Diagnostic yield and accuracy of CT angiography, MR angiography, and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage: prospective, multicentre cohort study.

Study question:\ud What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage?\ud \ud Methods:\ud This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year’s follow-up.\ud \ud Study answer and limitations:\ud A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed.\ud \ud What this study adds:\ud CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA.\ud \ud Funding, competing interests, data sharing:\ud Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additional data to the corresponding author

Diagnostic yield and accuracy of CT angiography, MR angiography, and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage: Prospective, multicentre cohort study

Study question What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage? Methods This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up. Study answer and limitations A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced p

Predicting the presence of macrovascular causes in non-traumatic intracerebral haemorrhage: the DIAGRAM prediction score

Paroxysmal Cerebral Disorder

Imaging of non-traumatic intracerebral and intraventricular haemorrhage

The diagnostic yield and accuracy of CT angiography (CTA), and of additional MR imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) for detection of macrovascular causes of intracerebral haemorrhage are described. The reference standard was the best available evidence from all findings during follow-up (median duration of 450 days). We enrolled 298 patients, aged 18 to 70 years, excluding those older than 45 years of age with hypertension and ICH in basal ganglia, thalamus, or posterior fossa. A macrovascular cause was identified in 69 patients (23%). The overall yield of CTA and MRI/MRA for detection of a macrovascular cause was slightly higher than the yield of early CTA as a single modality (18 versus 17%), whereas the combination of CTA, MRI/MRA and DSA increased the overall yield to 23%. The positive predictive value (PPV) of CTA was 72%, of additional MRI/MRA 35%, and of additional DSA 100%. The standardised diagnostic workup failed to identify a cavernoma in one patient, which was identified by a repeated MRI. Predictors for a macrovascular cause were younger age, lobar or posterior fossa ICH location, and absence of signs of small vessel disease on non-contrast CT. The discriminative ability of the proposed prediction score was good (c statistic 0.83, 95%CI 0.78-0.88) for estimation of low (15%) risk of a macrovascular cause. Prediction charts were generated for patients aged 18-50 years old and patients aged 51-70. We conclude that CTA is an appropriate initial investigation and additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is indicated to find macrovascular causes undetected by CTA or MRI/MRA. The DIAGRAM prediction score may be helpful for clinical practice to estimate the probability of finding a macrovascular cause, and needs external validation. We also provide a case series and systematic review of the literature on the yield of angiographic examinations in patients with isolated intraventricular haemorrhage. In conclusion, the reported yield of DSA in isolated IVH varies considerably, which is probably related to confounding by indication. Data on the yield of CTA and MRI/MRA in patients with isolated IVH are urgently needed. Also a Markov decision-analytic model was developed to examine the cost-effectiveness of different diagnostic strategies to find macrovascular causes in patients with ICH. Adding MRI/MRA and DSA to CTA as single investigation in the diagnostic workup of patients with ICH does not improve health outcomes but does increase healthcare costs

Imaging of non-traumatic intracerebral and intraventricular haemorrhage

The diagnostic yield and accuracy of CT angiography (CTA), and of additional MR imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) for detection of macrovascular causes of intracerebral haemorrhage are described. The reference standard was the best available evidence from all findings during follow-up (median duration of 450 days). We enrolled 298 patients, aged 18 to 70 years, excluding those older than 45 years of age with hypertension and ICH in basal ganglia, thalamus, or posterior fossa. A macrovascular cause was identified in 69 patients (23%). The overall yield of CTA and MRI/MRA for detection of a macrovascular cause was slightly higher than the yield of early CTA as a single modality (18 versus 17%), whereas the combination of CTA, MRI/MRA and DSA increased the overall yield to 23%. The positive predictive value (PPV) of CTA was 72%, of additional MRI/MRA 35%, and of additional DSA 100%. The standardised diagnostic workup failed to identify a cavernoma in one patient, which was identified by a repeated MRI. Predictors for a macrovascular cause were younger age, lobar or posterior fossa ICH location, and absence of signs of small vessel disease on non-contrast CT. The discriminative ability of the proposed prediction score was good (c statistic 0.83, 95%CI 0.78-0.88) for estimation of low (15%) risk of a macrovascular cause. Prediction charts were generated for patients aged 18-50 years old and patients aged 51-70. We conclude that CTA is an appropriate initial investigation and additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is indicated to find macrovascular causes undetected by CTA or MRI/MRA. The DIAGRAM prediction score may be helpful for clinical practice to estimate the probability of finding a macrovascular cause, and needs external validation. We also provide a case series and systematic review of the literature on the yield of angiographic examinations in patients with isolated intraventricular haemorrhage. In conclusion, the reported yield of DSA in isolated IVH varies considerably, which is probably related to confounding by indication. Data on the yield of CTA and MRI/MRA in patients with isolated IVH are urgently needed. Also a Markov decision-analytic model was developed to examine the cost-effectiveness of different diagnostic strategies to find macrovascular causes in patients with ICH. Adding MRI/MRA and DSA to CTA as single investigation in the diagnostic workup of patients with ICH does not improve health outcomes but does increase healthcare costs

Diagnostic yield and accuracy of CT angiography, MR angiography and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage - a prospective, multicentre cohort study

Paroxysmal Cerebral Disorder

Diagnostic yield and accuracy of CT angiography, MR angiography, and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage: prospective, multicentre cohort study

Item does not contain fulltextSTUDY QUESTION: What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage? METHODS: This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up. STUDY ANSWER AND LIMITATIONS: A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed. WHAT THIS STUDY ADDS: CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA. FUNDING, COMPETING INTERESTS, DATA SHARING: Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additional data to the corresponding author