J Korean Neurosurg Soc.  2019 Sep;62(5):526-535. 10.3340/jkns.2018.0238.

Should Cerebral Angiography Be Avoided within Three Hours after Subarachnoid Hemorrhage?

• An H
• Park J
• Kang DH
• Son W
• Lee YS
• Kwak Y
• Ohk B

• KMID: 2457942
• DOI: http://doi.org/10.3340/jkns.2018.0238

Abstract

OBJECTIVE
While the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH.
METHODS
Patients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans.
RESULTS
In-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p =0.032). Cerebral angiography after SAH was performed on 88 patients ≤3 hours, 74 patients between 3-6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ≤3 hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography.
CONCLUSION
Despite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.

Keyword

Aneurysm, Ruptured; Angiography; Intracranial aneurysm; Subarachnoid hemorrhage

MeSH Terms

Aneurysm
Aneurysm, Ruptured
Angiography
Angiography, Digital Subtraction
Catheters
Cerebral Angiography*
Emergencies
Hemorrhage
Humans
Hypertension
Intracranial Aneurysm
Logistic Models
Multivariate Analysis
Risk Factors
Subarachnoid Hemorrhage*

Reference

References

1. Allan DM, Witcombe JB. Intracranial extravasation of contrast medium during carotid angiography. Br J Radiol. 50:404–411. 1977.

2. Amagasa M, Yoshimoto T, Mizoi K, Suzuki J. Early cerebral angiography after aneurysm rupture. Analysis of 197 cases. J Neurosurg. 65:776–778. 1986.

3. Aoyagi N, Hayakawa I. Rerupture of intracranial aneurysms during angiography. Acta Neurochir (Wien). 98:141–147. 1989.

4. Boogaarts HD, van Lieshout JH, van Amerongen MJ, de Vries J, Verbeek AL, Grotenhuis JA, et al. Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis. J Neurosurg. 122:921–928. 2015.

5. Cha KC, Kim JH, Kang HI, Moon BG, Lee SJ, Kim JS. Aneurysmal rebleeding: factors associated with clinical outcome in the rebleeding patients. J Korean Neurosurg Soc. 47:119–123. 2010.

6. Clarençon F, Piotin M, Pistocchi S, Babic D, Blanc R. Evaluation of stent visibility by flat panel detector CT in patients treated for intracranial aneurysms. Neuroradiology. 54:1121–1125. 2012.

7. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg. 84:35–42. 1996.

8. Guo LM, Zhou HY, Xu JW, Wang Y, Qiu YM, Jiang JY. Risk factors related to aneurysmal rebleeding. World Neurosurg. 76:292–298. discussion 253-254. 2011.

9. Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson KE. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 97:771–778. 2002.

10. Inagawa T. Ultra-early rebleeding within six hours after aneurysmal rupture. Surg Neurol. 42:130–134. 1994.

11. Inagawa T, Kamiya K, Ogasawara H, Yano T. Rebleeding of ruptured intracranial aneurysms in the acute stage. Surg Neurol. 28:93–99. 1987.

12. Jane JA, Kassell NF, Torner JC, Winn HR. The natural history of aneurysms and arteriovenous malformations. J Neurosurg. 62:321–323. 1985.

13. Juvela S. Rebleeding from ruptured intracranial aneurysms. Surg Neurol. 32:323–326. 1989.

14. Kassell NF, Torner JC. Aneurysmal rebleeding: a preliminary report from the Cooperative Aneurysm Study. Neurosurgery. 13:479–481. 1983.

15. Koenig GH, Marshall WH Jr, Poole GJ, Kramer RA. Rupture of intracranial aneurysms during cerebral angiography: report of ten cases and review of the literature. Neurosurgery. 5:314–324. 1979.

16. Komiyama M, Tamura K, Nagata Y, Fu Y, Yagura H, Yasui T. Aneurysmal rupture during angiography. Neurosurgery. 33:798–803. 1993.

17. Kusumi M, Yamada M, Kitahara T, Endo M, Kan S, Iida H, et al. Rerupture of cerebral aneurysms during angiography--a retrospective study of 13 patients with subarachnoid hemorrhage. Acta Neurochir (Wien). 147:831–837. 2005.

18. Laidlaw JD, Siu KH. Poor-grade aneurysmal subarachnoid hemorrhage: outcome after treatment with urgent surgery. Neurosurgery. 53:1275–1280. discussion 1280-1282. 2003.

19. Ohkuma H, Tsurutani H, Suzuki S. Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management. Stroke. 32:1176–1180. 2001.

20. Park J, Woo H, Kang DH, Kim YS, Kim MY, Shin IH, et al. Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes. J Neurosurg. 122:383–391. 2015.

21. Park SD, Kim JH, Chang CH, Jung YJ. Procedure-related complication rate for the endovascular treatment of aneurysmal subarachnoid hemorrhage under local anesthesia. J Cerebrovasc Endovasc Neurosurg. 18:215–222. 2016.

22. Saitoh H, Hayakawa K, Nishimura K, Okuno Y, Murayama C, Miyazawa T, et al. Intracarotid blood pressure changes during contrast medium injection. AJNR Am J Neuroradiol. 17:51–54. 1996.

23. Saitoh H, Hayakawa K, Nishimura K, Okuno Y, Teraura T, Yumitori K, et al. Rerupture of cerebral aneurysms during angiography. AJNR Am J Neuroradiol. 16:539–542. 1995.

24. Sampei T, Yasui N, Mizuno M, Nakajima S, Ishikawa T, Hadeishi H, et al. Contrast medium extravasation during cerebral angiography for ruptured intracranial aneurysm--clinical analysis of 26 cases. Neurol Med Chir (Tokyo). 30:1011–1015. 1990.

25. Söderman M, Babic D, Holmin S, Andersson T. Brain imaging with a flat detector C-arm : technique and clinical interest of XperCT. Neuroradiology. 50:863–868. 2008.

26. Sorimachi T, Takeuchi S, Koike T, Minakawa T, Tanaka R. Intra-aneurysmal pressure changes during angiography in coil embolization. Surg Neurol. 48:451–457. 1997.

27. Tsementzis SA, Kennett RP, Hitchcock ER. Rupture of intracranial vascular lesions during arteriography. J Neurol Neurosurg Psychiatry. 47:795–798. 1984.

28. Waldenberger P, Chemelli A, Mallouhi A. Intra-arterial haemodynamic changes during cerebral three-dimensional rotational angiography. Eur Radiol. 19:503–508. 2009.

29. Yuguang L, Tao J, Meng L, Shugan Z, Jiangang W, Yang Y, et al. Rerupture of intracranial aneurysms during cerebral angiography. J Clin Neurosci. 10:674–676. 2003.

30. Zaehringer M, Wedekind C, Gossmann A, Krueger K, Trenschel G, Landwehr P. Aneurysmal re-rupture during selective cerebral angiography. Eur Radiol 12 Suppl. 3:S18–S24. 2002.