Multidetector row CT angiography in spontaneous lobar intracerebral hemorrhage: a prospective comparison with conventional angiography

Diagnostic yield of computed tomography angiography in patients presenting with spontaneous intracerebral hemorrhage

BACKGROUND

Hypertension and cerebral amyloid angiopathy are the most common causes of spontaneous intracerebral hemorrhage (ICH); however, these conditions do not imply macrovascular pathology. Still, computed tomography (CT) angiography (CTA) is often performed in the acute phase in patients with ICH.

PURPOSE

To assess the diagnostic yield of CTA in the detection of secondary etiology in consecutive patients with spontaneous ICH.

MATERIAL AND METHODS

We performed a retrospective analysis of data from a prospective single-center cohort study of 203 patients presenting with spontaneous ICH admitted to a comprehensive stroke center over a two-year period (15 October 2016 to 15 October 2018). The underlying vascular pathology was assessed using CTA.

RESULTS

CTA was performed in addition to non-contrast CT and/or magnetic resonance imaging (MRI). Vascular pathology was found in 11 of 203 (5.4%) patients and included arteriovenous malformations (n=4), aneurysms (n=4), vasospasms (n=1), cerebral venous thrombosis (n=1), and other vascular malformations (n=1). In eight cases, the finding was deemed symptomatic. Patients with vascular pathology on CTA more often had lobar located hemorrhages (63.6% vs. 36.4%, P = 0.049). Numerically, patients with vascular pathology were younger, had smaller hematoma volumes, and lower mortality.

CONCLUSION

Underlying macrovascular pathology was detected on CTA in only approximately 1 of 20 consecutive patients with ICH. The patients with vascular pathology more often had a hemorrhage with a lobar location and young age and the present study is supportive of a risk-based stratification approach in performing CTA.

Current Evaluation of Intracerebral Hemorrhage

Advanced imaging is currently critical in diagnosing, predicting, and managing intracerebral hemorrhage. MD CT angiography has occupied the first line of evaluating patients with a clinical diagnosis of a stroke, given its rapid acquisition time, high resolution of vascular structures, and sensitivity for secondary causes of ICH.

Chinese Cerebrovascular Neurosurgery Society and Chinese Interventional & Hybrid Operation Society, of Chinese Stroke Association Clinical Practice Guidelines for Management of Brain Arteriovenous Malformations in Eloquent Areas

Aim: The aim of this guideline is to present current and comprehensive recommendations for the management of brain arteriovenous malformations (bAVMs) located in eloquent areas. Methods: An extended literature search on MEDLINE was performed between Jan 1970 and May 2020. Eloquence-related literature was further screened and interpreted in different subcategories of this guideline. The writing group discussed narrative text and recommendations through group meetings and online video conferences. Recommendations followed the Applying Classification of Recommendations and Level of Evidence proposed by the American Heart Association/American Stroke Association. Prerelease review of the draft guideline was performed by four expert peer reviewers and by the members of Chinese Stroke Association. Results: In total, 809 out of 2,493 publications were identified to be related to eloquent structure or neurological functions of bAVMs. Three-hundred and forty-one publications were comprehensively interpreted and cited by this guideline. Evidence-based guidelines were presented for the clinical evaluation and treatment of bAVMs with eloquence involved. Topics focused on neuroanatomy of activated eloquent structure, functional neuroimaging, neurological assessment, indication, and recommendations of different therapeutic managements. Fifty-nine recommendations were summarized, including 20 in Class I, 30 in Class IIa, 9 in Class IIb, and 2 in Class III. Conclusions: The management of eloquent bAVMs remains challenging. With the evolutionary understanding of eloquent areas, the guideline highlights the assessment of eloquent bAVMs, and a strategy for decision-making in the management of eloquent bAVMs.

