88 years). Fifty patients were female (64.9%) and 27 male (35.1%). Forty-three patients had nonperimesencephalic SAH (55.8%), 29 patients had perimesencephalic SAH (37.7%), and 5 patients had CSF xanthochromia (6.5%). Computed tomography angiography demonstrated a causative cerebral aneurysm in 4 patients (5.2% yield), all of whom had nonperimesencephalic SAH (9.3% yield). Mean aneurysm size was 2.6 mm (range 2.1-3.3 mm). Magnetic resonance angiography demonstrated only 1 of these aneurysms. No causative cerebral aneurysms were found in patients with perimesencephalic SAH or CSF xanthochromia. CONCLUSIONS Computed tomography angiography is a valuable adjunct in the evaluation of patients with nonperimesencephalic SAH who have a negative initial catheter angiogram, demonstrating a causative cerebral aneurysm in 9.3% of patients.
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Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University Schoolof Medicine, Saint Louis, Missouri, USA.
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Stetson ND, Pile-Spellman J, Brisman JL. Contrast extravasation on computed tomographic angiography mimicking a basilar artery aneurysm in angiogram-negative subarachnoid hemorrhage: report of 2 cases. Neurosurgery 2012; 71:E1047-52; discussion E1052. [PMID: 22806079 DOI: 10.1227/neu.0b013e318268fecb] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Contrast extravasation on computed tomography angiography (CTA) is becoming more common, with increasing use of CTA for myriad intracranial vascular pathologies. This article describes the first 2 documented cases of contrast extravasation from a nonaneurysmal basilar artery source seen on CTA and discusses possible pathophysiologic mechanisms. CLINICAL PRESENTATION We present 2 cases of diffuse atraumatic subarachnoid hemorrhage in which the CTA showed an abnormality in association with the basilar artery highly suggestive of a ruptured aneurysm. Follow-up digital subtraction angiography, however, was completely negative. Subsequent repeat digital subtraction angiography failed to reveal a vascular lesion. Both patients were treated for complications associated with SAH, but given the negative digital subtraction angiography, no intervention was performed. CONCLUSION Because of the frequent use of CTA, contrast extravasation is an increasingly common observation. Physicians should be aware that basilar artery extravasation can mimic the appearance of an aneurysm.
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Affiliation(s)
- Nate D Stetson
- Department of Neurosurgery, North Shore Hospital, Manhasset, New York, USA
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Delgado Almandoz JE, Jagadeesan BD, Refai D, Moran CJ, Cross DT, Chicoine MR, Rich KM, Diringer MN, Dacey RG, Derdeyn CP, Zipfel GJ. Diagnostic yield of repeat catheter angiography in patients with catheter and computed tomography angiography negative subarachnoid hemorrhage. Neurosurgery 2012; 70:1135-42. [PMID: 22105208 DOI: 10.1227/neu.0b013e318242575e] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The yield of repeat catheter angiography in patients with subarachnoid hemorrhage (SAH) who have negative initial catheter and computed tomography (CT) angiograms is not well understood. OBJECTIVE To determine the yield of repeat catheter angiography in a prospective cohort of patients with SAH and negative initial catheter and CT angiograms. METHODS From January 1, 2005, until September 1, 2010, we instituted a prospective protocol in which patients with SAH documented by noncontrast CT (NCCT) or cerebrospinal fluid (CSF) xanthochromia and negative initial catheter and CT angiograms were evaluated with repeat catheter angiography 7 days and 3 months after presentation to assess for causative vascular abnormalities. RESULTS Seventy-two patients were included, with a mean age of 53.1 years (median, 53.5 years; range, 19-88 years). Forty-six patients were female (63.9%) and 26 male (36.1%). Thirty-nine patients had nonperimesencephalic SAH (54.2%), 29 patients had perimesencephalic SAH (40.3%), and 4 patients had CSF xanthochromia (5.5%). The first repeat catheter angiogram performed 7 days after presentation demonstrated a causative vascular abnormality in 3 patients (yield of 4.2%), 2 of which had nonperimesencephalic SAH (yield of 5.1%), and 1 had perimesencephalic SAH (yield of 3.4%). The second repeat catheter angiogram performed in 43 patients (59.7%) did not demonstrate any causative vascular abnormalities. No causative abnormalities were found in patients with CSF xanthochromia. CONCLUSION Repeat catheter angiography performed 7 days after presentation is valuable in the evaluation of patients with SAH who have negative initial catheter and CT angiograms, demonstrating a causative vascular abnormality in 4.2% of patients.
