gms | German Medical Science

Objective: The data concerning the handling of subarachnoid hemorrhage with negative initial DSA is still inconclusive. There are recommendations that one DSA is sufficient for subarachnoid hemorrhage with a perimesencephalic bleeding pattern. The risk of rebleeding including a severe neurological outcome due to a misdiagnosed aneurysm always contrasts to possible complications that may occur during a DSA. The intention of this study was to evaluate the need of repeat DSA in patients with negative initial DSA.

Methods: In a retrospective study we analyzed all patients with a subarachnoid hemorrhage and negative initial DSA between 2006 and 2017 treated in our department. The initial CT scans and all DSA scans were reviewed by a neuroradiologist and a neurosurgeon. The patients were divided according to an established classification into perimesencephalic (pm) and non-perimesencephalic (npm) subarachnoid hemorrhage. In addition, age, sex, Hunt and Hess, the complications of DSA as well as the occurrence of vasospasm, hydrocephalus, and the need for external ventricular drain or shunt care were assessed.

Results: There were 52 patients with negative initial DSA, among 36 patients with a pm and 16 with a npm bleeding pattern. All patients underwent a second and 23 patients a third DSA. On the average the second DSA was performed 28 days after the bleeding event. In total, 2 aneurysms were detected during the second DSA (3,85%). Both were in the perimesencephalic group and located in the superior cerebellar artery and in the posterior communicating artery. The third DSA showed no new aneurysms. Complications after the DSA occurred in only 2 patients out of a total of 127 DSA (1, 57%). The patients suffered reversible deficits such as loss of visual acuity, visual field loss, aphasia and vertigo. The rate of complications concerning vasospasm (pm 44, 4%, npm 44, 2%), hydrocephalus (pm 47, 2%, npm 50%), and the need for temporary or permanent shunt (pm 44, 4%, npm 50%) was similar in both groups.

Conclusion: In our study we found two cases of perimesencephalic bleeding pattern with an evidence of an aneurysm in the second DSA. In addition, it shows a low rate of complications after a DSA. In our patient cohort, the rate of complications was similar to the nonperimesencephalic bleeding pattern. In summary, a second DSA is not redundant in subarachnoid hemorrhages with negative initial DSA, in particular in the case of perimesencephalic subarachnoid hemorrhage. However, a third DSA was not necessary in this series.