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Spiral CT Angiography in Diagnosis of Cerebral Aneurysms of Cases With Acute Subarachnoid Hemorrhage

Spiral CT Angiography in Diagnosis of Cerebral Aneurysms of Cases With Acute Subarachnoid Hemorrhage

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77
© Turkish Society of Radiology 2005
Spiral CT angiography in diagnosis of cerebralaneurysms of cases with acute subarachnoidhemorrhage
Ender Uysal, Barış Yanbuloğlu, Mehmet Ertürk, Bekir M. Kılınç, Muzaffer Başak
From the Departments of Radiology (E.U.
*
 
enderuysal@ hotmail.com
, B.Y., M.E., M.B.), and Neurosurgery (B.M.K.), ŞişliEtfal Training and Research Hospital, İstanbul, Turkey.
Received 2 January 2004; rst revision requested 2 June 2004;rst revision received 10 October 2004; second revision requested17 January 2005; second revision received 25 January 2005;accepted 28 January 2005.
M
ortality is high in subarachnoid hemorrhages (SAH) due torupture of aneurysms. Most deaths occur due to the firstbleeding or repetitive bleeding (1, 2). For this reason, fast andaccurate evaluation of the patients is of great importance in planningthe therapeutic interventions. For the time being, selective digital sub-traction angiography (DSA) is used as the standard method in diagnosisand preoperative evaluation of cerebral aneurysms. Although the per-manent neurologic complication risk is low (0.07%-0.5%) in DSA examsperformed in cases with suspected cerebral aneurysms, this method isinvasive, time consuming and expensive (3). DSA has high sensitivityand specificity values in diagnosis of cerebral aneurysms while falsenegative results ranging from 5% to 10% have been reported in theliterature (4). The main reason for this is, not being able to obtain theoptimal projections necessary for diagnosis of some aneurysms due tophysical limitations rather than the insufficiency of spatial resolution of the angiography machine (5). When compared to DSA, spiral CT angi-ography (CTA) is a faster and a more easily applied method. In contrastto another non-invasive imaging method, magnetic resonance angiog-raphy (MRA), spiral CTA enables faster acquisition of three dimensionalimages related to the cerebral vascular anatomy without patient motionartifacts or artifacts due to flow rate. Another advantage of CTA is itsapplicability following routine non-enhanced cranial computed tom-ography (CT) in patients with suspected SAH in emergency conditions.In this study, we aimed to compare the effectiveness of single detectorspiral CTA to DSA in diagnosis and evaluation of intracranial aneurysmsin cases with acute SAH.
Materials and methods
Thirty-two cases who had CTAs and DSAs with suspicion of aneurysmdue to SAH detected by non-enhanced cranial CT between September2002 and May 2004 were included in the study. There were 17 womenand 15 men, ages ranging from 32-75 (mean, 45.5) years. All CTA exami-nations were performed with spiral technique by a single row detectorCT machine (General Electric Hi-Speed, Milwaukee, WI, USA). After de-tection of the location from lateral scanogram, slices parallel to orbito-meatal line were obtained in caudo-cranial direction starting from 1 cmbelow the base of sella turcica up to the level of lateral ventricles. SpiralCTA was obtained with 1 mm collimation, 1.5:1 pitch, 120 kV, 150 mAsand 25 cm field-of-view. Slice reconstruction thickness was 0.5 mm. Onehundred and twenty ml non-ionic iodinated contrast (Iomeron 400,Bracco Diagnostic, Milan, Italy) was administered through a 20 G needlefrom the antecubital vein with a rate of 3 ml/second. Acquisition of im-ages started after 15 seconds and examination lasted for about 40-60 sec-onds. No allergic reaction occurred in any cases. Spiral CTA images were
PURPOSETo investigate the diagnostic accuracy of spiral CT angi-ography (CTA) in detection of cerebral aneurysms in caseswith acute subarachnoid hemorrhage (SAH).MATERIALS AND METHODSSpiral CT angiography and DSA examinations wereperformed in 32 cases due to non-traumatic SAH. CTAdata were obtained by maximum intensity projection(MIP) method. CTA and DSA ndings were evaluatedand compared in terms of existence of aneurysm, sizeand location.RESULTSIn 32 patients, DSA detected 34 aneurysms with di-ameters ranging from 3 to 13 mm while four caseswere free of aneurysms. With CTA, an aneurysm atanterior communicating artery location could not bedemonstrated. In all other cases CTA correlated wellwith DSA in detecting the site, size and orientation of the aneurysms. It was found that CTA sensitivity was97% and specicity was 100% in diagnosis of intrac-ranial aneurysms.CONCLUSIONSpiral CTA is a highly accurate, cheap and non-in-vasive imaging method in diagnosis of intracranialaneurysms in cases with SAH and can be used as a safealternative method to DSA when emergency surgeryis needed.
Key words: • intracranial aneurysm • subarachnoid hemorrhage • tomography, spiral computed 
ORIGINAL ARTICLE
Diagn Interv Radiol 2005; 11:77-82
NEURORADIOLOGY
 
