Angio Negative Spontaneous Subarachnoid Hemorrhage: Cost Benefit Analysis

Objective: Subarachnoid hemorrhage his account for ~5% of stroke admissions in the United States. The concern for subarachnoid hemorrhage is an underlying ruptured aneurysm. However, in an estimated 15% of the subarachnoid hemorrhages, causative lesion is identified. With rising costs in healthcare, it is important to determine whether or not these hemorrhages require repeat vascular imaging. The literature currently states that subarachnoid hemorrhages can be separated into diffuse or perimesencephalic and the latter seems to do better and does not require repeat imaging. This aim of this study was to perform a cost-benefit analysis of repeat angiograms on subarachnoid hemorrhage patients with an initial negative angiogram.

Methods: Between 2010 and 2015, a retrospective review of all patients admitted to UNC for subarachnoid hemorrhages was done. All patients who ended up having an initial negative angiogram were included in the study. The typical protocol at UNC for initial angiogram negative subarachnoid hemorrhages is to repeat another angiogram in 1 to 3 weeks.

Results: Ninety-one patients were eligible for the study. All patients had a negative initial angiogram. The average length of ICU stay was 8.9 days and the average length of hospital stay was 11.4 days. Seven patients had three DSA and two patients had four DSA. Fifty-two magnetic resonance imaging and 42 magnetic resonance angiogram were performed after negative angiograms. Five out of ninety-one (1%) patients had positive finding on repeat angiograms but none required any intervention. In-hospital complications included deep venous thrombosis and hospital acquired pneumonia.

Conclusion: Hospital stays can impact more than the patient’s health. The associated costs of additional workup after the initial negative angiogram as well as the economic loss to the patient in terms of days of work missed have been understated. Given the number of subarachnoid hemorrhages that are admitted to hospitals and the low incidence of aneurysms seen on repeat angiograms, this suggests that the costs may outweigh the benefits of continued hospitalization and additional vascular imaging.