Spontaneous Intracranial Hemorrhage: Which Patients Need Diagnostic Cerebral Angiography?

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Abstract
In spontaneous intracerebral hemorrhage (ICH), the site, age of the patients, and preexisting hypertension are important factors in determining the possibility of finding an underlying vascular abnormality by cerebral angiography. To what extent these three factors affect the indication for angiography remains controversial. A prospective study was carried out to correlate the angiographic findings with these three factors. Two hundred six consecutive spontaneous ICH cases with an age range from 5 to 79 years (median, 45) were investigated with CT and cerebral angiography over a 3-year period (April 1993 through March 1996). Exclusion criteria were (1) poor surgical risk or severely neurologically disabled patients, (2) refusal of angiography, (3) patients in whom severe coagulopathy accounted for the hemorrhage, (4) bleeding into tumor, or (5) subarachnoid hemorrhage-predominant cases. Angiographic yield (the frequency of positive angiography in a defined patient group) was significantly higher in patients (1) at or below the median age of 45 than those above (53/105, 50%, versus 18/101, 18%; P < .001) and (2) without preexisting hypertension than those with (64/145, 44%, versus 5/58, 9%; P < .001). The correlation of age and preexisting hypertension to angiographic yield was independent (logistic regression coefficients -0.056 and -1.59 and SE 0.12 and 0.515, respectively, both P < .001). In patients of the younger age group without preexisting hypertension, angiographic yield was 48% in putaminal, thalamic, or posterior fossa ICH and 65% in lobar ICH. In the older hypertensive patients, the yields were 0% and 10%, respectively. However, in patients with isolated intraventricular hemorrhage, most were normotensive and the yield was high in both age groups (67% versus 63%). Diagnostic cerebral angiography should be considered for all spontaneous ICH patients except those over 45 years old with preexisting hypertension in thalamic, putaminal, or posterior fossa hemorrhage.