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Dr. Abhinav Gupta, Dr. Manish Vaish, Dr. S.Mishra, Dr. A.D. Sehgal,

Dr.Rana Patir

Department of Neurosurgery, Sir Ganga Ram Hospital, New Delhi

Acute Aneurysm Surgery With CTAngiography Alone

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Current Literature

CTA of circle of willis is a useful technique for

evaluation of suspected aneurysm in SAH. Alberico et

al: AJNR,1995

CTA can be used in substantial no of patients as

preoperative evaluation techniques for aneurysm

surgery. Velthuis BK et al: Radiology, 1998

CTA in patients with SAH can replace DSA as

preoperative imaging technique for aneurysm detection .

Brigitta et al : J Neurosurg,1999

Spiral CTA in patients of SAH in whom DSA was

negative can reveal additional aneurysms. Hashimoto et

al : J Neurosurg 2000.

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3D-CT angiography can omit DSA in diagnosis andsurgery of acutely ruptured aneurysms and guidedsurgery of acutely ruptured aneurysms. Mastomatsumoto et al: J Neurosurg 2001.

Complementary CTA examination of the

vertebrobasilar complex provides a higher rateofaneurysm detection and improves theopticaldefinition and anatomic projection ofthese

aneurysms, compared with DSA scanning

alone.This facilitates therapeutic decision-making(surgicalversus endovascular procedures) andallows neurosurgeonsto use more restrictedsurgical exposures. Mario N. Carviy Nievas et al:

Neurosurgery 2002

Current Literature

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Why Ct-angio?

Acquisition of multislicer

spiral CT scanner ( light

speed QX/i - GE ,USA)

DSA availability

Authors experience

Current literature

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Object

To assess 3D CT ang iog raphy

prospect ively as the only imaging

modal ity in the management o facu tely rup tured aneurysms

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Patient population

All cases of subarachnoid haemorrage withoutprior imaging other than a plain CT admitted to SirGanga Ram Hospital since Dec 2000 to date

Patients who had come with a prior MRA and/orDSA were excluded

All patients underwent 3D-CT angiography andwere managed according to protocol

All records were maintained and all CT angiographswere preserved on CDs

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DSA

Patients underwent DSA as and when required

and reason for doing DSA was noted

Any new findings in DSA were also noted

Complications if any were recorded

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Subarachnoid hemorrhage

CT angiography

Positive study Negative study

ConservativeSurgery/Intervention

Suspected deterioration

due to vasospasm

DSA

Angioplasty/papaverine infusion

Medical treatment

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Patient population

n=61

0

5

10

15

20

25

20-

29

30-

39

40-

49

50-

59

60-

69

70-

79

Patients

male

female

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Contrast - 100-120 ml (Omnipaque)

Injection Rate - 3.5 ml/sec (Pressure injector)

Mode - Spiral

Slice thickness - 1.25 mm Table speed - 0.63 mm

Pitch - 3.75 mm

Scan orientation - Caudal to cranial

Scan delay - 18 - 20 sec.

KV, mA - 120 KV, 200 mA

FOV - 18 cm

CT angiography proceduremultislicer spiral CT scanner, light speed QX/i - GE

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Post processing

Data is transferred to

Advantage window

where it is processed

into MIP images

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Post processing

Multiplanner

reconstruction is

done

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Post processing

& evaluation of CTA

Finally SSD images

are made and surgical

simulation done

CT Angiograms wereevaluated by 2

radiologists and 2

neurosurgeons

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Surgery

Same team of 2 neurosurgeons operated on all

patient using standard protocols

After surgery they were asked

Any new finding which was not visible on CTA

Correlation with pre-op findings

any difficulty encountered

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Subarachnoid hemorrhage (61)

