Abstract
Several reports have demonstrated the use of three-dimensional (3D) computed tomographic
angiography (CTA) for preoperative planning in patients with intracranial aneurysms.
Until now, there are no reports on the potential role of navigation systems in combination
with CTA in aneurysm surgery. In the present study we report our experience with neuronavigation
based on CTA in 16 patients with unruptured anterior circulation aneurysms for 1)
planning craniotomy; 2) guided approach to the aneurysm; and 3) 3D presentation of
the aneurysm and adjacent arteries in correct orientation. The reconstructed CTA images
were analyzed preoperatively with regard to diameter of aneurysm neck and dome as
well as projection and possible daughter aneurysms, and these parameters were compared
with the intraoperative findings. In addition the accuracy of the navigator to locate
the aneurysm neck was measured intraoperatively. Navigated approach planning resulted
in variable keyhole craniotomies for the 7 middle cerebral artery aneurysms, but did
not result in deviation from small standard craniotomies for the internal carotid
and anterior communicating artery aneurysms. Precision of the indication of the navigator
with regard to the aneurysm neck ranged from < 1 mm to 4 mm. Intraoperative assessment
confirmed the CTA data with regard to aneurysm size and projection in all, and definition
of daughter aneurysms and adjacent arteries in most cases. The computer assisted approach
allowed a smaller, exactly placed craniotomy primarily in MCA aneurysms. 3D presentation
of the aneurysms and the adjacent arteries in correct orientation facilitated identification
and dissection the aneurysms. Current navigation systems are not precise enough to
allow “blind” aneurysm clipping by placing a real clip on the virtual aneurysm neck.
Key words
Aneurysm surgery - neuronavigation - three-dimensional computed tomographic angiography
References
- 1
Aoki S, Sasaki Y, Machida T, Ohkubo T, Minami M.
Cerebral aneurysms: detection and delineation using 3-D-CT angiography.
AJNR Am J Neuroradiol.
1992;
13
1115-1120
- 2
Matsumoto M, Sato M, Nakano M, Endo Y, Watanabe Y, Sasaki T, Suzuki K, Kodama N.
Three-dimensional computerized tomography angiography-guided surgery of acutely ruptured
cerebral aneurysms.
J Neurosurg.
2001;
94
718-727
- 3
Kallmes D F, Evans A J, Woodcock R J, Omary R A, Dix J E, McNulty B C, Holder C A,
Dion J E.
Optimization of parameters for the detection of cerebral aneurysms: CT angiography
of a model.
Radiology.
1996;
200
403-405
- 4
Harrison M J, Johnson B A, Gardner G M, Welling B G.
Preliminary results on the management of unruptured intracranial aneurysms with magnetic
resonance angiography and computed tomography angiography.
Neurosurgery.
1997;
40
947-955
- 5
Anderson G B, Findlay J M, Steinke D E, Ashforth R.
Experience with computed tomographic angiography for the detection of intracranial
aneurysms in the setting of acute subarachnoid hemorrhage.
Neurosurgery.
1997;
41
522-527
- 6
Kato Y, Katada K, Hayakawa M, Nakane M, Ogura Y, Sano K, Kanno T.
Can 3D-CTA surpass DSA in diagnosis of cerebral aneurysm?.
Acta Neurochir Wien.
2001;
143
245-250
- 7
Schwartz R B, Tice H M, Hooten S M, Hsu L, Stieg P E.
Evaluation of cerebral aneurysms with helical CT: correlation with conventional angiography
and MR angiography.
Radiology.
1994;
192
717-722
- 8
Hashimoto H, Iida J, Hironaka Y, Okada M, Sakaki T.
Use of spiral computerized tomography angiography in patients with subrachnoid hemorrhage
in whom subtraction angiography did not reveal cerebral aneurysms.
J Neurosurg.
2000;
92
278-283
- 9
Anderson G B, Steinke D E, Petruk K C, Ashforth R, Findlay J M.
Computed tomographic angiography versus digital subtraction angiography for the diagnosis
and early treatment of ruptured intracranial aneurysms.
Neurosurgery.
1999;
45
1315-1320
- 10
Hope J K, Wilson J L, Thomson F J.
Three-dimensional CT angiography in the detection and characterization of intracranial
berry aneurysms.
AJNR Am J Neuroradiol.
1996;
17
439-445
- 11
Hsiang J N, Liang E Y, Lam J M, Zhu X L, Poon W S.
The role of computed tomographic angiography in the diagnosis of intracranial aneurysms
and emergent aneurysm clipping.
Neurosurgery.
1996;
38
481-487
- 12
Kato Y, Sano H, Katada K, Ogura Y, Hayakawa M, Kanaoka N, Kanno T.
