Diagnostic Cerebral Angiography and Spontaneous Intracranial Hemorrhage
Diagnostic Cerebral Angiography and Spontaneous Intracranial Hemorrhage
ABSTRACT & COMMENTARY
Source: Zhu XL, et al. Spontaneous intracranial hemorrhage: Which patients need diagnostic cerebral angiography? Stroke 1997;28:1406-1409.
Zhu and colleagues report angiographic findings in 206 consecutive patients evaluated in Prince of Wales Hospital, Hong Kong, for structural vascular abnormalities causing acute parenchymal brain hemorrhage. Risk factors included the anatomical location of the bleed, the age of the patient, and the presence or absence of hypertension (HCVD). Excluded were patients suffering acute subarachnoid hemorrhage, those with overwhelming neurological or medical illness-disability, and those who either had bleeding diatheses or refused arteriography. Some statistics follow:
Population: n = 206 (129 males, 74 females); mean age, 42 years; HCVD, 28%.
Angiography positive: non-HCVD = 45%; with HCVD = 9%; P < 0.001.
Angiography positive: age < 45 years = 50%; age > 45 years = 18%; P < 0.001.
Hypertension a significant risk factor (P < 0.01) in both groups.
Sites of hemorrhage among older and younger patients were similar; lobar, 44%; putamen-thalamus-caudate, 38%; intraventricular, 8%; and cerebellar-brainstem, 8.5%. Two patients had acute subdural hematomas. Among all 206 patients, 35% possessed structural vascular abnormalities with the highest incidence occurring in lobar, intraventricular, and cerebellar locations. Other than anatomic location, the principal pre-existing and independent risks were age and hypertension. The authors recommend angiography in all patients under age 45 who suffer an intracranial hemorrhage. They also suggest that the procedure be omitted on hypertensive patients older than 45 years who have hemorrhages involving the thalamus, putamen, and posterior fossa.
COMMENTARY
This clearly expressed report indicates the value of angiography in cases of structural vascular abnormalities of the brain. They also relate material in the literature indicating that MRI-MRA may have ± 90% sensitivity in detecting such structural abnormalities but express the caveat that "a negative result cannot completely exclude a vascular lesion." This conclusion may or may not be true since its clinical validity depends entirely on the "so what" question (i.e., how many patients with lesions identified by arteriography received surgical therapy, and what was their immediate and long-term outcome?). Only with such information can the clinician decide whether to expend radiologic and surgical resources in an effort to achieve a reasonably advantageous future for the patient. fp
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