Surgical Neurology
Volume 65, Issue 1 , Pages 26-27, January 2006

Commentary

Department of Neurosurgery, Helsinki University Central Hospital, SF-00260 Helsinki, Finland

Article Outline

 

Digital subtraction angiography (DSA) is becoming obsolete in the diagnostics of patients with cerebral aneurysms [2], [5] even if equipped with 3-dimensional (3D) rotational angiography. After diagnosing subarachnoid hemorrhage with computed tomography (CT), it is very easy to continue with CT angiography (CTA) which is quick, noninvasive, and therefore a safe and also cost-effective method to reveal or exclude an aneurysm. The same goes for unconscious patients with aneurysmal intracerebral hemorrhage necessitating emergent clot removal with clipping. In these cases, processing of the 3D images can be done while the patient is transferred to the operating room. Our experience is in concordance with the authors' observation that often aneurysms that rupture are smaller in size than the artificial 7 mm set by the ISUIA. In CTA, only tiny 1- to 2-mm aneurysms may not be seen, but it would be very exceptional that these tiny ones would rupture. Naturally, complex and giant aneurysms are exceptions and still necessitate DSA (3D) after CTA for flow dynamics. Postoperative or preferably intraoperative angiography is still crucial to confirm the result after clipping [3]. However, intraoperative DSA can be replaced in selected cases by indocyanine green angiography that permits a simple and quick assessment of vessel patency and occlusion after clip placement using surgical microscope–integrated near-infrared video technology [4]. Notably, postoperative CTA can be used with equal accuracy in comparison to DSA in visualization of neck (remnant) after clipping if titanium clips are used [1]. This necessitates a modern multislice CT with proper software and a dedicated person (preferably a vascular neuroradiologist) to process and interpret the images with 24-hour service.

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References 

  1. Dehdashti A, Binaghi S, Ushe A, Regli L. The value of multi-slice CT angiography in postoperative control of clipped aneurysms. Abstract no 56 (oral presentation) in the 8th Joint Annual Meeting of the AANS/CNS Cerebrovascular Section and the American Society 2002. 2002;
  2. Kangasniemi M, Mäkelä T, Koskinen S, Porras M, Poussa K, Hemesniemi J. Detection of intracranial aneurysms with two-dimensional and three-dimensional multislice helical computed tomographic angiography. Neurosurgery. 2004;54(2):336–340
  3. Kivisaari RP, Porras M, Ohman J, Siironen J, Ishii K, Hernesniemi J. Routine cerebral angiography after surgery for saccular aneurysms: is it worth it?. Neurosurgery. 2004;55(5):1015–1022
  4. Raabe A, Beck J, Seifert V. Technique and image quality of intraoperative indocyanine green angiography during aneurysm surgery using surgical microscope integrated near-infrared video technology. Zentralbl Neurochir. 2005;66:1–8
  5. Wintermark M, Uske A, Chalaron M, Regli L, Maeder P, Meuli R, et al. Multislice computerized tomography angiography in the evaluation of intracranial aneurysms: a comparison with intra-arterial digital subtraction angiography. J Neurosurg. 2003;98(4):828–836

PII: S0090-3019(05)00375-7

doi:10.1016/j.surneu.2005.06.003

Refers to article:

  • Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography

    Jürgen Beck, Stefan Rohde, Joachim Berkefeld, Volker Seifert, Andreas Raabe
    Surgical Neurology January 2006 (Vol. 65, Issue 1, Pages 18-25)

Surgical Neurology
Volume 65, Issue 1 , Pages 26-27, January 2006

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