Benefits and Risks of CT Angiography Immediately after Emergency Arrival for Patients with Intracerebral Hematoma

Computed tomography angiography (CTA) immediately after diagnosis of intracerebral hematoma (ICH) on noncontrast CT in the emergency room has benefits, which consist of early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH, but CTA also involves possible risks of acute kidney injury (AKI) and adverse reactions. The purpose of this study was to evaluate the benefits and risks of CTA. A total of 1423 consecutive adult patients diagnosed with ICH who were admitted within 3 days of onset between 2010 and 2017 were retrospectively analyzed. Of 1082 patients undergoing CTA, 162 patients (15.0%) showed secondary ICH, and the sensitivity of CTA for secondary ICH was 95.7%. Of 920 patients with primary ICH, a logistic regression model using the spot sign and four other previously reported risk factors (antiplatelet agents, anticoagulants, interval from onset to arrival, hematoma volume) with an area under the curve (AUC) of 0.787 significantly improved model performance to predict hematoma growth compared with a model using the same four factors without the spot sign (AUC: 0.697) (DeLong’s test: P = 0.0002). Rates of AKI occurrence were 9.0% and 9.8% in patients with and without CTA, respectively. The odds ratio of AKI in patients with CTA adjusted by reported risk factors was 1.16 (95% confidence interval: 0.72–1.95, P = 0.5548). Emergency CTA following noncontrast CT in patients with ICH could be useful for early diagnosis of secondary ICH and prediction of hematoma growth using the spot sign in primary ICH with little risk.

High-Resolution MRI Vessel Wall Imaging in Acute Aneurysmal Subarachnoid Hemorrhage : Spatiotemporal Pattern and Clinicoradiologic Implications

PURPOSE

The spatiotemporal pattern of vessel wall changes was investigated on two time point magnetic resonance images (MRI) in patients with aneurysmal subarachnoid hemorrhages (aSAH) and its association with clinicoradiologic severity score and delayed cerebral ischemia (DCI) was analyzed.

METHODS

A total of 32 prospectively enrolled patients with aSAH (mean age 56.94 years; 9 male and 23 female) underwent vessel wall imaging (VWI) MRI. Of the patients 20 completed two time point MRIs early and late during the admission, 10 patients only had early MRI and 2 patients only had late MRI. Timing of early MRI had a mean of 2.5 days (range 1-6 days) and late MRI had a mean of 10.5 days (range 7-16 days) from time of admission. Spatiotemporal pattern of vessel wall enhancement (VWE), vasospasm, diffusion-weighted imaging (DWI) lesion burden (grade 0-III) and infarcts were analyzed against the clinicoradiologic severity score (high-risk: vasograde red and yellow, low-risk: vasograde green) and DCI.

RESULTS

On the early MRI, mild VWE alone was significantly more frequent in the high-risk group (36.7% versus 20.0%; P = 0.024). On the late MRI, vasospasm was significantly more frequent in the high-risk group (27.2% versus 4.5%; P = 0.022). Vasospasm infrequently showed mild VWE (6.67% on early MRI and 9.09% on late MRI). Both mild VWE alone on early MRI and on late MRI were significantly associated with development of DCI during the admission (P = 0.034 and P = 0.035, respectively).

CONCLUSION

Mild VWE on early MRI and vasospasm on late MRI were significantly more prevalent in high-risk and DCI patients suggesting VWI might enable imaging of early neuroinflammatory changes which are part of the pathomechanism of vasospasm and DCI.

An update on neurocritical care for intracerebral hemorrhage

Introduction: Intracerebral hemorrhage remains one of the leading causes of death and disability worldwide with few established interventions that improve neurologic outcome. Research dedicated to better understanding and treating hemorrhagic strokes has multiplied in the past decade. Areas Covered: This review aims to discuss the current landscape of management of intracerebral hemorrhage in a critical care setting and provide updates regarding developments in therapeutic interventions and targets. PubMed was utilized to review recent literature, with a focus on large trials and meta-analyses, which have shaped current practice. Published committee guidelines were also included. A focus was placed on research published after 2015 in an effort to supplement previous reviews included in this publication. Expert Opinion: Literature pertaining to ICH management has allowed for a greater understanding of ineffective strategies as opposed to those of benefit. Despite this, mortality has improved worldwide, which may be the result of growing research efforts. Areas of future research that will impact mortality and improve neurologic outcomes include prevention of hematoma expansion, optimization of blood pressure targets, effective coagulopathy reversal, and minimally invasive surgical techniques to reduce hematoma burden.

Developing an algorithm to identify patients with intracerebral haemorrhage secondary to a macrovascular cause

Introduction

Determining the cause of spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is critical to guide treatment and prognosis. We investigated whether small vessel disease (SVD) in addition to clinical and other radiological findings on acute neuroimaging predicts a low risk of a macrovascular cause (e.g. an arterio-venous malformation, aneurysm or dural arteriovenous fistula).

Patients and methods

We identified patients with acute spontaneous ICH who underwent acute non-contrast CT, CT angiography (CTA) and intra-arterial digital subtraction angiography (IADSA) at our institution from January 2010 to April 2014. Logistic regression including CTA result, SVD, age, pre-ICH hypertension and ICH location was used to derive a prediction model, validated using bootstrapping.

Results

173 patients (46% female, median age 49) of whom 78 had a macrovascular cause on IADSA were included. Predictors of a macrovascular cause were: abnormal CTA (OR 67.4; p < 0.001); absence of SVD (OR 5.0; p = 0.019); and absence of pre-ICH hypertension (OR 3.4; p = 0.05). In our internally derived prediction model, the combination of CTA, SVD and pre-ICH hypertension predicted the likelihood of an underlying macrovascular cause (optimism-adjusted ROC area 0.919). Patients with negative CTA, SVD and pre-ICH hypertension have a low likelihood of an underlying macrovascular cause (1.8%).

Discussion and conclusion

A combination of CTA, SVD and pre-ICH hypertension predict the likelihood of finding a macrovascular cause in patients with acute spontaneous ICH, allowing informed decisions regarding the likely benefit and risk of IADSA.

Patients with Blunt Traumatic Brain Injury: A Role for Computed Tomography Angiography of the Head to Evaluate Nontraumatic Causes?

BACKGROUND

In the setting of trauma, the cause of intracranial hemorrhage (ICH) is frequently attributed to the physical, traumatic event. Caution should still be directed toward nontraumatic (or spontaneous) causes responsible for the trauma, such as hypertension, cerebral amyloid angiopathy, aneurysms, vascular malformation, and hemorrhagic infarcts. The role for immediate computed tomography angiography remains controversial to evaluate for nontraumatic causes.

METHODS

A systematic review of the available literature in the Medline PubMed database.

RESULTS

In the available literature, only 12 patients with traumatic brain injury underwent computed tomography angiography of the head that either showed a vascular malformation and/or altered clinical management because of concerns of a vascular malformation. The ICH in 11 patients was attributed to rupture of a cerebral aneurysm; the other patient received a diagnostic angiogram that was negative.

CONCLUSIONS

ICH in patients with traumatic brain injury seems to be vastly associated with the traumatic event. Only rare cases have been attributed to aneurysmal rupture. None has been associated with arteriovenous malformation. Nevertheless, clinical vigilance remains reasonable, especially in younger patients and those with hemorrhage within the subarachnoid cisterns or sylvian fissure.

320-Row Multidetector CT Angiography in the Detection of Critical Cerebrovascular Anomalies

BACKGROUND

The acquisition of a new 320-row multidetector computed tomography angiography (CTA) scanner at the Montreal Neurological Institute and Hospital has provided higher quality imaging with less radiation exposure and shorter time of acquisition. However, its reliability has not been fully proven in critical vascular lesions when it comes to replacing a more invasive examination such as cerebral angiography. We wished to validate the accuracy of this equipment to investigate four common indications for patients to undergo conventional digital subtraction angiography: subarachnoid hemorrhage, vasospasm, unusual intracerebral hemorrhage, and unruptured aneurysm.

METHODS

Radiological reports and relevant imaging from 82 consecutive subjects who underwent a 320-row multidetector CTA followed by cerebral angiography from February 2010 to February 2014 were retrospectively analysed. A total of 102 cerebrovascular anomalies were found. Reports from both imaging modalities were compared to determine the diagnostic accuracy of CTA.

RESULTS

The overall sensitivity and specificity of 320-row multidetector CTA for detecting cerebrovascular abnormalities were, respectively, 97.60% and 63.20%. Similar results were obtained for all four categories of clinical indications.

CONCLUSION

Results obtained from CTA were consistent with those obtained on digital subtraction angiography regardless of the vascular pathology. To our knowledge, this study is the first validating the accuracy of 320-row CTA in diagnosing critical cerebrovascular lesions.

