Three-dimensional Computed Tomography Angiography Research Articles

脳血管攣縮 経時的３Ｄ‐ＣＴＡによる，くも膜下出血後の脳血管攣縮の評価

We assess the usefulness of serial three-dimensional CT angiography (CTA) in the diagnosis of cerebral vasospasm (VS), and evaluate the contribution of VS to symptomatic vasospasm (SVS), cerebral infarction, and modified Rankin scale (mRS) in patients with aneurysmal subarachnoid hemorrhage (SAH). Within 3 hours after the onset of symptoms, CTA was performed in 48 patients with SAH. CTA was repeated on Day 5-8 (median 7) and Day 12-15 (median 14) to assess VS. Vasospasm was defined as ≥25% vascular narrowing, and rated with the following criteria (degree of VS): moderate spasm (25-50% decrease in vessel diameter), and severe spasm (≥50% decrease). Vasospasm was also categorized as follows (CTA grade): no VS, local VS, and diffuse VS. By local VS we mean an area of narrowing of the vessel in continuity with an aneurysm and not extending more than 2 cm to the aneurysm, or limited to the A-1, A-2 portion (≤2 cm). Diffuse VS means any stenosis affecting either a long segment of vessel or distal segments of cerebral arteries. Aggressive treatments for the VS including triple H therapy were started, when either SVS was revealed or Diffuse VS was detected on CTA. We statistically investigate correlations of Hunt and Kosnik grade, Fisher CT group, degree of VS, and CTA grade, with SVS, cerebral infarction, and mRS. Of the 48 patients, 32 (67%) showed VS and 19 (40%) revealed SVS by the 3rd CTA. Cerebral infarction on CT was detected in 13 (27%) patients. With logistic regression analysis, CTA grade significantly correlated with SVS and infarction, while Hunt and Kosnik grade and age of the patients significantly correlated with mRS. Prospective evaluation of CTA following SAH might allow early recognition of VS and promote aggressive treatment and improved neurological outcomes.

Unique variation of the hepatic artery identified on preoperative three-dimensional computed tomography angiography in surgery for gastric cancer: Report of a case

Hepatic artery injury is one complication associated with surgery for gastric cancer. This complication does not occur frequently, but it can cause serious problems. Anatomical variations of the hepatic arteries are thought to be a factor in such injuries. Recognizing vascular variations before the operation is thus very important. This report presents a case with a rare variation of the hepatic arteries identified on three-dimensional computed tomography (3D-CT) angiography before gastric cancer surgery. Hepatic artery injury was avoided as a result of the recognition of this extremely rare variation. Preoperative 3D-CT angiography is useful for preventing the complications associated with hepatic artery injury during surgery for gastric cancer.

Pulmonary Sequestration: Angioarchitecture Evaluated by Three-Dimensional Computed Tomography Angiography

Pulmonary sequestration represents an anomaly of nonfunctioning tracheobronchial branching with retention of the embryonic systemic arterial supply. We report a case of intralobar pulmonary sequestration, in which the abnormal supplying artery and especially the abnormal draining vein were demonstrated by three-dimensional computed tomography angiography and were confirmed and treated using a video-assisted thoracoscopic procedure.

Pulmonary vein analysis using three-dimensional computed tomography angiography for thoracic surgery

Little information is available regarding the variations in pulmonary vein anatomy for the purpose of thoracic or video-assisted thoracoscopic surgery (VATS). To learn about the types and frequency of pulmonary vein variations for VATS, we reviewed a "tailor-made virtual lung" of patients that was constructed using three-dimensional multidetector computed tomography (3D-MDCT) angiography. We reviewed routine 64-row 3D-MDCT pulmonary angiography of 140 patients before surgery between June 2006 and February 2009. We observed that most patients had the expected anatomy (98%) on the left side and on the right side (86%). On the right side, 10% of patients had three branches, and 4% patients had four or five branches. Independent drainage of the middle lobe vein directly into the left atrium was observed in 8% patients. Common ostia were observed on the left side in 33% and on the right side in 13% of the patients. The right inferior pulmonary veins branched immediately in 23% of the patients. Right isolated superior posterior branches were observed occasionally (2%). We observed common ostia more frequently on the left side than on the right. The middle lobe variations were frequent, and the right inferior pulmonary vein often divided at the root. Preoperative 3D-MDCT presented correct pulmonary vein anatomy of the patients.

