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..Currentusageofthree-dimensionalcomputedtomographyangiographyforthediagnosisandtreatmentofrupturedcerebralaneurysmsKenichiAmagasakiMD,NobuyasuTakeuchiMD,TakashiSatoMD,ToshiyukiKakizawaMD,TsuneoShimizuMDKantoNeurosurgicalHospital,Kumagaya,Saitama,JapanSummaryOurpreviousstudysuggestedthat3D-CTangiographycouldreplacedigitalsubtraction(DS)angiographyinmostcasesofrupturedcerebralaneurysms,especiallyintheanteriorcirculation.Thisstudyreviewedourfurtherexperience.OnehundredandfiftypatientswithrupturedcerebralaneurysmsweretreatedbetweenNovember1998andMarch2002.Only3D-CTangiographywasusedforthepreoperativework-upstudyinpatientswithanteriorcirculationaneurysms,unlesstheattendingneurosurgeonsagreedthatDSangiographywasrequired.Both3D-CTangiographyandDSangiographywereperformedinpatientswithposteriorcirculationaneurysms,exceptforrecentcasesthatwerepossiblytreatedwith3D-CTangiographyalone.Onehundredsixteen(84%)of138patientswithrupturedanteriorcirculationaneurysmsunderwentsurgicaltreatment,butadditionalDSangiographywasrequiredin22cases(16%).资料 ..Onlytworecentpatientsweretreatedsurgicallywith3D-CTangiographyalonein12patientswithposteriorcirculationaneurysms.Mostpatientswithrupturedanteriorcirculationaneurysmscouldbetreatedsuccessfullyafter3D-CTangiographyalone.However,additionalDSangiographyisstillnecessaryinatypicalcases.3D-CTangiographymaybelimitedtocomplementaryuseinpatientswithrupturedposteriorcirculationaneurysms.a2003ElsevierLtd.Allrightsreserved.Keywords:3D-CTangiography,cerebralaneurysm,subarachnoidhaemorrhage,surgeryINTRODUCTIONRecently,three-dimensionalcomputedtomography(3D-CT)angiographyhasbecomeoneofthemajortoolsfortheidentificationofcerebralaneurysmsbecauseitisfaster,lessinvasive,andmoreconvenientthancerebralangiography.1–7Patientswithrupturedaneurysmscouldbetreatedunderdiagnosesbasedononly3D-CTangiography.5;63D-CTangiographyhassomelimitationsforthepreoperativework-upforrupturedcerebralaneurysms,soadditionaldigitalsubtraction(DS)angiographyisstillnecessary,especiallyforaneurysmsintheposteriorcirculation.8Ourpreviousstudy资料 ..suggestedthat3D-CTangiographycouldreplaceDSangiographyinmostpatientswithrupturedcerebralaneurysmsintheanteriorcirculation.1Thisstudyreviewedourexperienceoftreatingrupturedcerebralaneurysmsintheanteriorandposteriorcirculationsbasedon3D-CTangiographyin150consecutivepatientstoassessthecurrentusageof3D-CTangiography.METHODSANDMATERIALPatientpopulationWetreated150patients,60menand90womenagedfrom23to80years(mean57.5years),withrupturedcerebralaneurysmidentifiedby3D-CTangiographybetweenNovember1998andMarch2002.ManagementofcasesThepresenceofnontraumaticsubarachnoidhaemorrhage(SAH)wasconfirmedbyCTorlumbarpuncturefindingsofxanthochromiccerebrospinalfluid.3D-CTangiographywasperformedroutinelyinallpatients.DSangiographywasperformedinpatientswithanteriorcirculationaneurysmsonlyifadditionalinformationwasconsiderednecessaryfollowingaconsensusinterpretationoftheinitialCTand3D-CTangiographybyfourneurosurgeons.Patientswithruptured资料 ..aneurysmsintheposteriorcirculationunderwentboth3D-CTangiographyandDSangiographyexceptfortworecentpatientswithtypicalvertebralarteryposteriorinferiorcerebellarartery(VA-PICA)aneurysm.Typicalsaccularaneurysmsweretreatedbyclippingsurgery.Fusiformanddissectinganeurysmsweretreatedbyproximalocclusionbyeithersurgeryorendovasculartreatmentwithorwithoutbypasssurgery.Regrowthofbleedinganeurysmswastreatedbyeithersurgeryorendovasculartreatment.Postoperatively,allpatientsweremanagedwithaggressivepreventionandtreatmentofvasospasmincludingintra-arterialinfusionofpapaverineortransluminalangioplasty.3D-CTangiographyacquisitionandpostprocessingCTangiographywasperformedwithaspiralCTscanner(CT-W3000AD;Hitachi,Ibaraki,Japan).Acquisitionusedastandardtechniquestartingattheforamenmagnum,withinjectionof130mlofnonioniccontrastmaterial(Omnipaque;DaiichiPharmaceutical,Tokyo,Japan).Thesourceimagesofeachscanweretransferredtoanoff-linecomputerworkstation(VIPstation;TeijinSystemTechnology,Japan).Bothvolume-renderedimagesandmaximumintensityprojectionimagesofthecerebralarterieswereconstructed.Theanterior资料 ..circulationandposteriorcirculationwereevaluatedseparatelyonthevolume-renderedimages,afterageneralsuperiorviewwasobtained.Theanteriorcirculationwasevaluatedbyfirstobservingtheanteriorcommunicatingartery(ACoA)byrotatingtheview,andtheneachsideofthecarotidsystembyrotatingtheimagewitheditingoutofthecontralateralcarotidartery.Theposteriorcirculationwasalsoevaluatedbyrotatingtheimagebutwithouteditingoutofanyvessel.Onceapossiblerupturesitewasfound,theviewwaszoomedandcloselyrotatedwiththeothervesselseditedout.Theaneurysmsizewasmeasuredon3D-CTangiographyasthelargerofthelengthofthedomeorthewidthoftheneck.Manipulationwasperformedbythescannertechnician,withaneurosurgeontoprovideeditingassistance.DSangiographyacquisitionStandardselectivethree-orfour-vesselDSangiogramswithfrontal,lateral,andobliqueprojectionswereobtained.The3D-CTangiogramwasalwaysavailableasaguideforpossibleadditionalDSangiographyprojections.AneurysmsizewasmeasuredwithDSangiographywhenthequalityof3D-CTangiographywasinadequate.AllpatientsexceptelderlypatientsorpatientsinsevereconditionunderwentDS资料 ..angiographypostoperatively.GradingofpatientsTheclinicalconditionsofthepatientsatadmissionwereclassifiedaccordingtotheHuntandKosnikgrade.9Clinicaloutcomewasdeterminedat3monthsaccordingtotheGlasgowOutcomeScale.10RESULTSTheaneurysmlocationsandsizesareshowninTable1.Onehundredsixteen(84%)of138casesofaneurysmsintheanteriorcirculationweretreatedafteronly3D-CTangiography,and22cases(16%)requiredadditionalDSangiography.Tenof12casesofaneurysmsintheposteriorcirculationrequiredboth3D-CTangiographyandDSangiography,buttworecentcasesoftypicalVA-PICAaneurysmwereclippedafteronly3D-CTangiography(Fig.1).Thefirst10ofthe22casesintheanteriorcirculation,whichrequiredadditionalDSangiographyweredescribedpreviously,1sothemostrecent12patientsarelistedinTable2.Theserecentcasesincludedsomeatypicalaneurysms.Cases6and8hadafusiformaneurysmoftheinternalcarotidartery(ICA).AdditionalDSangiographywasperformedtoobtainhaemodynamicinformation.ICAtrappingwithsuperficial资料 ..temporalartery-middlecerebralarteryanastomosiswasperformedinCase6becausetheatheroscleroticarteriesfailedtodemonstratetheballoonocclusiontest(Fig.2).ICAocclusionbyendovasculartreatmentwasperformedinCase8becausethepatientcouldtoleratetheballoonocclusiontest.Cases4,9,and10sufferedregrowthofbleedinganeurysmsafterclippingsurgery.Clipartifactspreventedevaluationoftherupturedsiteaswellasidentificationofdenovoaneurysmsinthesecases(Fig.3).SurgicalclippingwasperformedinCases4and10andendovasculartreatmentinCase9.Case11hadanACoAaneurysmassociatedwithanarteriovenousmalformation(AVM)(Fig.4).DSangiographywasperformedtoevaluatetheAVM.Case12hadalargeICA-posteriorcommunicatingartery(PCoA)aneurysm,andadditionalDSangiographywasperformedbecausethePCoAcouldnotbedetectedby3D-CTangiography(Fig.5).Cases1,2,3,5,and7presentedwithsmallaneurysms,andDSangiographywasperformedtoexcludeotherlesionsaswellastoobtaininformationabouttheproximalICAforpatientswithsupraclinoidtypeaneurysms.Table1Distributionandsizeofcerebralaneurysmsin150consecutivepatients资料 ..SiteNo.ofpatientsAnteriorcirculation138ICA(supraclinoid)3ICAbifurcation1ICA-OphA3ICA-PCoA39(1)ICAfusiform2ACoA50DistalACA4MCA36(1)Posteriorcirculation12PCA1BAtip3BA-SCA1BAtrunk1(1)VA-PICA3VAdissecting3(1)Size(mm)<542P5to<1299P129资料 ..Numberinparenthesesindicatespatientswhounderwentendovasculartreatment.OphA,ophthalmicartery;ACA,anteriorcerebralartery;MCA,middlecerebralartery;PCA,posteriorcerebralartery;BA,basilarartery;SCA,superiorcerebellarartery.Table2TwelvepatientswithrupturedanteriorcirculationaneurysmswhounderwentadditionalDSangiographyCaseNo.LocationSize(mm)1lt.ICA-PCoA3.12ACoA2.23lt.ICAsupraclinoid1.64lt.ICA-PCoA7.85lt.ICAsupraclinoid2.46lt.ICA(fusiform)11.87lt.ICA-PCoA3.28rt.ICA(fusiform)18.89lt.MCA9.610lt.ICA-PCoA10.511ACoA10.1资料 ..12lt.ICA-PCoA18.2Thesurgicalfindingscorrelatedwellwiththe3D-CTangiographyorDSangiography.Table3showstheconditiononadmissionandoutcomeat3monthsaftersurgery.Somepatientswithgoodgradesonadmissiondiedofseverespasm,acutebrainswelling,orpoorgeneralcondition,buttheseoutcomeswerenotrelatedtothepreoperativeradiologicalinformation.DISCUSSIONThepresentstudyofrupturedaneurysmsinbothanteriorandposteriorcirculationsfoundthattheindicationsforadditionalDSangiographyintheanteriorcirculationaresimilartothatfoundpreviously,butweexperiencedsomenewatypicalcases.Treatmentoffusiformaneurysmsdependsonthehaemodynamicinformation,whichcouldonlybeobtainedbyDSangiography.ACoAaneurysmassociatedwithAVM,althoughtheinitialCTindicatedthattheaneurysmhadbled,requiredaccurateevaluationoftheAVMpriortosurgery.Clipartifactsaffected3D-CTangiographyincasesofrecurrentSAHafterclippingsurgery,so3DCTangiographyisnotindicatedforsuchcases.3D-CTangiographywasonlyofcomplementaryuseinmostofthe12casesofposteriorcirculationaneurysms.Onlytwocasesof资料 ..typicalVA-PICAaneurysmsweretreatedbasedononly3D-CTangiography.Typicalbasilarartery-superiorcerebellararteryandVA-PICAaneurysmscanbetreatedsurgicallyafteronly3D-CTangiography.DSangiographyshouldalwaysbeperformedforbasilartipaneurysmstoevaluatetheperforatingarteriesnearbyaswellasassessthevesseltortuosityforthepossibilityofendovasculartreatment.TreatmentofVAdissectinganeurysmsneedsinformationaboutthetrueandfalselumensoftheVAwhichrequiresDSangiography.ThesmallpopulationofposteriorcirculationaneurysmsinthisstudyindicatesthatthevariationofaneurysmsaswellasthetreatmentchoicesintheposteriorcirculationrequireDSangiographyinmostcases.Inourseries,mostaneurysmsmeasured5–12mm,andtypicalsaccularaneurysmsofthatsizecouldbetreatedafter3D-CTangiography.However,therewereproblemswithsomelargeaneurysms.DSangiographywasnotnecessaryiftheneckandnearbyarteriesofalargeaneurysmwereclearlydetected.DSangiographywasnecessaryintwocasesoflargeaneurysms.Acaseoflargeophthalmicarteryaneurysmwaslocatedclosetotheanteriorclinoidprocess.1SmallPCoAaneurysmsmaynotbedetectedby3D-CTangiography,butthearterywouldnotbe资料 ..difficulttoobserveduringtheoperation.InourcaseofalargePCoAaneurysm,DSangiographywasperformedbecausethelargeneckwouldpreventintraoperativeobservationofthePCoA.Althoughnotexperiencedinourseries,treatmentincludingbypasssurgeryforsomelargeorgiantaneurysmswillrequirethehaemodynamicinformationprovidedbyDSangiography.Somesmallaneurysms(lessthan4mm)requiredadditionalDSangiography.3D-CTangiographymaybebetterfordetectingsmallaneurysmthanDSangiography.11;12However,wesuggestDSangiographyisstillnecessaryinthefollowingcases.Firstly,compatibilityoftheinitialCTscanandaneurysmlocationby3DCTangiographyisimportant.PatientswithrupturedaneurysmandasymmetricalSAHwithlateralitycompatiblewiththerupturesitepresentnoproblem.However,wecannotalwaysdependontheinitialCTscansiftheSAHisdiffuseorsymmetrical,especiallyifACoAaneurysmorbasilartipaneurysmisnotfoundtheresponsiblelesion.DSangiographyismoreusefultoexcludeotherlesionsbecauseofthesmoothopacificationofthevessels.Secondly,caseswithsmallaneurysmlocatedonthesupraclinoidportionrequireproximalICAcontrolduringtheoperation.DS资料 ..angiographyisnecessarytoprovideinformationaboutthehaemodynamicsincludingthecrosscirculation.Magneticresonance(MR)angiographyispotentiallytheonlymodalityrequiredforpreoperativeassessmentofrupturedcerebralaneurysms.13However,MRimagingistime-consumingandaccesstoMRscannersmayberestricted.PatientscouldbeinanunstableconditionintheveryearlyperiodofSAH,sothattheemergentconditionofthepatientscouldbemucheasiertomanageintheCTfacility.Ontheotherhand,MRangiographydoesreducetheuseofcontrastmedium,soisasafediagnostictool.MRangiographymaybethebestmodalityfordiagnosisinpatientswithgoodgradepresentingseveraldaysaftertheonset,becausetheriskofrerupturefallswithtime.3D-CTangiographyhasbeenusedtoanalyzetheanatomicalstructuresforsurgery.14;15Informationaboutthevenousandarterialstructuresneartheaneurysmarepreferable,butdonotalwaysreflectthefindingsofDSangiography.Normalanatomicalstructures,suchasperforatingarteriesandveins,arelikelytobeencounteredduringsurgeryalthoughnotdetectedclearlyby3D-CTangiography.Thisstudyoftheoverallmanagementofrupturedcerebral资料 ..aneurysmswith3D-CTangiographyandadditionalDSangiographyindicatesthatmorepatientswithanteriorcirculationaneurysmswillbetreatedafteronly3D-CTangiographyexceptforthefollowingcasesrequiringadditionalDSangiography:Aneurysmsclosetobonestructures,suchasanICA-ophthalmicarteryaneurysm;fusiformaneurysms,andlargeorgiantaneurysmsrequiringaccurateneckinformationandhaemodynamicinformationforbypasssurgery;patientswithdiscrepanciesbetweenthedistributionofSAHonCTandthelocationoftheaneurysm,especiallysmallaneurysms,toexcludeotherlesions;smallaneurysmslocatedonthesupraclinoidportionofICA,whichrequireinformationabouthaemodynamicsandproximalICAcontrol;regrowthofaneurysmsthatleadsclipartifacts;andaneurysmsassociatedwithAVMinrelatedlocations.Aclearconclusionaboutpatientswithposteriorcirculationaneurysmscannotbereachedbecauseofthesmallpopulation.Typicalbasilarartery-superiorcerebellararteryandVA-PICAaneurysmscanbetreatedsurgicallyafteronly3D-CTangiography,but3D-CTangiographymaybelimitedtocomplementaryuseforbasilartipaneurysmsandotherposteriorcirculationaneurysmsbecauseoftheneedforcloseobservationofnearbyperforatingarteriesandthepossibilityof资料 ..endovasculartreatment.Dissectinganeurysm,whichisoftenobservedintheVA,requiresDSangiographytodetecttrueandfalselumens.REFERENCES1.AmagasakiK,SatoT,KakizawaT,ShimizuT.Treatmentofrupturedanteriorcirculationaneurysmbasedoncomputerizedtomographyangiography:surgicalresultsandindicationsforadditionaldigitalsubtractionangiography.JClinNeurosci2002;9:22–29.2.AndersonGB,SteinkeDE,PetrukKC,AshforthR,FindlayJM.Computedtomographicangiographyversusdigitalsubtractionangiographyforthediagnosisandearlytreatmentofrupturedintracranialaneurysms.Neurosurgery1999;45:1315–1322.3.HsiangJN,LiangEY,LamJM,ZhuXL,PoonWS.Theroleofcomputedtomographicangiographyinthediagnosisofintracranialaneurysmsandemergentaneurysmclipping.Neurosurgery1996;38:481–487.4.LenhartM,BretschneiderT,GmeinwieserJ,UllrichOW,SchlaierJ,FeuerbachS.CerebralCTangiographyinthediagnosisofacutesubarachnoidhemorrhage.ActaRadiol1997;38:791–796.5.MatsumotoM,SatoM,NakanoMetal.Three-dimensional资料 ..computerizedtomographyangiography-guidedsurgeryofacutelyrupturedcerebralaneurysms.JNeurosurg2001;94:718–727.6.VelthuisBK,VanLeeuwenMS,WitkampTD,RamosLM,VanDerSprenkelJW,RinkelGJ.Computerizedtomographyangiographyinpatientswithsubarachnoidhemorrhage:fromaneurysmdetectiontotreatmentwithoutconventionalangiography.JNeurosurg1999;91:761–767.7.ZouaouiA,SahelM,MarroBetal.Three-dimensionalcomputedtomographicangiographyindetectionofcerebralaneurysmsinacutesubarachnoidhemorrhage.Neurosurgery1997;41:125–130.8.CarviyNievasMN,HaasE,HollerhageHG,DrathenC.Complementaryuseofcomputedtomographicangiographyintreatmentplanningforposteriorfossasubarachnoidhemorrhage.Neurosurgery2002;50:1283–1289.9.HuntWE,KosnikEJ.Timingandperioperativecareinintracranialaneurysmsurgery.ClinNeurosurg1974;21:78–79.10.JennettB,BondM.Assessmentofoutcomeafterseverebraindamage.Lancet1975;1:480–484.11.HashimotoH,IidaJ,HironakaY,OkadaM,SakakiT.Useofspiralcomputerizedtomographyangiographyinpatientswith资料 ..subarachnoidhemorrhageinwhomsubtractionangiographydidnotrevealcerebralaneurysms.JNeurosurg2000;92:278–283.12.TakabatakeY,UnoE,WakamatsuKetal.Thethree-dimensionalCTangiographyfindingsofrupturedaneurysmshardlydetectablebyrepeatedcerebralangiography.NoShinkeiGeka2000;28:237–243(Jpn).13.WatanabeZ,KikuchiY,IzakiK,WatanabeKetal.Theusefulnessof3DMRangiographyinsurgeryforrupturedcerebralaneurysms.SurgNeurol2001;55:359–364.14.KaminogoM,HayashiH,IshimaruHetal.Depictingcerebralveinsbythree-dimensionalCTangiographybeforesurgicalclippingofaneurysms.AJNRAmJNeuroradiol2002;23:85–91.15.VelthuisBK,vanLeeuwenMS,WitkampTD,RamosLM,vanderSprenkelJW,RinkelGJ.Surgicalanatomyofthecerebralarteriesinpatientswithsubarachnoidhemorrhage:comparisonofcomputerizedtomographyangiographyanddigitalsubtractionangiography.JNeurosurg2001;95:206–212.