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Slonimsky E, Upham K, Pepley S, Ouyang T, King T, Fiorelli M, Thamburaj K. Multiplanar CT evaluation of aneurysm rupture signs in subarachnoid hemorrhage. Emerg Radiol 2022; 29:427-435. [PMID: 35067812 DOI: 10.1007/s10140-022-02020-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE In subarachnoid hemorrhage, noncontrast CT features are used to guide the localization of ruptured aneurysms on CT angiography and DSA. Multiplanar CT may improve the localization of aneurysm rupture sites over axial plane CT alone. METHODS Multiplanar CT in three orthogonal planes was used to evaluate 94 cases of SAH. Two investigators independently evaluated each imaging plane for focal thick SAH with mass effect, intracerebral hemorrhage, focal edema, filling defect, subdural hemorrhage, and dominant intraventricular hemorrhage. Also, rupture site was qualitatively identified by combining these variables in each plane and combination of three planes. DSA served as the gold standard to locate the rupture sites. RESULTS Interobserver agreement was k 0.60 to 0.79 for axial, k 0.43 to 0.86 for coronal and k 0.43 to 0.74 for sagittal planes. Good to substantial agreement was observed for the localization of rupture site in three planes (focal SAH with mass effect - k 0.78 to 0.85; filling defect - k 0.95 to 1.0; intracerebral hemorrhage - k 1.0; focal edema k 1.0; subdural hemorrhage - k 0.61 to 0.83). Dominant intraventricular hemorrhage revealed significant association with DSA to locate ruptured aneurysms (Fisher's exact test - Pr < = P (< 0.001)). With non-missing data, frequency of correct ratings to locate rupture site was 66/67 (99%) in axial plane, 59/66 (89%) in coronal plane, 64/67 (96%) in sagittal plane and 77/77 (100%) in combined 3 planes. CONCLUSIONS Multiplanar CT head is more successful than axial plane CT alone for the localization of aneurysm rupture sites in SAH.
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Affiliation(s)
- Einat Slonimsky
- Department of Radiology, Penn State Health Milton Hershey Medical Center, Hershey, PA, 17036, USA
| | - Kent Upham
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Sarah Pepley
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tao Ouyang
- Department of Radiology, Penn State Health Milton Hershey Medical Center, Hershey, PA, 17036, USA
| | - Tonya King
- Department of Biostatistics, Penn State Health College of Medicine, Hershey, PA, USA
| | - Marco Fiorelli
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Krishnamoorthy Thamburaj
- Department of Radiology, Penn State Health Milton Hershey Medical Center, Hershey, PA, 17036, USA.
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Rotim K, Kalousek V, Splavski B, Tomasović S, Rotim A. HYBRID MICROSURGICAL AND ENDOVASCULAR APPROACH IN THE TREATMENT OF MULTIPLE CEREBRAL ANEURYSMS: AN ILLUSTRATIVE CASE SERIES IN CORRELATION WITH LITERATURE DATA. Acta Clin Croat 2021; 60:33-40. [PMID: 34588719 PMCID: PMC8305362 DOI: 10.20471/acc.2021.60.01.05] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 02/26/2021] [Indexed: 11/24/2022] Open
Abstract
Contemporary cerebral aneurysm treatment has advanced due to the expansion of microsurgical and endovascular techniques having different advantages and restraints. However, some aneurysms cannot be effectively treated by a single method alone due to their specific anatomy, location, complexity, and/or multiplicity. Subsequently, multiple aneurysms sometimes necessitate a hybrid strategy integrating both methods. The study aims were to discuss indications, possibilities, and challenges of a hybrid strategy in the decision making and treatment of multiple intracranial aneurysms. A single-institution illustrative case series of multiple intracranial aneurysm patients treated by a hybrid approach was analyzed and management outcome discussed and correlated with literature data. Following the treatment, both patients from our case series recovered well, having complete and stable aneurysmal occlusion with no relapse and no postoperative procedure-related complications or long-lasting neurological symptoms. In conclusion, a hybrid approach is advised as a treatment option for multiple cerebral aneurysms when a single modality is insufficient to bring satisfactory results. It may be a suitable and safe addition to an assortment of treatments pledging clinical improvement and enabling positive management outcome in patients with ruptured and non-ruptured multiple cerebral aneurysms.
