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Cerebral angiographic findings in non traumatic intracranial bleed: unenhanced computed tomographic correlation.

MESHTERMS:

* Cerebral Hemorrhage.

* Intracranial Hemorrhage.

* Aneurysm, Ruptured/complications.

* Aneurysm, Ruptured/radiography *.

* Aneurysm, Ruptured/surgery.

* Angiography, Digital Subtraction *.

* Female.

* Humans.

* Intracranial Aneurysm/complications.

* Intracranial Aneurysm/radiography *.

* Intracranial Aneurysm/surgery.

* Male.

* Sensitivity and Specificity.

* Subarachnoid Hemorrhage/etiology *.

* Subarachnoid Hemorrhage/radiography *.

* Tomography, X-Ray Computed *.

INTRODUCTION: Spontaneous intracranial hemorrhage refers to those cases that occur in the absence of trauma. One of the major management tasks is to find out whether hemorrhage is secondary to underlying structural vascular abnormality, such as arteriovenous malformation (AVM) and aneurysm, prior to treatment to prevent rebleeding. Despite great advances in imaging technology, such as CTA, MRI, and MRA, conventional catheter angiography remains the gold standard for diagnosis of vascular abnormality. The intracranial hemorrhage demonstrated on early CT images (Obtained within the first 24 hours) is classified according to the location of the bleed into parenchymal, intraventricular and subarachnoid. In case of subarachnoid bleed, specific cisternal site of the bleed is also assessed. Further an attempt is made to predict the site of ruptured aneurysm based on the site of subarachnoid haemorrhage. It has been documented that the site of haemorrhage, the patient's age, and the presence of preexisting hypertension are important factors affecting the likelihood of finding a vascular abnormality by cerebral angiography in spontaneous intracranial haemorrhage.

AIMS AND OBJECTIVES: To correlate the angiographic findings in spontaneous intracerebral hemorrhage (ICH) with the CT determined site of haemorrhage, age of the patients, and preexisting hypertension.

METHODS:

Study Design           Cross Sectional

Study Setting          Government Medical College, Kozhikode;
                       Patients with CT evidence of
                       intracranial hemorrhage

Study Period           From December 2013 to Sept 2014

Inclusion Criteria     Presence of non-traumatic intracranial
                       hemorrhage

Exclusion Criteria     Poor surgical risk Severe neurological
                       disability Refusal of angiography;
                       Severe coagulopathy that accounted for
                       the hemorrhage Bleeding into tumor that
                       was diagnosed by CT or MRI

Sample size            60-70 cases of non-traumatic
                       intracranial haemorrhage who undergo DSA

Study Method           Four vessel catheter Angiography via the
                       femoral approach under local anesthesia
                       was performed. For internal carotid
                       angiogram, 8-10 ml of non ionic contrast
                       medium (Ultravist-Iopromide 370 mg I/
                       ml) was used. Vertebral artery
                       injections were done with 6-8ml of
                       contrast. Image acquisition was done as
                       Digital Subtraction Angiography using
                       Alpha Impulse Cathlab, manufactured and
                       supplied by Philips electronics Ltd.,
                       capable of online DSA at 3.7, 7.5, 25
                       and 30 frames/sec. A positive
                       angiography was defined by the
                       identification of a vascular abnormality
                       accounting for the hemorrhage.

Study Method           Subarachnoid hemorrhage on NECT seen in
                       anterior interhemispheric fissure
                       /septum pellucidum/pericallosal sulci
                       were assumed to be from rupture of Acom
                       /ACA aneurysm Subarachnoid haemorrhage
                       in sylvian fissure from rupture of MCA/
                       ICA aneurysm Subarachnoid haemorrhage in
                       perimesencephalic cistern/Prepontine
                       cistern from rupture of Posterior
                       circulation aneurysm

                       This is compared with DSA findings (Gold
                       standard) and validity parameters are
                       assessed.

Statistical analysis   SPSS software. Validity parameters--
                       quantitative data. X2 test--association
                       between two independent
                       variables.


