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ORIGINAL ARTICLE
Year : 2013  |  Volume : 61  |  Issue : 1  |  Page : 51-55

Diagnosing residual or recurrent cerebral aneurysms after clipping by computed tomographic angiography: Meta-analysis


Department of Neurosurgery, West China Hospital, Sichuan University, Sichuan, People's Republic, China

Date of Submission01-Nov-2012
Date of Decision29-Nov-2012
Date of Acceptance20-Jan-2013
Date of Web Publication4-Mar-2013

Correspondence Address:
Chao You
West China Hospital, Sichuan University, 37 Guo Xue Xiang Street, Chengdu, Sichuan 610041, People's Republic
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.107942

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 » Abstract 

Background: A cerebral aneurysm with incomplete treatment may re-grow and cause new bleeding. This meta-analysis calculates the sensitivity and specificity of computed tomographic angiography (CTA) in the detection of the residual or recurrent cerebral aneurysms after clipping, in comparison with digital subtraction angiography (DSA). Materials and Methods: Between October 1997 and October 2012, relevant data were systematically and prospectively collected without language restrictions from the PUBMED and EMBASE databases for analysis. A total of 10 eligible studies compared CTA with DSA in the detection of the residual or recurrent cerebral aneurysms after clipping by two independent observers. The sensitivity, specificity, positive likelihood ratio (+LR), and negative likelihood ratio (-LR) were calculated on a per-aneurysm basis, and the area under the sROC curve (AUC), heterogeneity, and publication bias also were evaluated. Results: A total of 487 aneurysms were included for meta-analysis. The pooled sensitivity, specificity, +LR, -LR, DOR, and AUC of CTA for detecting the residual or recurrent aneurysms after clipping were 71%, 94%, 9.39, 0.32, 28.32, and 0.8558, respectively. The between-study heterogeneity of DOR and the presence of publication bias were not statistically significant. Conclusions: As a noninvasive and convenient screening method, CTA has a high diagnostic value for the detection of the residual or recurrent aneurysms after clipping. In the future, it may be used as a routine diagnostic tool for evaluation of aneurysms after clipping.


Keywords: Aneurysm CT angiography, computed tomographic angiography, digital subtraction angiography


How to cite this article:
Sun H, Ma J, Liu Y, Lan Z, You C. Diagnosing residual or recurrent cerebral aneurysms after clipping by computed tomographic angiography: Meta-analysis. Neurol India 2013;61:51-5

How to cite this URL:
Sun H, Ma J, Liu Y, Lan Z, You C. Diagnosing residual or recurrent cerebral aneurysms after clipping by computed tomographic angiography: Meta-analysis. Neurol India [serial online] 2013 [cited 2020 Feb 28];61:51-5. Available from: http://www.neurologyindia.com/text.asp?2013/61/1/51/107942



 » Introduction Top


It is well-known that the aneurysms become safe after clipping surgery, but an aneurysm with incomplete treatment may re-grow and cause re-bleeding; [1],[2],[3] moreover, the proportion of postoperative residual or recurrent aneurysms ranges from 5 to 30%. [4-13] Therefore, detection of the residual or recurrent aneurysms after clipping is clinically significant. All the time, both computed tomographic angiography (CTA) and digital subtraction angiography (DSA) are deemed as valuable tools to detect cerebral aneurysms, whereas the residual or recurrent aneurysms after clipping is mainly evaluated by the use of DSA. [14] As DSA is invasive as well as time and money consuming, an increasing number of articles have reported CTA as a noninvasive screening method for the postoperative assessment of clipped aneurysms, [4-13] and with recent technological developments, some authors believe that CTA can even replace DSA for routine postoperative assessment of clipped aneurysms. [5],[15] The meta-analysis meant to evaluate the sensitivity and specificity of CTA in the detection of the residual or recurrent aneurysms after clipping in comparison with DSA.


 » Materials and Methods Top


The PUBMED, MEDLINE, and EMBASE were searched without language restriction from October 1997 to October 2012, using the following strategy: ("computed tomographic angiography" OR CTA) AND aneurysm AND ("digital subtraction angiography" OR DSA) AND clip*. In addition, the reference lists of all relevant articles and literature reviews were also searched for relevant studies.

