Comparison

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1

T

he treatment of paraclinoid aneurysms remains chal-

lenging.7,8,10,17,18,25 It is important to differentiate the exact location of the paraclinoid aneurysm, whether intradural or not, when considering treatment options. The distal dural ring (DDR) is the anatomical boundary between the intra- and extradural segments of the internal

carotid artery (ICA) in the paraclinoid region.2,9,19,24 Some studies tried to delineate the DDR with imaging methods and differentiate the aneurysm in the vicinity of the an-terior clinoid process (ACP).5,16,23 However, these studies either lacked direct surgical confirmation or comprised a small case number.

aBBreViatiOnS ACP = anterior clinoid process; C 4 = cavernous segment; C 5 = clinoid segment; C 6 = ophthalmic segment; CTA = CT angiography; DDR = distal dural ring; DSA = digital subtraction angiography; ICA = internal carotid artery; OphA = ophthalmic artery; OS = optic strut; PDR = proximal dural ring; ROC = receiver operating characteristic; TS = tuberculum sellae.

SuBmitted May 6, 2015. accepted July 27, 2015.

include when citing Published online January 8, 2016; DOI: 10.3171/https://www.sodocs.net/doc/2911273793.html,parison of the effectiveness of using the optic strut and tuberculum sellae as radiological landmarks in diagnosing paraclinoid aneurysms with CT angiography

chih-hsiang liao, md,1 chung-Jung lin, md,2,3 chun-Fu lin, md,1,3 hsin-Yi huang, mS,4 min-hsiung chen, md,1,3 Sanford p. c. hsu, md,1,3 and Yang-hsin Shih, md 1,3

Departments of 1Neurosurgery, Neurological Institute, and 2Radiology and 4Biostatistics Task Force (under Department of Medical Research and Education), Taipei Veterans General Hospital; and 3National Yang Ming University, School of Medicine, Taipei, Taiwan, Republic of China

OBJectiVe The treatment of paraclinoid aneurysms remains challenging. It is important to determine the exact loca-tion of the paraclinoid aneurysm when considering treatment options. The authors herein evaluated the effectiveness of using the optic strut (OS) and tuberculum sellae (TS) as radiographic landmarks for distinguishing between intradural and extradural paraclinoid aneurysms on source images from CT angiography (CTA).

methOdS Between January 2010 and September 2013, a total of 49 surgical patients with the preoperative diagnoses of paraclinoid aneurysm and 1 symptomatic cavernous-clinoid aneurysm were retrospectively identified. With the source images from CTA, the OS and the TS were used as landmarks to predict the location of the paraclinoid aneurysm and its relation to the distal dural ring (DDR). The operative findings were examined to confirm the definitive location of the para -clinoid aneurysm. Statistical analysis was performed to determine the diagnostic effectiveness of the landmarks.

reSultS Nineteen patients without preoperative CTA were excluded. The remaining 30 patients comprised the current study. The intraoperative findings confirmed 12 intradural, 12 transitional, and 6 extradural paraclinoid aneurysms, the diagnoses of which were significantly related to the type of aneurysm (p < 0.05) but not factors like sex, age, laterality of aneurysm, or relation of the aneurysm to the ophthalmic artery on digital subtraction angiography. To measure agree-ment with the correct diagnosis, the OS as a reference point was far superior to the TS (Cohen’s kappa coefficients 0.462 and 0.138 for the OS and the TS, respectively). For paraclinoid aneurysms of the medial or posterior type, using the base of the OS as a reference point tended to overestimate intradural paraclinoid aneurysms. The receiver operating characteristic curve indicated that if the aneurysmal neck traverses the axial plane 2 mm above the base of the OS, the aneurysm is most likely to grow across the DDR and present as a transitional aneurysm (sensitivity 0.806; specificity 0.792).

cOncluSiOnS High-resolution thin-cut CTA is a fast and crucial tool for diagnosing paraclinoid aneurysms. The OS serves as an effective landmark in CTA source images for distinguishing between intradural and extradural paraclinoid aneurysms. The DDR is supposed to be located 2 mm above the base of the OS in axial planes.

https://www.sodocs.net/doc/2911273793.html,/doi/abs/10.3171/2015.7.JNS151046

KeY wOrdS computed tomographic angiography; distal dural ring; optic strut; paraclinoid aneurysm; proximal dural ring; tuberculum sellae; vascular disorders

?AANS, 2016

c. h. liao et al.

