DOI: 10.1148/radiol.2442060394
Intracranial Aneurysms: Role of Multidetector CT Angiography in Diagnosis and Endovascular Therapy Planning1
Karsten Papke, MD,
Christiane K. Kuhl, MD,
Martin Fruth, MD,
Cornel Haupt, MD,
Martin Schlunz-Hendann, MD,
Dieter Sauner, MD,
Martin Fiebich, PhD,
Alan Bani, MD, and
Friedhelm Brassel, MD
1 From the Departments of Radiology and Neuroradiology (K.P., M. Fruth, C.H., M.S., D.S., F.B.) and Neurosurgery (A.B.), Klinikum Duisburg, Zu den Rehwiesen 9, D-47055 Duisburg, Germany; Department of Radiology, Rheinische Friedrich-Wilhelms-University of Bonn, Bonn, Germany (C.K.K.); and University of Applied Sciences Giessen-Friedberg, Giessen, Germany (M. Fiebich). From the 2003 RSNA Annual Meeting. Received March 2, 2006; revision requested May 1; revision received August 2; accepted August 30; final version accepted December 15.
Address correspondence to K.P. (e-mail: karsten.papke{at}klinikum-duisburg.de).
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Figure 1: Flowchart shows composition of the study group, which consisted of 87 patients (pts.) who underwent both multidetector CT angiography (MDCTA) and DSA. The reference standard consisted of a combined reading of multidetector CT angiography and DSA results, as well as additional clinical information. SAH = subarachnoid hemorrhage.
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Figure 2a: False-positive (a) multidetector CT angiography and (b) DSA images in a patient with prepontine subarachnoid hemorrhage. (a) No aneurysm is visible at multidetector CT angiography. The left anterior oblique targeted maximum intensity projection image (40-mm slab thickness) shows the A1 segment of the anterior cerebral artery (arrowhead), with no evidence of an aneurysm. (b) DSA image obtained in the same projection shows a small (approximately 1 mm) sacculation arising from the proximal part of the A1 segment (arrowhead). This finding was misinterpreted as an aneurysm. At surgery, the sacculation was identified as an infundibular dilatation of a branch of the A1 segment, which was subsequently wrapped.
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Figure 2b: False-positive (a) multidetector CT angiography and (b) DSA images in a patient with prepontine subarachnoid hemorrhage. (a) No aneurysm is visible at multidetector CT angiography. The left anterior oblique targeted maximum intensity projection image (40-mm slab thickness) shows the A1 segment of the anterior cerebral artery (arrowhead), with no evidence of an aneurysm. (b) DSA image obtained in the same projection shows a small (approximately 1 mm) sacculation arising from the proximal part of the A1 segment (arrowhead). This finding was misinterpreted as an aneurysm. At surgery, the sacculation was identified as an infundibular dilatation of a branch of the A1 segment, which was subsequently wrapped.
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Figure 3a: Images in a patient with acute subarachnoid hemorrhage with distribution throughout all basal cisterns. At initial interpretation, anteroposterior multidetector CT angiography and DSA images were negative for aneurysms (arrowhead). (a) Initial DSA image. (b) Volume-rendering technique image. After repeat detailed interpretation of multidetector CT angiograms and DSA images, an anterior communicating artery aneurysm (arrowhead) was suspected on the basis of multidetector CT angiography data acquired with the coronal oblique volume-rendering technique of the multidetector CT angiography data. (c) DSA was repeated 3 days later in a projection similar to that of the volume-rendering technique image (b), and an anterior communicating artery aneurysm (arrowhead) was confirmed. Even retrospectively, the aneurysm could not be distinguished from overlying vessels on a.
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Figure 3b: Images in a patient with acute subarachnoid hemorrhage with distribution throughout all basal cisterns. At initial interpretation, anteroposterior multidetector CT angiography and DSA images were negative for aneurysms (arrowhead). (a) Initial DSA image. (b) Volume-rendering technique image. After repeat detailed interpretation of multidetector CT angiograms and DSA images, an anterior communicating artery aneurysm (arrowhead) was suspected on the basis of multidetector CT angiography data acquired with the coronal oblique volume-rendering technique of the multidetector CT angiography data. (c) DSA was repeated 3 days later in a projection similar to that of the volume-rendering technique image (b), and an anterior communicating artery aneurysm (arrowhead) was confirmed. Even retrospectively, the aneurysm could not be distinguished from overlying vessels on a.
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Figure 3c: Images in a patient with acute subarachnoid hemorrhage with distribution throughout all basal cisterns. At initial interpretation, anteroposterior multidetector CT angiography and DSA images were negative for aneurysms (arrowhead). (a) Initial DSA image. (b) Volume-rendering technique image. After repeat detailed interpretation of multidetector CT angiograms and DSA images, an anterior communicating artery aneurysm (arrowhead) was suspected on the basis of multidetector CT angiography data acquired with the coronal oblique volume-rendering technique of the multidetector CT angiography data. (c) DSA was repeated 3 days later in a projection similar to that of the volume-rendering technique image (b), and an anterior communicating artery aneurysm (arrowhead) was confirmed. Even retrospectively, the aneurysm could not be distinguished from overlying vessels on a.
