title: Subarachnoid hemorrhage with negative initial catheter angiography: a review of 254 cases evaluating patient clinical outcome and efficacy of short- and long-term repeat angiography.
abstract: BACKGROUND
  Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial.
  
  
  OBJECTIVE
  To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging.
  
  
  METHODS
  Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram.
  
  
  RESULTS
  Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of short-term and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients.
  
  
  CONCLUSIONS
  Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH.
authors.affiliation: Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA.
authors.forename: Richard
authors.initials: R
authors.lastname: Dalyai
authors.forename: Nohra
authors.initials: N
authors.lastname: Chalouhi
authors.forename: Thana
authors.initials: T
authors.lastname: Theofanis
authors.forename: Pascal M
authors.initials: PM
authors.lastname: Jabbour
authors.forename: Aaron S
authors.initials: AS
authors.lastname: Dumont
authors.forename: L Fernando
authors.initials: LF
authors.lastname: Gonzalez
authors.forename: David S
authors.initials: DS
authors.lastname: Gordon
authors.forename: Vismay
authors.initials: V
authors.lastname: Thakkar
authors.forename: Robert H
authors.initials: RH
authors.lastname: Rosenwasser
authors.forename: Stavropoula I
authors.initials: SI
authors.lastname: Tjoumakaris
mesh_terms: D002404:Catheterization / Q000379:methods* / Q000639:trends; D002533:Cerebral Angiography / Q000379:methods* / Q000639:trends; D005500:Follow-Up Studies; D006801:Humans; D011446:Prospective Studies; D015203:Reproducibility of Results; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000000981:diagnostic imaging* / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome