Parameter of rupture pc oa
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Morphological Parameters Associated with Ruptured Posterior communicating Aneurysm : Allen Ho, Ning Lin , Nareerat Charoenvimolphan: Department of neurosurgery
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Parameter of rupture pc oa
- 2. 犖犖劇犢犖犖劇犖犖犖犖迦 犖犖迦犖犖謹犖犖 犖犖犖 ISUIA ( International Study of Unruptured Intracranial aneurysm ) The treatment decision of Unruptured intracranial aneurysm based mainly on the size of aneurysm How to deal with Unruptured intracranial aneurysm ?
- 3. Recent large prospective Natural history of study of Unruptured aneurysm conducted by Unruptured Cerebral aneurysm Study ( UCAS ) of Japan 犢犖犢犖÷元犖犖迦牽犖犖巌犖迦牽犖犖 犢犖犖劇犖犖 1. Size 2. location 犢犖ム鍵 3. Morphology 犖犢犖о権 犖犢犖犖÷顕犖犢犖÷元犖犖迦牽犖犖謹犖犖迦賢犖朽犖犖ム顕犖∇犖犖迦犖犖朽犖犖謹犖犖迦犖犖朽犖∇硯犖犖園 mixed aneurysm 犢犖ム鍵犖犖園硯犢犖犖 犢犖犢犖 Aspect ratio , size ratio, Undulation ( curling ) index 犖о犖 犢犖犖朽犖∇硯犖犖園 犖犖о顕犖÷犖犖朽犖∇犢犖犖犖迦牽 rupture 犖犖犖劇賢 犢犖÷ 犖犖犖犖犖迦犖犖朽 犖÷元犖犖迦牽犖犖謹犖犖 犖犖劇犖犢犖犖朽 犢犖犢犖 犖÷元犖犖迦権犖犖迦犖犖迦牽犖犖謹犖犖迦犖謹 Association of MCA rupture 犢犖犢犢犖犢 Aspect ratio , flow angle 犢犖ム鍵 犢犖犖劇犖犖犖犖犖 Parent-daughter Matsukawa at al 犖÷元犖犖迦牽犖犖迦権犖犖迦権犢犖犖朽犖∇硯犖犖園 ACom Rupture 犖о犖 犢犖犖朽犖∇硯犖犢犖犖犖犖園 Anterior dome projection, The presence of Blebs 犢犖ム鍵 Size > 5 mm
- 4. PCoA aneurysm : 犖犖犖о犖迦犖迦牽犖犖謹犖犖迦犖朽犖犢犖迦犖÷顕 犖÷元 prevalence of aneurysm measuring < 10 mm 犖犖犖萎検犖迦 87.5% 犢犖ム鍵 犖犖犖о犖 犖÷顕犖犖犖о犖 85.6% 犖犖朽犖犖 犖о犖迦検犖朽犖迦牽犢犖犖犖犖犖 Aneurysm size < 10 mm. 犖犖園犖犖園犖 犖犖犖о犖 犖犖迦牽犖犖巌犖迦牽犖犖 犢犖犖朽権犖犢犖犢 犖犖犖迦犖犖∇犖迦犢犖犖朽犖∇硯 犖犖迦 犢犖÷犢犖犖朽権犖犖犖犢犖犖犖迦牽犖犖犖犖犖о顕犖÷犖犖朽犖∇犢犖犖犖迦牽 犢犖犖 How about PCoA aneurysm ?
- 5. Large sample of Posterior communicating aneurysm using a diverse array of morphological variables to determine the parameter associated with rupture Posterior communicating artery aneurysms.
- 6. Inclusion 1. All patients with a diagnosis of PCoA aneurysm 2. Treated at the Brigham and Womens Hospital during a 7-year period between 2005 to 2012 Exclusion Aneurysm that underwent re-operation AVM or those that lacked pre op CTA Patient selection
- 7. Demographic and clinical information collected from medical record Patient data on risk factor common associated with aneurysm : smoking status, family history , presence of multiple aneurysm , history of hypertension, and prior history of aneurysm rupture/ SAH Patient selection
- 8. Pre op CTA image were utilised to generate composite 3D model of the aneurysm and surround vasculature , Siemens. 犖÷元犖犖迦牽犖犖ム犖迦硯 犖犖謹犖犖迦権犖ム鍵犢犖犖朽権犖 犢犖犖劇犖犖犖犖迦犖犖園犖犖迦 CTA 犢犖犢犖 3D model Reconstruction of 3D models
- 9. Aneurysm Size Volume Aspect ratio Aneurysm angle Vessel angles Size ratio De鍖nition of morphological parameters Flow angles Vessel-to vessel angles
- 10. Parameter to specific anatomy of PCoA 1. Distance from PCoA origin ( or proximal neck of the aneurysm ) to the ICA bifurcation 2. Angle between the proximal ICA and PCoA De鍖nition of Speci鍖c anatomy parameters term
- 11. 1. Aneurysm maximum height = 犢犖犖劇犖犖犖迦牽犖犖犖萎犖÷鹸犖 犢犖犖劇犖犖 Aneurysm size.犢犖ム鍵 犢犖犖朽犖∇硯犖犖園 Largest cross- sectional diameter of aneurysm 犖犖迦牽犖о険犖 犖犖橿犖迦 Base of aneurysm 犖犖迦犖犖迦 3D 2. The maximum perpendicular height =犖犖о顕犖÷肩犖項犖犖迦 Centre of the Base to dome 3. Aspect ratio = the maximum perpendicular height / Average neck diameter of aneurysm 4. Aneurysm angle = 犖÷幻犖÷牽犖萎見犖о犖迦 plane of neck of aneurysm 犢犖ム鍵 vector of maximum height of aneurysm 犖о険犖犖犖迦 Centre of the aneurysm neck to furthest point of the dome of aneurysm Angle of inclination of the aneurysm from the plane of the neck De鍖nition of morphological parameters
- 12. 5. The main surrounding vessels 犢犖犢犢犖犢 ICA Proximal to aneurysm ( ICA 1 ), ICA distal to aneurysm ( ICA2 ).犢犖ム鍵 PCoA 6. Size ratio = Ratio between the maximum aneurysm height and mean vessel diameters of all branches associated with the aneurysm 7. The diameter of particular vessel = Averaging the diameter of cross-section at the neck of the aneurysm (D1) with the dimeter of the cross-section at 1.5 x D1 from the neck of aneurysm Average diameter was calculated for all vessel diameter 犢犖犖劇犖犢犖犢犢犖犖犖迦牽犖犖橿犖о Size ratio 8. Vessel angle = angle between the respective vessel and the plane of aneurysm neck 9. Centerlines for each vessel = linking the two center point of the cross-sections utilised to measure the vessel dimeter in size ratio De鍖nition of morphological parameters
- 13. 10. The ICA1/PCoA flow angle = angle between the vector of maximum height of the aneurysm and the vector of centreline through the ICA1/PCoA that represent the vector of flow This angle 犢犖犖犖犖犖謹 犖÷幻犖 犖犖朽. Aneurysm tiled with respect to the vector of flow through parent vessels De鍖nition of morphological parameters
- 16. Vascular angles 犢犖犢犢犖犢 Aneurysm , Vessels and Vessel -to-Vessel angles 犢犖犖∇犖迦牽犖о険犖犢犖犖朽犖∇硯犖犢犖犖犖犖園 ICA1, ICA2 犢犖ム鍵 PCoA The ICA1 to PCoA angle = the angle from between the proximal ICA and PCoA 犖犖÷顕犖∇犖謹 犖犖迦牽犖о険犖 Degree of blood flow deviation from proximal ICA 1 to PCoA 犖犖∇犖迦犢犖犖犢犖犖迦検犖犖犖о犖 PCoA 犢犖÷犢犖犢犢犖犢犖犢犖犖犖項犖犢犖о権犖犖伍 犖犖 The Vessel-to Vessel angle are independent of aneurysm itself and capture the contact of the surround vasculature within with the aneurysm arise Angles
- 17. 犢犖犢犖 new parameter 犖犖朽犖犖橿犖犖迦鍵犖犖園 PCoA 犢犖ム鍵犖∇険犖犢犖÷犢犖犢犖÷元犖犖迦牽犖犖謹犖犖迦検犖迦犢犖犖 犖犖÷顕犖∇犖謹 Distance from the proximal neck of the aneurysm 犖犖犖犖謹 Bifurcation of the ICA into the the middle cerebral and anterior cerebral artery Distance to ICA Bifurcation
- 18. Demographic and clinical characteristic by rupture status : Chi- square and two-tailed T test Univariated analysis : compared the value of morphology parameter between the rupture and enrapture group Multivariate logistic regression : Odds ratio(ORs ) and 95%CI for the likelihood of aneurysm rupture after adjusting for age, sex , smoking status , facility history and multiple aneurysm , HT and prior history of SAH Statistical Analysis
- 19. 犢犖犖劇犖犖犖犖迦 犖犖犖о犖 犖犖迦犢犖÷犖犖犖о犖迦検犖. PCoA 犖犖園犢犖犖犖犖伍犖犖迦権 犖犖園犖犖園犖 犢犖犖犖迦牽 犖犖園犖犖迦犖謹 Morphology 犖犖犖 PCoa 犢犖犢犖÷元犖犖迦牽犖犖園犢犖 犢犖犢犖÷元犖犖迦牽犖犖謹犖犖迦犖犖 Subgroup analysis 犢犖∇犖犖犖犖÷顕 Statistical significant : Type I error < 0.05 * multiple variate logistic regression was conducted to Crete a model for predicting present of ICH. 犖犖園犖犖園権犖犖朽犢犖犖迦検犖迦絹犖謹犖犖迦犖犢犢犖犢 1. Morphological of aneurysm 2. Relation to the ICA JMP Pro10, SAS version 0.2 Statistical Analysis
- 20. 148 PCoA aneurysm 40 ruptured 23 Unruptured Inclusion 63 9 / 40 presented with ICH
- 21. Patient with unruptured aneurysm were significantly more likely to have multiple aneurysm 犖犖犖劇賢 History of prior aneurysm rupture ( p = 0.034 )
- 23. Rupture aneurysm were associated 1. shorted distance to ICA bifurcation in a relationship to approach ( 11.3mm enrapture VS 10.4 mm rupture ) p = 0.076 2. Larger ICA1 to ICA2 angle and ICA1 to PCoA angle 犢犖犢犖犖迦犖犖迦牽犖犖謹犖犖迦犖朽犖犖犖о犖 犢犖÷犖÷元 Significant 3. Larger ICA1 to ICA2 angle was significantly associated with lateral projection of aneurysm ( lateral projection 85.8 degree VS 73.5 ) p= 0.013 4. PCoA aneurysm with lateral projection more associated with rupture and relationship also approached significant ( 30% unruptured VS 55% rupture ) p= 0.052 5. Aneurysm size 犖犖犖о犖迦検犖朽犖迦牽犖о険犖 5.85 mm unruptured VS 5.97 mm rupture p = 0.441 Table 2
- 28. Factors that associated with rupture aneurysm after adjusting for all other clinical and morphological variables ( multivariate Analysis ) 1. Aneurysm Volume (OR 0.98, 95% CI 0.950.99, p = 0.011) 2. Aneurysm neck diameter (OR 3.52, 95% CI 1.0117.9, p = 0.048) 3. ICA bifurcation distance (OR 0.44, 95% CI 0.190.80 p = 0.005).
- 29. Factors that associated with rupture aneurysm in Subgroup analysis ( visualised PCoA ) after adjusting for all other clinical and morphological variables ( multivariate Analysis ) 1. Younger age (OR 0.71, 95% CI 0.030.98, p = 0.031) 2. Increased neck diameter (OR 79.5, 95% CI 1.741.561012, p = 0.018) 3. Shorter ICA bifurcation to aneurysm distance (OR 0.04, 95% CI 5.78610290.59, p = 0.011).
