Comparison of the Role of CT Angiography and DSA in Detecting Aneurysms in Cases with Spontaneous Subarachnoid Hemorrhage

Transcription

1 Originl Artile Print ISSN: Online ISSN: X DOI: /ijss/2017/515 Comprison of the Role of CT Angiogrphy nd DSA in Deteting Aneurysms in Cses with Spontneous Surhnoid Hemorrhge Ch Surendr Kumr 1, KV Devr Anil 2, KSV Prsd 3, B Rmn 4 1 Assistnt Professor, Deprtment of Neurosurgery, Andhr Medil College, Viskhptnm, Andhr Prdesh, Indi, 2 Neurordiologist, Deprtment of Rdiology, King George Hospitl, Viskhptnm, Andhr Prdesh, Indi, 3 Professor nd Hed, Deprtment of Neurosurgery, Andhr Medil College, Viskhptnm, Andhr Prdesh, Indi, 4 Senior Resident, Deprtment of Neurosurgery, Andhr Medil College, Viskhptnm, Andhr Prdesh, Indi Astrt Bkground nd Purpose: Surhnoid hemorrhge (SAH) due to rupture of neurysms is one of the most lrming nd tstrophi ondition s it n use signifint moridity nd mortlity nd poses formidle hllenge oth in its dignosis nd mngement. The present study is to ompre the role of omputed tomogrphy (CT) ngiogrphy in deteting ruptured neurysm with spontneous SAH nd the role of digitl sutrtion ngiogrphy (DSA). Mterils nd Methods: During the period of 5 yers from Septemer 2012 to August 2017, ptients presented with spontneous SAH were studied. These ptients underwent oth 3 D - omputerized tomogrphy ngiogrphy (CTA) nd 4 - vessel ererl DSA. CTA nd DSA findings were evluted nd ompred in terms of the existene of neurysm, size, shpe, numer, lotion, nd mjor vessel rnhing. Results: Totl 32 ses only 17 ses were positive with 19 neurysms, 2 ptients hving 2 neurysms eh nd 15 were negtive. CTA hs sensitivity of 89% in imging neurysms nd in 86% of negtive CTA ses DSA lso negtive for delineting neurysm. Conlusion: CTA is good proedure with sensitivity of 89% in the detetion nd delinetion of ererl neurysms. Owing to the lower speifiity of CTA in some ses, DSA remins the gold stndrd in evluting ptients with ererl neurysms. In omplex neurysms, DSA supplements CTA imges in plnning their mngement. Key words: Computerized tomogrphy ngiogrphy, Digitl sutrtion ngiogrphy, Intrrnil neurysms, Surhnoid hemorrhge INTRODUCTION Surhnoid hemorrhge (SAH) due to rupture of neurysms is one of the most lrming nd tstrophi onditions s it n use signifint moridity nd mortlity nd poses formidle hllenge oth in its dignosis nd mngement. The erliest referene out SAH ws found in Avienn s reords ( AD) where he desries Aess this rtile online Month of Sumission : Month of Peer Review : Month of Aeptne : Month of Pulishing : poplexy due to snguineous tumor effusing suddenly out the ventriles. Morggni ( ) gve the first desription of neurysm s the use of SAH. The inidene of SAH is reportedly /100,000. [1,2] In Indi, though initilly reported low, the numers hve een inresing stedily. An utopsy series found 21% of SAH due to neurysms in the ererl vsulture. While the linil entity of SAH ws known, its use remined n enigm for long s dignosti methods were not ville. Quinke ushered in new er in the dignosis of SAH with his lumr punture proedure in Egz Moniz in 1927 developed the tehnique of ererl ngiogrphy. In 1933, he demonstrted n neurysm in living ptient. This ntomil loliztion of the use of SAH y Corresponding Author: Dr. Ch. Surendr Kumr, Deprtment of Neurosurgery, Andhr Medil College, Viskhptnm, Andhr Prdesh, Indi. Phone: / E-mil: surendr.neurosurgeon@gmil.om 23 Interntionl Journl of Sientifi Study Novemer 2017 Vol 5 Issue 8

