Hemorragia subaracnoídea no traumática con angiografía por tomografía computada inicial "negativa / Non-traumatic subarachnoid hemorrhage with "negative" initial computed tomography angiography

La hemorragia subaracnoidea (HSA) no traumática es un subtipo de ictus hemorrágico que representa aproximadamente el 5% de todos los accidentes vasculares encefálicos (AVE). El 85% de los casos de HSA espontánea (no traumática) son secundarios a un aneurisma intracraneano roto, el 10% a hemorragia perimesencefálica no aneurismática y el otro 5% a otras causas. Entre estas se incluyen malformaciones arterio-venosas, fístulas durales, vasculits, trombosis de vena cortical, síndrome de vasoconstricción reversible, angiopatía amiloidea y síndrome de encefalopatía posterior reversible. La aproximación inicial a una HSA no traumática requiere un estudio angiográfico no invasivo con tomografía computada para la toma de decisiones terapéuticas. Si no se detecta un aneurisma sacular intradural que explique el sangrado, las conductas a seguir dependerán del patrón de distribución de la sangre. En esta revisión sugerimos una aproximación basada en 1) revisar el estudio inicial tomando en cuenta los puntos ciegos para la detección de aneurismas, 2) analizar el patrón de distribución de la sangre y 3) analizar los hallazgos en imágenes de acuerdo a las posibles causas según patrón.

Non-traumatic subarachnoid hemorrhage represents approximately 5% of strokes. From these, 85% of nontraumatic subarachnoid hemorrhage are secondary to a ruptured aneurysm, 10% to nonaneurysmal perimesencephalic hemorrhage and the other 5% to other causes. These include but are not limited to arteriovenous malformations, dural fistulae, vasculitis, cortical vein thrombosis, reversible cerebral vasoconstriction syndrome, amyloid angiopathy and posterior reversible encephalopathy syndrome. Initial workup of nontraumatic subarachnoid hemorrhage requires a non-enhanced CT and CT angiography for decision making and management. If there is no aneurysm as a source of hemorrhage, subsequent imaging studies will depend on blood distribution pattern. In this review we suggest an approach: 1) review blind spots for aneurysm detection in the initial CT angiography, 2) analyze blood distribution pattern and 3) evaluate imaging findings and possible causes according to each pattern.

Angio TC en la identificación preoperatoria de vasos perforantes / CT angiography in preoperative identification of perforator vessels

Introducción: Los colgajos de perforantes se han convertido en una opción de cobertura válida cada vez más utilizada en cirugía reconstructiva. Se caracterizan porque requieren de la identificación preoperatoria y disección intraoperatoria del vaso perforante. El objetivo del presente trabajo fue evaluar el Angio TC en el estudio preoperatorio de los vasos perforantes y su correlación con los hallazgos intraoperatorios. Material y Métodos: Análisis retrospectivo de todos los colgajos de perforantes realizados en la Unidad de Cirugía Plástica del Hospital Clínico de la Universidad de Chile entre junio de 2009 y junio de 2012. A todos los pacientes se les solicitó un Angio TC según el protocolo de la Universidad de Gent (Bélgica). Se utilizaron puntos de referencias específicos y un sistema de coordenadas para localizar el punto en el cual la perforante cruza la fascia superficial. La información entregada por el Angio TC se comparó con los hallazgos quirúrgicos. Resultados: A un total de 41 pacientes se les realizó Angio TC para la planificación de un colgajo de perforante durante el período en estudio, 40 fueron operados: 18 mujeres y 22 hombres, edad promedio de 46,6 +/- 5,7 años. Se realizaron los siguientes colgajos: Anterolateral de Muslo (ALT) = 14, Epigástrica Inferior (DIEP) = 18, Glútea Superior (SGAP) = 5, Tibial Posterior (PTAP) = 4 y Toracodorsal (TDAP) = 2. En todos ellos el Angio TC ubicó una o varias perforantes en forma precisa y 100 por ciento concordante con los hallazgos intraoperatorios. Conclusiones: El Angio TC es un examen con alto rendimiento en la identificación preoperatoria del vaso perforante y su trayecto. Es una herramienta de gran ayuda al momento de planificar la realización de este tipo de colgajos.