CT angiography

Conservative

3

Surgery

46

DSA

Positive 51 negative 10

Negative 9Positive 1

Intervention

3

3

1

2

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Results

Total of 67 aneurysms were detected

52 ruptured and 15 unruptured

46 ruptured and 9 unruptured aneurysms wereclipped

10 patients who had negative CT angiogramsunderwent DSA

1 patient who was reported negative on CTA wasfound to have aneurysm on DSA

Smallest aneurysm detected was 2mm on CTA Preoperative evaluation matched with the

surgical findings

6 patients underwent DSA for clinical

deterioration related to vasospasm

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Table-1

DISTRIBUTION OF CEREBRAL ANEURYSMS IN

CONSECUTIVE PATIENTS

Site & Size Ruptured Unruptured Total

SITE

ICA 08 07 15

ICA - PCoA 03 01 04

ACoA 19 03 22

Distal ACA 05 00 05

MCA 16 03 19

PCA 01 01 02BA tip 00 00 00

_________________________________________________________

Total 52 15 67

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Table-2

DISTRIBUTION OF CEREBRAL ANEURYSMS WHICH WERE

CLIPPED

Site & Size Ruptured Unruptured

SITE

ICA 06 04ICA - PCoA 02 00

ACoA 19 03

Distal ACA 04 00

MCA 14 02

PCA 01 00BA tip 00 00

____________________________________________________

Total 46 09

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Multiple aneurysms

No of aneurysm No of patients

6 1

3 2

2 6 Multiple aneurysms were picked up in 9/52

(17.5%)

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Giant aneurysms

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Which side to go in midline

aneurysms?

22 Acom aneurysms weredetected

19 of which were rupturedwere clipped on basis of

CTA alone. Laterality was judged on

viewing the location ofhaematoma on plain CT,the base, MIP, reformattedand SSD images.

It was never felt that theaneurysm was approachedfrom the wrong side

I

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WFNS Glasgow outcome scale

GRADE n Good Moderate Severe disability Death

I 21 17 02 00 02II 17 13 03 01 00

III 11 06 02 01 02

IV 05 01 02 01 01

V 07 01 00 01 05 (2+3)_____________________________________________________TOTAL 61 38 9 04 10(7+3)

Comparison of condition at

admission with outcome

Ad t f 3D CT

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Advantages of 3D CT

angiography

Reliable and quick

Minimally invasive

Less dosage of radiation

Cost half of DSA

Better co-relative anatomy

Rotation of images thereby better orientation

better neck definition Information about calcification and thrombus

Surgical simulation

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Limitation of 3D CT

angiography

Vessels smaller than 1 mm

not visualized

Both arteries and veins

visualized simultaneously

Does not supply dynamic

information on cerebral

circulation

Operator dependence

Quality of checkangiogram inadequate due

to clip artifacts

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Limitation of 3D CT

angiography

Vessels smaller than 1 mm

not visualized

Both arteries and veins

visualized simultaneously

Does not supply dynamic

information on cerebral

circulation

Operator dependence

Quality of checkangiogram inadequate due

to clip artifacts

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Limitation of 3D CT

angiography

Vessels smaller than 1 mm

not visualized

Both arteries and veins

visualized simultaneously

Does not supply dynamic

information on cerebral

circulation

Operator dependence

Quality of checkangiogram inadequate due

to clip artifacts

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Limitation of 3D CT

angiography

Vessels smaller than 1 mm not visualized

Both arteries and veins visualized

simultaneously Does not supply dynamic information on

cerebral circulation

Operator dependence

Quality of check angiogram inadequate

due to clip artifacts

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Check angiogram

Check angiogram wasperformed only when therewas doubt regardingadequacy of clipping.

Clipping was consideredadequate if the localanatomy was definedpreserving all vessels, noresidual neck was seenand deliberate rupture of

the fundus either bycutting it or puncturingwith a needle deflated theaneurysm.

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Recommendation for doing DSA

While the only indication for doing a DSA in thepresent study was a negative CTA, in retrospectwe agree with existing literature that it should bedone in:

In giant aneurysms to evaluate for bypasssurgery

Patients in whom cerebral infarction is seen onCT

Aneurysms close to bone ie., carotid-opthalmicaneurysms.

Patients with dissecting aneurysms

In patients with descrepancy in SAH pattern andlocation of aneurysm.

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Conclusions

Using high quality 3D-CT angiography

images, surgery can be performed in

acutely ruptured aneurysms.

CTA has high degree of detection of

multiple aneurysm.

Laterality can be accessed.

better morphological deliniation in

presence of haematoma , tumor or any

other nearby lesion.

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Thank you