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60th Annual Meeting of the German Society of Neurosurgery (DGNC)
Joint Meeting with the Benelux countries and Bulgaria

German Society of Neurosurgery (DGNC)

24 - 27 May 2009, Münster

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Comparison of DSA and MD-CT-angiography in diagnosing the cause of a pre-pontine cryptic SAH

Meeting Abstract

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  • B. Prümer - Klinik für Radiologie, Clemenshospital Münster
  • S. Terwey - Klinik für Neurochirurgie, Clemenshospital Münster
  • P. Bell - Klinik für Radiologie, Clemenshospital Münster
  • C. Reckels - Klinik für Radiologie, Clemenshospital Münster
  • A. Sepehrnia - Klinik für Neurochirurgie, Clemenshospital Münster
  • A.R. Fischedick - Klinik für Radiologie, Clemenshospital Münster
  • U. Haverkamp - Klinik für Radiologie, Clemenshospital Münster

Deutsche Gesellschaft für Neurochirurgie. 60. Jahrestagung der Deutschen Gesellschaft für Neurochirurgie (DGNC), Joint Meeting mit den Benelux-Ländern und Bulgarien. Münster, 24.-27.05.2009. Düsseldorf: German Medical Science GMS Publishing House; 2009. DocP13-12

doi: 10.3205/09dgnc398, urn:nbn:de:0183-09dgnc3980

Published: May 20, 2009

© 2009 Prümer et al.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by-nc-nd/3.0/deed.en). You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.

Outline

Text

Objective: A circumscribed small amount of subarachnoid blood in a pre-pontine localization is a finding which triggers questions concerning the diagnostic work-up as well as the therapeutic consequences. Literature says that one hardly detects a precise cause for the actual bleeding, rendering therapeutic approaches rather questionable.

Methods: This study covers the investigation of 135 consecutive patients, admitted to our hospital with an acute SAH during a five year period. The patients presenting with a limited pre-pontine SAH received a DS-angiography (Integris-5000, Philips) as well as a MD-CT-angiography (Aquilion-64, Toshiba) to determine the bleeding cause. Both investigation techniques were compared to one another in terms of detecting an aneurysm, an AV-malformation, a vascular spasm or other associated pathologies.

Results: Out of 135 patients presenting with an acute SAH, in 27 patients (20%) a limited pre-pontine SAH was discovered. The patients presented with a mean GCS of 10.4 (14–6) and a Hunt&Hess state of 1.8 (1–4). In all 27 patients a DSA and an MSCTA was technically feasible. A control study was performed between 12 days and 2 weeks later. The average time to perform the diagnostic procedures took 55 minutes for the DSA, while MSCTA took 12 minutes. While the DSA procedure caused one complication with a temporary hemiparesis resolving after two weeks, MSCTA showed none.

With neither modality we discovered an aneurysm or an AVM responsible for the SAH. The control studies after 2 weeks and 6 months were also negative.

DSA demonstrated vasospasm in 6 patients (22%), while CTA revealed spasm in only 3 patients (11%). On the other hand, MSCTA is superior in detecting associate pathologies like intraparenchymal – 1 patient (4%) – and intraventricular bleeding – two patients (7%) – or an evolving hydrocephalus – three patients (11%).

Conclusions: In all 27 cases of a cryptic pre-pontine SAH neither DSA, nor MSCTA could reveal a definitive bleeding cause. Neither an aneurysm, nor an AVM was found.

DSA has a higher sensitivity in finding vasospasm, while MSCT is to be preferred in detecting concomitant pathologies like intraparenchymal and intraventricular bleeding or an evolving hydrocephalus.

We suggest a combined diagnostic workup of a cryptic pre-pontine SAH: 1) Initial MSCTA after diagnosing an SAH, 2) DSA after 12–14 days and 3) MSCTA-control study after 4–6 months, given the preceding angiography is negative.