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  • CT angiography: Improving diagnostic yield and cost-effectiveness in the initial evaluation of spontaneous non-subarachnoid intracerebral hemorrhage

    Final Number:

    Kimon Bekelis MD; Atman Desai MD; Wenyan Zhao; Dan Gibson; Dan Gologorsky; Clifford Eskey MD, PhD; Kadir Erkmen MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2012 Annual Meeting

    Introduction: CT angiography (CTA) is being increasingly used as a screening tool in the investigation of spontaneous intracerebral hemorrhage. However, CTA carries additional cost and risks, necessitating its judicious use. We hypothesized that CTA can be safely eliminated as a screening tool in a subgroup of patients.

    Methods: We performed a retrospective analysis of 1376 patients admitted to our institution with intracerebral hemorrhage over an 8-year period. Patients with subarachnoid hemorrhage, hemorrhagic conversion of ischemic infarcts, trauma, and known prior malignancy were excluded from the analysis resulting in 257 patients for final analysis. Multiple logistic regression analysis was used to investigate the joint effects of baseline variables of interest. Model selection was done using the stepwise method with p=0.10 being the significance level for variable entry and p=0.05 being the significance level for variable retention.

    Results: CTA studies detected vascular pathology in 34 patients (13.2%). Patient characteristics that were associated with significantly higher likelihood of identifying a structural vascular lesion as the source of hemorrhage included: patient age younger than 65 years (OR=16.36, p=0.0039), female gender (OR=14.9, p=0.0126), non-smokers (OR=103.8, p=0.0008), patients with intraventricular hemorrhage (OR=9.42, p=0.0379), and patients without hypertension (OR=515.78, p<0.0001). Patients who were older than 65 years of age, with a history of hypertension, and hemorrhage located in the cerebellum or basal ganglia were never found to have an identified structural source of hemorrhage on CTA.

    Conclusions: Patient characteristics and risk factors are important considerations when ordering diagnostic tests in the work-up non-subarachnoid, non-traumatic spontaneous intracerebral hemorrhage. While CTA is an accurate diagnostic examination, it can usually be omitted in the workup of patients with the described characteristics. The use of this algorithm has the potential to increase the yield and thus the safety and cost effectiveness of this diagnostic tool.

    Patient Care: Our study demonstrates that: 1) patients older than 65 years of age, who had preexisting hypertension, and location of hemorrhage in the basal ganglia or cerebellum were never found to have a positive CTA 2) all patients younger than 45 years of age without hypertension, smoking history, and impaired coagulation had a structural cause of hemorrhage found on further work-up. Most were identified on CTA, however one patient was found to have an AVM on subsequent DSA, and two patients had cavernous malformations discovered on MRI. Therefore patient care can be improved by following this algorithm based on the above results: 1) For patients who present with spontaneous ICH (without SAH, history of trauma, or malignancy) in the emergency room and belong to the first group, the clinician should have an extremely high threshold to perform a CTA, protecting the patients from the risks associated with it. 2) Young patients that belong to the second group should all undergo an angiographic study for further investigation. Given that all those patients in our study eventually had a conventional angiogram for further lesion characterization or treatment (and in one case for definitive diagnosis given the negative CTA), the use of DSA could be considered as a first-line screening tool for this subgroup of patients, to avoid the additional radiation and contrast exposure. 3) If DSA is negative, MRI should be performed to investigate the possibility of a cavernous malformation or newly diagnosed tumor. 4) In the rest of the patients no definitive conclusion can be drawn about the necessity of an initial angiographic study and therefore the decision needs to be tailored based on the clinical scenario.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the importance of the tailored use of CTA in the initial screening of spontaneous non-subarachnoid intracerebral hemorrhage (ICH). 2) Discuss, in small groups the relative importance of several risk factors that could increase the yield of CTA in the detection of vascular etiologies in patients with non-traumatic non-subarachnoid intracerebral hemorrhage. 3) Identify groups of patients where the use of CTA is of minimal yield and can be omitted from the initial workup of ICH 4) Identify groups of ICH patients where a vascular study would have very high yield. Those patients will be identified as candidates for immediate digital angiography, while omitting the screening step with CTA.

    References: 1. Badjatia N, Rosand J: Intracerebral hemorrhage. Neurologist 11:311-324, 2005 2. Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al: Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 38:2001-2023, 2007 3. Delgado Almandoz JE, Jagadeesan BD, Moran CJ, Cross DT, Zipfel GJ, Lee J, et al: Independent validation of the secondary intracerebral hemorrhage score with catheter angiography and findings of emergent hematoma evacuation. Neurosurgery 70:131-140, 2011 4. Goddard AJ, Tan G, Becker J: Computed tomography angiography for the detection and characterization of intra-cranial aneurysms: current status. Clin Radiol 60:1221-1236, 2005

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