title: Diagnostic yield and accuracy of CT angiography, MR angiography, and digital subtraction angiography for detection of macrovascular causes of intracerebral haemorrhage: prospective, multicentre cohort study.
abstract: OBJECTIVE
  What are the diagnostic yield and accuracy of early computed tomography (CT) angiography followed by magnetic resonance imaging/angiography (MRI/MRA) and digital subtraction angiography (DSA) in patients with non-traumatic intracerebral haemorrhage?
  
  
  METHODS
  This prospective diagnostic study enrolled 298 adults (18-70 years) treated in 22 hospitals in the Netherlands over six years. CT angiography was performed within seven days of haemorrhage. If the result was negative, MRI/MRA was performed four to eight weeks later. DSA was performed when the CT angiography or MRI/MRA results were inconclusive or negative. The main outcome was a macrovascular cause, including arteriovenous malformation, aneurysm, dural arteriovenous fistula, and cavernoma. Three blinded neuroradiologists independently evaluated the images for macrovascular causes of haemorrhage. The reference standard was the best available evidence from all findings during one year's follow-up.
  
  
  CONCLUSIONS
  A macrovascular cause was identified in 69 patients (23%). 291 patients (98%) underwent CT angiography; 214 with a negative result underwent additional MRI/MRA and 97 with a negative result for both CT angiography and MRI/MRA underwent DSA. Early CT angiography detected 51 macrovascular causes (yield 17%, 95% confidence interval 13% to 22%). CT angiography with MRI/MRA identified two additional macrovascular causes (18%, 14% to 23%) and these modalities combined with DSA another 15 (23%, 18% to 28%). This last extensive strategy failed to detect a cavernoma, which was identified on MRI during follow-up (reference strategy). The positive predictive value of CT angiography was 72% (60% to 82%), of additional MRI/MRA was 35% (14% to 62%), and of additional DSA was 100% (75% to 100%). None of the patients experienced complications with CT angiography or MRI/MRA; 0.6% of patients who underwent DSA experienced permanent sequelae. Not all patients with negative CT angiography and MRI/MRA results underwent DSA. Although the previous probability of finding a macrovascular cause was lower in patients who did not undergo DSA, some small arteriovenous malformations or dural arteriovenous fistulas may have been missed.
  
  
  CONCLUSIONS
  CT angiography is an appropriate initial investigation to detect macrovascular causes of non-traumatic intracerebral haemorrhage, but accuracy is modest. Additional MRI/MRA may find cavernomas or alternative diagnoses, but DSA is needed to diagnose macrovascular causes undetected by CT angiography or MRI/MRA.
  
  
  BACKGROUND
  Dutch Heart Foundation and The Netherlands Organisation for Health Research and Development, ZonMw. The authors have no competing interests. Direct requests for additional data to the corresponding author.
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands c.j.j.vanasch@gmail.com.
authors.forename: Charlotte J J
authors.initials: CJ
authors.lastname: van Asch
authors.affiliation: Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands.
authors.forename: Birgitta K
authors.initials: BK
authors.lastname: Velthuis
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands.
authors.forename: Gabriël J E
authors.initials: GJ
authors.lastname: Rinkel
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
authors.forename: Ale
authors.initials: A
authors.lastname: Algra
authors.affiliation: Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands.
authors.forename: Gérard A P
authors.initials: GA
authors.lastname: de Kort
authors.affiliation: Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands.
authors.forename: Theo D
authors.initials: TD
authors.lastname: Witkamp
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands.
authors.forename: Johanna C M
authors.initials: JC
authors.lastname: de Ridder
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands.
authors.forename: Koen M
authors.initials: KM
authors.lastname: van Nieuwenhuizen
authors.affiliation: Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands.
authors.forename: Frank-Erik
authors.initials: FE
authors.lastname: de Leeuw
authors.affiliation: Department of Neurology, St Antonius Hospital, Nieuwegein, Netherlands.
authors.forename: Wouter J
authors.initials: WJ
authors.lastname: Schonewille
authors.affiliation: Department of Neurology, St Elisabeth Hospital, Tilburg, Netherlands.
authors.forename: Paul L M
authors.initials: PL
authors.lastname: de Kort
authors.affiliation: Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands.
authors.forename: Diederik W
authors.initials: DW
authors.lastname: Dippel
authors.affiliation: Department of Neurology, Meander Medical Center, Amersfoort, Netherlands.
authors.forename: Theodora W M
authors.initials: TW
authors.lastname: Raaymakers
authors.affiliation: Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands.
authors.forename: Jeannette
authors.initials: J
authors.lastname: Hofmeijer
authors.affiliation: Department of Neurology, Leiden University Medical Center, Leiden, Netherlands.
authors.forename: Marieke J H
authors.initials: MJ
authors.lastname: Wermer
authors.affiliation: Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands.
authors.forename: Henk
authors.initials: H
authors.lastname: Kerkhoff
authors.affiliation: Department of Neurology, MCH Westeinde, The Hague, Netherlands.
authors.forename: Korné
authors.initials: K
authors.lastname: Jellema
authors.affiliation: Department of Neurology, Flevo Hospital, Almere, Netherlands.
authors.forename: Irene M
authors.initials: IM
authors.lastname: Bronner
authors.affiliation: Department of Neurology, Amphia Hospital, Breda, Netherlands.
authors.forename: Michel J M
authors.initials: MJ
authors.lastname: Remmers
authors.affiliation: Department of Neurology, Gelre Hospital, Apeldoorn, Netherlands.
authors.forename: Henri Paul
authors.initials: HP
authors.lastname: Bienfait
authors.affiliation: Department of Neurology, Tergooi Hospitals, Blaricum, Netherlands.
authors.forename: Ron J G M
authors.initials: RJ
authors.lastname: Witjes
authors.affiliation: Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands.
authors.forename: Jacoba P
authors.initials: JP
authors.lastname: Greving
authors.affiliation: Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, PO box 85500, 3508 GA Utrecht, Netherlands Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands.
authors.forename: Catharina J M
authors.initials: CJ
authors.lastname: Klijn
mesh_terms: D000328:Adult; D000368:Aged; D015901:Angiography, Digital Subtraction; D002543:Cerebral Hemorrhage / Q000175:diagnosis* / Q000209:etiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D002538:Intracranial Arteriovenous Malformations / Q000150:complications / Q000175:diagnosis*; D016015:Logistic Models; D018810:Magnetic Resonance Angiography; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D014057:Tomography, X-Ray Computed