Tag: Digital subtraction angiography

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Neuroimaging of Intracerebral Hemorrhage

Neurosurgery 86:E414–E423, 2020

Intracerebral hemorrhage (ICH) accounts for 10% to 20% of strokes worldwide and is associated with high morbidity and mortality rates. Neuroimaging is indispensable for rapid diagnosis of ICH and identification of the underlying etiology, thus facilitating triage and appropriate treatment of patients.

The most common neuroimaging modalities include noncontrast computed tomography (CT), CT angiography (CTA), digital subtraction angiography, andmagnetic resonance imaging (MRI). The strengths and disadvantages of each modality will be reviewed.

Novel technologies such as dual-energy CT/CTA, rapid MRI techniques, near-infrared spectroscopy, and automated ICH detection hold promise for faster pre- and in-hospital ICH diagnosis that may impact patient management.

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Accuracy of 320-detector row nonsubtracted and subtracted volume CT angiography in evaluating small cerebral aneurysms

J Neurosurg 127:725–731, 2017

The study aimed to assess the diagnostic accuracy of 320-detector row nonsubtracted and subtracted volume CT angiography (VCTA) in detecting small cerebral aneurysms (< 3 mm) compared with 3D digital subtraction angiography (3D DSA).

METHODS Six hundred sixty-two patients underwent 320-detector row VCTA and 3D DSA for suspected cerebral aneurysms. Five neuroradiologists independently reviewed VCTA and 3D DSA images. The 3D DSA was considered the reference standard, and the sensitivity, specificity, and accuracy of nonsubtracted and subtracted VCTA in depicting small aneurysms were analyzed. A p value < 0.05 was considered a significant difference.

RESULTS According to 3D DSA images, 98 small cerebral aneurysms were identified in 90 of 662 patients. Nonsubtracted VCTA depicted 90 small aneurysms. Ten small aneurysms were missed, and 2 small aneurysms were misdiagnosed. The missed small aneurysms were located almost in the internal carotid artery, near bone tissue. The sensitivity, specificity, and accuracy of nonsubtracted VCTA in depicting small aneurysms were 89.8%, 99.2%, and 96.5%, respectively, on a per-aneurysm basis. Subtracted VCTA depicted 97 small aneurysms. Three small aneurysms were missed, and 2 small aneurysms were misdiagnosed. The sensitivity, specificity, and accuracy of subtracted VCTA in depicting small aneurysms were 96.9%, 99.2%, and 98.6%, respectively, on a per-aneurysm basis. There was no difference in accuracy between subtracted VCTA and 3D DSA (p = 1.000). However, nonsubtracted VCTA had significantly less sensitivity than 3D DSA and subtracted VCTA (p = 0.039 and 0.016, respectively).

CONCLUSIONS Subtracted 320-detector row VCTA is sensitive enough to replace 3D DSA in the diagnosis of small cerebral aneurysms (< 3 mm). The accuracy rate of nonsubtracted VCTA was lower than that of subtracted VCTA and 3D DSA, especially in the assessment of small internal carotid artery aneurysms adjacent to the skull base.

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Vascular complications of penetrating brain injury

Vascular complications penetrating BI

J Neurosurg 121:1275–1283, 2014

The authors conducted a study to compare the sensitivity and specificity of helical CT angiography (CTA) and digital subtraction angiography (DSA) in detecting intracranial arterial injuries after penetrating traumatic brain injury (PTBI).

Methods. In a retrospective evaluation of 48 sets of angiograms from 45 consecutive patients with PTBI, 3 readers unaware of the DSA findings reviewed the CTA images to determine the presence or absence of arterial injuries. A fourth reader reviewed all the disagreements and decided among the 3 interpretations. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CTA were calculated on a per-injury basis and in a subpopulation of patients with traumatic intracranial aneurysms (TICAs).

Results. Sensitivity of CTA for detecting arterial injuries was 72.7% (95% CI 49.8%–89.3%); specificity, 93.5% (95% CI 78.6%–99.2%); PPV, 88.9% (95% CI 65.3%–98.6%); and NPV, 82.9% (95% CI 66.4%–93.4%). All 7 TICAs were correctly identified by CTA. Sensitivity, specificity, PPV, and NPV of CTA in detecting TICAs were 100%. To compare agreement with DSA, the standard of reference, confidence scores categorized as low, intermediate, and high probability yielded an overall effectiveness of 77.8% (95% CI 71.8%–82.9%).

Conclusions. Computed tomography angiography had limited overall sensitivity in detecting arterial injuries in patients with PTBI. However, it was accurate in identifying TICAs, a subgroup of injuries usually managed by either surgical or endovascular approaches, and non-TICA injuries involving the first-order branches of intracranial arteries.