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Figure 4a: Patient with a ruptured aneurysm of the anterior communicating artery and an additional aneurysm of the posterior communicating artery. The aneurysm of the right posterior communicating artery was initially missed with both multidetector CT angiography and DSA. (a) The paracoronal volume-rendering technique image shown here had the strongest conspicuity. After successful embolization of the anterior communicating artery aneurysm (arrowhead), review of the multidetector CT angiography data the next day raised suspicion of an additional posterior communicating artery aneurysm (arrow). With the aneurysm parallel to the course of the posterior communicating artery, the aneurysm appeared broad based and not coilable. (b) At repeat DSA, a projection angle similar to that of the volume-rendering technique image is used, and the posterior communicating artery aneurysm (arrow) is confirmed. At DSA, the same projection angle used for volume-rendering technique multidetector CT angiography was used and the relatively narrow neck could be appreciated. The aneurysm was successfully treated with coil placement, and stent placement was not necessary. Note the coil package after embolization of the anterior communicating artery aneurysm (arrowhead).
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Figure 4b: Patient with a ruptured aneurysm of the anterior communicating artery and an additional aneurysm of the posterior communicating artery. The aneurysm of the right posterior communicating artery was initially missed with both multidetector CT angiography and DSA. (a) The paracoronal volume-rendering technique image shown here had the strongest conspicuity. After successful embolization of the anterior communicating artery aneurysm (arrowhead), review of the multidetector CT angiography data the next day raised suspicion of an additional posterior communicating artery aneurysm (arrow). With the aneurysm parallel to the course of the posterior communicating artery, the aneurysm appeared broad based and not coilable. (b) At repeat DSA, a projection angle similar to that of the volume-rendering technique image is used, and the posterior communicating artery aneurysm (arrow) is confirmed. At DSA, the same projection angle used for volume-rendering technique multidetector CT angiography was used and the relatively narrow neck could be appreciated. The aneurysm was successfully treated with coil placement, and stent placement was not necessary. Note the coil package after embolization of the anterior communicating artery aneurysm (arrowhead).
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Figure 5a: False-positive multidetector CT angiograms of an aneurysm of the right internal carotid artery. (a) Transverse volume-rendering technique image of a lobulated aneurysm at the left internal carotid artery (arrow) and a broad-based sacculation with a diameter of 2.5 mm directed dorsomedially from the right internal carotid artery (arrowhead). These findings were misinterpreted as a mirror aneurysm. However, DSA revealed an infundibular dilatation of the right posterior communicating artery. (b) Targeted thin-slab maximum intensity projection multidetector CT angiograms obtained at different transverse oblique projections show that the posterior communicating artery (arrowheads) originates from the dilatation and does not run parallel to it. These findings represent an enlarged infundibulum and not an aneurysm.
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Figure 5b: False-positive multidetector CT angiograms of an aneurysm of the right internal carotid artery. (a) Transverse volume-rendering technique image of a lobulated aneurysm at the left internal carotid artery (arrow) and a broad-based sacculation with a diameter of 2.5 mm directed dorsomedially from the right internal carotid artery (arrowhead). These findings were misinterpreted as a mirror aneurysm. However, DSA revealed an infundibular dilatation of the right posterior communicating artery. (b) Targeted thin-slab maximum intensity projection multidetector CT angiograms obtained at different transverse oblique projections show that the posterior communicating artery (arrowheads) originates from the dilatation and does not run parallel to it. These findings represent an enlarged infundibulum and not an aneurysm.
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Figure 6a: Images in a patient with two potentially ruptured aneurysms, one situated at the posterior communicating artery and one originating from the carotid artery at its bifurcation into the anterior and medial cerebral arteries. (a) The sagittal volume-rendering technique image demonstrates a well-defined neck of the posterior communicating artery aneurysm (white arrow), which was considered coilable. The carotid aneurysm (black arrow) was considered not coilable because of the apparently absent neck. (b) Coronal road map DSA image. Coil placement was attempted in the carotid aneurysm, with the coil protruding into the vessel lumen (arrow). The coil was withdrawn, and a stent was placed across the wide neck of the aneurysm. (c) Coronal unsubtracted DSA image obtained after successful stent (arrowheads) placement and coil (white arrow) embolization of the carotid aneurysm. The posterior communicating artery aneurysm (black arrow) was successfully treated with coil placement; stent placement was not required.
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Figure 6b: Images in a patient with two potentially ruptured aneurysms, one situated at the posterior communicating artery and one originating from the carotid artery at its bifurcation into the anterior and medial cerebral arteries. (a) The sagittal volume-rendering technique image demonstrates a well-defined neck of the posterior communicating artery aneurysm (white arrow), which was considered coilable. The carotid aneurysm (black arrow) was considered not coilable because of the apparently absent neck. (b) Coronal road map DSA image. Coil placement was attempted in the carotid aneurysm, with the coil protruding into the vessel lumen (arrow). The coil was withdrawn, and a stent was placed across the wide neck of the aneurysm. (c) Coronal unsubtracted DSA image obtained after successful stent (arrowheads) placement and coil (white arrow) embolization of the carotid aneurysm. The posterior communicating artery aneurysm (black arrow) was successfully treated with coil placement; stent placement was not required.
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Figure 6c: Images in a patient with two potentially ruptured aneurysms, one situated at the posterior communicating artery and one originating from the carotid artery at its bifurcation into the anterior and medial cerebral arteries. (a) The sagittal volume-rendering technique image demonstrates a well-defined neck of the posterior communicating artery aneurysm (white arrow), which was considered coilable. The carotid aneurysm (black arrow) was considered not coilable because of the apparently absent neck. (b) Coronal road map DSA image. Coil placement was attempted in the carotid aneurysm, with the coil protruding into the vessel lumen (arrow). The coil was withdrawn, and a stent was placed across the wide neck of the aneurysm. (c) Coronal unsubtracted DSA image obtained after successful stent (arrowheads) placement and coil (white arrow) embolization of the carotid aneurysm. The posterior communicating artery aneurysm (black arrow) was successfully treated with coil placement; stent placement was not required.
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Copyright © 2007 by the Radiological Society of North America.
