Use of CT angiography and digital subtraction angiography in patients with ruptured cerebral aneurysm: evaluation of a large multihospital data base

RAPID aneurysm accurately measures aneurysm size on CT angiography compared to three-dimensional digital subtraction angiography

BACKGROUND

Cerebral aneurysms are often identified and characterized on non-invasive CT Angiography (CTA) images, but digital subtraction angiography (DSA) is the gold standard for aneurysm evaluation.

OBJECTIVE

We compared cerebral aneurysm size measurements as measured from CTA processed by a semi-automated artificial intelligence software program (RAPID Aneurysm) and three-dimensional rotational DSA (3D-DSA).

METHODS

We performed a retrospective cohort study of consecutive patients with a cerebral aneurysm who underwent CTA and DSA with 3D reformations. CTA images were processed by RAPID Aneurysm to determine aneurysm height, width, and neck width. The reference standard was aneurysm measurements on 3D-DSA as measured by two neurointerventionalists. Both readers were blinded to RAPID Aneurysm measurements. Correlation and bias between these measurements were determined.

RESULTS

Results from 50 patients with 50 aneurysms were compared. 32 patients (64%) were female. Median age was 65 (IQR: 56.25-71.75). 37 patients (74%) presented with ruptured aneurysms. The aneurysms represented a range of aneurysm sizes (1.9-33.3 mm; IQR 3.6-7.2 mm). RAPID Aneurysm size measurements showed excellent correlation and low bias (correlation, mean difference) when compared to the reference standard for aneurysm height (0.98, -0.9 mm), width (0.98, 0.1 mm), and neck width (0.94, 1.1 mm). The inter-reader comparison between the two neurointerventionalists was similarly excellent for aneurysm height (0.97, -0.4 mm), width (0.98, -0.2 mm), and neck width (0.89, 0.8 mm).

CONCLUSION

RAPID Aneurysm measurement of cerebral aneurysm height, width, and neck width on CTA is strongly correlated to expert neurointerventionalist measurements on 3D-DSA.

Intracranial varix of the transverse-sigmoid dural arteriovenous fistula mimicking a ruptured middle cerebral artery aneurysm: A case report

Background:

Hemorrhagic stroke is caused by various vascular abnormalities, such as aneurysms, arteriovenous malformations, and dural arteriovenous fistulas (DAVF). Magnetic resonance angiography (MRA) and three-dimensional computed tomography angiography (3DCTA) are used as efficient initial diagnostic modalities in assessing the etiology of hemorrhagic stroke. We describe the unusual case of a false-positive aneurysm on MRA and 3DCTA.

Case Description:

A 65-year-old nonhypertensive woman was brought to our hospital with a sudden onset of headache and left hemiparesis. She also had chemosis in the right eye. CT and magnetic resonance imaging showed an intracerebral hemorrhage in the right temporal lobe. MRA and 3DCTA showed a rounded mass suggestive of an aneurysm arising from the bifurcation of the middle cerebral artery (MCA) and also demonstrated an abnormal tortuous vessel contacting with a rounded mass. Digital subtraction angiography showed a transversesigmoid sinus DAVF with a varix in contact with the MCA bifurcation. Hematoma evacuation and venous drainage disconnection through the right frontotemporal craniotomy were performed.

Conclusion:

This case is very instructive and clinicians should keep in mind that detailed neurological and radiological examinations are essential in obtaining an accurate diagnosis, especially if the bleeding source is similar in shape and location to common lesions (such as a cerebral aneurysm).

Vascular Lesions of the Pineal Region: A Comprehensive Review of the Therapeutic Options

OBJECTIVE

Vascular lesions of the pineal region comprise aneurysms of the pineal region, arteriovenous malformations, cavernous malformations, and vein of Galen malformations. In the present report, we have offered an extensive review of each vascular pineal region lesion.

METHODS

We performed an extensive literature review, focusing on the current therapeutic options available for the different vascular lesions of the pineal region.

RESULTS

Vascular lesions of the pineal region are rare. Microneurosurgery remains a valid treatment of cavernomas, arteriovenous malformations, and aneurysms. Endovascular treatments seem to be the first option for the vein of Galen malformations, followed by microneurosurgery. Radiosurgery seems beneficial for small-size arteriovenous malformations. Complex and large vascular lesions will require a combination of multiple treatments.

CONCLUSIONS

Vascular lesions of the pineal region are complex, uncommon diseases. Thus, definitive therapeutic modalities for these lesions require further research.

Radiological investigations in non-aneurysmal subarachnoid haemorrhage: A 5-year review

•

All patients with a Fisher grade 2 bleed and a negative CT angiogram had catheter angiography negative for any abnormality.

•

Neuroradiologists identified vascular abnormalities not reported by district general hospitals.

•

Follow-up MRI may be a useful adjunct in subarachnoid haemorrhage.