Hemorrhagic cerebrovascular disease

Primary or nontraumatic spontaneous intracerebral hemorrhage (ICH) accounts for 10-15% of all strokes, and has a poor prognosis. ICH has a mortality rate of almost 50% when associated with intraventricular hemorrhage within the first month, and 80% rate of dependency at 6 months from onset. Neuroimaging is critical in identifying the underlying etiology and thus assisting in the important therapeutic decisions. There are several imaging modalities available in the workup of patients who present with ICH, including computed tomography (CT), magnetic resonance imaging (MRI), and digital subtraction angiography (DSA). A review of the current imaging approach, as well as a differential diagnosis of etiologies and imaging manifestations of primary versus secondary intraparenchymal hemorrhage, is presented. Active bleeding occurs in the first hours after symptom onset, with early neurologic deterioration. Identifying those patients who are more likely to have hematoma expansion is an active area of research, and there are many ongoing therapeutic trials targeting this specific patient population at risk.

The clinical management of acute intracerebral hemorrhage

Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and significant disability among survivors. The management of ICH has been influenced by the results of several major trials completed in the last decade. It is now recognized that hematoma expansion is a major cause of morbidity and mortality. However, efforts to improve clinical outcome through mitigation of hematoma expansion have so far been unsuccessful. Acute blood pressure management has recently been shown to be safe in the setting of acute ICH but there was no reduction in mortality with early blood pressure (BP) lowering. Two large trials of surgical evacuation of supratentorial ICH have not shown improvement in outcome with surgery, thus minimally invasive surgical strategies are currently being studied. Lastly, a better understanding of the pathophysiology of ICH has led to the identification of several new mechanisms of injury that could be potential therapeutic targets.

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage.

METHODS

A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee.

RESULTS

Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated.

CONCLUSIONS

Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

Computed tomography angiography or magnetic resonance angiography for detection of intracranial vascular malformations in patients with intracerebral haemorrhage

BACKGROUND

Intracranial vascular malformations (brain or pial/dural arteriovenous malformations/fistulae, and aneurysms) are the leading cause of intracerebral haemorrhage (ICH) in young adults. Early identification of the intracranial vascular malformation may improve outcome if treatment can prevent ICH recurrence. Catheter intra-arterial digital subtraction angiography (IADSA) is considered the reference standard for the detection an intracranial vascular malformation as the cause of ICH. Computed tomography angiography (CTA) and magnetic resonance angiography (MRA) are less invasive than IADSA and may be as accurate for identifying some causes of ICH.

OBJECTIVES

To evaluate the diagnostic test accuracy of CTA and MRA versus IADSA for the detection of intracranial vascular malformations as a cause of ICH.

SEARCH METHODS

We searched MEDLINE (1948 to August 2013), EMBASE (1980 to August 2013), MEDION (August 2013), the Database of Abstracts of Reviews of Effects (DARE; August 2013), the Health Technology Assessment Database (HTA; August 2013), ClinicalTrials.gov (August 2013), and WHO ICTRP (International Clinical Trials Register Portfolio; August 2013). We also performed a cited reference search for forward tracking of relevant articles on Google Scholar (http://scholar.google.com/), screened bibliographies, and contacted authors to identify additional studies.

SELECTION CRITERIA

We selected studies reporting data that could be used to construct contingency tables that compared CTA or MRA, or both, with IADSA in the same patients for the detection of intracranial vascular malformations following ICH.

DATA COLLECTION AND ANALYSIS

Two authors (CBJ and RA-SS) independently extracted data on study characteristics and measures of test accuracy. Two authors (CBJ and PMW) independently extracted data on test characteristics. We obtained data restricted to the subgroup undergoing IADSA in studies using multiple reference standards. We combined data using the bivariate model. We generated forest plots of the sensitivity and specificity of CTA and MRA and created a summary receiver operating characteristic plot.

MAIN RESULTS

Eleven studies (n = 927 participants) met our inclusion criteria. Eight studies compared CTA with IADSA (n = 526) and three studies compared MRA with IADSA (n = 401). Methodological quality varied considerably among studies, with partial verification bias in 7/11 (64%) and retrospective designs in 5/10 (50%). In studies of CTA, the pooled estimate of sensitivity was 0.95 (95% confidence interval (CI) 0.90 to 0.97) and specificity was 0.99 (95% CI 0.95 to 1.00). The results remained robust in a sensitivity analysis in which only studies evaluating adult patients (≥ 16 years of age) were included. In studies of MRA, the pooled estimate of sensitivity was 0.98 (95% CI 0.80 to 1.00) and specificity was 0.99 (95% CI 0.97 to 1.00). An indirect comparison of CTA and MRA using a bivariate model incorporating test type as one of the parameters failed to reveal a statistically significant difference in sensitivity or specificity between the two imaging modalities (P value = 0.6).

