Points to consider when evaluating three-dimensional digital subtraction angiography of intracranial aneurysms and their effects on treatment

BACKGROUND/AIM: In this study, we aimed to investigate what should be regarded as potential determinants of treatment strategies when evaluating 3D digital subtraction angiography (DSA) images. MATERIAL AND METHODS: Our inclusion criteria were as follows: (1) presence of at least one intracranial aneurysm demonstrated by conventional angiography, (2) having both 2D and 3D images, and (3) being over 18 years old. First, two-dimensional (2D) and then 3D angiography images of 226 aneurysms of 150 patients were scanned. Morphological characteristics such as size, configurations, relationship with parent artery, baby counts, and other incidental findings were determined. RESULTS: Of the 226 aneurysms, 11 (4.9%) were only detected on 3D images. Four of these 11 additional aneurysms were believed to be babies of other aneurysms seen in 2D images. Middle cerebral artery (MCA) M1 segment was the most common localization in terms of missed aneurysms. Of the 28 aneurysms located in the communicating segment of the internal carotid artery, the absolute locations of 7 (25%) could not be detected in 2D images or detected in the wrong location. Of the 24 aneurysms located in the ophthalmic segment, the origin of 8 (33%) could not be clearly identified in 2D images. Truncus relationships of MCAs bifurcation/trifurcation aneurysms were seen in 41 of 63 aneurysms (65%) on 2D images, whereas all were confirmed on 3D images. Fenestrations not seen in 2D images were identified in 3D images of 4 patients (3%). CONCLUSION: The superiority of 3D images compared to 2D images in determining the morphologic characteristics of intracranial aneurysms has been known for a long time. The contribution of 3D images to the treatment can be summarized as evaluating the parent artery relationship, revealing the number and shapes of aneurysm babies more clearly, detecting fenestrations, and shortening procedure time by finding the correct working angle.