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 » Introduction
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Table of Contents    
ORIGINAL ARTICLE
Year : 2012  |  Volume : 60  |  Issue : 3  |  Page : 299-303

Accuracy of computed tomography angiography in detecting the underlying vascular abnormalities for spontaneous intracerebral hemorrhage: A comparative study and meta-analysis


1 Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, China
2 Department of Neurosurgery, Westchina Medical School, Sichuan University, Chengdu, China

Date of Submission25-Apr-2012
Date of Decision25-Apr-2012
Date of Acceptance04-Jun-2012
Date of Web Publication14-Jul-2012

Correspondence Address:
Chao You
Department of Neurosurgery, West China Hospital, Sichuan University, 37, Guoxuexiang Street, Chengdu 610041
China
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Source of Support: This study was supported by the Scientific projects of Chinese Ministry of Health (No. 2011BAI08B05), Conflict of Interest: None


DOI: 10.4103/0028-3886.98515

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 » Abstract 

Background: Computed tomography angiography (CTA) is a rapid, non-invasive procedure with a small risk for evaluating patients with various types of strokes. But the effectiveness of CTA in detecting the etiology of spontaneous intracerebral hemorrhage (SICH) has not been well established. Aim: To evaluate the diagnostic value of CTA for detecting underlying vascular abnormalities in patients with SICH. Settings and Design: This is a comparative study to evaluate the diagnostic accuracy of CTA and digital subtraction angiography (DSA) in SICH. We also did a meta-analysis, combining our results with those of all previous studies to determine a more precise estimate of CTA in detecting the etiology of SICH.. Materials and Methods: Between July 2009 and October 2011, CTA and DSA were routinely performed in consecutive young patients (age between 18 and 45 years) with acute non-hypertensive SICH. Imaging data were prospectively stored in the database for analysis. Statistical Analysis: The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), and accuracy were used for evaluating the diagnostic value of CTA for vascular lesion. Results: This study included 92 patients. The sensitivity, specificity, PPV, NPV, and accuracy of CTA for detecting DSA-positive pathologies were 94.6%, 100%, 100%, 96.5%, and 97.8%, respectively. A total of 544 cases were included for meta-analysis. The pooled sensitivity, specificity, PPV, NPV, and accuracy of CTA for detecting the etiology in SICH were 95.4%, 98.3%, 96.9%, 97.4%, and 97.2%, respectively. There was no substantial heterogeneity between the studies. Conclusions: CTA has high PPV and NPV for vascular pathologies. It should be performed as the initial vascular investigation for patients with acute SICH. Future technical advancement of CTA is still needed to eliminate the false-negative results.


Keywords: CT angiography, DSA, spontaneous intracerebral hemorrhage


How to cite this article:
Ma J, Li H, You C, Huang S, Ma L, Ieong C. Accuracy of computed tomography angiography in detecting the underlying vascular abnormalities for spontaneous intracerebral hemorrhage: A comparative study and meta-analysis. Neurol India 2012;60:299-303

How to cite this URL:
Ma J, Li H, You C, Huang S, Ma L, Ieong C. Accuracy of computed tomography angiography in detecting the underlying vascular abnormalities for spontaneous intracerebral hemorrhage: A comparative study and meta-analysis. Neurol India [serial online] 2012 [cited 2021 Sep 17];60:299-303. Available from: https://www.neurologyindia.com/text.asp?2012/60/3/299/98515



 » Introduction Top


Spontaneous intracerebral hemorrhage (SICH) is defined as non-traumatic intraparenchymal hemorrhage. [1],[2] Although hypertension is the most common cause of SICH, there is still a proportion of SICH caused by structural vascular abnormalities, such as arteriovenous malformation (AVM), aneurysm, or moyamoya diseases. [3],[4] Determining the underlying structural vascular abnormality is critical for instituting the appropriate treatment. Digital subtraction angiography (DSA) is an invasive procedure and may not readily be available for critically ill patients. On the other hand, computed tomography angiography (CTA) is a rapid, non-invasive procedure with a small risk and may be more practical for the evaluation of underlying vascular lesions in SICH. [5] However, the effectiveness of CTA in detecting the etiology of SICH is still uncertain, although the value of CTA in detecting intracranial aneurysms in spontaneous subarachnoid hemorrhage (SAH) has been well documented. [6] We have designed a study to evaluate the diagnostic accuracy of CTA in patients with SICH, comparing it with DSA. We also did a meta-analysis, combining our results with those of all previous studies to provide a more precise estimate of CTA in detecting the etiology of SICH.