Application of three-dimensional CT angiography (3D-CTA) to cerebral aneurysms.
Surg Neurol.
1999;
52
113-121
- 13
Ogawa T, Okudera T, Noguchi K, Sasaki N, Inugami A, Uemura K, Yasui N.
Cerebral aneurysms: evaluation with three-dimensional CT angiography.
AJNR Am J Neuroradiol.
1996;
17
447-454
- 14
Preda L, Gaetani P, Rodriguez y Baena R, Di-Maggio E M, La-Fianza A, Dore R, Fulle I,
Solcia M, Cecchini A, Infuso L, Campani R.
Spiral CT angiography and surgical correlations in the evaluation of intracranial
aneurysms.
Eur Radiol.
1998;
8
739-745
- 15
Wardlaw J M, White P M.
The detection and management of unruptured intracranial aneurysms.
Brain.
2000;
123
205-221
- 16
Zouaoui A, Sahel M, Marro B, Clemenceau S, Dargent N, Bitar A, Faillot T, Capelle L,
Marsault C.
Three-dimensional computed tomographic angiography in detection of cerebral aneurysms
in acute subarachnoidal hemorrhage.
Neurosurgery.
1997;
41
125-130
- 17
Villablanca J P, Martin N, Jahan R, Gobin Y P, Frazee J, Duckwiler G, Bentson J, Hardart M,
Coiteiro D, Sayre J, Vinuela F.
Volume-rendered helical computerized tomography angiography in the detection and characterization
of intracranial aneurysms.
J Neurosurg.
2000;
93
254-264
- 18
Steiger H J, Loon J J van.
Virtues and drawbacks of titanium alloy aneurysm clips.
Acta Neurochir Suppl Wien.
1999;
72
81-88
- 19
Nagasawa S, Ohta T, Tsuda E.
Magnetic resonance angiographic source images for depicting topography and surgical
planning for middle cerebral artery aneurysms: technique application.
Surg Neurol.
1998;
50
62-64
- 20
Spetzler R F, Lee K S.
Reconstruction of temporalis muscle for the pterional craniotomy. Technical note.
J Neurosurg.
1990;
73
636-637
- 21
Steiger H J, Schmid-Elsaesser R, Uhl E, Stummer W.
Transorbital key hole approach to anterior communicating artery aneurysms.
Neurosurgery.
2001;
48
347-352
- 22
Muacevic A, Steiger H J.
Computer-assisted resection of cerebral arteriovenous malformations.
Neurosurgery.
1999;
45
1164-1171
- 23
Villavicencio A T, Gray L, Leveque J C, Fukushima T, Kureshi S, Friedman A H.
Utility of three-dimensional computed tomographic angiography for assessment of relationships
between the vertebrobasilar system and the cranial base.
Neurosurgery.
2001;
48
318-326
- 24
Roos E J, Rinkel G J, Velthuis B K, Algra A.
The relation between aneurysm size and outcome in patients with subarachnoid hemorrhage.
Neurology.
2000;
54
2334-2336
- 25
Takabatake Y, Uno E, Wakamatsu K, Okada Y, Kaneko T, Tsuchiya Y, Miyayama S.
The three-dimensional CT angiography findings of ruptured aneurysms hardly detectable
by repeated cerebral angiography.
No Shinkei Geka.
2000;
28
237-243
- 26
Korogi Y, Takahashi M, Katada K, Ogura Y, Hasuo K, Ochi M, Utsunomiya H, Abe T, Imakita S.
Intracranial aneurysms: detection with three-dimensional CT angiography with volume
rendering - comparison with conventional angiographic and surgical findings.
Radiology.
1999;
211
497-506
- 27
Rubin G D, Beaulieu C F, Argiro V, Ringl H, Norbash A M, Feller J F, Dake M D, Jeffrey R B,
Napel S.
Perspective volume rendering of CT and MR images: applications for endoscopic imaging.
Radiology.
1996;
199
321-330
- 28
Iwanaga S, Shrier D A, Okawara S H, Numaguchi Y.
Value of CT angiography in the evaluation of a peripheral anterior inferior cerebellar
artery aneurysm: case report.
Clin Imaging.
1999;
23
77-80
- 29
Dorsch N W, Young N, Kingston R J, Compton J S.
Early experience with spiral CT in the diagnosis of intracranial aneurysms.
Neurosurgery.
1995;
36
230-236
- 30
Velthuis B K, Leeuwen M S Van, Witkamp T D, Ramos L M, Sprenkel J W Van Der, Rinkel G J.
Surgical anatomy of the cerebral arteries in patients with subarachnoid hemorrhage:
comparison of computerized tomography angiography and digital subtraction angiography.
