General discussion 147 Since the first description of a patient with an aneurysmal subarachnoid hemorrhage (SAH) was published 250 years ago,1 prospects for survival of these patients have significantly improved, thanks to diagnostic improvements and treatment innovation. In addition, the management of these patients, laid out in different guidelines, has evolved over time, based on continuous research.2-5 This thesis centers on the various diagnostic aspects of aneurysmal subarachnoid hemorrhage. Based on available literature and the work carried out for this thesis, we have several proposals pertaining to the diagnosis, treatment and follow-up of patients with an aneurysmal SAH. Diagnosis of SAH The first problem to be addressed in the diagnosis of SAH is that of establishing the presence of SAH. In the most recent guidelines, lumbar puncture CSF examination is still recommended.3 However, based on the evidence in the available literature described in Chapter 1, there are compelling arguments for the use of CT and CT angiography (CTA) as the first examination of patients presenting with clinical signs of SAH.6-8 Proposal 1. NECT and CTA should be performed in all patients with clinical suspicion of SAH. A subsequent lumbar puncture is unnecessary. Despite some promising results in previous studies the role of MRI in diagnosing SAH appeared very limited in this acute setting.9 DSA in CTA-negative SAH Conform all guidelines, catheter digital subtraction angiography (DSA) should be performed - preferably using rotational 3D technique - if the diagnosis of SAH is established by non-contrast enhanced CT (NECT), and CTA does not show an aneurysm as the cause of the hemorrhage.3,10 If the first DSA study does not show an aneurysm, repeat DSA is recommended.3 However, recent studies show that the yield of repeat DSA is low if the distribution pattern of the SAH is clearly perimesencephalic.9,11-13 Proposal 2. If NECT shows SAH, and CTA does not show an aneurysm, 3D DSA is recommended. If the first DSA study is negative, repeat DSA is recommended only if the pattern of SAH is non- perimesencephalic. Some caution is necessary here, because the diagnosis of a perimesencephalic SAH on the basis of its distribution pattern is not always straightforward.14-16 It is recommended that a second DSA study in case of a negative first DSA should be performed within a week after the first study; delayed repeat DSA appears to have very little extra diagnostic value.12 Additional MRI of the cervical spine to rule out spinal vascular malformations may be considered, although this too has a low diagnostic yield.17 MRA in patients with SAH The use of MR angiography as the primary diagnostic modality seems attractive because no potentially harmful X-rays and iodinated contrast media are used. However, there are logistic disadvantages: MRI is less readily available than CT, and the lengthy MRI acquisitions are more susceptible to patient motion than CT. Because the diagnosis SAH is generally established by CT, the patient will need to be
proefschrit Van Zwam inhoud met kaft en stellingen.indd
To see the actual publication please follow the link above