Hypo-attenuating Berry Sign as a Novel Imaging Marker of Ruptured Aneurysm in Patients with Subarachnoid Hemorrhage; a Diagnostic Accuracy Study
Archives of Academic Emergency Medicine,
Vol. 12 No. 1 (2024),
1 January 2024
,
Page e31
https://doi.org/10.22037/aaem.v12i1.2154
Abstract
Introduction: Aneurysmal subarachnoid hemorrhage (SAH) constitutes a life-threatening condition, and identifying the ruptured aneurysm is essential for further therapy. This study aimed to evaluate the diagnostic accuracy of hypo-attenuating berry sign (HBS) observed on computed tomography (CT) scan in distinguishing ruptured aneurysms.
Methods: In this diagnostic accuracy study, patients who had SAH and underwent non-enhanced brain CT scan were recruited. The HBS was defined as a hypo-attenuating area with an identifiable border in the blood-filled hyper-dense subarachnoid space. The screening performance characteristics of HBS in identifying ruptured aneurysms were calculated considering the digital subtraction angiography (DSA) as the gold standard.
Results: A total of 129 aneurysms in 131 patients were analyzed. The overall sensitivity and specificity of HBS in the diagnosis of aneurysms were determined to be 78.7% (95%CI: 73.1% - 83.4%) and 70.7% (95%CI: 54.3% - 83.4%), respectively. Notably, the sensitivity increased to 90.9% (95%CI: 84.3% - 95.0%) for aneurysms larger than 5mm. The level of inter-observer agreement for assessing the presence of HBS was found to be substantial (kappa=0.734). The diagnostic accuracy of HBS in individuals exhibited enhanced specificity, sensitivity, and reliability when evaluating patients with a solitary aneurysm or assessing ruptured aneurysms. The multivariate logistic regression analysis revealed a statistically significant relationship between aneurysm size and the presence of HBS (odds ratios of 1.667 (95%CI: 1.238 - 2.244; p < 0.001) and 1.696 (95%CI: 1.231 - 2.335; p = 0.001) for reader 1 and reader 2, respectively).
Conclusions: The HBS can serve as a simple and easy-to-use indicator for identifying a ruptured aneurysm and estimating its size in SAH patients.
- subarachnoid hemorrhage
- intracranial aneurysm
- angiography
- artificial intelligence
- non-enhanced CT
How to Cite
References
Macdonald RL, Schweizer TA. Spontaneous subarachnoid haemorrhage. Lancet. 2017;389(10069):655-66.
Claassen J, Park S. Spontaneous subarachnoid haemorrhage. Lancet. 2022;400(10355):846-62.
Connolly ES, Jr., Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43(6):1711-37.
Cloft HJ, Joseph GJ, Dion JE. Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke. 1999;30(2):317-20.
Lubicz B, Levivier M, Francois O, Thoma P, Sadeghi N, Collignon L, et al. Sixty-four-row multisection CT angiography for detection and evaluation of ruptured intracranial aneurysms: interobserver and intertechnique reproducibility. AJNR Am J Neuroradiol. 2007;28(10):1949-55.
Hillman J. Selective angiography for early aneurysm detection in acute subarachnoid haemorrhage. Acta Neurochir (Wien). 1993;121(1-2):20-5.
Hino A, Fujimoto M, Iwamoto Y, Yamaki T, Katsumori T. False localization of rupture site in patients with multiple cerebral aneurysms and subarachnoid hemorrhage. Neurosurgery. 2000;46(4):825-30.
Lee KC, Joo JY, Lee KS. False localization of rupture by computed tomography in bilateral internal carotid artery aneurysms. Surg Neurol. 1996;45(5):435-40; discussion 40-1.
Liliequist B, Lindqvist M, Valdimarsson E. Computed tomography and subarachnoid hemorrhage. Neuroradiology. 1977;14(1):21-6.
Karttunen AI, Jartti PH, Ukkola VA, Sajanti J, Haapea M. 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 61.
Latchaw RE, Silva P, Falcone SF. The role of CT following aneurysmal rupture. Neuroimaging Clin N Am. 1997;7(4):693-708.
Vajda J, Juhasz J, Orosz E, Pasztor E, Toth S, Horvath M. Surgical treatment of multiple intracranial aneurysms. Acta Neurochir (Wien). 1986;82(1-2):14-23.
