Article Figures & Data
Figures
- Fig 1.
Arteriographic projections used to assess aneurysm dimensions. Posterior-anterior Townes and direct lateral projections demonstrate the presence of the right carotid–ophthalmic aneurysm, but these projections do not allow for optimal assessment of aneurysm size, dome-to-neck ratio, or artery-to-neck ratio. Magnified posterior-anterior Waters and lateral oblique projections in this particular case provide better planar imaging to assess the aneurysm for surgical or endovascular treatment.
- Fig 2.
CT brain scan with intravenous iodinated contrast of a patient with a partially thrombosed, giant right middle cerebral aneurysm. A, 5-mm contiguous axial images through the aneurysm demonstrate a ring-enhancing mass with a maximal dimension of 4.8 cm and a total volume of 48 mL. B, The patent component of the aneurysm measures only 14 mm in maximal dimension with a volume of 1.33 mL. The opacified component of the aneurysm at catheter arteriography represents 2.8% of the total aneurysm volume.
- Fig 3.
Diagram of measurements to determine aneurysm dimensions without geometric magnification using 1-cm measuring rings attached to the patient's head. All measurements are made on radiographic images using x-rays. Tube side magnification factor (T), film-side magnification factor (F), and the uncorrected lesion size (L) are measured on the radiograph. The distance from the tube side of the head to the lesion (D) and the width of the head (H) are measured from radiographs in the orthogonal plane. The magnification factor (M) at the level of the lesion is derived by the following formula:
. Due to inherent geometric magnification in radiographic images, the actual aneurysm size is calculated by dividing the apparent aneurysm size as follows:
. - Fig 4.
Common location of cerebral aneurysms surrounding the circle of Willis. (A) Middle cerebral (proximal to bifurcation, bifurcation, distal to bifurcation); (B) carotid terminus; (C) anterior choroidal; (D) superior hypophyseal; (E) anterior communicating (proximal to communicating artery, at communicating artery); (F) posterior communicating; (G) ophthalmic; (H) basilar artery (terminus, trunk); (I) superior cerebellar; (J) V4 segment, vertebral; (K) posterior inferior cerebellar; (L) pericallosal artery.
- Fig 5.
Consensus grading scale for endovascular aneurysm occlusion is applied to orthogonal images obtained in optimal projections to assess aneurysm dimensions: Grade 0, complete aneurysm occlusion; Grade 1, ≥90% aneurysm occlusion; Grade 2, 70% to 89% aneurysm occlusion; Grade 3, 50% to 69% aneurysm occlusion; Grade 4, 25% to 49% aneurysm occlusion; Grade 5, <25% aneurysm occlusion.
- Fig 6.
Modification to consensus grading scale for endovascular aneurysm occlusion describing interstitial opacification within coil mass. A, Left internal carotid arteriography in right frontal oblique projection during the arterial phase of injection shows coil occlusion of a 12×11×14 mm left posterior communicating artery aneurysm. B, Because there is a small ventral neck remnant and residual opacification within the aneurysm sac (colored areas), this represents consensus Grade 1 occlusion with “I” for persistent interstitial opacification within the coil mass.
Tables
General definitions Clinical presentation Symptomatic: hemorrhage or mass Hunt and Hess Grade or World Federation of Neurological Surgeons Grading Scale Glasgow Coma Scale and NIHSS Modified Rankin Scale score Fisher CT score Date of presentation Time to diagnosis (hours to days) Time to arteriography (hours to days) Time to treatment (hours to days) Imaging source and date Aneurysm shape Saccular Other types excluded Dissecting Serpentine Giant, partially thrombosed Dolichoectatic Size and location (see Table 5) Planar dimensions Neck width and area Parent artery diameter Dome-to-neck ratio Neck-to-artery ratio Aneurysm volume Single or multiple Arteriographic comorbidities (see Table 5) Procedural technique Catheter type Guide wire type Guiding catheter type Adjunctive techniques Coil types, diameters, lengths, and numbers of coils Technical success Recanalization and recanalization rate Computational results Arteriographic occlusion Volumetric occlusion Advanced computational features Computational flow dynamics Clinical success 30-day morbidity and mortality (assessed by independent physician) Modified Rankin Scale46 Barthel Index47 Glasgow Outcome Scale45 NIHSS48 -
NIHSS indicates National Institutes of Health Stroke Scale.
