Resident Physician in Neurosurgery Cleveland Clinic Foundation Cleveland, Ohio, United States
Disclosure(s):
Ahmed I. Kashkoush, MD: No financial relationships to disclose
Introduction: Intracranial hemorrhage (ICH) secondary to hypertension (HTN) classically occurs in the basal ganglia, cerebellum, or pons. Vascular lesions such as aneurysms or arteriovenous malformations (AVMs) are more common in younger patients. We investigated the utility of diagnostic subtraction angiography (DSA) in young hypertensive patients with non-lobar ICH.
Methods: A retrospective review (2013-2022) identified young (18-60 years) patients who underwent DSA for ICH. HTN history, ICH location, presence/absence of subarachnoid hemorrhage (SAH), and CTA (computed tomography angiography) findings were collected. The main outcome was DSA-positivity, defined as presence of an AVM, aneurysm, Moyamoya disease, reversible cerebral vasoconstriction syndrome (RCVS), or dural arteriovenous fistula (dAVF) on DSA.
Results: Two hundred sixty patients were included, and the DSA-positivity rate was 19%. The rate of positive-DSA was lower in hypertensive patients with ICHs located in either the cerebellum, pons, or basal ganglia compared to the rest of the patient sample (9% vs. 26%, p=0.0002, Fisher’s Exact Test). In patients with a CTA prior to DSA (n=191), CTA detected the underlying vascular abnormality in all but 1 patient with RCVS. We developed the ICH-Angio score (0-5 points) based on CTA findings, ICH location, HTN history, and presence of SAH to predict risk of underlying vascular lesions. DSA-positivity was lower in those with a score of 0 (0/62; 0%) compared to a score of 1 (5/52; 10%), 2 (17/48; 35%), 3 (10/20; 50%), 4 (5/6; 83%), or 5 (3/3; 100%). The correlation between risk score and DSA-positivity was significant based on linear-by-linear association test (p < 0.0001).
Conclusion : The ICH-Angio score was able to non-invasively rule out an underlying vascular etiology for ICH in up to one-third of patients. HTN, ICH location, CTA findings, and associated SAH can identify patients at low risk for harboring underlying vascular lesions.