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Affiliation(s)
- Josser E Delgado Almandoz
- Division of Neuroradiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, Saint Louis, Missouri, USA.
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Two cases of ruptured cerebral aneurysms presenting with contralateral hematomas. Emerg Radiol 2011; 18:39-42. [DOI: 10.1007/s10140-010-0900-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2010] [Accepted: 08/14/2010] [Indexed: 10/19/2022]
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21
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Westerlaan HE, van Dijk J, Jansen-van der Weide MC, de Groot JC, Groen RJM, Mooij JJA, Oudkerk M. Intracranial Aneurysms in Patients with Subarachnoid Hemorrhage: CT Angiography as a Primary Examination Tool for Diagnosis—Systematic Review and Meta-Analysis. Radiology 2011; 258:134-45. [DOI: 10.1148/radiol.10092373] [Citation(s) in RCA: 157] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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22
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Song JH, Yeon JY, Kim KH, Jeon P, Kim JS, Hong SC. Angiographic analysis of venous drainage and a variant basal vein of Rosenthal in spontaneous idiopathic subarachnoid hemorrhage. J Clin Neurosci 2010; 17:1386-90. [DOI: 10.1016/j.jocn.2010.02.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Revised: 02/18/2010] [Accepted: 02/22/2010] [Indexed: 11/25/2022]
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23
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Valle EP, Tamargo RJ, Gailloud P. Thrombosis and subsequent recanalization of a ruptured intracranial aneurysm in 2 children, demonstrating the value of repeating catheter angiography after an initial negative study. J Neurosurg Pediatr 2010; 5:346-9. [PMID: 20367338 DOI: 10.3171/2009.10.peds0966] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The cases of 2 children with true aneurysmal subarachnoid hemorrhages (SAHs) and initial false-negative angiograms are reported. In both cases, the initial angiogram was of adequate technical quality and included the projections on which aneurysms were later documented. There was no significant vasospasm at the time of initial angiography; therefore, transient aneurysm sac thrombosis was the most likely explanation for the initial false-negative studies. It is particularly interesting to note that 1 of the 2 patients had a pattern of hemorrhage compatible with the most limited definition of a perimesencephalic SAH, that is, a small prepontine cistern hemorrhage. If a second angiogram had been deemed unnecessary based on that criterion alone, a ruptured basilar tip aneurysm would have escaped detection and treatment.
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Affiliation(s)
- Edison P Valle
- Division of Interventional Neuroradiology, The Johns Hopkins Hospital, Baltimore, Maryland, USA
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Kang DH, Park J, Lee SH, Park SH, Kim YS, Hamm IS. Does non-perimesencephalic type non-aneurysmal subarachnoid hemorrhage have a benign prognosis? J Clin Neurosci 2009; 16:904-8. [PMID: 19362482 DOI: 10.1016/j.jocn.2008.10.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2008] [Accepted: 10/05/2008] [Indexed: 10/20/2022]
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Dall'Olio M, Princiotta C, Leonardi M. Ruptured “Occult” Aneurysm Disclosed by Three-Dimensional Angiographic Reconstructions. Neuroradiol J 2009; 22:222-7. [DOI: 10.1177/197140090902200214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Accepted: 04/19/2009] [Indexed: 11/16/2022] Open
Abstract
Rotational angiographic sequences and their three-dimensional reconstructions have led to major improvements in angiographic diagnostics, especially in the study of brain aneurysms. Reconstructions accurately depict the morphology of the aneurysm, namely any wall irregularities and the possible origin of arterial branches from the aneurysmal sac, and display the aneurysm on multiple spatial planes, measuring its different diameters and ratios (particularly the dome to neck ratio). Lastly, three-dimensional angiographic reconstructions will sometimes disclose ruptured or intact aneurysms not depicted by digital subtraction angiography. A 43-year-old woman was admitted to the emergency room of Maggiore Hospital, Bologna Local Health Trust, presenting severe headache, confusion and nuchal rigidity. Emergency CT scan disclosed cisternal subarachnoid haemorrhage. Subsequent 3D sequences revealed an aneurysm of the left carotid artery siphon. This occult aneurysm found in our patient had been masked by the overlying infundibular origin of the posterior communicating artery. This prevented detection of the lesion not only in standard oblique anteroposterior, craniocaudal and lateral sequences but also in the rotational sequence. Identification of the aneurysm in our patient was the result of the diagnostic strategy adopted. When cisternal subarachnoid haemorrhage is detected, our protocol routinely includes a rotational angiographic sequence centred on the anterior circulation and on the posterior circulation when the standard examination fails to depict the course of all the vessels or when the features of subarachnoid haemorrhage strongly suggest aneurysm rupture in that anatomical location. Three-dimensional angiographic reconstructions are extremely useful not only to characterize brain aneurysms, but also to disclose ruptured occult aneurysms and additional zero grade lesions.