Huang ZQ, Zhou XW, Hou ZJ, Huang SQ, Meng ZH, Wang XL, et al. Risk factors analysis of mirror aneurysms: A multi-center retrospective study based on clinical and demographic profile of patients. Eur J Radiol. 2017;96:80-4.
Huang ZQ, Meng ZH, Hou ZJ, Huang SQ, Chen JN, Yu H, et al. Geometric Parameter Analysis of Ruptured and Unruptured Aneurysms in Patients with Symmetric Bilateral Intracranial Aneurysms: A Multicenter CT Angiography Study. AJNR Am J Neuroradiol. 2016;37(8):1413-7.
Backes D, Vergouwen MD, Velthuis BK, van der Schaaf IC, Bor AS, Algra A, et al. Difference in aneurysm characteristics between ruptured and unruptured aneurysms in patients with multiple intracranial aneurysms. Stroke. 2014;45(5):1299-303.
van der Jagt M, Hasan D, Bijvoet HW, Pieterman H, Dippel DW, Vermeij FH, et al. Validity of prediction of the site of ruptured intracranial aneurysms with CT. Neurology. 1999;52(1):34-9.
Nehls DG, Flom RA, Carter LP, Spetzler RF. Multiple intracranial aneurysms: determining the site of rupture. J Neurosurg. 1985;63(3):342-8.
Slonimsky E, Upham K, Pepley S, Ouyang T, King T, Fiorelli M, et al. Multiplanar CT evaluation of aneurysm rupture signs in subarachnoid hemorrhage. Emerg Radiol. 2022;29(3):427-35.
Sawicki M, Kosciukiewicz K, Jezewski D, Chelstowski K, Golofit P, Skoczylas MM, et al. Diagnostic value of non-enhanced computed tomography in identifying location of ruptured cerebral aneurysm in patients with aneurysmal subarachnoid haemorrhage. Neurol Neurochir Pol. 2020;54(1):47-53.
Takeuchi S, Takasato Y, Masaoka H, Hayakawa T, Otani N, Yoshino Y, et al. [Unusual distribution of blood in a ruptured aneurysm--case report]. Brain Nerve. 2009;61(12):1425-8.
Kayama T, Sugawara T, Sakurai Y, Ogawa A, Onuma T, Yoshimoto T. Early CT features of ruptured cerebral aneurysms of the posterior cranial fossa. Acta Neurochir (Wien). 1991;108(1-2):34-9.
Tryfonidis M, Evans AL, Coley SC, Hodgson TL, Connolly DJ, Romanowski CA, et al. The value of radio-anatomical features on non-contrast CT scans in localizing the source in aneurysmal subarachnoid haemorrhage. Clin Anat. 2007;20(6):618-23.
Jamieson KG. Rupture of an intracranial aneurysm during cerebral angiography. J Neurosurg. 1954;11(6):625-8.
Waga S, Kondo A, Moritake K, Handa H. Rupture of intracranial aneurysm during angiography. Neuroradiology. 1973;5(3):169-73.
Huang ZQ, Yang WJ, Xiao G, Yang Z, Yu H, Wu JW, et al. Characteristics of Radiation-Related Intracranial Aneurysms: A Multicenter Retrospective Study. AJNR Am J Neuroradiol. 2022;43(8):1131-5.
Alons IME, Goudsmit BFJ, Jellema K, van Walderveen MAA, Wermer MJH, Algra A. Yield of Computed Tomography (CT) Angiography in Patients with Acute Headache, Normal Neurological Examination, and Normal Non Contrast CT: A Meta-Analysis. J Stroke Cerebrovasc Dis. 2018;27(4):1077-84.
Kaladji A, Dumenil A, Mahe G, Castro M, Cardon A, Lucas A, et al. Safety and accuracy of endovascular aneurysm repair without pre-operative and intra-operative contrast agent. Eur J Vasc Endovasc Surg. 2015;49(3):255-61.
Kaka H, Zhang E, Khan N. Artificial Intelligence and Deep Learning in Neuroradiology: Exploring the New Frontier. Can Assoc Radiol J. 2021;72(1):35-44.
Hata A, Yanagawa M, Yamagata K, Suzuki Y, Kido S, Kawata A, et al. Deep learning algorithm for detection of aortic dissection on non-contrast-enhanced CT. Eur Radiol. 2021;31(2):1151-9.
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