Two observers independently evaluated the eligibility of studies and excluded studies after reading titles, abstracts, and keywords. Then, the two observers independently selected the publications that met the inclusion criteria by assessing the full text of the rest of the publications. The inclusion criteria were the following: (1) all patients with clipped intracranial aneurysms; (2) all patients should have underwent both CTA and DSA to detect the residual or recurrent aneurysms after clipping; (3) DSA as the reference standard; (4) the study should have provided adequate information for sensitivity and specificity; (5) four-fold table could be rebuilt on a per-aneurysm basis; and (6) the enrolled patients and aneurysms should have not been reported in other publications. If any one of the above-mentioned criteria was not met, the publication was excluded.

The Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool [16],[17] was used as the scoring criteria to evaluate the quality of studies by two observers. If disagreement appeared, it was resolved by consensus. QUADAS includes 14 questions and each question are answered "yes," "no," or "unclear." We determined 1 point for each item if fulfilled, 0 points if not fulfilled, and 0.5 points if the answer is unclear. The same observers independently extracted information from each included study and finally solved disagreement by consensus. Extracted information comprised about information of patients, type of CT scanner used, study design, QUADAS score, diagnostic accuracy numbers, and the numbers of true-positive, false-positive, true-negative, and false-negative results [Table 1] and [Table 2].
Table 1: Characteristics of studies included in this meta-analysis


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Table 2: The data and diagnostic accuracy in included studies


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For each included study, sensitivity, specificity, +LR, -LR, and their 95% confidence intervals (CI) were calculated on a per-aneurysm basis. The area under curve (AUC) was also estimated. Heterogeneity was tested by Cochran-Q tests, I 2 , and Chi-square test. If the heterogeneity was statistically significant, we pooled sensitivities and specificities by the random-effect model of DerSimonian-Laird method. Furthermore, the fix-effect model of Mantel-Haenszel method was performed when heterogeneity was not statistically significant. The variations of sensitivities and specificities from different studies were displayed by forest plots, and the summary receiver-operating characteristic (SROC) curve was plotted too. The number of CT detector rows, the number of clips, clip material, and the size of the clipped aneurysms, which may be correlated significantly with the diagnostic accuracy of CTA, were planned as additional analyses. The abovementioned analyses were performed with Meta-Disc 1.4. Publication bias was assessed by Deeks' Funnel Plot that was analyzed using State, version 11.0.


 » Results Top


From the initial 233 articles, 219 articles were excluded by reading titles and abstracts. After detailed evaluation of the remaining 14 articles, 10 articles fulfilled the inclusion criteria. Three studies were excluded because four-fold tables could not be constructed from the data, [18-20] and the remaining one study was not included because the authors excluded 7 patients due to poor image quality in the comparison of CTA and DSA [15] [Figure 1].
Figure 1: Flow diagram of the search results

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A total of 487 aneurysms were included for meta-analysis. The pooled sensitivity, specificity, +LR, -LR, and DOR of CTA for detecting the residual or recurrent aneurysms after clipping were 71% (95% CI 0.60-0.81), 94% (95% CI 0.91-0.96), 9.39 (95% CI 6.37-13.85), 0.32 (95% CI 0.23-0.44), and 28.32 (95% CI 14.99-53.51), respectively [Figure 2]. The area under the sROC curve (AUC) was 0.8558 (SE =0.0708) and the Q* point value was 0.7867 (SE =0.0677) [Figure 3]. The value of Cochran's Q of DOR was 12.86 (P =0.1692) and the I 2 was 30.0%, indicating that the between-study heterogeneity of DOR was not statistically significant. There was no evidence for publication bias showed by the results of Deeks' Funnel Plot Asymmetry Test (P =0.258) [Figure 4]. In addition, when the influence of CT detector rows was considered, the diagnostic accuracy of CTA with 16 or more CT detector rows was significantly higher than for CTA with 1 or 4 CT detector rows (P < 0.05) [Table 3].
Table 3: The diagnostic accuracy in different number of CT detector rows


