Evaluation and treatment of intracranial aneurysms using Dual Energy CT Angiography (DECTA) and rotational Digital Subtraction Angiography (DSA).

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1 Evaluation and treatment of intracranial aneurysms using Dual Energy CT Angiography (DECTA) and rotational Digital Subtraction Angiography (DSA). L. Testaverde, G. Pelle, A. Saltarelli, P. Rabuffi, M. Iozzino, E. Notarianni, V. Pasqualini, L. Caporali, R. Cianni U.O.C. Diagnostica Avanzata e Radiologia Interventistica Ospedale «S. Maria Goretti» Latina, Italy

2 Epidemiology & Etiopathogenesis Spontaneous SAH (not caused by trauma) affects about 9/100,000 inhabitants/year in Europe and North America. Spontaneous SAH is caused by the rupture of a cerebral aneurysm in the 85% of cases while less than 5% is caused by arterovenous malformation (AVM)

3 Epidemiology & The peaketiopathogenesis of incidence is at the age of (30% of female patients are over 70). Prevalence is higher in females than males (F:M=1.6:1) Symptoms and Diagnosis Symptoms and signs (ordered by frequency) of SAH are: headache, dizziness, vomiting, seizures, diplopia Diagnosis could be suspected on the base of clinical symptoms and signs but CT scan is needed for confirmation.

4 CT signs of SAH Hyperdensity in the subarachnoid spaces, variable in extention according to the conspicuity of the bleeding is the typical sign. In case of copious SAH the blood may form large coagules and intraparenchymal hematomas could be associated

5 Purpose This study wants to evaluate the diagnostic accuracy of DECTA compared to Digital Subtraction Angiography (DSA) in the detection of intracranial aneurysms in patients with SAH. Moreover we want to assess if DECTA is able to adequately depict type and structure of the bleeding aneurysm and can be considered as first diagnostic tool in SAH patients

6 Materials & Methods From October 2010 to September 2011, 48 patients (F 37, M 11; mean age 58) with spontaneous SAH, diagnosed by standard CT made in Emergency Radiology Unit, underwent DECTA scan at Diagnostic and Interventional Radiology Unit of «S. M. Goretti» Hospital of Latina.

7 Dual Source CT for Dual Energy CT Angiography (DECTA) Our DECT consists of two groups tube-detector (Dual Source CT) placed othogonal to one another and collocated in the same rotating gantry (Somatom Definition, Siemens, Germany). The two tubes in the Dual Energy mode operate at different voltages: tube A at 140 kv, tube B at 80 kv). From the DECTA scan we obtain three dataset of images: 140kV, 80kV and an average set equivalent to a 120kV monoenergetic conventional scan. X-ray s attenuation for iodinated contrast media is much higher at lower kv; this phenomenon is not observed for bone and consents differentiating it from vascular structures permitting easy post processing and automatic bone removal

8 Materials & Methods DECTA scan parameters Elements Description Tube A 140 kv, 50 mas Tube B 80 kv, 213 mas Collimation 64 x 0.6 mm Pitch 0.9 Rotation time 0.5 sec Contrast 50 ml iomeprole (400 mgi/ml) at 5 ml/sec, followed by 50 ml of saline flush Using bolus tracking with a ROI on the ascending aorta and trigger at 60 UH. Scan Delay

9 Materials & Methods DECTA images are transferred to the workstation (Syngo Multi Modality Workplace, Siemens Healthcare, Germany) to be post-processed using the commercial software provided. Thanks to the automated bone removal the bone is automatically subtracted from the images in less than a minute. Then three dimensional maximum intensity projection (MIP) and volume rendering (VR) reformations could be obtained. In our institution we have timed the entire reading process (starting from automatic bone removal and stopping at diagnosis) estimating about 5-10 minutes are required to identify the aneurysm and evaluate the entire Willis circle.

10 DECTA VR 3D

11 Materials & Methods Of 48 patients submitted to DECTA, 28 underwent also interventional DSA, performed using a robotic multi-axis angiography system (Artis Zeego, Siemens Healthcare, Forchheim,

12 Results DECTA identified 67 aneurysms in 48 patients. Patients had the following outcome Only one patient had an intraoperational complication (bleeding) No one is dead due to the interventional procedure patients Therapeutic decision 28 Interventional DSA 3 Transferred to neurosurgery 16 Not eligible for treatment 1 Deceased before treatment 1 Transferred to another hospital

13 Results Aneurysm distribution per patient, type and location Aneurysm per patient patients 1 aneurysm 32 2 aneurysms 12 > 3 aneurysms 4 Dimension of aneurysm 3mm occurrence >3mm e 5mm 28 >5mm * location ICA occurrence 11 CoA 22 ACA 5 MCA 19 * BA 6 PICA AICA 3 1 * = 2 microaneurysms (<3mm) not revealed by DECTA and detected by DSA

14 Some cases

15 & some treatment.

16 DECTA and DSA An important feature of DECTA is the possibility to search the MIP or VR images to find the visualization angle (described by spin and tilt parameters) that best depict the aneurysm, and particularly its neck and record this data in the DICOM file which can be uploaded into the rotating angiography equipment to obtain an identical or really quite similar visualization of the aneurysm during the interventional procedure. This consents 1. time saving during interventional procedure 2. reduce need for diagnostical DSA before interventional 3. consciousness of problems that may occur during the procedure (e.g. needs for stent or flow diverter instead of (or with) coils) and therefore better planification

17 DECTA and DSA

18 DECTA and DSA.

19 Results In all 48 patients with SAH the DECTA scan revelead at least one aneurysm, consenting correct diagnosis of SAH due to aneurismatic rupture, and in all treated patients (including surgery) DECTA identified the bleeding source, as confirmed in the following endovascular or neurosurgical intervention.

20 Results Sensitivity of DECTA (compared to DSA) Per patient basis 100% Per aneurysm basis 97,1% Per aneurysm basis for aneurysms >5mm 100% Per aneurysm basis for aneurysms 5mm and >3mm 100% Per aneurysm basis for aneurysms 3mm 71,4%

21 Take home messages DECTA is a fast and powerful exam to get correct diagnosis in patients with SAH in fact 1.DECTA could be used as one stop shop exam because it is able to identify and depict the bleeding aneurysm, orienting therapeutic decision (surgery/endovascular/no treatment) 2.MIP and VR images reduce (eliminate) the need for diagnostic angiography before interventional angiography 3.Microaneurysms (<3mm) could not be revealed by DECTA

22 THE END

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