Spontaneous subarachnoid haemorrhage with negative initial angiography: a review of 143 cases

The need for repeat angiography in patients with subarachnoid haemorrhage (SAH) who initially present with a negative angiogram is still debated. The aim of this study was to provide a management protocol for 'angiogram-negative SAH'. From January 1986 to June 2004, 143 patients with SAH were admitted to our institution with negative initial angiograms. We classified the 143 patients into three groups: group I, with no SAH on CT scan, but confirmed by cerebrospinal fluid analysis; group II, with a perimesencephalic pattern of SAH; and group III, with a non-perimesencephalic pattern of SAH. Out of the 143 patients, 103 underwent repeat angiography, and 18 were found to have ruptured aneurysms that were not detected on the initial angiogram (false negative rate: 17.5% overall, 0% in group I, 1.5% in group II, and 45.9% in group III). Repeat angiography should be performed, particularly in patients who have a non-perimesencephalic SAH pattern, for detection of initially unrecognised ruptured aneurysms.