The ACP is a short triangular bony projection of the lesser sphenoid wing and attached to the body of the sphe-noid by 1 superior root, the roof of the optic canal, and 1 inferior root, the optic strut (OS). The OS is also the ante-rior limit of the clinoid (C5) segment of the ICA, and the proximal dural ring (PDR) attaches to the inferior margin of the OS and is the roof of the cavernous sinus.21 The DDR and PDR are separated by the OS and the bulk of the ACP anteriorly but are fused at the tip of the ACP posteri-orly. In addition, the medial part of the DDR is continuous with the dura covering the tuberculum sellae (TS). In the current study, we used the OS and the TS as radiological landmarks in source images from CT angiography (CTA) to determine if the paraclinoid aneurysm was intra- or ex-tradural (i.e., either distal or proximal to the DDR). The definitive diagnoses of the paraclinoid aneurysms were confirmed by direct surgical inspection. The diagnostic effectiveness of these 2 landmarks was analyzed, and the relationship between the DDR and landmark was defined through statistics.

methods

patient group and Selection criteria

Between January 2010 and September 2013, 49 con-secutive surgical patients with the preoperative diagnosis of paraclinoid aneurysm, either ruptured or not, were re-cruited retrospectively from the operation logbook. The preoperative diagnoses were based on CTA and/or digital subtraction angiography (DSA). CTA was a prerequisite. Patients without preoperative CTA or operation videos were excluded. This retrospective study was approved by the institutional review board of our hospital.

Study design

To determine if the paraclinoid aneurysm is intra- or extradural (i.e., either distal or proximal to the DDR), 2 bony landmarks, the TS19 and OS, were chosen as refer-ence points (Fig. 1B and C). Aneurysms located below these reference points were regarded as extradural, and aneurysms above were regarded as intradural. In this ret-rospective study, we used the source images from the CTA and operation videos to analyze the diagnostic effective-

ness of these 2 landmarks.

cta protocol

High-resolution CTA with a multidetector CT scanner (Brilliance 64; Philips Healthcare) was applied for para-clinoid aneurysms. 3D CTA scans were obtained with the following parameters: 120 kV, 250 mA, field of view 22 to 24 cm, matrix size 512 × 512, and UB filter type. The reconstructed axial image was 1 mm thick with 0.625-mm intervals.

measurement

At a 3D workstation (Philips Brilliance Workspace CT workstation), the axial orientation was adjusted to an angle parallel to the planum sphenoidale. The base of the OS is defined as the midpoint along the slope of the great-er sphenoid wing where the OS attaches on the coronal multiplanar reformats (Figs. 2 and 3). One neuroradiolo-gist (C.J.L.) and 1 neurosurgeon (C.H.L.), who were both blinded to the intraoperative findings and definitive diag-noses, concurred on the position of the base of the OS, which was simultaneously cross-referenced in the axial and sagittal planes. The same coronal cut used to define the base of the OS was also used to define the location of the TS in the axial and sagittal planes with the aid of a digital cross-referencing tool.

The distances between the axial cuts where the base of the OS and the aneurysmal neck (both the most proximal and distal points) were measured (Figs. 2 and 3). The base of the OS is set as 0. For example, if the proximal point of the aneurysmal neck is 3 mm below the base of the OS (-3 mm), and the distal point is 5 mm above (+5 mm), this aneurysm is then regarded as a transitional paraclinoid an-eurysm. If both the proximal and distal points of the aneu-

rysmal neck are below the OS, the preoperative diagnosis Fig. 1. ICA classification and the anatomy discussed in this study. a: The Bouthillier nomenclature for ICA segments. B: Superior view of the right paraclinoid region (dura preserved). The area surrounded by the green dots is the oculomotor triangle, where third cranial nerve (CN3) pierces into the cavernous sinus. c: Superior view of the right paraclinoid region (dura and ACP removed). The green dots represent the DDR, the purple dots represent the PDR, and the C5 segment of the ICA and OS is flanked by the rings. d: According to the neck origin of the paraclinoid aneurysm on the ICA, we classified the aneurysms

as anterior (A), medial (M), lateral (L), and posterior (P) types. ACA

= anterior cerebral artery; AChoA = anterior choroidal artery; CNII = optic nerve; CN3 = oculomotor nerve; CN4 = trochlear nerve; MCA = middle cerebral artery; PComA = posterior communicating artery; PCP = posterior clinoid process; V1 = ophthalmic nerve; V2 = maxillary nerve. Panels B–D are reproduced and used with permission from Rhoton AL Jr: The cavernous sinus, the cavernous venous plexus, and the carotid collar. Neurosurgery 51 (4 Suppl):S375–S410, 2002. Figure is available in color online only.

