1、 Currentusageofthree-dimensionalcomputedtomographyangiographyforthediagnosisandtreatmentofrupturedcerebralaneurysmsKenichiAmagasakiMD,NobuyasuTakeuchiMD,TakashiSatoMD,ToshiyukiKakizawaMD,TsuneoShimizuMDKantoNeurosurgicalHospital,Kumagaya,Saitama,JapanSummaryOurpreviousstudysuggestedthat3D-CTangiogra

2、phycouldreplacedigitalsubtraction(DS)angiographyinmostcasesofrupturedcerebralaneurysms,especiallyintheanteriorcirculation.Thisstudyreviewedourfurtherexperience.OnehundredandfiftypatientswithrupturedcerebralaneurysmsweretreatedbetweenNovember1998andMarch20XX.Only3D-CTangiographywasusedforthepreoperat

3、ivework-upstudyinpatientswithanteriorcirculationaneurysms,unlesstheattendingneurosurgeonsagreedthatDSangiographywasrequired.Both3D-CTangiographyandDSangiographywereperformedinpatientswithposteriorcirculationaneurysms,exceptforrecentcasesthatwerepossiblytreatedwith3D-CTangiographyalone.Onehundredsixt

4、een(84%)of138patientswithrupturedanteriorcirculationaneurysmsunderwentsurgicaltreatment,butadditionalDSangiographywasrequiredin22cases(16%).Onlytworecentpatientsweretreatedsurgicallywith3D-CTangiographyalonein12patientswithposteriorcirculationaneurysms.Mostpatientswithrupturedanteriorcirculationaneu

5、rysmscouldbetreatedsuccessfullyafter3D-CTangiographyalone.However,additionalDSangiographyisstillnecessaryinatypicalcases.3D-CTangiographymaybelimitedtocomplementaryuseinpatientswithrupturedposteriorcirculationaneurysms.a20XXElsevierLtd.Allrightsreserved.Keywords:3D-CTangiography,cerebralaneurysm,sub

6、arachnoidhaemorrhage,surgeryINTRODUCTIONRecently,three-dimensionalcomputedtomography(3D-CT)angiographyhasbecomeoneofthemajortoolsfortheidentificationofcerebralaneurysmsbecauseitisfaster,lessinvasive,andmoreconvenientthancerebralangiography.17Patientswithrupturedaneurysmscouldbetreatedunderdiagnosesb

7、asedononly3D-CTangiography.5;63D-CTangiographyhassomelimitationsforthepreoperativework-upforrupturedcerebralaneurysms,1 soadditionaldigitalsubtraction(DS)angiographyisstillnecessary,especiallyforaneurysmsintheposteriorcirculation.8Ourpreviousstudysuggestedthat3D-CTangiographycouldreplaceDSangiograph

8、yinmostpatientswithrupturedcerebralaneurysmsintheanteriorcirculation.1Thisstudyreviewedourexperienceoftreatingrupturedcerebralaneurysmsintheanteriorandposteriorcirculationsbasedon3D-CTangiographyin150consecutivepatientstoassessthecurrentusageof3D-CTangiography.METHODSANDMATERIALPatientpopulationWetr

9、eated150patients,60menand90womenagedfrom23to80years(mean57.5years),withrupturedcerebralaneurysmidentifiedby3D-CTangiographybetweenNovember1998andMarch20XX.ManagementofcasesThepresenceofnontraumaticsubarachnoidhaemorrhage(SAH)wasconfirmedbyCTorlumbarpuncturefindingsofxanthochromiccerebrospinalfluid.3

10、D-CTangiographywasperformedroutinelyinallpatients.DSangiographywasperformedinpatientswithanteriorcirculationaneurysmsonlyifadditionalinformationwasconsiderednecessaryfollowingaconsensusinterpretationoftheinitialCTand3D-CTangiographybyfourneurosurgeons.Patientswithrupturedaneurysmsintheposteriorcircu

11、lationunderwentboth3D-CTangiographyandDSangiographyexceptfortworecentpatientswithtypicalvertebralarteryposteriorinferiorcerebellarartery(VA-PICA)aneurysm.Typicalsaccularaneurysmsweretreatedbyclippingsurgery.Fusiformanddissectinganeurysmsweretreatedbyproximalocclusionbyeithersurgeryorendovasculartrea

12、tmentwithorwithoutbypasssurgery.Regrowthofbleedinganeurysmswastreatedbyeithersurgeryorendovasculartreatment.Postoperatively,allpatientsweremanagedwithaggressivepreventionandtreatmentofvasospasmincludingintra-arterialinfusionofpapaverineortransluminalangioplasty.3D-CTangiographyacquisitionandpostproc

13、essingCTangiographywasperformedwithaspiralCTscanner(CT-W3000AD;Hitachi,Ibaraki,Japan).Acquisitionusedastandardtechniquestartingattheforamenmagnum,withinjectionof130mlofnonioniccontrastmaterial(Omnipaque;DaiichiPharmaceutical,Tokyo,Japan).Thesourceimagesofeachscanweretransferredtoanoff-linecomputerwo