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Affiliation(s)
- M. Dall'Olio
- Neuroradiology Service, University of Bologna, Bellaria Hospital; Bologna, Italy
| | - C. Princiotta
- Neuroradiology Service, University of Bologna, Bellaria Hospital; Bologna, Italy
| | - M. Leonardi
- Neuroradiology Service, University of Bologna, Bellaria Hospital; Bologna, Italy
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Andaluz N, Zuccarello M. YIELD OF FURTHER DIAGNOSTIC WORK-UP OF CRYPTOGENIC SUBARACHNOID HEMORRHAGE BASED ON BLEEDING PATTERNS ON COMPUTED TOMOGRAPHIC SCANS. Neurosurgery 2008; 62:1040-1047. [DOI: 10.1227/01.neu.0000315895.74803.82] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023] Open
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27
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Andaluz N, Zuccarello M. YIELD OF FURTHER DIAGNOSTIC WORK-UP OF CRYPTOGENIC SUBARACHNOID HEMORRHAGE BASED ON BLEEDING PATTERNS ON COMPUTED TOMOGRAPHIC SCANS. Neurosurgery 2008; 62:1040-6; discussion 1047. [DOI: 10.1227/01.neu.0000325865.22011.1f] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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van Rooij WJ, Peluso JPP, Sluzewski M, Beute GN. Additional value of 3D rotational angiography in angiographically negative aneurysmal subarachnoid hemorrhage: how negative is negative? AJNR Am J Neuroradiol 2008; 29:962-6. [PMID: 18258701 DOI: 10.3174/ajnr.a0972] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In some patients with nonperimesencephalic nontraumatic subarachnoid hemorrhage (aneurysmal SAH), no aneurysm can be found on digital subtraction angiography (DSA), and repeat DSA is advocated. 3D rotational angiography (3DRA) is considered superior to DSA in the detection of small intracranial aneurysms. In this study, we assessed the additional diagnostic value of 3DRA in detecting DSA-occult aneurysms in 23 patients with aneurysmal SAH. MATERIALS AND METHODS Between January 2006 and September 2007, 298 patients with suggested ruptured intracranial aneurysm were referred for DSA, and in 98 patients, DSA was negative. Of these 98 patients, 28 had aneurysmal SAH, and in 23 of these additional 3DRA was performed in the same or in a repeat angiographic procedure. RESULTS In 18 of 23 patients (78%), a ruptured small aneurysm was diagnosed on additional 3DRA. The location of 18 aneurysms was the anterior communicating artery (n = 11), the middle cerebral artery (n = 3), the posterior communicating artery (n = 2), the ophthalmic artery (n = 1), and the posterior inferior cerebellar artery (n = 1). Aneurysm size was 3 mm in 4, 2 mm in 9, and 1 mm in 5. Of 18 aneurysms, 9 were treated with coil placement; 7 with surgical clipping; and 2 were not treated. CONCLUSION In this study, 18 of 23 (78%) patients with negative findings on DSA had a small ruptured aneurysm when studied with 3DRA. These were most commonly located on the anterior communicating artery.
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Affiliation(s)
- W J van Rooij
- Department of Radiology, St. Elisabeth Ziekenhuis, Tilburg, the Netherlands.