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Affiliation(s)
| | - Vladimir Kalousek
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Bruno Splavski
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Sanja Tomasović
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
| | - Ante Rotim
- 1Department of Neurosurgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 2Josip Juraj Strossmayer University of Osijek, Faculty of Medicine, Osijek, Croatia; 3University of Applied Health Sciences, Zagreb, Croatia; 4Department of Radiology, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia; 5Josip Juraj Strossmayer University of Osijek, Faculty of Dental Medicine and Health, Osijek, Croatia; 6Department of Neurology, Sveti Duh University Hospital, Zagreb, Croatia
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3
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Tsunoda S, Yoshikawa G, Ishikawa O. A predictive score for identification of rupture site in subarachnoid haemorrhage with multiple intracranial aneurysm. Br J Neurosurg 2020; 35:145-150. [PMID: 32510237 DOI: 10.1080/02688697.2020.1775783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE The rigid method of identifying the rupture site in cases of subarachnoid haemorrhage (SAH) with multiple intracranial aneurysms (MIAs) is still unclear. Here we present a reliable method by using a combination of six predictors. MATERIALS AND METHODS Concerning the 48 SAH patients with MIAs who visited the Showa General Hospital during the period from January 2005 to March 2016, several predictors of rupture site such as the aneurysm-related morphologic features (size, aspect ratio, shape, bleb), aneurysm location, and the distribution of SAH were investigated. Compared with other coexisting aneurysms in each predictor, each aneurysm was categorized into 'suspicion' or 'non-suspicion', and we analyzed the association between 'suspicion' and rupture. RESULTS In the first analysis, all variables were associated with rupture and included in the multivariate logistic regression analysis. The presence of bleb (OR, 20.7; CI, 2.3-186; p = .007) and the aneurysm location (OR, 23.5; CI, 5.2-106; p < .001) were significantly associated with rupture in multivariate logistic regression analysis. Based on the results, a predictive score for rupture was created and calculated for each aneurysm, and the aneurysm with highest predictive score in each patient was categorized into 'suspicion'. 'Suspicion' in the predictive score was significantly associated with rupture (OR, 412.5; CI, 52.2-16384; p < .001). The sensitivity (0.90), specificity (0.98) and the accuracy (0.94) of identifying the rupture site by the predictive score were quite satisfactory. CONCLUSION Our results suggest that the predictive score may be an excellent parameter to identify the rupture site in cases of SAH with MIAs.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan.,Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Osamu Ishikawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan.,Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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Yao A, Jia L, Li J, Wang B, Zhang J, Xue Z, Zhao K, Zhao Y, You N, Zhang J, Xu B. Fusion of subarachnoid hemorrhage data and computed tomography angiography data is helpful to identify the rupture source in patients with multiple intracranial aneurysms. Neurosurg Rev 2020; 44:1411-1416. [PMID: 32506389 DOI: 10.1007/s10143-019-01221-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/20/2019] [Accepted: 12/02/2019] [Indexed: 10/24/2022]
Abstract
Determining the rupture source is imperative in patient with aneurysmal subarachnoid hemorrhage (SAH). About one third of SAH cases with multiple intracranial aneurysms cannot be certain of the rupture source according to the hemorrhage pattern. This study aims to identify of the rupture source in patients with multiple intracranial aneurysms by fusing SAH data and computed tomography angiography (CTA) data. This retrospective study included 52 aneurysmal SAH patients with multiple intracranial aneurysms. In the 52 patients, 36 had definitive hemorrhage patterns on computed tomography imaging. And the other 16 patients had non-definitive hemorrhage patterns, which were bewildered for us to determine the ruptured aneurysms. Fusion of SAH data and CTA data was performed to demonstrate the spatial relationship between the SAH with each aneurysm by using the 3D Slicer software. For the patients with definitive bleed patterns, all of the suspected ruptured aneurysms were confirmed to be accurate according to the surgical records. Interestingly, the suspected rupture sources were correct in 14 of 16 patients with non-definitive hemorrhage patterns. For all 52 patients with multiple intracranial aneurysms, the ruptured aneurysms were identified in 50 cases (96.2%). In conclusion, fusion of SAH data and CTA data can precisely demonstrate the spatial relationship between the SAH with each aneurysm, which is helpful to determine the ruptured aneurysm in patients with multiple intracranial aneurysms.