- 30. Factors that associated with ICH 犖犖犖о犖迦犖 40 犖犖犖犖朽犖÷顕犖犢犖о権 Rupture aneurysm 犖÷元 9/40 犖犖犖犖朽犖÷顕犖犢犖о権 ICH Multivariated 1. Male sex (female OR 7.561026, 95% CI 6.86102200.5, p=0.032) 2. Patients with lack of hypertension (hypertension OR 3.461026, 95% CI 2.7610240.2, p = 0.009) 3. Aneurysms with lateral projection (OR 644, 95% CI 2.12.661011, p = 0.020) 4. Smaller volume (OR 0.9, 95% CI 0.60.98, p=0.010) 5. Larger maximum height (OR 16.4, 95% CI 1.74.26105, p = 0.007) 6. Smaller aneurysm angle (OR 0.9, 95% CI 0.60.99, p=0.029).
- 31. The majority of PCoA aneurysm rupture have found rupture rate in the smaller sizes in the follow-up studies than would be expected based on ISUIA. 犖犖迦犢犖犖劇犖犖犖÷顕犖犖犖迦 Flow induced hemodynamic stress involved at aneurysm site 犖÷元犖犖о顕犖÷肩犖橿犖園 犖÷顕犖犖犖о犖 犢犖犖朽犖∇硯犖犖園 犖犖迦牽 Rupture 犖犖犖犢犖犖犖劇賢犖犖迦犖犖園犖犖園権犢犖犖劇犖犖 Size of aneurysm 犖犖迦犖犖迦牽犖犖謹犖犖迦犖朽犖犖犖о犖 犢犖÷犖÷元犖犖о顕犖÷犖犖犖犢犖迦犖犖園犢犖犢犖犖劇犖犖 Aneurysm size 犢犖犢犖犖劇犖犖犖犖犖 Rupture 犢犖ム鍵 Unruptured 犢犖犖∇犖項犖犖園犖犖 犢犖犢犢犖犖犖犖犖謹 Impact of morphological parameters unrelated to size What do we learn ? Rupture rate in smaller size
- 32. 犢犖犖犖迦牽犖犖謹犖犖迦犢犖犖犖犖犢犖迦犖朽犖犖犖犖犖迦犖犖項犖犖園犖犖 犢犖犖朽犖∇硯犖犖園 Morphologic characteristics of MCA aneurysm 犢犖犢犢犖犢犖犖犖犖犢犖犢犖 3 犖犢犖о犖犖朽犖犖迦犢犖犖朽犖∇硯犖犢犖犖犖犖園犖犖迦牽 Rupture 犖犖犖 Aneurysm 犢犖犢犢犖犢 (1) Morphology of aneurysm itself. (2) Interactive between the aneurysm and associated vessels. (3) Relationship among the surrounding vasculature 犢犖犖犖迦牽犖犖謹犖犖迦犖朽犖犖朽犖犖朽犖∇硯犖犖園 PCoA aneurysm 犖犖犖о犖 The most significant factor 犢犖犢犢犖犢 relationship of the surround vasculature What do we learn ? Relationship of surround vasculature
- 33. Smaller ICA bifurcation to aneurysm distance 犖犖犖о犖 Associated with ruptured ( the mean difference between 2 groups was almost 1 mm and represented a more than 10% decrease in distance) 犢犖犢犢犖犖犖朽権犖犢犖犖朽権犖犖о犖 ICA bifurcation 犖犖朽犢犖犖 犖犖迦 PCoA origin 犖犢 犢犖犖÷厳犖犖犖犖園犖犖犖犖朽犖朽 犢犖犢犖 MCA bifurcation aneurysm 犖犖橿犖犢犢犖犖犖迦肩犖犖迦牽犢犖犖犖犢犖迦犖萎犢犖犖∇犖о犖 犢犖犢犖犖迦犢犖犢犖 犖犖犖犖 犢犖犖ム 犖犖園 ICA bifurcation 犖犢犢犖犖朽権犖犖犖園犖犖о ACoA aneurysm 犖犖謹犖 犖犖園検犖犖園犖犢犢犖犖犖園 犖犖ム犖犖 