2 ngiogrphy helped to move the tretment of SAH from medil to the surgil mode nd presently the evolving field of endovsulr therpy. The 20 th entury sw the evolution of newer imging modlities, nmely, omputerised tomogrphy (CT), mgneti resonne imging, nd digitl sutrtion ngiogrphy (DSA). This study ttempts to ompre the use of CT ngiogrphy (CTA) in the dignosis of ererl neurysms with DSA in CTA negtive ses. Signifint moridity nd mortlity our due to the first leeding or repetitive leeding. [3,4] For this reson, fst nd urte evlution of the ptients is of gret importne in plnning the therpeuti interventions. CTA is fster nd more esily pplied method s ompred to DSA. Another dvntge of CTA is its ppliility following routine non-enhned rnil CT in ptients with suspeted SAH in emergeny onditions. DSA is invsive, time-onsuming nd expensive. [5] In this study, we imed to ompre the effetiveness of CTA to DSA in dignosis nd evlution of intrrnil neurysms in ses with spontneous SAH. The presene of n neurysm, its lotion, numer, size, shpe, nd orienttion were studied in oth the imging modlities. MATERIALS AND METHODS During the period of Septemer 2012 August 2017, 32 ptients dmitted with spontneous SAH in King George Hospitl, Andhr Medil College, Viskhptnm underwent 3 D - CTA nd 4 - vessel ererl DSA in CTA negtive nd doutful ses. These ptients reported with spontneous SAH nd hd high index of suspiion of hroring n neurysm. All the ptients were ssessed linilly sed on the Glsgow om sle (GCS) nd the World Federtion of Neurosurgil Soieties (WFNS) sle t the time of dmission. Out of 32 ptients 4 ptients presented with GCS sore of 15 WFNS Grde 1, 2 ptients presented with GCS 14 with no motor defiit WFNS Grde 2, 22 ptients presented with GCS 13 or 14 with fol defiits WFNS Grde 3, 2 ptients presented with GCS 12 nd 8 with fol defiit WFNS Grde 4, nd 2 ptients presented with GCS 5 with defiit WFNS Grde 5. Ptients were immeditely sujeted to CTA t the time of dmission, nd if CTA is negtive, the DSA ws tken on the next dy to 3 dys depending on the generl ondition of the ptient. If DSA is lso negtive, then CTA nd DSA were repeted fter 1 3 months intervl depending on ptient ondition nd mount of suspiion of hroring n neurysm. The liver nd renl funtion tests were done long with n ehordiogrm to ssess the rdi sttus of the ptients These tests were done s high doses of ontrst ws dministered rpidly whih requires good left ventriulr funtion, liver nd renl funtion to metolize nd exrete the ontrst. 16 slie CT of GE Helth Cre ws used in ll the ses with Iohexol (Omnipque) s intrvenous ontrst. Imge proessing onsisted of stndrdized xil, oronl, sgittl, multiplnr, nd 3D reonstrutions were tken. DSA ws performed using neurongiogrphy unit of GE Medil Systems with 4-vessel study with stndrd Towne nd lterl views s well s rottionl spin ngiogrms. The dye used is Iohexol (Omnipque) s intrvenous ontrst. Out of 32 ptients, 19 re mle with ges from 26 to 72 nd 13 re femle with ge rnge from 31 to 81. CTA whih is fster nd esily pplied ws rried out in ll the ptients with SAH. DSA positive ses in initil CTA negtive were studied. No omplitions were enountered during DSA proedures. CTA nd DSA negtive ses were followed nd in ses where there is strong suspiion of hroring ruptured neurysm, repet CTA ws done during the follow-up period rnging from 1 to 3 months. Agin, DSA ws repeted in negtive CTA ses during follow-up [Figure 1]. RESULTS The dt from this study hve een nlyzed under the prmeters suh s linil presenttion, findings on CT sn with grding, findings of CTA, findings of DSA in CTA negtive ses, nd results of repet CTA/DSA during follow-up. Of the 32 ptients who presented with spontneous SAH, there ws history of severe hedhe in 29 ptients nd in 3 ptients presented in unonsious stte, ptient ttendnts ould not give history of omplining hedhe efore illness. Fol defiits re seen in 18 ptients. 