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Affiliation(s)
- Anhui Yao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.,Department of Neurosurgery, the 988 Hospital of PLA, Zhengzhou, Henan Province, China
| | - Liyun Jia
- Department of Medical Genetics & Cell Biology, School of Basic Medical Sciences, Zhengzhou University, Zhengzhou, Henan Province, China
| | - Jun Li
- Department of Medical Imaging, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan Province, China
| | - Benhan Wang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jiashu Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Zhe Xue
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Kai Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Yue Zhao
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Na You
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China
| | - Jun Zhang
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
| | - Bainan Xu
- Department of Neurosurgery, Chinese PLA General Hospital, Beijing, China.
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5
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Hadjiathanasiou A, Schuss P, Brandecker S, Welchowski T, Schmid M, Vatter H, Güresir E. Multiple aneurysms in subarachnoid hemorrhage - identification of the ruptured aneurysm, when the bleeding pattern is not self-explanatory - development of a novel prediction score. BMC Neurol 2020; 20:70. [PMID: 32113481 PMCID: PMC7049209 DOI: 10.1186/s12883-020-01655-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 02/25/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In aneurysmal subarachnoid hemorrhage (SAH) and multiple intracranial aneurysms (MIAs) identification of the bleeding source cannot always be assessed according to the hemorrhage pattern. Therefore, we developed a statistical model for the prediction of the ruptured aneurysm in patients with SAH and multiple potential bleeding sources at the time of ictus. METHODS Between 2012 and 2015, 252 patients harboring 619 aneurysms were admitted to the authors' institution. Patients were followed prospectively. Aneurysm and patient characteristics, as well as radiological findings were entered into a computerized database. Gradient boosting techniques were used to derive the statistical model for the prediction of the ruptured aneurysm. Based on the statistical prediction model, a scoring system was produced for the use in the clinical setting. The aneurysm with the highest score poses the highest possibility of being the bleeding source. The prediction score was then prospectively applied to 34 patients suffering from SAH and harboring MIAs. RESULTS According to the statistical prediction model the main factors affecting the rupture in patients harboring multiple aneurysms were: 1) aneurysm size, 2) aneurysm location and 3) aneurysm shape. The prediction score identified correctly the ruptured aneurysm in all the patients that were used in the prospective validation. Even in the five most debatable and challenging cases assessed in the period of prospective validation, for which the score was designed for, the ruptured aneurysm was predicted correctly. CONCLUSIONS This new and simple prediction score might provide additional support for neurovascular teams for treatment decision in SAH patients harboring multiple aneurysms. In a small prospective sample, the prediction score performed with high accuracy but larger cohorts for external validation are warranted.
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Affiliation(s)
- Alexis Hadjiathanasiou
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Sigmund-Freud-Str. 25, 53127, Bonn, Germany.
