Spontaneous intracranial hematomas: role of dynamic CT and angiography

Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage

BACKGROUND

Intracranial vascular malformations (brain or pial/dural arteriovenous malformations/fistulae, and aneurysms) are the leading cause of intracerebral haemorrhage (ICH) in young adults. Early identification of the intracranial vascular malformation may improve outcome if treatment can prevent ICH recurrence. Catheter intra-arterial digital subtraction angiography (IADSA) is considered the reference standard for the detection an intracranial vascular malformation as the cause of ICH. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are less invasive than IADSA and may be as accurate for identifying some causes of ICH.

OBJECTIVES

To evaluate the diagnostic test accuracy of CTA and MRA versus IADSA for the detection of intracranial vascular malformations as a cause of ICH.

SEARCH METHODS

We searched MEDLINE (1948 to August 2013), EMBASE (1980 to August 2013), MEDION (August 2013), the Database of Abstracts of Reviews of Effects (DARE; August 2013), the Health Technology Assessment Database (HTA; August 2013), ClinicalTrials.gov (August 2013), and WHO ICTRP (International Clinical Trials Register Portfolio; August 2013). We also performed a cited reference search for forward tracking of relevant articles on Google Scholar (http://scholar.google.com/), screened bibliographies, and contacted authors to identify additional studies.

SELECTION CRITERIA

We selected studies reporting data that could be used to construct contingency tables that compared CTA or MRA, or both, with IADSA in the same patients for the detection of intracranial vascular malformations following ICH.

DATA COLLECTION AND ANALYSIS

Two authors (CBJ and RA-SS) independently extracted data on study characteristics and measures of test accuracy. Two authors (CBJ and PMW) independently extracted data on test characteristics. We obtained data restricted to the subgroup undergoing IADSA in studies using multiple reference standards. We combined data using the bivariate model. We generated forest plots of the sensitivity and specificity of CTA and MRA and created a summary receiver operating characteristic plot.

MAIN RESULTS

Eleven studies (n = 927 participants) met our inclusion criteria. Eight studies compared CTA with IADSA (n = 526) and three studies compared MRA with IADSA (n = 401). Methodological quality varied considerably among studies, with partial verification bias in 7/11 (64%) and retrospective designs in 5/10 (50%). In studies of CTA, the pooled estimate of sensitivity was 0.95 (95% confidence interval (CI) 0.90 to 0.97) and specificity was 0.99 (95% CI 0.95 to 1.00). The results remained robust in a sensitivity analysis in which only studies evaluating adult patients (≥ 16 years of age) were included. In studies of MRA, the pooled estimate of sensitivity was 0.98 (95% CI 0.80 to 1.00) and specificity was 0.99 (95% CI 0.97 to 1.00). An indirect comparison of CTA and MRA using a bivariate model incorporating test type as one of the parameters failed to reveal a statistically significant difference in sensitivity or specificity between the two imaging modalities (P value = 0.6).

AUTHORS' CONCLUSIONS

CTA and MRA appear to have good sensitivity and specificity following ICH for the detection of intracranial vascular malformations, although several of the included studies had methodological shortcomings (retrospective designs and partial verification bias in particular) that may have increased apparent test accuracy.

Diagnostic accuracy of a simple clinical score to screen for vascular abnormalities in patients with intracerebral hemorrhage

BACKGROUND

Patients with intracerebral hemorrhage may have vascular abnormalities. There is no consensus about which patients should be studied with angiographic methods. Our aim was to derive a simple clinical score to screen for vascular abnormalities in intracerebral hemorrhage (ICH) and test its accuracy.

METHODS

The data were extracted from 2 different registries of patients with ICH. Variables associated with a vascular abnormality were studied in the derivation cohort. We derived a scale by assigning scores to the degree of association. We applied the score to the validation cohort and calculated sensitivity, specificity, positive and negative predictive values, positive and negative likelihood ratios (LRs), receiver operating curves (ROC) and area under the curve (AUC).

RESULTS

The performance of the scale in the derivation cohort showed the maximum operating point (MOP) at ≥5 (sensitivity .77, specificity .5). In the validation cohort, the MOP was a cutoff point of ≥5 (sensitivity .76, specificity .467). The positive and negative LRs were 2.1 and .6, respectively. The ROC showed similar AUC for both cohorts: .7. The probability of a vascular malformation was 23% with scores ≤5 and 83% with scores ≥9 in the validation cohort.

CONCLUSIONS

This simple clinical score can be used immediately on diagnosing an ICH to decide accurately whether to perform an angiographic study or not. Further studies using this simple score should be used to validate it in larger prospective unselected cohorts and consecutive patients.

State of the art in managing nontraumatic intracerebral hemorrhage

Nontraumatic intracerebral hemorrhage constitutes a major public health problem worldwide. Intracerebral hemorrhage leads to a high rate of morbidity and mortality. To date, no medical or surgical trials have clearly attested to the benefit of a particular therapy. The aim of this review was to summarize the best evidence for management decision-making in intracerebral hemorrhage.