犖犖迦牽犖犖謹犖犖迦犖犢犖迦 (UCAs) 犖犖朽犖犖犖о犖 ACoa 犖÷元 higher rupture rate 犖÷顕犖犖犖о犖 MCA 犢犖犖∇肩犖迦検犖迦牽犖犖犖犖巌犖迦権犢犖犢犖犖迦 Hemodynamic modeling of aneurysm Fluid dynamics evaluation of the two geometric 犖犖犖о犖 犢犖犖犖犖犖朽犖朽 犖÷元 long ICA 犖犖萎犖犖о犖迦検犖 high wall shear stress 犖÷顕犖犖犖о犖 犖犖迦硯犖萎犖朽犖犖 Short ICA 犢犖ム鍵犖犖迦硯犖 Low wall shear stress 犖犢犖犖萎肩犖園検犖犖園犖犢犖犖園 Aneurysm rupture 犖÷顕犖犖犖о犖 What do we learn ? Smaller ICA bifurcation to aneurysm distance
- 34. Rupture rate were also associated with larger ICA1 to ICA2 angle and ICA1 to PCoA angle but these trends were not statistically significant * 犖犖犖犖朽犖朽犖÷元 Larger ICA1 to ICA2 犖犖÷顕犖∇犖謹犖犖犖犖朽犖朽犖÷元 Sharper turn in ICA 犖犖橿犖犢犢犖犖巌 Hemodynamic stress on daughter vessels 犢犖犢犢犖犢 PCoA * 犖犢犖о犖犖犖犖 Larger proximal ICA1 to PCoA angle 犖犖園犖犖犖犖巌犖迦権犢犖犢犖犖迦 Sharper parent- daughter angle 犖犖犖о犖 the greater the angle between the ICA1 and PCoA 犖犖橿犖犢犖÷元 the smaller deviation of flow form ICA1 parent vessel to PCoA daughter vessel 犖犖о顕犖÷肩犖園検犖犖園犖犢犖犖朽 犖犖犖о犖 犢犖犖朽犖∇硯犖犢犖犖犖犖園犖犖о Hemodynamic of flow 犢犖ム鍵犢犖犖朽犖∇硯犖犖園犢犖犖劇犖犖 Wall shear stress 犖犖朽犖犖橿犖犖犢犖 vascular branch point and aneurysm dome 犖犖朽犖÷元犖犖о顕犖÷肩犖橿犖園犖犖 Increase risk of rupture What do we learn ? Larger ICA1 to ICA2 angle
- 35. The anatomical relationship of ICA and PCoA vessel and Aneurysm 犖犖犖о犖迦検犖朽犖о顕犖 犖犖ム顕犖犖犖ム顕犖 -Yasargil 犢犖犢 犢犖犢犖犖犖犖巌犖犖謹 ICA-PCoA aneurysm 犖犖迦検 orientation of the aneurysm fundus 犖犖犖犢犖犢犖 5 犖犖犖巌犢犖犢犖犖犢 1. Anterolateral 2. Superolateral 3. Superior posterolateral ( supratentorial ) 4. Inferior posterolateral ( infratentorial ) 5. Inferior posteomedial What do we learn ?
- 36. Recent investigation 犖犖犖о犖 Rupture aneurysm associated with lateral projection of the aneurysm dome - 犢犖犖劇犖犖犖犖迦 the most important Configuration in modern study 犖犖犖о犖 犖犖о顕犖÷肩犖園検犖犖園犖犢犖犖萎見犖о犖迦 Lateral VS inferior projection of aneurysm dome of PCoA 犖犖犖о犖 犖犖迦犢犖犢犖犖犖 Inferior projection 犖÷険犖犖犖萎検犖迦犢犖о権 犖犖迦牽犖犖.CNIII 犖÷顕犖犖犖о犖 犖犖犖萎犖朽 lateral projection 犖÷険犖犖犖萎犖巌犖犖園犖犖о Temporal lobe 犢犖ム鍵 犖÷険犖 犖犖萎犖犖巌犖犖о Temporal haemorrhage ( ICH ) 犖犖迦犖÷元犖犖迦牽犢犖犖 What do we learn ?
