Ares William J, Kenmuir Cynthia L, Panczykowski David M, Weiner Gregory M, Jadhav Ashu P, Jovin Tudor G, Gross Bradley A, Jankowitz Brian T
Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
World Neurosurg. 2018 Feb;110:e84-e89. doi: 10.1016/j.wneu.2017.10.095. Epub 2017 Oct 26.
Intraoperative digital subtraction angiography (ioDSA) is touted as the gold standard imaging evaluation for aneurysm clip constructs. Candid evaluations of its limitations are sparse.
A prospectively collected hospital billing database was queried to identify craniotomies for aneurysm clipping from January 2010 to December 2013. We evaluated the rate of occult residual and parent vessel stenosis determined on follow-up angiography for patients undergoing ioDSA and those not undergoing ioDSA. Comparisons were performed via Fisher exact test, with P < 0.05 considered statistically significant.
From our database search, we found 187 patients who underwent ioDSA after aneurysm clipping and an additional 91 patients who did not. Results from ioDSA influenced operative management in 17% of cases. Sixty-four patients with 70 treated aneurysms undergoing ioDSA had postoperative angiography; 7 occult residuals were discovered, yielding a 10% false-negative rate, with 10% of aneurysms showing residual. Occult residuals at the middle cerebral artery bifurcation represented most discovered residuals (6/7). Thirty-two patients with 37 treated aneurysms did not undergo ioDSA and had angiographic follow-up; 24% of patients were found to have residual aneurysms (P = 0.08 compared with patients undergoing ioDSA). Residuals at the anterior communicating artery (ACoA) represented 56% of all residuals, whereas the ACoA represented only 18% of aneurysms clipped. The rate of residuals was significantly higher than that for patients with clipped ACoA aneurysms undergoing ioDSA (P = 0.008).
ioDSA influenced management in nearly one fifth of cases. It can be particularly beneficial in detecting residuals for ACoA aneurysms; its benefit was less apparent for middle cerebral artery aneurysms.
术中数字减影血管造影（ioDSA）被吹捧为动脉瘤夹闭结构的金标准成像评估方法。对其局限性进行公正评估的研究较少。
查询前瞻性收集的医院计费数据库，以确定2010年1月至2013年12月期间因动脉瘤夹闭而进行开颅手术的患者。我们评估了接受ioDSA和未接受ioDSA的患者在随访血管造影中确定的隐匿性残余和供血血管狭窄的发生率。通过Fisher精确检验进行比较，P<0.05被认为具有统计学意义。
通过数据库搜索，我们发现187例患者在动脉瘤夹闭后接受了ioDSA，另有91例患者未接受。ioDSA的结果在17%的病例中影响了手术管理。64例接受ioDSA的70个治疗动脉瘤患者进行了术后血管造影；发现7例隐匿性残余，假阴性率为10%，10%的动脉瘤有残余。大脑中动脉分叉处的隐匿性残余占发现的残余的大多数（6/7）。32例接受37个治疗动脉瘤的患者未接受ioDSA并进行了血管造影随访；24%的患者被发现有残余动脉瘤（与接受ioDSA的患者相比，P=0.08）。前交通动脉（ACoA）处的残余占所有残余的56%，而ACoA仅占夹闭动脉瘤的18%。残余率显著高于接受ioDSA的ACoA动脉瘤夹闭患者（P=0.008）。
ioDSA在近五分之一的病例中影响管理。它在检测ACoA动脉瘤的残余方面可能特别有益；对大脑中动脉瘤的益处不太明显。