| | - Patrick Schuss
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Simon Brandecker
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Thomas Welchowski
- Institute for Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Matthias Schmid
- Institute for Medical Biometry, Informatics and Epidemiology, Faculty of Medicine, Rheinische Friedrich-Wilhelms-University, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
| | - Erdem Güresir
- Department of Neurosurgery, Rheinische Friedrich-Wilhelms-University, Sigmund-Freud-Str. 25, 53127, Bonn, Germany
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6
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Tsunoda S, Yoshikawa G, Ishikawa O. One-stage Operation with Ipsilateral Two-Piece Craniotomies for a Case of Subarachnoid Hemorrhage with Multiple Intracranial Aneurysms. Asian J Neurosurg 2020; 14:1226-1230. [PMID: 31903368 PMCID: PMC6896625 DOI: 10.4103/ajns.ajns_165_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) with multiple intracranial aneurysms is common, but the difficulties often arise in determining treatment strategy in the acute phase. We experienced a case of SAH with distal anterior cerebral artery aneurysm coexisting with middle cerebral artery and anterior communicating artery aneurysms, in which it was difficult to identify the precise rupture site preoperatively, and both pterional approach and interhemispheric approach were required in the acute phase of SAH. However, we could treat whole aneurysms in one stage and obtained an excellent outcome using our surgical procedure with ipsilateral frontotemporal and frontal parasagittal craniotomies through a single skin incision.
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Affiliation(s)
- Sho Tsunoda
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan.,Department of Neurosurgery, NTT Medical Center Tokyo, Tokyo, Japan
| | | | - Osamu Ishikawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, Japan.,Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan
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7
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Rajabzadeh-Oghaz H, Wang J, Varble N, Sugiyama SI, Shimizu A, Jing L, Liu J, Yang X, Siddiqui AH, Davies JM, Meng H. Novel Models for Identification of the Ruptured Aneurysm in Patients with Subarachnoid Hemorrhage with Multiple Aneurysms. AJNR Am J Neuroradiol 2019; 40:1939-1946. [PMID: 31649161 DOI: 10.3174/ajnr.a6259] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 08/23/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In patients with SAH with multiple intracranial aneurysms, often the hemorrhage pattern does not indicate the rupture source. Angiographic findings (intracranial aneurysm size and shape) could help but may not be reliable. Our purpose was to test whether existing parameters could identify the ruptured intracranial aneurysm in patients with multiple intracranial aneurysms and whether composite predictive models could improve the identification. MATERIALS AND METHODS We retrospectively collected angiographic and medical records of 93 patients with SAH with at least 2 intracranial aneurysms (total of 206 saccular intracranial aneurysms, 93 ruptured), in which the ruptured intracranial aneurysm was confirmed through surgery or definitive hemorrhage patterns. We calculated 13 morphologic and 10 hemodynamic parameters along with location and type (sidewall/bifurcation) and tested their ability to identify rupture in the 93 patients. To build predictive models, we randomly assigned 70 patients to training and 23 to holdout testing cohorts. Using a linear regression model with a customized cost function and 10-fold cross-validation, we trained 2 rupture identification models: RIMC using all parameters and RIMM excluding hemodynamics. RESULTS The 25 study parameters had vastly different positive predictive values (31%-87%) for identifying rupture, the highest being size ratio at 87%. RIMC incorporated size ratio, undulation index, relative residence time, and type; RIMM had only size ratio, undulation index, and type. During cross-validation, positive predictive values for size ratio, RIMM, and RIMC were 86% ± 4%, 90% ± 4%, and 93% ± 4%, respectively. In testing, size ratio and RIMM had positive predictive values of 85%, while RIMC had 92%. CONCLUSIONS Size ratio was the best individual factor for identifying the ruptured aneurysm; however, RIMC, followed by RIMM, outperformed existing parameters.
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Affiliation(s)
- H Rajabzadeh-Oghaz
- From the Canon Stroke and Vascular Research Center (H.R.-O., N.V., A.H.S., J.M.D., H.M.).,Departments of Mechanical and Aerospace Engineering (H.R.-O., N.V., H.M.)
| | - J Wang
- Biostatistics (J.W.), University at Buffalo, Buffalo, New York
| | - N Varble
- From the Canon Stroke and Vascular Research Center (H.R.-O., N.V., A.H.S., J.M.D., H.M.).,Departments of Mechanical and Aerospace Engineering (H.R.-O., N.V., H.M.)