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Grade Hunt and Hess World Federation of Neurological Surgeons 0 Intact aneurysm 1 Asymptomatic or mild headache Glasgow Coma Scale (GCS) 15 1a Fixed neurological deficit without meningeal or brain reaction 2 Moderate to severe headache, cranial nerve palsy, nuchal rigidity GCS 13–14 without motor deficit 3 Lethargy, confusion, mild focal deficit GCS 13–14 with motor deficit 4 Stupor, hemiparesis, early decerebrate posturing GCS 7–12 without or with motor deficit 5 Coma, decerebrate posturing, moribund appearance GCS 3–6 without or with motor deficit Points Eye Opening Response Verbal Response Motor Response 6 NA NA Obeys 5 NA Oriented Localizes to pain 4 Spontaneous Confused Withdraws to pain 3 To speech Inappropriate Flexor (decorticate) 2 To pain Incomprehensible Extensor (decerebrate) 1 None None None -
NA indicates not applicable.
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Fisher Group Blood Pattern on Nonenhanced CT 1 No subarachnoid blood detected 2 Diffuse or vertical layers <1 mm thick* 3 Localized clot or vertical layers ≥1 mm thick 4 Intracerebral or intraventricular clot with diffuse or no subarachnoid hemorrhage -
* “Vertical” cisterns include interhemispheric, insular, and ambient.
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General Definitions (Choose all that apply) Clinical presentation Hemorrhage Incidental Evidence of new hemorrhage Hemorrhage Age of new hemorrhage Seizure Is new hemorrhage symptomatic Neurological deficit Evidence of old hemorrhage Headache Age of old hemorrhage Other Was old hemorrhage symptomatic Date of presentation Evidence of new cerebral infarction Imaging source and date Evidence of intraparenchymal hemorrhage Location and size Size of parenchymal hemorrhage Lesion side Presence of mass effect Right Presence of hydrocephalus Left Opening pressure on insertion of ventricular catheter Midline Requirement for ongoing ventricular drainage Handedness Comorbid vascular conditions Right Fibromuscular dysplasia Left Arteriovenous malformation Aneurysm size (greatest diameter in mm) Bacterial endocarditis Multiple aneurysms Polycystic disease No. of aneurysms Familial history of aneurysms Aneurysm location Vascular occlusion Internal carotid Vascular anomalies Proximal intradural or ophthalmic Vasospasm Posterior communicating Nonatherosclerotic narrowing of the cerebral arteries Bifurcation Grading of vasospasm (mild, moderate, severe) Other internal carotid Possible clinical symptoms and signs related to vasospasm Anterior cerebral Treatment for vasospasm Anterior communicating Vasodilator, intra-arterial Proximal to anterior communicating Type and dosage of vasodilator Pericallosal Balloon angioplasty Middle cerebral Balloon type Proximal to bifurcation Vessels treated with angioplasty Bifurcation Technical success of endovascular treatment Distal to main bifurcation Unable to catheterize aneurysm Posterior circulation Unable to deploy adjunctive devices such as balloon or stent Basilar bifurcation Unable to deploy embolic materials in aneurysm Basilar trunk Embolic material herniation beyond aneurysm confines Superior cerebellar Neck remnant Posterior cerebral Interstitial opacification Posterior inferior cerebellar Near complete occlusion Other posterior circulation Complete occlusion Gradea,b Definition 0 Complete aneurysm occlusion 1 90% or greater aneurysm occlusion 2 70–89% aneurysm occlusion 3 50–69% aneurysm occlusion 4 25–49% aneurysm occlusion 5 Less than 25% aneurysm occlusion -
a The modifier “I” may be used to describe interstitial opacification within the confines of the coil mass.
