Acute Aneurysm Surgery With CT Angiography Alone

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

History

Charter Whetstone (1830) : Concept of 3D images Egas Moinz: Angiograpy (1927) Cornelius& Vigot: 3D Angiography (1975) Akoi S ,Machida,et al: 3D CT Angiography for cerebral aneurysms (1992)

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.

Current Literature

3D-CT angiography can omit DSA in diagnosis and surgery of acutely ruptured aneurysms and guided surgery of acutely ruptured aneurysms. Masto matsumoto et al: J Neurosurg 2001. Complementary CTA examination of the vertebrobasilar complex provides a higher rate of aneurysm detection and improves the optical definition and anatomic projection of these aneurysms, compared with DSA scanning alone. This facilitates therapeutic decision-making (surgical versus endovascular procedures) and allows neurosurgeons to use more restricted surgical exposures. Mario N. Carvi y Nievas et al: Neurosurgery 2002

Why Ct-angio?

Acquisition of multislicer spiral CT scanner ( light speed QX/i - GE ,USA)

DSA availability Authors experience Current literature

Object

To assess 3D CT angiography prospectively as the only imaging modality in the management of acutely ruptured aneurysms

Patient population

All cases of subarachnoid haemorrage without prior imaging other than a plain CT admitted to Sir Ganga Ram Hospital since Dec 2000 to date Patients who had come with a prior MRA and/or DSA were excluded All patients underwent 3D-CT angiography and were managed according to protocol All records were maintained and all CT angiographs were preserved on CDs

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

Subarachnoid hemorrhage
CT angiography

Positive study

Negative study DSA

Surgery/Intervention

Conservative

Suspected deterioration due to vasospasm

Medical treatment

Angioplasty/papaverine infusion

Patient population n=61

25 20 15 10 5 0 20- 3029 39 4049 5059 6069 7079 Patients male female

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

Contrast Injection Rate Mode Slice thickness Table speed Pitch Scan orientation Scan delay KV, mA FOV

- 100-120 ml (Omnipaque) - 3.5 ml/sec (Pressure injector) - Spiral - 1.25 mm - 0.63 mm - 3.75 mm - Caudal to cranial - 18 - 20 sec. - 120 KV, 200 mA - 18 cm

Post processing

Data is transferred to Advantage window where it is processed into MIP images

Post processing

Multiplanner reconstruction is done

Post processing & evaluation of CTA

Finally SSD images are made and surgical simulation done CT Angiograms were evaluated by 2 radiologists and 2 neurosurgeons

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

Subarachnoid hemorrhage (61)

Positive 51 CT angiography negative 10

DSA 3
2

Positive 1

Negative 9

1
Surgery 46 Intervention 3 Conservative 3

Results

Total of 67 aneurysms were detected 52 ruptured and 15 unruptured 46 ruptured and 9 unruptured aneurysms were clipped 10 patients who had negative CT angiograms underwent DSA 1 patient who was reported negative on CTA was found 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

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 02 BA tip 00 00 00 _________________________________________________________ Total 52 15 67

Table-2
DISTRIBUTION OF CEREBRAL ANEURYSMS WHICH WERE CLIPPED
Site & Size Ruptured Unruptured SITE ICA 06 04 ICA - PCoA 02 00 ACoA 19 03 Distal ACA 04 00 MCA 14 02 PCA 01 00 BA tip 00 00 ____________________________________________________ Total 46 09

Multiple aneurysms

No of aneurysm No of patients 6 1 3 2 2 6 Multiple aneurysms were picked up in 9/52 (17.5%)

Giant aneurysms

Which side to go in midline aneurysms?

22 Acom aneurysms were detected 19 of which were ruptured were clipped on basis of CTA alone. Laterality was judged on viewing the location of haematoma on plain CT, the base, MIP, reformatted and SSD images. It was never felt that the aneurysm was approached from the wrong side

Comparison of condition at admission with outcome

WFNS
GRADE n

Glasgow outcome scale

Good Moderate Severe disability Death

I 21 17 02 00 02 II 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)

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

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

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

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

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

Check angiogram

Check angiogram was performed only when there was doubt regarding adequacy of clipping. Clipping was considered adequate if the local anatomy was defined preserving all vessels, no residual neck was seen and deliberate rupture of the fundus either by cutting it or puncturing with a needle deflated the aneurysm.

Recommendation for doing DSA

While the only indication for doing a DSA in the present study was a negative CTA, in retrospect we agree with existing literature that it should be done in: In giant aneurysms to evaluate for bypass surgery Patients in whom cerebral infarction is seen on CT Aneurysms close to bone ie., carotid-opthalmic aneurysms. Patients with dissecting aneurysms In patients with descrepancy in SAH pattern and location of aneurysm.

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.

Thank you