Subarachnoid Hemorrhage with a Cerebral Aneurysm not recognized at Conventional Angiography: A Retrospective Study
نویسندگان
چکیده
Reprint requests to: Dr. Shy-Chyi Chin Department of Medical Imaging & Intervention, ChangGung Memorial Hospital at Linkou, School of Medicine, Chang Gung University. No. 5, Fu Sing Road, Gueishan, Taoyuan 333, Taiwan, R.O.C. To investigate the possible causes of a falsenegat ive init ial cerebral d ig ital subtract ion angiography (DSA) of aneurysmal subarachnoid hemorrhage (SAH). Six initially unrecognized ruptured aneurysms were reviewed from among approximately 160 aneurysmal SAH cases collected from the medical records. The standard angiographic procedure and findings on repeat DSA were used to identify the possible causes. The initial DSA was reviewed and the falsenegative impression resulted from an initial overlooking with or without incomplete procedure (4/6), presumed thrombosis or vasospasm with no recognized aneurysm, even when reviewed retrospectively (3/6), and the presence of a blister aneurysm (1/6). Two of the six cases had multiple causes. Whenever the DSA is negative in a pat ient strongly suspected of an aneurysmal SAH, the three above-mentioned causes should be considered and repeat DSA in the proper clinical setting is recommended. Roughly 15~30% of the initial cerebral digital subtraction angiography (DSA) performed in patients with subarachnoid hemorrhage (SAH) fails to show a cause [1-3]. These DSA-negative SAH patients have a better prognosis if no aneurysm is found on repeat DSA [4]. In clinical practice, however, the etiology of SAH in this patient group must be zealously considered to avoid the devastating medical and legal consequences that result from an interpretation error. In 2002, Friedman et al. recommended selective repeat DSA when (1) vasospasm compromised the first study, (2) part of the cerebral circulation is not seen well, (3) CT shows a large diffuse or focal SAH, and (4) a second SAH occurs (5). To verify these recommendations, we retrospectively reviewed six patients with ruptured cerebral aneurysms with an initial false-negative DSA. The analysis focused on the causes of failure to make the correct diagnosis of ruptured aneurysm. We hope to enhance our diagnostic ability when future cases are encountered.
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