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b The modifier “G” may be used to describe interval growth in the overall dimensions of the aneurysm as a separate phenomenon from coil compaction with recanalization of the aneurysm.
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Definition Description Complication Neurological deterioration, NIHSS ≥1 Transient ischemic attack Resolution of new focal deficit within 24 hours No CT or MRI evidence of infarction Cerebrovascular accident, symptomatic Greater than 30 days duration Major NIHSS ≥4, mRS ≥3 Minor NIHSS <4, mRS ≤2 -
NIHSS indicates National Institutes of Health Stroke Scale; mRS, Modified Rankin Scale.
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Complication Category of Complication Abscess Infectious/inflammatory Angina/coronary ischemia Cardiac Idiosyncratic reaction Medication-related Allergic/anaphylactoid reaction Contrast-related Arterial occlusion/thrombosis, puncture site Vascular Arterial occlusion/thrombosis, remote from puncture site Vascular Arteriovenous fistula Vascular Congestive heart failure Cardiac Device malfunction with adverse effect Device-related Death related to procedure Death Death unrelated to procedure (30-day mortality) Death Dysrhythmia, cardiac Cardiac Embolization, arterial Vascular Fluid/electrolyte imbalance General nonvascular Hematoma bleed, remote site Vascular Hematoma bleed at needle, device path: nonvascular procedure Vascular Hematoma bleed, puncture site: vascular procedure Vascular Incorrect drug Medication-related Incorrect dosage Medication-related Intimal injury/dissection Vascular Ischemia/infarction of tissue/organ Vascular Incorrect site of administration Medication-related Local infection Infectious/inflammatory Liver failure General nonvascular Migration of embolic material from target site Device-related Myocardial infarction Cardiac Malposition Device-related Nausea/vomiting General nonvascular Other (cardiac) Cardiac Other (contrast-related) Contrast-related Other (central nervous system complication) Neurologic Other dose-dependent complication Contrast-related Other (device-related) Device-related Other (gastrointestinal) General nonvascular Other (general nonvascular) General nonvascular Other (hematologic) General nonvascular Other (infectious/inflammatory) Infectious/inflammatory Other (medication-related) Medication-related Other (neurologic) Neurologic Other (respiratory/pulmonary) Respiratory/pulmonary Other (vascular) Vascular Pancreatitis Infectious/inflammatory Pulmonary embolism Respiratory/pulmonary Pulmonary embolism Vascular Peritonitis Infectious/inflammatory Hypotension Cardiac Hypoxia Respiratory/pulmonary Pulmonary edema Respiratory/pulmonary Peripheral nervous system complication Neurologic Pneumothorax Respiratory/pulmonary Pseudoaneurysm Vascular Respiratory arrest Respiratory/pulmonary Renal failure Contrast-related Septicemia/bacteremia Infectious/inflammatory Seizure Neurologic Septic shock Infectious/inflammatory Stroke, ischemic Neurologic Stroke, hemorrhagic Neurologic Tissue extravasation Contrast-related Transient ischemic attack Neurologic Unintended perforation of hollow viscus General nonvascular Vascular perforation or rupture Vascular Vagal reaction Cardiac Vasospasm Vascular Venous occlusion/thrombosis, puncture site Vascular Venous occlusion/thrombosis, remote from puncture site Vascular Minor complications A. No therapy, no consequence B. Nominal therapy, no consequence; includes overnight admission for observation only Major complications C. Require therapy, minor change in length of hospitalization (<48 hours) D. Require major therapy, unplanned increase in level of care, prolonged hospitalization (>48 hours) E. Permanent adverse sequelae F. Death
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