| | - S-I Sugiyama
- Department of Neuroanesthesia (S.-I.S.), Kohnan Hospital, Sendai, Japan.,Department of Neurosurgery (S.-I.S., A.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - A Shimizu
- Department of Neurosurgery (S.-I.S., A.S.), Tohoku University Graduate School of Medicine, Sendai, Japan
| | - L Jing
- Department of Interventional Neuroradiology (L.J., J.L., X.Y., H.M.), Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - J Liu
- Department of Interventional Neuroradiology (L.J., J.L., X.Y., H.M.), Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - X Yang
- Department of Interventional Neuroradiology (L.J., J.L., X.Y., H.M.), Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - A H Siddiqui
- From the Canon Stroke and Vascular Research Center (H.R.-O., N.V., A.H.S., J.M.D., H.M.).,Departments of Neurosurgery (A.H.S., J.M.D.).,Radiology (A.H.S.), Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Jacobs Institute (A.H.S., J.M.D), Buffalo, New York
| | - J M Davies
- From the Canon Stroke and Vascular Research Center (H.R.-O., N.V., A.H.S., J.M.D., H.M.).,Departments of Neurosurgery (A.H.S., J.M.D.).,Bioinformatics (J.M.D.).,Jacobs Institute (A.H.S., J.M.D), Buffalo, New York
| | - H Meng
- From the Canon Stroke and Vascular Research Center (H.R.-O., N.V., A.H.S., J.M.D., H.M.) .,Departments of Mechanical and Aerospace Engineering (H.R.-O., N.V., H.M.).,Department of Interventional Neuroradiology (L.J., J.L., X.Y., H.M.), Beijing Neurosurgical Institute, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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8
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Kim HC, Rhim JK, Ahn JH, Park JJ, Moon JU, Hong EP, Kim MR, Kim SG, Lee SH, Jeong JH, Choi SW, Jeon JP. Machine Learning Application for Rupture Risk Assessment in Small-Sized Intracranial Aneurysm. J Clin Med 2019; 8:jcm8050683. [PMID: 31096607 PMCID: PMC6572384 DOI: 10.3390/jcm8050683] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 05/11/2019] [Accepted: 05/13/2019] [Indexed: 12/21/2022] Open
Abstract
The assessment of rupture probability is crucial to identifying at risk intracranial aneurysms (IA) in patients harboring multiple aneurysms. We aimed to develop a computer-assisted detection system for small-sized aneurysm ruptures using a convolutional neural network (CNN) based on images of three-dimensional digital subtraction angiography. A retrospective data set, including 368 patients, was used as a training cohort for the CNN using the TensorFlow platform. Aneurysm images in six directions were obtained from each patient and the region-of-interest in each image was extracted. The resulting CNN was prospectively tested in 272 patients and the sensitivity, specificity, overall accuracy, and receiver operating characteristics (ROC) were compared to a human evaluator. Our system showed a sensitivity of 78.76% (95% CI: 72.30%-84.30%), a specificity of 72.15% (95% CI: 60.93%-81.65%), and an overall diagnostic accuracy of 76.84% (95% CI: 71.36%-81.72%) in aneurysm rupture predictions. The area under the ROC (AUROC) in the CNN was 0.755 (95% CI: 0.699%-0.805%), better than that obtained from a human evaluator (AUROC: 0.537; p < 0.001). The CNN-based prediction system was feasible to assess rupture risk in small-sized aneurysms with diagnostic accuracy superior to human evaluators. Additional studies based on a large data set are necessary to enhance diagnostic accuracy and to facilitate clinical application.
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Affiliation(s)
- Heung Cheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon 24252, Korea.
| | - Jong Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju 63241, Korea.
| | - Jun Hyong Ahn
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon 24252, Korea.
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul 05030, Korea.
| | - Jong Un Moon
- Department of Neurosurgery, National Medical Center, Seoul 04564, Korea.
| | - Eun Pyo Hong
- Molecular Neurogenetics Unit, Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA 02114, USA.
| | | | | | | | | | | | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon 24252, Korea.
- Institute of New Frontier Stroke Research, Hallym University College of Medicine, Chuncheon 24252, Korea.
- Genetic and Research Inc., Chuncheon 24252, Korea.