AUTHORS' CONCLUSIONS

CTA and MRA appear to have good sensitivity and specificity following ICH for the detection of intracranial vascular malformations, although several of the included studies had methodological shortcomings (retrospective designs and partial verification bias in particular) that may have increased apparent test accuracy.

Spontaneous brain parenchymal hemorrhage: an approach to imaging for the emergency room radiologist

Spontaneous intracranial hemorrhage is a neurological emergency commonly encountered by the emergency radiologist. This article reviews the approach to spontaneous brain parenchymal hemorrhage, including common causes and the role of various neuroimaging modalities in the diagnostic workup. We emphasize the need for a primary survey directed at conveying information needed for emergent clinical management of the patient and a secondary survey directed at identifying the etiology of the hemorrhage.

The cost-utility of CT angiography and conventional angiography for people presenting with intracerebral hemorrhage

OBJECTIVE

To determine the optimal imaging strategy for ICH incorporating CTA or DSA with and without a NCCT risk stratification algorithm.

METHODS

A Markov model included costs, outcomes, prevalence of a vascular lesion, and the sensitivity and specificity of a risk stratification algorithm from the literature. The four imaging strategies were: (a) CTA screening of the entire cohort; (b) CTA only in those where NCCT suggested a high or indeterminate likelihood of a lesion; (c) DSA screening of the entire cohort and (d) DSA only for those with a high or indeterminate suspicion of a lesion following NCCT. Branch d was the comparator.

RESULTS

Age of the cohort and the probability of an underlying lesion influenced the choice of optimal imaging strategy. With a low suspicion for a lesion (<12%), branch (a) was the optimal strategy for a willingness-to-pay of $100,000/QALY. Branch (a) remained the optimal strategy in younger people (<35 years) with a risk below 15%. If the probability of a lesion was >15%, branch (b) became preferred strategy. The probabilistic sensitivity analysis showed that branch (b) was the optimal choice 70-72% of the time over varying willingness-to-pay values.

CONCLUSIONS

CTA has a clear role in the evaluation of people presenting with ICH, though the choice of CTA everyone or CTA using risk stratification depends on age and likelihood of finding a lesion.

Computed Tomography Angiography in the Assessment of Patients With Stroke/TIA

Rapid advance in medical technology has resulted in the availability of numerous tests and treatment strategies in the management of acute stroke. The increasingly evidence-based context of clinical medicine necessitates that clinicians use only appropriate tools to facilitate the diagnostic process and patient management. In this review, we seek to explore the use of computed tomography angiography (CTA) in the diagnosis and management of patients presenting with acute stroke (ischemic and hemorrhagic) or transient ischemic attack (TIA). We present evidence in favor of the use of CTA, highlight the disadvantages of this imaging modality, and present a heuristic model based on our experience at utilizing CTA for decision making in acute stroke and TIAs.

Emergency noninvasive angiography for acute intracerebral hemorrhage

Spontaneous ICH is a devastating condition and is associated with significant mortality in the acute phase due to ongoing hemorrhage and hematoma expansion. A growing body of evidence suggests that there may be considerable utility in performing noninvasive vascular imaging during the acute-to-early phase of ICH. CTA has become widely available and is sensitive and specific for detecting vascular causes of secondary ICH such as aneurysms, arteriovenous malformations, dural arteriovenous fistulas, intracranial dissections, and neoplasm. CT venography can also diagnose dural sinus thrombosis presenting as hemorrhagic infarction. Recent data from stroke populations demonstrate a relatively low risk to patients when contrast is administered in the absence of a known serum creatinine. Detection of acute contrast extravasation within the hematoma ("spot sign") with CT angiography is predictive of subsequent hematoma expansion and is associated with increased morbidity and mortality. Risk stratification based on acute CTA can inform and expedite decision-making regarding intensive care unit admission, blood pressure control, correction of coagulopathy, and neurosurgical consultation. Noninvasive vascular imaging should be considered as an important component of the initial diagnostic work-up for patients presenting with acute ICH.

