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.
Predicting the Presence of Macrovascular Causes in Non-Traumatic Intracerebral Haemorrhage: The DIAGRAM Prediction ScoreNA Hilkens et al. J Neurol Neurosurg Psychiatry 89 (7), 674-679. PMID 29348301.The DIAGRAM scores help to predict the probability of a macrovascular cause in patients with non-traumatic ICH based on age, ICH location, SVD and CTA.
Diagnostic Yield and Accuracy of CT Angiography, MR Angiography, and Digital Subtraction Angiography for Detection of Macrovascular Causes of Intracerebral Haemorrhage: Prospective, Multicentre Cohort StudyCJ van Asch et al. BMJ 351, h5762. PMID 26553142.Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additiona …
Vascular and Nonvascular Mimics of the CT Angiography "Spot Sign" in Patients With Secondary Intracerebral HemorrhageS Gazzola et al. Stroke 39 (4), 1177-83. PMID 18292380.This study describes mimics of the CTA Spot Sign and classifies them as vascular (microAVM, aneurysm, Moya Moya) or nonvascular (tumor and choroid plexus calcification). …
Is Four-Dimensional CT Angiography as Effective as Digital Subtraction Angiography in the Detection of the Underlying Causes of Intracerebral Haemorrhage: A Systematic ReviewCE Denby et al. Neuroradiology. PMID 31901972. - ReviewThe review of current literature has demonstrated that there are few published studies comparing 4D-CTA with DSA in spontaneous ICH, with only four suitable studies ident …
Thrombolysis in Acute Stroke Patients With Cerebral Small Vessel DiseaseL Pantoni et al. Cerebrovasc Dis 37 (1), 5-13. PMID 24355873. - ReviewThe studies herein reviewed show that thrombolysis is an effective treatment in acute lacunar stroke, and that the presence of cerebral SVD increases the risk of ICH duri …