Erlaubt die Computertomographie nach aneurysmatischer Subarachnoidalblutung die korrekte Vorhersage der Aneurysmalokalisation?

Zusammenfassung

Zielsetzung: Untersucht werden sollte, inwieweit die initiale Computertomographie (CT) nach akuter aneurysmatischer Subarachnoidalblutung die korrekte Vorhersage der Aneurysmalokalisation respektive des aneurysmatragenden Gefäßes erlaubt.
Methoden: Das Studienkollektiv bestand aus 99 konsekutiven Patienten mit akuter Subarachnoidalblutung und angiographischem Aneurysmanachweis. Ein Aneurysma der A. communicans anterior (ACoA) fand sich bei 38 Patienten, der A. cerebri media (MCA) bei 26 Patienten, der A. carotis interna (ICA) bei 25 Patienten, der A. pericallosa (A2) bei 5 Patienten, der A. basilaris (BA) bei 4 Patienten und der A. vertebralis (VA) bei 1 Patienten. 21 Patienten hatten ein weiteres asymptomatisches Aneurysma. Anhand der initialen CT-Bilder mussten 2 in der operativen Therapie kranieller Aneurysmen erfahrene Neurochirurgen die Lokalisation des rupturierten Aneurysmas in Unkenntnis des Angiographiebefundes benennen.
Resultate: Begutachter 1 gelang die korrekte Vorhersage der Aneurysmalokalisation in 56 (57 %), Begutachter 2 in 59 der 99 Fälle (60 %). Begutachter 1 gelang insbesondere die Identifikation der MCA-Aneurysmen (n = 21/26 MCA-Aneurysmen [81 %]), Begutachter 2 die Identifikation der ACoA- Aneurysmen (n = 28/38 [74 %]). Gemeinsam von beiden Begutachtern wurden allerdings nur 46 der 99 Aneurysmalokalisationen (47 %) korrekt benannt.
Schlussfolgerung: In Anbetracht des geringen Prozentsatzes korrekter Aneurysmalokalisationsvorhersagen anhand der Verteilung des subarachnoidalen Blutes im initialen CT lassen sich klinisch relevante Fragen (Identifikation des rupturierten Aneurysma bei Patienten mit multiplen Aneurysmen; explorative Operation bei nicht-perimesenzephaler SAB, aber negativer Angiographie) kaum beantworten.

Abstract

Objective: To investigate if the intracisternal distribution of subarachnoid hemorrhage (SAH) following aneurysm rupture allows the correct prediction of the symptomatic aneurysm site.
Methods: Ninety-nine consecutive patients with acute SAH and angiographically proven aneurysm were included into the study. The parent vessel of the diagnosed aneurysms were the anterior communicating artery (ACoA) in 38 patients, the middle cerebral artery (MCA) in 26 patients, the internal carotid artery (ICA) in 25 patients, the pericallosal artery (A2) in 5 patients, the basilar artery (BA) in 4 patients and the vertebral artery (VA) in 1 patient. In 21 patients, an additional asymptomatic aneurysm was diagnosed. The initial computerized tomography (CT) scans of the 99 patients were given to 2 experienced vascular neurosurgeons, who were blinded for the angiography findings. The 2 investigators had to predict the site of the ruptured aneurysm.
Results: Investigator 1 correctly predicted the aneurysm site in 56 (57 %), investigator 2 in 59 of the 99 patients (60 %). Investigator 1 correctly identified 81 % of the MCA aneurysms, and investigator 2 74 % of the ACoA aneurysms. However, in only 46 of the 99 patients (47 %), the aneurysm site was correctly predicted by both investigators together.
Conclusion: The results indicate, that the distribution of the subarachnoid blood as shown on the first CT scan after aneurysm rupture barely allows to predict the symptomatic aneurysm site. Thus, neurosurgical decision making (identification of the ruptured aneurysm in patients with multiple aneurysms; surgical exploration in patients with non-perimesencephal SAH, but negative angiography) should not rely on the first CT scan after SAH.

Schlüsselwörter

Aneurysma - Computertomographie - Subarachnoidalblutung - angiographisch okkultes Aneurysma - multiple Aneurysmen

Key words

Aneurysm - computerized tomography - subarachnoid hemorrhage - angiographically occult aneurysm - multiple aneurysms

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