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Comparison Analysis Between320-Slice Dynamic Volume Computerized Tomography Angiography and Three Dimensional Digital Subtraction Angiography(3D-DSA) in the Diagnosis of Small Intracranial Aneurysm

Author: LiuZuo
Tutor: QinShangZhen; PanLi
School: Southern Medical University,
Course: Surgery
Keywords: Small intracranial aneurysm Dynamic volume CT Tomography X-raycomputed
CLC: R739.41
Type: Master's thesis
Year: 2013
Downloads: 5
Quote: 0
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Abstract


Research backgroundIntracranial aneurysm refers to the brain artery vascular abnormality of cerebral vascular tumor-like protrusions, which is made on the Willis ring and its branches, bifurcations and bend objective. Multiple aneurysms accounted for about15-20%, according to its size, intracranial aneurysm can be divided into very small aneurysms, small aneurysm, aneurysm, large aneurysm and giant aneurysm.For patients with cerebrovascular accident, aneurysm incidence is in the third, which is lower than cerebral thrombosis and cerebral hemorrhage, and about80%of the SAH is caused by the rupture of intracranial aneurysms, the death rate and disability rate is high. In the first hemorrhage, fatality rate and mutilation rate is around30%, but in the second bleeding the mortality rate and disability rate rose to80%, which is serious harm to public health. For the clinical manifestation which is highly suspected in patients with subarachnoid hemorrhage,it needs to clear whether the hemorrhage is caused by ruptured intracranial aneurysms, and the aneurysm size,shape, number,and the relationship between location and parent artery, the correct diagnosis and early treatment has important clinical significance to reduce the mortality and improve patient prognosis.With the rapid development of medical imaging equipment and computer technology, developing a technology for intracranial aneurysm follow-up diagnosis which is simple, convenient,and has small trauma, high accuracy, low cost has become the main direction for medical workers to study. At present,3D-DSA is still " gold standard" for the clinical diagnosis of intracranial aneurysm, but its limitation is that it cannot display the spatial relationship between the aneurysm and the base of the skull, for serious aneurysmal vasospasm or completely thrombosed it is difficult to display, or aneurysm is showed significantly less than the actual size, in addition, DSA is a traumatic examination, which may easily cause vasospasm, damage intima, and result in thrombosis risk, DSA also has high cost, radiation dose and long time inspection, such shortcomings are not easy to be accepted by the patients,DSA is not good for screening and postoperative examination means.With the rapid development of computer technology and the advent of a new generation of high performance of CT, intracranial aneurysm imaging technology is gradually perfect. The320row dynamic volume CT scanning mode avoid the helical scan in patients with horizontal movement of mobile data error, image composition time and the needless scanning dose of repeated scanning.Considering detector coverage of Z axis in320row CT, the acquisition time is obviously shortened, so the ladder artifact can be avoided for the disturbance of consciousness patients, one can get the cerebral vascular image in a short time, and it can be as dynamic as DSA to observe the blood flow direction, provide hemodynamic information.But with the development of multi-layer CT technology, especially the320row dynamic volume CT, in order to further improve the diagnosis of intracranial aneurysm rate, relative to the DSA, CTA has the advantages of convenient, fast, non-invasive, low cost and other advantages, for small intracranial aneurysm (diameter≤5mm Small Aneurysm, SAN), the320row dynamic volume CT has important implications for screening and diagnosis. With a new generation of high performance of CT, it has, to some extent, the trend of replacing DSA, and can be widely applied to the screening and treatment of intracranial aneurysms after treatment.ObjectiveCompared to three-dimensional digital subtraction angiography (3D-DSA), this research aims at the study of320row dynamic volume CT angiography (4D-CTA) on the accuracy of diagnosis and the evaluation in the diagnosis of small intracranial aneurysm, and the clinical application value, it can provide a reliable basis for clinical treatment. Methods 1Average dataFrom2012January to2012April hospitalized in Department of neurosurgery in our hospital,185patients with clinical suspected intracranial aneurysms are diagnosed by3D-DSA, small aneurysms (diameter≤5mm) in87patients, male39cases, female48cases. Age from30to78years old, average55.2years old. There are75cases of ruptured aneurysm patients, they show the typical features of subarachnoid hemorrhage (sudden severe headache, with nausea and vomiting), including6cases with unilateral oculomotor palsy; the remaining12cases of unruptured aneurysm patients show intermittent headache, dizziness and a black mask. Hunt-Hess grading: grade0in12cases,10cases of grade Ⅰ,17cases of grade@,29cases of grade Ⅲ,12cases of grade Ⅳ,7cases of grade Ⅴ, Fisher classification:18cases of grade Ⅰ,34cases of grade Ⅱ,26cases of grade Ⅲ,9cases of grade Ⅳ, after admission all patients underwent3D-DSA and320rows of CTA examination.2Checking methods(1):CTA examination is done by Toshiba Aquilion ONE320CT. The scanning range is from carotid1centrum lower edge to the top of the head, the scanning line parallels with the skull base, data collection layer thickness is0.5mm, scanning speed is0.35s/R. Contrast medium Ultravist370, using bolus injection method and double tube injector through antecubital vein injection, the injection of contrast agent is calculated according to1.5ml/kg. The injection speed is5ml/s, using bolus tracking technology to calculate the injection delay time, using volume rendering (VR) and maximum intensity projection method (MIP) and other processing methods to obtain the cerebral vascular reconstruction. Image analysis was completed by two experienced neuroradiologist, who are able to rotate the image workstation arbitrarily according to the need to obtain the best viewing angle.