CT Angiography-for-All: Beyond “Diagnostic Nihilism” in Acute Intracerebral Hemorrhage Care – A Personal View

Abstract – Introduction: The role of CTA in acute intracerebral hemorrhage (ICH) remains debated, yet its benefits are clear. In this viewpoint, we provide a case for the routine use of CTA in the initial assessment of patients with acute ICH. Method: To argue for the clinical value of immediate CTA in acute ICH, six key domains were considered: (i) diagnostic performance (does it improve diagnosis?), (ii) prognostic performance (does it improve prognosis?), (iii) predictive performance (does it predict the treatment effect of an intervention?), (iv) safety (does it pose any risks?), (v) costs (is it too expensive?), and (vi) implementation (is it practical to implement?). Results: CTA (i) enhances the etiological diagnosis of ICH, allowing prompt and appropriate early secondary prevention and specific acute treatment, (ii) improves prognostication, (iii) enables better prediction of ICH expansion with possible implications for acute treatment effect, and (iv) has a favorable safety profile, with minimal concern for contrast nephropathy, radiation exposure, or procedural delay, (v) a CTA-for-all-ICH approach seems economically justified, and (vi) its implementation is straightforward – simply continue the ischemic stroke imaging protocol. Conclusion: We advocate for routine CTA in all suspected stroke cases – ischemic or hemorrhagic – supporting a unified “CTA-for-all” approach. Minimizing imaging in ICH (“diagnostic nihilism”) reflects the same mindset that once limited early treatment (“therapeutic nihilism”), contributing to persistently poor outcomes in this population.