When Is Diagnostic Subtraction Angiography Indicated Before Clipping of Unruptured and Ruptured Intracranial Aneurysms? An International Survey of Current Practice.

Martina Sebök,Marco Cenzato,Jean-Philippe Dufour,Yasuhiko Kaku,Luca Regli,Michihiro Tanaka,Tetsuya Tsukahara,Giuseppe Esposito

doi:10.1007/978-3-030-63453-7_2

Abstract

The goal of this survey is to investigate the indications for preoperative digital subtraction angiography (DSA) before clipping of ruptured and unruptured intracranial aneurysms in an international panel of neurovascular specialists. An anonymous survey of 23 multiple-choice questions relating to indications for DSA before clipping of an intracranial aneurysm was distributed to the international panel of attendees of the European-Japanese Cerebrovascular Congress (EJCVC), which took place in Milan, Italy on 7-9 June 2018. The survey was collected during the same conference. Descriptive statistics were used to analyze the data. A total of 93 surveys were distributed, and 67 (72%) completed surveys were returned by responders from 13 different countries. Eighty-five percent of all responders were neurosurgeons. For unruptured and ruptured middle cerebral artery (MCA) aneurysms without life-threatening hematoma, approximately 60% of responders perform surgery without preoperative DSA. For aneurysms in other locations than MCA, microsurgery is done without preoperative DSA in 68% of unruptured and in 73% of ruptured cases. In cases of ruptured MCA or ruptured non-MCA aneurysms with life-threatening hematoma, surgery is performed without DSA in 97% and 96% of patients, respectively. Factors which lead to preoperative DSA being performed were: aneurysmal shape (fusiform, dissecting), etiology (infectious), size (>25mm), possible presence of perforators or efferent vessels arising from the aneurysm, intra-aneurysmal thrombus, previous treatment, location (posterior circulation and paraclinoid aneurysm) and flow-replacement bypass contemplated for final aneurysm treatment. These are all factors that qualify an aneurysm as a complex aneurysm. There is still a high variability in the surgeons' preoperative workup regarding the indication for DSA before clipping of ruptured and unruptured intracranial aneurysms, except for ruptured aneurysms with life-threatening hematoma. There is a general consensus among cerebrovascular specialists that any angioanatomical feature indicating a complex aneurysm should lead to a more detailed workup including preoperative DSA.

Highlights

Digital subtraction angiography (DSA) is considered the gold standard for understanding the angioanatomy in ruptured and unruptured intracranial aneurysms (IAs) [1–5]
Responders were asked the situations and aneurysm locations (MCA or locations other than Middle cerebral artery (MCA)) in which microsurgical treatment is to be performed without preoperative DSA
The goal of the survey was to investigate, among an international panel of neurovascular specialists participating at the ninth EJCVC, the workup and in particular the indication for preoperative DSA for patients undergoing microsurgical treatment of ruptured or unruptured intracranial aneurysms

Summary

Introduction

Digital subtraction angiography (DSA) is considered the gold standard for understanding the angioanatomy in ruptured and unruptured intracranial aneurysms (IAs) [1–5]. Computed tomography angiography (CTA) has been introduced as an alternative imaging modality for ruptured aneurysms [6]. Sensitivities ranging from 77–97% and specificities ranging from 87–100% for the identification of ruptured aneurysms using CTA have been reported [3, 4, 7–9]. High-resolution magnetic resonance angiography (MRA), on the other hand, is frequently used for unruptured aneurysms as an alternative noninvasive modality [10]. In a systematic review [11] of studies evaluating the value of MRA for the diagnosis of intracranial aneurysms, a pooled sensitivity of 95% and pooled specificity of 89% have been reported.

Methods

Results

Conclusion