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Perimesencephalic non-aneurysmal subarachnoid hemorrhage: is there a need for repeat digital subtraction angiography?
Rosa Schubert1, Maharani Budi Santoso2, Yan Li2
1Institute for Diagnostic and Interventional Radiology and Neuroradiology, University of Duisburg-Essen, Essen, Germany. rosa.schubert@stud.uni-due.de.
Purpose:
To assess the diagnostic yield and clinical relevance of repeated digital subtraction angiography (DSA) in patients with spontaneous perimesencephalic non-aneurysmal subarachnoid hemorrhage (PMSAH) and to evaluate DSA-related complication rates.
Methods:
Retrospective analysis of 82 patients with PMSAH confirmed by non-contrast CT between March 2002 and February 2025. All patients underwent initial computed tomography angiography (CTA) and first DSA on average within 24 h. If no bleeding source was identified, a second DSA was performed after 10-14 days. Clinical data, radiological findings, and complications were evaluated.
Results:
The initial DSA showed no vascular abnormality in 76/82 patients (92.7%). A second DSA was performed in 60/76 cases (78.9%) and identified two small basilar artery aneurysms (3.3%) that were not visible on the initial CTA or DSA but were detectable on repeat 3D rotational angiography (3DRA). Procedure-related complications occurred in three DSAs (2%), including a cerebellar infarct, supratentorial embolism, and local puncture site complication. Most patients had a benign clinical course, and only one in-hospital death was documented.
Conclusion:
The diagnostic benefit of repeat DSA in typical PMSAH is low, with no clear therapeutic impact and a relevant risk of complications. Given the benign course of PMSAH and the availability of high-resolution non-invasive imaging such as dual-source, photon-counting CTA, or vessel wall MRI, repeat DSA should be reserved for selected cases with atypical features or clinical deterioration.
Insights
Repeat digital subtraction angiography (DSA) for perimesencephalic non-aneurysmal subarachnoid hemorrhage (PMSAH) has low diagnostic yield and carries complication risks. Non-invasive imaging is preferred over repeat DSA for typical PMSAH cases.
Area of Science:
- Neurology
- Neuroradiology
- Vascular Imaging
Background:
- Spontaneous perimesencephalic non-aneurysmal subarachnoid hemorrhage (PMSAH) is a specific subtype of subarachnoid hemorrhage.
- The diagnostic workup for PMSAH typically involves initial non-contrast CT, CTA, and DSA.
Purpose of the Study:
- To evaluate the diagnostic yield and clinical relevance of repeat digital subtraction angiography (DSA) in PMSAH patients.
- To assess the complication rates associated with DSA procedures in this patient cohort.
Main Methods:
- Retrospective analysis of 82 patients diagnosed with PMSAH.
- Initial computed tomography angiography (CTA) and first DSA performed within 24 hours.
- Second DSA conducted 10-14 days later if no bleeding source was identified initially.
Main Results:
- Initial DSA revealed no vascular abnormality in 92.7% of patients.
- Repeat DSA identified two small aneurysms (3.3%) missed by initial CTA and DSA.
- DSA-related complications occurred in 2% of procedures.
Conclusions:
- Repeat DSA offers limited diagnostic benefit in typical PMSAH cases.
- The risk of DSA complications outweighs the benefit for most PMSAH patients.
- High-resolution non-invasive imaging modalities are recommended over repeat DSA for typical PMSAH.
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