Ruptured Cerebral Aneurysms Missed by Initial Angiographic Study

Iwanaga, Hideaki; Wakai, Susumu; Ochiai, Chikayuki; Narita, Junichi; Inoh, Satoshi; Nagai, Masakatsu

doi:10.1227/00006123-199007000-00006

Cited by 89 publications

(27 citation statements)

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“…However, in 2 to 21% of NNSAH cases, additional information may be provided via repeat DSA investigations to determine the source of bleeding (4,31,49,57). Some authors even advocated a third or fourth DSA (4).…”

Section: ) Subtypes Were Classified As They Were Classified In Ourmentioning

confidence: 99%

“…of patients with non-traumatic subarachnoid hemorrhage, no underlying cause was detected on initial four to six vessel digital subtraction angiography (DSA) (13,21,31,48,52,54).…”

Section: Introductionmentioning

confidence: 99%

“…

MATERIAL and METHODS:

Between January 2004 and December 2014, 81 patients with angiography-negative non-traumatic subarachnoid hemorrhage (SAH) were treated at our institution.

…”

mentioning

confidence: 99%

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Clinical course of nontraumatic nonaneurysmal subarachnoid hemorrhage: a single institution experience over 10 years and review of the contemporary literature

Akçakaya

Aydöseli²,

Aras³

et al. 2016

Turkish Neurosurgery

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ABSTRACTof patients with non-traumatic subarachnoid hemorrhage, no underlying cause was detected on initial four to six vessel digital subtraction angiography (DSA) (13,21,31,48,52,54).Although the clinical course of non-traumatic non-aneurysmal subarachnoid hemorrhage (NNSAH) has been reported to be █ INTRODUCTION T he majority of non-traumatic subarachnoid hemorrhage (SAH) events are caused by the rupture of saccular aneurysms, which are associated with significant morbidity and mortality (16). However, in approximately 15% AIM: To report our experience with a relatively large series of patients with non-traumatic non-aneurysmal subarachnoid hemorrhage (NNSAH) to identify the prognosis associated with different bleeding patterns as well as a further diagnostic work-up to determine the underlying cause. MATERIAL and METHODS:Between January 2004 and December 2014, 81 patients with angiography-negative non-traumatic subarachnoid hemorrhage (SAH) were treated at our institution. Diagnosis was confirmed with a typical history of spontaneous SAH and cranial computed tomography (CT) scan or lumbar puncture (LP). The patients were grouped according to the bleeding pattern on the CT scan: Group 1: Perimesencephalic (PM) SAH (n=33, 40.7%); Group 2: Non-perimesencephalic (nPM) SAH (n=41, 50.6%); and Group 3: CT-negative NNSAH (n=7, 8.6%). The clinical course, hospitalization period, and complications were noted. All patients underwent an initial four-vessel digital subtraction angiography (DSA). Cranial magnetic resonance imaging (MRI), repeat DSA investigations and spinal MRI were performed in all patients. RESULTS:The mean hospital stays were 6.3, 14.7 and 10.1 days for patient groups 1, 2, and 3, respectively. The mortality rate was 1.2% (1 patient) in our series. Repeat DSA investigations were positive in two patients (2.5%), both from Group 2 (4.9%). Cranial MRI revealed 100% negative results. Spinal MRI revealed positive results in three patients from Group 2 (7.3%). CONCLUSION:We suggest our diagnostic work-up for patients with nPM-SAH, namely repeat DSA and spinal MRI, until an evidence-based guideline is established for the patient management.

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Section: ) Subtypes Were Classified As They Were Classified In Ourmentioning

confidence: 99%

“…of patients with non-traumatic subarachnoid hemorrhage, no underlying cause was detected on initial four to six vessel digital subtraction angiography (DSA) (13,21,31,48,52,54).…”

Section: Introductionmentioning

confidence: 99%

“…

MATERIAL and METHODS:

Between January 2004 and December 2014, 81 patients with angiography-negative non-traumatic subarachnoid hemorrhage (SAH) were treated at our institution.

…”

mentioning

confidence: 99%

See 1 more Smart Citation

Clinical course of nontraumatic nonaneurysmal subarachnoid hemorrhage: a single institution experience over 10 years and review of the contemporary literature

Akçakaya

Aydöseli²,

Aras³

et al. 2016

Turkish Neurosurgery

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“…Studies from the pre-CTA era have shown that a repeat DSA study is valuable in these patients, with a diagnostic yield up to 46%. 10,11,18 It is therefore common practice to perform repeat DSA in such patients. Nevertheless, cranial DSA is an invasive procedure that carries a 0.5%-1.8% risk of neurological complications, with permanent deficit in 0.09%-0.5%.…”

confidence: 99%

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

Bakker¹,

Groen²,

Foumani³

et al. 2014

JNS

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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.

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“…Because of the nodular appearance and upward direction of the stump of the P1 segment, it was misinterpreted as an aneurysm. During the operation, a tiny ruptured aneurysm missed on preoperative angiograms was found in the left A1-A2 junction and was clipped safely 1,4) . Kalia and colleagues 5) reported a patient with a subarachnoid hemorrhage in whom a partially thrombosed, fenestrated basilar artery mimicking an aneurysm of the vertebrobasilar junction was seen on preoperative angiography.…”

Section: Discussionmentioning

confidence: 99%

Occlusion of the Middle Cerebral Artery Branch Mimicking Aneurysm

Lee

et al. 2007

J Korean Neurosurg Soc

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A 26-year-old man was admitted to our department due to intermittent left hemiparesis for 3 months. Magnetic resonance image showed subacute infarction in the right precentral gyrus. Digital subtraction angiography and magnetic resonance angiography revealed an aneurysmal protrusion at the right middle cerebral artery (MCA) bifurcation. It was difficult to differentiate the aneurysm from the occlusion of the middle trunk of the MCA trifurcation. Brain single photon emission computerized tomography showed a decrease in perfusion in the right posterior frontal lobe without vascular reserve. Therefore, we planned a superficial temporal artery-MCA anastomosis with an exploration of the right MCA bifurcation. Intraoperatively, the aneurysmal opacification on preoperative angiography proved to be the proximal stump of the occluded middle trunk of the MCA trifurcation. An aneurysmal protrusion at the MCA bifurcation does not always indicate an aneurysm. In diagnosing protruding vascular lesions at the MCA bifurcation, the possibility of a vascular stump should be considered according to their angioanatomical appearance and the history of the patient.

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Ruptured Cerebral Aneurysms Missed by Initial Angiographic Study

Cited by 89 publications

References 0 publications

Clinical course of nontraumatic nonaneurysmal subarachnoid hemorrhage: a single institution experience over 10 years and review of the contemporary literature

Clinical course of nontraumatic nonaneurysmal subarachnoid hemorrhage: a single institution experience over 10 years and review of the contemporary literature

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

Occlusion of the Middle Cerebral Artery Branch Mimicking Aneurysm

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