STATISTICS: The Null hypothesis (Ho) assumes that there is no association between the predictor and outcome variables in the study population. When we conclude that there is statistical significance, the P value tells us what the probability is that our conclusion is wrong when in fact H0 is correct. The lower the P value, the less likely that our rejection of Ho is erroneous. By convention, most analysts will not claim that they have found statistical significance if there is more than a 5% chance of being wrong (P=0.05).

RESULTS: 62 patients of non-traumatic intracranial haemorrhage proven by CT, who underwent DSA were included in the study.

Of the DSA positive cases aneurysms and arteriovenous malformations were the identified causes for intracranial hemorrhage, with aneurysms accounting for 77.4% (48 numbers) and AVM 8% (5 numbers).

More number of angiographically positive intracranial hemorrhage were found in females. However, [chi square] test to determine association between sex and positive DSA finding revealed p value of 0.089, (>0.05). So according to this study, the chance of finding a positive DSA finding was independent of the sex of the patient i.e., there was no significant association between sex of the patient and the probability of finding a positive DSA finding.

Distribution of aneurysms is seen evenly in normotensives and hypertensives. All cases of arteriovenous malformation detected were seen in normotensives. 6(9.6%) normotensives have no identifiable cause of intracranial hemorrhage. However, [chi square] test to determine association between presence of hypertension and positive DSA finding revealed p value of 0.572, (>0.05), which is not significant. According to this, the chance of finding a positive DSA finding was independent of the hypertensive status of the patient.

Detection of aneurysms of ACA and ACom by early CT as compared to a gold standard (DSA) had a sensitivity of 100% (31/31) positive predictive value of 81.6% (31/38), specificity of 63 % (12/19) and negative predictive value of 100% (12/12).

Detection of aneurysms of MCA by early CT as compared to a gold standard (DSA) had a sensitivity of 100% (9/9) positive predictive value of 28.1% (9/32), specificity of 43.9% (18/41) and negative predictive value of 100%. (18/18)

Detection of aneurysms of posterior circulation by early CT as compared to a gold standard (DSA) had a sensitivity of 100% (8/8); positive predictive value of 20.5% (8/39), specificity of 26.2 % (11/54) and negative predictive value of 100% (11/11).

DISCUSSION: 62 cases of non-traumatic intracranial hemorrhage proven by CT were evaluated by DSA. Angiographically detectable cause for non-traumatic intracranial hemorrhage was obtained in 85.5% cases evaluated. The most common vascular abnormality identified in the study was aneurysm (77.4%), followed by arteriovenous malformation. Among aneurysms, maximum number of ACom (35.5%) aneurysms were detected, followed by ACA and MCA (14.5% each), PCom (11.6%), and by basilar top aneurysm (1.6%). Arteriovenous malformations accounted for 8% cases.14.5% cases were angiographically occult.

In studies by Kitkhuandee A (1) et al DSA findings are as described below.

Association of Intracranial Hemorrhage with Age, Sex and Hypertension: Considering any single decade, maximum number of cases of non-Traumatic intracranial hemorrhage were detected in the age group 50-59 years. Maximum angiographic yield was also observed in the 50-59 years age group.

Our study has found more number of angiographically occult lesions in males but this observation is not statistically significant (p value =0.089).

Similarly angiographically occult cases of intracranial hemorrhage were seen to be more frequently distributed in normotensives. However, this observation also has not reached statistical significance (p value=0.572)

Thus, according to our study there is no association between age, sex or hypertension and detection of positive angiographic finding.

This is in accordance with studies by McCormick et al, (1) who have found no positive association between hypertension and non-traumatic intracranial hemorrhage.

However studies by S F S Halpin, (2) et al have found that positive angiographic findings are more common in younger individuals and normotensive patients in a study evaluating 102 cases of intracranial hemorrhage.

Mutlu et al, (3) have also found a positive association between hypertension and non-traumatic intracranial hemorrhage.

X L Zhu, (4) et al have also found that in patients with <45 years, and normotensives the detection of angiographicaly detectable abnormality is more.