Dual-energy CT in the evaluation of intracerebral hemorrhage of unknown origin: differentiation between tumor bleeding and pure hemorrhage

BACKGROUND AND PURPOSE

Detection of underlying tumor in patients with unknown-origin acute ICH may be difficult because acute hematoma may mask enhancement of tumor on postcontrast CT. We intended to investigate the clinical utility of DECT in differentiating tumor bleeding from pure ICH.

MATERIALS AND METHODS

Using a dual-source CT scanner, we obtained TNC single-energy and postcontrast DECT scans for 56 patients with unknown-origin spontaneous ICH. From the 2 sets of postcontrast DECT images obtained with different tube energy, EA (equivalent to conventional postcontrast CT), VNC, color-coded iodine overlay, fusion images of iodine overlay and VNC images were produced. The diagnostic performances of fusion, EA, and combined EA and TNC images for detecting underlying tumors were compared.

RESULTS

Of the 56 patients, 17 had primary or metastatic tumors (18 lesions) and 39 had nontumorous ICH. The sensitivities of fusion, EA, and combined EA and TNC images for detecting brain tumors were 94.4%, 61.1%, and 66.7%, respectively, and their specificities were 97.4%, 92.3%, and 89.7%, respectively. The areas under the ROC curves were 0.964, 0.786, and 0.842, respectively. Overall, the diagnostic performance of fusion images was significantly superior to EA (P = .006) and combined EA and TNC (P = .011) images.

CONCLUSIONS

DECT may be useful in detecting underlying tumors in patients with unknown-origin ICH.

Advanced CT imaging in the evaluation of hemorrhagic stroke

Multidetector computed tomographic (CT) angiography is rapidly becoming a pivotal examination in the initial evaluation of patients with hemorrhagic stroke. This article provides an update of the literature on this dynamic topic, focusing on (1) the utility of CT angiography in the identification of hemorrhagic stroke patients who harbor an underlying vascular etiology and the role of the secondary intracerebral hemorrhage score, as well as (2) the clinical value of the CT angiography spot sign and spot sign score in patients with primary intracerebral hemorrhage.

Vascular imaging adds value in investigation of basal ganglia hemorrhage

The risk of basal ganglia hemorrhage (BGH) increases in patients of older age and with hypertension. Current guidelines do not recommend routine vascular imaging. However, a proportion of patients with BGH have underlying vascular abnormalities, and these patients may require a different treatment approach. We aimed to assess the proportion of underlying vascular abnormalities in patients with BGH. In this retrospective study, we included all patients who presented with BGH between January 2007 and December 2009 at a single institution. The following data were collected: patient demographics, vascular risk factors, medications, volume of hematoma, CT scans, CT angiogram, magnetic resonance angiography and digital subtraction angiography. We determined the proportion of underlying vascular abnormalities and correlated these findings with risk factors for BGH. A total of 113 consecutive patients with BGH were identified, and vascular imaging was performed in 61. The median age was 62 years and 48 (78.7%) of these patients were male. Forty-two (68.9%) of 61 patients had hypertension. Positive vascular imaging findings were identified in eight of 61 patients (13.1%): three intracranial aneurysms, three cavernous malformations, one Moyamoya disease and one arteriovenous malformation. There were no significant associations between demographic features, vascular risk factors and the hematoma volume between patients with positive and negative vascular imaging. Specifically, an underlying vascular abnormality was not associated with age (≥ 60 years, 6/36 patients had an underlying vascular abnormality, compared with 2/25 patients< 60 years; p=not significant [n.s.]). There was no relationship with hypertension (5/42 hypertensive patients and 3/19 normotensive patients (n.s.) had an underlying vascular abnormality). We concluded that there is a significant proportion of relevant underlying vascular abnormalities in patients with BGH. This likelihood is not predicted by risk factors such as hypertension and age. These findings indicate the importance of vascular imaging in patients with BGH who are not neurologically devastated.

The value of magnetic resonance imaging for the detection of the bleeding source in non-traumatic intracerebral haemorrhages: a comparison with conventional digital subtraction angiography

INTRODUCTION

Conventional digital subtraction angiography (DSA) is currently regarded as the gold standard in detecting underlying vascular pathologies in patients with intracerebral haemorrhages (ICH). However, the use of magnetic resonance imaging (MRI) in the diagnostic workup of ICHs has considerably increased in recent years. Our aim was to evaluate the diagnostic accuracy and yield of MRI for the detection of the underlying aetiology in ICH patients.

