Overviewofimagingmodalitiesfor

cerebralaneurysms

SoroushZaghi
BIDMCPCE:Radiology
August2008
(ImagesfromBIDMC,PACS.)

OurPatient:Presentation

Ourpatientisa57y/o womanwhoreportsblowinghernosewitha
subsequent"worstheadacheofherlife."Shedescribestheheadacheas
painina"helmetlike"cranialdistribution.Shereportsanearsyncope
eventandsaysshevomitedonce.

T:99.3BP:107/58HR:84RR:16O2Sats:100%RA.
Noacutedistress.
Alert,oriented,andcooperative.
CNIIXIIintactindetail.
Nofocalneurologicaldeficits.

MildKernig's sign:flexionoflegathipandkneecausespain,spasm,or
resistance;asignofmeningeal irritation.

Ourpatient:AxialC HeadCT

Fociofincreasedattenuationintheoccipital
hornsofthelateralventriclesconsistentwith
layeringofblood,anabnormalfinding.
Calcifiedpinealgland,normal.

Calcificationinchoroidplexus,normal.

(ImagesfromBIDMC,PACS.)

OurPatient:AxialC HeadCT(cont)

Continuingcaudallydownthis
axialCTatthelevelofthe
frontalsinus

Hyperdense layeringisapparent
alongthefrontalparietalhorn
attheSylvian fissure.

Thisimageisconsistentwith
subarachnoidhemorrhage.

(ImagefromBIDMC,PACS.)

SubarachnoidHemorrhage

SymptomsofSAHresultfrombloodspillingintotheCSFandthe
subsequentincreasedintracranialpressureandbreakdownofblood
products.

Symptomsincludeanintenseheadachewithrapidonset,vomiting, and
alteredlevelofconsciousness.Signsofmeningeal irritationmayalsobe
present.

CTistheimagingmodalityofchoiceforsuspectedintracranialbleeds.

Carefullyplannedlumbarpunctureisindicatedforthe3%ofpatientswho
presentclinicallywithsymptomsofSAHbutshownosignsofbleedingon
CTscan.

ManagementofSAH

ItisquiteimportanttodistinguishbetweenSAHduetoaneurysmal rupture
fromothercausesofSAH.
Othercausesinclude:Inflammatoryandnon inflammatorylesionsofcerebral
arteries,vascularlesionsofspinalcord,sicklecelldisease,drugabuse,
coagulopathy,andtumors.(SeeappendixE.)

85%ofSAHarecausedbyruptureofcerebralaneurysm.
Intracranialaneurysmsarecommon(15%ofadults),andrupture
accountsfor515%ofstroke.
Thecasefatalityafteraneurysmalhaemorrhage is50%.
ThemostimminentdangerisriskofREBLEEDING!!

ImagingModalities
Computedtomographyangiography(CTA)
Magneticresonanceangiography(MRA).
Intraarterialdigitalsubtractionangiography
(IADSA)

CTA
Involvesobtaininganormal
CToftheheadwhileIV
contrastmaterialisinjected
intoaperipheralvein.

Contrastmaterialisradiopaque soitappearswhiteontheCTimage
(upperleft).

SerialaxialslicesoftheCTscanareanalyzedbyacomputerprogram
forminga3Dreconstructionofthevascularanatomy(upperright).

Benefits:sensitiveandnoninvasive.
Limitations:radiationexposure;contrastmaterialmaybe
nephrotoxic orallergenic.
(ImagesfromBIDMC,PACS.)

Ourpatient:
BasilarTipAneurysmonC+CTHead

Coronalviewofthebrainin
contrastenhancedCTA.

Weseeafocaldilatationatthe
tipofthebasilarartery.

Thisisaradioopaque,smooth
marginated,saccular outpouching
ofthecerebralvasculature.

C/wintracerebral aneurysm.

(ImagefromBIDMC,PACS.)

OurPatient:CTAReconstruction
7mmaneurysm
ofthetipofthe
basilarartery

Superior
Cerebellar Artery(right)

PosteriorCerebralArtery

AnteriorInferiorCerebellar
Artery(left)
BasilarArtery
PosteriorInferiorCerebellar
Artery(right)
LeftVertebralArtery

RightVertebralArtery

(ImagefromBIDMC,PACS.)

CompanionPatient1:MRA

MRAisanimagingtechniquesimilartoCTA
thatdoesnotrequiretheuseofIVcontrast
material.

