Sensitivität und Spezifität bildgebender Verfahren für den Nachweis intrakranieller Aneurysmen

Zusammenfassung

Aneurysmen der intrakraniellen Arterien treten mit einer Prävalenz von etwa 2 % auf. Die Rupturwahrscheinlichkeit beerenförmiger Aneurysmen liegt bei etwa 0,1 %/Jahr.

Die Letalität innerhalb von 30 Tagen nach der Ruptur eines zerebralen Aneurysmas wird auf 45 % geschätzt; zusätzlich behält die Hälfte der überlebenden Patienten schwere neurologische Defizite. Der rechtzeitige Nachweis und die prophylaktische Behandlung eines Aneurysmas sind die zuverlässigsten Methoden, um eine Ruptur zu vermeiden. Insofern ist es relevant, das Potenzial der aktuellen bildgebenden Verfahren zu kennen und anwenden zu können.

Diese Arbeit stellt das diagnostische Potenzial der CT, MRT und Katheterangiografie zur Detektion, Therapieplanung und Nachsorge von Aneurysmen dar und leitet daraus eine Handlungsempfehlung ab.

Abstract

The prevalence or cerebral aneurysms is estimated at 2 %. Out of these aciniform aneurysm, 0,1 % rupture each year. The 30-day-mortality after a subarachnoid hemorrhage (SAH) is estimated at 45 %. Additionally, about 50 % of the patients suffer from severe persistent neurologic deficits.

The most reliable way to prevent rupture is early detection and prophylactic therapy of an unruptured aneurysm. For this, knowledge of the different imaging methods currently available and their diagnostic potential is highly desirable.

This review describes the potential of CT, MRI and catheter angiography in diagnosing cerebral aneurysms, as well as therapy planning and follow-up care of patients. Based on this, some recommendations are made for management of patients with SAH.

Kernaussagen

• Trotz großer technischer Fortschritte haben sowohl CT-Angiografie, MR-Angiografie als auch die DSA ihre Daseinsberechtigung in der Aneurysmadetektion, der Therapieplanung und der Verlaufskontrolle. Der Nachweis eines inzidentellen Aneurysmas mittels CT oder MRT sollte nur dann nicht zu einer DSA führen, wenn sich aufgrund der Gesamtsituation des Patienten keine therapeutische Konsequenz ergäbe. Ansonsten ist eine ergänzende DSA z. Zt. überwiegend zu empfehlen und oft noch notwendig.

• Für alle 3 Verfahren ist die dreidimensionale Rekonstruktion der Bilder heute obligat. In bestimmten Situationen, z. B. nach einer akuten SAB, kann eine CT-Angiografie allein zur Therapieplanung ausreichen, insbesondere wenn ein unmittelbares, lebensrettendes chirurgisches Eingreifen notwendig ist. Eine ergänzende DSA ist aber nach der Akutversorgung sinnvoll, um weitere Aneurysmen oder andere Gefäßpathologien auszuschließen, die der CT-Angiografie/MR-Angiografie entgangen sein könnten, und, um die Lage des Clips adäquat zu beurteilen. Letzteres gelingt mittels Dual-Energy-CT-Angiografie noch nicht mit gleicher Bildqualität.

• Aneurysmen, deren Therapierisiko z. B. das Rupturrisiko aktuell übersteigt, sollten verlaufskontrolliert werden. Dazu ist die von allen Verfahren am wenigsten invasive MR-Angiografie die Methode der Wahl. Eine kontrastmittelunterstützte MR-Angiografie hat geringe, aber messbare Vorteile gegenüber einer TOF-MR-Angiografie, aber eine Feldstärke von mindestens 3 Tesla verbessert die diagnostische Sicherheit entscheidend. Die MR-Angiografie erreicht zufriedenstellende Sensitivitäts- und Spezifitätswerte für die Verlaufskontrolle coilembolisierter Aneurysmen. Eine „prophylaktische“ katheterangiografische Kontrolle des therapierten Aneurysmas ist daher nur noch bei unklaren MR-Angiografie-Befunden in Einzelfällen notwendig. Sollte sich eine ungünstige Befunddynamik des Aneurysmas zeigen, die im Verlauf eine invasive Therapie oder Re-Therapie sinnvoll erscheinen lässt, ist eine prätherapeutische DSA allerdings häufig noch sinnvoll.

Keywords

Cerebral aneurysms - imaging techniques - patient management

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