Prospective Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Radiol. Jun 28, 2023; 15(6): 201-215
Published online Jun 28, 2023. doi: 10.4329/wjr.v15.i6.201
Interobserver reliability of computed tomography angiography in the assessment of ruptured intracranial aneurysm and impact on patient management
Ali H Elmokadem, Basma Abdelmonaem Elged, Ahmed Abdel Razek, Lamiaa Galal El-Serougy, Mohamed Ali Kasem, Mohamed Ali EL-Adalany
Ali H Elmokadem, Basma Abdelmonaem Elged, Ahmed Abdel Razek, Lamiaa Galal El-Serougy, Mohamed Ali EL-Adalany, Department of Radiology, Mansoura University, Mansoura 35516, Egypt
Mohamed Ali Kasem, Department of Neurosurgery, Mansoura University, Mansoura 35516, Egypt
Author contributions: Abdel Razek A and El-Serougy LG proposed the study concept and design; Elged BA searched Database; Kasem MA performed surgical procedures; Elmokadem AH performed DSA; Elged BA, EL-Adalany MA, and El-Serougy LG contributed to analysis and interpretation of data; Elged BA and Elmokadem AH contributed to drafting of the manuscript; Elmokadem AH and Abdel Razek A contributed to Revision of the manuscript; EL-Adalany MA and El-Serougy LG supported technical, or material.
Institutional review board statement: The study was approved by Mansoura university institutional review board (IRB).
Informed consent statement: Patients were not required to give a written consent for the study as the analysis used anonymous data.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: All data generated or analyzed during this study are included in this published article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Ali H Elmokadem, MD, PhD, Associate Professor, Department of Radiology, Mansoura University, Elgomhoria St, Mansoura 35516, Egypt. mokademr83@gmail.com
Received: December 23, 2022
Peer-review started: December 23, 2022
First decision: March 28, 2023
Revised: April 17, 2023
Accepted: May 31, 2023
Article in press: May 31, 2023
Published online: June 28, 2023
Processing time: 186 Days and 10.5 Hours
ARTICLE HIGHLIGHTS
Research background

Aneurysmal subarachnoid hemorrhage (SAH) is an emergency that can lead to a high mortality rate and many severe complications. It is critical to make a rapid radiological evaluation of ruptured intracranial aneurysms (RIAs) to determine the appropriate surgical treatment.

Research motivation

The high morbidity and mortality of RIAs nicissitate rapid diagnosis and management decision. Compared to Digital subtraction angiography, computed tomography angiography (CTA) is a safe, relatively inexpensive, and noninvasive imaging. Computed tomography (CT) angiography is not associated with significant patient risks other than those related to administering iodinated contrast media. Images can be relatively safely obtained without the need for arterial puncture or catheter manipulation that carries the possibility of acquiring a permanent neurologic deficit. Our motivation is to assess the reliability of CTA in assessing different features of ruptured intracranial aneurysm and its impact on patient management.

Research objectives

To assess the reliability of CTA in assessing different features of ruptured intracranial aneurysm and its impact on patient management. We found out that CTA is a promising diagnostic imaging modality for assessing intracranial aneurysm features and help in management decision and patient outcomes. We recommend further studies assessing the inter-observer agreement between neuroradiologists, neurologists, neurosurgeons, and neuro-interventionist.

Research methods

Helical cerebral CT angiography has been widely used in detecting intracranial aneurysms, with a reported sensitivity of 70%–96%. Currently, multidetector CT angiography has the ability to detect most intracranial aneurysms of 5 mm or larger. Multidetector row CT scanners provide increased spatial resolution and decreased scanning time, which should increase the sensitivity of the technique in depicting aneurysms of less than 5 mm in diameter. Currently, CT angiography is accepted as a first-line diagnostic imaging modality for evaluating intracranial aneurysms. Nevertheless, using CT angiography to depict intracranial aneurysms showed variable sensitivity. The reported sensitivity of CTA in detections of small intracranial aneurysms (< 3 mm) varied from 28%–43% in a study that included 99 small aneurysms to 83%-92% in another study had 579 small aneurysms. CTA examinations for 146 patients in the current study were revised and interpreted by two experienced neuroradiologists to assess the inter-observer agreement of CTA findings related to intracranial aneurysms. Data extracted from CT was considered in patient management decision.

Research results

This study evaluated the interobserver reliability of CTA in the assessment of ruptured intracranial aneurysm features among 146 patients. Our results showed good to an excellent inter-observer agreement in imaging features related to the aneurysm, aneurysm characters, measurements, and perianeurysmal information. Imaging data extracted from NCCT and CTA guided the multidisciplinary neurovascular team to better treatment approach selection. There are a few limitations to this study. First, there is no correlation with conventional angiography in all cases. Second, the general drawbacks of CT include patient exposure to ionizing radiation and the risks of iodinated contrast medium.

Research conclusions

We concluded that CTA is a promising diagnostic imaging modality for assessing intracranial aneurysm features that impact management and patient outcomes. We recommend endovascular approach in a ruptured intracranial aneurysm with comorbidity, old age, narrow neck, and a posterior circulation aneurysm, and surgical clipping is warranted if the patient is young with an MCA aneurysm and interested in durability.

Research perspectives

Further studies with applications of low-dose CTA, such as the use of automatic tube current modulation and a small amount of contrast medium, are recommended. Additionally, future studies using advanced CT techniques such as higher 320 slices CT scan, dual-energy or source CTA, and time-resolved 4D CTA will improve temporal and spatial resolution and the image quality CTA. Also, applications of advanced vascular post-processing packages for analyzing CTA images will give comprehensive image interpretation in different planes and angles.