4 ptients presented with loss of onsiousness, 4 ptients presented with symptoms of rised intrrnil pressure nd seizures in 1 ptient. In 24 ptients, there ws history of hroni, episodi hedhe. Aording to modified Fisher grding out of the 32 ptients, 13 ptients were presented in Grde 1, 9 in Grde 2, 6 in Grde 3, nd 4 Grde 4. Of the 32 ptients who underwent CTA, 17 neurysms were seen in 15 ptients. Among these 15 ptients, 2 ptients were hving 2 neurysms eh, in whih one ptient hd middle rotid rtery (MCA) nd silr tip neurysms nd in the other ICA nd DACA neurysms were seen. Out of Interntionl Journl of Sientifi Study Novemer 2017 Vol 5 Issue 8 24

3 17 neurysms, 7 re Aom, 3 MCA, 2 PCOM, 2 ICA, 2 silr tip, nd 1 DACA. All the negtive CTA ptients re sujeted to DSA in 1 3 dys fter initil SAH nd 4 of CTA positive ptients were lso sujeted to DSA for detiled study of neurysm nd mjor vessel rnhing visuliztion. In CTA negtive ptients, DSA ould detet neurysm in 2 ptients 1 DACA nd 1 ICA. Retrospetively ICA neurysm ould lso e mde out in CTA. Out of 4 ptients with CTA positive ses, DSA ould give dditionl imging findings to help the tretment pln in 3 ses. DSA depited two loes of the Aom neurysm where CTA showed only one loe [Figure 2]. For one PCOM neurysm delineted in CTA, DSA ould detet the rnhing of mjor vessel from neurysm. For MCA neurysm in CTA, the nek ould not e seen lerly whih is with wide nek nd inorporting mjor rnhes s seen in DSA [Figure 3]. CTA remined negtive in ll [Figure 4]. Severl studies like Ogw et l., JKA Hope hve demonstrted the sensitivity of CTA of nerly 90% [6,7] while in this study the sensitivity ws 89%. The lose proximity of suprlinoid, vernous nd ophthlmi segment neurysms to ony strutures pose diffiulty in their identifition in CTA nd suh diffiulties hs een reported in literture. [8] Furthermore, CTA missed one loe of neurysm of Aom, the reson for whih remins osure. CTA imge of PCOM neurysm nd MCA neurysm yielded inferior results s omprle to those of DSA in reltion to djent mjor rnhing pttern. Of 15 ptients where there is strong suspiion of neurysm euse of perimesenephli nd diffuse type of SAH with initil CTA nd DSA were negtive, repet CTA nd DSA were done in the follow-up period 1 3 months, nd only two ses showed lister neurysms on DSA nd Spontneous SAH CTA Aneurysm Negtive CTA Figure 2: Cse 2 () Anterior interhemispheri surhnoid hemorrhge, () omputerized tomogrphy ngiogrphy with AomA neurysm single loe, () digitl sutrtion ngiogrphy showing iloed AomA neurysm Surgil Clipping OR Endo-vsulr Coiling Perimesenephli SAH OR Diffuse neursyml pttern SAH Aneurysm DSA Negtive DSA Repet CTA in the follow-up period nd repet DSA if neessry (follow-up period of 1-3 months) Figure 1: Imging pproh to ptients presenting with spontneous surhnoid hemorrhge sed on our study Figure 3: Cse 3 () Perimesenephli surhnoid hemorrhge, () 3 D omputerized tomogrphy ngiogrphy right PCOM neurysm, () digitl sutrtion ngiogrphy showing right PCOM inoperting the nek of neurysm 25 Interntionl Journl of Sientifi Study Novemer 2017 Vol 5 Issue 8

4 neurysms. [11] Ogw et l. reported tht they hd visulized 73 neurysms with shded surfe disply nd the sensitivity of CTA ws 94% in detetion of neurysms. [6] CTA sensitivity ws reported to e 100% y Pred et l. in 1998 [10] nd Mtsumoto et l. [13] Another feture of SAH, nmely, vsospsm is not evident on CTA. In the hrteriztion of omplex lrge neurysms, CTA imges were inferior with DSA in reveling the lotion, projetion nd its reltionship with djent rteries. No ses of ererl vsulitis on DSA imging were seen. DISCUSSION Figure 4: Cse 1 () Perimesenephli surhnoid hemorrhge, () omputerized tomogrphy ngiogrphy negtive, () digitl sutrtion ngiogrphy negtive Due to high mortlity nd moridity rtes ssoited with spontneous SAH, erly dignosis