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April2014 Vol.51 Issue:      2 Table of Contents
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The Role of Multidetector CT Angiography In Diagnosis and Treatment Planning of Aneurysmal Subarachnoid Hemorrhage

Ashraf Ahmed Zaher1, Talal Amer2, Nahed Abd El-Gaber2, Hany A. Fikry Eldawoody3, Ashraf El-Mitwalli1, Wael Gabr1, Ashraf M. AbdelRahman2

Departments of Neurology1, Radiology2, Neurosurgery3, University of Mansoura; Egypt


Background: Rates of misdiagnosis and treatment delays for subarachnoid hemorrhage are still common. The availability of effective less invasive techniques might be an alternative to the conventional angiography. Objective: To determine the role of multidetector row computed tomography angiography (CTA) in detection of aneurysms in patients with acutely ruptured aneurysm and to assess how therapeutic decision-making can be based on this method. Methods: A total of 66 patients with acute subarachnoid hemorrhage (SAH) were included, 35 females and 31 males with mean age of 53.75 years.  Each patient underwent a 16-detector row CT scanner CTA; the data were recorded and reviewed by three independent readers. Treatment options using surgical clipping, endovascular coil embolization or medical treatment were proposed depending on CTA data. Results: Sixty-eight aneurysms were detected in 60 patients (90.9 %); 6 of them showed multiple aneurysms. According to the aneurysms location; 39 (57%) were in the anterior cerebral artery (ACA), 9 (13.2%) in the middle cerebral artery (MCA), 6 (8.8%) in the posterior cerebral artery (PCA), and 5(7.3%) the main internal carotid artery (ICA). Thirty three aneurysms have been subjected to endovascular treatment, while the remaining 35 were offered either surgical or medical treatment. There was disagreement among the reviewers in seven aneurysms (10.3 %). Conclusion: The CTA is a non-invasive rapid and effective method for assessment and treatment options in cases of intracranial aneurysms limiting the need for invasive angiography to flow related studies or to assess small critical arteries, specially related to skull base. [Egypt J Neurol Psychiat Neurosurg.  2014; 51(2): 235-241]

 Key Words: aneurysmal SAH, CTA

 Correspondence to Ashraf Ahmed Zaher, Department of Neurology, Faculty of medicine, University of Mansoura, Egypt. Tel.: +201222816432. Email:



Intracranial aneurysms are relatively common in population aged over 30 years with female predominance.1 The mean annual incidence of subarachnoid hemorrhage (SAH) in the United States is 10/100,000, with roughly 28,000 episodes per year.2-5 The case fatality rate is between 25 and 50%, the median mortality rate in the United States is 32% versus 44% in Europe and 27% in Japan.6,7 Prompt localization of the aneurysm is critical for determining the appropriate neurosurgical or endovascular intervention.8

Digital subtraction angiography (DSA) has been the golden standard for the detection of intracranial aneurysm in patients with acute SAH.9 However; it is invasive with complication rate of about 0.3 % and 0.07% risk of permanent neurologic complications.10,11

Magnetic resonance angiography (MRA) has been preferred noninvasive intracranial imaging12, its performance in the evaluation of acute SAH also has been compared favorably with that of DSA13, but it can be technically challenging to perform in the acutely ill patient and aneurysms less than 5 mm in diameter were missed.12 Angiography with single detector row helical computerized tomography (CT) scanners compared favorably with DSA in detection of intracranial aneurysms.14,15 The CT techniques with multidetector row acquisition, considerably improving the spatial resolution of computed tomography angiography (CTA) data, has high sensitivity and specificity for the detection of intracranial aneurysms in patients with acute SAH and also has been used as a pre-therapeutic tool in the preparatory phase of aneurysm clipping.16-20

Aim of the work is to determine the role of multidetector row CTA in detection of intracranial aneurysms in SAH patients with acutely ruptured aneurysm and to assess how therapeutic decision-making can be based on this method.



We prospectively studied 66 consecutive patients with non-traumatic subarachnoid hemorrhage admitted to departments of Neurology and Neurosurgery, Mansoura University, Egypt from May 2011 through May 2013. The work has been approved by the ethics committee of Mansoura University. All patients were subjected to a thorough history taking including; the risk factors profile, clinical and neurological examinations as well as a baseline Hunt and Hess grading systems21, routine laboratory investigations and non-contrast CT-brain scan.