Preoperative three-dimensional CT angiography to distinguish between an aberrant subclavian artery and a double aortic arch in thyroid surgery: Report of 2 cases

A non-recurrent inferior laryngeal nerve (NRILN), a very rare anatomic variation, is easily damaged during thyroid surgery. Due to impairments during embryonic development, a NRILN is frequently associated with an aberrant subclavian artery. Thus, an aberrant subclavian artery is now regarded as an important vascular anomaly for predicting the presence of a NRILN using various imaging modalities. However, precise imaging is often necessary as other vascular anomalies, such as a double aortic arch, can cause difficulties in discriminating between an aberrant subclavian artery and other anatomic variations. For this reason, computed tomography (CT) is usually necessary before thyroid surgery. but, to take more precise images, newly developed techniques such as computed tomography angiography (CTA) are needed. To indentify NRILNs, we performed CTA preoperatively in two patients with thyroid cancer. CTA demonstrated an aberrant subclavian artery with an associated NRILN in one patient and a double aortic arch with a recurrent inferior laryngeal nerve (RILN) in the second patient. Thyroid surgery was successful, and the laryngeal nerve was preserved in both patients. Preoperative CTA is much safer and less time-consuming than catheter angiography. Also, CTA is a cost-effective three-dimensional imaging modality for identifying aberrant subclavian arteries associated with NRILNs, as compared with double aortic arches associated with RILNs.

Clinical experience with the delay phenomenon in autologous breast reconstruction with the deep inferior epigastric artery perforator flap

The delay phenomenon has been used for breast reconstruction with pedicled flaps but has not been widely reported with free flaps. Our goals were to (1) describe our operative technique for vascular delay of deep inferior epigastric artery perforator (DIEP) flaps when a large percentage of the contralateral hemiabdomen would be needed for added volume of a breast reconstruction, (2) document any clinical improvement in flap vascularization after the delay period, and (3) develop a patient selection algorithm for this procedure. From August 2008 through July 2009, six patients at The Johns Hopkins Breast Center underwent autologous breast reconstruction with vascularly delayed DIEP flaps, a technique that preserves lateral skin bridges to the flap. This technique was used based on preoperative three-dimensional computed tomography angiograms showing potential vascular compromise. We assessed length of delay, flap weight, length of stay, and outcome. Transfer delay averaged 15.8 ± 4.1 days from the original surgery. Transferred flap weight averaged 620.2 ± 156.7 g. The flaps in all six patients developed adequate arterial inflow and/or venous drainage on reassessment at final transfer. Preoperative screening with three-dimensional computed tomography angiography of the abdominal wall and modification of the flap harvest technique, including use of the clamp test to establish need for delay, were thought to be paramount for patient selection. In a very select group of patients undergoing breast reconstruction whose DIEP flaps showed vascular compromise before detachment, the delay phenomenon successfully enhanced vascularity and prevented fat necrosis.

A comparison of 3D-CTA and 4D-CE-MRA for the dynamic monitoring of angiogenesis in a rabbit VX2 tumor

To compare three-dimensional computed tomography angiography (3D-CTA) and four-dimensional contrast-enhanced magnetic resonance angiography (4D-CE-MRA) for the in vivo monitoring of tumor angiogenesis. VX2 tumors were implanted into the right thigh muscle of 30 New Zealand white rabbits. The animals were randomly assigned to 5 groups, which, respectively, were scanned by 3D-CTA and 4D-CE-MRA on day 4, 7, 10, 13, or 16 after tumor implantation. After scanning, tumors were resected and processed for conventional histology and CD-31 immunohistochemistry. Tumor volume measurements derived from CT and MR imaging were compared with histopathological data. The minimum tumor diameter and the number of new tumor blood vessels detectable by 3D-CTA and 4D-CE-MRA were also compared. There were no significant differences in the tumor volume measurements derived from CT, MR, and histological analysis. The minimum diameter of tumor vessels detectable by 3D-CTA (0.68 ± 0.07 mm) was significantly less than that by 4D-CE-MRA (0.85 ± 0.12 mm) (P=0.005). The number of tumor vessels detected by each imaging method was not significantly different until day 13 after implantation, when 3D-CTA detected a greater number (P<0.001). The morphologic process of tumor angiogenesis was demonstrated dynamically by 3D-CTA and 4D-CE-MRA in vivo. Tumor angiogenesis can be dynamically monitored in vivo by 3D-CTA and 4D-CE-MRA. Of the two methods, 3D-CTA has better spatial resolution, but 4D-CE-MRA allows temporal resolution of tumor angiogenesis.