Thesignalobtaineddependsonthe
magneticpropertiesoftheareabeing
imaged.

Amagneticpulsealignsalltheprotonsina
certainarea;measuringtheamountoftime
ittakesforthoseprotonstoreturntotheir
premagnetizedstategeneratesamagnetic
resonancesignal.

Withamovingsubstance,suchasblood,the
protonsalignedduringthemagneticpulse
moveoutoftheareabeingimagedandnon
magnetizedprotonstaketheirplace.This
createsasignalvoid,whichisseenasareas
ofhypointensity onthisimage.

Gadoliniumcanbeusedtoprovideenhanced
imagingonMRA.

C MRAofacompanionpatient

Benefits:noninvasive,noradiationexposure,
IVcontrastnotrequired,canbeusedin
patientsallergictoiodinebasedcontrast.
Limitations:limitedspatialresolution,
expensive.
(ImagefromBIDMC,PACS.)

CompanionPatient2:
Intraarterialdigitalsubtractionangiography(IADSA)

IADSAisatechniqueoffluoroscopyusedininterventional
radiologytovisualizebloodvesselsinthebony
environmentoftheskull.

Acomputerprogramcomparesxrayimagesofthebrain
beforeandafterradiopaque iodinebaseddyehasbeen
injectedviaanintraarterialcatheterattheregionof
interest.

Tissuesandbloodvesselsonthefirstimagearedigitally
subtractedfromthesecondimage,leavingaclearpicture
ofthearterialnetwork.

Theimagescanbereconstructedtoprovidea3Drotational
view.

Benefits:Highestspatialresolution.
Limitations:Costly,invasive,increasedrisk(0.5%ofpatientsareleftwith
permanentneurologicalcomplications).
(CompanionPatient2,C+IADSA,ImagesfromBIDMC,PACS.)

CompanionPatient2:IADSA,cont.

Anadditionalbenefitofintraarterial
angiographyisthecapacitytodeliver
endovasculartreatmentsatthesiteof
pathology.

Hereweseeadeployedplatinumcoilat
thesiteofapreviousaneurysmofthe
anteriorcommunicatingartery.

ManagementofCerebralAneurysm
50 80%ofaneurysmswillneverruptureduringapersons
lifetime
Riskofruptureisrelatedtosizeofaneurysm
Smallaneurysms(<710mmindiameter)
Riskofrupture=0.05%peryear
Largeaneurysms(>10mm)
Riskofrupture=1%peryear
Riskofintervention(0.5%)outweighsbenefitforsmall
aneurysms.

GuidelinesforEndovascularTreatment

Patientsshouldnot undergointerventionformanagementofcerebral
aneurysmwhen:
Aneurysmsize<7mmindiameter
And
Lackofsymptoms
Locationofaneurysmattheanteriorcirculation
Ageolderthan64yearsold,
NopersonalorfamilyhistoryofSAH.

Patientswhoshould betreated:
Patientsyoungerthan50years,withsymptomaticaneurysmofsize
>25mmintheposteriorcirculationwithapersonalorfamilyhistory
ofSAH.

Insituationsbetweenthesetwoextremes,thebesttreatmentdecisionis
oftennotclearandlefttoclinicaljudgment.

TreatmentOptions
Observation:SerialnoninvasivemonitoringwithMRA,
CTA,orevenpossiblytranscranial Doppler
ultrasonography.
EndovascularTherapy: Intravasculardeliveryofa
thrombogenic coilcompletelyfillsthelumenofthe
aneurysm,inducestheformationofathrombus,and
occludestheaneurysmpreventingfuturerupture.
SurgicalTherapy: Surgicalplacementofaclipatthe
junctionofhealthyarteryandtheneckoftheaneurysm.

OurPatient:FollowUp

Patientwasadmittedtoneurosurgeryforasubarachnoidhemorrhage.

ItwasdeterminedthattheSAHwassecondarytoarupturedbasilartipaneurysm.

Shewenttotheangiographysuiteonthedayofpresentation.

Angiogramrevealedthepresenceofbothabasilarandananteriorcommunicating
artery(ACOMM)aneurysm.

Sheunderwentcoilingofthebasilararteryaneurysmthatdayandsheunderwent
coilingfortheACOMManeurysmthreedayslater.Shetoleratedbothprocedurewell.

Shewasdischarged8daysafterinitialpresentation.

