Vol 54, No 1 (2020)
Research Paper
Published online: 2020-01-22

open access

Page views 1198
Article views/downloads 1071
Get Citation

Connect on Social Media

Connect on Social Media

Diagnostic value of non-enhanced computed tomography in identifying location of ruptured cerebral aneurysm in patients with aneurysmal subarachnoid haemorrhage

Marcin Sawicki1, Krzysztof Kościukiewicz1, Dariusz Jeżewski2, Kornel Chełstowski3, Piotr Gołofit1, Michał M. Skoczylas1, Michał Gębka1, Kornelia Grabizna4, Katarzyna Kołaczyk1, Łukasz Zwarzany1, Leszek Sagan2, Wojciech Poncyljusz1
Pubmed: 31967317
Neurol Neurochir Pol 2020;54(1):47-53.


Background. In patients with SAH and multiple aneurysms, the ruptured lesion must be identified to prevent recurrent bleeding.

Aim of the study.
To assess the diagnostic value of non-enhanced computed tomography (NECT) in identifying the rupture site in patients with subarachnoid haemorrhage (SAH) and multiple aneurysms.

Material and methods.
We included patients with SAH revealed by NECT and multiple aneurysms detected on computed tomography angiography (CTA) in whom a ruptured aneurysm was identified during neurosurgery. Two radiologists predicted the location of the ruptured aneurysm based on the distribution of the SAH and location of intracerebral haematoma (ICH) by NECT.

Eighty-three patients with a mean age of 55.7 ± 14.4 years were included. Ruptured aneurysms were significantly larger (mean size 7.7 ± 4.7 mm) than unruptured aneurysms (mean size 5.9 ± 4.5 mm; p = 0.014). Interobserver agreement was 0.86 (p < 0.001). Overall sensitivity and specificity of radiological prediction were 78.3% (95% CI, 68.6%-87.1%) and 96.4% (95% CI, 94.3%-97.8%) respectively. Overall PPV and NPV were 78.3% (95% CI, 67.6%-86.3%) and 96.8% (95% CI, 94.8%-98.1%) respectively. The sensitivity and PPV for aneurysms in the anterior communicating, anterior, and middle cerebral arteries appeared to be significantly higher than in other locations (p = 0.015 and 0.019 respectively). Analysis of independent predictive factors of correct radiological location revealed that ICH predisposes to a correct radiological diagnosis with an odds ratio of 8.57 (95% CI, 1.07-68.99; p = 0.03).

NECT has a high diagnostic value in identifying the source of bleeding in patients with multiple aneurysms for anterior circulation aneurysms, especially with coexisting ICH. For other locations, NECT is not reliable enough to base treatment decisions upon.

Article available in PDF format

View PDF Download PDF file


  1. Rinne J, Hernesniemi J, Puranen M, et al. Multiple intracranial aneurysms in a defined population: prospective angiographic and clinical study. Neurosurgery. 1994; 35(5): 803–808.
  2. van der Jagt M, Hasan D, Bijvoet HW, et al. Validity of prediction of the site of ruptured intracranial aneurysms with CT. Neurology. 1999; 52(1): 34–39.
  3. Lindgren A, Vergouwen MDI, van der Schaaf I, et al. Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev. 2018; 8: CD003085.
  4. Molyneux AJ, Kerr RSC, Yu LM, et al. International Subarachnoid Aneurysm Trial (ISAT) Collaborative Group. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005; 366(9488): 809–817.
  5. Nehls DG, Flom RA, Carter LP, et al. Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg. 1985; 63(3): 342–348.
  6. Beck J, Rohde S, Berkefeld J, et al. Size and location of ruptured and unruptured intracranial aneurysms measured by 3-dimensional rotational angiography. Surg Neurol. 2006; 65(1): 18–25; discussion 25.
  7. Nagahata S, Nagahata M, Obara M, et al. Wall Enhancement of the Intracranial Aneurysms Revealed by Magnetic Resonance Vessel Wall Imaging Using Three-Dimensional Turbo Spin-Echo Sequence with Motion-Sensitized Driven-Equilibrium: A Sign of Ruptured Aneurysm? Clin Neuroradiol. 2016; 26(3): 277–283.
  8. Kondo R, Yamaki T, Mouri W, et al. [Magnetic resonance vessel wall imaging reveals rupture site in subarachnoid hemorrhage with multiple cerebral aneurysms]. No Shinkei Geka. 2014; 42(12): 1147–1150.
  9. Matouk CC, Mandell DM, Günel M, et al. Vessel wall magnetic resonance imaging identifies the site of rupture in patients with multiple intracranial aneurysms: proof of principle. Neurosurgery. 2013; 72(3): 492–6; discussion 496.
  10. Karttunen AI, Jartti PH, Ukkola VA, et al. Value of the quantity and distribution of subarachnoid haemorrhage on CT in the localization of a ruptured cerebral aneurysm. Acta Neurochir (Wien). 2003; 145(8): 655–61; discussion 661.
  11. Latchaw RE, Silva P, Falcone SF. The role of CT following aneurysmal rupture. Neuroimaging Clin N Am. 1997; 7(4): 693–708.
  12. Hijdra A, Brouwers PJ, Vermeulen M, et al. Grading the amount of blood on computed tomograms after subarachnoid hemorrhage. Stroke. 1990; 21(8): 1156–1161.
  13. Takeuchi S, Takasato Y, Masaoka H, et al. [Unusual distribution of blood in a ruptured aneurysm--case report]. Brain Nerve. 2009; 61(12): 1425–1428.
  14. Lee KC, Joo JY, Lee KS. False localization of rupture by computed tomography in bilateral internal carotid artery aneurysms. Surgical Neurology. 1996; 45(5): 435–441.
  15. Jing L, Fan J, Wang Y, et al. Morphologic and Hemodynamic Analysis in the Patients with Multiple Intracranial Aneurysms: Ruptured versus Unruptured. PLoS One. 2015; 10(7): e0132494.
  16. Zhang Y, Yang X, Wang Y, et al. Influence of morphology and hemodynamic factors on rupture of multiple intracranial aneurysms: matched-pairs of ruptured-unruptured aneurysms located unilaterally on the anterior circulation. BMC Neurol. 2014; 14: 253.

Neurologia i Neurochirurgia Polska