Abstract Number ‐ 254: Yield of CTA in Patients over 50 with Brain Hemorrhages at Sites Typical for Hypertension
Authors: Abuelgasim Nazik A , Mannem Narmada , Ullmann Dawn W , Schmidley James W 
Published: April 2023

Introduction
Approximately 10%–15% of acute strokes are spontaneous, nontraumatic intraparenchymal cerebral hemorrhage (IPH). Hypertension (HTN), amyloid angiopathy, or impaired coagulation cause most spontaneous IPHs, in which case the CTA is unlikely to identify an underlying vascular lesion. Prior investigators have identified clinical and non‐contrast CT (NCCT) features that increase the likelihood of identifying a vascular etiology for an IPH, including younger age (< 40–50), absence of hypertension, and presence of subarachnoid (SAH) or intraventricular hemorrhage (IVH). Findings from earlier studies of patients with IPH suggested that older age, HTN, together with certain locations (basal ganglia, thalamus, cerebellum, and pons) could reliably exclude IPH patients with underlying lesions. We aimed to assess the yield of CTA, a costly study with risks of radiation, contrast induced renal injury and death, in identifying vascular lesions in this group.

Methods
This retrospective study involved reviewing medical records of all patients admitted to Carilion RMH hospital for brain hemorrhage during the period 2008–2020, inclusive. Patients were considered if they were over 50 year of age, had HTN (and/or left ventricular hypertrophy on electrocardiograms or echocardiograpy) and IPH in the thalamus, basal ganglia, cerebellum or pons. Patients with SAH, lobar IPH, traumatic IPH, pure IVH, and patients with known vascular lesions were excluded. Imaging of all patients was reviewed with attention to finding CTAs showing vascular lesions that might have caused of the recent symptomatic IPH (arteriovenous malformations, aneurysms, venous anomalies and dural venous sinus thrombosis). Small saccular aneurysms at remote sites were not considered relevant, nor were intra‐ or extracranial stenoses.

Results
A total of (446) charts were reviewed, of which 143 met the inclusion criteria (94 males and 49 females). Family history was positive for cerebral aneurysm in one patient and Alzheimer’s with brain hemorrhage in another. Twenty‐six patients were on anticoagulation: 10 on NOAC, 14 on Warfarin (INR was < 2 in 8, 2–3 in 5, and >3 in only one patient). One was on subcutaneous heparin (PTT was 53). No other patient had major coagulation abnormalities; only 5 patients had platelets count < 100K, the lowest was 62K. CTA was negative for underlying vascular lesion at the site of bleeding in all 143 patients, confidence interval 2.6% using Confidence intervals for proportions, using Wilson’s method for proportions.

Conclusions
In patients over 50 year of age with evidence of hypertension, and ICH in the basal ganglia, thalamus, brain stem and cerebellum; the diagnostic yield of CTA is negligible. Performing this study routinely in the evaluation of these patient increases health care costs, and exposes patients to the risks of unnecessary radiation, contrast induced kidney injury and death. We recommend against the routine use of CTA in patients meeting the above criteria.