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Figure 2: Forest plot of the sensitivity, specificity, and diagnostic OR of CTA for detecting the residual or recurrent aneurysms after clipping

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Figure 3: Summary receiver-operating characteristic (sROC) curve of CTA for detecting the residual or recurrent aneurysms after clipping

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Figure 4: Results of Deek's funnel plot asymmetry test (P = 0.258), showing that there was no evidence for publication bias

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Twenty-three residual or recurrent aneurysms after clipping were missed at CTA. Among them, the size of the anuerysms was smaller than 3 mm in 11 cases, and the number of clips used was more than two in five cases. Three cases were missed on CTA because the image quality was poor for comparison, while 7 of 26 false-positive cases had insufficient image quality too.


 » Discussion Top


The results of the meta-analysis demonstrate that CTA has a high diagnostic value for the detection of the residual or recurrent aneurysms after clipping, especially when 16 or more CT detector rows were used in CT scan. In the 23 false-negative cases, the size of the residual or recurrent aneurysms was smaller than 3 mm in 11 cases. Very small (<5 mm) intracranial aneurysms are equally hard to detected in DSA. [21] In the other five false-negative cases, there were more than two clips used for one aneurysm. CTA is a valuable screening tool to detect postoperative remnants in single clip used to clip the aneurysm, [12] while the number of clips may influence the image quality, which may result in false-negative and false-positive cases. Beside the number of clips, several factors including the material of the clips, [13],[20] clip angle, [4] and the number of CT detector rows may also influence the image quality of CTA.

As the number of clips, clip material, and the size of the clipped aneurysms might correlate significantly with the detection of the residual or recurrent aneurysms by CTA after clipping, [4],[6],[12] additional analyses should be performed. Our study failed to perform the analyses due to the fact that it was difficult to get the information of the above three factors from each included study and our attempt to contact the authors was unsuccessful.

There were also several limitations in the studies included in the analysis. (1) Some of the sso several limitations in the studies included in the analysis. (1) Some of the studies did not adequately mention the time at which CTA and DSA was performed after clipping. [5],[6],[7],[13] (2) Those studies in which the authors failed to mention about vasospasm, [5],[7],[8],[10],[11],[13] which may very likely be a significant factor in the analysis of radiology. [6],[9],[12] (3) Although the results of Deek's Funnel Plot asymmetry test do not show significant publication bias, there are still some overlooked publication biases. For example, a small number of studies are less liable to be accepted for publication by some journals because they have negative results. As a result, the diagnostic accuracy may be overestimated when one get information only from published studies.

Though the pooled sensitivity is 71%, as a noninvasive and convenient screening method, CTA has a high diagnostic value for the detection of the residual or recurrent aneurysms after clipping, specifically when detecting single clipped aneurysms and using modern multidetector CT and titanium clips. In future, it may be used as a routine diagnostic tool for evaluation of aneurysms after clipping.

 
 » References Top

1.Lin T, Fox AJ, Drake CG. Regrowth of aneurysm sacs from residual neck following aneurysm clipping. J Neurosurg 1989;70:556-60.  Back to cited text no. 1
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2.David CA, Vishteh AG, Spetzler RF, Lemole M, Lawton MT, Partovi S. Late angiographic follow-up review of surgically treated aneurysms. J Neurosurg 1999;91:396-401.  Back to cited text no. 2
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3.Sluzewski M, van Rooij WJ. Early rebleeding after coiling of ruptured cerebral aneurysms: Incidence, morbidity, and risk factors. AJNR Am J Neuroradiol 2005;26:1739-43.  Back to cited text no. 3
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4.Sagara Y, Kiyosue H, Hori Y, Sainoo M, Nagatomi H, Mori H. Limitations of three-dimensional reconstructed computerized tomography angiography after clip placement for intracranial aneurysms. J Neurosurg 2005;103:656-61.  Back to cited text no. 4
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5.Sakuma I, Tomura N, Kinouchi H, Takahashi S, Otani T, Watarai J, et al. Postoperative three-dimensional CT angiography after cerebral aneurysm clipping with titanium clips: Detection with single detector CT. Comparison with intra-arterial digital subtraction angiography. Clinical Radiol 2006;61:505-12.  Back to cited text no. 5
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6.Han MH, Kim YD. Role of multislice computerized tomographic angiography after clip placement in aneurysm patients based on comparison with three dimensional digital subtraction angiography. J Korean Neurosurg Soc 2007;42:103-11.  Back to cited text no. 6
    