Diagnostic accuracy and inter-rater reliability of 64-multislice 3D-CTA compared to intra-arterial DSA for intracranial aneurysms

Catheter-based intra-arterial digital subtraction angiography (IADSA) is widely trusted for diagnosing cerebral aneurysms. However, three-dimensional CT angiography (3D-CTA) is evolving. This study compares the diagnostic performance and inter-rater reliability of 64-slice 3D-CTA and IADSA. Nineteen patients with 26 suspected cerebral aneurysms (23 with confirmed aneurysms, three negative controls) underwent both IADSA and 3D-CTA. Two independent reviewers assessed both imaging modalities for the presence of an aneurysm and subsequently described aneurysmal location, size, shape, orientation, and number of emanating arteries. Inter-observer agreement was followed to control for observer bias. The sensitivity of 3D-CTA was 78% and 96%, the negative predictive value (NPV) was 38% and 75%, and the accuracy of 3D-CTA was 81% and 96%. Both reviewers found 100% specificity and 100% positive predictive value (PPV). There was a clear correlation between 3D-CTA and IADSA for describing cerebral aneurysms. The authors conclude that 3D-CTA has equivocal diagnostic advantage but is less reliable for ruling out aneurysm presence. Anatomy, however, is superior with 3D-CTA.

Three-dimensional CT Angiography Is Useful for Diagnosis of Postabortion Uterine Hemorrhage: 3 Case Reports and Review of the Literature

Uterine hemorrhage is a major complication associated with abortion. There are various causes of postabortion uterine hemorrhage. The objective of this article is to estimate the efficacy of three-dimensional computed tomography (3D-CT) angiography in the diagnosis of this condition. We present 3 case reports of women with massive genital bleeding after abortion. 3D-CT angiography clearly demonstrated the 3-D features of the feeding artery, the draining vein, and the surrounding normal structures. The diagnosis in patient 1 was a uterine arteriovenous malformation, in patient 2 was a placental polyp mimicking a uterine arteriovenous malformation, and in patient 3 was a placental polyp. Patients were all successfully treated with uterine artery embolization or transcervical resection of the placental polyp. We conclude that 3D-CT angiography is useful for making a differential diagnosis and for preoperative planning in patients with postabortion uterine hemorrhage.

Invited Commentary

Invited Commentary

Computed tomographic angiography with three-dimensional reconstruction for transoral laser microsurgery

Objective To identify major arteries in relationship to large pharyngeal tumors during transoral laser microsurgery. Study Design Case series with planned data collection. Setting Mayo Clinic, Jacksonville, Florida. Subjects and Methods We developed a new technique that combines three-dimensional CT angiography and enhanced soft-tissue neck CT for evaluation of pharyngeal tumors before transoral laser microsurgery. Data from CT angiography were used to create three-dimensional images of the tumor and adjacent arterial branches to better orient the surgeon to the spatial relationships of major arteries and pharyngeal tumors. Included were selected patients who had large tumors involving the pharynx and who underwent transoral laser microsurgery. Results Eighteen patients were studied from June 2008 through January 2009. Tumor enhancement was absent or modest in four of 18 patients. Three of these four patients had superficial squamous cell carcinomas and one had adenoid cystic carcinoma. The remaining 14 patients had good tumor enhancement. The tumor involved the lingual artery in three and displaced the lingual or facial artery in two of these 14 patients. One anomalous right inferior thyroid artery was identified. Compared with routine enhanced soft-tissue neck CT, three-dimensional CT angiography greatly enhanced the anatomical relationships of the major arteries. In one patient, the surgeon's approach was changed after three-dimensional CT angiography demonstrated an encased lingual artery. Conclusion Three-dimensional CT angiography was useful in identifying the anatomical orientation of major arteries and the planning of transoral laser microsurgery to treat tumors involving the pharynx.