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9
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Xu L, Gu L, Liu H. Exploring potential association between flow instability and rupture in patients with matched-pairs of ruptured-unruptured intracranial aneurysms. Biomed Eng Online 2016; 15:166. [PMID: 28155701 PMCID: PMC5260036 DOI: 10.1186/s12938-016-0277-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Background Patients with multiple intracranial aneurysms present a great challenge to the neurosurgeon, particularly when presenting with subarachnoid hemorrhage. Misjudgment may result in disastrous postoperative rebleeding from the untreated but true-ruptured lesion. Methods In this study, computational fluid dynamic simulations of two matched-pairs of ruptured–unruptured cerebral aneurysms were performed to investigate the potential association between flow instability and aneurysm rupture. Two pairs of cerebral aneurysms from two patients were located in the middle cerebral artery and the anterior communicating artery respectively. Results Our results demonstrated highly disturbed states of the blood flows in the ruptured aneurysms of the two patients with multiple aneurysms, which are characterized by remarked velocity and wall shear stress (WSS) fluctuations at late systole. The ruptured aneurysms exhibit obviously temporal intra-cycle WSS fluctuations rather than the unruptured aneurysms of the same patient. Cycle-to-cycle fluctuations are further observed in the ruptured aneurysms when the flow turns to decelerate. Conclusions The obvious differences observed between matched-pairs of ruptured–unruptured aneurysms imply that flow instability may be a potential source correlating to aneurysm rupture.
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Affiliation(s)
- Lijian Xu
- Shanghai Jiao Tong University and Chiba University International Cooperative Research Center (SJTU-CU ICRC), School of Biomedical Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Minhang district, Shanghai, People's Republic of China.,Graduate School of Engineering, Chiba University, 1-33, Yayoi-cho, Inage-ku, Chiba-shi, Chiba, Japan
| | - Lixu Gu
- Shanghai Jiao Tong University and Chiba University International Cooperative Research Center (SJTU-CU ICRC), School of Biomedical Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Minhang district, Shanghai, People's Republic of China.
| | - Hao Liu
- Shanghai Jiao Tong University and Chiba University International Cooperative Research Center (SJTU-CU ICRC), School of Biomedical Engineering, Shanghai Jiao Tong University, 800 Dongchuan Road, Minhang district, Shanghai, People's Republic of China. .,Graduate School of Engineering, Chiba University, 1-33, Yayoi-cho, Inage-ku, Chiba-shi, Chiba, Japan.
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10
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Morphologic and Hemodynamic Analysis in the Patients with Multiple Intracranial Aneurysms: Ruptured versus Unruptured. PLoS One 2015; 10:e0132494. [PMID: 26147995 PMCID: PMC4492509 DOI: 10.1371/journal.pone.0132494] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 06/15/2015] [Indexed: 11/26/2022] Open
Abstract
Background and Purpose The authors evaluated the impact of morphologic and hemodynamic factors on multiple intracranial aneurysms and aimed to identify which parameters can be reliable indexes as one aneurysm ruptured, and the others did not. Methods Between June 2011 and May 2014, 69 patients harboring multiple intracranial aneurysms (69 ruptured and 86 unruptured) were analyzed from 3D-digital subtraction angiography (DSA) images and computational fluid dynamics (CFD). Morphologic and hemodynamic parameters were evaluated for significance with respect to rupture. Receiver operating characteristic (ROC) analysis identified area under the curve (AUC) and optimal thresholds separating ruptured from unruptured intracranial aneurysms for each parameter. Significant parameters were examined by binary logistic regression analysis to identify independent discriminators. Results Nine morphologic (size, neck width, surface area, volume, diameter of parent arteries, aspect ratio, size ratio, lateral/bifurcation type and regular/irregular type) and 6 hemodynamic (WSSmean, WSSmin, OSI, LSA, flow stability and flow complexity) parameters achieved statistical significance (p<0.05). Six morphologic (size, surface area, volume, aspect ratio, size ratio and regular/irregular type) and five hemodynamic (WSSmean, WSSmin, LSA, flow stability and flow complexity) parameters had high AUC values (AUC>0.7). By binary logistic regression analysis, large aspect ratio and low WSSmean were the independently significant rupture factors (AUC, 0.924; 95% CI, 0.883–0.965). Conclusions Large aspect ratio and low WSSmean were independently associated with the rupture status of multiple intracranial aneurysms.