(2) DSA examination:application of Siemens double flat panel digital subtraction angiography machine. Using Seldinger technology to puncture the right femoral artery, the placement of6F arterial sheath, arterial sheath inserted5F Cordis catheter, choose to left, right internal carotid artery and the left, right vertebral artery respectively. Contrast agent:internal carotid angiography flow rate is6ml/s, the total amount is9ml/time; vertebral artery flow rate is5ml/s, total7ml/; internal carotid artery3D angiography total flow rate is3ml/s,18ml/;3D angiography of vertebral artery flow rate is2.5ml/s, total15ml/, using VR technology for processing. Image analysis was completed by two interventional physician. 3Statistical methods(1) Taking3D-DSA detection of SAN number as the standard,, Kappa Text is used to calculate the sensitivity, specificity and accuracy between the320row CTA and DSA for SAN.(2) Measure the maximum aneurysm diameter with CTA-VR and3D-DSA VR,which are both detected by CTA readers and3D-DSA readers, compare the difference between them, use paired T test(a=0.05test standard), with P<0.05as the statistically significant differences.Results1.In87patients diagnosed by3D-DSA,99aneurysms were detected., the average diameter of aneurysm is3.3mm, the average neck width is2.5mm, the tiny aneurysms which were less than3mm were38(38.4%).Finally,28aneurysms were clipped by operation,61by endovascular therapy,8aneurysms were seen in regular shape, smooth surface (including5aneurysms in the anterior circulation,3in the posterior circulation, the average diameter is2.9mm), as for unruptured aneurysm,after explaining the disease to the family, the family requested the conservative treatment, ask the patients to take regular follow-up,2aneurysms ruptured again after admission in patients,which caused death.2. CTA examination reported a total of94aneurysms of87patients, compared with3D-DSA, which include92aneurysms in the same location, but with the emergence of false positive in2, false negative in7. The2false positive patients with CTA showed right internal carotid artery posterior communicating aneurysm, but was confirmed by DSA as right after initial traffic arterial cone, so a retrospective analysis was performed on CTA images, to do the image processing, expand the threshold range, small blood vessels could be visible in posterior communicating artery local bulge. CTA missed7artery aneurysms, missed diagnosis of aneurysm of the site is as follows:the clinoid segment of left internal carotid artery in1, the ophthalmic artery of the left internal carotid artery is1, right anterior cerebral artery in I, basilar artery in2, left vertebral artery in1, right vertebral artery in1, minimum diameter of missed diagnosis aneurysm is1.1mm, maximum diameter is2.1mm, average1.68mm.3. CTA detected a total of43small aneurysms in the anterior communicating artery, middle cerebral artery and anterior cerebral artery, which are same to3D-DSA position, the sensitivity was97.7%; the detection of intracranial segment of internal carotid artery are38aneurysms,36of which are consistent with the position of DSA, the sensitivity was94.7%,13were found in vertebrobasilar artery,4were missed, the sensitivity was76.5%.4.Using3D-DSA detection of SAN number as the standard, the sensitivity of SAN detected by320rows CTA was92.9%, the specificity was93.9%, the accuracy was93.2%, Kappa value is0.83, their value on detecting small aneurysms are in good agreement. With CTA VR and3D-DSA VR image, measured maximum aneurysm diameter is texted by paired t test, P=0.075>0.05, there ia no statistical significance.Conclusions1.With respect to DSA, the320layer dynamic volume CTA has the advantages of convenient, fast, non-invasive, low cost and other advantages,which is of great significance for screening, diagnosis of small intracranial aneurysm diameter≤5mm, it can be used as the preferred method of examination or suspicious aneurysm patients with subarachnoid hemorrhage, and its risk is small and it is easy to be accepted by patients, the measurement results of small aneurysm diameter is accurate and reliable, it can provide information for guiding clinical therapy.2.Due to the interference of overlapping vessels and bone structure, during the segmentation in the skull and vascular imaging process, it is easy to cause the loss of information and image warping, the blood vessels may show incomplete or limited range,small aneurysms in the brain skull may be showed less significantly by320CTA.3.320rows of CTA still sometimes missed small intracranial aneurysms, which were less than3mm, so for the patients with clinical manifestations of suspected intracranial aneurysm, however CTA image is negative, it is suggested that the units take3D-DSA as the gold standard for inspection.4.The correct diagnosis of intracranial aneurysm is also required that image post-processing operator have good nerve and brain operation to learn relevant knowledge, at the same time, as an important factor of rate of accuracy, the experience and observation of readers also affect CTA diagnosis.

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