Detection of intracranial aneurysms using three-dimensional multidetector-row CT angiography: Is bone subtraction necessary?

Purpose The aim of this study was to evaluate the usefulness of three-dimensional CT angiography (3D CTA) with bone subtraction in a comparison with 3D CTA without bone subtraction for the detection of intracranial aneurysms. Materials and methods Among 337 consecutive patients who had intracranial aneurysms detected on 3D CTA, 170 patients who underwent digital subtraction angiography (DSA) were included in the study. CTA was performed with a 16-slice multidetector-row CT (MDCT) scanner. We created the 3D reconstruction images with and without bone subtraction by using the volume rendering technique. Three neuroradiologists in a blinded fashion interpreted both 3D CTA images with and without bone subtraction. The diagnostic accuracy of both techniques was evaluated using the alternative free-response receiver operating characteristic (ROC) analysis. The sensitivity and positive predictive value were also evaluated. Results A total of 200 aneurysms (size: 2–23 mm) were detected in 170 patients. The area under the receiver operating characteristic curve (Az) for 3D CTA with bone subtraction (mean, Az = 0.933) was significantly higher than that for 3D CTA without bone subtraction (mean, Az = 0.879) for all observers ( P < 0.05). The sensitivity of 3D CTA with bone subtraction for three observers was 90.0, 92.0 and 92.5%, respectively, while the sensitivity of 3D CTA without bone subtraction was 83.5, 83.5 and 87.5%, respectively. No significant difference in positive predictive value was observed between the two modalities. Conclusions 3D CTA with bone subtraction showed significantly higher diagnostic accuracy for the detection of intracranial aneurysms as compared to 3D CTA without bone subtraction.

Benefits of Clipping Surgery Based on Three-Dimensional Computed Tomography Angiography

The recent development of three-dimensional computed tomography (3D-CT) angiography with multi detector row CT (MDCT) improves cerebral artery imaging due to faster scanning at thinner collimation over a large scanning volume. Aneurysm clipping was performed using only 3D-CT angiography created by MDCT with 16 detector arrays (16-MDCT angiography), in place of digital subtraction angiography (DSA) to evaluate the suitability of 16-MDCT angiography for preoperative examination before aneurysm clipping, and identify the essential points when making 3D images. Thirty-two patients with subarachnoid hemorrhage (SAH) identified by initial CT or with non-ruptured aneurysm were entered in this study. Twenty-six SAH patients underwent 3D-CT angiography, and aneurysms were treated by clipping (n = 25) or coil embolization (n = 4). One patient with no aneurysm depicted by 3D-CT angiography underwent conventional DSA twice subsequently. The sensitivity of 16-MDCT angiography to depict aneurysms in patients with SAH, and time between admission and entering the operating room were evaluated, and compared with those under the former protocol using DSA. The sensitivity of 16-MDCT angiography for aneurysm detection was 100%. Shapes of all aneurysms depicted by 3D-CT angiography were validated intra-operatively. The mean operation waiting time was 2.8 hours, with the shortest time being 1.5 hours. Re-bleeding occurred in one of the 20 patients. We conclude that shorter preoperative waiting time decreased the incidence of premature re-bleeding, resulting in better outcomes. We highly recommend that the surgeon sets the threshold value, and rotates the 3D image to establish better surgical orientation.

