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A Hidden Bomb!

Topic: Adult

Created on Thursday, October 23 2008 by rednucleus

Last modified on Thursday, October 23 2008.

A 56-year-old woman is brought to the ER drowsy. Her husband says that the patient developed sudden severe occipital headache which is followed by this drowsiness. Non-contrast brain CT scan reveals blood in the basal cisterns. Next day, her conventional 4-vessel cerebral angiography is reported as "normal." Which one of the following is not a possible cause of this patient's angiography negative subarachnoid hemorrhage?

 
        A) Bleeding from a cavernous angioma
 
        B) Aneurysm with a thrombus
 
        C) Bleeding from a venous angioma
 
        D) Wrong timing of the investigation
 
        E) Small aneurysm
 

 


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This question was created on October 23, 2008 by rednucleus.
This question was last modified on October 23, 2008.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANSWERS AND EXPLANATIONS



A) Bleeding from a cavernous angioma

This answer is incorrect.


Although cavernous angiomas carry a low risk of bleeding, they are low flow vascular malformations that are not visualized by conventional angiography.  (See References)

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B) Aneurysm with a thrombus

This answer is incorrect.


The aneurysm "cavity" is filled out and will not appear on angiogrpahy.  (See References)

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C) Bleeding from a venous angioma

This answer is incorrect.


This is a low flow vascular malformation that is not seen by conventional angiography.  (See References)

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D) Wrong timing of the investigation

This answer is correct.


Ideally, 4-vessel conventional angiography should be done within 48 hours of the ictus (which was applied here). "Early" angiography does not have a negative impact on the imaging findings!  (See References)

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E) Small aneurysm

This answer is incorrect.


The ruptured aneurysm might be so small so as to escape detection by conventional angiography.  (See References)

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References:

1. Victor, M., and Ropper, A.H. (2001). Adams and Victor's Principles of Neurology, 7th Edition. McGraw-Hill, New York. (ISBN:0070674973)Advertising:
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adult
A Hidden Bomb!
Question ID: 102308086
Question written by rednucleus. (C) FrontalCortex.com 2006-2009, all rights reserved. Created: 10/23/2008
Modified: 10/23/2008
Estimated Permutations: 120

User Comments About This Question:

2 user entries
 

jdmiles
adult References Nov 20, 2008 @ 07:49

This is a good question, but additional references are needed.

As far as I can tell, Adams & Victor does not say anything about when the scan should be performed, or about the limits of angiography, and that is what this question is about.



 

jdmiles
adult Re: References Nov 25, 2008 @ 07:55

Timing of angio is discussed in:

Selman, W.R., Sunshine, J.L., Tarr, R.W., and Ratcheson, R.A. (2004). Intracranial aneurysms and subarachnoid hemorrhage. In Bradley, W.G., Daroff, R.B., Fenichel, G.M., and Jankovic, J. (Eds.). Neurology in Clinical Practice, Fourth Edition. Butterworth Heinemann, Philadelphia, pp. 1269-1283 (ISBN:0750674695).

Specifically, page 1271.

DDx of negative angio is discussed in:

Topcuoglu, M.A., Ogilvy, C.S., Carter, B.S., Buonanno, F.S., Koroshetz, W.J., and Singhal, A.B. (2003). "Subarachnoid hemorrhage without evident cause on initial angiography studies: diagnostic yield of subsequent angiography and other neuroimaging tests." J Neurosurg, 98(6) 1235-40. (PMID:12816270)

 



 
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