Angiogram-negative subarachnoid hemorrhage: is a repeat digital subtraction angiography necessary? George Hadjigeorgiou Department of Neurosurgery Red Cross Hospital Athens, Greece

Introduction 1100 patients with SAH/year in Greece ~15% of SAH have a negative initial DSA Previous reports have estimated that a vascular origin of SAH could be identified in 2% to 24% of these cases on repeat DSA DSA carries a neurological complication rate in the order of 2,6% and a 0,06% chance of death (Kaufmann,2008)

Is a repeat DSA necessary?

Material & Methods Retrospective analysis Single-center experience 2008- 2012 Patients with SAH and a negative initial DSA were included in the study Exclusion criteria: traumatic SAH

Material & Methods All patients have underwent biplane DSA within 24 h of admission and a repeat angiography approximately 3-weeks after the initial study MRI was also performed on attending neurosurgeon’s discretion during hospitalization Clinical evaluation was based on the GCS and H&H grade at the time of admission, and functional outcome was assessed according to GOS Hemorrhage patterns were categorized as perimesencephalic (PM) or nonperimesencephalic (NPM)

Material & Methods PMC hemorrhage (Van Gijn’s definition, 1985): “a centre of hemorrhage located immediately anterior to the midbrain or within the prepontine cistern, with or without extension to the ambient cisterns; absence of complete filling of the anterior interhemispheric fissure; absence of extension of blood into the lateral sylvian fissure and into the ventricular system” PM SAH NPM SAH

Results 480 patients with SAH Among them, 72 patients (15%) had a negative initial DSA Mean age: 57.9 yo 39males : 33 females 42 PM-SAH : 30 NPM-SAH Mean Age 57.9 Males 54.2% Females 45.8% PM-SAH 58,3% NPM-SAH 41,7%

Results GCS PM (n:42) NPM (n:30) 15 22 12-14 20 11 9-11 3 3-8 1 3 3-8 1 H&H Grade PM (n:42) NPM (n:30) I 19 11 II 17 14 III 6 4 IV 1 V Fisher PM (n:42) NPM (n:30) 1 2 4 3 38 16 12

Results GOS PM (n: 42) NPM (n:30) 1 2 3 4 5 40 22

Results Repeat DSA 3 weeks after the initial 0/42 aneurysms for the PM-group 3/30 aneurysms for the NPM-group (1 Acom, 1 AChA, 1 BA) Overall false negative rate of the initial DSA 3/72 (4.2%)

Illustrative Case Female, 54 yo Medical History: G6PD def, thyroiditis Hashimoto Sudden suboccipital headache, vomiting, nuchal rigidity GCS 15/15, H& H II, Fisher III DSA (24h upon admission): negative CT on admission DSA (24h) CT on 4th day

Illustrative Case Rebleeding on the 14th day 2nd DSA : 3mm aneurysm of the right anterior choroidal a.  coiling Discharge 1 week after the embolization on a GOS of 5 CT after the rebleeding DSA prior the embolization DSA after the embolization

Discussion Reasons for missing the aneurysm on the initial negative DSA: vasospasm thrombosed aneurysm very small aneurysm suboptimal angiographic projection

Discussion Clinical grades corresponding to GCS on admission and GOS at discharge were higher in PN group than the NPN group; however no statistical difference was shown The majority of the patients in both groups had good clinical outcomes

Discussion Need for evidence-based guidelines and a standardized protocol for the management of the DSA negative SAH Conflicting findings from several studies Study Number of SAH pt % of negative initial DSA % of repeat DSA % positive repeat DSA In favour of repeat DSA Gilbert (1990) 1086 2% 89% 0% No Iwanaga (1990) 469 10% 84% 18% Yes Duong (1996) 295 31% 100% 5% Urbach (1998) 694 55% 3% Jung (2006) 3214 4% 72% 13% Fontanella (2011) 882 12% 71% 9% Yu (2012) 904 57% Khan (2013) 459 11% 16% Current Study 480 15%

Discussion Limitations of our study: Retrospective study Small sample size 3-D reconstruction was not performed, thereafter some aneurysms could have been missed initially

Conclusions In the line with the results of this study, we should be suspicious of patients with a non-perimesencephalic SAH and a negative initial DSA We found no patient with perimesencephalic SAH and a negative initial DSA to conceal an aneurysm on the repeat DSA Therefore, this may call into question the necessity of subsequent DSA in the PM-SAH group Need for evidence-based guidelines

Thank you!