CT to Predict Site or Ruptured Aneurysm: Considering distribution of subarachnoid hemorrhage in early CT taken within 24hours, based on previous studies, presence of subarachnoid hemorrhage in anterior interhemispheric fissure and/or septum pellucidum and/or pericallosal sulci is assumed to be due to Acom/ACA aneurysm rupture. Similarly presence of subarachnoid hemorrhage in sylvian fissure is equated to MCA/ ICA aneurysm. This is compared with DSA findings (gold standard) and validity parameters were assessed

Our study has found that detection of aneurysms of ACA and ACom by early CT as compared to a gold standard (DSA) had a sensitivity of 100% (31/31) positive predictive value of 79.5% (31/39), specificity of 74.2% (23/31) and negative predictive value of 100% (23/23). However the validity to detect MCA/ICA and posterior circulation aneurysms with CT is poor.

Positive predictive value for MCA/ICA aneurysms is only 28.1% and specificity is 56.6%.

In case of posterior circulation aneurysms positive predictive value is 20.5% and specificity is 42.6%.

This is very similar to results obtained by Karttunen et al, (1) and Vander Jagt M et al.(5)

CASE 1: Unenhanced CT shows serpiginous hyperdensities with hyperdense blood density along the pericallosal region. DSA shows an arteriovenous malformation involving the corpus callosum with intranidal aneurysms and early drainage via deep veins.

CASE 2: SAH in left ambient cistern, DSA showing Pcom aneurysm.

CASE 3: Symmetric SAH seen in anterior interhemispheric fissure, suprasellar cistern, bilateral sylvian fissures. An anterior communicating artery aneurysm seen on DSA.

CASE 4: CT showing massive SAH in basal cisterns, perimesencephalic cisterns, left sylvian fissure and in parietal cortical sulci. DSA revealed a left middle cerebral artery aneurysm.

DOI: 10.14260/jemds/2015/1039

REFERENCES:

(1.) Kitkhuandee A, Thammaroj J, Munkong W, Duangthongpon P, Thanapaisal C. Cerebral angiographic findings in patients with non-traumatic subarachnoid hemorrhage. J Med Assoc Thai. Thailand; 2012 Nov; 95 Suppl 1: S121-9.

(2.) Halpin SFS, Britton JA, Byrne J V, Clifton A, Hart G, Moore A. Prospective evaluation of cerebral angiography and computed tomography in cerebral haematoma. 1994; 1180-6.

(3.) MUTLU N, RG B, BJ A. Massive cerebral hemorrhage: Clinical and pathological correlations. Arch Neurol [Internet]. 1963 Jun 1; 8 (6): 644-61. Available from: http://dx.doi.org/10.1001/archneur.1963.00460060074008.

(4.) Zhu XL, Chan MS, Poon WS. Spontaneous intracranial hemorrhage: which patients need diagnostic cerebral angiography? A prospective study of 206 cases and review of the literature. Stroke. UNITED STATES; 1997 Jul; 28 (7): 1406-9.

(5.) Van der Jagt M, Hasan D, Bijvoet HW, Pieterman H, Dippel DW, Vermeij FH, et al. Validity of prediction of the site of ruptured intracranial aneurysms with CT. Neurology. UNITED STATES; 1999 Jan; 52 (1): 34-9.

Jospaul Lukas [1], Gomathy Subramaniam [2], Jineesh T [3], Noufal P [4], V. R. Rajendran [5], Padma Menon [6], Saanida M. P [7], Junaina P [8]

AUTHORS:

[1.] Jospaul Lukas

[2.] Gomathy Subramaniam

[3.] Jineesh T.

[4.] Noufal P.

[5.] V. R. Rajendran.

[6.] Padma Menon

[7.] Saanida M. P.

[8.] Junaina P.

PARTICULARS OF CONTRIBUTORS:

[1.] Junior Resident, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[2.] Additional Professor, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[3.] Assistant Professor, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[4.] Assistant Professor, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[5.] Professor & HOD, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[6.] Junior Resident, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[7.] Assistant Professor, Department of Radiodiagnosis, Government Medical College, Kozhikode.

