Currentusageofthree-dimensionalcomputedtomographyan giographyforthediagnosisandtreatmentofrupturedcereb ralaneurysmsKenichiAmagasakiMD,NobuyasuTakeuchiMD,TakashiSatoMD,Toshiyu kiKakizawaMD,TsuneoShimizuMDKantoNeurosurgicalHospital,Kuma gaya,Saitama,JapanSummaryOurpreviousstudysuggestedthat3D-CTangiographycou ldreplacedigitalsubtraction(DS)angiographyinmostcasesofrupt uredcerebralaneurysms,especiallyintheanteriorcirculation.Th isstudyreviewedourfurtherexperience.Onehundredandfiftypatie ntswithrupturedcerebralaneurysmsweretreatedbetweenNovember1 998andMarch20XX.Only3D-CTangiographywasusedforthepreoperati vework-upstudyinpatientswithanteriorcirculationaneurysms,un lesstheattendingneurosurgeonsagreedthatDSangiographywasrequ ired.Both3D-CTangiographyandDSangiographywereperformedinpati entswithposteriorcirculationaneurysms,exceptforrecentcasest hatwerepossiblytreatedwith3D-CTangiographyalone.Onehundreds ixteen(84%)of138patientswithrupturedanteriorcirculationaneu rysmsunderwentsurgicaltreatment,butadditionalDSangiographyw asrequiredin22cases(16%).Onlytworecentpatientsweretreatedsu rgicallywith3D-CTangiographyalonein12patientswithposteriorc irculationaneurysms.Mostpatientswithrupturedanteriorcircula tionaneurysmscouldbetreatedsuccessfullyafter3D-CTangiograph yalone.However,additionalDSangiographyisstillnecessaryinaty picalcases.3D-CTangiographymaybelimitedtocomplementaryusein patientswithrupturedposteriorcirculationaneurysms.a20XXElsevierLtd.Allrightsreserved.Keywords:3D-CTangiography,cerebralaneurysm,subarachnoidhaem orrhage,surgeryINTRODUCTIONRecently,three-dimensionalcomputedtomography(3D-CT)angiogra phyhasbecomeoneofthemajortoolsfortheidentificationofcerebra laneurysmsbecauseitisfaster,lessinvasive,andmoreconvenientt hancerebralangiography.1–7Patientswithrupturedaneurysmscouldbetreatedunderdiagnosesb asedononly3D-CTangiography.5;63D-CTangiographyhassomelimita tionsforthepreoperativework-upforrupturedcerebralaneurysms,soadditionaldigitalsubtraction(DS)angiographyisstillnecessa ry,especiallyforaneurysmsintheposteriorcirculation.8Ourprev iousstudysuggestedthat3D-CTangiographycouldreplaceDSangiogr aphyinmostpatientswithrupturedcerebralaneurysmsintheanterio rcirculation.1Thisstudyreviewedourexperienceoftreatingruptu redcerebralaneurysmsintheanteriorandposteriorcirculationsba sedon3D-CTangiographyin150consecutivepatientstoassessthecur rentusageof3D-CTangiography.METHODSANDMATERIALPatientpopulationWetreated150patients,60menand90womenagedfrom23to80years(mea n57.5years),withrupturedcerebralaneurysmidentifiedby3D-CTan giographybetweenNovember1998andMarch20XX. Managementofcases Thepresenceofnontraumaticsubarachnoidhaemorrhage(SAH)wascon firmedbyCTorlumbarpuncturefindingsofxanthochromiccerebrospi nalfluid.3D-CTangiographywasperformedroutinelyinallpatients .DSangiographywasperformedinpatientswithanteriorcirculation aneurysmsonlyifadditionalinformationwasconsiderednecessaryf ollowingaconsensusinterpretationoftheinitialCTand3D-CTangio graphybyfourneurosurgeons.Patientswithrupturedaneurysmsinth eposteriorcirculationunderwentboth3D-CTangiographyandDSangi ographyexceptfortworecentpatientswithtypicalvertebralartery posteriorinferiorcerebellarartery(VA-PICA)aneurysm. Typicalsaccularaneurysmsweretreatedbyclippingsurgery. Fusiformanddissectinganeurysmsweretreatedbyproximalocclusio nbyeithersurgeryorendovasculartreatmentwithorwithoutbypasss urgery.Regrowthofbleedinganeurysmswastreatedbyeithersurgery orendovasculartreatment.Postoperatively,allpatientsweremana gedwithaggressivepreventionandtreatmentofvasospasmincluding intra-arterialinfusionofpapaverineortransluminalangioplasty .3D-CTangiographyacquisitionandpostprocessingCTangiographywa sperformedwithaspiralCTscanner(CT-W3000AD;Hitachi,Ibaraki,J apan).Acquisitionusedastandardtechniquestartingattheforamen magnum,withinjectionof130mlofnonioniccontrastmaterial(Omnip aque;DaiichiPharmaceutical,Tokyo,Japan).Thesourceimagesofea chscanweretransferredtoanoff-linecomputerworkstation(VIPstation;TeijinSystemTechnology,Japan).Bothvolume-renderedimage sandmaximumintensityprojectionimagesofthecerebralarterieswe reconstructed.Theanteriorcirculationandposteriorcirculation wereevaluatedseparatelyonthevolume-renderedimages,afteragen eralsuperiorviewwasobtained.Theanteriorcirculationwasevalua tedbyfirstobservingtheanteriorcommunicatingartery(ACoA)byro