Each patient underwent a post contrast CTA examination with a 16 multidetector row CT scanner (Brilliance CT 16; Philips Medical Systems, Cleveland, Ohio and General Electric brightspeed CT scanners). The parameters for CTA acquisition were collimation of 16 × 0.75 mm, Pitch =0.56, Rotation time =0.5sec, Kv =120, mAs 440, image matrix =768 × 768, reconstruction slice thickness of 2mm and Slice increment =0.5mm. The scanning volume extended from the superior aspect of the first cervical vertebra up to a point of one cm above the level of the lateral ventricles determined by non-contrast CT scan. A total amount of 100 ml of non-ionic contrast media; Scanlux® (Iopamidol) 370 mg/mL were used (Sanochemia, Austria). It was administered intravenously using a power injector at a rate of 4 mL/sec via an 18 or 20 gauge canula positioned in antecubital or other suitable arm vein. Determining the best time for the start of examination was done by using test injection of 15ml contrast and performing single level examination at the level of the circle of Willis to draw time/intensity curve of contrast enhancement of the vessels. This was followed by injection of 85 mL of contrast and starting examination at the predetermined time.

The angiographic results were interpreted at a second workstation. Original source images were reviewed, followed by assessment by multiplanar reformatted images, multiplanar maximum intensity projection (MIP) technique and 3D volume rendering. Bone extraction was done using skull removal software. The angiographic studies were interpreted by three independent expert radiologists. The aneurysm dome and neck were measured on CT angiographic images and the ratio of neck to dome (D/N) was measured.

The choice of treatment was based on the patient’s age, the extent of the intracranial hemorrhage and the location and the morphologic features of the aneurysm. To evaluate the impact of CTA on decision-making, treatment plans were classified into 4 groups; (a) Endovascular coiling considering contraindications of coiling are branches arising from the neck or sac, unfavorable D/N ratio, partially thrombosed aneurysms, small aneurysms (2mm) or inaccessible aneurysm, (b) Surgical clipping if one or more contraindications to coiling are present, (c) Medical treatment for micro-aneurysm, mycotic aneurysms and fusiform aneurysm (if not the cause of hemorrhage), and (d) Surgery for aneurysms in easily accessible places like bifurcation of MCA, with/without associated perianeurysmal surgical hematoma.

Large aneurysm and giant aneurysm are considered separately as their management may require direct diagnostic catheter angiography and balloon test occlusion.


Statistical Analysis

The data were coded and entered into a computer using Statistical Package for Social Sciences (SPSS) version 16.0 (Chicago, IL, USA). Data are expressed as mean ± standard deviation (SD), number and percentage. The level of P<0.05 was considered as the cut-off value of significance.




A total of 66 patients were studied (35 females and 31 males) with age ranges from 23-69 years, mean age of 53.7 years. The commonest clinical presentation was headache and neck pain with depressed consciousness, hemi- or paraparesis, cranial nerve palsies and blurring of vision being less common presenting symptoms.  Head CT scans revealed SAH in 59 cases; intra-axial hematoma in11 cases, early hydrocephalic changes in 27 cases, infarction in 7 cases, and only one case showed subdural hematoma (Table 1).

The prevalence aneurysms were significantly higher in females older in age (Table 2). Aneurysms were identified by CTA in 60 patients (90.9%), six patients (10 %) had multiple aneurysms. The smallest detected aneurysm was 2.0 mm in diameter while the largest one was 25mm, average (8.4 mm).

The 68 aneurysms were detected in internal carotid artery (ICA); 5 aneurysms, ICA/ophthalmic artery 2 aneurysms, anterior communicating artery (A com A) 39 aneurysms, posterior communicating artery aneurysms (P com A) 6, MCA 9, distal ACA 1 aneurysm, vertebral artery (VA) 1 aneurysm, vertebrobasilar junction 1 aneurysm, basilar trunk 1 aneurysm, basilar artery/superior cerebellar junction 1 aneurysm, and basilar tip 2 aneurysms; (right and left sides are summed together).

Thirty-three aneurysms were offered endovascular treatment and 35 aneurysms were offered either surgical or medical treatment; of these; 3 aneurysms showed important side branches, 8 aneurysms showed D/N ratio less than 2, 2 aneurysms were fusiform, and 2 near total thrombosed aneurysms (Tables 3).

Among the three reviewers;  discrepancy in diagnosis, grading or other criteria of aneurysm was present in only 7 aneurysms (10.3%), however consensus was reached among them on reviewing the original images as well as MIP and 3D images.

Figures (1) and (2) show the neuroimaging of some cases in our patients’ series.


Table 1. Demographic and CT scan findings of the patients.


