Neuroimaging Clinics of North America: Intracranial Aneurysms, Vol. 16, No. 3

doi:10.3174/ajnr.A0578

A. Biondi, guest ed. Philadelphia: WB Saunders; 2006. 157 pages, $94.00.

In this short monograph, the major clinical, diagnostic, and therapeutic issues in intracranial aneurysms are considered. Biondi is the guest editor of this 157-page volume of the Neuroimaging Clinics of North America, and she has assembled an international group of authors who are known for their contributions to the field. The book spans nearly the entire clinical spectrum of the subject, taking the reader from an overview of intracranial aneurysms through subsequent chapters on imaging and treatment. There are 10 chapters, and all should be of interest to radiologists (neuroradiologists in particular), even including those chapters dealing with treatment regardless of whether the radiologist performs endovascular interventions.

The reader is first introduced to the basic aspects of intracranial aneurysms, including pathology, pathogenesis, hemodynamics, histology, epidemiology, and aneurysm classification/types. The author’s intent is sustained throughout the opening chapter, but the reader is jolted by strange wording and poor editing. For example, in speaking of hemodynamic factors, “blood blow” is mentioned instead of “blood flow,” or when the authors probably want to indicate that there was ventricular decompression before an arteriogram, the words “ventricular derivation” are used. One also gets bounced back and fourth between “aneurysm” and “aneurism.” In a chapter that is supposed to introduce the reader to the subject, a figure is shown where a Hunt and Hess Grade II and a Fischer Grade III subarachnoid hemorrhage is mentioned, but nowhere in that chapter are these grading systems described. In fact, if one then goes to the index in hopes of finding where this is discussed in other chapters, one comes up with nothing under those terms. Despite these editorial guffaws, there is good information here, and the imaging is of high quality.

Chapters on unruptured and ruptured intracranial aneurysms give the reader an understanding of aneurysm size and the subsequent chances of rupture/rerupture, along with treatment considerations. Both chapters are well written, and this reviewer likes the Socratic manner in which a portion of the material is presented: questions of importance asked and then answered.

The chapter on current diagnostic modalities should be of most interest to the reader. The images are good, and modern techniques (CT angiography, MR angiography, 3D angiography, and various display methods) are described; however, more specifics on CT angiography, for example, could have been included. There is no mention of delays in initiating imaging postinjection, nor is there a discussion of the value of the newer 64–128 multidetector CT scanners. To the author’s credit, they describe risks of angiography, importantly including radiation risks. Again, however, the manuscript editing is not up to what one would expect. The term “sensibility” is used time and again, and to this reviewer that is not a recognized statistical term. The probable intent was to use sensitivity, and one wonders why this was not changed. One is left with baffling statements such as, “All teams insisted on the inferior sensibility concerning diagnosis of aneurysms not responsible for the hemorrhage,” or “CT angiography, next to considerable improvement in spatial and temporal resolution, has become a high performance diagnostic tool.”

A relatively long (40 pages, nearly one quarter of the book) but very worthwhile chapter deals with the endovascular treatment of aneurysms. Here, the radiologist who is unfamiliar with advances in endovascular treatment gets a run down of the various devices used in therapy: different coil types, balloons and stents, liquid embolic material, microcatheters, and wires. What makes for good reading are the sections on the techniques for coiling and stent placement, the strategies and thought processes involved with common and uncommon situations, and the complications involved. There is much to be learned by virtue of this chapter, particularly if one is not involved in interventional neuroradiology–not that reading and digesting this chapter will make the noninterventionalist want to run out and start coiling aneurysms, but at least it will give that person a firm understanding of the field and where it is headed. To this reviewer, this chapter was most interesting, because many previously unappreciated (or forgotten) issues were discussed, among them the reason for the abandonment of tungsten coils, methods of detachment of coils from the pusher wire, the constituents and mechanism of action of bioactive coils, the different types of stents, and preprocedural/postprocedural care. Specific strategies for coiling large-necked aneurysms (as developed by Dr. Jacques Moret, who is one of the authors) and how to approach confounding or difficult cases are thoroughly described and illustrated. This is an excellent chapter; however, improvement could have been achieved by the use of diagrams, illustrating the devices and their configurations in deployed positions.

The remaining chapters deal with the less common or less frequently treated aneurysms, such as dissecting, atherosclerotic, and fusiform aneurysms; aneurysms seen in association with various disorders, such as neoplasms, trauma, infections, arteriovenous malformations (AVMs), radiation, polycystic kidneys, connective tissue disorders (Ehlers-Daulos and Marfan), vasculitis, and neurofibromatosis; the evaluation and treatment of aneurysmal subarachnoid hemorrhage; which aneurysms require surgery; and follow-up of treated aneurysms.

Most neuroradiologists will find the chapter dealing with nonsaccular aneurysms that arise in the context of accompanying disorders to be of great interest. The case material chosen by the author (Biondi) of this chapter is excellent (in fact, high-quality imaging is present throughout the book) and serves to emphasize the subject’s main point. More extensive labeling and an expanded legend in a number of cases would have been helpful, because to many not involved directly in intervention, such labeling and longer description would have cleared up a few figures, as for instance, in a figure that is said to show occlusion of an intranidal aneurysm in an AVM, it may have been helpful to say that the figure showed glue filling the pedicle and the aneurysm.

Although those performing endovascular surgery of intracranial aneurysms will have primary interest in this book, all neuroradiologists should be aware of the material in this book, and it, therefore, is highly recommended.