Additional value of 3D rotational angiography in angiographically negative aneurysmal subarachnoid hemorrhage: how negative is negative?

Abstract

Background and purpose: In some patients with nonperimesencephalic nontraumatic subarachnoid hemorrhage (aneurysmal SAH), no aneurysm can be found on digital subtraction angiography (DSA), and repeat DSA is advocated. 3D rotational angiography (3DRA) is considered superior to DSA in the detection of small intracranial aneurysms. In this study, we assessed the additional diagnostic value of 3DRA in detecting DSA-occult aneurysms in 23 patients with aneurysmal SAH.

Materials and methods: Between January 2006 and September 2007, 298 patients with suggested ruptured intracranial aneurysm were referred for DSA, and in 98 patients, DSA was negative. Of these 98 patients, 28 had aneurysmal SAH, and in 23 of these additional 3DRA was performed in the same or in a repeat angiographic procedure.

Results: In 18 of 23 patients (78%), a ruptured small aneurysm was diagnosed on additional 3DRA. The location of 18 aneurysms was the anterior communicating artery (n = 11), the middle cerebral artery (n = 3), the posterior communicating artery (n = 2), the ophthalmic artery (n = 1), and the posterior inferior cerebellar artery (n = 1). Aneurysm size was 3 mm in 4, 2 mm in 9, and 1 mm in 5. Of 18 aneurysms, 9 were treated with coil placement; 7 with surgical clipping; and 2 were not treated.

Conclusion: In this study, 18 of 23 (78%) patients with negative findings on DSA had a small ruptured aneurysm when studied with 3DRA. These were most commonly located on the anterior communicating artery.

Fig 1.

Flow chart of 298 patients with suggested ruptured intracranial aneurysm referred for cerebral angiography. Asterisk indicates no additional imaging because of advanced age in 4 and death soon after admission in 1. PMH indicates perimesencephalic hemorrhage; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SDH, subdural hemorrhage.

Fig 2.

A 48-year-old man presenting 4 days after headache of sudden onset in good clinical condition. A, CT scan shows a small amount of blood in the left Sylvian fissure (arrow). B–D, DSA in 3 projections fails to show a middle cerebral artery aneurysm. E and F, 3DRA depicts a 1-mm aneurysm on a M2-M3 junction (arrow). G and H, Operative view (compare with F) before (G) and after (H) clipping. Blood remnants are proof of rupture of the small aneurysm.

Fig 3.

A 67-year-old woman admitted with grade IV SAH, comatose and ventilated. CT scan showed diffuse subarachnoid blood. A–C, Right internal carotid artery angiogram in 3 projections fails to demonstrate an aneurysm. Note filling of both A2s and A1s. D, Posterior view of 3DRA depicts a 1.6-mm anterior communicating artery aneurysm (arrow). This aneurysm was clipped 1 week later.