[8.] Assistant Professor, Department of Radiodiagnosis, Government Medical College, Kozhikode.

NAME ADDRESS EMAIL ID OF THE CORRESPONDING AUTHOR:

Dr. Jospaul Lukas, Nakkuzhikatt, Nazareth Hill, P. O. Kuravilangad, Kottayam, Kerala, India.

E-mail: jpl5686@gmail.com

Date of Submission: 24/04/2015.

Date of Peer Review: 25/04/2015.

Date of Acceptance: 13/05/2015.

Date of Publishing: 19/05/2015.

Table 1. Site of bleed on CT in study population

Site of bleed on CT           Number   Percentage

Subarachnoid hemorrhage         50        80.6
Intraparenchymal hemorrhage     12        19.4
Total                           62        100

Table 2: Comparison of CT Vs Dsa In The Diagnosis
of ACA/Acom Aneurysm

Anterior               DSA positive   DSA negative   Total
circulation aneurysm

Positive CT                 31             7          38
Negative CT                 0              12         12
Total                       31             19         50

Table 3: Comparison of ct vs dsa in the diagnosis of MCA/ICA aneurysm

Middle cerebral    MCA aneurysm   Negative for   Total
artery aneurysm                   MCA aneurysm

Positive s              9              23         32
Negative CT             0              18         18
Total                   9              41         50

Table 4: Comparison of CT Vs DSA in the Diagnosis of
Posterior Circulation Aneurysm

Posterior              DSA Positive   DSA Negative   Total
circulation aneurysm

Positive CT                 8              31         39
Negative CT                 0              11         11
TOTAL                       8              42         50

Table 5: Comparing distribution of DSA findings with previous studies

                             Kitkhuandee a et al (1)  Present study

Dsa positive                         62.6%                85.5%
Aneurysm                             57.6%                77.4%
Arteriovenous malformation            4.2%                 8%
Other causes                 Moyamoya disease-0.8%         Nil
Angiographically occult              37.4%                14.5%

Table 6: Comparing distribution of aneurysms in various studies

                           Kitkhuandee    Sinagawa t   Present study
                           a et al, (1)

Acom                          35.5%         34.7%          35.5%
Anterior cerebral artery                     8.2%          14.5%
Pcom                          17.1%                        11.3%
Middle cerebral artery        15.7%          25%           14.5%
Internal carotid artery       11.8%          24%            --
Basilar artery                 2.6%                        1.6%
Vertebrobasilar junction       1.3%
Others                        10.5%          10%            --


Figure 1. Frequency Distribution of the Study Sample

ACA               14.5%
ACom              35.5%
MCa               14.5%
PCom              11.3%
BASILAR TOP        1.6%
PARIETAL           3.2%
TEMPORAL           1.6%
OCCIPITAL          1.6%
CORPUS CALLOSUM    1.6%
NEGATIVE DSA      14.5%

Note: Table made from bar graph.

Figure 2. Frequency distributions of angiogram
Findings according to Age

               <30yr   30-39   40-49   50-59   >60

NEGATIVE DSA     2       1       3       1       2
AVM              1       3       0       1       0
ANEURYSM         4       5      10      14      15

Note: Table made from bar graph.

Figure 3. Sex Distribution of DSA Findings

               Male     FEMALE

POSITIVE DSA   40.30%   45.20%
NEGATIVE DSA   11.30%   3.20%

Note: Table made from bar graph.

Figure 4. DSA finding Vs BP status

aneurysm                  37%     40.30%
avm                       0       8%
angiographically occult   4.80%   9.60%

Note: Table made from bar graph.
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Title Annotation:ORIGINAL ARTICLE
Author:Lukas, Jospaul; Subramaniam, Gomathy; Jineesh, T.; Noufal, P.; Rajendran, V.R.; Menon, Padma; Saanid
Publication:Journal of Evolution of Medical and Dental Sciences
Date:May 21, 2015
Words:2243
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