METHODS

Sixty-seven consecutive patients with an acute ICH who underwent MRI (including magnetic resonance angiography (MRA) and DSA during their diagnostic workup) were included in the study. Magnetic resonance images were retrospectively analysed by two independent neuroradiologists to determine the localisation and cause of the ICH. DSA was used as a reference standard.

RESULTS

In seven patients (10.4%), a DSA-positive vascular aetiology was present (one aneurysm, four arteriovenous malformations, one dural arteriovenous fistula and one vasculitis). All of these cases were correctly diagnosed by both readers on MRI. In addition, MRI revealed the following probable bleeding causes in 39 of the 60 DSA-negative patients: cerebral amyloid angiopathy (17), cavernoma (9), arterial hypertension (8), haemorrhagic transformation of an ischaemic infarction (3) and malignant brain tumour with secondary ICH (2).

CONCLUSION

Performing MRI with MRA proved to be an accurate diagnostic tool in detecting vascular malformations in patients with ICH. In addition, MRI provided valuable information regarding DSA-negative ICH causes, and thus had a high diagnostic yield in ICH patients.

Brain imaging in stroke: insight beyond diagnosis

Stroke, whether hemorrhagic or ischemic in nature, has the ability to lead to devastating and debilitating patient outcomes, which not only has direct implications from a healthcare standpoint, but its effects are longstanding and they impact the community as a whole. For decades, the goal of advancement and refinement in imaging modalities has been to develop the most precise, convenient, widely available and reproducible interpretable modality for the detection of stroke, not only in its hyperacute phase, but a method to be able to predict its evolution through the natural course of disease. Diagnosis is one of the most important initial roles, which imaging fulfills after the identification of existent pathology. However, imaging fulfills an even more important goal by using a combination of imaging modalities and their precise interpretation, which lends itself to understanding the mechanisms and pathophysiology of underlying disease, and therefore guides therapeutic decision-making in a patient-tailored fashion. This review explores the most commonly used brain imaging modalities, computer tomography, and magnetic resonance imaging, with an aim to demonstrate their dynamic use in uncovering stroke mechanism, facilitating prognostication, and potentially guiding therapy.

Frequency of adequate contrast opacification of the major intracranial venous structures with CT angiography in the setting of intracerebral hemorrhage: comparison of 16- and 64-section CT angiography techniques

BACKGROUND AND PURPOSE

DVST is an important cause of ICH because its treatment may require anticoagulation or mechanical thrombectomy. We aimed to determine the frequency of adequate contrast opacification of the major intracranial venous structures in CTAs performed for ICH evaluation, which is an essential factor in excluding DVST as the ICH etiology.

MATERIALS AND METHODS

Two readers retrospectively reviewed CTAs performed in 170 consecutive patients with ICH who presented to our emergency department during a 1-year period to determine by consensus whether qualitatively, contrast opacification in each of the major intracranial venous structures was adequate to exclude DVST. "Adequate contrast opacification" was defined as homogeneous opacification of the venous structure examined. "Inadequate contrast opacification" was defined as either inhomogeneous opacification or nonopacification of the venous structure examined. Delayed scans, if obtained, were reviewed by the same readers blinded to the first-pass CTAs to determine the adequacy of contrast opacification in the venous structures according to the same criteria. In patients who did not have an arterial ICH etiology, the same readers determined if thrombosis of an inadequately opacified intracranial venous structure could have potentially explained the ICH by correlating the presumed venous drainage path of the ICH with the presence of inadequate contrast opacification within the venous structure draining the venous territory of the ICH. CTAs were performed in 16- or 64-section CT scanners with bolus-tracking, scanning from C1 to the vertex. Patients with a final diagnosis of DVST were excluded. We used the Pearson χ(2) test to determine the significance of the differences in the frequency of adequate contrast opacification within each of the major intracranial venous structures in scans obtained using either a 16- or 64-section MDCTA technique.