Age range (mean)

23 to 63 years (53.75 years)

Sex (male/female)


Clinical presentation

Number (%)


60 (91)

Neck pain ± rigidity

54 (76)

Depressed level of consciousness

35 (53)

Hemi- or paraparesis

16 (24)


9 (14)

Blurring of vision

8 (12)

Cranial nerve palsy

4 (6)

CT finding


Subarachnoid hemorrhage




Intra-cerebral hematoma


Cerebral infarction


Subdural hematoma



Table 2. Age and sex distribution of patients with aneurysm on CT angiography.


Age Group

Number of Patient

Male / Female
















33 females age (59.4±7.7), 27 males (52.8±9.2) t= 3.02 , p= 0.005


Table 3. Aneurysms management according to different criteria.



Management option applied

Number (%)

Endovascular management


Surgical Clipping/Parent artery occlusion


Medical treatment and Follow-up


Unfit for endovascular treatment (n=35)

Important side branches


Dome to neck ratio < 2


Small size < 2 mm




Fusiform aneurysm


Peripheral location


Giant  aneurysm


Financial reasons


Patient/Family refusal



35 (100)



Figure 1. 45 years old female presented with SAH, left frontal intracerebral hematoma (ICH) due to ruptured giant paraclinoid aneurysm underwent parent artery occlusion of the right ICA. (A) CTA axial MIP, (B) 3D volume rendering reformate showed giant right paraclinoid aneurysm. (C) Intra-operative view shows the aneurysm *: tip of suction tube #: (D) one week postoperative CT axial non contrast does not show any obvious ischemic insult.




Figure 2. 63 years old female patient presented with SAH due to ruptured left ICA dorsal wall large aneurysm underwent successful neck clipping. (A) Non-contrast axial CT brain showed SAH in the basal cisterns and more prominent on the left side. (B) CTA 3D volume rendering reformate showed sharp kink in the proximal ICA in the neck, which reflects difficulty in endovascular treatment. (C, D, E) CTA 3D volume rendering reformate showed the relation of the aneurysm to the surrounding structures namely the anterior clinoid process, and the secondary bleb, which reflects the bleeding point mostly. (F) CTA 3D volume rendering transparent reformate with accurate neck diameter just at the neck of the aneurysm.

(G, H, I) CTA axial, sagittal, coronal reformate MIP showed the aneurysm well and the relations to the surrounding bony structures. (J) Intra-operative view showed the aneurysm [yellow arrow] points to the proximal control by temporary clip, dashed blue line refer to the aneurysm neck. (K, L) one year post operative DSA showed complete obliteration of the aneurysm, preservation of the parent artery and the aneurysm clips in place [K: Left ICA DSA A-P view; L: Left ICA 3D DSA lateral view].





The ideal imaging examination for aneurysm detection should not only be noninvasive but should also depict aneurysms with a high degree of accuracy.12 CTA is minimally invasive and the amount of contrast material utilized is less than that required for diagnostic DSA study, so allow lesion visualization from any angle desired.22

In our study, 68 aneurysms were detected in 60 (90.9%) out of the examined 66 patients and the most common sites were the arteries of the circle of Willis, these results were in accordance with another studies which reported aneurysmal rupture etiology to spontaneous SAH ranged between 75-90% 1,23, and usually arise from the circle of Willis or branch artery.1Multiple aneurysms were found in 6 patients (10.6%); 4 cases had two aneurysms, 2 cases each had three aneurysms, this percentage was nearly the same reported by other studies.24-26

Small ruptured aneurysms that were not revealed by DSA were identified only on 3D-CTA.27 We were able to detect aneurysms between 1-2 mm in diameter a figure near to that of Matsumoto and colleagues.17 Hypoplastic or absent large-vessel segments were clearly demonstrated on CTA.12 Anomalies of the vessels of the circle of Willis were detected in about 25% of our cases, these include;  hypoplastic and aplastic A1 segments, persistent fetal circulation between the P. Com. A and  PCA and post-hemorrhagic vasospasm in any of the arteries of the circle of Willis.

Radiologist experience both with the CTA technique and with image review at the workstation plays a crucial role in image interpretation.22 Aneurysms detected on multidetector row CT A with sensitivity ranging between 90% and 81% and specificity of 93% when two readers of examination were implemented.12 The disagreement among our three observers was only regarding 7 aneurysms (10.3%); however differences were settled by consensus on reviewing the source images, MIP and 3D images by them.