Radiological investigation of spontaneous intracerebral hemorrhage: systematic review and trinational survey

BACKGROUND AND PURPOSE

It is not always clear whether, how, and when to undertake further radiological investigation of spontaneous (nontraumatic) intracerebral hemorrhage (ICH).

METHODS

We systematically reviewed Ovid MEDLINE and EMBASE databases for studies of the diagnostic utility of radiological investigations of the cause(s) of ICH. We sent a structured survey to neurologists, stroke specialists, neurosurgeons, and neuroradiologists in the United Kingdom, the Netherlands, and France to assess whether, how, and when they would investigate supratentorial ICH.

RESULTS

This systematic review detected 20 relevant studies (including 1933 patients), which either quantified the yield of a radiological investigation/imaging strategy (n=15) or compared 2 imaging techniques (n=5). Six hundred ninety-two (49%) physicians responded to the survey. Further investigation would have been undertaken by the following: 99% of respondents, for younger (38 to 43 years), normotensive adults with lobar or deep ICH; 76%, for older (age 72 to 83 years), normotensive adults with deep ICH; and 31%, for older adults with deep ICH and prestroke hypertension. Younger patient age was the strongest influence on the decision to further investigate ICH (odds ratio=16; 95% confidence interval, 13 to 20), followed by the absence of prestroke hypertension (odds ratio=5; 95% confidence interval, 4 to 6) and lobar ICH location (odds ratio=2; 95% confidence interval, 1 to 2).

CONCLUSIONS

The paucity of studies on the diagnostic utility of imaging investigations of the cause(s) of ICH may contribute to the variation observed in when and how and which patients are investigated in current clinical practice. Studies comparing different types of diagnostic strategies are required.

Angiographic examination of spontaneous putaminal hemorrhage

BACKGROUND

This study was carried out to examine indications for angiographic evaluation in the case of spontaneous putaminal hemorrhage.

METHODS

Angiographic examinations were performed on 62 consecutive adults with spontaneous putaminal hemorrhage without remarkable subarachnoid hemorrhage. Most patients were evaluated using conventional catheter angiography except for hypertensive patients over the age of 60 who underwent a magnetic resonance angiogram or a computed tomography angiogram. Computed tomography and clinical factors such as age and hypertension were correlated with the angiographic findings.

RESULTS

Nine of the 62 patients (15%) exhibited angiographic abnormalities, including middle cerebral artery aneurysm (n = 1), arteriovenous malformations (n = 3), moyamoya disease (n = 2), and the moyamoya phenomenon associated with a proximal middle cerebral artery occlusion (n = 3). The angiographic yield was significantly higher (1) among patients at or below the median age of 55 compared with those above (9/33, 27%, versus 0/29, 0%; p < 0.01), and (2) among patients without hypertension compared with those with hypertension (5/9, 56%, versus 4/53, 8%; p < 0.01).

CONCLUSIONS

Although our data could be biased due to the patient selection procedure, they suggest that angiographic evaluation is highly useful for spontaneous putaminal hemorrhage regardless of volume and shape of the hematomas, excepting hypertensive patients over 55 years of age.

Imaging of hemorrhagic stroke

Neuroimaging by CT or MR is necessary for the detection of hemorrhagic stroke and provides important data regarding the cause of stroke. Serial changes in the CT and MR appearance of hematoma attributable to temporal evolution must be assessed to assure accurate diagnosis. Emerging evidence suggests that the use of MR imaging alone may be adequate for identifying hemorrhage in acute stroke patients and that GRE MR imaging is superior to both CT and conventional spin-echo MR imaging sequences for the detection of chronic microbleeds and hemorrhagic conversion of infarction.

Hemorrhagic stroke

Neuroimaging by CT or MR imaging is necessary for the identification of hemorrhagic stroke and provides information about its cause. The appearance of intracranial hematoma (ICH) on CT and MR imaging evolves over time and must be understood to facilitate accurate diagnosis. The cause of ICH varies by location. New evidence suggests that MR imaging alone may be adequate to identify hemorrhagic stroke in the acute setting, and that MR imaging is superior to CT for identification of chronic microbleeds and hemorrhagic conversion of infarction.

Imagerie vasculaire non invasive et malformations artérioveineuses cérébrales

Imaging evaluation of cerebral arteriovenous malformations (AVM) requires selective visualization of the different compartments of the malformation in order to select the therapeutic management. Conventional angiography remains the reference to analyze intracranial vessel conspicuity but non-invasive methods constitute an excellent alternative. Among these techniques, CT angiography is rarely used because of the need to inject iodinated contrast material and because of irradiation. MR angiography provides useful information and can be performed using several techniques: time of flight with or without contrast material injection, phase contrast, three-dimensional (3D) gradient echo acquisition after contrast material injection and, more recently, MR digital subtraction angiography. The purpose of this review article is to summarize the different non-invasive techniques for vascular imaging and to analyze the usefulness of these techniques for the assessment of brain AVMs.