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Putora PM, Almeida GG, Wildermuth S, Weber J, Dietrich T, Vernooij MW, van Doormaal PJ, Smagge L, Zeleňák K, Krainik A, Bonneville F, van Den Hauwe L, Möhlenbruch M, Bruno F, Ramgren B, Ramos-González A, Schellhorn T, Waelti S, Fischer T. Diagnostic imaging strategies of acute intracerebral hemorrhage in European academic hospitals-a decision-making analysis. Neuroradiology 2023; 65:729-736. [PMID: 36633612 DOI: 10.1007/s00234-022-03110-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
PURPOSE To evaluate and compare which factors are relevant to the diagnostic decision-making and imaging workup of intracerebral hemorrhages in large, specialized European centers. METHODS Expert neuroradiologists from ten large, specialized centers (where endovascular stroke treatment is routinely performed) in nine European countries were selected in cooperation with the European Society of Neuroradiology (ESNR). The experts were asked to describe how and when they would investigate specific causes in a patient who presented with an acute, atraumatic, intracerebral hemorrhage for two given locations: (1) basal ganglia, thalamus, pons or cerebellum; (2) lobar hemorrhage. Answers were collected, and decision trees were compared. RESULTS Criteria that were considered relevant for decision-making reflect recommendations from current guidelines and were similar in all participating centers. CT Angiography or MR angiography was considered essential by the majority of centers regardless of other factors. Imaging in clinical practice tended to surpass guideline recommendations and was heterogeneous among different centers, e.g., in a scenario suggestive of typical hypertensive hemorrhage, recommendations ranged from no further follow-up imaging to CT angiography and MR angiography. In no case was a consensus above 60% achieved. CONCLUSION In European clinical practices, existing guidelines for diagnostic imaging strategies in ICH evaluation are followed as a basis but in most cases, additional imaging investigation is undertaken. Significant differences in imaging workup were observed among the centers. Results suggest a high level of awareness and caution regarding potentially underlying pathology other than hypertensive disease.
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Affiliation(s)
- Paul Martin Putora
- Department of Radio-Oncology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Gonçalo G Almeida
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Simon Wildermuth
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Johannes Weber
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Tobias Dietrich
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Meike W Vernooij
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Lucas Smagge
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Netherlands
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Alexandre Krainik
- Department of Neuroradiology, University Hospital of Grenoble, Grenoble, France
| | - Fabrice Bonneville
- Department of Neuroradiology, Toulouse University Hospital, University Toulouse 3-Paul Sabatier, Toulouse, France
| | - Luc van Den Hauwe
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Federico Bruno
- Department of Biotechnology and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Birgitta Ramgren
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Ana Ramos-González
- Department of Neuroradiology, University Hospital, 12 de Octubre, Madrid, Spain
| | - Till Schellhorn
- Department of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Stephan Waelti
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Tim Fischer
- Department of Radiology and Nuclear Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland.
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van den Berg R, Jeung L, Post R, Coert BA, Hoogmoed J, Coutinho JM, Majoie CB, Verbaan D, Emmer BJ, Vandertop WP. The added value of cerebrospinal fluid analysis in patients with subarachnoid hemorrhage after negative noncontrast CT. J Neurosurg 2022; 136:1024-1028. [PMID: 34560662 DOI: 10.3171/2021.4.jns21656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/01/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In patients presenting within 6 hours after signs and symptoms of suspected subarachnoid hemorrhage (SAH), CSF examination is judged to be no longer necessary if a noncontrast CT (NCCT) scan rules out SAH. In this study, the authors evaluated the performance of NCCT to rule out SAH in patients with positive CSF findings. METHODS Between January 2006 and April 2018, 1657 patients were admitted with a nontraumatic SAH. Of these patients, 1546 had positive SAH findings on the initial NCCT and 111 patients had an NCCT scan that was reported as negative in the acute setting, but with positive CSF examination for subarachnoid blood. Demographic data, World Federation of Neurosurgical Societies grade, and SAH time points (ictus, time of NCCT, and time of lumbar puncture) were collected. All 111 NCCT scans were reevaluated by an experienced neuroradiologist. RESULTS Of the 111 patients with positive CSF findings, SAH was initially missed on NCCT in 25 patients (23%). Reevaluation of 21 patients presenting within 6 hours of symptom onset confirmed NCCT negative findings in 12 (5 aneurysms), an aneurysmal SAH (aSAH) pattern in 8 (7 aneurysms), and a perimesencephalic pattern in 1 patient. Reevaluation of 90 patients presenting after 6 hours confirmed negative NCCT findings in 74 patients (37 aneurysms), aSAH pattern in 10 (4 aneurysms), and a perimesencephalic pattern in 6 (2 aneurysms). CONCLUSIONS CSF examination is still mandatory to rule out SAH as NCCT can fail to show blood, even within 6 hours after symptom onset. In addition, the diagnosis SAH was frequently missed during initial reporting.
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Affiliation(s)
| | | | | | | | | | - Jonathan M Coutinho
- 3Neurology, Amsterdam University Medical Centers (location AMC), Amsterdam, The Netherlands
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