 » Materials and Methods Top


Between July 2009 and October 2011, 436 patients with acute SICH were referred for admission to the neurosurgery department, Westchina Hospital, within 96 h of onset of ictus and the diagnosis of SICH was established on CT scan. Only consecutive young patients (age between 18 and 45 years) with acute non-hypertensive SICH had DSA. [4]

Of the 436 patients, 97 patients satisfied the inclusion criteria: 1) acute SICH; 2) non-hypertension (non-hypertensive patients were defined by either their medical history or clinical evidence of normal blood pressure); 3) non-traumatic, primarily non-subarachnoid hemorrhage; and 4) age between 18 and 45 years. Of these 97 patients, one patient was excluded because of renal impairment. Four patients were excluded as the magnetic resonance imaging (MRI) showed tumor with hemorrhage. Thus, only 92 patients were included in the comparative study. Both CTA and DSA were performed in all these patients, and the imaging data were prospectively stored in our database for analysis. Informed consent was obtained from all patients or their legal representatives after admission.

CT angiographies were performed using GE Lightspeed VCT 64 with the following protocol: Scan rostral from C-2 with 0.625-mm-thick slices every 0.6mm, 513:1 pitch, 10.62 mm per rotation speed, 120 kVp, and 330 mA. A total of 125 cc Omnipaque 300 at a rate of 4.0-5.0 cc/ second with a 15-second prep delay was injected through an 18-gauge angiocatheter. 3D reformatted images were created on a GE Advantage Workstation. DSA was performed on the GE LCV + Advantx system with 3D rotation package linked to a GE Advantage Workstation. Vascular lesions were assessed on both CTA and DSA, and DSA served as gold standard for comparison. All CT angiographies were independently reviewed by two neuroradiologists blinded to patient information. The data of DSA were reviewed by another two endovascular neuroradiologists blinded to clinical and the CTA data. The disagreements between reviewers were resolved by consensus after discussion. The sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV), and accuracy were used for the evaluation and determining the predictive values of CTA for vascular lesion. Data analysis was carried out using Meta-Disc 1.4. [7]

Meta-analysis

To further investigate the diagnostic accuracy of CTA for underlying vascular abnormalities in SICH, a meta-analysis based on published studies was carried out. Systematic literature search was performed independently by three of the authors in PubMed, MEDLINE, and EMBASE from 1980 to April 2012, using the search strategy based on combinations of the keywords: "intracerebral hemorrhage," "ICH," and "CTangiography," "CTA," "Computed tomography angiography." There were no language or publication status restrictions. The reference lists of all relevant papers and literature reviews were also examined to identify any additional relevant articles. Two of the authors independently screened the titles, abstracts, and keywords of citations to assess the eligibility of studies and excluded studies that were clearly irrelevant. The same two review authors independently assessed the full text of the remaining studies to identify which trials met the predefined inclusion criteria. Studies were selected when they met the following entry criteria: (1) case series with consecutive patients enrollment; (2) clinical trials evaluating the effect of CTA for detecting underlying vascular abnormalities in patients with SICH; (3) studies with multi-slice CT scans; (4) studies with DSA or any other gold standard for the assessment of underlying vascular pathologies; and (5) studies with study participants who were generally healthy adults at study baseline. Two of the authors independently extracted data from each study included in the analysis using a standard extraction form, including study name, publication year, patients' information, imaging technique, and accuracy of diagnosis of vascular pathologies.