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landmarks in diagnosing paraclinoid aneurysms with cta

is total extradural aneurysm; if both points were above the OS, the diagnosis is total intradural. Using the TS as an-other reference point, measurements were repeated with the methods identical to that of the OS.

In this study, the Bouthillier classification of ICA seg -ments was adopted (Fig. 1A).1 We further classified para -clinoid aneurysms as the medial, lateral, anterior, or poste-rior type according to the neck origin of the aneurysm on the ICA for later discussion (Fig. 1D).

Surgical approach

The pretemporal transclinoid/transcavernous approach along with extradural anterior clinoidectomy was used for clipping.12–15 The C 5 segment of the ICA, DDR, and PDR were clearly exposed in the operation. The span of the an-eurysmal neck and its relation with the rings were identi-fied and confirmed.

Statistical analysis

Each aneurysmal neck has the most proximal and dis-tal points along the ICA. Hence, 2 sets of measurement data from each paraclinoid aneurysm could be retrieved to examine if the point of interest was intra- or extradu-ral, the results of which were compared with the definitive intraoperative diagnoses using linear regression. To com-pare the diagnoses with other factors (sex, age, laterality of aneurysm, type of aneurysm, and relation of the aneurysm to the ophthalmic artery [OphA] on DSA), the chi-square test or McNemar’s test for nominal variables and ANOV A for continuous variables were used. To measure agreement with the correct diagnosis (interrater reliability), Cohen’s kappa coefficient was used. The Biostatistics Task Force of Taipei Veterans General Hospital assisted in the data

processing and statistical analysis using IBM SPSS Statis-tics version 20.0.

results

Of the 49 surgical patients with preoperative diagno-ses of paraclinoid aneurysms, 19 patients without source images from preoperative CTA were excluded. The re-maining 30 patients (7 men and 23 women) comprised the current retrospective study. The mean patient age was 56 years (range 37–76 years). The demographics, intraopera-tive diagnoses, and the measurement results of using the OS and TS as reference points in the CTA source images were shown in Table 1. There were 12 medial, 8 anterior, 2 lateral, and 8 posterior types of paraclinoid aneurysms in this study. The intraoperative findings confirmed 12 intra -dural, 12 transitional, and 6 extradural paraclinoid aneu-rysms. The follow-up DSA showed no residual aneurysms.Statistical analysis

The definitive intraoperative diagnoses were signifi -cantly related to the type of aneurysm, but not factors like sex, age, laterality of aneurysm, and relation of the aneurysm to the OphA on DSA (Table 2). Paraclinoid an-eurysms of the medial type were mostly transitional or in-tradural, the reason for which was due to the carotid cave (discussed later). Paraclinoid aneurysms of the anterior type were either intradural or transitional. In this series, there were no extradural paraclinoid aneurysms of the an-terior type, and there were no such aneurysms (i.e., ante-rior clinoid aneurysms) in our experience. We speculate that the anterior wall of the short extradural clinoid seg-

ment of the ICA does not take much hemodynamic force.

Fig. 2. Case 24. Measurement with the concordant diagnosis using both the OS and TS as the reference points. a and B: CT angiogram (A) and DS angiogram (B) showing a right paraclinoid aneurysm of the medial type. c and e: The proximal neck of the aneurysm is indicated by the yellow arrows on the axial (C) and sagittal (E) source CTA images. d: Using digital cross-referencing and measurement tools, the distances were determined (+5 mm for OS and 0 mm for TS). F: The usual reformatted 8-mm-thick coronal CTA image is shown for comparison and better delineation of the OS. The yellow star indicates the base of the OS. De-tailed measurement was still performed on thin-cut source images with digital cross-referencing tools. The data of the distal neck were also retrieved (not shown here) in the same way (+8.9 mm for OS and +3.4 mm for TS). Hence, the preoperative diagnosis was an intradural paraclinoid aneurysm with both the OS and the TS as reference points. g: The pretemporal transclinoid/trans-cavernous approach along with extradural anterior clinoidectomy was used for clipping. The intraoperative findings confirmed that the diagnosis is correct. The aneurysm (AN) was located distal to the DDR. Figure is available in color online only.

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Instead, the segment of the ICA between the DDR and the take-off site of the OphA takes most of the upward force. Paraclinoid aneurysms of the posterior type with a medial projection component tended to be transitional or intradu-ral. The number of paraclinoid aneurysms of the lateral type was too small to analyze.

is the OS or tS Better?

In this study, we found that the definitive diagnoses and the vertical distances between the axial planes of the an-eurysmal neck and the reference points were significantly correlated in the linear regression (0.921 and 0.905 for the OS and TS, respectively). Comparing the diagnostic ac-curacy of the OS and TS, the OS is far superior to the TS (k 0.462 and 0.138 for the OS and TS, respectively), which means that the OS has a higher interrater reliability and serves as a better radiological landmark.

