Diagnostic Yield of Catheter Angiography in Patients with Subarachnoid Hemorrhage and Negative Initial Noninvasive Neurovascular Examinations

J.E. Delgado Almandoz; B.M. Crandall; J.L. Fease; J.M. Scholz; R.E. Anderson; Y. Kadkhodayan; D.E. Tubman

doi:10.3174/ajnr.A3291

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Fig. 1.
A 58-year-old woman with a known allergy to iodinated contrast material who presented with acute onset of severe headache. A, NCCT demonstrates a diffuse pattern of SAH centered in the posterior aspect of the basal cisterns with extension to the occipital and parietal sulci. B, MRA source image in the region of the hemorrhage does not demonstrate a causative vascular abnormality. C, Oblique left vertebral angiogram obtained 1 day after the MRA and following premedication with steroids demonstrates a small DAVF deriving arterial supply from an enlarged meningeal branch of the left vertebral artery (arrow) and with early venous drainage to the straight sinus (arrowheads). The DAVF was treated with radiosurgery.
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Fig. 2.
A 71-year-old man who presented with the worst headache of his life. A, NCCT demonstrates a diffuse pattern of SAH in the basal cisterns. B, Axial CTA source image was initially interpreted as not demonstrating a causative vascular abnormality for the hemorrhage. In retrospect, a small aneurysm is present in the lateral aspect of the left internal auditory canal (arrowhead). C, Frontal right vertebral angiogram obtained 1 day after the CTA demonstrates a small pial AVM in the region of the left cerebellopontine angle (arrow) with an associated 2-mm feeding artery aneurysm from a distal branch of an enlarged left anterior inferior cerebellar artery (arrowhead). The patient underwent aneurysm coiling followed by radiosurgery of the AVM nidus.
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Fig. 3.
A 50-year-old man who presented with sudden onset of severe headache, nausea, and vomiting. A, NCCT demonstrates a diffuse pattern of SAH with extension to the Sylvian fissures. B, Axial CTA source image did not demonstrate a causative vascular abnormality. C, Oblique right internal carotid angiogram obtained 1 day after the CTA demonstrates a 1.5-mm blister right supraclinoid ICA aneurysm. The patient underwent endovascular aneurysm treatment with the Pipeline Embolization Device (Covidien/ev3 Neurovascular, Irvine, California).
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Fig. 4.
A 52-year-old woman with a history of migraine headaches who presented with sudden onset of severe frontal headache. A, NCCT demonstrates a peripheral sulcal pattern of SAH in the left frontal region. B, Axial MRA maximum-intensity-projection image does not demonstrate a causative vascular abnormality. C, Lateral right external carotid angiogram obtained 2 days after the MRA demonstrates multiple segmental areas of luminal narrowing and dilation affecting the right superficial temporal artery (arrowheads), consistent with vasculopathy. The clinical scenario was consistent with reversible cerebral vasoconstriction syndrome. D, Lateral right external carotid artery angiogram obtained 3 months after cessation of the inciting medication demonstrates resolution of the abnormalities in the right superficial temporal artery.
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Fig. 5.
A 67-year-old woman who presented with sudden onset of severe headache. A, NCCT demonstrates a diffuse pattern of SAH with extension to the Sylvian fissures and ventricular system. B, Axial CTA source image did not demonstrate a causative vascular abnormality. C, Frontal left internal carotid angiogram obtained on the same day as the CTA did not demonstrate a causative vascular abnormality. D, Frontal left internal carotid artery angiogram obtained 8 days after the initial CTA demonstrates a 2-mm anterior communicating artery aneurysm (arrowhead). The patient underwent aneurysm coiling.