Introduction: Prior to minimally invasive intracerebral hemorrhage (ICH) evacuation, many patients undergo digital subtraction angiography (DSA) to rule out culprit vascular lesions. The diagnostic yield of performing pre-operative DSA in these patients is not known. Previous studies have investigated the yield and effectiveness of DSA in ICH for various populations (1–3), but there is no data available for the subset of patients deemed good candidates for surgical evacuation. Nonetheless, DSA prior to hematoma evacuation is commonly performed to identify vascular lesions prior to surgery (4–8).
Methods: Thirty patients were deemed good candidates (medically fit for surgery, >20cc hemorrhage) for minimally invasive intracerebral hemorrhage evacuation at our institution starting in December 2015. All patients underwent pre-operative DSA immediately prior to the planned evacuation procedure.
Results: Of the 30 patients, 5 had positive DSA findings (17%). The causative vascular lesions included one aneurysm, three AVMs, and one tumor. The aneurysm and tumor were visible on CTA, but the AVMs were not.
Conclusions: ICH secondary to an aneurysm, arteriovenous malformation, or tumor requires addressing the source lesion in addition to hematoma evacuation. In certain cases, evacuation cannot be safely completed. A rate of 17% in our cohort represents a significant percentage of patients that would benefit from DSA prior to the planned ICH evacuation procedure.
Patient Care: A significant subset of patients will benefit from routine DSA prior to undergoing minimally invasive intracerebral hematoma evacuation. DSA results can identify culprit vascular lesions not visible on CTA and alter operative management.
Learning Objectives: By the conclusion of this session, participants should be able to describe the importance of performing DSA prior to minimally invasive intracerebral hematoma evacuation.
References: 1. Zhu, X. L., Chan, M. S. Y. & Poon, W. S. Spontaneous Intracranial Hemorrhage: Which Patients Need Diagnostic Cerebral Angiography??: A Prospective Study of 206 Cases and Review of the Literature. Stroke 28, 1406–1409 (1997).
2. Wong, G. K. C. et al. Computed Tomographic Angiography and Venography for Young or Nonhypertensive Patients With Acute Spontaneous Intracerebral Hemorrhage. Stroke 42, 211–213 (2011).
3. Kadkhodayan, Y. et al. Yield of catheter angiography in patients with intracerebral hemorrhage with and without intraventricular extension. J. Neurointerv. Surg. 4, 358–363 (2012).
4. Yamamoto, T., Nakao, Y., Mori, K. & Maeda, M. Endoscopic Hematoma Evacuation for Hypertensive Cerebellar Hemorrhage. Minim. Invasive Neurosurg. 49, 173–178 (2006).
5. Beynon, C., Schiebel, P., Bösel, J., Unterberg, A. W. & Orakcioglu, B. Minimally invasive endoscopic surgery for treatment of spontaneous intracerebral haematomas. Neurosurg. Rev. 38, 421–428 (2015).
6. Montes, J. M., Wong, J. H., Fayad, P. B. & Awad, I. A. Stereotactic computed tomographic-guided aspiration and thrombolysis of intracerebral hematoma?: protocol and preliminary experience. Stroke 31, 834–840 (2000).
7. Auer, L. M. et al. Endoscopic surgery versus medical treatment for spontaneous intracerebral hematoma: a randomized study. J. Neurosurg. 70, 530–535 (1989).
8. Barlas, O. et al. Image-guided keyhole evacuation of spontaneous supratentorial intracerebral hemorrhage. Minim. Invasive Neurosurg. 52, 62–68 (2009).