Heit J J, Pastena G T, Nogueira R G, Yoo A J, Leslie-Mazwi T M, Hirsch J A, Rabinov J D
From the Department of Radiology (J.J.H.), Interventional Neuroradiology Division, Stanford University Hospital, Stanford, California.
Department of Radiology (G.T.P.), Albany Medical Center, Albany, New York.
AJNR Am J Neuroradiol. 2016 Feb;37(2):297-304. doi: 10.3174/ajnr.A4503. Epub 2015 Sep 3.
CT angiography is increasingly used to evaluate patients with nontraumatic subarachnoid hemorrhage given its high sensitivity for aneurysms. We investigated the yield of digital subtraction angiography among patients with SAH or intraventricular hemorrhage and a negative CTA.
An 11-year, single-center retrospective review of all consecutive patients with CTA-negative SAH was performed. Noncontrast head CT, CTA, DSA, and MR imaging studies were reviewed by 2 experienced interventional neuroradiologists and 1 neuroradiologist.
Two hundred thirty patients (mean age, 54 years; 51% male) with CTA-negative SAH were identified. The pattern of SAH was diffuse (40%), perimesencephalic (31%), sulcal (31%), isolated IVH (6%), or identified by xanthochromia (7%). Initial DSA yield was 13%, including vasculitis/vasculopathy (7%), aneurysm (5%), arteriovenous malformation (0.5%), and dural arteriovenous fistula (0.5%). An additional 6 aneurysms/pseudoaneurysms (4%) were identified by follow-up DSA, and a single cavernous malformation (0.4%) was identified by MRI. No cause of hemorrhage was identified in any patient presenting with isolated intraventricular hemorrhage or xanthochromia. Diffuse SAH was due to aneurysm rupture (17%); perimesencephalic SAH was due to aneurysm rupture (3%) or vasculitis/vasculopathy (1.5%); and sulcal SAH was due to vasculitis/vasculopathy (32%), arteriovenous malformation (3%), or dural arteriovenous fistula (3%).
DSA identifies vascular pathology in 13% of patients with CTA-negative SAH. Aneurysms or pseudoaneurysms are identified in an additional 4% of patients by repeat DSA following an initially negative DSA. All patients with CT-negative SAH should be considered for DSA. The pattern of SAH may suggest the cause of hemorrhage, and aneurysms should specifically be sought with diffuse or perimesencephalic SAH.
鉴于CT血管造影对动脉瘤具有较高的敏感性，其在评估非创伤性蛛网膜下腔出血患者中的应用日益广泛。我们调查了蛛网膜下腔出血或脑室内出血且CT血管造影（CTA）结果为阴性的患者中数字减影血管造影（DSA）的诊断率。
对所有连续的CTA阴性的蛛网膜下腔出血患者进行了一项为期11年的单中心回顾性研究。两名经验丰富的介入神经放射科医生和一名神经放射科医生对非增强头部CT、CTA、DSA和磁共振成像（MRI）研究进行了评估。
共确定了230例CTA阴性的蛛网膜下腔出血患者（平均年龄54岁；51%为男性）。蛛网膜下腔出血的类型为弥漫性（40%）、中脑周围性（31%）、脑沟性（31%）、孤立性脑室内出血（6%）或通过黄变症确定（7%）。初次DSA的诊断率为13%，包括血管炎/血管病变（7%）、动脉瘤（5%）、动静脉畸形（0.5%）和硬脑膜动静脉瘘（0.5%）。通过随访DSA又发现了6个动脉瘤/假性动脉瘤（4%），通过MRI发现了1个海绵状血管畸形（0.4%）。在任何表现为孤立性脑室内出血或黄变症患者中均未发现出血原因。弥漫性蛛网膜下腔出血是由于动脉瘤破裂（17%）；中脑周围性蛛网膜下腔出血是由于动脉瘤破裂（3%）或血管炎/血管病变（1.5%）；脑沟性蛛网膜下腔出血是由于血管炎/血管病变（32%）、动静脉畸形（3%）或硬脑膜动静脉瘘（3%）。
DSA在13%的CTA阴性的蛛网膜下腔出血患者中发现了血管病变。在初次DSA结果为阴性的患者中，通过重复DSA又在另外4%的患者中发现了动脉瘤或假性动脉瘤。所有CTA阴性的蛛网膜下腔出血患者均应考虑进行DSA检查。蛛网膜下腔出血的类型可能提示出血原因，对于弥漫性或中脑周围性蛛网膜下腔出血应特别寻找动脉瘤。