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Nakau H, Nagatani H, Nakau R, Ametani T. Acute disappearance of ruptured aneurysm located near the origin of the superior cerebellar artery - case report - . Neurol Med Chir (Tokyo) 2008; 47:468-70. [PMID: 17965564 DOI: 10.2176/nmc.47.468] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A 63-year-old woman presented with a ruptured aneurysm which apparently spontaneously thrombosed. She was admitted after sudden onset of severe headache. Computed tomography (CT) demonstrated subarachnoid hemorrhage (SAH) in the pontine and interpeduncular cisterns. Initial three-dimensional CT (3D-CT) angiography revealed an aneurysm (diameter, 9 mm) near the origin of the left superior cerebellar artery. However, angiography 3 hours later failed to show the aneurysm. Total thrombosis was thought to have occurred in the aneurysm. The patient returned home with no deficit 1 month after admission. T(1)- and T(2)-weighted magnetic resonance imaging 75 days after the SAH demonstrated the thrombosed aneurysm as an isointense mass lesion. 3D-CT angiography showed no recanalization of the aneurysm 9 months after the SAH.
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Affiliation(s)
- Hiroya Nakau
- Department of Neurosurgery, Uji Tokushukai Hospital, Uji, Kyoto, Japan
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Little AS, Garrett M, Germain R, Farhataziz N, Albuquerque FC, McDougall CG, Zabramski JM, Nakaji P, Spetzler RF. EVALUATION OF PATIENTS WITH SPONTANEOUS SUBARACHNOID HEMORRHAGE AND NEGATIVE ANGIOGRAPHY. Neurosurgery 2007; 61:1139-50; discussion 1150-1. [PMID: 18162892 DOI: 10.1227/01.neu.0000306091.30517.e7] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Andrew S. Little
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mark Garrett
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Rasha Germain
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Nabeel Farhataziz
- Department of Radiology, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Felipe C. Albuquerque
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Cameron G. McDougall
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Joseph M. Zabramski
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Peter Nakaji
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Robert F. Spetzler
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona
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Kakarla UK, Maughan PH, Deshmukh VR, Spetzler RF. Giant, partially thrombosed aneurysm develops after remote angiographically negative subarachnoid hemorrhage: case report. Neurosurgery 2007; 60:E572; discussion E572. [PMID: 17327766 DOI: 10.1227/01.neu.0000249285.92255.a4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE This is the first report of the rupture of a giant aneurysm in a patient who sustained a remote angiographically negative subarachnoid hemorrhage (SAH). CLINICAL PRESENTATION A 62-year old woman initially presented with a Fisher Grade III SAH 9 years ago. Her evaluation, which included cerebral angiography, magnetic resonance imaging scans, and magnetic resonance angiography of the head and neck, failed to reveal the cause of the hemorrhage. Nine years after her initial hemorrhage, the patient presented with a Fisher Grade IV SAH and a giant right supraclinoid internal carotid artery aneurysm. INTERVENTION Computed tomographic and catheter angiography showed a partially thrombosed giant aneurysm of the right supraclinoid internal carotid artery. She underwent clip reconstruction and obliteration of the aneurysm. Review of her previous angiograms and magnetic resonance imaging scans did not show an aneurysm in its nascency. CONCLUSION Initial catheter angiography and magnetic resonance imaging scans may fail to disclose a subtle dissection or blister aneurysm as a cause for SAH. As in our case, the dissection or blister may progress to a giant aneurysm with time.
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Affiliation(s)
- Udaya K Kakarla
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
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Nishizaki T, Ikeda N, Kurokawa Y, Okamura T, Abiko S. Ruptured Internal Carotid Artery Anterior Wall Aneurysm Identified During Vasospasm: Case Report. Neurosurgery 2005. [DOI: 10.1227/01.neu.0000178238.36637.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Alves JV, Andersson T, Edner G, Söderman M. Subarachnoid Haemorrhage from a Large Cerebral Aneurysm Visible only on Repeat Angiography. Interv Neuroradiol 2005; 11:59-62. [PMID: 20584436 DOI: 10.1177/159101990501100109] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2005] [Accepted: 02/20/2005] [Indexed: 11/16/2022] Open
Abstract
SUMMARY We report the case of a 49-year-old woman with a massive subarachnoid haemorrhage in conjunction with trauma. The initial cerebral angiography was normal. Three weeks later she had a second subarachnoid haemorrhage. A repeat angiography demonstrated an eight mm aneurysm of the internal carotid artery bifurcation, a region clearly normal in the previous angiography.
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Affiliation(s)
- J V Alves
- Neuroradiology Service, Hospital Geral de Santo António, Porto; Portugal -
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