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Influence of morphology and hemodynamic factors on rupture of multiple intracranial aneurysms: matched-pairs of ruptured-unruptured aneurysms located unilaterally on the anterior circulation. BMC Neurol 2014; 14:253. [PMID: 25551809 PMCID: PMC4301794 DOI: 10.1186/s12883-014-0253-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 12/12/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The authors evaluated the impact of morphological and hemodynamic factors on the rupture of matched-pairs of ruptured-unruptured intracranial aneurysms on one patient's ipsilateral anterior circulation with 3D reconstruction model and computational fluid dynamic method simulation. METHODS 20 patients with intracranial aneurysms pairs on the same-side of anterior circulation but with different rupture status were retrospectively collected. Each pair was divided into ruptured-unruptured group. Patient-specific models based on their 3D-DSA images were constructed and analyzed. The relative locations, morphologic and hemodynamic factors of these two groups were compared. RESULTS There was no significant difference in the relative bleeding location. The morphological factors analysis found that the ruptured aneurysms more often had irregular shape and had significantly higher maximum height and aspect ratio. The hemodynamic factors analysis found lower minimum wall shear stress (WSSmin) and more low-wall shear stress-area (LSA) in the ruptured aneurysms than that of the unruptured ones. The ruptured aneurysms more often had WSSmin on the dome. CONCLUSIONS Intracranial aneurysms pairs with different rupture status on unilateral side of anterior circulation may be a good disease model to investigate possible characteristics linked to rupture independent of patient characteristics. Irregular shape, larger size, higher aspect ratio, lower WSSmin and more LSA may indicate a higher risk for their rupture.
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Oh K, Lim YC. Single-session Coil Embolization of Multiple Intracranial Aneurysms. J Cerebrovasc Endovasc Neurosurg 2013; 15:184-90. [PMID: 24167798 PMCID: PMC3804656 DOI: 10.7461/jcen.2013.15.3.184] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Revised: 08/24/2013] [Accepted: 08/28/2013] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE There is no clear treatment strategy for the management of multiple intracranial aneurysms because of variable anatomical distribution, difficult identification of the aneurysm ruptured, and poor overall outcomes. The purpose of this study was to assess the efficacy and safety of single-session coil embolization for multiple intracranial aneurysms. METHODS Between September 2008 and December 2012, 209 aneurysms in 117 patients were treated at our institute. Twenty eight among the 117 patients had multiple aneurysms with a total of 71, and 60 of the 71 aneurysms underwent coil embolization in a single-session. RESULTS A total of 60 aneurysms were treated with a single-session coil embolization, of which the most frequent locations were in the posterior communicating artery, followed by the middle cerebral artery. Immediate post-embolization angiographies showed total occlusion in 49 (81.7%) aneurysms, remnant neck in 6 (10%), and body-filling in 5 (8.3%). Procedure-related complications had developed in 2 (3.3%) of the 60 embolized aneurysms: an asymptomatic thromboembolic event, and a partial coil protrusion without a subsequent thromboembolic complication. CONCLUSION With careful evaluation of individual aneurysm characteristics and configuration, multiple intracranial aneurysms previously thought to require multimodality therapy can be safely treated in a single-session coil embolization.