J Neurosurg.
2001;
95
206-212
- 31
Hashimoto H, Lida J, Hironaka Y, Shin Y, Sakaki T.
Wall imaging of cerebral aneurysms with a modified surface-rendering technique of
spiral CT.
Acta Neurochir Wien.
2000;
142
1003-1012
- 32
Lenhart M, Bretschneider T, Gmeinwieser J, Ullrich O W, Schlaier J, Feuerbach S.
Cerebral CT angiography in the diagnosis of acute subarachnoid hemorrhage.
Acta Radiol.
1997;
38
791-796
- 33
Velthuis B K, Rinkel G J, Ramos L M, Witkamp T D, Leeuwen M S Van.
Perimesencephalic hemorrhage. Exclusion of vertebrobasilar aneurysms with CT angiography.
Stroke.
1999;
30
1103-1109
- 34
Velthuis B K, Rinkel G J, Ramos L M, Witkamp T D, Sprenkel J W Van Der, Vandertop W P,
Leeuwen M S Van.
Subarachnoid hemorrhage: aneurysm detection and preoperative evaluation with CT angiography.
Radiology.
1998;
208
423-430
- 35
Okuyama T, Saito K, Hirano A, Takahashi A, Inagaki T, Inamura S.
Improvement of MRA and 3D-CTA does away with the need for cerebral angiography in
many cerebral aneurysm operations.
No Shinkei Geka.
1998;
26
607-612
- 36
Lai P H, Yang C F, Pan H B, Chen C, Ho J T, Hsu S S.
Detection and assessment of circle of Willis aneurysms in acute subarachnoid hemorrhage
with three-dimensional computed tomographic angiography: correlation with digital
substraction angiography findings.
J Formos Med Assoc.
1999;
98
672-677
- 37
Velthuis B K, Leeuwen M S Van, Witkamp T D, Ramos L M, Sprenkel J W Van Der, Rinkel G J.
Computerized tomography angiography in patients with subarachnoid hemorrhage: from
aneurysm detection to treatment without conventional angiography.
J Neurosurg.
1999;
91
761-767
- 38
Batjer H, Samson D.
Intraoperative aneurysmal rupture: incidence, outcome, and suggestions for surgical
management.
Neurosurgery.
1986;
18
701-707
- 39
Greenberg I M.
Cerebral aneurysm rupture during neurosurgery.
Neurosurgery.
1984;
15
243-245
- 40
Houkin K, Kuroda S, Takahashi A, Takikawa W, Ishikawa T, Yoshimoto T, Itamato K.
Intra-operative premature rupture of the cerebral aneurysms. Analysis of the causes
and management.
Acta Neurochir Wien.
1999;
141
1255-1263
- 41
Tidswell P, Dias P S, Sagar H J, Mayes A R, Battersby R D.
Cognitive outcome after aneurysms rupture: relationship to aneurysm site and perioperative
complications.
Neurology.
1995;
45
875-882
- 42
Schramm J, Cedzich C.
Outcome and management of intraoperative aneurysm rupture.
Surg Neurol.
1993;
40
26-30
- 43
Koyama T, Okudera H, Kobayashi S.
Computer-assisted geometric design of cerebral aneurysms for surgical simulation.
Neurosurgery.
1995;
36
541-546
- 44
Boor S, Resch K M, Perneczky A, Stoeter P.
Virtual endoscopy (VE) of the basal cisterns: its value in planning the neurosurgical
approach.
Minim Invasive Neurosurg.
1998;
41
177-182
- 45
Koyama T, Hongo K, Tanaka Y, Kobayashi S.
Simulation of the surgical manipulation involved in clipping a basilar artery aneurysm:
concepts of virtual clipping.
J Neurosurg.
2000;
93
355-360
- 46
Braun V, Rath S A, Antoniadis G, Richter H P.
In vivo experiences with frameless stereotactically guided screw placement in the
spine - results from 75 consecutive cases.
Neurosurg Rev.
2001;
24
74-79
- 47
Tanoue S, Kiyosue H, Kenai H, Nakamura T, Yamashita M, Mori H.
Three-dimensional reconstructed images after rotational angiography in the evaluation
of intracranial aneurysms: surgical correlation.
Neurosurgery.
2000;
47
866-871
PD Dr. Robert Schmid-Elsaesser
Department of Neurosurgery · Ludwig-Maximilians-University · Klinikum Großhadern
Marchioninistr. 15
81377 Munich
Germany
Phone: +49-89-7095-2695
Fax: +49-89-7095-5694
Email: Schmid-Elsaesser@nc.med.uni-muenchen.de