**1. Introduction**

Aneurysm was the primary cause of more than 10,597 deaths and a contributing cause of over 17,215 deaths in the USA in 2009 [1], shown in **Figure 1**. Some essential details on aneurysm, its diagnosis, factors of influence and prevention and treatment are described by Nordqvist [2]. The author gives a more detailed description of aneurysm. The disease occurs when an artery or cardiac chamber swells. This results in the damage of artery or weakness of its walls. The swelling balloons out at its weakest point resulting from increasing blood pressure. This means there should be a threshold pressure above which only ballooning out

**Figure 1.**

*Subcategorization of data elements used in this study.*

happens. Although small swellings may be confined to a small area of the artery, large ones can extend along the whole length of the affected area. The balloon may become too large, and it may rupture when pressure build-up continues. Furthermore, a threshold point is indicated for the rupture. The rupture naturally leads to hemorrhage and other complications and even sudden death. Although aneurysm can occur in any part of the body, it is more common in the arteries, particularly in the aorta. True aneurysms can be atherosclerotic, syphilitic, congenital or ventricular following transmural myocardial infarctions and can occur in any of the three walls of the artery.

False aneurysm (pseudo-aneurysm) is also possible when there is complete leaking of blood out of an artery or vein confined to the tissue surrounding the vessel. Eventually, this blood-filled cavity may clot to seal the leak, or it may rupture out of the surrounding tissue. Trauma can be caused by punctures in the artery created by knife, bullet and so forth. Pseudo-aneurysms can be caused by percutaneous surgical procedures like coronary angiography or arterial grafting or an injection into the artery. Aneurysms are classified according to their morphology or by location. Morphologically, saccular aneurysms are spherical, 5–20 cm in diameter, partially or fully filled by thrombus and involve only a portion of the vessel wall. Fusiform types are spindle-shaped, with varying diameter up to 20 cm and with varying length, involving large portions of ascending and transverse aortic arch, abdominal aorta or iliac arteries.

include type, location, educational qualifications and experience of health-care professionals and patient volume. However, not many studies have reported on the influence of using various types of imaging modalities and their capability to lead and guide aneurysm repair procedures to decrease the mortality rate of aortic aneurysm patients. One of the important aspects in hospital context is its adherence with the American College of Radiologists (ACR) guideline especially on medical imaging methods and patients safety aspects. The lack of protocols and costs have been cited as important reasons for not practising the most desirable or appropriate imaging methods in the case of aneurysm [4]. Obviously this affects the extent of compliance with ACR. However, not many studies have been reported on the influence of extent of compliance of medical imaging guidelines of ACR on the in-

**Affected region Aneurysm nomenclature** Aortic aneurysm Thoracic aortic aneurysm

*DOI: http://dx.doi.org/10.5772/intechopen.86711*

*Challenges for Intelligent Data Analysis Methods in Medical Image Analysis during Surgical…*

Cranial and neck aneurysm artery Cerebral artery aneurysm

Intrathoracic aneurysm arteries Heart aneurysm

Intra-abdominal and pelvic aneurysm arteries Renal artery aneurysm

Upper extremity arteries Brachial artery aneurysm

Lower extremity arteries Femoral artery

Ruptured thoracic aortic aneurysm Thoracicoabdominal aortic aneurysm Ruptured thoracicoabdominal aortic aneurysm

Ruptured cerebral artery aneurysm Ruptured syphilitic cerebral aneurysm Congenital cerebral artery aneurysm

Mediastinal and spinal artery aneurysm

Abdominal aortic aneurysm Ruptured abdominal aortic aneurysm

Carotid artery aneurysm Subclavian artery aneurysm

Coronary artery aneurysm Pulmonary artery aneurysm

Splenic artery aneurysm Visceral artery aneurysm Iliac artery aneurysm

Radial artery aneurysm

Popliteal artery

Scientific knowledge is the basis of diagnostic and treatment procedures. It determines the diagnostic methods to be used for accurate assessment of the disease

Imaging is a scientific method used for the diagnosis of aneurysm. If appropriate imaging methods are not used, the treatment outcome may be negative. The guidelines of ACR are relevant in this respect. Hospitals are rated according to their compliance with ACR, and its influence on in-hospital mortality is evaluated. The relationship between in-patient hospital mortality and aneurysm and the relationship between compliance with ACR and in-hospital mortality of aneurysm patients point to the importance of evidence-based diagnosis and treatment procedure. Thus, effectiveness of diagnosis using imaging techniques and its outcome in terms of mortality for hospitalized patients forms the most important components

hospital mortality of aortic aneurysm patients.

of the findings.

**25**

**Table 1.**

*Comprehensive list of aneurysm types.*

so that effective treatment procedure can be determined.