Followupexaminationatonemonthshowednofocalneurologicaldeficits,andher
onemonthfollowupCTAshowedthatbothaneurysmswerecoiledandhadnot
recanalized.

Sheiscurrentlyscheduledforfollowupcerebralangiographyat6months.

Summary

Welearnedthattheimagingmodalityofchoiceforasuspected
intracranialbleedisanoncontrastCT.

Welearnedthatruptureofacerebralaneurysmaccountsforthevast
majorityofsubarachnoid bleeds.

ImagingmodalitiesforcerebralaneurysmsincludeCTA,MRA,IADSA.We
viewedexamplesofeachanddiscussedtheriskandbenefits.

Intraarterialcoilembolization canbeahighlyeffectivetreatmentfor
cerebralaneurysm,butcarriessomerisk.

Endovasculartreatmentisindicatedforaneurysms>7mminsizeandat
highriskofrupture.

Appendix
A)AnatomyReview:TheCircleofWillis.
B)Mostcommonsitesof cerebralaneurysms.
C)Commonsitesofcerebralaneurysms(alternateview).
D)Riskfactorsforcerebralaneurysm.
E)Rarecausesofsubarachnoidhemorrhage.

A)AnatomyReview:TheCircleofWillis.

CircleofWillis.
Wikipedia.Adaptation
basedonGraysAnatomy,
1919.Imagereleasedto
publicdomain.Last
accessed:August18,2008

B)Mostcommonsitesofcerebralaneurysms.
AnteriorCommunicating
Artery:30%
PosteriorCommunicating
Artery:25%
MiddleCerebralArtery:20%
InternalCarotidArtery
Bifurcation:7.5%
BasilarTip:7%
Pericallosal artery:4%
PosteriorInferiorCerebellar
Artery:3%

Brisman,et al(2006).MedicalProgress:CerebralAneursyms.
NEJM355;9:August31,2006.

C)Commonsitesofcerebralaneurysms(alternateview).

JanvanGijn,Richard
SKerr,andGabrielJE
Rinkel (2007).
Subarachnoid
haemorrhage. The
Lancet.Volume369,
Issue9558,27
January20072
February2007,Pages
306318.

D)Riskfactorsforcerebralaneurysm.

Polycystickidneydisease
Coarctation oftheaorta
Anomalousvessels
Fibromuscular dysplasia
Connectivetissuedisorders(eg,Marfan,Ehlers
Danlos)
Highflowstates(eg,vascularmalformations,
fistulae)
Spontaneousdissections

E)RareCausesofSAH.
Inflammatorylesionsofcerebralarteries
Mycotic aneurysms
Borreliosis
Behets disease
Primaryangiitis
Polyarteritis nodosa
ChurgStrausssyndrome
Wegenersgranulomatosis
Noninflammatorylesionsofintracerebral
vessels
Arterialdissection
Cerebralarteriovenous malformations
Fusiform aneurysms
Cerebraldural arteriovenous fistulae
Intracerebral cavernousangiomas
Cerebralvenousthrombosis
Cerebralamyloid angiopathy
Moyamoya disease

Vascularlesionsinthespinalcord
Saccular aneurysmofspinalartery
Spinalarteriovenous fistulaormalformation
Cavernousangioma atspinallevel
Coagulopathies.
Drugs
Cocaineabuse
Anticoagulantdrugs
Tumours
Pituitaryapoplexy
Cerebralmetastasesofcardiacmyxoma
Malignantglioma
Acousticneuroma
Angiolipoma
Schwannoma ofcranialnerve
Cervicalmeningiomas
Cervicalspinalcordhaemangioblastoma
Spinalmeningeal carcinomatosis
Melanomaofthecauda equina

Sicklecelldisease.
(Panel1.fromJanvanGjin,etal.2007:Subarachnoid
haemorrhage. TheLancet.)

Acknowledgement
ThankyoutoDr.Ajith ThomasandDr.
GillianLiebermanfortheirhelpinthe
preparationofthispresentation.

Bibliography
Keedy,Alexander(2006).Anoverviewofintracranial
aneurysms. McGillJournalofMedicine,2006:9(2):141146.
Brisman,J.L.;Song,J.K.;Newell,D.W.(2006).Medical
Progress:CerebralAneurysms. NEJM2006:355:92839.
JanvanGijn,RichardSKerr,andGabrielJERinkel (2007).
Subarachnoidhaemorrhage. TheLancet.Volume369,Issue
9558,27:306318.