nd ntomi hrteriztion of ruptured neurysms hve vitl importne for oth surgil nd endovsulr tretment options. CTA is highly urte, hep nd non-invsive imging method in the dignosis of intrrnil neurysms in ses with SAH nd n e used s sfe method when emergeny surgery is needed. DSA is universlly epted s the gold stndrd imging modlity in the dignosis nd evlution of neurysms. In our study, we hve done DSA for ll CTA negtive ses. DSA is time onsuming, n expensive nd invsive proedure tht my led to omplitions in 1% nd permnent neurologi defiit in 0.5% ording to literture. [9] No omplitions were seen in our study during DSA. Depending on different studies in the literture, it ws reported tht the sensitivity of CTA in dignosing intrrnil neurysms rnges etween 67% nd 100%. [6,7,10,11] In our present study, CTA sensitivity is 89%. Lenhrt et l. stted tht CTA hd supplied dditionl informtion to DSA in their study tht hd found the sensitivity of CTA s 98%. [12] White et l., in their reserh of 142 ses pulished in 2001, hd found CTA sensitivity s 69% nd speifiity s 80% in detetion of intrrnil Aneurysm size is n importnt ftor in plnning surgil or endovsulr tretment euse it ffets the size of the lip or oil tht is going to e used. [14] Alerio et l. reported tht CTA nd DSA hve no signifint differene in mesurement of neurysm sizes. [15] In our study men neurysm size mesured y CTA is 5.2 nd DSA is 5.7 hd no sttistilly signifint differene. Due to the low sptil resolution in CTA, smll rteries tht re importnt for the surgil pproh, suh s nterior horoidl rtery or thlmoperfortor rteries nnot e visulized. CTA nnot demonstrte the ollterl flow tht n e evluted y DSA. Differentition of smll neurysms from one tht re loted ner the ony strutures t the skull se suh s posterior ommuniting rtery nd silr rtery my not e possile in some ses. Cvernous segment neurysms of ICA my e osured y opified lood in the vernous sinus. Smll neurysms loted t ifurtion of MCA my e overlooked y CTA due to rnhing of the vsulr struture. All these were enountered in our present study. Out of 19 neurysms in the present study, 17 ould e imged in CTA nd 14 neurysms intervention ould e rried out with the findings on CTA. In 3 neurysms dditionl imging findings on DSA ould help our tretment pln. 2 neurysms were deteted in DSA with negtive CTA. CTA hs sensitivity of 89% in imging neurysms nd in 86% of negtive CTA ses DSA lso negtive for delineting neurysm. Thus, in 86% of ses, negtive CTA ould rule out the presene of neurysm. Of 15 ptients where there is strong suspiion of neurysm due to perimesenephli nd diffuse type of leed with initil CTA nd DSA were negtive, repet CTA nd DSA were done in the follow-up period 1 3 months, only two ses showed lister neurysms on DSA nd CTA remined negtive in ll. In the study of Rinkel et l. [16] the use of Perimesenephli hemorrhge (PMH) is likely not neurysml ut my e venous, nd the ptients hve no risk of releed. [17] Thus, Rinkel et l. hve stted tht ptients with PMH do not need repet DSA fter initil negtive findings on DSA. [17] They lso suggested tht DSA is not needed t ll in ptients with PMH who hd negtive CTA findings. [18] In the study of Kershenovih et l. [19] they retrospetively evluted 30 ptients with perimesenephli SAH pttern Interntionl Journl of Sientifi Study Novemer 2017 Vol 5 Issue 8 26

