Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois.
Neurosurgery. 2018 Jul 1;83(1):62-68. doi: 10.1093/neuros/nyx339.
Subarachnoid hemorrhage cases with multiple cerebral aneurysms frequently demonstrate a hemorrhage pattern that does not definitively delineate the source aneurysm. In these cases, rupture site is ascertained from angiographic features of the aneurysm such as size, morphology, and location.
To examine the frequency with which such features lead to misidentification of the ruptured aneurysm. METHODS : Records of patients who underwent surgical clipping of a ruptured aneurysm at our institution between 2004 and 2014 and had multiple aneurysms were retrospectively reviewed. A blinded neuroendovascular surgeon provided the rupture source based on the initial head computed tomography scans and digital subtraction angiography images. Operative reports were then assessed to confirm or refute the imaging-based determination of the rupture source.
One hundred fifty-one patients had multiple aneurysms. Seventy-one patients had definitive hemorrhage patterns on initial computed tomography scans and 80 patients had nondefinitive hemorrhage patterns. Thirteen (16.2%) of the cases with nondefinitive hemorrhage patterns had discordance between the imaging-based determination of the rupture source and intraoperative findings of the true ruptured aneurysm, yielding an imperfect positive predictive value of 83.8%. Of all multiple aneurysm cases with subarachnoid hemorrhage treated by surgical or endovascular means at our institution, 4.3% (13 of 303) were misidentified.
Morphological features cannot reliably be used to determine rupture site in cases with nondefinitive subarachnoid hemorrhage patterns. Microsurgical clipping, confirming obliteration of the ruptured lesion, may be preferentially indicated in these patients unless, alternatively, all lesions can be contemporaneously and safely treated with endovascular embolization.
蛛网膜下腔出血合并多发脑动脉瘤的患者，其出血模式常无法明确确定责任动脉瘤。在这些情况下，破裂部位是根据动脉瘤的血管造影特征（如大小、形态和位置）来确定的。
研究这些特征导致责任动脉瘤误判的频率。
回顾性分析 2004 年至 2014 年期间在我院接受手术夹闭破裂动脉瘤且存在多个动脉瘤的患者的病历。一位盲法神经介入外科医生根据初始头部 CT 扫描和数字减影血管造影图像提供破裂源。然后评估手术报告以确认或反驳基于影像学的破裂源确定。
151 例患者存在多个动脉瘤。71 例患者在初始 CT 扫描时有明确的出血模式，80 例患者有不明确的出血模式。13 例（16.2%）不明确出血模式的病例中，影像学确定的破裂源与术中真正破裂的动脉瘤之间存在差异，阳性预测值为 83.8%并不完美。在我院接受手术或血管内治疗的所有蛛网膜下腔出血合并多发动脉瘤的病例中，有 4.3%（303 例中的 13 例）被误判。
在不明确的蛛网膜下腔出血模式的情况下，形态学特征不能可靠地用于确定破裂部位。在这些患者中，可能优先选择显微手术夹闭，确认破裂病灶闭塞，除非所有病灶都可以同时且安全地通过血管内栓塞治疗。