Uysal et al.
78
 
 
June 2005
 
 
Diagnostic and Interventional Radiology
processed from the obtained sourceimages using the maximum intensityprojection (MIP) technique. Minimumthree planes of MIP images in sagittal,coronal and axial planes were obtainedin all cases. Images in different planeswith oblique angles were reconstructedin four cases for better demonstrationof the aneurysm’s neck. Time spent forobtaining CTA images in three planesusing the MIP technique ranged from6 to 8 minutes. Obtained images weretransferred to a workstation where theywere evaluated by two radiologists blind-ed to the DSA findings. They evaluatedimages in “cine” mode using differentdensity levels and formed a commondecision at the end. Evaluation of im-ages took 10-20 minutes. Presence of an aneurysm, location, number, sizeand orientation were detected in MIPimages. Aneurysm size is determined bymeasuring the widest dimension.Cerebral DSA (Philips V 3000, Best,The Netherlands) examination was per-formed in another center outside ourhospital with Seldinger method andpercutaneous femoral catheterization. Atotal of 33 DSA examinations were per-formed with one case having a secondDSA for follow-up. Magnified imageswere obtained besides conventional im-ages in cases with aneurysms. No compli-cations occurred during DSA procedures.DSA images were evaluated by a radiolo-gist uninformed of spiral CTA findings.Student paired t test was used to comparethe sizes of aneurysms demonstrated byDSA and CTA.
Results
With DSA, a total of 34 aneurysms
Figure 1. a-d.
Spiral CTA(
a
, antero-posterior view and
b
,sagittal view) reveals 3-mm sizedanterior communicating arteryaneurysm with antero-inferior orientation
(white arrows)
. DSA(
c
, right CCA antero-posterior view and
d
, right CCA leftposterior oblique view) revealsthis aneurysm to be in the samelocation
(white arrows).
bacd
Figure 2. a, b.
The case thatspiral CTA (
a
, sagittal view)evaluation revealed a negativeresult for aneurysm. An anterior communicating artery aneurysm
(white arrow)
with superior orientation and a narrow neck inDSA examination was shown (
b
,left CCA antero-posterior view).
ba
 
Spiral CT angiography in subarachnoid hemorrhage
 
 
79
Volume 11
 
 
Issue 2
were detected in 28 of the 32 casesinvolved in the study while no aneu-rysm was detected in 4 cases. Of the5 cases in whom multiple aneurysmswere detected, four had two aneu-rysms and one had three aneurysms.Thirteen aneurysms (38%) at anteriorcommunicating artery (Figures 1 and2), 11 (32%) at middle cerebral artery(Figure 3), 6 (17%) at internal carotidartery (Figure 4), 1 (3%) at anteriorcerebral artery, 1 (3%) at posterior cer-ebral artery, 1 (3%) at superior cerebel-lar artery, 1 (3%) at basilar artery weredetected. Smallest aneurysm measured3 mm and largest measured 13 mm(mean, 6.05 mm).A total of 33 aneurysms were de-tected in 28 of 32 cases with CTA.Smallest aneurysm detected with CTAwas 3 mm and largest was 13 mm(mean size, 5.93 mm). There were 18(53%) aneurysms measured between3 to 5 mm while 16 (47%) of themwere larger than 5 mm. When com-pared to DSA, the sensitivity of CTAin diagnosing aneurysms between 3to 5 mm was found to be 94% and100% in aneurysms larger than 5 mm.Only a 4-mm anterior communicatinganeurysm detected at DSA could notbe visualized by CTA (Figure 2). Exceptthis case, all the aneurysms detectedby DSA were detected at the same loca-tions by CTA.Thirty-one of the 34 aneurysms de-tected by DSA were surgically clippedand one was treated by coil emboliza-tion. Two cases died before operation.
Discussion
Based on autopsy and angiographystudies, incidence of intracranial an-eurysms were reported ranging from1% to 7% (6). Eighty percent to 90%of symptomatic intracranial aneu-rysms present with SAH. Due to highmortality and morbidity rates, earlydiagnosis and anatomic characteriza-tion of ruptured aneurysms have avital importance for both surgical andendovascular treatment options. DSAis accepted as the gold standard imag-ing modality in diagnosis and evalua-tion of aneurysms. On the other hand,DSA is a time consuming, expensiveinvasive procedure that may lead tocomplications in 1% and permanentneurologic deficit in 0.5% (7). Re-cently, there has been a search for analternative, non-invasive and quickmethod for diagnosis of intracranialaneurysms. MRA and CTA are amongthese alternative imaging modalities.Performance of spiral CTA is improv-ing with technologic developments inmulti slice CT machines.Depending on different studies inthe literature, it was reported thatthe sensitivity of CTA in diagnosingintracranial aneurysms ranges between67% to 100% and specificity between50% to 100% (8-11). Maximum inten-sity projection (MIP), shaded surfacedisplay (SSD) and volume rendering(VR) are among methods for process-ing the source images obtained atCTA examination. In MIP method,brightest voxels within the inspectedvolume are used to create an image.In MIP, two-dimensional images are
Figure 3. a-c.
Fifty-six year-old male. DSA (
a
, left ICA right posterior oblique view) and spiral CTA (
b
, axial view) images reveal a 7-mmsized left middle cerebral artery aneurysm
a
 , black arrowhead;
b
 ,white arrow)
at bifurcation.
c.
Three dimensional CTA image of the aneurysm obtained with SSD (shaded surface display) method
 (white arrow)
.
bac

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