Subarachnoid hemorrhage has been traditionally ruled-out in the emergency department (ED) through computed tomography (CT) followed by lumbar puncture if indicated. Mounting evidence suggests that non-contrast CT with CT angiography (CTA) can safely rule-out subarachnoid hemorrhage and obviate the need for lumbar puncture, but adoption of this approach is hindered by concerns of identifying incidental aneurysms. This study aims to estimate the incidence of incidental aneurysms identified on CTA head and neck in an ED population.
This was a health records review of all patients ≥ 18 years who underwent CTA head and neck for any indication at four large urban tertiary care EDs over a 3 month period. Patients were excluded if they underwent CT venogram only, had previously documented intracranial aneurysms, or had intracranial hemorrhage with or without aneurysm. Imaging reports were reviewed by two independent physicians before extracting relevant demographic (age, sex), clinical (CTAS level, CEDIS primary complaint) and radiographic (number, size, and location of aneurysms) information. The incidence rate of incidental aneurysms was calculated.
A total of 1089 CTA studies were reviewed with a 3.3% (95% CI 2.3-4.6) incidence of incidental intracranial aneurysms. The median size of incidental aneurysms was 4 mm (0.7-11) and 10 (27.7%) patients had multiple aneurysms. Patients with incidental aneurysms did not differ based on mean age, sex, and CTAS levels.
The \"risk\" of discovering an incidental aneurysm is 3.3%. Clinicians should not be deterred from using CTA in the appropriate clinical settings. These estimates can inform shared decision-making conversations with patients when comparing subarachnoid hemorrhage rule-out options.
RéSUMé: CONTEXTE: L\'hémorragie sous-arachnoïdienne (HSA) a été traditionnellement exclue au service des urgences (SU) par tomodensitométrie cérébrale (TDM) suivie d\'une ponction lombaire si indiquée. Des preuves de plus en plus nombreuses suggèrent que la tomographie sans contraste avec l\'angiographie par tomodensitométrie (l\'angio-TDM) permet d\'exclure en toute sécurité les HSA et d\'éviter la ponction lombaire, mais l\'adoption de cette approche est entravée par les craintes d\'identifier des anévrismes accidentels. Cette étude vise à estimer l\'incidence des anévrismes accidentels identifiés par l\'angiographie de la tête et du cou dans une population d\'urgences. MéTHODES: Il s’agissait d\'une étude des dossiers médicaux de tous les patients âgés de ≥ 18 ans qui ont subi une angioplastie de la tête et du cou, quelle qu\'en soit l\'indication, dans quatre grands services d\'urgence urbains de soins tertiaires sur une période de trois mois. Les patients étaient exclus s\'ils n\'avaient subi qu\'une phlébographie par tomodensitométrie, s\'ils avaient déjà eu des anévrismes intracrâniens documentés ou s\'ils avaient eu une hémorragie intracrânienne avec ou sans anévrisme. Les rapports d’imagerie ont été examinés par deux médecins indépendants avant d’extraire les informations démographiques pertinentes (âge, sexe), cliniques (niveau CTAS, plainte primaire CEDIS) et radiographiques (nombre, taille et emplacement des anévrismes). Le taux d’incidence des anévrismes accidentels a été calculé. RéSULTATS: Un total de 1089 études angio-TDM ont été examinées avec une incidence de 3,3 % (IC à 95 % : 2,3-4,6) d\'anévrismes intracrâniens accidentels. La taille médiane des anévrismes fortuits était de 4 mm (plage : 0,7-11) et 10 (27,7 %) patients présentaient des anévrismes multiples. Les patients présentant des anévrismes accidentels ne différaient pas en fonction de l\'âge moyen, du sexe et des niveaux CTAS. CONCLUSIONS: Le « risque » de découvrir un anévrisme fortuit est de 3,3 %. Les cliniciens ne doivent pas être dissuadés d\'utiliser l\'angio-TDM dans les contextes cliniques appropriés. Ces estimations peuvent éclairer les conversations de prise de décision partagée avec les patients lors de la comparaison des options d\'exclusion de l\'HSA.

OBJECTIVE: The aim of this study is to analyze the effectiveness of our protocol of the use of multimodality tools, namely indocyanine green-dual image video angiography, neuroendoscope, neuromonitoring with motor-evoked potential, micro-Doppler in the microsurgical clipping of unruptured anterior circulation aneurysms, operated at our institute from January 2016 to December 2018.
METHODS: We performed a retrospective analysis of all cases of unruptured anterior circulation aneurysms, operated at Fujita Health University Banbuntane-Hotokukai Hospital, Japan, from January 2016 to December 2018. We assessed outcome at immediate postoperative, at discharge, and at 3 months follow-up by defining permanent morbidity as drop in Modified Rankin Scale (MRS) by 1 at 3 months follow-up and transient morbidity as temporary deficit that improved at discharge or follow-up. Postoperative events, namely seizures, infection that did not affect/change. Preoperative MRS and discharge timing were excluded. We concluded poor outcome as MRS ≥3 and good outcome as MRS < 3 (0-2). All patients had a minimum of 3 months follow-up before outcome conclusion.
RESULTS: In 2016, a total of 98 cases were operated with no mortality or permanent morbidity (i.e., change in preoperative MRS), only transient morbidity was seen in (two cases) 2.04%. In 2017, a total of 119 cases were operated with no mortality or morbidity. In 2018, a total of 130 cases were operated with no mortality or permanent morbidity, only transient morbidity 0.7%. Summarizing from January 2016 to December 2018, a total of 347 cases of anterior circulation aneurysms were operated. Mostly, in the female sex (73.3%), the most common was middle cerebral artery aneurysm (39.1%). The mean size was 5.3 mm with no mortality or permanent morbidity with only transient morbidity in 0.9%. No poor outcome (MRS ≥3) was seen in our series.
CONCLUSIONS: In our center for most unruptured anterior circulation aneurysms, microsurgical clipping is the treatment of choice. We believe our protocol of the intra-operative usage of multimodality tools have aided in the safe microsurgical clipping and have consistently resulted in good operative outcomes. Hence, we recommend and continue to use our Fujita-Bantane Protocol in all cases of micro-surgical clipping of aneurysms to consistently achieve good operative outcomes.