Introduction: Perforator flaps have become a coverage option validated and increasingly used in reconstructive surgery. These flaps require preoperative identification and intraoperative dissection of the perforator vessels. The aim of this study was to evaluate the use of Angio CT in the preoperative assessment of perforating vessels and its correlation with intraoperative findings. Material and Methods: We retrospectively reviewed all perforator flaps performed at the Division of Plastic Surgery, University of Chile Clinical Hospital between June 2009 and June 2012. All patients were asked for an Angio CT according to the protocol of the University of Gent (Belgium). Data points were used and a specific coordinate system to locate the point at which the perforator vessel fenestrate the deep fascia. The information provided in the Angio CT was compared with surgical findings. Results: A total of 41 patients underwent perforator flap planning during the study period. 40 underwent surgery: 18 women and 22 men, with a mean age of 46.6 ± 5.7 years. Flaps were performed as follows: anterolateral thigh (ALT) = 14, inferior epigastric (DIEP) = 18, superior gluteal (SGAP) = 5, posterior tibial (PTAP) = 4 and thoracodorsal (TDAP) = 2. In all cases the Angio CT identified one or more perforator vessel with a 100% concordance with intraoperative findings. Conclusions: CT Angio is a test with high performance in preoperative characterization of perforator vessels. It is a helpful tool that must be considered whenever planning this type of flaps.

Active extravasation of contrast within the hemorrhage (spot sign): a multidetector computed tomography finding that predicts growth and a worse prognosis in non-traumatic intracerebral hemorrhage / Extravasamento ativo de contraste no interior da hemorragia (spot sign): um achado de TCMD que prediz crescimento e pior prognostico nas hemorragias intraparenquimatosas cerebrais nao traumaticas

Intracerebral hemorrhage (ICH) causes high rates of disability and neurological sequelae Objective To evaluate spot signs as predictors of expansion and worse prognosis in non-traumatic ICH in a Brazilian cohort. Method We used multidetector computed tomography angiography to study 65 consecutive patients (40 men, 61.5%), with ages varying from 33 to 89 years (median age 55 years). Clinical and imaging findings were correlated with the findings based on the initial imaging. Results Of the individuals who presented a spot sign, 73.7% died (in-hospital mortality), whereas in the absence of a spot sign the mortality rate was 43.0%. Although expansion of ICH was detected in 75% of the patients with a spot sign, expansion was observed in only 9.0% of the patients who did not present a spot sign. Conclusions The spot sign strongly predicted expansion in non-traumatic ICH and an increased risk of in-hospital mortality. .

A hemorragia intraparenquimatosa cerebral (HIC) apresenta altas taxas de incapacidade e sequela neurológica. Objetivo Avaliar a presença de spot sign como preditor de expansão e pior prognóstico no follow-up de HIC não-traumática em brasileiros. Método Usamos a ângio-tomografia para estudar prospectivamente 65 pacientes consecutivos (40 homens 61,5%), com idades variando de 33 a 89 anos (mediana 55 anos). Evolução clínica e achados de imagem foram correlacionados com a interpretação dos achados do exame inicial. Resultados 73,7% dos indivíduos com spot sign no estudo tomográfico inicial evoluíram para óbito e, na sua ausência, a taxa de mortalidade foi 43,0%. Enquanto a expansão da HIC foi detectada em 75% dos pacientes com spot sign, ela foi notada em 9% daqueles sem este sinal. Conclusão O spot sign mostrou-se forte preditor de expansão da HIC não traumática e representa maior risco de morte hospitalar nesta coorte de pacientes. .