Should Cerebral Angiography Be Avoided Within Three Hours After Subarachnoid Hemorrhage?

Overview

Journal J Korean Neurosurg Soc

Date 2019 Sep 5

PMID 31484228

Citations 3

Authors

Hong An

Jaechan Park

Dong-Hun Kang

Wonsoo Son

Young-Sup Lee

Youngseok Kwak

Boram Ohk

Affiliations

Soon will be listed here.

Abstract

Objective: While the risk of aneurysmal rebleeding induced by catheter cerebral angiography is a serious concern and can delay angiography for a few hours after a subarachnoid hemorrhage (SAH), current angiographic technology and techniques have been much improved. Therefore, this study investigated the risk of aneurysmal rebleeding when using a recent angiographic technique immediately after SAH.

Methods: Patients with acute SAH underwent immediate catheter angiography on admission. A four-vessel examination was conducted using a biplane digital subtraction angiography (DSA) system that applied a low injection rate and small volume of a diluted contrast, along with appropriate control of hypertension. Intra-angiographic aneurysmal rebleeding was diagnosed in cases of extravasation of the contrast medium during angiography or increased intracranial bleeding evident in flat-panel detector computed tomography scans.

Results: In-hospital recurrent hemorrhages before definitive treatment to obliterate the ruptured aneurysm occurred in 11 of 266 patients (4.1%). Following a univariate analysis, a multivariate analysis using a logistic regression analysis revealed that modified Fisher grade 4 was a statistically significant risk factor for an in-hospital recurrent hemorrhage (p =0.032). Cerebral angiography after SAH was performed on 88 patients ≤3 hours, 74 patients between 3-6 hours, and 104 patients >6 hours. None of the time intervals showed any cases of intra-angiographic rebleeding. Moreover, even though the DSA ≤3 hours group included more patients with a poor clinical grade and modified Fisher grade 4, no case of aneurysmal rebleeding occurred during erebral angiography.

Conclusion: Despite the high risk of aneurysmal rebleeding within a few hours after SAH, emergency cerebral angiography after SAH can be acceptable without increasing the risk of intra-angiographic rebleeding when using current angiographic techniques and equipment.

Citing Articles

Association of Onset-to-Treatment Time With Discharge Destination, Mortality, and Complications Among Patients With Aneurysmal Subarachnoid Hemorrhage.

Buscot M, Chandra R, Maingard J, Nichols L, Blizzard L, Stirling C JAMA Netw Open. 2022; 5(1):e2144039.

PMID: 35061040 PMC: 8783267. DOI: 10.1001/jamanetworkopen.2021.44039.

Hematoma expansion unrelated to rebleeding in ruptured anterior cerebral artery aneurysms treated by early endovascular embolization.

Okamura K, Morofuji Y, Horie N, Izumo T, Sato K, Fujimoto T Surg Neurol Int. 2021; 12:571.

PMID: 34877057 PMC: 8645492. DOI: 10.25259/SNI_816_2021.

An in vitro study of pressure increases during contrast injections in diagnostic cerebral angiography.

Marfoglio S, Kovarovic B, Hou W, Fiorella D, Sadasivan C Interv Neuroradiol. 2021; 27(5):695-702.

PMID: 33631993 PMC: 8493344. DOI: 10.1177/1591019921996099.

References

Ohkuma H, Tsurutani H, Suzuki S . Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management. Stroke. 2001; 32(5):1176-80. DOI: 10.1161/01.str.32.5.1176. View

Hillman J, Fridriksson S, Nilsson O, Yu Z, Saveland H, Jakobsson K . Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg. 2002; 97(4):771-8. DOI: 10.3171/jns.2002.97.4.0771. View

Zaehringer M, Wedekind C, Gossmann A, Krueger K, Trenschel G, Landwehr P . Aneurysmal re-rupture during selective cerebral angiography. Eur Radiol. 2003; 12 Suppl 3:S18-24. DOI: 10.1007/s00330-002-1460-9. View

Yuguang L, Tao J, Meng L, Shugan Z, Jiangang W, Yang Y . Rerupture of intracranial aneurysms during cerebral angiography. J Clin Neurosci. 2003; 10(6):674-6. DOI: 10.1016/j.jocn.2002.08.001. View

