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, 2 (4), 369-376

Developing an Algorithm to Identify Patients With Intracerebral Haemorrhage Secondary to a Macrovascular Cause

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Developing an Algorithm to Identify Patients With Intracerebral Haemorrhage Secondary to a Macrovascular Cause

Duncan Wilson et al. Eur Stroke J.

Abstract

Introduction: Determining the cause of spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is critical to guide treatment and prognosis. We investigated whether small vessel disease (SVD) in addition to clinical and other radiological findings on acute neuroimaging predicts a low risk of a macrovascular cause (e.g. an arterio-venous malformation, aneurysm or dural arteriovenous fistula).

Patients and methods: We identified patients with acute spontaneous ICH who underwent acute non-contrast CT, CT angiography (CTA) and intra-arterial digital subtraction angiography (IADSA) at our institution from January 2010 to April 2014. Logistic regression including CTA result, SVD, age, pre-ICH hypertension and ICH location was used to derive a prediction model, validated using bootstrapping.

Results: 173 patients (46% female, median age 49) of whom 78 had a macrovascular cause on IADSA were included. Predictors of a macrovascular cause were: abnormal CTA (OR 67.4; p < 0.001); absence of SVD (OR 5.0; p = 0.019); and absence of pre-ICH hypertension (OR 3.4; p = 0.05). In our internally derived prediction model, the combination of CTA, SVD and pre-ICH hypertension predicted the likelihood of an underlying macrovascular cause (optimism-adjusted ROC area 0.919). Patients with negative CTA, SVD and pre-ICH hypertension have a low likelihood of an underlying macrovascular cause (1.8%).

Discussion and conclusion: A combination of CTA, SVD and pre-ICH hypertension predict the likelihood of finding a macrovascular cause in patients with acute spontaneous ICH, allowing informed decisions regarding the likely benefit and risk of IADSA.

Keywords: CT angiography; intra-arterial digital subtraction angiogram; intracerebral haemorrhage; small vessel disease.

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Figures

Figure 1.
Figure 1.
Flow chart for study. IADSA: intra-arterial digital subtraction angiography; ICH: intracerebral hemorrhage; CTA: computed tomography angiography; AVM: arteriovenous malformation.
Figure 2.
Figure 2.
Optimised model ROC curve with abnormal CTA, no pre-stroke hypertension and no moderate to severe SVD on CT used as predictors of macrovascular cause.
Figure 3.
Figure 3.
Suggested diagnostic algorithm. CTA: computed tomography angiogram; HTN: known pre-ICH hypertension; WMH: white matter hyperintesities; IADSA: intra-arterial digital subtraction angiography. ‘Positive’ includes patients where the acute CTA shows a ‘definite’ or ‘possible’ macrovascular cause; ‘negative’ CTA denotes those with no suspicion of a vascular malformation.

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