三维CT血管造影对破裂脑动脉瘤的诊断和治疗的当前应用资料 ..KenichiAmagasakiMD,NobuyasuTakeuchiMD,TakashiSatoMD,ToshiyukiKakizawaMD,TsuneoShimizuMDKantoNeurosurgicalHospital,Kumagaya,Saitama,Japan摘要我们以往的研究表明，3D-CT血管造影破裂脑动脉瘤大多数情况下，可以取代（DS）的数字减影造影，尤其是前循环的动脉瘤。本研究回顾了我们更多的经验。1998年11月和2002年3月间共收治一百五十脑动脉瘤破裂患者。只有3D-CT血管造影用于前循环动脉瘤患者的术前准备工作，除非在场的神经外科医生同意，才使用DS数字减影造影。对于后循环动脉瘤患者我们同时采用3D-CT血管造影和DS数字减影造影，只是最近我们才尝试单独使用3D-CT血管造影。164（84%）例前循环动脉瘤破裂患者中有138例需要手术治疗，但需要额外的DS数字减影造影的只有22（16%）例。在12例手术治疗的后循环动脉瘤患者中只有最近两例患者只使用三维CT血管造影。对于大部分单独前循环动脉瘤破裂患者来说，只需行3D-CT血管造影就可成功治疗。然而，非典型病例的额外的DS造影仍然是必要的。3D-CT血管造影在后循环动脉瘤破裂的患者中的使用可能会受到限制。关键词:3D-CT血管造影,颅内动脉瘤,蛛网膜下腔出血,外科引言最近，三维计算机断层扫描（3D-CT）造影成为脑动脉瘤鉴定的主要工具之一，它具有速度快，创伤小，比脑血管造影更方便的优点[1–7]。动脉瘤破裂患者可以在仅行有3D-CT血管造影诊断的基础上进行治疗[5－6]。3D-CT血管造影在破裂脑动脉瘤术前的准备工作方面资料 ..有一定的局限性，所以额外的数字减影（DS）的血管造影仍然是必要的，尤其是在后循环动脉瘤[8]。我们以往的研究表明，3D-CT血管造影在大部分前循环破裂脑动脉瘤患者的诊断中可以取代DS血管造影[1]。本研究回顾我们150例基于3D-CT血管造影治疗前循环和后循环破裂脑动脉瘤的经验，以评估目前3D-CT血管造影目前使用情况。方法和材料患者情况我们治疗的患者共150例，60名男性和90名妇女，年龄23至80岁（平均57.5岁），1998年11月至2002年三月之间以3D－CT血管造影确诊脑动脉瘤破裂。病例管理由CT或脑脊液的腰椎穿刺结果证实非创伤性蛛网膜下腔出血的存在。所有患者常规进行3D-CT造影。只有在四个神经外科医生分析初始的CT和3D-CT后共同认为需要更多的信息时才进行DS血管造影。在后循环动脉瘤破裂的患者中除了最近两个典型的椎小脑动脉（VA-PICA）瘤患者外都同时进行了三维CT血管造影和DS造影。对于典型的囊状动脉瘤使用夹闭手术治疗。梭形和夹层动脉瘤采用近端闭塞治疗，可以通过带或不带旁路手术的外科开放手术或介入手术治疗。对于再生动脉瘤可以采用外科开放手术或介入手术治疗。术后，对所有患者采用积极预防和治疗脑血管痉挛的措施，包括动脉内注射罂粟碱或腔内血管成形术。3D-CT资料 ..血管造影对螺旋CT扫描仪产生的血管造影影像进行采集和后处理(CT-W3000AD;日本茨县城，日立牌)。注射130ml非离子型造影剂(Omnipaque;日本东京第一制药公司)后从枕骨大孔区域开始，采用标准技术获取信息。每次扫描的源图像传输到一个离线的计算机工作站(VIPstation;日本帝人系统技术)。脑动脉的体积渲染图像和投影图像同时被建立。在得到较好的图像后，前循环和后循环分别在体积渲染图像进行了评价。首先通过旋转视图观察前交通动脉（ACOA）来对前循环进行评估，然后通过旋转删除对侧颈内动脉后的图像评估两侧颈动脉系统。后循环也通过旋转图像进行评估，但不需要删除任何血管。一旦发现一个可疑破裂的部位，就对已删除周围血管后的视图进行放大并密切观察。在3D-CT血管造影上测量动脉瘤的尺寸，包括瘤顶的大小、长度、瘤颈的宽度。机器由影像技术操作，神经外科医生提供编辑帮助。DS造影获取标准选择3或4组血管DS造影，得到正面，横向，斜向投影。对于可能需要的额外DS血管造影投影，3D-CT血管造影是始终可用的指导。如果3D-CT血管造影的质量不够，动脉瘤的大小由DS血管造影衡量。除老年患者或病情严重的患者，所有患者均接受DS造影术。患者分级患者入院时的临床情况根据Hunt分级和Kosnik分级级进行分类。[9]临床结果由3个月后的格拉斯哥愈后评分决定。结果动脉瘤的位置和大小，如表1所示。资料 ..164（84%）例前循环动脉瘤破裂患者中有138例需要手术治疗，但需要额外的DS数字减影造影的只有22（16%）例。12例后循环动脉瘤患者中有10例患者同时需要3D-CT血管造影和DS血管造影，但是最近两例典型的VA-PICA动脉瘤患者在只使用三维CT血管造影后顺利夹闭。22例前循环动脉瘤中的前10位需要前面所述的额外的DS血管造影[1]，最近的12位病人列在表2中。最近的这些案件包括一些非典型动脉瘤。第6和第8例有颈内动脉梭形动脉瘤（ICA）。为了获得血流动力学信息，做了额外的DS血管造影。在案例6中，ICA和颞浅动脉－大脑中动脉吻合失败，因为粥样硬化动脉不能耐受球囊阻断试验。因为病人能耐受球囊闭塞试验，案例8进行了ICA血管内介入闭塞治疗。案例4、9、和10在手术夹闭后发生了动脉瘤的复发。夹闭夹防止破裂部位再次出血，就像本例中动脉瘤头部特征。例4、例10和介入治疗的例9都采用了外科夹闭术。案例11是ACOA动脉瘤与动静脉畸形（AVM）。我们用DS血管造影来评估AVM。例12是一个巨大的ICA-后交通动脉瘤(PCoA)，因为3D-CT血管造影不能确诊，所以做了一个额外的DS血管造影。例1，2，3，5和7是小动脉瘤，都进行了DS血管造影以排除其他病变，并获得特殊类型动脉瘤患者的近端ICA的信息。表1150例脑动脉瘤的部位和大小部位病人数目前循环138ICA(上部)3ICA交叉处1资料 ..ICA-OphA3ICA-PCoA39(1)ICA梭形2ACoA50末端ACA4MCA36(1)后循环12PCA1BAtip3BA-SCA1BAtrunk1(1)VA-PICA3VAdissecting3(1)Size(mm)<542P5to<1299P129括号中的数字表明接受血管内介入治疗的患者。OphA,ophthalmicartery;ACA,anteriorcerebralartery;MCA,middlecerebralartery;PCA,posteriorcerebralartery;BA,basilarartery;SCA,superiorcerebellarartery.