İlk Anjiografisi Negatif Olan Spontan Subaraknoid Kanamalarda Anjiografi Tekrarının Gereksinimi Nedir?

Amaç: Bu çalışmanın amacı, obstetrik nedenli dissemine intravasküler kuagülasyonun (DİK) altta yatan nedenleriniaraştırmak ve Giriş: Tekrar anjiografi ilk anjiografisi negatif olan spontan subaraknoid kanamalı (SAK) hastalardagenelde uygulanır. Bu çalışmada tekrar anjiografinin gerekliliğini farklı klinik ve kanama paterni olan spontan SAK’lardaincelemeyi amaçladık.Yöntemler: Nöroşirurji Kliniğimize başvuran spontan SAK hasta verileri üzerinden retrospektif analiz yapıldı. Hastalarperimesensefalik ve nonperimesensefalik SAK olarak serebral BT’de kanama paternlerine göre iki gruba ayrıldı.Demografik, klinik veri, rutin iki hafta içinde uygulanan izlem serebral anjiografiler, anjiografi tekrarına bağlıkomplikasyonlar ve yeni saptanan vaskuler patoloji varlığı kaydedildi. Bulgular: 208 spontan SAK hastası ortalama yaş 60.00±15.82 (20-83) dahil edildi. Fisher skoru perimesensefalik SAKhastalarında daha düşük elde edildi. Mortalite de nonperimesensefalik SAK hastalarda daha sık izlenildi. SAK ile ilişkilivaskuler patoloji sadece nonperimesensefalik SAK hastalarında istatistiksel farklılık olmaksızın izlenildi (0 vs 4, p:0.078).Anjiografi tekrarına bağlı komplikasyon insidansı her iki grupta benzerdi.Sonuç: Klinisyenler spontan SAK’ta serebral vaskuler patolojileri bir kere daha dışlamak amacıyla ardışıknörogörüntüleme testleri düşünmelidir. Verilerimiz nonperimesensefalik ile kıyaslandığında perimesensefalik SAK’lardaFisher skorunun daha iyi ve daha az mortal olduğunu desteklemektedir. Perimesensefalik SAK hastalarımızın anjiografitekrarlarında herhangi vaskuler patoloji yoktu. Bu nedenle bu hastalarda invazif bir görüntüleme metodu olan serebralanjiografi yerine yüksek kalitede MRanjiografi veya BTanjiografi daha kolay uygulanabilir. Serebral anjiografi sadeceşüphelenilen perimesensefalik SAKlarda düşünülebilir.

What Is The Need For Repeat Angiography In SpontaneousSubarachnoid Hemorrhages With Negative Initial Angiogram?

Objective: Repeat angiography is usually performed in spontaneous SAH patients who have negative initial angiography. In this study we aimed to evaluate the yield of repeat angiography in spontaneous SAH with different clinics and bleeding paterns.Methods: A retrospective analysis was performed on spontaneous SAH patients who admitted to our neurosurgery clinic. The patients were divided into two groups as perimesencephalic and nonperimesencephalic SAH according to their bleeding patern on cerebral CT. Demographic and clinic data, routine follow-up cerebral angiography within 2 weeks, complications due to repeated cerebral angiography and the presence of new detected vascular pathology were all recorded.Results: 208 patients with spontaneous SAH with mean age 60.00±15.82 (20-83) years were included. The Fisher score was found lower in perimesencephalic SAH patients. Mortality was also seen more frequently in nonperimesencephalic SAH. In repeat angiography vascular pathology related with SAH was found in only nonperimesencephalic SAH patientswithout any statistically significancy (0 vs 4, p:0.078). The incidence of complications due to repeat angiography was similiar in both groups.Conclusion: In conclusion clinicians should consider to evaluate the spontaneous SAH with subsequent neuroimaging tests once more to rule out cerebral vascular pathologies. Our data suggested that perimesencephalic SAH has a better Fisher score and less mortality when compared with nonperimesencephalic SAH. Our perimesencephalic SAH patients have no vascular pathology even after repeat angiography. Therefore high quality MR angiography or CTangiography can be easily performed rather than cerebral angiography which is an invasive imaging method. Cerebral angiography should be considered only in suspected cases with perimesencephalic SAH.

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1. Andaluz N, Zuccarello M. Yield of further diagnostic work-up of cryptogenic subarachnoid hemorrhage based on bleeding patterns on computed tomographic scans. Neurosurgery. 2008 May; 62: 1040-6.
2. Alén JF, Lagares A, Lobato RD, et al. Comparison between perimesencephalic nonaneurysmal subarachnoid hemorrhage and subarachnoid hemorrhage caused by posterior circulation aneurysms. J Neurosurg 2003; 98: 529–35
3. Ildan F, Tuna M, Erman T, et al. Prognosis and prognostic factors in nonaneurysmal perimesencephalic hemorrhage: a follow-up study in 29 patients. Surg Neurol 2002; 57: 160–5.
4. Yılmaz A, Özkul A. Demographic and clinical features of subarachnoid hemorrhages with or without cerebral aneurysm. Turkish Journal of Cerebrovascular Diseases 2017; 23: 56-61.
5. Little AS, Garrett M, Germain R, et al. Evaluation of patients with spontaneous subarachnoid hemorrhage and negative angiography. Neurosurgery. 2007; 61: 1139–50.
6. Agid R, Andersson T, Almqvist H, et al. Negative CT Angiography findings in patients with spontaneous subarachnoid hemorrhage: when is digital subtraction angiography still needed? AJNR Am J Neuroradiol. 2010; 31: 696–705.
7. Hashimoto H, Iida J, Hironaka Y, Okada M, Sakaki T: Use of spiral computerized tomography angiography in patients with subarachnoid hemorrhage in whom subtraction angiography did not reveal cerebral aneurysms. J Neurosurg 2000; 92: 278–83.
8. Ildan F, Tuna M, Erman T, Göcer AI, Cetinalp E. Prognosis and prognostic factors in nonaneurysmal perimesencephalic hemorrhage: A follow-up study in 29 patients. Surg Neurol. 2002; 57: 160–6.
9. Delgado Almandoz JE, Jagadeesan BD, Refai D, et al. Diagnostic yield of repeat catheter angiography in patients with catheter and computed tomography angiography negative subarachnoid hemorrhage. Neurosurgery.2012May; 70: 1135-42.
10. Ildan F, Tuna M, Erman T, et al. Prognosis and prognostic factors for unexplained subarachnoid hemorrhage: Review of 84 cases.Neurosurgery 2002; 50: 1015–25.
11. Inamasu J, Nakamura Y, Saito R, et al. “Occult” ruptured cerebral aneurysms revealed by repeatangiography: Result from a large retrospective study. Clin Neurol Neurosurg.2003; 106: 33–7.
12. Ruigrok YM, Rinkel GJ, Buskens E, Velthuis BK, van Gijn J. Perimesencephalic hemorrhage and CT angiography. A decision analysis. Stroke.2000; 31: 2976–83.
13. Teke M, Kına A, Sarıca Ö, Albayram S. Susceptibility Weighted Imaging sequence applications in neuroradiology . Dicle Med J 2015; 42: 235-41.