Definite surgical treatment after acute SAH based on 3D-CT-angiography in rapidly deteriorating or comatose patients

Although intraarterial angiography is the gold standard in diagnosing cerebral aneurysms, there are indications for immediate surgical intervention without angiography in comatose patients with rapidly deteriorating neurological status. Here 3D-CT-angiography (3D-CTA) provides a rapid overview of the intracranial vasculature and suspected aneurysms. Patients: During the last 18 month 44 patients with acute SAH were examined with Spiral-CT. We report on five patients who presented deeply comatose or with rapid deterioration of their neurological status. Brain stem relfexes preserved. Immediate surgical intervention was mandatory due to a space-occupying hematoma in one case and acute, occlusive hydrocephalus in four cases. A cerebral aneurysm was diagnosed solely with CTA in all five cases (one MCA, four ACoA). The patients received definite treatment omitting presurgical, conventional angiography. Method: A General Electric High Speed Advantage CT Scanner and 60-80 ml of contrast media were used in a rapid infusion protocol. A spiral CT with 3 mm slice thickness and table feed and a pitch of one was performed. The prescan delay varied from 18 to 28 sec depending on the patients age and vascular situation. Diagnosis was established after data transformation to 1 mm slices and 3D-reconstruction in less than 20 minutes. Results: In all five cases 3D-CTA diagnosed the ruptured aneurysm accurately. It demonstrated the cerebral vaculature well and provided sufficient information regarding multiple aneurysms. 3D-CTA allowed immediate and definite surgical treatment with clipping of the aneurysm in a patient group where timing is critical. Conclusion: 3D-CTA provides a valuable tool for accurately diagnosing ruptured cerebral aneurysms in acute SAH requiring urgent neurosurgical intervention for additional life-threatening intracranial pathologies. In terms of postoperative management and outcome it can be beneficial for those patients to receive definite treatment of the aneurysm at the time of primary surgery based upon 3D-CTA alone.