Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies.
Underdiagnosis of posterior communicating artery aneurysm in noninvasive brain vascular studies.
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DOI：
10.1097/wno.0b013e3181f8d985
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发表时间：
2011-06
期刊：
影响因子：
--
通讯作者：
Biousse V
中科院分区：
文献类型：
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作者：
Elmalem VI;Hudgins PA;Bruce BB;Newman NJ;Biousse V
现代无创性神经影像学（如CTA或MRA）的专家解释应该可以检测到几乎所有导致孤立性第三神经麻痹的动脉瘤。对于CTA或MRA阴性的病例，是否仍应进行导管血管造影仍存在争议，主要取决于无创性研究是否正确进行和解释。本研究的目的是回顾一个大型学术中心用于评估孤立性三叉神经麻痹患者的诊断策略。回顾性审查了自2001年以来在我们机构观察到的所有后交通动脉（PCom A）囊性第三神经麻痹病例。我们确定了417例第三神经麻痹、动脉瘤或蛛网膜下腔出血的病例，其中17例与同侧PCom A动脉瘤相关的急性孤立性疼痛性第三神经麻痹（平均年龄52岁;范围33-83岁）。根据初次就诊时获得的无创成像结果，将患者分为3组。第一组包括4例蛛网膜下腔出血的病例，最初在急诊科获得的初始非造影头部CT，以评估其孤立的第三神经麻痹。第二组包括5例孤立性第三神经麻痹和正常的非造影剂头部CT表现，在转诊机构立即正确诊断为PCom A动脉瘤。第III组包括其余8例病例，这些病例均患有在外部机构的无创研究中遗漏的动脉瘤。对我们机构的这些外部研究进行审查，结果显示PCom A动脉瘤，证实了外部放射科医生对这些检查的误解，而不是技术不足。缺乏神经放射学的专门培训和提供给解释放射科医生的不准确临床信息与外部机构的测试误解有关。在所有3组中，导致孤立性第三神经麻痹的PCom A动脉瘤的平均尺寸为7.3 mm，各组相似。我们的研究表明，除了准确的病史外，解读放射科医生的培训和经验可能是确定孤立性第三神经麻痹患者无创扫描可靠性的最重要因素。
Expert interpretation of modern noninvasive neuroimaging such as CTA or MRA should detect nearly all aneurysms responsible for an isolated third nerve palsy. Whether a catheter angiogram should still be obtained in cases with negative CTA or MRA remains debated, and mostly relies on whether the noninvasive study was correctly performed and interpreted. The aim of our study was to review the diagnostic strategies used to evaluate patients with isolated aneurysmal third nerve palsy at a large academic center. Retrospective review of all cases with posterior communicating artery (PCom A) aneurysmal third nerve palsies seen at our institution since 2001. We identified 417 cases with third nerve palsy, aneurysm, or subarachnoid hemorrhage, among which 17 presented with an acute isolated painful third nerve palsy related to an ipsilateral PCom A aneurysm (mean age 52; range 33–83 years). Patients were classified into 3 groups based on the results of the noninvasive imaging obtained at initial presentation. Group I included 4 cases with subarachnoid hemorrhage on initial non-contrast head CT initially obtained in an emergency department for evaluation of their isolated third nerve palsy. Group II included 5 cases with isolated third nerve palsy and normal non-contrast head CT at presentation, immediately correctly diagnosed with a PCom A aneurysm at the referring institution. Group III included the 8 remaining cases who all had aneurysms that were missed on noninvasive studies at outside institutions. Review of these outside studies at our institution showed a PCom A aneurysm, confirming misinterpretation of these tests by the outside radiologists, rather than inadequate technique. Absence of specific training in neuroradiology and inaccurate clinical information provided to the interpreting radiologist were associated with test misinterpretation at the outside institutions. The average size of PCom A aneurysms causing an isolated third nerve palsy across all 3 groups was 7.3 mm, and was similar in each group. Our study suggests that aside from an accurate history, the training and experience of the interpreting radiologist is probably the most important factor in determining the reliability of a noninvasive scan in patients with isolated third nerve palsies.