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1、-. z.Current usage of three-dimensional puted tomography angiography for the diagnosis and treatment of ruptured cerebral aneurysmsKenichi Amagasaki MD, Nobuyasu Takeuchi MD, Takashi Sato MD, Toshiyuki Kakizawa MD, Tsuneo Shimizu MDKanto Neurosurgical Hospital, Kumagaya, Saitama, JapanSummary Our pr

2、evious study suggested that 3D-CT angiography could replace digital subtraction (DS) angiography in most cases of ruptured cerebral aneurysms, especially in the anterior circulation. This study reviewed our further e*perience. One hundred and fifty patients with ruptured cerebral aneurysms were trea

3、ted between November 1998 and March 2002. Only 3D-CT angiography was used for the preoperative work-up study in patients with anterior circulation aneurysms, unless the attending neurosurgeons agreed that DS angiography was required. Both 3D-CT angiography and DS angiography were performed in patien

4、ts with posterior circulation aneurysms, e*cept for recent cases that were possibly treated with 3D-CT angiography alone. One hundred si*teen (84%) of 138 patients with ruptured anterior circulation aneurysms underwent surgical treatment, but additional DS angiography was required in 22 cases (16%).

5、 Only two recent patients were treated surgically with 3D-CT angiography alone in 12 patients with posterior circulation aneurysms. Most patients with ruptured anterior circulation aneurysms could be treated successfully after 3D-CT angiography alone. However, additional DS angiography is still nece

6、ssary in atypical cases. 3D-CT angiography may be limited to plementary use in patients with ruptured posterior circulation aneurysms.a 2003 Elsevier Ltd. All rights reserved.Keywords: 3D-CT angiography, cerebral aneurysm, subarachnoid haemorrhage, surgeryINTRODUCTIONRecently, three-dimensional pute

7、d tomography (3D-CT) angiography has bee one of the major tools for the identification of cerebral aneurysms because it is faster, less invasive, and more convenient than cerebral angiography.17 Patients with ruptured aneurysms could be treated under diagnoses based on only 3D-CT angiography.5;6 3D-

8、CT angiography has some limitations for the preoperative work-up for ruptured cerebral aneurysms, so additional digital subtraction (DS) angiography is still necessary, especially for aneurysms in the posterior circulation.8 Our previous study suggested that 3D-CT angiography could replace DS angiog

9、raphy in most patients with ruptured cerebral aneurysms in the anterior circulation.1 This study reviewed our e*perience of treating ruptured cerebral aneurysms in the anterior and posterior circulations based on 3D-CT angiography in 150 consecutive patients to assess the current usage of 3D-CT angi

10、ography.METHODS AND MATERIALPatient populationWe treated 150 patients, 60 men and 90 women aged from 23 to80 years (mean 57.5 years), with ruptured cerebral aneurysmidentified by 3D-CT angiography between November 1998 andMarch 2002.Managementof casesThe presence of nontraumatic subarachnoid haemorr

11、hage (SAH)was confirmed by CT or lumbar puncture findings of *anthochromiccerebrospinal fluid. 3D-CT angiography was performedroutinely in all patients. DS angiography was performed in patientswith anterior circulation aneurysms only if additional informationwas considered necessary following a cons

12、ensusinterpretation of the initial CT and 3D-CT angiography by fourneurosurgeons. Patients with ruptured aneurysms in the posteriorcirculation underwent both 3D-CT angiography and DS angiographye*cept for two recent patients with typical vertebral arteryposteriorinferior cerebellar artery (VA-PICA)

13、aneurysm.Typical saccular aneurysms were treated by clipping surgery.Fusiform and dissecting aneurysms were treated by pro*imal occlusionby either surgery or endovascular treatment with orwithout bypass surgery. Regrowth of bleeding aneurysms wastreated by either surgery or endovascular treatment. P

14、ostoperatively,all patients were managed with aggressive prevention andtreatment of vasospasm including intra-arterial infusion of papaverineor transluminal angioplasty.3D-CT angiography acquisition and postprocessingCT angiography was performed with a spiral CT scanner (CT-W3000 AD; Hitachi, Ibarak

15、i, Japan). Acquisition used a standardtechnique starting at the foramen magnum, with injection of130 ml of nonionic contrast material (Omnipaque; Daiichi Pharmaceutical,Tokyo, Japan). The source images of each scan weretransferred to an off-line puter workstation (VIP station;Teijin System Technolog

16、y, Japan). Both volume-rendered imagesand ma*imum intensity projection images of the cerebral arterieswere constructed. The anterior circulation and posterior circulationwere evaluated separately on the volume-rendered images,after a general superior view was obtained. The anterior circulationwas ev

17、aluated by first observing the anterior municatingartery (ACoA) by rotating the view, and then each side of thecarotid system by rotating the image with editing out of thecontralateral carotid artery. The posterior circulation was alsoevaluated by rotating the image but without editing out of anyves