Sensitivity, specificity, PPV, NPV, and accuracy together with their 95% confidence intervals (CI) of the diagnostic value of CTA were calculated for each study and the total sample size of the studies. In addition, the area under curve (AUC) was also calculated. The heterogeneity between studies was assessed by chi-square test, I 2 , and Cochran's Q tests. If inter-study heterogeneity was not statistically significant, sensitivities and specificities were pooled by the fix-effect model of Mantel-Haenszel method. When heterogeneity was statistically significant, a random-effect model of DerSimonian-Laird method was used. Forest plots were used to display the variations of sensitivities and specificity from different studies. Summary receiver-operating characteristic (sROC) curve analysis was also applied to plots sensitivity versus specificity. It provides information on the overall performance of a test across different thresholds. All the analyses were performed using Meta-Disc 1.4.


 » Results Top


Of the 92 patients included in the study, in 37 patients (40.22%), DSA demonstrated vascular abnormalities: AVMs, 25 (27.17%); moyamoya disease, 6 (6.52%); intracranial aneurysm, 3 (3.26%); and dural arteriovenous fistula (dAVF), 3 (3.26%). Except two small AVMs, all the remaining vascular abnormalities were detected by CTA. There were no CTA false-positive results when compared with DSA. The sensitivity, specificity, PPV, NPV, and accuracy of CTA for detecting DSA-positive pathologies were 94.6% (95%CI 0.823-0.985), 100% (95%CI 0.935-1), 100% (95%CI 0.901-1), 96.5% (95%CI 0.881-0.99), 97.8% (95%CI 0.924-0.994), respectively [Table 1] and [Table 2].
Table 1: Characteristics of our study in comparison with those of the previous studies included in evaluating the diagnostic effect of CTA in SICH

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Table 2: The data and diagnostic accuracy in each included study and the total sample size of studies

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Meta-analysis

In the initial search, a total of nine relevant articles were obtained for full-text review. After detailed full article evaluation, five studies met the entry criteria; however, one study [12] was excluded because it was a pilot report of a subsequent study. [9] Thus, four studies and our data were included for analysis. [8],[9],[10],[11] Characteristics of our data are summarized in [Table 1] and [Table 2].

A total 544 cases were included for meta-analysis. The pooled sensitivity, specificity, PPV, NPV, and accuracy of CTA for detecting vascular lesions in SICH were 95.4% (95%CI 0.916-0.976), 98.3% (95%CI 0.963-0.992), 96.9% (95%CI 0.934-0.986), 97.4% (95%CI 0.952-0.986), and 97.2% (95%CI 0.955-0.983), respectively. There was no substantial heterogeneity between the studies [Figure 1]. The area under the sROC curve (AUC) was 0.9896 (SE= 0.0104) with a Q* point value of 0.9575 (SE = 0.0251) [Figure 2].
Figure 1: Forest plot of the sensitivity and specificity of CTA for detecting vascular lesions in patients with SICH

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Figure 2: Summary receiver-operating characteristic (sROC) curves of the CTA compared to final diagnosis of vascular lesions in patients with SICH

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 » Discussion Top


Although the value of CTA in detecting intracranial aneurysms has been well documented, very few studies have been reported on the role of CTA in SICH. As age >45 years and history of hypertension are the significant independent predictors of a negative DSA, [4] our data only focused on non-hypertensive patients with acute SICH. The results of our comparative study and meta-analysis of all relevant studies demonstrated that CTA has high PPV and NPV for vascular pathologies in patients with acute SICH, compared with DSA.

In this meta-analysis, there were 9 false-negative results in a total 544 patients, including 4 small AVMs (4/107), a small middle cerebral artery pseudoaneurysm, 1 moyamoya (1/13), 1 AVF (1/8), and 2 dAVF (2/7). A potential CTA limitation is the diagnosis of dAVFs and AVF which were missed, 2 of 7 dAVF and 1 of 8 AVFs, respectively. In addition, whether CTA can detect small AVM more accurately should be investigated further in future studies. [13] This meta-analysis has also several limitations. First, the study population in each study is not uniformly identical. Second, since the studies included in the meta-analysis were regarding diagnostic procedures, there were no protocols published before relevant studies. Therefore, publication bias may exist, as series with more positive results are more likely to have been reported and published.

