Yield of angiographic examinations in isolated intraventricular hemorrhage: A case series and systematic review of the literature

Background: It is unknown which patients with non-traumatic isolated intraventricular hemorrhage should undergo angiographic imaging to detect an underlying macrovascular cause and which modality has the highest yield. We studied yield of angiographic examinations in patients with isolated intraventricular hemorrhage. Methods: We reviewed medical records of patients with intraventricular hemorrhage admitted to the University Medical Center Utrecht between 2002 and 2012. We searched PubMed and Embase for studies on angiographic examinations in intraventricular hemorrhage until January 2014. We calculated yield of angiographic imaging and investigated influence of age, hypertension and anticoagulant use with meta-regression analysis. Results: We identified 39 patients of whom 30 underwent an angiographic study. CTA suggested a macrovascular abnormality in nine patients, which was confirmed by DSA in seven. In the literature, we found 16 studies describing 209 patients. Pooled analysis showed a yield of 58% for DSA (95% CI 48–68%; 147 patients). One small study described the yield of CTA or MRA (0%; 4 patients). Yield of angiographic imaging decreased with increasing age (−2.6%; −5.0 to −0.2 per year increase) but was not affected by history of hypertension (−8.3%; −80.8 to 64.2) or anticoagulant use (−47.1%; −110.3 to 16.1). Conclusion: The reported yield of DSA in isolated intraventricular hemorrhage is around 50% but varies considerably, probably due to differences in clinical judgment on the need for angiography performance. The yield is higher in younger patients but based on the available data, it is not possible to set age or other criteria for patients in whom DSA can be safely omitted.