Vogetseder Michael, Rass Verena, Lindner Anna, Kindl Philipp, Kofler Mario, Lenhart Lukas, Putnina Lauma, Helbok Raimund, Schiefecker Alois Josef, Pfausler Bettina, Grams Astrid, Beer Ronny
Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria.
World Neurosurg. 2024 Nov;191:e496-e504. doi: 10.1016/j.wneu.2024.08.158. Epub 2024 Sep 5.
The aim of this study was to assess the diagnostic yield of follow-up investigations in aneurysm-negative subarachnoid hemorrhage (SAH) patients.
In 109 (25%) of 435 patients with SAH and initial negative digital subtraction angiography (DSA), the diagnostic yield of repeat DSA and magnetic resonance imaging (MRI) of the brain and craniocervical junction was reviewed.
Of the 109 patients with an initial negative DSA, 51 (47%) had perimesencephalic (PM), 54 (50%) had nonperimesencephalic (NPM) blood distribution, and 4 (3.7%) had computed tomography-negative SAH. A delayed bleeding source was determined in 3 of 82 (3.7%) patients who underwent repeat DSA and in 1 of 5 patients who underwent a third DSA. The bleeding patterns of these patients were all NPM (n = 4). Repeat DSA did not identify a bleeding source in patients with PM-SAH. MRI of the brain and craniocervical junction after 2 days revealed a bleeding source in 1 of 105 patients (1%) in a computed tomography-negative SAH. When all diagnostic modalities, including exploratory craniotomy and MRI of the spinal axis, were considered, the rate of delayed diagnosis of the bleeding source was 6.4% (7/109). In addition to the bleeding pattern, patients with delayed diagnosis of the bleeding source were characterized by worse disease severity parameters, worse radiological grading scales, and more in-hospital complications than patients without delayed diagnosis of a bleeding source.
The results of this study support the use of repeat DSA in patients with NPM-SAH; however, routine repeat DSA may not be indicated in PM-SAH patients. The routine use of MRI remains controversial.
本研究的目的是评估动脉瘤阴性蛛网膜下腔出血（SAH）患者随访检查的诊断率。
回顾了435例SAH患者中109例（25%）初始数字减影血管造影（DSA）结果为阴性的患者重复DSA及脑和颅颈交界处磁共振成像（MRI）的诊断率。
109例初始DSA结果为阴性的患者中，51例（47%）为中脑周围（PM）型，54例（50%）为非中脑周围（NPM）型血液分布，4例（3.7%）为计算机断层扫描阴性SAH。在82例接受重复DSA的患者中有3例（3.7%）以及5例接受第三次DSA的患者中有1例确定了延迟出血源。这些患者的出血模式均为NPM型（n = 4）。重复DSA未在PM-SAH患者中发现出血源。2天后脑和颅颈交界处的MRI在1例计算机断层扫描阴性SAH的105例患者中发现了1例出血源（1%）。当考虑所有诊断方法，包括开颅探查和脊柱轴MRI时，出血源延迟诊断率为6.4%（7/109）。除出血模式外，与未延迟诊断出血源的患者相比，出血源延迟诊断的患者疾病严重程度参数更差、放射学分级量表更差且院内并发症更多。
本研究结果支持对NPM-SAH患者使用重复DSA；然而，PM-SAH患者可能无需常规重复DSA。MRI的常规使用仍存在争议。
