E1903. Value of CTA in the Setting of Parenchymal Hemorrhage With and Without Intraventricular and Subarachnoid Hemorrhage in the ED
Penn State Health Milton S. Hershey Medical Center
Johns Hopkins Hospital
The aim of this study is to evaluate the yield of CTA head and neck and MRA brain and neck ordered in the ED for patients who had an IPH, with or without subarachnoid hemorrhage, on their initial NCCT of the head. We hypothesized that, because of the higher prevalence of primary IPH from hypertensive bleeds and amyloid angiopathy, the rates of positive CTA or MRA of the brain would be low, i.e., less than 10%.
Materials and Methods:
This is a retrospective study, approved by the institutional review board of the hospital, and conducted with HIPAA compliance. The aim of this study is to retrospectively review patients presenting to the ED from July 19, 2017 to July 29, 2020 who had an initial NCCT or MRI brain showing nontraumatic intraparenchymal hemorrhage (IPH), with a subsequent CTA head and neck or MRA head and neck. The location of intraparenchymal hemorrhage was categorized as lobar, deep gray matter, brainstem, or cerebellar. We stratified the patients by the following age groups: 18–45 years, 46–70 years, and greater than 70 years old. Exclusion criteria involved traumatic IPH, hemorrhagic conversion from prior infarct, and patients younger than 18 years old. Epidemiological data were collected from EMR, including patient’s age, sex, history of hypertension, coagulopathy, and use of antiplatelets or anticoagulants.
The results reported here represent partial data of an ongoing study. A total of 50 patients were included for this submission. The most common location of intraparenchymal hemorrhage was lobar (n = 31, 62%), and the average age was 63.6 years old. The overall yield of CTA was 26% (n = 13/50), but only 7.1% for patients older than 70 years with hypertension. For such patients the yield of CTA was 0 when the location was deep gray matter. The yield of CTA/MRA among patients with lobar hemorrhage was 47% (8/17) among patients at the age group of 46–70 years, and only 16% (2/12) in patients older than 70 years. Twenty-eight percent (14/50) of patients had deep gray matter hemorrhage; 92.8% of patients with deep gray matter hemorrhage had a negative CTA/MRA, only one patient was found to a cavernous malformation. Two patients were found to have brainstem hemorrhage, both in the pons. One patient with history of hereditary hemorrhagic telangiectasia had a positive CTA, showing cavernous malformation. Three patients had cerebellar hemorrhage. CTA was positive for only one case, showing basilar aneurysm. Another patient at the same age group had a normal CTA with a subsequent DSA showing cerebellar AVM.
CTA and MRA have a lower yield for patients at older age with a history of hypertension and intraparenchymal hemorrhage in a deep gray matter or lobar distribution. The combination of those clinical and radiological findings suggests a primary etiology . In these scenarios, the value of CTA or MRA is limited.