7.Watanabe Y, Kashiwagi N, Yamada N, Higashi M, Fukuda T, Morikawa S, et al. Subtraction 3D CT angiography with the orbital synchronized helical scan technique for the evaluation of postoperative cerebral aneurysms treated with cobalt-alloy clips. AJNR Am J Neuroradiol 2008;29:1071-5.  Back to cited text no. 7
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10.Uysal E, Ozel A, Erturk SM, Kýrdar Ö, Basak M. Comparison of multislice computed tomography angiography and digital subtraction angiography in the detection of residual or recurrent aneurysm after surgical clipping with titanium clips. Acta Neurochir (Wien) 2009;151:131-5.  Back to cited text no. 10
    
11.Gerardin E, Tollard E, Derrey S, Langlois O, Dacher JN, Douvrin F, et al. Usefulness of multislice computerized tomographic angiography in the postoperative evaluation of patients with clipped aneurysms. Acta Neurochir (Wien) 2010;152:793-802.  Back to cited text no. 11
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12.Thines L, Dehdashti AR, Howard P, Da Costa L, Wallace MC, Willinsky RA, et al. Postoperative assessment of clipped aneurysms with 64-slice computerized tomography angiography. Neurosurgery 2010;67:844-53.  Back to cited text no. 12
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13.Tomura N, Sakuma I, Otani T, Nisii T, Sugawara M, Koga M, et al. Evaluation of postoperative status after clipping surgery in patients with cerebral aneurysm on 3-dimensional-CT angiography with elimination of clips. J Neuroimaging 2009;21:10-5.  Back to cited text no. 13
    
14.Meyer B, Urbach H, Schaller C, Baslam M, Nordblom J, Schramm J. Immediate postoperative angiography after aneurysm clipping-implications for quality control and guidance of further management. Zentralbl Neurochir 2004;65:49-56.  Back to cited text no. 14
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16.Whiting P, Rutjes AW, Reitsma JB, Bossuyt PM, Kleijnen J. The development of QUADAS: A tool for the quality assessment of studies of diagnostic accuracy included in systematic reviews. BMC Med Res Methodol 2003;3:25.  Back to cited text no. 16
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17.Whiting PF, Weswood ME, Rutjes AW, Reitsma JB, Bossuyt PN, Kleijnen J. Evaluation of QUADAS, a tool for the quality assessment of diagnostic accuracy studies. BMC Med Res Methodol 2006;6:9.  Back to cited text no. 17
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18.Lee JH, Kim SJ, Cha J, Kim HJ, Lee DH, Choi CG, et al. Postoperative multidetector computed tomography angiography after aneurysm clipping: Comparison with digital subtraction angiography. J Comput Assist Tomogr 2005;29:20-5.  Back to cited text no. 18
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19.van Loon JJ, Yousry TA, Fink U, Seelos KC, Reulen HJ, Steiger HJ. Postoperative spiral computed tomography and magnetic resonance angiography after aneurysm clipping with titanium clips. Neurosurgery 1997;41:851-7.  Back to cited text no. 19
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20.Teksam M, McKinney A, Cakir B, Truwit CL. Multi-slice computed tomography angiography in the detection of residual or recurrent cerebral aneurysms after surgical clipping. Acta Radiol 2004;45:571-6.  Back to cited text no. 20
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21.Teksam M, McKinney A, Cakir B, Truwit CL. Multi-slice CT angiography of small cerebral aneurysms: Is the direction of aneurysm important in diagnosis? Eur J Radiol 2005;53:454-62.  Back to cited text no. 21
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]

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