Multidetector CTA has a major benefit in the delineation of venous anatomy28, it also could guide operative corridor and delineating the amount and extent of bone removal in order to get the neck clipping clearly (Figures 1 and 2), together with the ability to rotate an aneurysm in multiple projections may provide significant information regarding the size of the lesion’s neck and the relationship of the aneurysm to the parent vessel and contiguous branches, and surgical simulation images are especially useful and give the correct orientation to approach an aneurysm29,17 as well as visualization of the aneurysm from any angle or perspective, while simultaneously depicting important bone landmarks, thus aiding in the selection of the optimal surgical approach.19 Thick calcified wall and intra-mural thrombus could be delineated clearly and its presence affects decision making.30

Endovascular coiling based on CTA was successful in 31 of our patients out of the 33 referred for coiling but failed in only two patients (6%); one patient due to intra-operative rupture and the procedure was under local anesthesia, and the other one was due to access problems. Thus, the vessels of the neck should be carefully scrutinized regarding accessibility for guiding catheter placement as the excessive vessel tortuosity may prevent placement of the guiding catheter.23In another case (Figure 2), the excess tortuosity of the cervical ICA depicted on 3D CTA has changed our decision to do surgical clipping.

In only one of our surgical cases, the neck definition of large ICA aneurysm near the bone of skull base appeared falsely clippable, upon intra-operative observation, the aneurysm neck could not be defined and the procedure changed to ICA ligation in the neck (Figure 1). We believe that the most accurate measurement of aneurysm neck, especially in crucial situations - should be 3D DSA with flat panel detector using transparent format on the working station. 



CT angiography is a non-invasive tool that offers rapid and effective method for assessment of intracranial aneurysms decreasing the need for invasive diagnostic angiography except for the cases in which flow related studies or the need to assess small critical arteries, the presence of large aneurysms without clearly defined neck - specially related to skull base- is present. Limitations to our study; we relied mainly on the CTA as a guide for triage of patient management without control angiogram and the short selection period for two year.


[Disclosure: Authors report no conflict of interest]




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الملخص العربي


دور التصوير المقطعي متعدد الكواشف للأوعية في تشخيص وخطط علاج تمدد الأوعية الدموية المخية

في المرضى الذين يعانون من نزيف تحت الأم العنكبوتية


الهدف: تحديد دور التصوير المقطعي متعدد الكواشف للأوعية في الكشف عن تمدد الأوعية الدموية في المرضى الذين يعانون من تمزق حاد بتلك التمددات وتقييم مدى امكانية صنع القرار العلاجي بناء على هذا الأسلوب.

المرضي وطرق البحث: تم تضمين مجموعه 66 من المرضى الذين يعانون من نزيف حاد تحت العنكبوتية: 35 من الإناث و31 من الذكور بمتوسط عمر 53 عاما وخضع كل مريض التصوير المقطعي متعدد الكواشف للأوعية، وسجلت البيانات وتم مراجعتها من قبل ثلاثة أطباء اشعة تشخيصية ذوي خبرة وبصورة مستقلة. واقترحت خيارات العلاج باستخدام هذا النوع من الأشعة ليكون اما الجراحة او لفائف (الكويل) أو العلاج الطبي.

النتائج: تم الكشف عن ثمانية وستين تمددا للأوعية الدموية في 60 مريضا (90.9٪)، أظهر الفحص تمددا متعددا للأوعية الدموية في ست حالات  ووفقا لموقع تمدد الأوعية الدموية؛ 39 (57٪) كانت في الشريان الدماغي الأمامي، 9 (13.2٪) في الشريان الدماغي الأوسط و 6 (8.8٪) في الشريان المخي الخلفي، و 5 (7.3٪) من الشريان السباتي الداخلي الرئيسي. وقد تعرض ثلاثة وثلاثين تمدد الأوعية الدموية لعلاج اللف (الكويل) بينما تم توجيه الخمس والثلاثون مريضا المتبقين إما للجراحة أو العلاج الطبي. كان هناك خلاف بين المراجعين في 7 تمدد للأوعية الدموية (10.3٪)، ولكن تم التوصل إلى توافق في التشخيص في جميع الحالات.

الاستنتاج: التصوير المقطعي متعدد الكواشف للأوعية طريقة سريعة وفعالة وغير غازية في التقييم وفي خيارات العلاج في حالات تمدد الأوعية الدموية داخل الجمجمة مما يحد من الحاجة لاستخدام التصوير التقليدي التداخلي (الغازي) للأوعية وقصرها فقط على دراسات التدفق خلال الشرايين أو لتقييم الشرايين الصغيرة خاصة ذات الصلة بقاعدة الجمجمة.

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