Laidlaw J, Siu K . Poor-grade aneurysmal subarachnoid hemorrhage: outcome after treatment with urgent surgery. Neurosurgery. 2003; 53(6):1275-80. DOI: 10.1227/01.neu.0000093199.74960.ff. View

Kusumi M, Yamada M, Kitahara T, Endo M, Kan S, Iida H . Rerupture of cerebral aneurysms during angiography--a retrospective study of 13 patients with subarachnoid hemorrhage. Acta Neurochir (Wien). 2005; 147(8):831-7. DOI: 10.1007/s00701-005-0541-3. View

SAMPEI T, Yasui N, Mizuno M, Nakajima S, Ishikawa T, Hadeishi H . Contrast medium extravasation during cerebral angiography for ruptured intracranial aneurysm--clinical analysis of 26 cases. Neurol Med Chir (Tokyo). 1990; 30(13):1011-5. DOI: 10.2176/nmc.30.1011. View

Soderman M, Babic D, Holmin S, Andersson T . Brain imaging with a flat detector C-arm : Technique and clinical interest of XperCT. Neuroradiology. 2008; 50(10):863-8. DOI: 10.1007/s00234-008-0419-1. View

Waldenberger P, Chemelli A, Mallouhi A . Intra-arterial haemodynamic changes during cerebral three-dimensional rotational angiography. Eur Radiol. 2008; 19(2):503-8. DOI: 10.1007/s00330-008-1161-0. View

10.

Cha K, Kim J, Kang H, Moon B, Lee S, Kim J . Aneurysmal rebleeding : factors associated with clinical outcome in the rebleeding patients. J Korean Neurosurg Soc. 2010; 47(2):119-23. PMC: 2836446. DOI: 10.3340/jkns.2010.47.2.119. View

11.

Guo L, Zhou H, Xu J, Wang Y, Qiu Y, Jiang J . Risk factors related to aneurysmal rebleeding. World Neurosurg. 2011; 76(3-4):292-8. DOI: 10.1016/j.wneu.2011.03.025. View

12.

Clarencon F, Piotin M, Pistocchi S, Babic D, Blanc R . Evaluation of stent visibility by flat panel detector CT in patients treated for intracranial aneurysms. Neuroradiology. 2012; 54(10):1121-5. DOI: 10.1007/s00234-011-1002-8. View

13.

Park J, Woo H, Kang D, Kim Y, Kim M, Shin I . Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes. J Neurosurg. 2014; 122(2):383-91. DOI: 10.3171/2014.9.JNS131784. View

14.

Boogaarts H, van Lieshout J, van Amerongen M, de Vries J, Verbeek A, Grotenhuis J . Aneurysm diameter as a risk factor for pretreatment rebleeding: a meta-analysis. J Neurosurg. 2015; 122(4):921-8. DOI: 10.3171/2014.12.JNS14931. View

15.

Aoyagi N, Hayakawa I . Rerupture of intracranial aneurysms during angiography. Acta Neurochir (Wien). 1989; 98(3-4):141-7. DOI: 10.1007/BF01407340. View

16.

Park S, Kim J, Chang C, Jung Y . Procedure-related Complication Rate for the Endovascular Treatment of Aneurysmal Subarachnoid Hemorrhage under Local Anesthesia. J Cerebrovasc Endovasc Neurosurg. 2016; 18(3):215-222. PMC: 5104845. DOI: 10.7461/jcen.2016.18.3.215. View

17.

Juvela S . Rebleeding from ruptured intracranial aneurysms. Surg Neurol. 1989; 32(5):323-6. DOI: 10.1016/0090-3019(89)90133-x. View

18.

Inagawa T, Kamiya K, Ogasawara H, Yano T . Rebleeding of ruptured intracranial aneurysms in the acute stage. Surg Neurol. 1987; 28(2):93-9. DOI: 10.1016/0090-3019(87)90079-6. View

19.

Amagasa M, Yoshimoto T, Mizoi K, Suzuki J . Early cerebral angiography after aneurysm rupture. Analysis of 197 cases. J Neurosurg. 1986; 65(6):776-8. DOI: 10.3171/jns.1986.65.6.0776. View

20.

Jane J, Kassell N, Torner J, Winn H . The natural history of aneurysms and arteriovenous malformations. J Neurosurg. 1985; 62(3):321-3. DOI: 10.3171/jns.1985.62.3.0321. View