14、rkstation(VIPsta2 tion;TeijinSystemTechnology,Japan).Bothvolume-renderedimagesandmaximumintensityprojectionimagesofthecerebralarterieswereconstructed.Theanteriorcirculationandposteriorcirculationwereevaluatedseparatelyonthevolume-renderedimages,afterageneralsuperiorviewwasobtained.Theanteriorcircula

15、tionwasevaluatedbyfirstobservingtheanteriorcommunicatingartery(ACoA)byrotatingtheview,andtheneachsideofthecarotidsystembyrotatingtheimagewitheditingoutofthecontralateralcarotidartery.Theposteriorcirculationwasalsoevaluatedbyrotatingtheimagebutwithouteditingoutofanyvessel.Onceapossiblerupturesitewasf

16、ound,theviewwaszoomedandcloselyrotatedwiththeothervesselseditedout.Theaneurysmsizewasmeasuredon3D-CTangiographyasthelargerofthelengthofthedomeorthewidthoftheneck.Manipulationwasperformedbythescannertechnician,withaneurosurgeontoprovideeditingassistance.DSangiographyacquisitionStandardselectivethree-

17、orfour-vesselDSangiogramswithfrontal,lateral,andobliqueprojectionswereobtained.The3D-CTangiogramwasalwaysavailableasaguideforpossibleadditionalDSangiographyprojections.AneurysmsizewasmeasuredwithDSangiographywhenthequalityof3D-CTangiographywasinadequate.Allpatientsexceptelderlypatientsorpatientsinse

18、vereconditionunderwentDSangiographypostoperatively.GradingofpatientsTheclinicalconditionsofthepatientsatadmissionwereclassifiedaccordingtotheHuntandKosnikgrade.9Clinicaloutcomewasdeterminedat3monthsaccordingtotheGlasgowOutcomeScale.10RESULTSTheaneurysmlocationsandsizesareshowninTable1.Onehundredsixt

19、een(84%)of138casesofaneurysmsintheanteriorcirculationweretreatedafteronly3D-CTangiography,and22cases(16%)requiredadditionalDSangiography.Tenof12casesofaneurysmsintheposteriorcirculationrequiredboth3D-CTangiographyandDSangiography,buttworecentcasesoftypicalVA-PICAaneurysmwereclippedafteronly3D-CTangi

20、ography(Fig.1).Thefirst10ofthe22casesintheanteriorcirculation,whichrequiredadditionalDSangiographyweredescribedpreviously,1sothemostrecent12patientsarelistedinTable2.Theser3 ecentcasesincludedsomeatypicalaneurysms.Cases6and8hadafusiformaneurysmoftheinternalcarotidartery(ICA).AdditionalDSangiographyw

21、asperformedtoobtainhaemodynamicinformation.ICAtrappingwithsuperficialtemporalartery-middlecerebralarteryanastomosiswasperformedinCase6becausetheatheroscleroticarteriesfailedtodemonstratetheballoonocclusiontest(Fig.2).ICAocclusionbyendovasculartreatmentwasperformedinCase8becausethepatientcouldtolerat

22、etheballoonocclusiontest.Cases4,9,and10sufferedregrowthofbleedinganeurysmsafterclippingsurgery.Clipartifactspreventedevaluationoftherupturedsiteaswellasidentificationofdenovoaneurysmsinthesecases(Fig.3).SurgicalclippingwasperformedinCases4and10andendovasculartreatmentinCase9.Case11hadanACoAaneurysma

23、ssociatedwithanarteriovenousmalformation(AVM)(Fig.4).DSangiographywasperformedtoevaluatetheAVM.Case12hadalargeICA-posteriorcommunicatingartery(PCoA)aneurysm,andadditionalDSangiographywasperformedbecausethePCoAcouldnotbedetectedby3D-CTangiography(Fig.5).Cases1,2,3,5,and7presentedwithsmallaneurysms,an

24、dDSangiographywasperformedtoexcludeotherlesionsaswellastoobtaininformationabouttheproximalICAforpatientswithsupraclinoidtypeaneurysms.Table1Distributionandsizeofcerebralaneurysmsin150consecutivepatientsSiteNo.ofpatientsAnteriorcirculationICA(supraclinoid)ICAbifurcation 11383ICA-OphAICA-PCoAICAfusifo

25、rmACoA339(1)250DistalACAMCA436(1)Posteriorcirculation123PCA1BAtipBA-SCABAtrunkVA-PICA11(1)34 VAdissectingSize(mm)53(1)94299P5to12P12Numberinparenthesesindicatespatientswhounderwentendovasculartreatment.OphA,ophthalmicartery;ACA,anteriorcerebralartery;MCA,middlecerebralartery;PCA,posteriorcerebralartery;BA,basilarartery;SCA,superiorcerebellarartery.Table2Twelvepatientswithrupturedanteriorcirculationaneurysmswhounderwentaddi