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Affiliation(s)
- Keun Oh
- Department of Neurosurgery, Ajou University School of Medicine, Ajou University Hospital, Suwon, Korea
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Mont'alverne F, Tournade A, Riquelme C, Musacchio M. Multiple intracranial aneurysms. Angiographic study and endovascular treatment. Interv Neuroradiol 2004; 8:95-106. [PMID: 20594518 DOI: 10.1177/159101990200800201] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2002] [Accepted: 05/09/2002] [Indexed: 11/16/2022] Open
Abstract
SUMMARY We evaluate endovascular treatment (EVT) as an option to deal with multiple intracranial aneurysms(MA). From 1994 to 2001, 24 patients underwent EVT for 59 MA. Patients were followed- up clinically and angiographically in a period ranging from 6 to 93 months (mean time of 22.2) and from 4 to 69 months (mean time of 19.3), respectively. Ten patients (41.6%) were treated either by EVT (n=7, 29,16%) or by mixed treatment (EVT and surgery; n=3, 12.5%). Reasons for treating just ruptured aneurysms: six (25%) had aneurysms smaller than 5 mm; three (12.5%) deaths; two (8.33%) were in the subacute period; two (8.33%) lost to follow-up; one (4.17%) authorised no procedure. No rebleeding was detected at the clinical follow-up, but there were five deaths.At immediate arteriographic control: 28 (85%) aneurysms were fully occluded, four (12%) with neck flow and one (03%) with sac flow. For 20 aneurysms followed-up: stability of occlusion was reached in seven cases (35%) and repermeabilization in 13 (65%). Management of recanalization was close arteriography in seven (54%), re-embolization in five (38%) and surgery in one (08%). When treating MA, EVT is advisable either alone or in mixed therapy. As a high degree of repermeabilization was disclosed, strict arteriographic control is required. The mechanisms underlying aneurysmal formation may be also involved in the recanalization phenomenon , a possible new manifestation of the fragility of the arterial wall.
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Affiliation(s)
- F Mont'alverne
- Interventional Neuroradiology, Centre Hospitalier Louis Pasteur, Colmar; France
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Porter PJ, Mazighi M, Rodesch G, Alvarez H, Aghakhani N, David PH, Lasjaunias P. Endovascular and Surgical Management of Multiple Intradural Aneurysms. Review of 122 Patients Managed between 1993 and 1999. Interv Neuroradiol 2002; 7:291-302. [PMID: 20663361 DOI: 10.1177/159101990100700403] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2001] [Accepted: 10/25/2001] [Indexed: 11/17/2022] Open
Abstract
SUMMARY Patients with multiple intradural aneurysms present unique clinical challenges, particularly when presenting with subarachnoid haemorrhage. This study was undertaken to retrospectively review the management of such patients treated at a single institution. Consecutive patients with multiple intradural aneurysms managed at our institution between 1993 and 1999 were studied. The 122 patients had a total of 305 aneurysms. In most patients presenting with subarachnoid haemorrhage, the aneurysm responsible for the bleed could be identified with a fair degree of certainty, as confirmed by subsequent surgical and autopsy findings. Irregularity of the aneurysm (false sac or polylobulation) was the most useful criterion for making this determination. Failure to recognize all aneurysms on the original angiogram remained an uncommon but clinically important problem. Posterior inferior cerebellar and anterior communicating artery aneurysm locations were disproportionately more likely, and para-ophthalmic less likely, to be responsible for the subarachnoid haemorrhage. There was a trend for patients with uncertainty regarding the site of bleeding to have all aneurysms treated, and for cure to be obtained in a shorter time. Surgical and endovascular complication rates and patient outcomes were not dissimilar from what one would expect for single aneurysm patients. During follow-up, we observed a haemorrhage rate from unruptured aneurysms of 1.1% per patient-year of observation, and a de novo aneurysm formation rate of 0.76% of patients per year. In conclusion, we feel that although patients with multiple intradural aneurysms have more complex management issues than those with single aneurysms, good outcomes can be achieved with appropriate use of endovascular and/or surgical therapy. The goal in the acute setting following subarachnoid haemorrhage is recognition of all aneurysms and urgent treatment of the one responsible for the haemorrhage. When there is uncertainty, more than one aneurysm may need to be treated. Decisions on subsequent treatment of remaining unruptured aneurysms must be individualized.
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Affiliation(s)
- P J Porter
- Service de Neuroradiologie Diagnostic et Thérapeutique, Hôpital de Bicêtre, Le Kremlin Bicêtre, France
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