Perimesencephalic subarachnoid hemorrhage cerebral angiography
A survey aimed to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, Wolfert et al. suggest to conceive new treatment guidelines including this finding 1)
95% of cases have a normal cerebral angiography and the source of bleeding is not identified; the cause is thought to be a venous bleed. The other 5% of cases are due to a vertebrobasilar aneurysm and the prognosis is worse.
Undertaking a DSA after a negative CTA may not add any further diagnostic value in patients with PMSAH and may lead to net harm. This observation needs to be validated in a large-scale prospective multicenter study with complete case ascertainment and robust data on CTA and DSA complications 2).
A repeat DSA is definitely not required in PM-SAH, but it should be done for all cases of nPM-SAH, before labeling them as nonaneurysmal SAH 3).