Developing an algorithm to identify patients with intracerebral haemorrhage secondary to a macrovascular cause

Abstract

Introduction: Determining the cause of spontaneous (non-traumatic) intracerebral haemorrhage (ICH) is critical to guide treatment and prognosis. We investigated whether small vessel disease (SVD) in addition to clinical and other radiological findings on acute neuroimaging predicts a low risk of a macrovascular cause (e.g. an arterio-venous malformation, aneurysm or dural arteriovenous fistula). Patients and methods:We identified patients with acute spontaneous ICH who underwent acute non-contrast CT, CT angiography (CTA) and intra-arterial digital subtraction angiography (IADSA) at our institution from January 2010 to April 2014. Logistic regression including CTA result, SVD, age, pre-ICH hypertension and ICH location was used to derive a prediction model, validated using bootstrapping. Results: 173 patients (46% female, median age 49) of whom 78 had a macrovascular cause on IADSA were included. Predictors of a macrovascular cause were: abnormal CTA (OR 67.4; p < 0.001); absence of SVD (OR 5.0; p ¼ 0.019); and absence of pre-ICH hypertension (OR 3.4; p ¼ 0.05). In our internally derived prediction model, the combination of CTA, SVD and pre-ICH hypertension predicted the likelihood of an underlying macrovascular cause (optimism-adjusted ROC area 0.919). Patients with negative CTA, SVD and pre-ICH hypertension have a low likelihood of an underlying macrovascular cause (1.8%). Discussion and conclusion: A combination of CTA, SVD and pre-ICH hypertension predict the likelihood of finding a macrovascular cause in patients with acute spontaneous ICH, allowing informed decisions regarding the likely benefit and risk of IADSA.

Acute intracerebral haemorrhage: diagnosis and management

“…39 ¶ Acute CTA should be performed within 2 days of CT, where possible. The diagnostic algorithm of the yield of intra-arterial DSA based on the CTA and clinical characteristics has been adapted from Wilson et al 40 MR/MR angiography performed acutely after a negative CTA may have additional value, particularly for the diagnosis of non-macrovascular causes, before considering intra-arterial DSA. 34 * Confluent leukoaraiosis (see fig ure 2 ) or lacunar infarction on acute CT brain scan.…”

CT and DSA for evaluation of spontaneous intracerebral lobar bleedings

“…Identification of small vessel disease (moderately severe leukoaraiosis or lacunar infarction on CT), in combination with abnormal CTA and pre-ICH hypertension ICH, can predict which patients have a low yield of an intracranial macrovascular cause ( 32 , 33 ).…”

Predicting the presence of macrovascular causes in non-traumatic intracerebral haemorrhage: the DIAGRAM prediction score

“…For external validation, we used a cohort of 173 patients with non-traumatic ICH 16. Consecutive patients who underwent IADSA at the National Hospital for Neurology and Neurosurgery in London between 2010 and 2014 were retrospectively reviewed.…”