18、sel. Once a possible rupture site was found, the view waszoomed and closely rotated with the other vessels edited out. Theaneurysm size was measured on 3D-CT angiography as the largerof the length of the dome or the width of the neck. Manipulationwas performed by the scanner technician, with a neuro

19、surgeon toprovide editing assistance.DS angiography acquisitionStandard selective three- or four-vessel DS angiograms withfrontal, lateral, and oblique projections were obtained. The 3D-CTangiogram was always available as a guide for possible additionalDS angiography projections. Aneurysm size was m

20、easured withDS angiography when the quality of 3D-CT angiography wasinadequate. All patients e*cept elderly patients or patients in severecondition underwent DS angiography postoperatively.Grading of patientsThe clinical conditions of the patients at admission were classifiedaccording to the Hunt an

21、d Kosnik grade.9 Clinical oute wasdetermined at 3 months according to the Glasgow OuteScale.10RESULTSThe aneurysm locations and sizes are shown in Table 1. Onehundred si*teen (84%) of 138 cases of aneurysms in the anteriorcirculation were treated after only 3D-CT angiography, and 22cases (16%) requi

22、red additional DS angiography. Ten of 12 casesof aneurysms in the posterior circulation required both 3D-CTangiography and DS angiography, but two recent cases of typicalVA-PICA aneurysm were clipped after only 3D-CT angiography(Fig. 1). The first 10 of the 22 cases in the anterior circulation,which

23、 required additional DS angiography were described previously,1 so the most recent 12 patients are listed in Table 2.These recent cases included some atypical aneurysms. Cases 6and 8 had a fusiform aneurysm of the internal carotid artery (ICA).Additional DS angiography was performed to obtain haemod

24、ynamicinformation. ICA trapping with superficial temporal artery-middle cerebral artery anastomosis was performed in Case 6because the atherosclerotic arteries failed to demonstrate theballoon occlusion test (Fig. 2). ICA occlusion by endovasculartreatment was performed in Case 8 because the patient

25、 couldtolerate the balloon occlusion test. Cases 4, 9, and 10 sufferedregrowth of bleeding aneurysms after clipping surgery. Clip artifactsprevented evaluation of the ruptured site as well as identificationof de novo aneurysms in these cases (Fig. 3). Surgicalclipping was performed in Cases 4 and 10

26、 and endovasculartreatment in Case 9. Case 11 had an ACoA aneurysm associatedwith an arteriovenous malformation (AVM) (Fig. 4). DS angiographywas performed to evaluate the AVM. Case 12 had a largeICA-posterior municating artery (PCoA) aneurysm, and additionalDS angiography was performed because the

27、PCoA couldnot be detected by 3D-CT angiography (Fig. 5). Cases 1, 2, 3, 5,and 7 presented with small aneurysms, and DS angiography wasperformed to e*clude other lesions as well as to obtain informationabout the pro*imal ICA for patients with supraclinoid type aneurysms.Table 1 Distribution and size

28、of cerebral aneurysms in 150 consecutivepatientsSite No. of patientsAnterior circulation 138ICA (supraclinoid) 3ICA bifurcation 1ICA-OphA 3ICA-PCoA 39 (1)ICA fusiform 2ACoA 50Distal ACA 4MCA 36 (1)Posterior circulation 12PCA1BA tip 3BA-SCA 1BA trunk 1 (1)VA-PICA 3VA dissecting3 (1)Size (mm)5 42P5 to

29、 12 99P12 9Number in parentheses indicates patients who underwent endovasculartreatment.OphA, ophthalmic artery; ACA, anterior cerebral artery; MCA, middle cerebralartery; PCA, posterior cerebral artery; BA, basilar artery; SCA, superiorcerebellar artery.Table 2 Twelve patients with ruptured anterio

30、r circulation aneurysms whounderwent additional DS angiographyCase No. Location Size (mm)1 lt. ICA-PCoA 3.12 ACoA 2.23 lt. ICA supraclinoid 1.64 lt. ICA-PCoA 7.85 lt. ICA supraclinoid 2.46 lt. ICA (fusiform) 11.87 lt. ICA-PCoA 3.28 rt. ICA (fusiform) 18.89 lt. MCA 9.610 lt. ICA-PCoA 10.511ACoA 10.11

31、2 lt. ICA-PCoA 18.2The surgical findings correlated well with the 3D-CT angiographyor DS angiography. Table 3 shows the condition on admissionand oute at 3 months after surgery. Some patientswith good grades on admission died of severe spasm, acute brainswelling, or poor general condition, but these

32、 outes were notrelated to the preoperative radiological information.DISCUSSIONThe present study of ruptured aneurysms in both anterior andposterior circulations found that the indications for additional DSangiography in the anterior circulation are similar to that foundpreviously, but we e*perienced

33、 some new atypical cases. Treatmentof fusiform aneurysms depends on the haemodynamic information,which could only be obtained by DS angiography. ACoA aneurysm associated with AVM, although the initial CTindicated that the aneurysm had bled, required accurate evaluationof the AVM prior to surgery. Cl