5 nd negtive CTA finding. DSA findings were negtive in ll of these ptients. They onluded tht CTA lone is onlusive dignosti tool for ruling out neurysms in ptients presenting with the lssi perimesenephli SAH pttern nd thus n reple DSA. In summry, CTA is highly sensitive, speifi, fst, nd non-invsive imging method for dignosis nd evlution of neurysms in ses with spontneous SAH with suspeted intrrnil neurysms. CTA should e the first line of the investigtion. A negtive CTA finding with SAH pttern of neurysml rupture, DSA is indited. In omplex neurysms, DSA supplements CTA imges in plnning the mngement deision etween surgil lipping nd endovsulr oiling. CONCLUSION CTA is the first line imging tehnique for the ptients presented with spontneous SAH in most of the ses with sensitivity of 89% in the detetion nd delinetion of ererl neurysms. DSA remins the gold stndrd in evluting ptients with ererl neurysms where the initil CTA is negtive. In omplex neurysms, DSA supplements CTA imges in plnning the mngement deision etween surgil lipping nd endovsulr oiling. REFERENCES 1. Rmmoorthy B. Inidene of intrrnil neurysms in Indi. J Neurosurg 1969;30: Rmkrishn E, Shnkr SK. SAH-n utopsy study of 158 ses. NIMHANS J 1990;8: Broderik JP, Brott TG, Duldner JE, Tomsik T, Leh A. Initil nd reurrent leeding re the mjor uses of deth following surhnoid hemorrhge. Stroke 1994;25: Hugenholtz H, Elgie RG. Considertion in erly surgery on good-risk ptients with ruptured intrrnil neurysms. J Neurosurg 1982;56: Cloft HJ, Joseph GJ, Dion JE. Risk of ererl ngiogrphy in ptients with surhnoid hemorrhge, ererl neurysm, nd rteriovenous mlformtion: A met-nlysis. Stroke 1999;30: Ogw T, Okuder T, Noguhi K, Sski N, Inugmi A, Uemur K, et l. Cererl neurysms evlution with 3D CT ngiogrphy. AJNR Am J Neurordiol 1996;17: Hope JKA, Wilson JL, Thomson FJ. 3D CTA in the detetion nd hrteristion of intrrnil erry neurysms. AJNR Am J Neurordiol 1996;17: Shwrtz RB, Tie HM, Hooten SM, Hsu L, Stieg PE, et l. Evlution of ererl neurysms with helil C.T: Correltion with onventionl ngiogrphy nd MR ngiogrphy. Rdiology 1994;192: Heisermn JE, Den BL, Hodk JA, Flom RA, Bird CR, Dryer BP, et l. Neurologi omplitions of ererl ngiogrphy. AJNR Am J Neurordiol 1994;15: Pred L, Getni P, Rodriguez y Ben R, Di Mggio EM, L Finz A, Dore R, et l. Spirl CT ngiogrphy nd surgil orreltions in the evlution of intrrnil neurysms. Eur Rdiol 1998;8: White PM, Tesdle EM, Wrdlw JM, Eston V. Intrrnil neurysms: CT ngiogrphy nd MR ngiogrphy for detetion prospetive linded omprison in lrge ptient ohort. Rdiology 2001;219: Lenhrt M, Bretshneider T, Gmeinwieser J, Ullrih OW, Shlier J, Feuerh S, et l. Cererl CT ngiogrphy in the dignosis of ute surhnoid hemorrhge. At Rdiol 1997;38: Mtsumoto M, Sto M, Nkno M, Endo Y, Wtne Y, Sski T, et l. Three-dimensionl omputerized tomogrphy ngiogrphyguided surgery of utely ruptured ererl neurysms. J Neurosurg 2001;94: Ng SH, Wong HF, Ko SF, Lee CM, Yen PS, Wi YY, et l. CT ngiogrphy of intrrnil neurysms: Advntges nd pitflls. Eur J Rdiol 1997;25: Alerio RA, Ptel M, Csey S, Jos B, Mguire W, Deker R, et l. Evlution of the irle of Willis with three-dimensionl CT ngiogrphy in ptients with suspeted intrrnil neurysms. AJNR Am J Neurordiol 1995;16: Rinkel GJ, vn Gijn J, Wijdiks EF. Surhnoid hemorrhge without detetle neurysm. A review of the uses. Stroke 1993;24: vn der Shf IC, Velthuis BK, Gouw A, Rinkel GJ. Venous dringe in perimesenephli hemorrhge. Stroke 2004;35: Velthuis BK, Rinkel GJ, Rmos LM, Witkmp TD, vn Leeuwen MS. Perimesenephli hemorrhge. Exlusion of verterosilr neurysms with CT ngiogrphy. Stroke 1999;30: Kershenovih A, Rppport ZH, Mimon S. Brin omputed tomogrphy ngiogrphi sns s the sole dignosti exmintion for exluding neurysms in ptients with perimesenephli surhnoid hemorrhge. Neurosurgery 2006;59: How to ite this rtile: Kumr CS, Anil KVD, Prsd KSV, Rmn B. Comprison of the Role of CT Angiogrphy nd DSA in Deteting Aneurysms in Cses with Spontneous Surhnoid Hemorrhge. Int J Si Stud 2017;5(8): Soure of Support: Nil, Conflit of Interest: None delred. 27 Interntionl Journl of Sientifi Study Novemer 2017 Vol 5 Issue 8