RESULTS

Fifty-eight patients were evaluated with a 16-section MDCTA technique (34.1%) and 112 with a 64-section technique (65.9%). Adequate contrast opacification within all major noncavernous intracranial venous structures was significantly less frequent in first-pass CTAs performed with a 64-section technique (33%) than in those performed with a 16-section technique (60%, P value < .0001). Delayed scans were obtained in 50 patients, all of which demonstrated adequate contrast opacification in the major noncavernous intracranial venous structures. In 142 patients with supratentorial or cerebellar ICH without an underlying arterial etiology, we found that thrombosis of an inadequately opacified major intracranial venous structure could have potentially explained the ICH in 38 patients (26.8%), most examined with a 64-section technique (86.8%).

CONCLUSIONS

Inadequate contrast opacification of the major intracranial venous structures is common in first-pass CTAs performed for ICH evaluation, particularly if performed with a 64-section technique. Acquiring delayed scans appears necessary to confidently exclude DVST when there is strong clinical or radiologic suspicion.

Practical scoring system for the identification of patients with intracerebral hemorrhage at highest risk of harboring an underlying vascular etiology: the Secondary Intracerebral Hemorrhage Score

BACKGROUND AND PURPOSE

An ICH patient's risk of harboring an underlying vascular etiology varies according to baseline clinical and NCCT characteristics. Our aim was to develop a practical scoring system to stratify patients with ICH according to their risk of harboring a vascular etiology.

MATERIALS AND METHODS

Using a data base of 623 patients with ICH evaluated with MDCTA during a 9-year period, we developed a scoring system based on baseline clinical characteristics (age group [0-2 points], sex [0-1 point], neither known HTN nor impaired coagulation [0-1 point]), and NCCT categorization (0-2 points) to predict the risk of harboring a vascular lesion as the ICH etiology (SICH score). We subsequently applied the SICH score to a prospective cohort of 222 patients with ICH who presented to our emergency department during a 13-month period. Using ROC analysis, we calculated the AUC and MOP for the SICH score in both the retrospective and prospective patient cohorts separately and the entire patient population. Patients with SAH in the basal cisterns were excluded.

RESULTS

A vascular etiology was found in 120 of 845 patients with ICH evaluated with MDCTA (14.2%), most commonly AVMs (45.8%), aneurysms with purely intraparenchymal rupture (21.7%), and DVSTs (16.7%). The MOP was reached at a SICH score of >2, with the highest incidence of vascular ICH etiologies in patients with SICH scores of 3 (18.5%), 4 (39%), 5 (84.2%), and 6 (100%). There was no significant difference in the AUC between both patient cohorts (0.86-0.87).

CONCLUSIONS

The SICH score successfully predicts a given ICH patient's risk of harboring an underlying vascular etiology and could be used as a guide to select patients with ICH for neurovascular evaluation to exclude the presence of a vascular abnormality.

Radiological investigation of spontaneous intracerebral hemorrhage: systematic review and trinational survey

BACKGROUND AND PURPOSE

It is not always clear whether, how, and when to undertake further radiological investigation of spontaneous (nontraumatic) intracerebral hemorrhage (ICH).

METHODS

We systematically reviewed Ovid MEDLINE and EMBASE databases for studies of the diagnostic utility of radiological investigations of the cause(s) of ICH. We sent a structured survey to neurologists, stroke specialists, neurosurgeons, and neuroradiologists in the United Kingdom, the Netherlands, and France to assess whether, how, and when they would investigate supratentorial ICH.

RESULTS

This systematic review detected 20 relevant studies (including 1933 patients), which either quantified the yield of a radiological investigation/imaging strategy (n=15) or compared 2 imaging techniques (n=5). Six hundred ninety-two (49%) physicians responded to the survey. Further investigation would have been undertaken by the following: 99% of respondents, for younger (38 to 43 years), normotensive adults with lobar or deep ICH; 76%, for older (age 72 to 83 years), normotensive adults with deep ICH; and 31%, for older adults with deep ICH and prestroke hypertension. Younger patient age was the strongest influence on the decision to further investigate ICH (odds ratio=16; 95% confidence interval, 13 to 20), followed by the absence of prestroke hypertension (odds ratio=5; 95% confidence interval, 4 to 6) and lobar ICH location (odds ratio=2; 95% confidence interval, 1 to 2).

CONCLUSIONS

The paucity of studies on the diagnostic utility of imaging investigations of the cause(s) of ICH may contribute to the variation observed in when and how and which patients are investigated in current clinical practice. Studies comparing different types of diagnostic strategies are required.