34、ip artifacts affected 3D-CT angiographyin cases of recurrent SAH after clipping surgery, so 3DCTangiography is not indicated for such cases.3D-CT angiography was only of plementary use in most ofthe 12 cases of posterior circulation aneurysms. Only two cases oftypical VA-PICA aneurysms were treated

35、based on only 3D-CTangiography. Typical basilar artery-superior cerebellar artery andVA-PICA aneurysms can be treated surgically after only 3D-CTangiography. DS angiography should always be performed forbasilar tip aneurysms to evaluate the perforating arteries nearby aswell as assess the vessel tor

36、tuosity for the possibility of endovasculartreatment. Treatment of VA dissecting aneurysms needsinformation about the true and false lumens of the VA whichrequires DS angiography. The small population of posterior circulationaneurysms in this study indicates that the variation ofaneurysms as well as

37、 the treatment choices in the posterior circulationrequire DS angiography in most cases.In our series, most aneurysms measured 512 mm, and typicalsaccular aneurysms of that size could be treated after 3D-CTangiography. However, there were problems with some largeaneurysms. DS angiography was not nec

38、essary if the neck andnearby arteries of a large aneurysm were clearly detected. DSangiography was necessary in two cases of large aneurysms. Acase of large ophthalmic artery aneurysm was located close to theanterior clinoid process.1 Small PCoA aneurysms may not bedetected by 3D-CT angiography, but

39、 the artery would not bedifficult to observe during the operation. In our case of a largePCoA aneurysm, DS angiography was performed because thelarge neck would prevent intraoperative observation of the PCoA.Although not e*perienced in our series, treatment including bypasssurgery for some large or

40、giant aneurysms will require thehaemodynamic information provided by DS angiography.Some small aneurysms (less than 4 mm) required additionalDS angiography. 3D-CT angiography may be better for detectingsmall aneurysm than DS angiography.11;12 However, we suggestDS angiography is still necessary in t

41、he following cases. Firstly,patibility of the initial CT scan and aneurysm location by 3DCTangiography is important. Patients with ruptured aneurysmand asymmetrical SAH with laterality patible with the rupturesite present no problem. However, we cannot always depend onthe initial CT scans if the SAH

42、 is diffuse or symmetrical, especiallyif ACoA aneurysm or basilar tip aneurysm is not found theresponsible lesion. DS angiography is more useful to e*cludeother lesions because of the smooth opacification of the vessels.Secondly, cases with small aneurysm located on the supraclinoidportion require p

43、ro*imal ICA control during the operation. DSangiography is necessary to provide information about the haemodynamicsincluding the cross circulation.Magnetic resonance (MR) angiography is potentially the onlymodality required for preoperative assessment of ruptured cerebralaneurysms.13 However, MR ima

44、ging is time-consuming and accessto MR scanners may be restricted. Patients could be in anunstable condition in the very early period of SAH, so that theemergent condition of the patients could be much easier to managein the CT facility. On the other hand, MR angiography doesreduce the use of contra

45、st medium, so is a safe diagnostic tool.MR angiography may be the best modality for diagnosis in patientswith good grade presenting several days after the onset,because the risk of rerupture falls with time.3D-CT angiography has been used to analyze the anatomicalstructures for surgery.14;15 Informa

46、tion about the venous and arterialstructures near the aneurysm are preferable, but do not always reflectthe findings of DS angiography. Normal anatomical structures, suchas perforating arteries and veins, are likely to be encountered duringsurgery although not detected clearly by 3D-CT angiography.T

47、his study of the overall management of ruptured cerebralaneurysms with 3D-CT angiography and additional DS angiographyindicates that more patients with anterior circulation aneurysmswill be treated after only 3D-CT angiography e*cept for thefollowing cases requiring additional DS angiography: Aneury

48、smsclose to bone structures, such as an ICA-ophthalmic arteryaneurysm; fusiform aneurysms, and large or giant aneurysmsrequiring accurate neck information and haemodynamic informationfor bypass surgery; patients with discrepancies between thedistribution of SAH on CT and the location of the aneurysm

49、, especiallysmall aneurysms, to e*clude other lesions; small aneurysmslocated on the supraclinoid portion of ICA, which require informationabout haemodynamics and pro*imal ICA control; regrowthof aneurysms that leads clip artifacts; and aneurysms associatedwith AVM in related locations. A clear conc

50、lusion about patientswith posterior circulation aneurysms cannot be reached because ofthe small population. Typical basilar artery-superior cerebellar arteryand VA-PICA aneurysms can be treated surgically after only3D-CT angiography, but 3D-CT angiography may be limited toplementary use for basilar

51、tip aneurysms and other posteriorcirculation aneurysms because of the need for close observation ofnearby perforating arteries and the possibility of endovasculartreatment. Dissecting aneurysm, which is often observed in the VA,requires DS angiography to detect true and false lumens.REFERENCES1. Ama

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