Aneurysms, by location, could be arterial or venous, the former being more common. Aneurysms related to heart can be coronary artery aneurysms, ventricular aneurysms and aneurysms of sinus of Valsalva. Aneurysms following cardiac surgery also occur. Related to aorta, abdominal aortic aneurysm and thoracic aortic aneurysm can occur. Results of some studies show that about 25% of aneurysms occur in the thoracic area [3]. Related to the brain, cerebral, berry or Charcot-Bouchard aneurysms can occur. Cerebral aneurysm (intracranial or brain aneurysm) is more common at the base of the brain and more common in the anterior cerebral artery, especially in the internal carotid artery. Aneurysms can occur in the legs, especially in popliteal arteries. In the kidney, renal artery or intra-parenchymal aneurysms can occur. However, renal and leg aneurysms are rare. A comprehensive list of various types of aneurysms is given in **Table 1**.

Some studies show that mortalities vary with patient characteristics as well as the specific hospital contexts. Patient characteristics, such as gender, age, and comorbidities of some aortic aneurysm types, have been studied. Hospital contexts


*Challenges for Intelligent Data Analysis Methods in Medical Image Analysis during Surgical… DOI: http://dx.doi.org/10.5772/intechopen.86711*

#### **Table 1.**

happens. Although small swellings may be confined to a small area of the artery, large ones can extend along the whole length of the affected area. The balloon may become too large, and it may rupture when pressure build-up continues. Furthermore, a threshold point is indicated for the rupture. The rupture naturally leads to hemorrhage and other complications and even sudden death. Although aneurysm can occur in any part of the body, it is more common in the arteries, particularly in the aorta. True aneurysms can be atherosclerotic, syphilitic, congenital or ventricular following transmural myocardial infarctions and can occur in any of the three

False aneurysm (pseudo-aneurysm) is also possible when there is complete leaking of blood out of an artery or vein confined to the tissue surrounding the vessel. Eventually, this blood-filled cavity may clot to seal the leak, or it may rupture out of the surrounding tissue. Trauma can be caused by punctures in the artery created by knife, bullet and so forth. Pseudo-aneurysms can be caused by percutaneous surgical procedures like coronary angiography or arterial grafting or an injection into the artery. Aneurysms are classified according to their morphology or by location. Morphologically, saccular aneurysms are spherical, 5–20 cm in diameter, partially or fully filled by thrombus and involve only a portion of the vessel wall. Fusiform types are spindle-shaped, with varying diameter up to 20 cm and with varying length, involving large portions of ascending and transverse aortic

Aneurysms, by location, could be arterial or venous, the former being more common. Aneurysms related to heart can be coronary artery aneurysms, ventricular aneurysms and aneurysms of sinus of Valsalva. Aneurysms following cardiac surgery also occur. Related to aorta, abdominal aortic aneurysm and thoracic aortic aneurysm can occur. Results of some studies show that about 25% of aneurysms occur in the thoracic area [3]. Related to the brain, cerebral, berry or Charcot-Bouchard aneurysms can occur. Cerebral aneurysm (intracranial or brain aneurysm) is more common at the base of the brain and more common in the anterior cerebral artery, especially in the internal carotid artery. Aneurysms can occur in the legs, especially in popliteal arteries. In the kidney, renal artery or intra-parenchymal aneurysms can occur. However, renal and leg aneurysms are rare. A comprehensive

Some studies show that mortalities vary with patient characteristics as well as the specific hospital contexts. Patient characteristics, such as gender, age, and comorbidities of some aortic aneurysm types, have been studied. Hospital contexts

walls of the artery.

**24**

**Figure 1.**

arch, abdominal aorta or iliac arteries.

*Subcategorization of data elements used in this study.*

*Aortic Aneurysm and Aortic Dissection*

list of various types of aneurysms is given in **Table 1**.

*Comprehensive list of aneurysm types.*

include type, location, educational qualifications and experience of health-care professionals and patient volume. However, not many studies have reported on the influence of using various types of imaging modalities and their capability to lead and guide aneurysm repair procedures to decrease the mortality rate of aortic aneurysm patients. One of the important aspects in hospital context is its adherence with the American College of Radiologists (ACR) guideline especially on medical imaging methods and patients safety aspects. The lack of protocols and costs have been cited as important reasons for not practising the most desirable or appropriate imaging methods in the case of aneurysm [4]. Obviously this affects the extent of compliance with ACR. However, not many studies have been reported on the influence of extent of compliance of medical imaging guidelines of ACR on the inhospital mortality of aortic aneurysm patients.

Scientific knowledge is the basis of diagnostic and treatment procedures. It determines the diagnostic methods to be used for accurate assessment of the disease so that effective treatment procedure can be determined.

