Abstract
Subarachnoid haemorrhage (SAH) is often associated with negative cerebral angiography. Following the exclusion of other causes, a patient may be suspected of harbouring an occult intracranial aneurysm, with risk of recurrent bleeding and death. These patients are often identified on the basis of clinical presentation and computed tomography (CT) findings, and require expeditious further investigation if morbidity and mortality are to be minimized. Currently available options include repeated cerebral angiography, surgical exploration, and the newer technologies of computed tomography angiography (CTA) and magnetic resonance angiography (MRA). We review these options, based on current literature, with particular emphasis on the expanding roles of CTA and MRA. A multimodality management protocol is proposed, with decisions based on clinical urgency, patient progress and the natural history of aneurysmal SAH, particularly vasospasm and aneurysm thrombosis.
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Papers reviewed
Gilbert JW, Lee C, Young B (1990) Repeat cerebral pan-angiography in subarachnoid hemorrhage of unknown etiology. Surg Neurol 33:19–21
Urbach H, Zentner J, Solymosi L (1998) The need for repeat angiography in subarachnoid hemorrhage. Neuroradiology 40:6–10
Jafar JJ, Weiner HL (1993) Surgery for angiographically occult cerebral aneurysms. J Neurosurg 79:674-679
Lenhart M, Bretschneider T, Gmeinwieser J, Ullrich OW, Schlaier J, Feuerbach S (1997) Cerebral CT angiography in the diagnosis of acute subarachnoid hemorrhage. Acta Radiol 38:791–796
Hsiang JNK, Liang EY, Lam JMK, Zhu XL, Poon WS (1996) The role of computed tomographic angiography in the diagnosis of intracranial aneurysms and emergent aneurysm clipping. Neurosurgery 38:481–487
Renowden SA, Molyneux AJ, Anslow P, Byrne JV (1994) The value of MRI in angiogram-negative intracranial hemorrhage. Neuroradiology 36:422–425
Keogh AJ, Sankhla SK (1996) Magnetic resonance angiography for anterior midline aneurysms. Br J Neurosurg 10:143–147
Vassilouthis J, Chrysikopoulos CH, Seferis CH (1997) Magnetic resonance angiography demonstration of an angiographically occult anterior communicating artery aneurysm. Br J Neurosurg 11:448–451
Further reading
Alexander MS, Dias PS, Uttley D (1991) Spontaneous subarachnoid hemorrhage and negative panangiography. J Neurosurg 64:537–542
Anderson GB, Findlay JM, Steinke DE, Ashforth R (1997) Experience with computed tomographic angiography for the detection of intracranial aneurysms in the setting of acute subarachnoid hemorrhage. Neurosurgery 41:522–528
Di Lorenzo N, Guidetti G (1988) Anterior communicating aneurysm missed at angiography: report of two cases treated surgically. Neurosurgery 23:494–497
Duong H, Melancon D, Tampieri D, Ethier R (1996) The negative angiogram in subarachnoid haemorrhage. Neuroradiology 38:15–19
Ferbert A, Hubo I, Biniek R (1992) Non-traumatic subarachnoid hemorrhage with normal angiogram. Long-term follow-up and CT predictors of complications. J Neurol Sci 107:14–18
Iwanaga H, Wakai S, Ochiai C, Narita J, Inoh S, Nagai M (1990) Ruptured cerebral aneurysms missed by initial angiographic study. Neurosurgery 27:45–51
Jeelani NUO, Sekhar LN, Bank WO (1997) “Angiogram-negative” subarachnoid hemorrhage: a current perspective. Crit Rev Neurosurg 7:324–332
Juul R, Torbjorn A, Fredriksen TA, Ringkjob R (1986) Prognosis in subarachnoid hemorrhage of unknown etiology. J Neurosurg 64:359–362
Kallmes DF, Clarke HP, Dix JE, Cloft HJ, Evans AJ, Dion JE, Kassell NF (1996) Ruptured vertebrobasilar aneurysms: frequency of the nonaneurysmal perimesencephalic pattern of hemorrhage on CT scans. Radiology 201:657–660
Kawamura S, Yasui N (1990) Clinical and long-term follow-up study in patients with spontaneous subarachnoid haemorrhage of unknown aetiology. Acta Neurochir (Wien) 106:110–114
Rinkel GJ, Wijdicks E, Vermeulen M, Ramos L, Tanghe H, Hasan D, Meirers L, Gijn J van (1991) Nonaneurysmal perimesencephalic subarachnoid hemorrhage: CT and MR patterns that differ from aneurysmal rupture. AJNR Am J Neuroradiol 12:829–834
Spetzler RF, Winestock D, Newton HT (1974) Disappearance and reappearance of cerebral aneurysm in serial arteriograms. Case report. J Neurosurg 41:508–510
Tatter SB, Crowell RM, Ogilvy CS (1995) Aneurysmal and microaneurysmal “angiogram-negative” subarachnoid hemorrhage. Neurosurgery 37:48–55
Young N, Dorsch NWC, Kingston RJ, Soo MYS, Robinson R (1998) Spiral CT scanning in the detection and evaluation of aneurysms of the circle of Willis. Surg Neurol 50:50–61
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McMahon, J., Dorsch, N. Subarachnoid haemorrhage of unknown aetiology: what next?. Crit Rev Neurosurg 9, 147–155 (1999). https://doi.org/10.1007/s003290050124
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DOI: https://doi.org/10.1007/s003290050124