Repeat digital subtraction angiography after a negative baseline assessment in nonperimesencephalic subarachnoid hemorrhage: a pooled data meta-analysis

Abstract

Object A repeat digital subtraction angiography (DSA) study of the cranial vasculature is routinely performed in patients with diffuse nonperimesencephalic subarachnoid hemorrhage (SAH) after negative baseline CT angiography (CTA) and DSA studies. However, DSA carries a low but substantial risk of neurological complications. Therefore, the authors evaluated the added value of repeat DSA in patients with initial angiographically negative diffuse nonperimesencephalic SAH. Methods A systematic review of the contemporary literature was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. Studies from January 2000 onward were reviewed since imaging modalities have much improved over the last decade. A pooled analysis was conducted to identify the detection rate of repeat DSA. In addition, the diagnostic yield of repeat DSAs in a prospectively maintained single-center series of 1051 consecutive patients with SAH was added to the analysis. Results An initial search of the literature yielded 179 studies, 8 of which met the selection criteria. Another 45 patients from the authors' institution were included in the study, providing 368 patients eligible for the pooled analysis. In 37 patients (10.0%, 95% CI 7.4%–13.6%) an aneurysm was detected on repeat DSA. The timing of the repeat DSA varied from 1 to 6 weeks after the initial DSA. The use of 3D techniques was poorly described among these studies, and no direct comparisons between CTA and DSA were made. Conclusions Repeat DSA is still warranted in patients with a diffuse nonperimesencephalic SAH and negative initial assessment. However, the exact timing of the repeat DSA is subject to debate.

Imaging of cerebral aneurysms: a clinical perspective

“…Even when DSA fails to demonstrate an aneurysm in the setting of spontaneous subarachnoid hemorrhage, delayed repeat imaging is indicated. One literature review identified 37 aneurysms out of 368 angiography-negative subarachnoid hemorrhage patients on delayed, repeat DSA from one to six weeks after their initial study [50]. The higher resolution of DSA also allows for better neck characterization to guide endovascular versus open surgical treatment and better visualization of associated branch vessels [30].…”

Increasing numbers of nonaneurysmal subarachnoid hemorrhage in the last 15 years: antithrombotic medication as reason and prognostic factor?

“…However, in up to 20% of patients with SAH, results of cerebral angiography, CT, and MRI are negative for aneurysms or other vascular malformations. 2,7,11 More recent data show an increasing number of cases of spontaneous SAH 18,24 as well as nonaneurysmal SAH (NASAH). 15,16 Long-term dipyridamole and warfarin use were associated with an increased risk for aneurysmal SAH (aSAH), whereas the data for low-dose acetylsalicylic acid (LDA) were inconsistent.…”

MRI-detection rate and incidence of lumbar bleeding sources in 190 patients with non-aneurysmal SAH

“…Given the vasospasm period and the chance of a thrombosed aneurysm, it is reasonable to perform a repeat DSA at least 10–14 days after the ictus [20]. …”