Cerebral Vasospasms After Intraventricular Hemorrhage From an Arteriovenous Malformation -Case Report-

A 33-year-old female presented with a rare case of severe vasospasm following the rupture of an arteriovenous malformation (AVM) without subarachnoid hemorrhage. Initial computed tomography (CT) revealed a subcutaneous hematoma and cast formation of intraventricular clots without the deposition of subarachnoid blood in any basal cistern. Cerebral angiography revealed a small AVM located in the right parietal lobe without aneurysmal formations. Repeat CT demonstrated no evidence of subarachnoid clots expected with the presence of intraventricular clots and she was transferred to a general ward. She suffered sudden onset of motor aphasia and disturbance of consciousness on Day 17 after the hemorrhage. Magnetic resonance imaging indicated diffuse cortical infarction and subsequent magnetic resonance angiography revealed severe narrowing of the bilateral internal carotid arteries. Three-dimensional CT angiography on the same day indicated similar findings. She was transferred back to the intensive care unit for critical treatment. However, she suffered persistent mild right hemiparesis and motor aphasia. The characteristic features of vasospasm after intraventricular hemorrhage from AVMs are delayed onset, acute deterioration of consciousness, female predominance, and localization to the bilateral internal carotid arteries. Treatment of patients with AVM rupture should consider the risk of severe vasospasm, even if there is no subarachnoid clot.

未破裂脳動脈瘤手術のピットホール―動脈硬化合併例での問題点と手術対策―

Three-dimensional CT angiography (3D-CTA) is a useful modality for planning in clipping surgery of cerebral aneurysms. In addition, maximum intensity projection (MIP) technique allows easy visualization of intramural calcification around the aneurysm. In the present study, we compared preoperative findings with intraoperative findings regarding atherosclerosis and encountered 2 cases of unruptured aneurysm with unexpected severe atherosclerosis, which considered potential limitations to the use of MIP image for preoperative planning. We discuss surgical techniques for both cases when the wall of the aneurysm and neighboring arteries are thick and atherosclerotic.

Intracerebral Hemorrhage From a Ruptured Aneurysm at the Site of Anastomosis 27 Years After Superficial Temporal Artery-Middle Cerebral Artery Bypass -Case Report-

A 77-year-old female presented with a very rare case of intracerebral hemorrhage (ICH) from a ruptured aneurysm at the site of the anastomosis 27 years after superficial temporal artery-middle cerebral artery (STA-MCA) bypass manifesting as sudden onset of unconsciousness and right hemiparesis. Computed tomography (CT) on admission demonstrated massive ICH in the left frontoparietal region. Magnetic resonance angiography showed good patency of the anastomosis and no obvious aneurysm, but three-dimensional CT (3D-CT) angiography revealed a small aneurysm at the site of the left STA-MCA anastomosis. Emergency evacuation of the hematoma was performed, and the aneurysm was trapped and resected after ligation. After the operation, she continued to exhibit deep consciousness disturbance. Unfortunately, her general condition grew steadily worse and she died 3 months later. Patients who undergo STA-MCA anastomosis should be carefully followed up by periodical imaging examinations. 3D-CT angiography is very useful to detect aneurysm formation at the anastomosis site.

Multiple Cerebral Aneurysms Caused by HIV-Associated Vasculopathy

A 43-year-old Japanese woman who had worked in Kenya, presented with fever, drowsiness and right hemiplegia. Her blood pressure was 100/64 mmHg. Her CD4 count was 12 cells/μL and her HIV viral load was 1,107,818 copies/mL. She was diagnosed as having AIDS. Threedimensional CT angiography revealed multiple fusiform aneurysms of the first and second branches of the middle cerebral arteries (arrows in Picture 1A) and left vertebral artery (arrowhead in Picture 1A). Blood cultures were repeatedly negative and no infective endocarditis was found on echocardiography. Introduction of HAART was reported to improve the prognosis of a patient with aneurysmal HIVassociated vasculopathy (1). Unfortunately, the present patient had multiple intracranial hemorrhages during her course (Picture 1B and Picture 1C) despite HAART. Previously, 12 adult cases with HIV vasculopathy were reported, including 5 patients with ischemic infarctions, 3 patients with subarachnoid hemorrhages and only 1 patient with intracranial hemorrhages (2). Patients with aneurysmal HIV vasculopathy can develop not only subarachnoid hemorrhages but also multiple hemorrhages in the brain paren-

Three-dimensional CT angiography for preoperative evaluation of patients undergoing hepatic resection using the Glissonean pedicle transection method

