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Oul. D 1068, 2010 Supervised by Professor Osmo Tervonen Docent Ari Karttunen Reviewed by Docent Timo Kallio Docent Tapani Tikkakoski ISBN 978-951-42-6288-3 (Paperback) ISBN 978-951-42-6289-0 (PDF) http://herkules.oulu.fi/isbn9789514262890/ ISSN 0355-3221 (Printed) ISSN 1796-2234 (Online) http://herkules.oulu.fi/issn03553221/ Cover design Raimo Ahonen JUVENES PRINT TAMPERE 2010 Jartti, Pekka, Computed tomography in subarachnoid haemorrhage. Studies on aneurysm localization, hydrocephalus and early rebleeding Faculty of Medicine, Institute of Diagnostics, Department of Diagnostic Radiology, Institute of Clinical Medicine, Department of Neurosurgery, University of Oulu, P.O.Box 5000, FI-90014 University of Oulu, Finland Acta Univ. Oul. D 1068, 2010 Oulu, Finland Abstract Subarachnoid haemorrhage (SAH) is a life-threatened disease with poor outcome. It is usually caused by an intracranial aneurysm (IA) rupture and rapid diagnosis and treatment are of great importance. Computed tomography (CT) is a reliable method to detect the blood in the subarachnoid (SA) spaces. Digital subtraction angiography (DSA) offers dynamic and morphological information of a ruptured IA. The treatment options for excluding an aneurysm from the main circulation are neurosurgical clipping and endovascular procedures. The purpose of the present study was to evaluate the risk factors of acute hydrocephalus (HC) and the reliability to localize the ruptured aneurysm based on non-contrast CT. The aim was also to compare the effect of neurosurgical and endovascular treatment on the development of chronic HC, and evaluate the incidence and the risk factors of early rebleeding (< 30 days) after coiling. The data of 180 operated patients with a ruptured IA were checked. Two neuroradiologists separately located the IAs based on non-contrast CT. The analyses of blood amount and distribution was a reliable method for estimating the location of ruptured middle cerebral artery (MCA) aneurysms and anterior communicate artery (ACoA) aneurysms. Intracerebral haemorrhage (ICH) was a predictor for detecting the precise site. The results confirmed that intraventricular haemorrhage (IVH) was the most consistent single risk factor for the development of acute HC. Haemorrhage in the basal region and the large total blood amount in the SA spaces were strong predictors. The effect of early treatment modality for ruptured IAs on the development of chronic HC with 102 clipped and 107 coiled patients was compared. The treatment method used was not significantly associated with the occurrence of chronic HC or the need for shunt operation. The incidence and risk factors of early rebleeding after coiling were investigated in 194 consecutive acutely (within 3 days) coiled patients with ruptured IAs. The incidence of early rehaemorrhage was 3.6%. The presence of ICH at admission and poor clinical condition were significant predictors for rebleeding. An early rehaemorrhage appeared as an enlargement of the ICH in all of these patients. In conclusion, the non-contrast CT is a reliable method to detect the location of ruptured IA in patients with MCA and ACoA aneurysms. The risk factor for the development of acute HC is IVH. Other predictors are the total SA blood amount and blood in the basal regions. The treatment method used for acutely ruptured IA has no significant effect on the occurrence of chronic HC. The incidence of early rebleeding after coiling is low. The risk factors of rebleeding are the presence of ICH and poor clinical condition. Rehaemorrhage appears often as an enlargement of the ICH. Keywords: aneurysm rerupture, computed tomography, endovascular treatment, intracranial aneurysm, subarachnoid haemorrhage To Airi, Jaakko and Olli-Pekka Acknowledgements The present thesis was carried out at the Department of Diagnostic Radiology, University of Oulu, during the years 2001–2010. It would not have been possible to do this research alone, so some acknowledgements are called for. I am deeply grateful to my supervisor Professor Osmo Tervonen, M.D., Head of the Department of Diagnostic Radiology, for support and encouragement throughout these years. He has created good facilities and an inspiring atmosphere for my scientifi c work. I wish to acknowledge to Emeritus Professor Ilkka Suramo, M.D., the former Head of the Department of Radiology, whose scientifi c experience, enthuasism, and optimism impressed me already in the 1990s. I want also to express my gratitude to Emeritus Professor Juhani Pyhtinen, M.D., a creative co-worker, with many ideas in scientifi c work and a good sence of humour in everyday life. I wish to express my particular gratitude to my supervisor and closest co-writer Docent Ari Karttunen, M.D., for his never-failing encouragement, expert practical guidance, advice and realism. I am grateful to Docent Eero Ilkko, M.D., who kindly provided me excellent facilities for writing this thesis. I want warmly thank the offi cial reviewers Docent Tapani Tikkakoski, M.D., and Docent Timo Kallio, M.D., for their help and constructive criticism and insipiring discussions in the fi nal outcome of this work. Their suggestions have markedly improved the quality of my thesis. I sincerely thank co-writer and colleague Matti Isokangas, M.D., Ph.D., for his positive and encouraging attitude towards my work. His vast knowledge of intracranial aneurysms helped me to carry out this project. I am grateful to Docent Topi Siniluoto, M.D., Head of the Interventional Neuroradiology Unit, for his comments and criticism. Marianne Haapea, M.Sc., Ph.D., is appreciated for giving help with statistical problems. I wish also to thank James Nimmo, B.Sc., for revising the language of this thesis. It has been a pleasure to get to know Professor John Koivukangas, M.D., and the other staff of the Department of Neurosurgery. My special thanks go to co-writer Tatu Koskelainen, M.D., for his comments. I am grateful to all my colleagues in the departments of Diagnostic Radiology, especially Michaela Bode, M.D., Ph.D., Vesa Kiviniemi M.D., Ph.D., and Harri Littow, M.D., in the Neuroradiology Unit. I have spent many unforgettable and joyful moments with you, and you have created the opportunity for me to involve deeply in scientifi c work. Finally, I want to express warmest gratitude to my wife Airi, for her strong believe in me and for her love, patience and support during this work. Being a 7 scientist herself, she has taught me a lot of scientifi c writing. My beloved sons, Jaakko and Olli-Pekka, have taught me how to put things in life into right perspective. I also dedicate my dearest thanks to my parents, Paula and Pentti Jartti, for their support and love throughout my life. I am deeply sorry my father could not see this day. The research was fi nancially supported by grants from the Radiological Society of Finland, The Finnish Medical Foundation, Aarne and Airi Turunen Foundation, and Maud Kuistila Foundation, all of which are gratefully acknowledged. Oulu, October 2010 Pekka Jartti 8