表212例破裂前循环动脉瘤接受额外的DS血管造影资料 ..编号位置大小(mm)1lt.ICA-PCoA3.12ACoA2.23lt.ICA上部1.64lt.ICA-PCoA7.85lt.ICA上部2.46lt.ICA(梭形)11.87lt.ICA-PCoA3.28rt.ICA(梭形)18.89lt.MCA9.610lt.ICA-PCoA10.511ACoA10.112lt.ICA-PCoA18.23D-CT血管造影或DS血管造影与手术结果相关性很好。表3显示了入院条件和手术后3个月的结果。有些患者入院时的分级较好但死于严重的脑血管痉挛，急性脑肿胀，或一般情况较差，但这些结果不涉及到术前的影像学信息。讨论目前的前循环和后循环动脉瘤破裂的研究发现，前循环进行额外的DS血管造影的适应症与以前的类似，但我们有了一些新的典型病例的经验。梭形动脉瘤的治疗取决于血流动力学信息，这只能由DS血管造影造影获得。ACoA资料 ..动脉瘤和血管畸形有关联，虽然最初的CT显示动脉瘤出血，仍然需要对动静脉畸形进行准确的术前评估。接受夹闭手术后的蛛网膜下腔出血病例的夹闭夹会影像3D-CT血管造影，所以3D-CT血管造影病例中未标识这类病例。3D-CT血管造影仅仅配套使用于12例后循环动脉瘤中的大多数。只有2例典型的VA-PICA动脉瘤的治疗仅基于3D-CT血管造影。典型的基底动脉，小脑上动脉和VA-PICA的动脉瘤，可仅凭3D-CT血管造影进行手术治疗。DS血管造影常被用于评估基底动脉尖动脉瘤附近的穿动脉及评估迂曲血管的血管内介入治疗的可能性。VA夹层动脉瘤的治疗需要使用DS血管造影来了解VA的真假官腔。这项研究表明，发病人数较少的后循环动脉瘤中的大部分病例需要用DS血管造影来明确动脉瘤的变化及后循环动脉瘤治疗方式的选择。在我们的研究系列中，大部分瘤体经测量直径为5-12毫米，这种规模的典型囊状动脉瘤可以在3D-CT血管造影下处理。但是，对于一些大型动脉瘤来说还是有问题的。如果颈部和附近的动脉的一个大瘤动脉能清楚地检测到，DS血管造影是没有必要的。有两种大型动脉瘤，DS血管造影是必须的。一种大型动脉瘤是靠近前床突的眼动脉瘤[1]。动脉瘤可能在3D-CT血管造影时不会被检测到，但是这列动脉瘤在手术中不难被发现。在我们的大型PCoA动脉瘤病例中，采用DS血管造影是由于宽大的瘤颈会阻碍我们术中观察PCoA。在我们的系列中没有需要在包括一些大型或巨大动脉瘤的旁路手术治疗中由DS血管造影提供血流动力学信息的经历。然而一些小的动脉瘤（小于4mm）需要额外的DS血管造影。虽然3D-资料 ..CT血管造影检测小动脉瘤时效果可能比DS血管造影更好[11，12]。但是，在下列的小动脉瘤病例中我们建议DS血管造影仍然是必需的。首先，相关的初始CT扫描及以3D－CT血管造影来确定动脉瘤的位置是重要的。动脉瘤破裂及不对称的一侧蛛网膜下腔出血患者出血部位所产生的表现是相似的。但是，我们不能总是依赖于初始CT扫描的蛛网膜下腔出血都是弥漫性或对称的，特别是没有发现主要病灶的ACoA动脉瘤或基底动脉顶端动脉瘤。在排除其他病因的时候DS血管造影更有效。第二，手术过程中需要控制近端ICA的床突上部小血管瘤，需要通过DS血管造影提供包括交叉循环情况在内的血流动力学信息。磁共振（MR）造影可能是破裂脑动脉瘤术前评估所需的唯一方式[13]。但是，MR图像耗时较长，且需要连接到MR扫描仪上，这可能是一个局限。病人在非常早期的蛛网膜下腔出血时可能处在一个不稳定状态，所以CT设备更容易管理这类处于紧急情况的病人。另一方面，磁共振血管造影减少造影剂的使用，因此是一种安全的诊断工具。磁共振血管造影可能是诊断在发病后数天评级较好的患者的最佳方式，因为随着时间的推移血管瘤再破裂的风险会下降。三维CT血管造影已被用来为手术分析解剖结构[14,15]。动脉瘤附近的静脉和动脉结构的信息是可取的，但并不总是反映DS血管造影的结果。正常的解剖结构，比如动脉和静脉，虽然在3D-CT血管造影中没有清晰的显示，在手术过程中经常会遇到。使用3D-CT血管造影和额外的DS造影对破裂颅内动脉瘤进行整体管理的研究表明，大部分前循环动脉瘤患者将只需要3D-CT血管造影资料 ..处理，只有下列情况需要额外的DS造影:靠近骨骼的动脉瘤，如眼动脉瘤;梭形动脉瘤,大型或巨型动脉瘤需要准确的瘤颈信息及旁路手术的血流动力学信息；患者CT显示的蛛网膜下腔出血部位和动脉瘤的位置有差异的，为了排除其它的发病灶；ICA床突上部的小动脉瘤，需要血流动力学信息和近端ICA控制的；因为夹闭夹导致的动脉瘤复发;及与AVM相关的动脉瘤。因为患者数少，对后循环动脉瘤患者不能得到一个明确的结论。典型的基底动脉，小脑上动脉和VA-PICA的动脉瘤，可在仅行3D-CT血管造影后手术治疗,但3D-CT血管造影可能仅限于基底动脉顶端动脉瘤和其它其他后循环动脉瘤的辅助诊断，因为需要密切观察附近的动脉并评估血管内介入治疗的可能性。常在VA发现的夹层动脉瘤需要DS血管造影来检测真假管腔。参考文献1.AmagasakiK,SatoT,KakizawaT,ShimizuT.Treatmentofrupturedanteriorcirculationaneurysmbasedoncomputerizedtomographyangiography:surgicalresultsandindicationsforadditionaldigitalsubtractionangiography.JClinNeurosci2002;9:22–29.2.AndersonGB,SteinkeDE,PetrukKC,AshforthR,FindlayJM.Computedtomographicangiographyversusdigitalsubtractionangiographyforthediagnosisandearlytreatmentofrupturedintracranialaneurysms.Neurosurgery1999;45:1315–1322.3.HsiangJN,LiangEY,LamJM,ZhuXL,PoonWS.Theroleof资料 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