Digital Subtraction Angiography for CT Angiogram Negative Haemorrhages

BACKGROUND

In patients with subarachnoid haemorrhage (SAH) and a negative finding on CT angiography (CTA), further imaging with digital subtraction angiography (DSA) is commonly performed to identify the source of bleeding. The purpose of this study was to investigate whether negative findings on CTA can reliably exclude aneurysms in patients with acute SAH.

METHODS

This retrospective study identified all DSAs performed between August 2010 and July 2014 within our institution. CT angiography was performed with a 64-section multidetector row CT scanner. Only DSAs from patients with confirmed SAH and a negative CTA result were included in the final analyses. A fellowship-trained neuroradiologist reviewed the imaging results.

RESULTS

Of the 857 DSAs, 50 (5.83%) were performed in 35 patients with CTA-negative SAH. Of the 35 patients, three (8.57%) had positive findings on the DSA. In one patient, suspicious dissection of the extra- and intra-cranial segment of the right vertebral artery could not be confirmed even in retrospect. In the second patient, the suspicious finding of tiny protuberance from the left paraclinoid internal carotid artery (ICA) on DSA did not change on follow-up and did not change patient's management. The third patient had a posterior inferior cerebellar artery aneurysm, which was not seen on the initial CTA owing to the incomplete coverage of the head on the CTA.

CONCLUSION

In patients with SAH, negative findings on a technically sound CTA are reliable in ruling out aneurysms in any pattern of SAH or no blood on CT. Our observations need to be confirmed with larger prospective studies.

A Multicenter Analysis of Computed Tomography Angiography Alone Versus Digital Subtraction Angiography for the Surgical Treatment of Poor-Grade Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased intracranial pressure, and these patients are unstable with a high risk of rebleeding. Computed tomography angiography (CTA) has been proposed as an examination tool for the rapid detection of ruptured aneurysms. We aimed to determine the safety and efficacy of CTA alone for surgical treatment of poor-grade aSAH compared with digital subtraction angiography (DSA).

METHODS

We conducted a multicenter retrospective analysis of 144 patients with poor-grade aSAH who underwent surgical treatment for 2 different cohorts. Patients were grouped into CTA alone and DSA groups. Baseline characteristics, postoperative complications, and clinical outcomes at discharge and at last follow-up were compared between the 2 groups. Multivariate logistic regression models were used to assess the association between CTA alone and clinical outcomes after we adjusted for potential confounders.

RESULTS

Of the 116 patients included, 42 (36.2%) patents received CTA alone and 74 patients (63.7%), including 12 patients with CTA and DSA and 62 patients with DSA alone, received DSA before surgical treatment. Patients with larger ruptured aneurysms (P = 0.006), aneurysm sizes of larger than 5 mm (P = 0.025), presence of single aneurysms (P = 0.018), and presence of intraventricular hemorrhage (P = 0.019) more often received CTA alone. All ruptured aneurysms were clipped successfully during surgery. There were no statistically significant differences in postoperative complications and clinical outcomes between the 2 groups.

CONCLUSIONS

Although CTA alone can be safely and effectively used in most patients requiring surgical treatment, additional DSA may be considered in patients with smaller ruptured aneurysms or in those with multiple aneurysms.

Detection and characterization of intracranial aneurysms: a 10-year multidetector CT angiography experience in a large center

BACKGROUND

CT angiography (CTA) is increasingly used for the detection, characterization, and follow-up of intracranial aneurysms. A lower threshold to request a CT angiogram may render a patient population that differs from previous studies primarily evaluated with conventional angiography. Our objective was to broaden our knowledge of the factors associated with aneurysm rupture and patient mortality in this population.

METHODS

All CTA studies performed over a 10-year period at a large neurovascular referral center were reviewed for the presence of an intracranial aneurysm. Patient demographics, mortality, CTA indication, aneurysm location, size, and rupture status were recorded.

RESULTS

2927 patients with aneurysms were identified among 29 003 CTAs. 17% of the aneurysms were ruptured at the time of imaging, 24% of aneurysms were incidentally identified, and multiple aneurysms were identified in 34% of patients. Aneurysms most commonly arose from the supraclinoid internal carotid artery (22%), the middle cerebral artery (18%), and the anterior communicating artery (13%). Male sex, age <50 years, aneurysms >6 mm, and aneurysms arising from the anterior communicating artery, posterior communicating artery, or the posterior circulation were independent predictors of aneurysm rupture. Independent mortality predictors included male sex, posterior circulation aneurysms, intraventricular hemorrhage, and intraparenchymal hemorrhage.

CONCLUSIONS

These results indicate that aneurysms detected on CTA that arise from the anterior communicating artery, posterior communicating artery, or the posterior circulation, measure >6 mm in size, occur in men, and in patients aged <50 years are associated with rupture.