Introduction: Intracranial hemorrhage (ICH) is associated with the highest rate of morbidity and mortality of all stroke subtypes. A subset of ICH occurs secondary to an underlying vascular abnormality and early recognition and management of these lesions may minimize the morbidity associated with rebleeding. Although non-invasive studies including magnetic resonance imaging (MRI) and computed tomographic angiography (CTA) are widely utilized in the workup of patients suspected of harboring a vascular lesion, they are limited in their resolution. We therefore sought to demonstrate the safety and efficacy of digital subtraction angiography (DSA) in the workup of patients with spontaneous ICH.
Methods: We retrospectively reviewed a prospectively maintained database of patients presenting with spontaneous ICH at our institution between 7/2012-12/2014 to identify 290 patients who underwent DSA as part of the workup for ICH. DSA was routinely performed in young patients without significant medical co-morbidities.
Results: Of the ICH patients who underwent angiography, the median age was 57 years, 45% had a diagnosis of hypertension, and 14% were diabetic. At the time of presentation, 30% of the patients were on anti-platelet therapy, and 10% were on anti-coagulation. A vascular etiology for the ICH was found in 30% of the patients evaluated with DSA, including cerebral aneurysm (36%), arteriovenous malformation (AVM) (33%), Arteriovenous fistula (6.7%), venous sinus thrombosis (6.7%), and vasculitis/vasculopathy (13.3%). Importantly, in patients with positive DSA that also underwent MRI, MRA, and/or CTA, 56% had negative findings on non-invasive imaging studies. Rate of stroke was one out of 290 patients (0.3%). Two patients experienced transient vessel dissections without associated sequelae. Two patients had groin hematomas that was managed conservatively.
Conclusions: DSA remains essential in the diagnosis of vascular etiology for ICH, particularly in a preselected high-yield population of young patients with few medical co-morbidities. In this population, DSA can be safely performed and may minimize the need for multiple non-invasive studies and may expedite diagnosis and treatment of these lesions. Further study is required to identify the optimal patient population for use of DSA as a first-line imaging strategy.
Patient Care: Patient care will be improved by prompt diagnosis and treatment of vascular pathologies underlying ICH.
Learning Objectives: By the conclusion of this session, participants should be able to 1) describe the importance of DSA in ICH 2) Discuss complications associated with DSA