Imaging is a scientific method used for the diagnosis of aneurysm. If appropriate imaging methods are not used, the treatment outcome may be negative. The guidelines of ACR are relevant in this respect. Hospitals are rated according to their compliance with ACR, and its influence on in-hospital mortality is evaluated. The relationship between in-patient hospital mortality and aneurysm and the relationship between compliance with ACR and in-hospital mortality of aneurysm patients point to the importance of evidence-based diagnosis and treatment procedure. Thus, effectiveness of diagnosis using imaging techniques and its outcome in terms of mortality for hospitalized patients forms the most important components of the findings.

Patient safety is an important aspect of both diagnosis and treatment. Radiation exposure in terms of type, dose and duration and conditions under which imaging is done are of critical importance, and ACR has critical points on these aspects. This applies to treatment also. So, ACR compliance level and other hospital contexts determine the extent to which patient safety is cared for. This is an aspect derivable from the findings of this work. Thus, some of the six dimensions of heath-care quality are evaluated in this work.

pre-contrast imaging series and at least one contrast-enhanced imaging are

for its mitigation, with a doubtful benefit at times.

*DOI: http://dx.doi.org/10.5772/intechopen.86711*

included. Although contrast injection protocols include a number of parameters, the critical challenge is the optimal delivery of appropriate quantity of contrast to the volume of interest. These protocols need to be carefully determined for each specific situation. CTA has a definite edge over MRA in many respects. Renal impairment prevents the use of iodine contrast agents. Renal protective strategies are used

*Challenges for Intelligent Data Analysis Methods in Medical Image Analysis during Surgical…*

CTA is a quick, reliable, simple and non-invasive diagnostic tool for aneurysms and can effectively replace conventional angiography [3]. Therefore, according to Prestigiacomo et al., 3-D CTA can be used as an initial screening tool in place of DSA. Sensitivity and predictive values of 100% were obtained by them. Sensitivity of 2D and 3D CTA to detect very small aneurysms was 98–100% compared to 95% for DSA [5]. CTA accuracy was also 99–100%. Based on these findings, Villablanca et al. recommended the use of CTA with commercial detectors to detect very small aneurysms [6]. Even without pre-operative angiography, pre-operative 3D CTA (instead of DSA angiography) can provide good anatomical information for microsurgical interventions of aneurysms, as was concluded by González-Darder et al. [7]. Forsting in 2005 concluded that CTA can effectively replace DSA and even MRA for diagnosis aneurysm [8]. Hoh et al. demonstrated the possibility of using only CTA instead of DSA for diagnosis and pretreatment planning in patients with ruptured and unruptured aneurysms in Massachusetts General Hospital [9]. In the findings of Karamessini et al., CTA had sensitivity, specificity, positive predictive, negative predictive and accuracy values of 88.7, 100, 100, 80.7, and 92.3%, respectively. The corresponding values for DSA were 87.8, 98, 97.7, 89.1, and 92.9%, respectively [10]. Based on these findings, the authors concluded that CTA and DSA were equally good for detection of aneurysms of 3 mm or more. With 100% detection accuracy, CTA is also useful to detect AcoA and MCA bifurcation aneurysms. According to Matsumoto et al., 3D CTA can effectively replace conventional catheter angiography in the diagnosis and surgery of most ruptured aneurysms [11]. Furthermore, a recent systematic review done by our group in 2015 also supports the use of CTA as an effective substitute for other imaging methods, at least to some extent, in the treatment and diagnosis of AAA [12]. In measuring the volume of aneurysms, CTA, MRA and rotational DSA produced statistically non-significant differences and hence can be considered equally as per the report of Piotin et al. [13]. On the other hand, in a comparative study, Biasi et al. found CTA inadequate to detect small aneurysms occasionally and therefore recommended DSA/3D rotational angiography [14]. Stavropoulos et al. also considered CTA inferior in detecting small aneurysms, and the use of DSA should be continued. Difficulty of detecting small aneurysms using CTA has been reported by many other workers [15]. According to latest study in 2015 by Chung et al., multi-slice 3D CTA offers better image resolution and is hence more useful than single-slice CTA to detect aortic aneurysms for post-EVAR [16]. In another finding, van Gelder [17]

supported further investigation of small aneurysms detected by CTA if there is no pretest probability of ruptured aneurysm. Very low probability of clinically significant aneurysms can be detected by CTA when screening is done for unruptured

Some technological improvements include Sailer et al. in 2014 on using fluoroscopy image fusion guidance for CTA in endovascular interventions to reduce iodine contrast dose and procedure duration [18], Deák et al. on automated systems for detection of aortic aneurysms in CTA images [19] and Wada et al. 2014 on com-

bining 3D CTA with 2D CT imaging guidance for clipping surgery [20].

aneurysms.

**27**

So, the following questions are relevant:


This chapter tries to answer the above questions based on our recent research findings.