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Essentials in intraoperative indocyanine green videoangiography assessment for intracranial aneurysm surgery

ICG aneurysm

Neurosurg Focus 36 (2):E7, 2014

Indocyanine green (ICG) videoangiography (VA) in cerebral aneurysm surgery allows confirmation of blood flow in parent, branching, and perforating vessels as well as assessment of remnant aneurysm parts after clip application. A retrospective analysis and review of the literature were conducted to determine the current essential advantages of ICG-VA in aneurysm surgery.

Methods. The authors retrospectively evaluated all aneurysm cases treated with the aid of intraoperative ICG-VA at a single institution between 2007 and 2013. They also analyzed the literature published since the initial description of ICG-VA in 2003.

Results. Two hundred forty-six procedures were performed in 232 patients harboring 295 aneurysms. The pa- tients, whose mean age was 54 years, consisted of 159 women and 73 men. One hundred twenty-four surgeries were performed after subarachnoid hemorrhage, and 122 were performed for incidental aneurysms. Single aneurysms were clipped in 185 patients, and multiple aneurysms were clipped in 47 (mean aneurysm diameter 6.9 mm, range 2–40 mm). No complications associated with ICG-VA occurred. Intraoperative microvascular Doppler ultrasonography was performed before ICG-VA in all patients, and postoperative digital subtraction angiography (DSA) studies were available in 121 patients (52.2%) for retrospective comparative analysis. In 22 (9%) of 246 procedures, the clip posi- tion was modified intraoperatively as a consequence of ICG-VA. Stenosis of the parent vessels (16 procedures) or occlusion of the perforators (6 procedures), not detected by micro-Doppler ultrasonography, were the most common problems demonstrated on ICG-VA. In another 11 procedures (4.5%), residual perfusion of the aneurysm was ob- served and one or more additional clips were applied. Vessel stenosis or a compromised perforating artery occurred independent of aneurysm location and was about equally common in middle cerebral artery and anterior communi- cating artery aneurysms. In 2 procedures (0.8%), aneurysm puncture revealed residual blood flow within the lesion, which had not been detected by the ICG-VA. In the postoperative DSA studies, unexpected small (< 2 mm) aneurysm neck remnants, which had not been detected on intraoperative ICG-VA, were found in 11 (9.1%) of 121 patients. However, these remnants remained without consequence except in 1 patient with a 6-mm residual aneurysm dome, which was subsequently embolized with coils.

Conclusions. In a large cohort of consecutive patients, ICG-VA proved to be a helpful intraoperative tool and led to a significant intraoperative clip modification rate of 15%. However, small, < 2-mm-wide neck remnants and a 6-mm residual aneurysm were missed by intraoperative ICG-VA in up to 10% of patients. Results in this study confirm that DSA is indispensable for postoperative quality assessment in complex aneurysm surgery.

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Subarachnoid Hemorrhage With Negative Initial Catheter Angiography

Subarachnoid_Hemorrhage_With_Negative_Initial

Neurosurgery 72:646–652, 2013

Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial.

OBJECTIVE: To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging.

METHODS: Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram.

RESULTS: Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of shortterm and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients.

CONCLUSION: Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH.

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Robotic Digital Subtraction Angiography Systems Within the Hybrid Operating Room

Neurosurgery 68:1427–1433, 2011 DOI: 10.1227/NEU.0b013e31820b4f1c

Fully equipped high-end digital subtraction angiography (DSA) within the operating room (OR) environment has emerged as a new trend in the fields of neurosurgery and vascular surgery.

OBJECTIVE: To describe initial clinical experience with a robotic DSA system in the hybrid OR.

METHODS: A newly designed robotic DSA system (Artis zeego; Siemens AG, Forchheim, Germany) was installed in the hybrid OR. The system consists of a multiaxis robotic C arm and surgical OR table. In addition to conventional neuroendovascular procedures, the system was used as an intraoperative imaging tool for various neurosurgical procedures such as aneurysm clipping and spine instrumentation.

RESULTS: Five hundred one neurosurgical procedures were successfully conducted in the hybrid OR with the robotic DSA. During surgical procedures such as aneurysm clipping and arteriovenous fistula treatment, intraoperative 2-/3-dimensional angiography and C-arm-based computed tomographic images (DynaCT) were easily performed without moving the OR table. Newly developed virtual navigation software (syngo iGuide; Siemens AG) can be used in frameless navigation and in access to deep-seated intracranial lesions or needle placement.

CONCLUSION: This newly developed robotic DSA system provides safe and precise treatment in the fields of endovascular treatment and neurosurgery.