Three-dimensional CT angiography for preoperative evaluation of patients undergoing hepatic resection using the Glissonean pedicle transection method

Diagnosis of Ductal Aneurysm Using Three-Dimensional CT Reconstruction

The prevalence of ductal aneurysms is approximately 8.8% [2]. Ductal aneurysms are associated with serious complications, which makes accurate diagnosis prudent. Diagnosis is traditionally made by echocardiography, however, additional imaging modalities are sometimes required for a definitive diagnosis. Our patient, D.C., is a full-term newborn male who was transferred from an outside hospital to our Neonatal Intensive Care Unit secondary to respiratory failure and dysmorphism. His physical examination was significant for hypertelorism and low-set ears. He had increased precordial activity and a 3/6 holosystolic murmur heard throughout the precordium. An echocardiogram was performed on day of life 5, which showed a primum atrial septal defect (ASD) with left-to-right shunt, a secundum ASD with left-to-right shunt, and atrioventricular canaltype ventricular septal defect with no physiologic shunt secondary to atrioventricular valve tissue filling the defect. At that time echocardiography demonstrated significant left pulmonary artery stenosis. A follow-up echocardiogram was performed to further evaluate the caliber of the left pulmonary artery. A 1.6 9 1.8-cm cystic mass was noted anterior to and to the left of the main pulmonary artery/left pulmonary artery junction. There appeared to be a connection via a small communication to the main pulmonary artery (Fig. 1). A CT angiogram was performed, which showed a well-circumscribed contrast-filled structure measuring 1.7 9 1.4 9 1.2 cm arising from the anterior aspect of the proximal portion of the descending thoracic aorta, located anterolateral to the left main pulmonary artery branch, most consistent with a pseudoaneurysm. However, the exact anatomy was still difficult to precisely delineate. Therefore, we used three-dimensional reconstruction of the CT angiogram to show the aneurysm in connection with the ductus arteriosus and to demonstrate compression of the left pulmonary artery by the aneurysm (Fig. 2). Ductal aneurysms are rare and are more frequently associated with patients who have had surgical ligation of the ductus arteriosus or in association with connective tissue disorders [1]. One study demonstrated a prevalence of 8.8% in all newborn infants [2]. Ductal aneurysms usually are asymptomatic and incidentally discovered on routine echocardiographic evaluation or diagnosed by fetal echocardiogram. Although rare, ductal aneurysms are associated with serious complications, which include thromboembolism, infection, rupture, and death [3]. The conventional method to identify ductal aneurysm anatomy is by two-dimensional echocardiogram with color Doppler. However, some patients require additional imaging with CT angiography or MRI to further define the anatomy [1]. In our patient, the connection between the aneurysm and the artery was difficult to isolate on two-dimensional echocardiogram and CT angiogram. Therefore, three-dimensional reconstruction of the CT angiogram was necessary to make the exact diagnosis. Additionally, the three-dimensional reconstruction replicated the exact area of aneurysmal connection to the pulmonary artery. Three-dimensional CT has been described more often in the adult literature for diagnosis of aneurysms. The most common use is as a diagnostic tool for circle of Willis aneurysms. However, three-dimensional CT angiography has been used to diagnose aortic aneurysms in the adult population. In pediatrics, three-dimensional CT angiography Deneen Heath and Russell Cross contributed equally to this work.

Three-dimensional CT angiography for the diagnosis and assessment of arteriovenous malformations in the oral and maxillofacial region

The purpose of this study was to evaluate the diagnostic performance of three-dimensional computed tomography angiography (3D-CTA) for arteriovenous malformations (AVMs) in the oral and maxillofacial region. Sixty four-slice spiral CT angiography of oral or maxillofacial region was performed in 8 patients with surgically proven arteriovenous malformations. The morphologic features, size, location, boundary, and feeding and draining vessels of lesions were reviewed. AVMs in 5 patients were located in the soft tissues and 3 were in the mandible. CTA of all cases showed tangles of disorganized vessels with well-defined borders. The feeding and draining vessels were enlarged and tortuous. Four patients had bone involvement. Sixty four-slice spiral CTA can accurately demonstrate the morphological characteristics of AVMs.