Nevertheless, the presence of spot sign in CTA, which refers to one or more extravascular foci of contrast enhancement within an acute primary parenchymal hematoma visible on the source images of CTA, has been found to highly relate to hematoma growth recently. [14] We feel that routine performance of CTA is necessary in patients with SICH, which not only detects underlying structural vascular abnormality in a non-invasive way, but also predicts the risk of hematoma growth and guides the use of hemostatic drugs. However, it should be pointed out that the advantages of CTA are its low risk, accessibility, and lower cost compared to DSA and MRI, but CTA cannot clearly display blood stream and blood supply for vascular abnormalities. Therefore, the place of CTA is not to replace DSA, but to limit the number of patients exposed to the invasive and more risky imaging examination. Recently, 4D-CTA imaging using a 320 detector row CT scanner was reported to be able to detect all AVMs, which is not only sufficiently accurate to diagnose the shunt and classify it, but also adds cross-sectional imaging and perfusion maps, which will be helpful in treatment planning. [15] 4D-CTA also appears to be a valuable new adjunct for the detection and grading of cranial dAVFs. [16] This technical advancement may be more helpful for detecting underlying vascular abnormality in SICH. In summary, CTA has high PPV and NPV for vascular pathologies. It should be performed as the initial vascular investigation for patients with acute SICH. However, future technical advancement of CTA is still needed to eliminate the false-negative results.


 » Acknowledgment Top


This study was supported by the scientific projects of Chinese Ministry of Health (No. 2011BAI08B05).

 
 » References Top

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3.Al-Jarallah A, Al-Rifai MT, Riela AR, Roach ES. Nontraumatic brain hemorrhage in children: Etiology and presentation. J Child Neurol 2000;15:284-9.  Back to cited text no. 3
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4.Zhu XL, Chan MS, Poon WS. Spontaneous intracerebral hemorrhage: Which patients need diagnostic cerebral angiography? Stroke 1997;28:1406-9.  Back to cited text no. 4
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5.Delgado Almandoz JE, Romero JM, Pomerantz SR, Lev MH. Computed tomography angiography of the carotid and cerebral circulation. Radiol Clin North Am 2010;48:265-81.  Back to cited text no. 5
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6.Yoon DY, Choi CS, Kim KH, Cho BM. Multidetector-row CT angiography of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: Comparison of volume-rendered images and digital subtraction angiography. AJNR Am J Neuroradiol 2006;27:370-7.  Back to cited text no. 6
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10.Yeung R, Ahmad T, Aviv RI, De Tilly LN, Fox AJ, Symons SP. Comparison of CTA to DSA in determining the etiology of spontaneous ICH. Can J Neurol Sci 2009;36:176-80.  Back to cited text no. 10
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11.Wong GK, Siu DY, Abrigo JM, Poon WS, Tsang FC, Zhu XL, et al. Computed tomographic angiography and venography for young or nonhypertensive patients with acute spontaneous intracerebral hemorrhage. Stroke 2011;42:211-3.  Back to cited text no. 11
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12.Romero JM, Artunduaga M, Forero NP, Delgado J, Sarfaraz K, Goldstein JN, et al. Accuracy of CT angiography for the diagnosis of vascular abnormalities causing intraparenchymal hemorrhage in young patients. Emerg Radiol 2009;16:195-201.  Back to cited text no. 12
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13.Wong GK, Siu DY, Abrigo JM, Ahuja AT, Poon WS. Computed tomographic angiography for patients with acute spontaneous intracerebral hemorrhage. J Clin Neurosci 2012;19:498-500.  Back to cited text no. 13
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14.Thompson AL, Kosior JC, Gladstone DJ, Hopyan JJ, Symons SP, Romero F, et al. Defining the CT angiography 'spot sign' in primary intracerebral hemorrhage. Can J Neurol Sci 2009;36:456-61.  Back to cited text no. 14
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15.Willems PW, Taeshineetanakul P, Schenk B, Brouwer PA, Terbrugge KG, Krings T. The use of 4D-CTA in the diagnostic work-up of brain arteriovenous malformations. Neuroradiology 2012;54:123-31.  Back to cited text no. 15
    
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