tatingtheview,andtheneachsideofthecarotidsystembyrotatingth eimagewitheditingoutofthecontralateralcarotidartery.Thepost eriorcirculationwasalsoevaluatedbyrotatingtheimagebutwithou teditingoutofanyvessel.Onceapossiblerupturesitewasfound,the viewwaszoomedandcloselyrotatedwiththeothervesselseditedout. Theaneurysmsizewasmeasuredon3D-CTangiographyasthelargerofth elengthofthedomeorthewidthoftheneck.Manipulationwasperforme dbythescannertechnician,withaneurosurgeontoprovideeditingas sistance.DSangiographyacquisitionStandardselectivethree-orfour-vesselDSangiogramswithfrontal ,lateral,andobliqueprojectionswereobtained.The3D-CTangiogra mwasalwaysavailableasaguideforpossibleadditionalDSangiograp hyprojections.AneurysmsizewasmeasuredwithDSangiographywhent hequalityof3D-CTangiographywasinadequate.Allpatientsexcepte lderlypatientsorpatientsinsevereconditionunderwentDSangiogr aphypostoperatively.Gradingofpatients Theclinicalconditionsofthepatientsatadmissionwereclassified accordingtotheHuntandKosnikgrade.9Clinicaloutcomewasdetermi nedat3monthsaccordingtotheGlasgowOutcomeScale.10RESULTSTheaneurysmlocationsandsizesareshowninTable1.Onehundredsixt een(84%)of138casesofaneurysmsintheanteriorcirculationweretr eatedafteronly3D-CTangiography,and22cases(16%)requiredaddit ionalDSangiography.Tenof12casesofaneurysmsintheposteriorcir culationrequiredboth3D-CTangiographyandDSangiography,buttwo recentcasesoftypicalVA-PICAaneurysmwereclippedafteronly3D-C Tangiography(Fig.1).Thefirst10ofthe22casesintheanteriorcirc ulation,whichrequiredadditionalDSangiographyweredescribedpr eviously,1sothemostrecent12patientsarelistedinTable2.Theserecentcasesincludedsomeatypicalaneurysms.Cases6and8hadafusif ormaneurysmoftheinternalcarotidartery(ICA).AdditionalDSangi ographywasperformedtoobtainhaemodynamicinformation.ICAtrapp ingwithsuperficialtemporalartery-middlecerebralarteryanasto mosiswasperformedinCase6becausetheatheroscleroticarteriesfa iledtodemonstratetheballoonocclusiontest(Fig.2).ICAocclusio nbyendovasculartreatmentwasperformedinCase8becausethepatien tcouldtoleratetheballoonocclusiontest.Cases4,9,and10suffere dregrowthofbleedinganeurysmsafterclippingsurgery.Clipartifa ctspreventedevaluationoftherupturedsiteaswellasidentificati onofdenovoaneurysmsinthesecases(Fig.3).Surgicalclippingwasp erformedinCases4and10andendovasculartreatmentinCase9.Case11 hadanACoAaneurysmassociatedwithanarteriovenousmalformation( AVM)(Fig.4).DSangiographywasperformedtoevaluatetheAVM.Case1 2hadalargeICA-posteriorcommunicatingartery(PCoA)aneurysm,an dadditionalDSangiographywasperformedbecausethePCoAcouldnotb edetectedby3D-CTangiography(Fig.5).Cases1,2,3,5,and7present edwithsmallaneurysms,andDSangiographywasperformedtoexcludeo therlesionsaswellastoobtaininformationabouttheproximalICAfo rpatientswithsupraclinoidtypeaneurysms.Table1Distributionandsizeofcerebralaneurysmsin150consecutiv epatientsSiteNo.ofpatientsAnteriorcirculation 138ICA(supraclinoid) 3ICAbifurcation 1ICA-OphA 3ICA-PCoA 39(1)ICAfusiform 2ACoA 50DistalACA 4MCA 36(1) Posteriorcirculation 12PCA 1BAtip 3BA-SCA 1BAtrunk 1(1)VA-PICA 3VAdissecting 3(1)Size(mm)<5 42P5to<12 99P12 9 Numberinparenthesesindicatespatientswhounderwentendovascula rtreatment.OphA,ophthalmicartery;ACA,anteriorcerebralartery;MCA,middle cerebralartery;PCA,posteriorcerebralartery;BA,basilarartery ;SCA,superiorcerebellarartery.Table2Twelvepatientswithrupturedanteriorcirculationaneurysm swhounderwentadditionalDSangiographyCaseNo. Location Size(mm)1 lt.ICA-PCoA 3.12 ACoA 2.23 lt.ICAsupraclinoid 1.64 lt.ICA-PCoA 7.85 lt.ICAsupraclinoid 2.46 lt.ICA(fusiform) 11.87 lt.ICA-PCoA 3.28 rt.ICA(fusiform) 18.89 lt.MCA 9.610 lt.ICA-PCoA 10.511 ACoA 10.112 lt.ICA-PCoA 18.2 Thesurgicalfindingscorrelatedwellwiththe3D-CTangiographyorD Sangiography.Table3showstheconditiononadmissionandoutcomeat 3monthsaftersurgery.Somepatientswithgoodgradesonadmissiondi edofseverespasm,acutebrainswelling,orpoorgeneralcondition,b uttheseoutcomeswerenotrelatedtothepreoperativeradiologicali nformation.DISCUSSION Thepresentstudyofrupturedaneurysmsinbothanteriorandposterio rcirculationsfoundthattheindicationsforadditionalDSangiogra phyintheanteriorcirculationaresimilartothatfoundpreviously, butweexperiencedsomenewatypicalcases.Treatmentoffusiformane urysmsdependsonthehaemodynamicinformation,whichcouldonlybeo。