J Cerebrovasc Endovasc Neurosurg.  2012 Sep;14(3):210-215. 10.7461/jcen.2012.14.3.210.

Subarachnoid Hemorrhage with Negative Baseline Digital Subtraction Angiography: Is Repeat Digital Subtraction Angiography Necessary?

• Yu DW
• Jung YJ
• Choi BY
• Chang CH

• KMID: 1808457
• DOI: http://doi.org/10.7461/jcen.2012.14.3.210

Abstract

INTRODUCTION
Patients with negative initial digital subtraction angiography (DSA) are at significant risk for re-bleeding, which can lead to severe disability and death. The purpose of this study was to evaluate the necessity of repeat DSA in subgroups of patients with subarachnoid hemorrhage (SAH) with negative initial DSA.
METHODS
A total of 904 spontaneous SAH patients were admitted to our department between May 2005 and May 2012. Twenty eight patients were selected for inclusion in this study because repeated DSA performed due to the etiology of the SAH could not be demonstrated on the initial DSA. According to the SAH pattern on initial computed tomography scans, patients were divided into perimesencephalic nonaneurysmal SAH (PN-SAH) and non PN-SAH (NPN-SAH) groups. Repeat DSA was performed in all patients, and two of these patients underwent a third DSA.
RESULTS
Of the 904 patients, 28 patients (3.1%) had no vascular abnormality on initial DSA. Sixteen PN-SAH patients underwent a repeat DSA; however, no aneurysms were found. In contrast, 12 patients with NPN-SAH underwent repeat DSA, with detection of two cerebral aneurysms. Overall, the false-negative rate of the initial DSA was 7.1% (2/28 patients). No significant differences in false-negative results on initial DSA were observed between the PN-SAH and NPN-SAH groups.
CONCLUSION
In the line with the results of the current study, we should be highly suspicious of patients with a nonaneurysmal SAH, especially those with a NPN-SAH pattern. In order to reduce the morbidity and mortality resulting from a misdiagnosis, repeat DSA is necessary, and exclusion of an aneurysm is important.

Keyword

Subarachnoid hemorrhage; Digital subtraction angiography; Aneurysm

MeSH Terms

Aneurysm
Angiography, Digital Subtraction
Diagnostic Errors
Humans
Intracranial Aneurysm
Subarachnoid Hemorrhage

Figure

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  Fig. 1 Initial noncontrast brain computed tomography (CT) and digital subtraction angiography (DSA). Diffuse subarachnoid hemorrhage (SAH) in the region of both the sylvian fissure and interhemispheric fissure (A). Initial three-dimensional rotational angiography image reveals no aneurysmal structure (B). Repeat DSA was performed on the eighth day of admission. Three-dimensional rotational angiography images clearly show a distal ICA aneurysm (C, D).

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  Fig. 2 Initial brain CT, magnetic resonance imaging (MRI) and DSA on admission. Brain noncontrast CT and MRI flair images show a subarachnoid hemorrhage on the right sylvian fissure (A, B), Mid-arterial phase DSA images show occlusion of the right M1 segment of the middle cerebral artery, but reveal no aneurysmal structure (C, D).

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  Fig. 3 Brain CT and repeat DSA on the sixth day of admission. A large amount of SAH is observed in the region of the basal cistern, both sylvian fissures, and interhemispheric fissure (A). Repeat DSA and three-dimensional angiography show an aneurysm on the ophthalmic segment of the right internal cerebral artery, probably a blister-like dorsal wall aneurysm (B, C, D).

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  Fig. 4 Flow-sheet for diagnosis of patients with subarachnoid hemorrhage.

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