- 37. 犖犖迦犖犖迦権犖犖迦犖犖迦牽犖犖謹犖犖迦犖犖о犖 Rupture aneurysm ( 55% ) 犖÷険犖犖÷元犖犖о顕犖 犖犖園検犖犖園犖犢犖犖園 lateral projection 犢犖犢犖÷顕犖犖犖謹 30% 犢犖ム鍵犖犖犖о犖 lateral projection 犖犖迦犖犖迦犖犖謹犖犖迦犖朽犖÷険犖犖÷元 Large ICA1 to ICA2 angles The larger the ICA2 to ICA2 angles in rupture aneurysms 犖犖朽犖犖園検犖犖園犖犢犖犖園 lateral projection of aneurysm dome 犢犖犖犖迦鍵犖о犖 犖÷元 sharper turns in vasculature and larger deviation in parent to daughter flow 犖犖園犖犖園犖 犖犖迦牽犖犖謹犖犢犖犖朽犖∇硯犖犖園 Surrounding vasculature 犖犖謹 犖÷元犖犖о顕犖÷肩犖橿犖園犢犖犖犖迦牽 犖犖謹犖犖迦犖犖朽犖∇硯犖犖園 Relationships of the aneurysm What do we learn ?
- 38. Rupture PCoA aneurysm 犖÷険犖犖犖犖о犖迦犖犖朽犖∇硯犖犖園 Temporal lobe rupture 犢犖犖朽犖∇硯犖犢犖犖犖犖園. Lateral projection of the aneurysm dome 犢犖ム鍵犖犖犖о犖迦肩犖園検犖犖園犖犢犖犖園犖犖迦牽犖犖謹犖犖迦犖朽 犖犖犖犖犖迦犖犖朽犖犖園犖犖園権犖犖朽犖÷元犖犖о顕犖÷犖犖朽犖∇硯犖犢犖犖犢犖犢犢犖犢 smaller volume , larger maximum height , smaller aneurysm angle The association of hypertension with intracerebral haemorrhage may be because hypertension increases rupture risk at a smaller size Finally, the association with male sex does not have a clear morphological explanation and warrants further study. Intracerebral haemorrhage Table 6
- 39. Limitation Retrospective study of patient with PCoA aneurysm who were treated 犖犖園犖犖園犖 犖犖迦犖犖 犖о犖迦検犖 Bias selection of the enrapture aneurysm 犖犖犖犖犖迦犖犖朽犖犖犖о犖 Parameter 犖犖朽犖÷元犖犖迦牽 犖犖謹犖犖 犖犖犖о犖迦賢犖迦犢犖犖朽犖∇硯犖犖園 犖犖о Rupture aneurysm 犖犖朽犖犢犖犖犖犖迦牽 犖犖迦牽犖犖園犖犖迦犖犢犖迦犖園犖 犢犖犖∇犖朽 犖犖о犖犖朽 犢犖÷犖犖橿犖犢犖 犖犖朽犖犢犖犖犖÷元犖犖迦牽 犖犖橿犖迦権 Risk rupture Certain feature of the aneurysm may be altered by rupture state Their model is the simplified one 犢犖犖∇犖朽 犖犖園犖犖園権 犖犖劇犖犢 犖犖朽犖犖迦犢犖犖朽犖∇硯犖犖園 Fluid dynamics 犢犖犢犢犖犢犖犖о material properties of the arterial wall, boundary conditions 犖犖犖劇賢 犖犖劇犖犢 犖犖迦 犢犖÷犢犖犢犖÷顕犖犖謹犖犖 犖犖迦牽犖о険犖 犖犖橿犖犢 犢犖犖 Manually 犖犖犖犖迦 3D 犖犖∇犖迦犢犖犖犢犢犖犢 犢犖犢犖犖迦絹犖園権犖犖о Automated method of assessment morphology to achieve greater consistency in measurement 犖犖謹犖犖犖迦犖犖項 犖犖園犖犖 犖犢 犢犖犖ム検犖о犖 Best recreate the applicability of our methodology in clinical setting
- 40. Conclusion Rupture aneurysm significantly associated with Shorter distance from the aneurysm to the internal carotid artery bifurcation ICH associated with 1. Smaller aneurysm volume 2. Larger aneurysm maximum height 3. Smaller aneurysm angle Lateral projection , male, sex, lack of hypertension