In addition, there were no correlations between the de-finitive diagnoses and the horizontal distances between the sagittal planes of the aneurysmal neck and each refer-ence point.

medial type, carotid cave, and Superior hypophyseal artery aneurysms

While the lateral aspect of the DDR is tightly adher-ent to the ICA, the medial aspect of it is attached more loosely and may be incomplete, allowing a small pouch of subarachnoid space to herniate inferior and medial to the ICA,11,21 where the paraclinoid aneurysm of the me-dial type, carotid cave, and superior hypophyseal artery aneurysms occur. However, by using the base of the OS

as a reference point, overestimation of intradural portion of the paraclinoid aneurysms occurred in 9 patients whose aneurysms were presumed to be intradural but turned out to be transitional, in 2 patients whose aneurysms were pre-sumed to be intradural but turned out to be extradural, and in 1 patient whose aneurysm was presumed to be transi-tional but turned out to be extradural, which means the DDR is located slightly higher than the OS base (Table 3). In this series, there were a total of 6 extradural aneurysms. By using the OS base as a reference point in advance, we could detect 3 of these aneurysms preoperatively and thus could have avoided unnecessary exploration. Further improvement of the diagnostic sensitivity and specificity through the receiver operating characteristic (ROC) curve is discussed below. Of note, among these 12 patients, 10 were either the medial or posterior type. An example of overestimation is shown in Fig. 4.

predictive Value

The ROC curve was used to determine the cut-point value for the OS as a reference point (Fig. 5). The TS had worse interrater reliability than the OS, so it was not con-sidered for further analysis. The result for the OS was 2.050 mm (sensitivity 0.806; specificity 0.792), which means that the DDR was located 2 mm above the base of the OS in the axial planes. In other words, if the neck of the paracli-noid aneurysm traverses the axial plane 2 mm above (i.e., +2 mm) the base of the OS, the aneurysm is most likely transitional. If above the +2 mm axial plane, the aneurysm is intradural; if completely below the +2 mm plane, the

aneurysm is extradural and covered by the DDR.

Fig. 3. Case 5. Measurement with concordant pre- and postoperative diagnosis using the OS as a reference point. a and B: CT angiogram (A) and DS angiogram (B) showing a left paraclinoid aneurysm of the posterior type. c and e: The proximal neck of the aneurysm is indicated by the yellow arrows on axial (C) and sagittal (E) source CTA images. d: Using digital cross-referencing and measurement tools, the distances were determined (?2.0 mm for OS and ?6.3 mm for TS). The yellow star stands the base of the OS. The data of the distal neck were also retrieved (not shown here) in the same way (+3.0 mm for OS and ?1.9 mm for TS). Hence, the preoperative diagnosis was either a transitional paraclinoid aneurysm using the OS as a reference point or an extradural paraclinoid aneurysm using the TS as another reference point. F: The pretemporal transclinoid/transcavernous ap-proach along with extradural anterior clinoidectomy was used for clipping. The intraoperative findings confirmed the aneurysm as transitional. The DDR spanned across the aneurysm and its neck. Figure is available in color online only.

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Fig. 4. Case 3. Overestimation of the intradural portion of the paraclinoid aneurysm using the OS as a reference point. a and

CT angiogram (A) and DS angiogram (B) showing a left paraclinoid aneurysm of the posterior type.c and d: The proximal

neck of the aneurysm is indicated by the yellow arrows on sagittal source CTA images. The yellow star stands for the base of the OS. Using digital cross-referencing and measurement tools, the distance between the neck of the aneurysm and the base of the OS was 0 mm.e and F: The data of the distal neck were also retrieved in the same way, and the distance was +1.8 mm. The

preoperative diagnosis by our definition (the base of the OS as a reference point) was an intradural paraclinoid aneurysm. g and The pretemporal transclinoid/transcavernous approach along with extradural anterior clinoidectomy was used for clipping. How-ever, other than an intradural paraclinoid aneurysm, the intraoperative findings confirmed the aneurysm as extradural extracavern-

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landmarks in diagnosing paraclinoid aneurysms with cta

Fig. 5. ROC curve of the OS as a radiological landmark for predicting

the location of the DDR. The cutoff point for the OS as a reference point

is +2.050 mm (sensitivity 0.806; specificity 0.792), which means that the

DDR is located 2 mm above the base of the OS in axial planes. Figure

is available in color online only.

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高中作文写作有亮点的方法介绍

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