CASE REPORT
DIAGNOSIS OF A RUPTURED CEREBRAL ANEURYSM ON 128 SLICE
CT CEREBRAL ANGIOGRAPHY
Deepa Gandra1, Chennamaneni Vikas2
HOW TO CITE THIS ARTICLE:
Deepa Gandra, Chennamaneni Vikas. ”Diagnosis of a Ruptured Cerebral Aneurysm on 128 Slice CT Cerebral
Angiography”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 27, July 06, 2015;
Page: 4051-4055.
ABSTRACT: Conventional angiography is the gold standard for detecting cerebral aneurysm but
multisclice CT cerebral angiography has gained significant role in diagnosing cerebral aneurysms
because of its non invasive nature and increasing sensitivity to detect aneurysms owing to latest
technological advances.We report a case of ruptured cerebral aneurysm diagnosed on 128 slice
CT cerebral angiography with intraoperative correlation.
KEYWORDS: 128 slice CT cerebral angiography, Aneurysms.
INTRODUCTION: Digital subtraction angiography (DSA) has been the standard of reference for
the detection and characterization of intracranial aneurysms because of its high spatial resolution
and large field of view, but it has the disadvantage of being invasive and operator dependent. As
a result of recent innovations in CT scanner and workstation technology, Computed Tomographic
Angiography (CTA) has become a useful, non-invasive imaging technique for evaluating
cerebrovascular disease and can be first line investigation where CTA is available. We report a
case of ruptured intracranial aneurysm detected on 128 slice CT cerebral Angiography with
intraoperative correlation.
CASE HISTORY: A sixty four year old female with a acute history of severe headache and
diagnosed as suffering from acute subarachnoid haemorrhage on plain CT, was referred for CT
cerebral angiography for detection of ruptured cerebral aneurysms if any. CT cerebral
angiography was performed on our 128 slice CT scanner. 60 ml of non-ionic contrast
(OMNIPAQUE, 350mg/ml) and 25 ml of saline was infused through antecubital vein with power
injector and bolus tracking was used to initiate scanning. Both arterial and venous phase were
taken. Acquired images were analysed at PHILIPS BRILLIANCE Workstation. Images were viewed
in multiple views and 3D reconstruction. A diagnosis of ruptured aneurysm arising from
supraclinoid portion of left internal carotid artery was made (Figures 1 & 2). These findings were
confirmed and intraoperative an aneurysm clip was positioned at the site of aneurysm.
Postoperative CT cerebral angiography was performed to know status of the clip and aneurysm
(Figure 3 & 4). There were no complications after surgery.
DISCUSSION: One of the most important causes of subarachnoid haemorrhage is ruptured
cerebral aneurysm. Cerebral digital subtraction angiography has been used as the gold standard
for aneurysm detection.[1,2,3,4] However, DSA has the disadvantage of being an invasive study. The
risk of acquiring a permanent neurologic deficit with cerebral angiography in patients with
subarachnoid haemorrhage is around 0.1%.[5,6,7] Computed tomographic cerebral angiography is
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 27/July 06, 2015
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CASE REPORT
a noninvasive imaging modality that is being increasingly used for the evaluation of suspected
intracranial aneurysms. The introduction of 64 slice and 128 slice CT scanners has greatly
advanced the role of CT angiography in neurovascular imaging.[8,9,10]
The technique of CT angiography entails fast thin section volumetric spiral CT examination
performed with a time optimized bolus of contrast medium.[11] A bolus tracking method is used
routinely to achieve optimal synchronization of contrast medium flow and scanning. Usually 70-80
ml of non-ionic contrast material is administered followed by a saline chase. Once the source
images are acquired, CT angiography data can be evaluated by variety of techniques. The most
widely used techniques are multiplanar reformation (MPR), thin-slab maximum intensity
projection (MIP) and volume rendering. Sophisticated segmentation algorithms, vessel analysis
tools and automatic lumen boundary definition are established techniques.
Aneurysm if identified is characterized according to shape as saccular, lobulated or
fusiform. Signs of aneurysmal rupture like lobulated appearance, tit sign or contrast extravasation
are documented. Imaging after surgical aneurysm clipping has traditionally been achieved with
conventional catheter-based angiography. CT angiography may provide an acceptable alternative
in many cases.[12] It can often effectively depict aneurysm remnants, demonstrate patency,
stenosis, or vasospasm in the adjacent parent vessels. Accurate detection and characterization of
intracranial aneurysms is an essential prerequisite for surgical treatment planning.
Pitfalls of CT angiography include lack of visibility of small arteries, difficulty in
differentiating the infundibular dilatation at the origin of an artery from an aneurysm, the kissing
vessel artifact, demonstration of venous structures that can simulate aneurysms, inability to
identify thrombosis and calcification on three-dimensional images, and beam hardening artifacts
produced by aneurysm clips. Small perforating arteries with a diameter below 0.5 mm are not
visible on CT angiograms.[11,13]
Recent studies found higher overall detection rates of up to 97%, and some authors
already solely rely on the findings of CT angiography in patients with subarachnoid
haemorrhage.[11] Imaging after surgical aneurysm clipping has traditionally been achieved with
conventional catheter-based angiography, CT angiography (CTA) may provide an acceptable
alternative in many cases[14,15]
CONCLUSION: Digital subtraction CT angiography can be the preferred noninvasive modality for
the evaluation of intracranial aneurysms in patients with acute subarachnoid haemorrhage
because of its high diagnostic accuracy, short scan time and noninvasiveness.[4,13,16] Negative CT
angiography findings in a patient with SAH must always be corroborated with DSA. CTA is an
accurate imaging technique for detection and characterization of intracranial aneurysms and has
the potential to substitute, in most cases, for DSA.
REFERENCES:
1. Timothy J. Kaufmann and David F. Kallmes. Diagnostic Cerebral Angiography: Archaic and
Complication-Prone or Here to Stay for another 80 Years? American Journal of
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J Neuroradiol 2008; 29(3): 594– 602.
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Figure 1: 3D CT angiography axial view image showing aneurysm arising from supraclinoid
portion of left internal carotid artery (arrow).
Figure 2: 3D CT angiography oblique view showing the aneurysm (arrow).
Figure 1
Figure 2
Figure 3: Post-operative axial CT image showing the aneurysmal clip.
Figure 4: Post-operative CT angiography showing the aneurysmal clip.
Figure 3
Figure 4
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CASE REPORT
AUTHORS:
1. Deepa Gandra
2. Chennamaneni Vikas
PARTICULARS OF CONTRIBUTORS:
1. Assistant Professor, Department of
General Medicine, Prathima Institute
of Medical Sciences, Nagunur,
Karimnagar.
2. Associate Professor, Department of
Radiology, Prathima Institute of
Medical Sciences, Nagunur,
Karimnagar.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Deepa Gandra,
H. No. 3-1-294,
Opposite Children’s Home,
Christian Colony,
Karimnagar-505001.
E-mail: deepagandra@yahoo.co.in
Date
Date
Date
Date
of
of
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Submission: 22/06/2015.
Peer Review: 23/06/2015.
Acceptance: 26/06/2015.
Publishing: 06/07/2015.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 27/July 06, 2015
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