Tag: CTangiography

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Infundibular dilation and aneurysm at the origin of the posterior communicating artery: differential diagnosis by CT angiography

Infundibular dilation and aneurysm at the origin of the posterior communicating artery- differential diagnosis by CT angiography

Neuroradiology (2014) 56:917–923

Infundibular dilation (ID) and aneurysm at the internal carotid artery (ICA)–posterior communicating artery (PComA) junction can be difficult to distinguish but may differ in clinical significance. The aim of this study was to evaluate the utility of CT angiography (CTA) in differentially diagnosing IDs and small unruptured aneurysms at the ICA– PComA junction.

Methods This retrospective study comprised 88 patients diagnosed with 107 protrusions (70 IDs and 37 aneurysms <5 mm; 19 bilateral lesions) at the ICA–PComA junction who underwent both CTA and digital subtraction angiography (DSA). Two neuroradiologists independently reviewed CTA and DSA images according to these criteria: (a) size (maximum dimension <3 or ≥3 mm), (b) shape (triangular or round/ oval/irregular), (c) aneurysmal neck (absent or present), (d) horizontal direction (posteriomedial or posteriolateral), and (e) PComA origin (apex, no PComA, or base). The intermodality (between CTA and DSA) and interobserver (between the two readers) agreement were determined for each finding.We also evaluated the sensitivity and specificity of CTA for distinguishing ID and aneurysm, using DSA as the reference standard.

Results The mean κ values of intermodality agreement for the size, shape, aneurysmal neck, horizontal direction, and PComA origin were 0.88, 0.87, 0.84, 0.71, and 0.56, respectively. All interobserver agreements of CTA and DSA were excellent. The sensitivity, specificity, and accuracy of CTA for differentiating aneurysms from IDs were 94.6, 100, and 98.0 %, respectively.

Conclusion CTA may be a useful noninvasive modality for differential diagnosis of ID and aneurysm at the ICA–PComA junction.

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Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms

Focused opening of the sylvian fissure for microsurgical management of MCA aneurysms

Acta Neurochir (2014) 156:17–25

A wide sylvian opening, with either a proximal or distal start, has been standard for microsurgical management of middle cerebral artery (MCA) aneurysms. However, extensive sylvian dissection is potentially associated with increased incidence of iatrogenic injury to the brain and neurovascular structures. The aim of the present study was to describe the technique of focused opening of the sylvian fissure for microsurgical management of MCA aneurysms with additional tips on handling difficulties which may be encountered with this technique.

Method A 3D image-based anatomic orientation, clipping field–focused surgical planning, slack brain, and high magnification are the basic requirements for this approach. A 10– 15 mm sylvian opening is placed so that it allows safe access and a good surgical view of the MCA aneurysm clipping field. Under proximal control of the MCA, the aneurysm neck can be dissected and clipped effectively and safely, in this small surgical field.

Results The presented technique has been developed and refined by the senior author during the surgery of 1,097 aneurysms over the last 13 years. It has proved to be safe, and effective for clipping of both ruptured and unruptured MCA aneurysms. Its greatest advantages are a shorter operative time and less brain and vessel manipulation compared to more extensive approaches.

Conclusion The focused sylvian opening is a less-invasive alternative to the classical wide sylvian opening for the microsurgical management of most MCA aneurysms.

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