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Usefulness of multislice computerized tomographic angiography in the postoperative evaluation of patients with clipped aneurysms

Acta Neurochir (2010) 152:793–802 DOI 10.1007/s00701-009-0465-4

The aim of our study was to evaluate the diagnostic efficacy of multislice computed tomographic angiography (MSCTA) regarding exclusion quality after aneurysm clipping.
Methods. Sixty patients (74 aneurysms) underwent microsurgical exclusion using titanium clips. The presence of aneurysm remnants on MSCTA was compared by a neuroradiologist to 2D digital subtraction angiography (DSA), which was considered as a reference examination. The contribution of 3D DSA was assessed in a subpopulation of 29 patients (35 aneurysms).
Results. With 2D DSA, six aneurysm remnants (8%) were diagnosed, and only five (7%) by MSCTA. The specificity and sensitivity were 98.5 and 83%, respectively. MSCTA failed to demonstrate one large remnant (>2 mm) because of clip artifacts (six clips). With 3D DSA six supplementary remnants were diagnosed. Two were large remnants blinded by vessel overlaps and clip artifacts. Four were small “dogeared” remnants (≤2 mm). No additional treatment was required for small remnants.
Conclusion. In the postoperative period, MSCTA was considered a useful tool to evaluate the large remnants as well as a non-invasive ulterior examination for suspected bifurcation. Nevertheless, 3D DSA is still required for an accurate evaluation of aneurysms treated by more than three clips.

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Sinus pericranii in children: report of 16 patients and preoperative evaluation of surgical risk

J Neurosurg Pediatrics 4:050360–500420, 2009.(DOI: 10.3171/2009.7.PEDS0994)

Sinus pericranii (SP) is a rare venous varix in an extracranial location connected to the intracranial venous system. The aim of this retrospective study was to report on 16 pediatric cases of SP with consideration of the preoperative evaluation of surgical risk.

Methods. The study population consisted of 10 patients who had undergone surgery for SP and 6 patients with concomitant craniosynostosis and SP. The mean age of the patients at presentation was 3.7 years. To identify characteristics of SP with high operative risk, 8 cases in this report and 11 previously reported cases of SP with sufficient information were categorized on the basis of the number and size of SP, the number and size of transcranial channels, the venous drainage type, and the amount of blood loss. Hemorrhage amounts were classified into 3 grades based on the description of intraoperative blood loss.

Results. Sinus pericranii not associated with craniosynostosis were resected without any postoperative morbidity. Sinus pericranii associated with craniosynostosis were preserved. After craniofacial reconstruction, 2 cases of SP with craniosynostosis regressed, completely in one patient and partially in another. These 2 patients with SP were confirmed to have compromised intracranial sinus before craniofacial reconstruction. Among a total of 19 patients, multiplicity or size (> 6 cm) of SP (p = 0.036) and multiplicity (> 3) or size (> 3 mm) of transcranial channels (p = 0.004) was associated with more severe hemorrhage grade. Sinus pericranii with peripheral venous drainage (drainer type) was not associated with hemorrhage grade after classification into 3 grades (p = 0.192). However, all 3 cases of SP with massive Grade 3 hemorrhage were the drainer type. Hemorrhage grade was correlated with the number of risk factors for SP (r = 0.793, p < 0.001).

Conclusions. Three risk factors of SP and the presence of compromised intracranial sinus are markers for high-risk SP. “Squeezed-out sinus syndrome” is suggested as a concept for SP associated with compromised intracranial sinus, mainly caused by craniosynostosis. Sinus pericranii in squeezed-out sinus syndrome probably serves as a crucial alternative to venous drainage of the brain with intracranial venous compromise. Conservative treatment for such patients with SP is recommended.


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Aneurysmal subarachnoid hemorrhage diagnosis with computed tomographic angiography and OsiriX

Acta Neurochir DOI 10.1007/s00701-009-0508-x

Purpose Recent advances in computed tomographic angiography (CTA) have resulted in its replacing digital subtraction angiography (DSA). However, CTA requires a powerful workstation and experienced technicians for image postprocessing. OsiriX, a free open-source medical imaging software with powerful three-dimensional (3D) capability, enables neurosurgeons to perform 3D rendering without extensive training. In this study, we examined the sensitivity and specificity of CTA with OsiriX as the primary diagnostic tool for intracranial aneurysms.

Method From May 2006 to March 2009, 121 patients with spontaneous subarachnoid hemorrhage (SAH) underwent CTA. The CTA source images were 3D rendered by neurosurgeons using OsiriX. All the possible locations for aneurysms were carefully reviewed. DSA was performed on every patient in any of the following conditions: for negative CTA findings, after surgical clipping of aneurysms or before transarterial embolization of aneurysms.

Results Of the 121 patients, 8 were excluded because DSA data were not available. In the remaining 113 patients, 20 patients had negative CTA findings. CTA with OsiriX detected 106 aneurysms in 93 patients, of which 103 were confirmed by DSA or postoperative DSA; 3 infundibular dilated pouches of small arteries were mistaken for aneurysms. Two anterior communicating artery aneurysms (1.5 mm and 1 mm) were missed by CTA from among all 113 patients. The sensitivity and specificity of CTA for detecting aneurysms on a per-patient basis were 98.9% and 100%, respectively. The sensitivity and specificity of CTA for detecting aneurysms on a per-aneurysm basis for detecting aneurysms were 98.1% and 86.3%, respectively.

Conclusion CTA with OsiriX enables accurate detection of intracranial aneurysms. Cerebral DSA should be reserved for those patients with negative CTA findings.

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